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Admission Date: [2153-4-5] Discharge Date: [2153-4-10] Date of Birth: [2122-2-24] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Latex Attending:[First Name3 (LF) 5134] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Mechanical Intubation and extubation Lumbar puncture History of Present Illness: 31 year old man with a history of spina bifida s/p VP shunt, question seizure [5-11], who presents from OSH after presenting with a seizure. Per discussion with patient's mother, patient was at home this morning sitting in his wheelchair at 10:30am on [2153-4-5] when she noticed he started having generalized movements of all 4 extremities. He almost fell out of his chair and his mother caught his fall, however, he still hit his head slightly and developed a small abrasion on his forehead. Per his mother, he began foaming a bit and bleeding from his mouth, but she could not confirm tongue biting, fecal/urinary incontinence. He was a bit disoriented for a few minutes after the seizure per his mother. [Name (NI) ] family, the patient had been in his usual state of health up until today. The only complaints he recently had were headaches recently and diarrhea in the recent past that had resolved. She decided to call EMS. . EMS arrived 10 minutes after he started seizing. He reportedly had 2 seizures within 15 minutes before valium given IV. In the field he was intubated and given diazepam 5mg IV, versed 5mg IV, etomidate IV, and succinylcholine IV and was transferred to [Hospital 8641] Hospital. At [Hospital 8641] Hospital he had the following vital signs: 99.7 140 151/84 12 100% on ventilation. He was noted to be still seizing lasting minutes with generalized motor activity with incontinence of urine. Post-ictal obtundation was also noted. He received ativan 2mg IV x 4, fosphenytoin 1gm IV ONCE, phenobarbital 1gm IV ONCE. . In the ED, he had the following vital signs: 102.6 120/76 110 100% CPAP: [4-5] FiO2 40%. In the ED, he began to shake both upper arms, which were thought to be rigors. Rectal exam was brown trace guiac positive. Neurology was consulted who recommended bedside EEG, keppra, and LP. Neurosurgery saw the patient who recommended shunt series, repeat CT head, and LP by flouro given his spina bifida history. Repeat CT head was unchanged from prior OSH scan, notable for persitent right ventricular enlargement. He was given acyclovir 600mg IV ONCE, Zosyn 4.5gm IV ONCE, vancomycin 1gm IV ONCE, ceftriaxone 2gm IV ONCE, propofol gtt titrate to sedation, and tylenol 1,300mg PR ONCE, levophed gtt titrated to MAP>65, keppra 1gm IV ONCE. His last set of vitals were 100.6 105 111/63 21 100% on CMV 450/14/40/5. Total in: 7L, total out: 2.1L. . ROS: Per HPI. No recent chest pain, shortness of breath, cough, sputum, dysuria, abdominal pain, fevers, chills, nausea, vomitting, neurologic symptoms such as focal weakness, black outs, or recent seizures. Denies sick contacts or recent travel. Past Medical History: 1) Spina bifida: S/p VP shunt, wheelchair bound, contractures, unable to void 2) Mental retardation (mild) 3) Frequent UTIs from straight cathing 4) Partial SBO of unknown etiology, resolved with supportive care 5) One seizure episode in [5-11], not started on AED due to no activity found on EEG 6) GERD 7) Hypertension 8) Hyperthyroidism 9) ?Cerebral palsy 10) Hip and hamstring surgery [52]) Spinal surgery after birth Social History: Lives at home with his mother, wheelchair bound, works at a grocery store. Two brothers heavily involved in his life, mother overwhelmed with COPD. Does not smoke, drink, or use drugs. Family History: Remote family h/o spina bifida 2 generations prior. Physical Exam: Admission Exam VS: Temp: BP: / HR: RR: O2sat Has GEN: Intubated, sedated young man with frontal bossing, NAD HEENT: Pinpoint 1mm b/l but PERRL, anicteric, MMM, no jvd, negative Svostek's sign RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, lower extremities with contractures SKIN: no rashes/no jaundice/no splinters NEURO: Heavily sedated with propofol. 0+DTR's-patellar and biceps, does not withdraw in any of all four extremities. Downgoing toes. Discharge Physical Exam Tm:98.2 BP:129-142/92-97 P:93-109 RR:18 O2sat:94-98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Horizontal nystagmus 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: Surgical scar at lower back consistent with spina bifida. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact. [4-5] UE strength and sensation. LE sensation intact. 0/5 strength. No DTRs at [Name2 (NI) ]. Pertinent Results: OSH Labs [2153-4-5]: U/A: Cloudy Blood MOD pH 5 Prot 30 Nitrate NEG Leuk NEG WBC rare Bact none seen . TSH 6.8 (H) . Dilantin: <0.5 . Mg 2.7 TB 0.6 TP 7.7 Alb 4.1 AST 21 ALT 42 AP 76 Na 136 K 4.4 Cl 99 CO2 11 Glc 239 BUN 10 Cr 0.9 Ca 8.7 . WBC 18 HCT 46.6 PLT 544 . N 63 L 30 E 2.4 . ABG: 7.35/45/186 on AC 500/12 50% RR 12 [Hospital1 18] LABS ON ADMISSION: [2153-4-5] 06:15PM BLOOD WBC-12.5* RBC-3.77* Hgb-10.6* Hct-30.3* MCV-80* MCH-28.2 MCHC-35.1* RDW-13.3 Plt Ct-279 [2153-4-5] 06:15PM BLOOD Neuts-82.9* Lymphs-11.5* Monos-4.9 Eos-0.3 Baso-0.4 [2153-4-5] 06:15PM BLOOD PT-11.6 PTT-27.3 INR(PT)-1.0 [2153-4-5] 05:00PM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-135 K-6.2* Cl-105 HCO3-21* AnGap-15 [2153-4-6] 03:27AM BLOOD ALT-20 AST-22 LD(LDH)-172 AlkPhos-39* TotBili-0.8 [2153-4-5] 08:30PM BLOOD Calcium-6.4* Phos-2.5* Mg-1.9 Iron-30* [2153-4-5] 08:30PM BLOOD calTIBC-200* VitB12-548 Folate-9.6 Ferritn-85 TRF-154* [2153-4-6] 03:27AM BLOOD TSH-1.9 [2153-4-6] 03:27AM BLOOD Free T4-1.3 [2153-4-5] 03:42PM BLOOD Type-ART Temp-38.3 pO2-479* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 Intubat-INTUBATED [2153-4-6] 03:38AM BLOOD O2 Sat-83 [2153-4-6] 03:38AM BLOOD freeCa-1.31 MICRO: [2153-4-7] URINE URINE CULTURE-PENDING INPATIENT [2153-4-7] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2153-4-6] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY INPATIENT [2153-4-5] URINE Legionella Urinary Antigen -FINAL INPATIENT [2153-4-5] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2153-4-5] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2153-4-5] URINE URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [Hospital1 ] URINE CULTURE (Final [2153-4-7]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2153-4-5] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] REPORTS: CXR AP [2153-4-5]: IMPRESSION: No acute cardiopulmonary abnormality. Discontinuity of the left ventriculoperitoneal shunt catheter. Endotracheal tube and nasogastric tubes in standard positions. LUMBAR SP [2153-4-5] There is moderately severe rotatory thoracolumbar scoliosis convex to the right centered at L1. Multilevel degenerative changes with facet arthropathy are moderate in extent. There is considerable pelvic tilt. Lucency overlying the L3-L5 vertebral bodies may represent known spina bifida; however, this could represent an overlying bowel loop. There are mild-to-moderate degenerative changes of both femoroacetabular joints. A ventriculoperitonal shunt is noted as is a nasogastric tube. The study and the report were reviewed by the staff radiologist. [2153-4-6] ANKLE FILM There is soft tissue swelling medially and laterally. There are no signs for acute fractures or dislocations. CT HEAD [2153-4-5] IMPRESSION: No interval change from OSH study [2153-4-5]. Ventricular asymmetry but the right ventricular morphology does not suggest that it is dilated or distended. The asymmetry may be due to partial agenesis of the corpus callosum. LENI LLE U/S [2153-4-6] CONCLUSION: No evidence of DVT in the left lower extremity. Brief Hospital Course: A/P: 31 year old man with a history of spina bifida s/p VP shunt, question seizure [5-11], who presents from OSH after presenting with a seizure and now hypotensive. 1. Hypotension: He dropped his pressures to the 80s in the ED after intubation. The etiology was most likely [1-3] sepsis, given his warm extremities, fever, and white count. Initially, the most likely source of infection was thought to be meningoencephalitis given his recent headache, seizures. Of chief concern is a bacterial process versus HSV encephalitis. He was also at high risk for a VP shunt infection. Urosepsis was also high on the list given his history of recurrent UTIs and his unhygenic self-cathing habits (he needs to be reeducated on this). Fortunately, his pressures quickly improved and he was weaned off of levophed overnight the night of [2153-4-5]. He was continued overnight vanc/zosyn for sepsis NOS, and ceftriaxone 2gm and acyclovir for meningitis tx started on [2153-4-5]. On [2153-4-6], zosyn and ceftriaxone were discontinued in favor of cefepime. CSF was very difficult to obtain, but with help of neurosurg and after 2 attempts, VP shunt CSF fluid was aspirated and sent off. Once CSF was negative (His VP shunt LP was found to be negative with 0 WBCs on [2153-4-7]), vanc and cefepime were discontinued on [2153-4-8]. His urine culture revealed pan-sensitive klebsiella, which was started on [2153-4-8]. Acyclovir was discontinued once it was deemed that HSV encephalitis was unlikely and HSV PCR eventually returned negative. He was discharged on po cefpodoxime 100 mg po BID to complete 14 day course. 2. Respiratory failure: No hypoxemia noted at time of intubation. Patient's respiratory failure was related to mental status precluding ability to protect airway in the setting of status epilecticus. He was extubated without difficulty on [2153-4-7]. He was noted to be hypoxic to the low 90s during the night of [2153-4-7] requiring 2-3 liters of O2, this normalized to 100% on RA by daytime on [2153-4-8]. The MICU team suspected OSA and recommended an outpatient sleep study. 3. Altered mental status: Patient with very probable seizure based on corroborated history from mother and OSH notes stating mouth foaming/bleeding, urinary incontience, and tonic/clonic movements per patient's mother and EMS. His altered mentation was very likely a post-ictal state. CT head negative. The most likely cause of seizure is febrile infection. Hypocalcemia was not present upon presentation at OSH and unlikely to be contributing given negative Svostek sign although this was corrected. He was treated with IV Keppra 1gm [Hospital1 ] and treated for possible CNS infection as above until ruled out. His mental status cleared quickly after extubation. He was discharged on keppra 1500 mg po BID indefinitely per neuro for seziures and will follow up with his neurologist in NH. 4. Anemia: Microcytic. Iron studies revealed iron deficiency anemia and he was started on iron. He did have trace guiac positive brown stools in ED but Hcts remained stable throughout his course. he will need outpatient follow up and perhaps a PCP directed GI referral for endscopy. 5. High bicarbonate: Stable throughout hospitalization. ? related to OSA and chronic CO2 retention. Will need further work up as an outpatient. 6. Hypothyroidism: High TSH likely sick euthyroid. T4 normal. Follow up for PCP 1. Anemia 2. Possible OSA Medications on Admission: 1) Lisinopril 20mg PO daily 2) Metoclopramide 10mg PO QHS 3) Levothyroxine 150mcg PO daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 2. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a day. 3. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:19 Tablet(s) Refills:0 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Seizure 2. Urinary tract infection Secondary Diagnosis 1. Spina bifida Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with an episode of seizure requiring intubation. You were started on medication called KEPPRA to help control your seizures. You were also noted to have urinary tract infection and started on antibiotics. Following medications were made your medical regimen START LEVICITERAZE START CEFPODOXIME 100 mg by mouth twice a day for 9 more days (End date: [2152-4-19]) for urinary tract infection Followup Instructions: Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16107] Location: [Location (un) ] HEALTH FAMILY PRACTICE Address: [Location (un) 30815], [Location (un) ],[Numeric Identifier 30816] Phone: [Telephone/Fax (1) 75860] Appt: We are working on a follow up appt for you within the next week. The office will call you at home with an apt. If you dont hear from them by tomorrow, please call them directly to book an appt. Dr. [Last Name (STitle) 89315] [Name (STitle) ] (neurologist) [Telephone/Fax (1) 89316] Wednesday [2153-4-18] at 10 am	[ "51881", "5990", "53081", "32723", "2449" ]
Admission Date: [2153-5-2] Discharge Date: [2153-5-2] Date of Birth: [2079-4-20] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 2297] Chief Complaint: Right subdural bleed Major Surgical or Invasive Procedure: Endotracheal extubation History of Present Illness: Mr. [Known lastname ] is a 74yo female being transferred to the MICU with large large right subdural bleed with shift. She fell and hit her head at 1:30am today. Since the fall she was disoriented and had trouble concentrating. Her husband helped her back into bed and then her condition continued to deteriorate. She was then brought to [Hospital 8641] Hospital where CT head revealed R subdural bleed. She is on Coumadin and Plavix as outpatient. She was intubated at 3:30am for airway protection and received Atropine 2mg and Atracurium for sedation. Her INR was 2.2 and she received 2 units FFP and vitamin K. She was then transferred to [Hospital1 18] for further management. In the [Hospital1 18] ED her initial vitals were T AF BP 133/81 AR 80 RR 20 O2 sat 96% on ventilator. CT scan was repeated with confirmed the massive bleed with significant shift. She received Dilantin IV and the organ bank was contact[Name (NI) ] for possible organ donation since the patient was an organ donor. Past Medical History: Hypertension Atrial fibrillation Hyperlipidemia Throat cancer Kidney cancer Social History: NC Family History: NC Physical Exam: vitals T 98.6 BP 133/83 AR RR 17 O2 sat 99% Gen: Patient not responsive to sternal command HEENT: ETT in place, pupils not reactive to light Heart: Irreg, irreg, no audible m,r,g Lungs: CTAB Abdomen: Soft, NT/ND, +BS Extremities: No LE edema, 1+ DP/PT pulses bilaterally Neuro: Absent corneal and pupillary reflexes. +Babinski reflex, withdraws lower extremities to stimulation Pertinent Results: CT head ([5-2]): Massive subdural and subarachnoid hemorrhage with severe mass effect and subfalcine, downward transtentorial, uncal and cerebellar herniation. Brief Hospital Course: Ms. [Known lastname ] is a 74yo female with atrial fibrillation on Plavix and Coumadin who is being transferred to the MICU for management of massive R subdural bleed. 1)Right subdural hematoma: Patient transferred from OSH for massive R SDH s/p fall in the setting of being on Coumadin and Plavix. INR was 2.2 at OSH and she received FFP and vitamin K. She was intubated for airway protection and then transferred to us for further management. Neurosurgery evaluated her in the ED and felt that she had no brainstem function. On our exam, she is breathing over the vent and she has a positive babinski and withdraws her lower extremities to stimulation. This suggests that she still has some brainstem function. Despite this, given the severity of this event she will likely have very poor neurological function and will unlikely recover to baseline functioning. She is also no longer a candidate for organ donation. Family meeting was held and decision was to extubate patient and change her code status to CMO. Patient expired on [5-2]. Medications on Admission: Coumadin 3mg PO daily Plavix 75mg PO daily Lopressor 25mg PO BID Norvasc 5mg PO daily Nexium 40mg PO daily Lasix 20mg PO daily Zoloft 50mg PO daily Zocor 20mg PO daily Diovan 320mg PO daily Digoxin 125 micrograms PO daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Patient expired on [5-2]. Discharge Condition: Patient expired on [5-2]. Discharge Instructions: Patient expired on [5-2]. Followup Instructions: Patient expired on [5-2].	[ "4019", "42731", "2724", "V5861" ]
Admission Date: [2139-11-7] Discharge Date: [2139-11-14] Date of Birth: [2082-8-19] Sex: M Service: SURGERY Allergies: Hayfever Attending:[First Name3 (LF) 5569] Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: orthotopic liver transplant History of Present Illness: 56M with a history of Hep C diagnosed twenty years ago on routine testing complicated by cirrhosis, variceal bleeding with banding, three hepatomas s/p ablation on [6-11] and biopsy confirmed HCC s/p RFA. The patient is a Child's class B with a MELD of 22 who is pre-op for OLT. Past Medical History: 1) HCV with cirrhosis- Genotype 1, nonresponder to pegIFN/RBV therapy; complicated with variceal bleed x 1 with banding; hepatic monitoring has revealed intrahepatic lesions suspicious for HCC and has undergone RFA ablation to 2. 2) mixed cardioperfusion defects on screening Sestamibi. 3) DM- well controlled 4) Cervical spine disc disease with radiculopathy 5) HTN 6) diverticulosis PSH: tonsillectomy, adenoidectomy, hepatoma EtOH ablation ([2-4]) Social History: Works as a mailman. He is married. Denies drug, alcohol or tobacco use. Family History: Family history is significant for a brother with bipolar disorder, sister with [Name2 (NI) 10282] and infantile paralysis and another brother who is alive and healthy. Physical Exam: VS: 97.6 123/78 67 18 99 RA General: Well developed Pulm: CTAB Cardio: RRR, no M/R/G clear S1, S2 Abd: soft, obese, non tender, bowel sounds present, no hernias or masses Rectal: stool in vault, no masses, G negative Ext: warm well perfused, palpable DP pulses bilaterally, no edema Pertinent Results: [2139-11-7] ALT(SGPT)-70* AST(SGOT)-92* ALK PHOS-255* TOT BILI-0.9 [2139-11-7] FIBRINOGEN-330 [2139-11-7] PT-15.8* PTT-28.5 INR(PT)-1.4* [2139-11-7] ALBUMIN-3.1* [2139-11-7] GLUCOSE-405* UREA N-19 CREAT-1.2 SODIUM-132* POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-11 [2139-11-8] Hepatic Duplex Ultrasound: The liver demonstrates a normal echotexture. The hepatic veins and portal veins are all patent and show directionally appropriate flow. The hepatic artery demonstrates normal arterial waveforms without evidence of parvus tardus. Resistive indices range from 0.5 to 0.6. [2139-11-13] Gravity Cholangiogram through Roux Tube: unable to visualize biliary structures or jejunum through Roux tube injection, final read pending. Brief Hospital Course: Mr. [Known lastname 30597] was admitted on [2139-11-7] and taken to the operating room for OLT on [2139-11-8]. Please see Dr.[Name (NI) 8584] OR note for details. He was admitted to the SICU postop and remained hemodynamically stable. Duplex U/S on [11-9] shwed patent vessels and no evidence of fluid collection. He was bolused 1.5L IVF for low UOP, sedation was weaned and he was extubated. He received 2 amps of bicarbonate for metabolic acidosis with improvement and he continued on the liver transplant pathway. The patient was tranferred to the floor on [2139-11-10]. Both JP drains remained serosanguinous. The lateral JP and NGT were removed on [2139-11-11]. The patient was ambulating independently and tolerating a diet. Endocrine was consulted for elevated blood sugars. He was started on 30 units lantus QAM and an insulin sliding scale. Gravity cholangiogram was obtained on [2139-11-13] which was unable to visualize the jejunum or biliary structures. JP drain was removed prior to discharge and 2 sutures were placed, without evidence of leak. Patient was discharged home with Roux drain in place with instructions to follow up with Dr. [Last Name (STitle) ] in clinic. Medications on Admission: vitamin D3-calcium carbonate ', celexa 20', welchol 3 tabs am, 4 tabs pm, humalog, nortryptiline 50', asa 81', nadolol 160', mvi,lasix 40', amlodipine 10', tylenol 1000'', MVT ' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:0 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 6. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours) for 2 doses. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 10 days: do not drive while taking pain medication. Disp:30 Tablet(s) Refills:0 11. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous QAM with breakfast: hold if blood glucose is less than 110. Disp:qs units Refills:2 14. insulin lispro 100 unit/mL Cartridge Subcutaneous Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: hepatitis C virus cirrhosis, status post orthotopic liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have any of the following warning signs: fever, chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain, Please call to schedule an appointment. You will then need to have blood drawn every Monday and Thursday at [Last Name (NamePattern1) 439], [Last Name (un) 2577] Office Medical Building [Location (un) ]. No driving while taking pain medication. No heavy lifting/straining for six weeks. Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2139-11-19] 12:50 Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2139-11-27] 2:20 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2139-12-3] 2:00 Follow-up with [Last Name (un) ] for management of your diabetes	[ "2762", "4019" ]
Admission Date: [2192-8-23] Discharge Date: [2192-8-25] HISTORY OF PRESENT ILLNESS: This is a 79 year old female patient with a history of chronic obstructive pulmonary disease, coronary artery disease status post non-Q wave myocardial infarction in [2192-7-11], chronic renal tracheostomy, gastrostomy tube, and chest computerized tomography scan. The patient was initially admitted to the [Hospital 882] Hospital status post a fall. The patient was found to have a left pneumothorax and during the hospital course developed a right lower lobe pneumonia. The patient was treated with antibiotics and transferred to [Hospital1 ] for rehabilitation where she had acute respiratory decompensation requiring intubation. The patient was extubated within 24 to 48 hours of readmission to [Hospital 882] Hospital, however, the patient failed this extubation and the remainder of the hospital course included an additional two episodes of failed extubation for a total of three failed extubations. It was felt that these failed extubations were likely secondary to right lower lobe pneumonia versus right lower lobe collapse. Of note, bronchoscopy obtained two weeks prior to transfer revealed pus in the right lower lobe positive for Stenotriphomonas. The patient's treatment for the Stenotriphomonas included Cefepime, Levaquin, Ceptaz according to the physician at [Hospital3 105]. Other significant hospital course includes the patient being found to have sputum that was positive for Methicillin-resistant Staphylococcus aureus and stool that was positive for Clostridium difficile. PAST MEDICAL HISTORY: 1. Hypertension 2. Chronic obstructive pulmonary disease 3. Coronary artery disease status post non-Q wave myocardial infarction in [2192-7-11] 4. Chronic renal insufficiency 5. History of gastrointestinal bleed secondary to non-steroidal anti-inflammatory drugs 6. Left femoral condyle fracture in [2192-7-11] 7. History of obstructive sleep apnea requiring home oxygen with 2 liters of nasal cannula MEDICATIONS ON TRANSFER: 1. Flagyl 500 q. 8 2. Levofloxacin 250 q. day 3. Cefipime 1 gm intravenous q. day 4. Diltiazem 30 mg p.o. q. 6 5. Labetalol 200 mg p.o. b.i.d. 6. Atorvastatin 10 mg p.o. q.h.s. 7. Terazosin 10 mg p.o. q. day 8. Protonix 40 mg p.o. q. day 9. 220 mcg b.i.d. 10. Salmeterol 2 puffs b.i.d. 11. Quinapril 40 mg p.o. b.i.d. 12. Clonidine 2 puffs q.i.d. ALLERGIES: Aspirin SOCIAL HISTORY: The patient has a 60 pack year history of tobacco use. Denies any alcohol use. The patient stopped smoking five years ago. PHYSICAL EXAMINATION: The patient is afebrile, pulse 83, blood pressure 146/82, oxygen saturation 96% on 2 liters of nasal cannula. Generally, the patient was intubated in no apparent distress, alert and oriented. Head, eyes, ears, nose and throat examination reveals him to be normocephalic, atraumatic with pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. There is presence of orogastric tube and endotracheal tube in place. Mucous membranes were dry. Lungs were clear to auscultation bilaterally except for sparse coarse breath sounds at the right base. Heart was irregular without any murmurs, rubs or gallops. Abdomen was soft, obese, nontender and nondistended with decreased bowel sounds. Extremities examination reveals there was 3+ pitting edema of the left lower extremity and 1% nonpitting edema of the right lower extremity. Neurological, the patient was alert and oriented times three. Cranial nerves II through XII were intact. LABORATORY DATA: White count 11.5, hematocrit 27.0, platelets 317, PT 13.4, PTT 34.3, INR 1.1, calcium 7.7, albumin 2.3, magnesium 2.3, phosphorus 4.1, sodium 138, potassium 5.1, chloride 103, bicarbonate 26, BUN 69, creatinine 1.1, glucose 85. HOSPITAL COURSE: The patient is a 79 year old female patient status post intubation secondary to pneumonia. She has had failed extubation times three at an outside hospital admitted for tracheostomy, percutaneous endoscopic gastrostomy tube and a chest computerized tomography scan. 1. Pulmonary - The patient is status post intubation secondary to pneumonia. The patient received a tracheostomy the morning of [8-24]. There were no complications. The patient is scheduled for a noncontrast chest computerized tomography scan which is not performed at the time of dictation but will be performed prior to discharge. Addendum will be dictated with the results of computerized tomography scan. The patient will also receive a bronchoscopy to evaluate the right lower lobe pneumonia/pus previously found on previous bronchoscopy. The patient has had increased secretions while in this hospital and it was felt that bronchoscopy would be beneficial to this patient. There was also bronchoscopy done at the time of dictation and cultures will probably be pending at the time of discharge. The patient's chronic obstructive pulmonary disease was stable during this hospital stay controlled with Albuterol and Atrovent metered dose inhalers. 2. Infectious disease - History of pneumonia and Clostridium difficile positive. The patient was placed on contact precautions for Clostridium difficile as well as history of Methicillin-resistant Staphylococcus aureus. The patient will be continued on Flagyl 500 mg p.o. t.i.d. for the Clostridium difficile and pneumonia coverage was covered with Levofloxacin 250 mg p.o. q. day. An Infectious Disease consult was obtained to evaluate for the necessity of Cefepime. It was felt that with Stenotrophomonas, the patient would benefit from Bactrim for more specific coverage. Although outside hospital states that the Stenotrophomonas was sensitive to Levofloxacin and Cefepime it is felt that Bactrim is better activity against this microbiology and in the future if not contraindicated would recommend switching antibiotics to Bactrim. It was also felt that the patient did not need to be on Cefepime for double coverage given no evidence of Pseudomonas with current cultures. The patient was just kept on Levofloxacin 250 mg p.o. b.i.d. 3. Gastrointestinal - The patient had a percutaneous endoscopic gastrostomy tube placed at 2:30 PM on [8-24]. There were no complications post procedure and tube feeds began 24 hours after placement. 4. Cardiac - History of coronary artery disease with nonspecific myocardial infarction. The patient was continued on chronic medications including Labetalol, Flagyl, Quinapril and Atorvastatin. The patient was found to be in atrial flutter which apparently was known at the outside hospital. 5. Renal - Patient has a history of chronic renal insufficiency, the patient showed no evidence of an elevated creatinine while at this hospital. Chest computerized tomography scan obtained is no contrast and should not affect the renal function. DISCHARGE STATUS: The patient is stable at the time of discharge. DISCHARGE CONDITION: The patient will be discharged back to Vancouver/[Hospital3 105] for further rehabilitation after percutaneous endoscopic gastrostomy, tracheostomy, chest computerized tomography scan and bronchoscopy performed at this hospital. DISCHARGE DIAGNOSIS: 1. Respiratory failure secondary to pneumonia with recurrent failed extubation attempts. 2. Placement of percutaneous trachesostomy 3. Stenotrophomonas Pneumonia DR.[Last Name (STitle) ],[First Name3 (LF) ] P. 12-948 Dictated By:[Name8 (MD) 2402] MEDQUIST36 D: [2192-8-24] 14:39 T: [2192-8-24] 15:33 JOB#: [Job Number 20917]	[ "51881", "496", "4019", "41401", "412" ]
Admission Date: [2100-11-3] Discharge Date: [2100-11-16] Date of Birth: [2035-2-21] Sex: M Service: MEDICINE Allergies: Imitrex / Biaxin Attending:[Doctor First Name 2080] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: rigid bronchoscopy, IR embolization of bleeding pulmonary vessels History of Present Illness: 65 y/oM with stage IV lung CA on home 2L [Hospital ] transferred from OSH with hemoptysis x 1 week and resultant Hct drop from baseline 28 to 17. Patient first started coughing up dark clots of blood on Friday; states last hemoptysis was 1 day prior to transfer to [Hospital1 18], and was about a tablespoon of blood. Patient had not required mechanical ventilation and was saturating well on room air in [Hospital Unit Name 153]. Per [Hospital Unit Name 153], patient also c/o dyspnea on mild exertion. Of note, dyspnea has been a longterm complaint and patient was recently admitted for removal of y-stent in [Month (only) 359](first placed 2 mo ago). Per report, OP oncologist who did not want to repeat bronchoscopy. . Patient also with recent chemo of [Doctor Last Name ]/gemcitabine (last dose on [2100-10-24]), and had radiation to lung in [2100-8-11]. Patient also c/o rib and right hip pain. In [Hospital Unit Name 153], radiographs revealed new lytic lesions in ribs and new right femur lytic lesion. . Finally, per [Hospital Unit Name 153], patient also c/o dysphagia x several days and states he can't take liquids+solids. The [Hospital Unit Name 153] team was concerned that the large mass in lungs may be compressing the esophagus, so GI consulted for feeding tube. Also with 75 pound weight loss. . Per [Hospital Unit Name 153] note, at OSH, transfused 2 UpRBC on [2100-10-28]. CT scan of chest no active source of hemorrhage or PE. Given concern for large volume bleed, patient was transferred to [Hospital1 18] for further evaluation and treatment. Upon arrival to [Hospital1 ], initial VS: 97.9 100 113/72 18 100% 4L NC, able to be weaned to 99% on RA. Physical exam notable for scattereed rales and trace guiac positive rectal exam. Repeat Hct had risen appropriate to 25, and Hct has been stable throughout [Hospital Unit Name 153] stay. . Because IP wanted to use a rigid bronch to see if they can coagulate and localize source of bleeding, patient was transferred West for OR. During bronchoscopy, found to be tumor invasion into both left and right proximal [Last Name (LF) 87542], [First Name3 (LF) ] invasion into the carina. IP able to obtain hemostasis/coagulate much of it, but areas are still oozing and will need IR angioembolization. Patient intubated in OR and comes to MICU intubated. Past Medical History: - Lung Cancer: poorly differentiated adenocarcinoma occluding R main stem bronchus, s/p rigid bronchoscopy, tumor excision and Y-stent [2100-7-28]. Medical oncologist and rad-onc doctors [First Name (Titles) ] [Name5 (PTitle) ]. Removed in [Month (only) 359]. - Hyperlipidemia - BPH - Migraines - Vertigo Social History: Recently quit smoker, 40 py history. No EtOH, no drugs. lives alone Family History: Mother: pancreatic cancer Maternal uncle: lung cancer Siblings: sister diabetes Physical Exam: GEN: thin, fragile, NAD, occassionally labored breathing HEENT: EOMI, PERRLA, no supraclavicular or cervical lymphadenopathy, RESP: rhonchorus breath sounds throughout CV: RRR, S1 and S2 wnl, systolic murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters EXT limited ROM of right hip, minimal pain on palpatition of right trochanter Neuro: II-XII intact; no sensory deficits Pertinent Results: Admission: [2100-11-3] 05:48PM HGB-9.2* calcHCT-28 [2100-11-3] 09:03AM HCT-23.8* [2100-11-3] 02:58AM WBC-5.4# RBC-2.98* HGB-9.0* HCT-25.8* MCV-87 MCH-30.0 MCHC-34.7 RDW-17.2* [2100-11-3] 02:58AM NEUTS-80.1* LYMPHS-10.8* MONOS-8.3 EOS-0.6 BASOS-0.3 [2100-11-3] 02:58AM PLT COUNT-235# [2100-11-3] 02:58AM RET AUT-3.0 [2100-11-3] 02:58AM PT-14.8* PTT-26.0 INR(PT)-1.3* [2100-11-3] 02:58AM GLUCOSE-86 UREA N-29* CREAT-0.6 SODIUM-140 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-20 [2100-11-3] 02:58AM ALT(SGPT)-11 AST(SGOT)-29 LD(LDH)-425* ALK PHOS-114 TOT BILI-1.5 . MICRO: RESPIRATORY CULTURE (Final [2100-11-7]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . ACINETOBACTER BAUMANNII COMPLEX. RARE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ACINETOBACTER BAUMANNII COMPLEX \| \| AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R <=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S VANCOMYCIN------------ 1 S IMAGING: CT Chest [11-3] 1. No aortic dissection, pulmonary embolism. 2. Persistent tumor encasing the posterior mediastinum, carina and right hilum. The overall extent of this tumor appears to have decreased from the previous study with resultant improved patency of the airways and resolution of right upper lobe and lower lobe atelectasis. 3. New bilateral lytic rib lesions consistent with metastatic disease. There is also a new pathologic left posterior eighth rib fracture. 4. Tumor involvement in the posterior mediastinum is inseparable from the esophagus and there is a large volume of ingested material seen in the proximal esophagus. This finding raises concern for aspiration. 5. Emphysema. 6. Unchanged thickening of both adrenal glands. . Bone Scan: [11-5] IMPRESSION: Multiple osseous metastatic lytic foci involving the thoracic ribsthe right femoral neck with associated pathologic fracture involvingthe left posterior 8th rib as can be correlated on recent CT/radiographs. . CT PELVIS: [11-5] IMPRESSION: 1. Innumerable lytic lesions throughout the sacrum, bilateral iliac bones, and proximal femurs. 2. The largest lesion is in the right intertrochanteric region of the femur which is not completely imaged. There is rarefaction of the medial aspect of the right femur medially at the site of the lesion which is at risk for pathologic fracture. 3. Interval development of ascites in the abdomen. . CT CHEST [11-11] IMPRESSION: 1. Overall progression of subcarinal and paraesophageal mass with occlusion of the distal unstented portions of the right middle and lower lobe bronchi. 2. Subtotal occlusion of the esophageal stent in its mid portion with associated distention of the proximal esophagus. 3. Marked interval enlargement of bilateral pleural effusions and associated compressive atelectasis at the lower lobes. Brief Hospital Course: # Metastatic Lung Cancer. During this hospitalization the was tumor found to be increasingly aggressive in nature with continued growth, despite active chemotherapy. Continued growth resulted in esophageal compression as well as invasion into the bronchial tree. Furthermore, patients additional presenting complaint of right hip weakness found to result from tumor infiltration of right intertrochanteric space. On admission patient optimistic and eager for treatment. Underwent angioembolization to treat bleed. Underwent tracheal and esophageal stenting in hopes of improving the dysphagia. Unfortunately, the force of the surrounding tumor resulted in near occlusion of esophageal stent 24hours after placement. The severity of the situation was relayed and after several discussions with the family, primary outpatient team as well as inpatient team patient changed code status to DNI/DNR with wish to proceed with hospice care. At time of discharge antibiotics, TPN were stopped, PICC line pulled and comfort measure were applied. Patient with plan to be discharged with home hospice. Provided with prescriptions to minimize pain, decrease nausea, decrease anxiety and improve work of breathing. . # Hemoptysis: Secondary to endobronchial tumor burden. Invasion of tumor into right and left proximal [Month/Year (2) 87542] and also into carina. Arrived in MICU intubated for airway protection. Now s/p rigid bronch with IP. Pt with continued slow bleeding initially, embolized by IR. s/p IR procedure no further episodes of active hemopytsis. . # Esophageal obstruction: Tumor was found to be compressing espogeal resulting in near occlusion. After reviewing imaging decision made to first stent tracheal stent to protect airway prior to esophageal stent placement. Unfortunately CT scan on day following stent placement revealed subtotal occlusion of distal esphagus. No further interventions performed. Patient able to tolerate liquid diet at time of discharge. . # Pelvic lesion. Spoke with both Ortho onc as well and Radiation Oncology. Initially discussion of possible operative intervention vs XRT. However after much discussion decision made to treat pain with and forego additional treatment measures. . # Pneumonia. Patient developed worsening post-obstructive pneumonia after esophageal stent placement. Treatment with antibiotics discontinued after code discussion finalized. Medications on Admission: - Atorvastatin 20 mg daily - Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr QHS - Menthol-Cetylpyridinium 3 mg Lozenge prn - Guaifenesin 600 mg Tablet Sustained Release 2 tabs [Hospital1 ] - Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily - Docusate Sodium 100 mg Capsule [Hospital1 ] - Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution q 6hrs prn - Acetylcysteine 20 % (200 mg/mL) Solution q 6hrs - Amoxicillin-Pot Clavulanate 875-125 mg Tablet x 4weeks - Benzonatate 100 mg Capsule TID - Cyclobenzaprine 10 mg Tablet TID - Oxycodone 5 mg Tablet q 4-6 hrs prn - Acetaminophen 325 mg q 6hrs prn - Lidocaine-Diphenhyd-[Doctor Last Name ]-Mag-[Doctor Last Name ] 200-25-400-40 mg/30 mL 5mL QID - Codeine Sulfate 30 mg Tablet QID prn Discharge Medications: 1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:1 Patch 72 hr(s) Refills:2 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:24 Tablet(s) Refills:0 3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for cough. 4. morphine 10 mg/5 mL Solution Sig: One (1) PO Q2H (every 2 hours) as needed for pain. Disp:1 bottle Refills:2 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Disp:2 inhalers Refills:0 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. Disp:2 cartridges Refills:0 7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:24 Tablet, Rapid Dissolve(s) Refills:0 8. acetaminophen 650 mg/20.3 mL Solution Sig: [12-12] PO every six (6) hours as needed for fever for 1 doses. Discharge Disposition: Home With Service Facility: Hospice of [Hospital3 ] Discharge Diagnosis: Primary: Metastatic Lung cancer Discharge Condition: Mental status: clear and coherent Unable to bear weight on left leg. Discharge Instructions: You were transferred to [Hospital1 18] for continued treatment of your lung cancer with associated complications of trouble swallowing, coughing up blood, and hip pain. . To address the bleeding, the team of interventional pulmonologists were able to a perform a bronchoscopy, a procedure which allows visualization of your airways. During this procedure they were able identify the source of the bleed and apply thermal energy to stop it. You had not further episodes of coughing up large volumes of blood while hospitalized. . You also noted difficulty swallowing. It was discovered that the tumor was compressing your esophagus making it difficult for you to swallow. The decision was made to place an esophageal stent in hopes of making swallowing easier. A tracheal stent was placed prior to the esophageal stent to ensure airway protection. Unfortunately, the force of the tumor on the esophageal stent caused the area of the stent to lessen only allowing passage of liquids. Prior to discharge you were able to swallow liquids with limited difficulty. . Imaging was taken of your hip. Ultimately it was determined that your increased pain was due to tumor involvement in the bones of the hip. Your pain was controlled with morphine and physical therapy worked with you to optimize your strength and ability to transfer. . During your hospitalization, ongoing discussion took place between your primary care physician, [Name10 (NameIs) ] primary oncologist as well as your inpatient medical team and consult services. After much discussion you determined that you would rather return home with hospice care rather than proceed with ongoing hospital care. Your ongoing goals of care will be optimizing comfort. . Mr [Known lastname ] it was an honor taking care of you. . You will be discharged with medications to control pain, decrease nasuea and improve breathing: - MORPHINE 5-10mg PO every 2 hours as needed for the pain - ZOFRAN 4mg tablets. Take one tablet every 8 hours as needed for pain - ALBUTEROL Inhaler 2 PUFFS as needed for shortness of breath - ALBUTEROL Nebulizer treatment. 1 every 6hrs as needed for shortness of breath - LORAZAPAM 0.5 mg SL Q4H as needed for anxiety - Guaifenesin [4-19] mL PO/NG every four hours for cough Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 27009] and Dr. [Last Name (STitle) 87543] as needed and contact your hospice program with any questions or difficulties Completed by:[2100-11-16]	[ "2851", "2761", "2724", "V1582" ]
Admission Date: [2156-2-26] Discharge Date: [2156-3-2] Date of Birth: [2096-11-3] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 678] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: From admission note: 59 y/o M with PMHx of ESRD on HD, GI bleeds, CAD and polysubstance abuse who was brought into the ED via EMS after his wife witnessed a syncopal episode. Pt was complaining of left sided chest pain but was drowsy on arrival. In the ED, initial vs were: T 96.8 P 60 BP 92/52 R O2 sat 100% on NRB. Pt some new TWI on EKG in V2-V6 and was being bolused for hypotension. At midnight, pt was noted to be having possible seizure activity with left eye deviation and foaming at his mouth. After this activity ceased, pt was post ictal and unable to be aroused. He was intubated with etomidate and rocuronium due to concern for inability to protect his airway. Pt remained mildly hypotensive and hct came back at 24 (down from baseline of 30). He had a right femoral CVL placed and rectal exam revealed brown stool mixed with blood. OG tube was placed and there was no evidence of hematemesis. Pt was typed and crossed for 4u prbcs and bolused with a total 3L IVF. He received Aspirin 325mg, Zofran, Protonix, Vanc & Zosyn for possible sepsis and was transferred to the ICU. On arrival to the ICU, pt was intubated and sedated. Review of sytems: unable to obtain Past Medical History: # ESRD on [First Name3 (LF) 13241] (Tues/Thurs/Sat, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9449] Dialysis, [Location 1268], [Telephone/Fax (1) 69669]) # Type 2 diabetes mellitus - peripheral neuropathy # CAD s/p MI (patient cannot recall) - cardiac catheterization in [9-/2155] without flow limiting stenoses - MIBI in [11/2152] showed reversible defects inferior/lateral # CHF with EF 30-35% ([9-/2155] TEE) # Atrial fibrillation/atrial flutter s/p Aflutter ablation [8-/2153] - not on anticoagulation # h/o atrial tachycardia s/p EPS [9-21] and ablation x 2 for L sided, triggered (not reentrant) Atachs # Hypertension # Dyslipidemia: [9-/2155] TC 101, LDL 54, HDL 29, TG 112 # History of gastrointestinal bleed: - Duodenal, jejunal, and gastric AVMs s/p thermal therapy - diverticulosis throughout colon # Chronic pancreatitis # ? Hepatitis C, positive HCV Ab in [10/2150], subsequently negative x 2 [4-/2154], [5-/2154] # GERD # Gout s/p arthroscopy with medial meniscectomy [5-/2149] # Depression s/p multiple hospitalizations due to SI # Polysubstance abuse: crack cocaine, EtOH, tobacco - frequent bouts of chest pain following crack/cocaine use # Erectile dysfunction s/p inflatable penile prosthesis [5-/2148] Social History: He lives with a female partner in [Location (un) 686], MA. 42 pack-year smoking history, recently up to 6 cigarettes per day. He has a history of alcohol abuse, with DTs and detoxification, with last drink on [Holiday 1451]. History of crack cocaine use, with last use ~2 weeks ago. Family History: Father with alcoholism. Mother with type 2 diabetes, renal failure, died at age 58. Son with diabetes. Cousin with [Name2 (NI) 14165] cell disease. Physical Exam: On discharge: VSs: 98, 133/86, 93, 22, 96% 2L Finger sticks: 212, 238, 93 Gen: Well-appearing. NAD. scratching skin. Skin: Numerous macular lesions diffuse over the trunk and limbs. No apparent involvement of the palms. HEENT: PERRL. MMM CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, mildly distended. No rebound or guarding. Ext: Trace bilateral edema. Neuro: A&Ox3. Pertinent Results: CT head [2156-2-26]: FINDINGS: There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. Ventricular and sulcal size are unchanged. Other than a small mucus-retention cyst in the right maxillary sinus the paranasal sinuses remain well aerated as are the mastoid air cells. The 3.4 x 1.1-cm hyperdense mass overlying the right occipital bone is unchanged compared to [2152-4-29]. IMPRESSION: No intracranial hemorrhage or edema. CXR [2156-2-29]: Again seen is moderate cardiomegaly. The endotracheal tube has been removed and the NG tube has been removed. There is a moderate right effusion with associated right lower lobe volume loss. There continues to be pulmonary vascular redistribution with perihilar haze, however, this is improved in appearance compared to the film from three days ago. RUQ US [2156-3-1]: 1. No intra- or extra-hepatic bile duct dilatation. 2. No significant gallbladder disease with redemonstration of a tiny gallbladder polyp and likely adenomyomatosis. 3. Increased hepatic echogenicity suggest diffuse fatty infiltration although more advanced forms of liver disease such as fibrosis/cirrhosis cannot be excluded. [2156-2-25] 11:00PM BLOOD WBC-6.5 RBC-2.60* Hgb-8.0* Hct-24.9* MCV-96# MCH-30.7 MCHC-32.1 RDW-18.3* Plt Ct-254 [2156-3-2] 07:45AM BLOOD WBC-6.4 RBC-3.08* Hgb-9.2* Hct-28.4* MCV-92 MCH-29.9 MCHC-32.5 RDW-17.0* Plt Ct-235 [2156-2-25] 11:00PM BLOOD Neuts-74.7* Bands-0 Lymphs-16.6* Monos-6.2 Eos-1.9 Baso-0.5 [2156-2-27] 04:34AM BLOOD PT-15.0* PTT-27.6 INR(PT)-1.3* [2156-3-2] 07:45AM BLOOD Glucose-91 UreaN-58* Creat-6.9* Na-135 K-5.5* Cl-98 HCO3-24 AnGap-19 [2156-2-25] 11:00PM BLOOD Glucose-242* UreaN-40* Creat-5.3* Na-135 K-8.1* Cl-91* HCO3-29 AnGap-23* [2156-3-2] 07:45AM BLOOD ALT-30 AST-27 AlkPhos-262* Amylase-166* TotBili-1.0 [2156-2-29] 08:00AM BLOOD GGT-296* [2156-2-25] 11:00PM BLOOD CK(CPK)-172 [2156-2-26] 04:27AM BLOOD CK-MB-NotDone cTropnT-0.29* proBNP-[Numeric Identifier 35433]* [2156-3-1] 07:15AM BLOOD Albumin-3.6 Iron-74 [2156-2-29] 08:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.9 [2156-3-1] 07:15AM BLOOD calTIBC-328 Ferritn-535* TRF-252 [2156-2-26] 04:27AM BLOOD VitB12-1252* Folate-13.9 [2156-2-26] 12:07PM BLOOD Ammonia-32 [2156-2-26] 04:27AM BLOOD Osmolal-310 [2156-2-26] 04:27AM BLOOD TSH-3.8 [2156-2-25] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2156-2-26] 03:01AM BLOOD Lactate-3.9* RPR neg Blood cultures neg Brief Hospital Course: 59 y/o M with PMHX of ESRD, GI bleed, CAD and polysubstance abuse who presents with borderline hypotension, MS changes and GI bleed. # Hypotension: Suspected etiology most likely hypovolemia exacerbated by GI bleed, with further drop peri-intubation. Given lack of tachycardia, fever or leukocytosis, sepsis was considered unlikely. Pt remained in baseline Wenkebach with rate in 70s-80s, without any additional symptoms or episodes on telemetry, specifically no intermittent complete heart block. BP improved with volume resuscitation. # MS changes/Seizure?: Suspect that hypotension lead to hypoperfusion and MS changes. It is unclear if there was true seizure activity prior to intubation. CT head negative for acute IC pathology. TSH, RPR, folate, Vit B12 were all normal # GI bleed: Pt with long standing history of AVMs and GI bleeds. OG did not reveal any coffee grounds but frank red stool in vault. Hematocrit stabilized after 2 units of PRBCs, although with persistent maroon stools. Pt was treated with IV PPI, and evaluated by GI who did not feel a scope was necessary at the time. On discharge pt was still having guaiac positive stools but Hct remained stable at 28.4. # Resp Failure: Pt was mildly hypoxic on arrival and CXR showed vascular congestion. Ultimately, pt was intubated after possible seizure activity and decreased responsiveness with successful extubation on [2156-2-26]. # CAD: Cath in [9-21] showed no flow limiting disease. He presented with CP and new TWIs in V2-V6. However, CK/MBs flat and troponin close to baseline given ESRD. Low suspician for ACS but was monitored on telemetry. He was continued on a statin while ASA and BP meds held. These were restarted prior to discharge once BP had stabilized. Pt may be in decompensated heart failure but unclear given unusual presentation. # ESRD on HD: Pt was maintained on his usual HD regimen and tolerated all dialysis sessions well. # Diabetes: Pt was monitored QID and treated with humalog sliding scale. Medications on Admission: Labetalol 100 mg TID Amiodarone 200 mg daily Lisinopril 10 mg daily Atorvastatin 20 mg daily Cinacalcet 30 mg daily Pantoprazole 40 mg daily Sertraline 100 mg daily Multivitamin daily Gabapentin 300 mg q48hr DILT-XR 180 mg daily Diphenhydramine HCl 25 mg QID NPH 15units [Date Range ] & 10units qpm Insulin lispro Sevelamer 800mg TID Discharge Medications: 1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. [Date Range ]:56 Capsule(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Insulin Continue NPH 15units every morning and 10units every evening; also continue lispro as before. 4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:2 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:2 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day. 12. Labetalol 100 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. DILT-XR 180 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO every other day. Discharge Disposition: Home With Service Facility: [Hospital 119] [Hospital 2256] Discharge Diagnosis: Primary: Syncope, GI bleed Secondary: h/o GI bleeds, ESRD on [Hospital 13241]. Discharge Condition: Stable, Hct 28.4 Discharge Instructions: You were admitted for bloody bowel movements and syncope. The gastroenterology team evaluated you and decided there was no need to re-scope your colon, but recommended that you get a small bowel capsule study as an outpt. Your blood counts stabilized with transfusion. Please take all of your medications as prescribed and follow up with the [Hospital 4314] below. Please bring your prescription bottles to your appointment with Dr [First Name (STitle) 216]. If you develop fever/chills, fainting, blood in your stool or any other concerning symptoms, please contact your doctor or go to the emergency room. It was a pleasure taking care of you, we wish you the best! Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2156-3-3] 3:50 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2156-3-10] 1:40 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684] Completed by:[2156-3-3]	[ "41401" ]
Admission Date: [2114-8-18] Discharge Date: [2114-8-29] Date of Birth: [2041-7-1] Sex: M Service: SURGERY Allergies: Ciprofloxacin Attending:[First Name3 (LF) 2777] Chief Complaint: Acute ischemia of the right lower extremity. Major Surgical or Invasive Procedure: [8-19]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. [8-23]: PROCEDURES: 1. Exploration of medial calf and drainage of hematoma. 2. Right anterior and lateral fasciotomy [8-19]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. Temporary HD catheter placement History of Present Illness: 73 M presented to [Hospital1 ] with acute onset abdominal pain, nausea and vomiting x3 this afternoon. Pain resolved and at 1700 on day of admission had acute onset right foot pain. Pain was severe ache, with nothing relieving. No prior episodes. Pt has been treated for UTI over past few weeks. Reports feeling well prior to today. Tolerating good PO and urinating normally. +BM, non-bloody. He has had good BP control at home. Past Medical History: PMH: 1. prostate ca s/p seeds ([3-12]) 2. Chronic renal insufficiency (baseline unknown) 3. HTN 4. Hyperlipidemia 5. Gout 6. trauma to right leg, s/p knee surgery ([2075]'s) Social History: SH: retired truck driver, never smoked, no EtOH. Married with children Family History: FH: non contributory Physical Exam: PE: 97.5 F 86 130/68 18 96% 2L NC Gen: appears uncomfortable, A&Ox3 Cor: RRR Pulm: CTAB Abd: soft, nontender, nondistended. No bruit, no pulsatile mass LE: RLE (affected): cool at the level of the ankle, decreased sensation in foot. Motor decreased. Delayed cap refill. No tissue loss or wounds. Pulses: Fem [Doctor Last Name ] AT DP PT [Name (NI) 167] 2 2 dop dop dop Left 2 2 2 2 2 Temporary HD line Pertinent Results: [2114-8-29] 06:10AM BLOOD WBC-13.5* RBC-3.35* Hgb-9.6* Hct-29.6* MCV-89 MCH-28.7 MCHC-32.4 RDW-15.9* Plt Ct-635* [2114-8-29] 06:10AM BLOOD PT-20.7* PTT-51.1* INR(PT)-1.9* [2114-8-29] 06:10AM BLOOD Glucose-97 UreaN-41* Creat-3.5* Na-144 K-4.3 Cl-101 HCO3-32 AnGap-15 [2114-8-29] 06:10AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.8 [2114-8-23] 09:27AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-[7-11]* WBC-[4-5] Bacteri-MOD Yeast-NONE Epi-0-2 ORTABLE CHEST RADIOGRAPH, [2114-8-24] INDICATION: Line placement. FINDINGS: Right internal jugular catheter terminates in the mid superior vena cava. No visible pneumothorax, but extreme lung apices have been excluded from the study, precluding assessment for a very small pneumothorax. Heart size is normal. The aorta is tortuous. Minor areas of atelectasis are present in both lung bases. MRA: FINDINGS: There is extensive atheromatous disease seen in the thoracic and the abdominal aorta. There is extensive ulcerated plaque present in the lower thoracic as well as the upper abdominal aorta. The infrarenal abdominal aorta shows minimal eccentric plaque. The iliac vessels do not demonstrate significant plaque. There is atelectasis versus an infiltrate at the right lung base. The liver, gallbladder, spleen, adrenal glands appear unremarkable. The pancreas is atrophic. There are bilateral renal lesions that are incompletely assessed due to lack of intravenous contrast. Correlation with prior ultrasound and CT demonstrate that most of these are cysts. There is a 2.4 x 2.1 cm cystic lesion at the lower pole of the left kidney that has imaging characteristics suggestive of a hemorrhagic cyst and better documented on CT of [2114-8-18]. There is no abdominal pelvic lymphadenopathy. There is no free fluid in the abdomen or pelvis. There is colonic diverticulosis without evidence of diverticulitis. There is a well-circumscribed high T1 weighted, high T2 weighted lesion in the body of T11, likely representing a hemangioma. Multiplanar 2D and 3D reformations provided multiple perspectives of the imaging findings. IMPRESSION: 1. Extensive atherosclerosis in the thoracic and the abdominal aorta. Extensive ulcerated plaque is seen in the lower thoracic and the upper abdominal aorta. The iliac vessels do not demonstrate significant plaque. 2. Atelectasis/infiltrate at the right lung base. This can be further assessed with a chest radiograph. ECHO: Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal global and regional biventricular systolic function. RENAL US: FINDINGS: The right kidney measures 7.3 cm. The left kidney measures 10.4 cm. Multiple simple cysts identified within both kidneys. For example, in the right upper pole, there is a 2.3 x 1.8 x 1.7 cm simple cyst. In the lower pole of the right kidney, there is a 3.8 x 3.1 x 3.6 cm simple cyst. In the left kidney, there is a 4.4 x 2.9 x 3.9 cm simple cyst. No evidence of hydronephrosis, solid renal masses or calculi. IMPRESSION: Bilateral renal cysts. No evidence of hydronephrosis. Brief Hospital Course: Mr. [Known lastname 15052],[Known firstname 15053] was admitted on [8-18] with cold leg. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. To note on admission he has IV CKD. On admission creatine was 5. CT scan calcification of either mural thrombus or intimal flap at the level of renal arteries. As well as multiple hyperdense renal cysts. Renal did follow the patient during the hospital course. They are aware and will follow at rehab, for his nephrologist is associated with [Hospital1 ] and [Hospital1 18]. [8-19]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. Pt did receive multiple blood transfusions. To keep HCT around 30 for end stage renal disease. While in the VICU his CK's were elevated. He still c/o RLE pain. An US was done showed fluid collection. It was decided ed that he would undergo further intervention. [8-23]: OPERATION PROCEDURE: 1. Exploration of medial calf and drainage of hematoma. 2. Right anterior and lateral fasciotomy. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, he was transferred to floor status Pt also had both asterixis and myoclonus. A neurology consult was obtained. This was secondary to toxic and metabolic encephalopathy. On the floor, she remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. To note pt was being followed by his nephrologist. He was on verge of getting HD. A Renal Consult was obtained. He still makes urine. Because of his fragile status. A temporary HD catheter was placed. He did receive HD. This may not be permanent. Renal At [Hospital ] rehab will follow. The latest word is that he may not receive HD permanently. He may recover from ARF on CRI. If this is the case renal will remove temporary HD catheter, Medications on Admission: atenolol 50', norvasc 10', simvistatin 20', allopurinol 300' Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: INR goal is [3-6]. 7. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [2-2] amp D50 61-139 mg/dL 0 Units 0 Units 0 Units 0 Units 140-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-179 mg/dL 4 Units 4 Units 4 Units 4 Units 180-199 mg/dL 6 Units 6 Units 6 Units 6 Units 200-219 mg/dL 8 Units 8 Units 8 Units 8 Units 220-239 mg/dL 10 Units 10 Units 10 Units 10 Units 240-259 mg/dL 12 Units 12 Units 12 Units 12 Units 260-279 mg/dL 14 Units 14 Units 14 Units 14 Units 280-299 mg/dL 16 Units 16 Units 16 Units 16 Units > 300 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Location (un) ] Discharge Diagnosis: Acute ischemia of the right lower extremity CRI Temporary HD catheter PAD Thrombus Hypovlemia requiring blood products CRI, HTN, lipids, gout Discharge Condition: Stable Discharge Instructions: Incision Care: Keep clean and dry. -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. -If you have staples, they will be removed during at your follow up appointment. What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [3-6] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([11-15] lbs) until your follow up appointment. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2114-9-13] 1:45 RENAL WILL FOLLOW AT [Hospital ] REHAB IN [Location (un) ] Completed by:[2114-8-29]	[ "5845", "40390", "2724", "V5861" ]
Admission Date: [2187-1-15] Discharge Date: [2187-1-17] Date of Birth: [2120-5-31] Sex: M Service: CCU CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 104311] is a 66 year-old gentleman with a long standing history of diabetes, end stage renal disease and an extensive coronary artery disease who presents to the hospital with shortness of breath. He has been in his usual state of health until five days ago when he had acute onset of shortness of breath that progressively worsened. He denies any chest pain, fevers or chills, or any other associated symptoms. He is admitted to the [Hospital Unit Name 196] Service on [2187-1-15] and there is shortness of breath was improved with hemodialysis, but ruled in for a non Q wave myocardial infarction with a troponin if 13, normal CK. He went to the catheterization laboratory this afternoon for intervention. In the cardiac catheterization laboratory he was noted to have three vessel disease with occlusion of two saphenous vein, with occlusion of his venous graft, which is new from 8/[2184]. His EF was noted to be only 15%. This is his left ventricular ejection fraction. His left internal mammary coronary artery to left anterior descending coronary artery was patent with extensive collateral left and right. His left circumflex and right coronary artery were diffusely diseased. The left circumflex was difficult to intervene upon due to difficulty engaging the vessel, but ultimately received a stent. During the procedure the patient had several episodes of ventricular tachycardia that was responsive to cardiac massage on at least one instance. He was started on Dopamine drip at the cardiac catheterization laboratory at the end of the procedure for a systolic blood pressure in the low 80s. The patient arrived in the Coronary Care Unit hemodynamically stable, tachycardic to 110 and sedated. PAST MEDICAL HISTORY: 1. Diabetes type 2 insulin dependent. 2. End stage renal disease on hemodialysis, with placement of an AV fistula in the right forearm in [2186-6-11]. 3. Hypertension. 4. Coronary artery disease, status post myocardial infarction and coronary artery bypass graft in [2185-6-11], (left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery, saphenous vein graft to obtuse marginal) as well as implantation of an AICD in [2185-7-12] for syncope and runs of nonsustained ventricular tachycardia. 5. History of central line infection times two as described previously. 6. Cholecystectomy. 7. Appendectomy. 8. Status post left fourth metatarsal debridement in [2186-3-12]. MEDICATIONS: Zestril 20 mg Tuesdays, Thursdays, Saturday and Sunday. NPH sliding scale, Lipitor 5 mg po q.d., Lopresor 12.5 mg Tuesdays, Thursday, Saturday and Sunday. Nephrocaps one tab po q.d., Neurontin 200 mg po q.d., Phos-Lo three tabs po t.i.d., Renagel 800 mg po t.i.d., Avandia 8 mg po q.h.s., Quinine 325 mg q.h.s. and q noon on days of hemodialysis. Aspirin 325 mg q.d., Plavix 75 mg q.d. A heparin drip was started on the cardiac catheterization laboratory. Protonix 40 mg q.d. FAMILY HISTORY: Father had a cerebrovascular accident at the age of 69. He also had diabetes. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a less then one pack per day smoking history for at least thirty five years. He quit fifteen years ago. He denies any alcohol use. He is divorced. He lives with his mother. [Name (NI) ] is a retired salesman. PHYSICAL EXAMINATION: His blood pressure is 88/48 on 5 mg of Dopamine. Pulse 118. Respiratory rate 16. Sating 91% on 5 liters nasal cannula. In general, he was sedated. He appears comfortable. He is an obese elderly man. HEENT pupils are equal, round and reactive to light. Sclera anicteric. Oropharynx clear. Respiratory clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Abdomen soft and benign. Extremities good peripheral pulses. Right groin sheath in place. LABORATORY: White blood cell count 8.3, hematocrit 34.9, platelets 213. Chem 7 sodium 140, potassium 3.7, chloride 96, bicarb 27, BUN 52, creatinine 9.3, glucose 97, PT 13, PTT 33, INR 1.3. Arterial blood gas, pH was 7.50, PCO2 34, PAO2 was 84, CK 98, troponin 13.4, bilirubin 3.7, calcium 9.1, phos 4.9, mag 1.9, B-12 [2137]. Electrocardiogram revealed normal sinus rhythm at a rate of 114, first degree AV block, normal axis, right bundle branch block, lateral ST depressions. Chest x-ray revealed an interval increase in cardiac shadow with a small pleural effusion suggestive of congestive heart failure. No infiltrates were identified. PA pressures on catheterization were 45/30. His pulmonary capillary wedge pressure was 25 to 30. HOSPITAL COURSE: The patient did fine until early the next morning where he developed progressive shortness of breath. Arterial blood gases was obtained, which revealed that the patient was severely acidotic. A chem 7 later on revealed that ............... metabolic. As respiratory therapy was called to intubate the patient emergently, the patient became apneic and pulseless. His electroencephalogram tracing on the defibrillator revealed that the patient was in ventricular tachycardia, which transformed into ventricular fibrillation. A code was called and the patient was immediately defibrillated with no conversion from VF. CPR was initiated and the patient was given pharmacotherapy according to standard HCL protocol with no success in improving the patient's condition. After over thirty minutes of trying to aggressively resuscitate the patient he was pronounced dead at 7:00 a.m. on [2187-1-17]. The patient's family was notified and they declined an autopsy. CONDITION ON DISCHARGE: Deceased. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Type 2 diabetes. 3. End stage renal disease on hemodialysis. 4. Hypertension. [Name6 (MD) ] [Last Name (NamePattern4) 5467], M.D. [MD Number(1) 5468] Dictated By:[Last Name (NamePattern1) 7690] MEDQUIST36 D: [2187-1-26] 21:14 T: [2187-1-30] 13:13 JOB#: [Job Number ]	[ "41071", "4280", "41401" ]
Admission Date: [2146-8-12] Discharge Date: [2146-8-16] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: SOB and chest pressure Major Surgical or Invasive Procedure: Cardiac catheterization with cypher stenting of the proximal RCA History of Present Illness: Pt is an 80 y.o. female h/o HTN, NIDDM, hypercholeserolemia presented to BIDCM from [Hospital 1474] hospital ER where she originally presented with c/o of chest pressure and SOB. She developed SOB and chest pressure across her upper chest after walking into the grocery store from the parking lot. This occurred just prior to 10 AM. Shopped for 30 mins, went home, began to have ache in bilateral shoulders and was dripping in sweat. Denies N/V, lightheadedness, abd pain or syncope. Called 911, was given 4 Baby ASA en route to ER. At ER (10:37 AM) EKG showed [Street Address(2) 2051] elevation in leads II,III AVF. , depressions in I and AVL and TWI in V2-V3. She was immediately transferred to [Hospital1 18] (11:57) for cath. Prior to arrival she received ASA 325 mg, morphine 2 mg IVx2, NTG gtt that was dc'd in med flight shortly after it was started, heparin bolus and drip. Cath report: LMCA: no angiographically apparent CAD LAD: tortuous vessel with 30% stenosis in D1 Lcx: tortuous vessel with only mild luminal irregularities RCA: large ectatic vessel with thrombotic 95% lesion in the proximal vessel 105 contrast CO/CI: 6.87/3.51 PCWP mean 19 RA mean 13 AO: 156/66 PA: 44/26 RV: 44/9 Atropine b/c bradycardic post reperfusion, received integrilin, heparin, nitroprusside, plavix . Arrived on floor, plts were low so integrellin stopped. Plts stable throughout day. Past Medical History: PMH: CVA- [April 2146], holter after was negative, no hx of stress test, echo NIDDM dx [April 2146], high cholesterol bleeding gastric ulcer, last bleed [3-18] yrs ago primary biliary cirrhosis dx in 80s htn OA hip replacement bilateral knee replacement tonsillectomy ankle fracture d&C Social History: no smoking, minimal ETOH hx, no drugs lives alone, functional and still drives, one daughter lives close by Family History: non-contributory Physical Exam: VS T 96.0 BP 148/71 rr20 O2 98% Gen: pleasant 80 yo female, A&Ox3, nad HEENT: anicteric sclera, perioral skin appears darker than rest of face Neck: supple, 8 cm JVP, no carotid bruits Cardio: Reg rate, nl S1s2 Pulm: CTA bilaterally Abd: soft, nt, nd with +BS Ext: LLE cool, RLE warm with good pulse pressure bandage in place in right groin No edema Pertinent Results: [2146-8-12] 02:07PM BLOOD WBC-9.3 RBC-4.02* Hgb-12.5 Hct-36.8 MCV-91 MCH-31.1 MCHC-34.0 RDW-13.6 Plt Ct-110* [2146-8-13] 10:20PM BLOOD Hct-34.4* [2146-8-14] 06:35AM BLOOD WBC-12.3* RBC-4.14* Hgb-12.4 Hct-37.3 MCV-90 MCH-30.0 MCHC-33.2 RDW-13.6 Plt Ct-143* [2146-8-15] 06:55AM BLOOD WBC-7.1 RBC-3.69* Hgb-11.3* Hct-32.8* MCV-89 MCH-30.8 MCHC-34.6 RDW-13.2 Plt Ct-109* [2146-8-12] 02:05PM BLOOD Plt Ct-150 [2146-8-12] 02:07PM BLOOD Plt Ct-110* [2146-8-13] 03:24AM BLOOD Plt Ct-125* [2146-8-14] 06:35AM BLOOD Plt Ct-143* [2146-8-15] 06:55AM BLOOD Plt Ct-109* [2146-8-14] 06:35AM BLOOD PT-13.0 PTT-24.2 INR(PT)-1.1 [2146-8-15] 06:55AM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1 [2146-8-12] 02:07PM BLOOD Glucose-194* UreaN-18 Creat-0.9 Na-142 K-4.3 Cl-111* HCO3-21* AnGap-14 [2146-8-13] 10:20PM BLOOD Glucose-152* UreaN-17 Creat-1.1 Na-140 K-3.9 Cl-107 HCO3-25 AnGap-12 [2146-8-15] 06:55AM BLOOD Glucose-118* UreaN-16 Creat-1.1 Na-141 K-4.0 Cl-106 HCO3-25 AnGap-14 [2146-8-12] 02:07PM BLOOD ALT-2 AST-15 LD(LDH)-198 CK(CPK)-182* AlkPhos-32* Amylase-89 TotBili-0.4 [2146-8-12] 10:23PM BLOOD CK(CPK)-358* [2146-8-13] 03:24AM BLOOD CK(CPK)-285* [2146-8-12] 02:07PM BLOOD CK-MB-26* MB Indx-14.3* cTropnT-0.76* [2146-8-13] 03:24AM BLOOD CK-MB-43* MB Indx-15.1* cTropnT-2.51* [2146-8-12] 02:07PM BLOOD Albumin-1.8* Calcium-9.5 Phos-3.4 Mg-1.4* Cholest-134 [2146-8-15] 06:55AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.7 [2146-8-12] 02:07PM BLOOD HDL-47 CHOL/HD-2.9 LDLmeas-82 [2146-8-13] 03:24AM BLOOD Triglyc-140 HDL-40 CHOL/HD-3.2 LDLcalc-61 [2146-8-12] 12:37PM BLOOD Type-ART pO2-94 pCO2-50* pH-7.25* calHCO3-23 Base XS--5 Cardiac catherization: 1. Selective angiography of this right dominant system revealed single (1) vessel coronary artery disease. Specifically the proximal RCA demonstrated a 95-100% thrombotic occlusion with severe limitiation in flow distal to the occlusion. The left main demonstrated no angiographic evidence of any flow limiting disease. The LAD was a very tortuous vessel with a 30% stenosis in D1 - TIMI III flow throughout the vessel. The LCX demonstrated only mild luminal irregularities. 2. Limited resting hemodynamics demonstrated elevated right and mildly elevated left filling pressures (RA mean 13; RVEDP 15; PCWP 19. The cardiac output/index was 6.8/3.3 using the Fick method. 3. LV ventriculography was not performed. 4. Successful senting of the RCA with a 3.5 mm Cypher drug-eluting stent, which was post-dilated to 4.5 mm. Final angiography showed no residual stenosis, no dissection and normal flow (see PTCA comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful senting of the RCA. [2146-8-15] echocardiogram: 1. The left atrium is mildly dilated. A small secundum atrial septal defect (ASD) is present. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is moderately dilated. 5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trace mitral regurgitation seen. 7.The estimated pulmonary artery systolic pressure is normal. 8. There is no pericardial effusion. Brief Hospital Course: 80 yo female with h/o HTN, hyperlipidemia and NIDDM s/p IMI with stent to proximal RCA . 1. ST elevation inferior MI s/p cypher stenting proximal RCA: Pt had IMI enzymes trended down but had some residual ST elevation persisting post cypher stent placement in proximal RCA. Post-cath course was otherwise uncomplicated and patient received aspirin, plavix, metoprolol, and integrilin drip, which was discontinued as platelets dropped. An ACE-I was not started at admission as her creatinine had been slightly increased and it was unclear whether or not there was a contraindication from past use. Her PCP was [Name (NI) 653] and said that this could be started as her creatinine was stable at 1.1 and she did not have problems with this in the past. She was started on lisinopril 5 mg po qday on the day of discharge and will have her electrolytes checked within the next few days by her PCP or at rehab. She was told to stop he aldactone and continue plavix, aspirin, lipitor (now at 80 mg) and metoprolol. Her echocardiogram on the day before discharge showed low normal EF (50-55%), mild symmetric LVH, estimated pulmonary artery pressurewas normal, 1+ AR, trace MR. She will follow up with her new cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 63953] 2 weeks. 2. Pump: Patient had no JVP or other evidence of fluid overload on exam. Her echocardiogram on day before discharge showed EF of 50-55%. She will continue the medications listed above and follow with her cardiologist on 2 weeks. . 3. Rhythm: Patient in NSR on day of discharge and had no events on telemetry. 4. Thrombocytopenia: Platelets have been low in the past and decreased to 110 which may have been secondary to integrilin or heparin which were discontinued. Platlets were 109 on day of discharge but there is no evidence of active bleeding. She will have her hematocrit and platelets re-checked in the next few days along with her electrolytes and these will be followed by her PCP on an outpatient basis. 5.HTN: Pt was on spirinolactone at home and pressures were elevated while in house. She was started on metoprolol, Norvasc and her spironolactone was discontinued. Her metoprolol was titrated up to 100 mg XL qday and she was started on lisinopril 5 mg q day on the day of discharge which she tolerated well. She will have her electrolytes checked in the next few days and will follow up with her PCP. 6. Diabetes: Patient recently dx with DM. She was on metformin at home which was discontinued on admission and she was put on an insulin sliding scale. Her glucose was well controlled while in house with finger sticks 110's-140's. She was discharged on metformin and will follow up with her PCP. . 7. Primary biliary cirrhosis: LFTs were checked b/c increasing lipitor dose. LFTs were normal except slightly elevated alk phos. She will continue her ursodiol at her current home dose at discharge. . 8. h/o bleeding ulcer: Treated [3-18] yrs ago, no episodes since or while in house and stools were guaiac negative. Hemtocrit stable. Is on prilosec at home and she will continue this at discharge and follow with her PCP. Medications on Admission: Metformin 100 mg po BID Glyburide Ursodiol 100 mg po BID (but patient thinks she may ahve written down the incorrect dose) Aldactone Prilosec OTC [Hospital1 ] ?? Ecotrin 325 mg Lipitor 10 mg po qday Discharge Disposition: Extended Care Facility: [Hospital3 ] Hospital - [Location (un) 701] Discharge Diagnosis: ST elevation inferior MI Discharge Condition: chest pain resolved, blood pressure stable Discharge Instructions: If you have chest pain, shortness of breath, dizziness, palpitations of any other concerning symptoms call you doctor or come to the emergency room. The following changes have been made to your medications: 1. Do NOT take your aldactone 2. Do NOT take you KLor 3. Your new medications for your blood pressure are: 1.lisinopril 5 mg once daily 2.Metoprolol XL 100 mg once daily 4. You may restart your metformin 500 mg twice a day when you are discharged from the hospital and make sure you check your fingersticks 4 time per day 5. You can restart your prilosec OTC 6. You can restart your Ursodiol 300 mg twice per day 7. Your lipitor dose has been increased from 10 mg to 80 mg once per day. 8. You have been started on Plavix 75 mg daily. It is important that you remember to take this medication each day. Followup Instructions: Please schedule an appointment with your primary doctor as soon as you are discharged from rehab. You will need to have your blood electrolytes checked in the next 3 days while you are at rehab as you have been started on a new blood pressue medicine(lisinopril). Please make an appointment with a cardiologist within the next 2 weeks. We recommend [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] of [Hospital1 1474] [Telephone/Fax (1) 3183].	[ "2875", "41401", "4019", "25000", "2720" ]
Admission Date: [2138-3-15] Discharge Date: [2138-3-21] Date of Birth: [2138-3-15] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [First Name8 (NamePattern2) ] [Known lastname ] delivered at 33-2/7 weeks gestation, birth weight [2105] grams, and was admitted to the Intensive Care Nursery for management of respiratory distress and prematurity. of delivery [2138-5-2]. Prenatal screens included blood type A positive, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B Strep unknown. The pregnancy was notable for elevated alpha fetoprotein with normal fetal survey. The pregnancy was otherwise uncomplicated until day of delivery when the mother presented with preterm labor at [Hospital6 1597]. She was [Country ]. Her labor progressed with delivery by cesarean section due to breech presentation. The infant emerged with spontaneous cry. Required free flow O2. Apgar scores were 8 and 9 at one and five minutes respectively. PHYSICAL EXAM ON ADMISSION: Weight [2105] grams (50th percentile), length 45.5 cm (50-75th percentile), head circumference 31 cm (50th percentile). In general noted for mild tachypnea, a nondysmorphic appearance. Anterior fontanel is soft, open, flat. Red reflex present bilaterally. Palate intact. Intermittent grunting and flaring. Intercostal retractions. Breath sounds crackly and slightly diminished. Heart rate regular without murmur. Normal pulses. Abdomen benign. No hepatosplenomegaly. Spine intact. Hips stable. Testes descended bilaterally. Neurologic examination: Age appropriate. HOSPITAL COURSE BY SYSTEMS: Respiratory: [Doctor Last Name ] had progressive respiratory distress following admission requiring intubation and one dose of Survanta. Maximum ventilator support pressures 20/5, rate of 25, 40% oxygen. Was extubated on day of life one to nasal cannula oxygen. Weaned to on room air on day of life four. Has remained on room air since with a respiratory rate from 30's-40's. He has had two brief episodes of apnea and bradycardia not requiring any treatment. Cardiovascular: Has remained hemodynamically stable since birth. No murmur. Heart rates in the 130's-150's. Recent blood pressure 68/39 with a rate of 50. Fluids, electrolytes, and nutrition: Was initially NPO and maintained on D10W. Enteral feeds was started on day of life one and has advanced to full enteral feeds of 150 cc/kg/day with breast milk or Premature Enfamil 20kcal/oz by gavage, has taken one po feeding. Electrolytes done on day of life two showed a sodium of 143, potassium 5.1, chloride 108, CO2 18. He is voiding and stooling appropriately. Discharge weight 1785 grams. GI: Phototherapy was started on day of life three for a bilirubin of 11.4 total, direct 0.3. Has remained under phototherapy with a bilirubin on [2138-3-20] with a total of 9 and direct 0.4. Hematology: Hematocrit on admission 36.6%. Infectious Disease: Received ampicillin and gentamicin for 48 hours for a rule out sepsis course. Complete blood count on admission: White count 11.5 with 36 polys, several bands, 271,000 platelets. Neurology: Head ultrasound not indicated as is greater than 32 weeks gestation. Sensory: Needs hearing screening prior to discharge. CONDITION ON DISCHARGE: Stable six day old former 33-2/7 weeker. DISPOSITION: Transferred to [Hospital6 1597]. NAME OF PRIMARY PEDIATRICIAN: Primary pediatrician has not been identified yet. CARE AND RECOMMENDATIONS: 1. Feeds: Breast milk or PE20 at 150 cc/kg/day, consider adding HMF to breast milk, advance oral feeds as tolerated. 2. Medications: Is not receiving any medications at this time. Consider iron supplementation. 3. Car seat position screening has not been done and will need to be prior to discharge. 4. State Newborn Screen was sent on [2138-3-18]. 5. Immunizations received: Has not received any immunizations. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS SCHEDULE RECOMMENDED: Per [Hospital6 37588]. DISCHARGE DIAGNOSES: 1. AGA preterm male. 2. Respiratory distress syndrome resolved. 3. Resolving indirect hyperbilirubinemia. 4. Sepsis ruled out. 5. Apnea of prematurity. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) 36138] MEDQUIST36 D: [2138-3-21] 00:05 T: [2138-3-21] 06:22 JOB#: [Job Number 49443]	[ "7742", "V290" ]
Admission Date: [2152-11-8] Discharge Date: [2152-11-16] Date of Birth: [2087-2-19] Sex: F Service: NEUROLOGY Allergies: Latex / Soap/Povidone-Iodine Attending:[First Name3 (LF) 5018] Chief Complaint: Right hemiparesis, aphasia Major Surgical or Invasive Procedure: Intra-arterial tPA History of Present Illness: Patient is a 65 yo woman with PMH of HTN who arrived as a code stroke transferred from an OSH. Per her daughter, she was last ween well at 1600. Daughter then returned home at 1840 and found patient with some difficulty speaking and complaining that her right leg was giving out on her. She was, however, actually able to stand. She was taken to an OSH where she was found to have a dense left MCA sign. She was then transferred. Past Medical History: HTN Social History: 2 PPD tob. No ETOH. Family History: no FH of disease including MI or stroke. Physical Exam: Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Stroke Scale 14. Mental status: Awake and alert, cooperative with most of exam, flat affect. Follows some simple commands, but not complex. Inattentive. Neglects right field. Speech profoundly dysarthric. Cannot name. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Appears to have right field neglect, and does not blink to threat right. Eyes do not cross midline to right very well. Right facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Right arm flaccid. Antigravity strength in left arm/leg for 10 and 5 seconds respectively. Flaccid right arm paresis. Right leg is antigravity only for 1 second. Sensation: Difficult to assess sensation with patient's severe dysarthria and aphasia. Gait: not tested Romberg: not tested Pertinent Results: [2152-11-8] 09:35PM URINE HOURS-RANDOM [2152-11-8] 09:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2152-11-8] 09:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2152-11-8] 09:35PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2152-11-8] 09:35PM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [2152-11-8] 09:05PM GLUCOSE-124* UREA N-21* CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 [2152-11-8] 09:05PM estGFR-Using this [2152-11-8] 09:05PM ALT(SGPT)-26 AST(SGOT)-22 CK(CPK)-95 ALK PHOS-69 AMYLASE-76 TOT BILI-0.3 [2152-11-8] 09:05PM cTropnT-<0.01 (2 sets negative) [2152-11-8] 09:05PM CK-MB-NotDone [2152-11-8] 09:05PM CALCIUM-9.7 PHOSPHATE-2.9 MAGNESIUM-2.2 [2152-11-8] 09:05PM WBC-14.1* RBC-4.59 HGB-14.9 HCT-41.7 MCV-91 MCH-32.5* MCHC-35.7* RDW-13.8 [2152-11-8] 09:05PM NEUTS-75.5* LYMPHS-17.6* MONOS-3.7 EOS-2.7 BASOS-0.5 [2152-11-8] 09:05PM PLT COUNT-471* [2152-11-8] 09:05PM PT-11.1 PTT-21.7* INR(PT)-0.9 [2152-11-9] Lactate 0.8 [2152-11-9] A1C: 5.9 [2152-11-9] Lipids: Chol 207, TG 273, HDL 63, LDL 89 [2152-11-10] ABG: pH 7.48/pCO2 30/pO2 72 [2152-11-10] CBC WBC 17.6, H/H 11.5/32.7, Plt 414 <br> STUDIES: CTA/CTP: CT-perfusion of the head/CTA head and neck; [2152-11-3] 8:49 pm: On non-contrast study, there is a hypodense left MCA representing occlusion from a M1 segment. There is slight decrease of the attenuation in the left basal ganglia. There is no evidence of acute intracranial hemorrhage or mass effect or shift of normally midline structures. On CT angiography, there is a left ICA occlusion involving almost entire length from bifurcation. There is heavily calcified atherosclerotic plaque at the bilateral bifurcations. The right ICA is narrowed approximately 60% just above the bifurcation. There is an abrupt cut-off of left MCA at the origin of M1 segment, consistent thrombus. All M2 branches are opacified. The rest of the intracranial vessels are unremarkable. On perfusion study, there is an increase of mean transit time in the left MCA territory with slight decrease of blood volume and the flow, suggesting the possibility of reversibility of ischemia except in basal ganglia region. IMPRESSION: 1. Acute left MCA occlusion from M1 segment . Perfusion study suggests the possibility of reversibility of ischemia. 2. Diffuse atherosclerotic disease with plaques and narrowing at bilateral carotid bifurcation. Complete occlusion of left ICA. 3. Severe emphysema. <br> NCHCT [2152-11-8] 12:19 am: The patient is status post tPA and angiogram. Hyperdensity along the falx and layering over the tentorium may reflect prior contrast administration. New 1.9 x 0.6 cm hyperdensity in the left basal ganglia may represent hemorrhage or enhancment status post angiography. There is no shift of the normally midline structures or hydrocephalus. An air fluid level in the left maxillary sinus and opacification of the nasal cavity is likely secondary to intubation. IMPRESSION: New 1.9 x 0.6 cm hyperdensity in the left basal ganglia representing contrast enhancement vs hemorrhage. Interval follow-up is warranted. <br> HEAD CT WITHOUT CONTRAST [2152-11-9] 8:13 am: Comparison was made with a prior head CT dated [11-9] and 19, [2151]. Previously noted high attenuation in the left basal ganglia is less conspicuous and more ill-defined compared to the prior study, with persistent vague areas of high attenuation without significant mass effect or shift of normally midline structure. There is no other area of hemorrhage. The [Doctor Last Name 352]-white differentiation is preserved on nonconrast CT. The appearance of the ventricles are unchanged and it is symmetric without hydrocephalus. There is mild bifrontal cortical atrophy. There is mild mucosal thickening in bilateral maxillary and ethmoid sinuses. Frontal sinuses are not pneumatized. The surrounding osseous structures are unremarkable. IMPRESSION: Less conspicuous and more ill-defined appearance of left basal ganglia high density compared to the study 8 hours ago, likely representing diliuting IV contrast in the area of infarct, rather than hemorrhage. MRI will help to further evaluate the finding. <br> Cerebral angiogram [2152-11-8]: IMPRESSION: [Known firstname ] [Known lastname 8389] underwent emergent stenting of a left internal carotid artery and mechanical chemical thrombolysis of left MCA with complete recanalization. <br> EKG [2152-11-8]: Baseline artifact. Sinus rhythm. Inferior ST segment depressions. No previous tracing available for comparison. <br> TTE [2152-11-9]: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Left ventricular systolic function is hyperdynamic (EF>75%) and the estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism seen. Hyperdynamic left ventricular systolic function. No significant valvular disease seen. <br> CXR [2152-11-9]: The ET tube tip is 4 cm above the carina. The NG tube tip passes below the diaphragm most likely terminating in the stomach. The cardiomediastinal silhouette is unremarkable. Marked perihilar opacities are demonstrated which may represent volume overload/mild pulmonary edema. There is no pneumothorax. Brief Hospital Course: On initial examination in the ED, the patient had an NIHSS of 16, and an exam notable for right hemiparesis of arm, leg, aphasia and neglect. CTA showed abrupt cut off of the left MCA M1 segment. There was some distal collateral flow. In addition nearly whole of left internal carotid artery is occluded. The etiology of her stroke appeared to be embolic on top of the local left carotid artery stenosis. IV thrombolysis was not considered as she was outside the window for IV TPA. She was still an IA TPA candidate. Family and the patient was informed of the diagnosis and the risks and benefits of IA intervention. Patient and family consented to the procedure. She reached the angio suite at 10.00 pm. During the procedure, angiogram showed nearly occluded left internal carotid artery. It was first traversed with the wire and then stented. Then left MCA was found to be occluded. Intra-arterial tpa at 6 mg was given in the left MCA which dissolved the clot. At the conclusion of the procedure, both left internal carotid artery and left MCA were patent. After the procedure she was taken for repeat CT head which showed minimal hyperdensity in the left basal ganglia region which likely represented contrast extavasation. She was subsequently admitted to the neurologic ICU for closer evaluation (frequent neurologic checks) and management. She was intubated for the angiogram and stenting and was kept intubated overnight. She was on a nipride drip after the procedure, but this was discontinued in an effort to allow her blood pressure to autoregulate. The was somewhat agitated on the ventilator and require propofol with some additional fentanyl. When the propofol was held, her examination at ~ 8 am on [2152-11-9] was notable for somnolence, eye opening to voice, equally round and reactive pupils, leftward conjugate eye deviation, and right hemiplegia (only occ spontaneous trace movement in right arm). A repeat head CT in the morning showed a resolving area of intensity in the left basal ganglia, likely resolving extravasated contrast in the infarcted territory. There was also extention of the infarct involving the left temporo-parietal region (not noted on radiology read). An ECHO to evaluate for thromboembolism revealed a hyperdynamic ventricle (EF 75%) and no thrombus. Given the stenting, the patient was started on aspirin and plavix; lipitor was started with LDL 89, HDL 63, and triglycerides 273. A1C was within normal limits. Her Hct dropped from an initial value of 41.7 on admission, and stabilized to the 30-33 range. Her angio site in her groin is stable without evidence of active bleeding. The patient was successfully extubated in the afternoon of [2152-11-9] without significant difficulty. She was started started on the nicotine patch on admission and prn neb treatments after extubation given her notable smoking history. The patient was treated with ciprofloxacin and subsequently ceftriaxone for a UTI by U/A (culture + E. coli); this was also continued for pneumonia, given perihilar infilatrates on CXR, leukocytosis, and low grade fever. Blood cultures were pending. She completed a 7-day course. The patient was initially kept npo (on IVF), and tube feeds were started on [2152-11-9]. She failed a swallowing evaluation on [2152-11-10] with the recommendation to continue the patient as npo, with all intake through the NG tube. She passed a subsequent evaluation; see instructions for her approved diet. She also had a vaginal prolapse. Ob-Gyn was consulted and recommended 3 weeks of estrogen cream per vagina. She will follow-up with them in about 3 months. Medications on Admission: None Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed. 11. Conjugated Estrogens 0.625 mg/g Cream Sig: One (1) gram Vaginal DAILY (Daily) for 3 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary: 1. Cerebral infarct (Stroke) of left MCA territory Secondary: 1. Hyperlipidemia 2. Hypertension Discharge Condition: Neurologically stable. She has a Broca aphasia and a dense right hemiplegia, with movement of her right toes. Otherwise intact. Discharge Instructions: You were evaluated for weakness and inability to speak, and were found to have had a stroke. You were treated with intra-arterial tPA and were started on Aspirin, Plavix, Lipitor, and Metoprolol to help prevent a second stroke. Please take all medications as directed and keep all follow-up appointments. If you should develop new weakness, sensory loss, double vision, dizziness, or any other symptom that is concerning to you, please call your neurologist or go to the nearest hospital emergency department. Followup Instructions: [Hospital ] CLINIC: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2153-1-2] 1:30 You will be contact[Name (NI) ] with an appointment in the [Hospital 2663] clinic ([Telephone/Fax (1) 2664]). [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2152-11-16]	[ "486", "5990", "2724", "4019", "3051" ]
Admission Date: [2140-1-29] Discharge Date: [2140-2-4] Date of Birth: [2085-2-5] Sex: F Service: MEDICINE Allergies: Adhesive Tape / Ativan Attending:[First Name3 (LF) 2009] Chief Complaint: s/p cardiac arrest, ? need for plasmapheresis Major Surgical or Invasive Procedure: [1-31] Laryngoscopy. [2-1] Flexible bronchoscopy with secretion aspiration. [2-2] Rigid bronchoscopy and button-on tracheostomy placement. History of Present Illness: This is a 54 yo female with history of myasthenia [Last Name (un) 2902], tracheomalacia s/p Y stent placement, history of multiple admissions for respiratory failure presents from OSH s/p cardiac arrest. She was in her usual state of health until about 2 days prior to her presentation at OSH, when she began to have SOB associated with greenish brownish sputum. On [2140-1-22], she activated EMS. Upon EMS arrival, she was apparently noted to be in PEA arrest. Received CPR, epinephrine, atropine and had LMA placed. In ED at OSH, had LMA tube exchanged for ETT. ETT then noted to be placed outside of Y stent. Bronchoscopy performed and ETT replaced over stent and secretions removed. X-rays thought to be consistent with bilateral infiltrates c/w ARDS. She was treated with vancomycin and zosyn for pneumonia, apparently required pressors briefly. Culture data negative. She was extubated today on the day of transfer without event. Pt was also noted to have new global CM with EF 20%, thought to be seconadry to sepsis per OSH cardiology c/s and started on ASA, lisinopril. Currently denies SOB, chest pain, palpitations. She does not recall the events leading up to her hospitalization. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: --myasthenia [Last Name (un) 2902] (+MUSK Ab): dx [4-29], treated with pyridostigmine, prednisone, cellcept, IVIG, plasmapheresis; difficult fibroscopic intubation, unable to tolerate BiPAP. --tracheomalacia s/p flexible and rigid bronchoscopy with stent placement on [2139-5-7], Y stent replacement [2139-10-15] --sinus tachycardia when awake or anxious, thought [1-25] to autonomic instability from myasthenia [Last Name (un) 2902] --DMII, diet controlled, on ISS while on steroids --anxiety --GERD --obesity --anxiety --s/p cholecystectomy, appendectomy, tonsillectomy --nephrolithiasis Social History: No smoking, etoh, illicit drug use. Lives alone. Does not use home O2 since she has a gas stove, feels uncomfortable with BiPAP. used to work as a case manager. Family History: father with CAD and DM, brother with bronchitis, no family hx of myasthenia [Last Name (un) 2902], autoimmune disease. Physical Exam: VS: 96.8 96/40 80 20 99% 2L Gen: NAD, not using accessory muscles to breathe HEENT: PERRL, sclera anicteric, MMM, O/P clear Neck: No LAD Cor: RRR nl s1 s2 no m/r/g Pulm: rhonchorous bronchial sounds diffusely Abd: obese, soft, NT ND Ext: +DP and PT pulses b/l Neuro: alert, oriented x 3. mild eyelid droop, CN otherwise in tact,5/5 strength upper and lower extremities. [4-26] neck extension and flexion. Pertinent Results: [2140-1-30] 01:26AM BLOOD WBC-5.9# RBC-3.83# Hgb-10.5 Hct-32.5# MCV-85 MCH-27.5 MCHC-32.4 RDW-20.4 Plt Ct-156# [2140-1-31] 07:20AM BLOOD WBC-5.9 RBC-4.11* Hgb-11.4* Hct-34.3* MCV-83 MCH-27.6 MCHC-33.1 RDW-19.5* Plt Ct-160 [2140-2-2] 07:05AM BLOOD WBC-6.6 RBC-4.00* Hgb-11.5* Hct-33.6* MCV-84 MCH-28.7 MCHC-34.2 RDW-19.8* Plt Ct-308# [2140-2-3] 06:45AM BLOOD WBC-5.4 RBC-4.09* Hgb-11.2* Hct-34.2* MCV-84 MCH-27.4 MCHC-32.7 RDW-19.9* Plt Ct-411 [2140-2-4] 08:05AM BLOOD WBC-5.8 RBC-3.80* Hgb-10.6* Hct-32.0* MCV-84 MCH-28.0 MCHC-33.3 RDW-19.0* Plt Ct-296 [2140-1-30] 01:26AM BLOOD PT-13.3 PTT-30.4 INR(PT)-1.1 [2140-1-31] 07:20AM BLOOD PT-13.1 PTT-30.9 INR(PT)-1.1 [2140-1-30] 01:26AM BLOOD Glucose-44* UreaN-19 Creat-0.5 Na-140 K-3.5 Cl-100 HCO3-32 AnGap-12 [2140-1-31] 07:20AM BLOOD Glucose-104 UreaN-13 Creat-0.5 Na-142 K-3.3 Cl-104 HCO3-33* AnGap-8 [2140-2-2] 07:05AM BLOOD Glucose-121* UreaN-16 Creat-0.6 Na-141 K-4.3 Cl-101 HCO3-32 AnGap-12 [2140-2-3] 06:45AM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-139 K-4.3 Cl-98 HCO3-34* AnGap-11 [2140-2-4] 08:05AM BLOOD Glucose-102 UreaN-12 Creat-0.7 Na-139 K-4.0 Cl-101 HCO3-32 AnGap-10 [2140-1-30] 01:26AM BLOOD ALT-37 AST-22 AlkPhos-57 TotBili-0.4 [2140-1-30] 01:26AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1 [2140-1-31] 07:20AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.9 [2140-2-3] 06:45AM BLOOD Cholest-149 [2140-2-3] 06:45AM BLOOD Triglyc-167* HDL-40 CHOL/HD-3.7 LDLcalc-76 [2140-1-30] 01:26AM BLOOD TSH-0.53 [2140-1-30] 01:26AM BLOOD Ferritn-37 . Imaging: . CXR [1-29]:FINDINGS: There is a right IJ catheter with tip in the superior vena cava. There is a orogastric tube, with tip in the stomach. Linear opacity is present at the left base, likely representing discoid atelectasis. Similar opacity is present at the right base. Otherwise, there is no gross infiltrate or effusion. There is no pneumothorax. IMPRESSION: Likely atelectasis as described above. Support lines and tubes as described above. . CXR [1-31]: FINDINGS: The subsegmental atelectatic changes do not appear differently compared to the prior study. A right CVL has been removed, and there is no PTX. I do not clearly see the Y-stent on this radiograph. However, I do note a narrowing of the trachea just above the carina overlying vertebral body interspace T4-5, a finding that was not apparent on the prior study. IMPRESSION: New apparent narrowing of the trachea just above the carina at the T4-5 interspace level. CT scan might be helpful in further evaluation. Status post line removal. No interval change in basilar atelectatic features. . CXR [2-2]: FINDINGS: AP single view obtained with patient in sitting semi-upright position is analyzed in direct comparison with a preceding similar study of [2140-1-31]. A metallic ring shape, approximately 1.5 cm diameter, structure has been placed in the trachea at the level of C7. There is no evidence of any pneumothorax or soft tissue emphysema in the lower neck area. Comparison with the preceding study, heart size is unchanged. There is no evidence of pulmonary vascular congestion. Plate atelectasis on left base without significant progression. Lateral pleural sinuses are free. No new parenchymal infiltrates. As on previous examination a simple radiograph does not clearly identify the previously mentioned Y-shaped tracheobronchial stent. A certain degree of narrowing is present as it was described before. IMPRESSION: No pneumothorax or any other significant changes status post bronchoscopy. . TTE [2-3]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (LVEF = 30-35 %). 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 estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate global hypokinesis (the septum may have relatively worse function). Mild mitral regurgitation. Compared with the prior study (images reviewed) of [2139-5-19], hypokinesis is now global and overall EF has decreased slightly. Brief Hospital Course: # Respiratory distress and cardiomyopathy s/p PEA arrest - initially transferred from OSH to [Hospital1 18] ICU on [1-29] after extubation and treatment of ARDS/sepsis with IV antibiotics. As clinical status had improved and CXRs were clear, IV abx were stopped. Echocardiogram at OSH showed global hypokinesis w/ EF 20-25%, decline from baseline EF 45% on echo in [4-/2139], and thought due to a septic state at the OSH. Repeat echocardiogram prior to discharge showed partial improvement to EF 30-35%. A TSH was checked and was normal. Patient was continued on home diuretic. No hemodynamic instability (sinus tachycardia discussed below) or breathing difficulties. . # Airway clearance: Evaluted by interventional pulmonology with significant mucous plugging cleared by bronchoscopy on [2-1], likely precipitant of PEA arrest on [1-22]. Pt underwent a button-hole tracheostomy placement on [2-2] for self-suctioning at home. Received mucomyst and saline nebs while hospitalized, however did not tolerate mucomyst due to taste/smell. Physical therapy evaluated and cleared patient. Teaching was provided concerning self-suctioning by respiratory therapy and interventional pulmonology. . # Myasthenia [Last Name (un) 2902] - on transfer to [Hospital1 18] ICU, evalauted by neurology service who found myasthenia to be well-controlled with no indications for plasmapheresis or IVIG. Remained clinically well with no diplopia or other CN palsies or overt muscle fatiguability and good NIF's while hospitalized. Stayed on her home regimen of azathioprine, prednisone, pyridostigmine. Bactrim prophylaxis had been initially held due to illness but was restarted prior to discharge. . # Throat soreness: Developed after extubation and noted by ENT to have viral pharyngitis, with pink/white papules and non-displacable plaques. Sent throat cx for strep, HSV, and other viruses. Started Nystatin, acyclovir, and fluconazole for possible candidal and HSV pharyngitis. Pain relief provided with visouc lidocaine. Throat cultures negative for strep and + for HSV. Fluconazole and acyclovir were continued on discharge for 7 day courses. . # s/p NSTEMI: Noted to have an NSTEMI on presentation to OSH in PEA arrrest ([1-22]), thought likely related to demand ischemia. Was started on aspirin 81 mg. Lipid profile was normal. . # Diarrhea: on [2-3], had multiple bouts of abdominal cramping followed by watery, non-bloody diarrhea, w/ resolution of cramping with bowel movement, with resolution by afternoon. No further bowel movements to test for C. diff. . # Sinus tachycardia: Long-standing sinus tachycardia thought due to autonomic instability from myasthenia [Last Name (un) 2902]. While hospitalized, HR ranged at baseline was 100's-110's with no symptoms/complaints. . # Diabetes mellitus, type II: Diet-controlled at home and placed on insulin sliding scale while hospitalized and on prednisone, with blood sugar's in 100's-200's. . # Asthma: Was well-controlled without symptoms/complaints and was continued on fluticasone nasal spray, ipratropium nebs. Albuterol nebs were not given due to baseline sinus tachycardia, and xopenex nebs were given instead. . # GERD: Was at baseline during stay, continued PPI treatment. Medications on Admission: Medications at time of transfer: ASA 325 Calcium carbonate 1250 TID Fluticasone 50 [Hospital1 ] Lasix 20 QD Hycosamine 0.125 Glargine 20 units QHS Atrovent 1 neb Lansoprazole 30 [Hospital1 ] Lisinopril 2.5 Ativan 2 q4H prn Mestinon 60 QID Morphine 2 mg q4H prn Mucinex 1200 mg Omeprazole 40 [Hospital1 ] Paroxetine 15 Zosyn Vancomycin Azathioprine 100 [Hospital1 ] Methylprednisolone 125 [Hospital1 ] Discharge Medications: 1. Portable suction machine with supplies Needs portable suctions for health care appointment for 6 hours/week Dx: Myasthenia [Last Name (un) 2902], tracheobronchomalacia Medicaid ID# [Telephone/Fax (3) 78745] 2. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: On Sunday. Tablet(s) 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO five times a day for 5 days. Disp:25 Tablet(s) Refills:0 4. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours for 5 days. Disp:5 Tablet(s) Refills:0 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day. Disp:60 Tab, Multiphasic Release 12 hr(s) Refills:2 7. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO 3x/week on MWF. Disp:90 Tablet(s) Refills:2 8. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane QID (4 times a day) as needed for throat pain for 7 days. Disp:140 ML(s) Refills:0 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 7 days. Disp:140 ML(s) Refills:0 10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [12-25] Tablet, Sublinguals Sublingual QID (4 times a day) as needed. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 12. Paroxetine HCl 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q6H (every 6 hours). 17. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 19. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Myasthenia [Last Name (un) 2902]. PEA arrest. Respiratory distress. Tracheostomy placement. Discharge Condition: Stable with baseline vital signs. Able to ambulate without assistance. Discharge Instructions: You were transferred to the [Hospital3 ] [Hospital 1225] Medical Center for further management of your respiratory failure and myasthenia [Last Name (un) 2902] after cardiac arrest on [2140-1-22]. You came from another hospital after being extubated. While here, you were initially in the ICU and the antibiotics you were receiving were stopped, as your chest x-rays showed significant improvement, with no fluid or infection in the lungs. You were evaluated by the neurology service, who felt your myasthenia was well-controlled and did not recommend urgent plasmapheresis or IVIG treatment. You underwent laryngoscopy by the ENT service on [1-31], who felt you had a viral infection/inflammation of your throat. You also underwent bronchoscopy by the interventional pulmonology service on [2-1] with thick secretions cleared and had a new button-on tracheostomy placed on [2-2]. We continued giving you your medications for your myasthenia [Last Name (un) 2902]. For your throat soreness, we gave you medications to help numb the pain and treat possible viral and fungal infections. You should complete the full course of these medications, acyclovir and fluconazole, unless instructed to stop by your physician. [Name10 (NameIs) 6] ultrasound of your heart on [2-3] showed that you have gained back some of your pump function, though it has not yet completely normalized. It is important that you talk to your physician about getting [Name Initial (PRE) ] repeat echocardiogram in several months. . You should continue to do suctioning through your tracheostomy at home as you practiced in the hospital and continue to do saline nebulizer treatments at least 3 times daily. . If you experience increased cough or secretions, [Name Initial (PRE) 7186] of breath, wheezing, worsening or persistent sore throat, inability to swallow, neck pain, chest pain, nausea, vomiting, diarrhea or abdominal pain, or weakness, seek immediate medical attention. Followup Instructions: You have the following appointments scheduled with [Hospital1 18] providers, including plasmapheresis next week. . Provider: [Name10 (NameIs) 1248],BED FOUR [Name10 (NameIs) 1248] ROOMS Date/Time:[2140-2-9] 10:15 Provider: [Name10 (NameIs) 1248],BED THREE [Name10 (NameIs) 1248] ROOMS Date/Time:[2140-2-10] 10:15 Provider: [Name10 (NameIs) 1248],CHAIR FIVE [Name10 (NameIs) 1248] ROOMS Date/Time:[2140-2-11] 10:15 . You have an appointment with your neurologists, Dr. [Last Name (STitle) 557] and [Doctor Last Name 575] on [2-16] at 10am on the eighth floor of the [Hospital Ward Name 23] building. . On the same day as your neurology appointment, you have a follow-up appointment with the Ear Nose and Throat specialist, Dr. [Last Name (STitle) ] on [2-16] at 1:15om on the [Location (un) ] of the [Hospital Unit Name ] at [Last Name (NamePattern1) ]. . You have an appointment with your primary care doctor, Dr. [First Name (STitle) ], on [2140-2-18] at 4:00 pm. . You have an appointment with your interventional pulmonary physicians, [Year (4 digits) ]. [Last Name (STitle) ] and [Name5 (PTitle) ], on [2140-2-19] at 8:30 am.	[ "41071", "25000", "53081", "49390" ]
Admission Date: [2197-5-2] Discharge Date: [2197-5-12] Date of Birth: [2148-7-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Acute mental status change Major Surgical or Invasive Procedure: VP shunt placement History of Present Illness: 48 yo woman who has hx oligodendroglioma, thyroid dz, GERD, HTN, depression, urinary incontinence, who initially presented to the ED with altered mental status on [5-2]. Per ONC H and P, patient had had worsening new tremor for the past few weeks along with weakness in her legs. MRI of head done day of admission showed multiple intraparencymal masses in the right frontal/temporal lobes with vasculogenic edema, increased in size compared to [4-10]; with increased mass effect and shift; new hydrocephalus. There was also findings of leptomeningeal spread and new enchancing tumor in the (R) hypothalamus. . She was admitted to the ONC service where she was started on Decadron. An EEG was also obtained (per notes, negative). Neurosurgery saw the patient and recommended not attempting further debulking given advanced disease. Neurology also saw patient, agreed with poor prognosis, and concurred that the hydrocephalus was from the tumor entering the ventricles. They also noted (B) mild papilledema. On [5-6] the patient and VP shunt placed to palliate increased ICP. On [5-7] had 2 Head CTs; the second showed a 4.1 x 3.3 cm right frontal intraparenchymal hemorrhage with associated slight worsening in regional mass effect with shift of the falx approximately 6 mm to the left and effacement of the adjacent portion of the suprasellar cistern. This was thought to represent bleeding into the tumor. Later in the day, the Moonlighter was called for ?aniscicora. Neuro-ONC attending called, who recommended continuing with DMS and giving hydral for MAP of 123. . Had urgent repeat Head CT [5-8] showed large right frontal intraparenchymal hemorrhage measuring approximately 3.8 x 3.2 cm, unchanged in size compared to [2197-5-7]; however, the overall density of this region has increased suggesting ongoing hemorrhage. The amount of intraventricular blood in the right lateral ventricle has increased. Dilatation of the supratentorial ventricular system has increased. She was thus transferred to the [Hospital Unit Name 153] for frequent Neuro checks, mannitol, and close monitoring of her MAPs (goal 100-120). Of note, Nsurg saw patient this morning, tapped VP shunt, opening pressure 7-8 cm, "probably functioning well". . Currently the patient denies HA, N, V, or blurry vision but intermittently non-sensical speech. Past Medical History: -Brain tumor: Tumor hx: briefly, Ms. [Known lastname ] had presented in 6/98 with seizure (GTC) and was found on MRI to have R frontotemporal lesion; she underwent R temporal lobectomy in 7/98 and pathology revealed glioma. She underwent radiation in [9-1]. In [2193], she had apparent right hemifacial spasm that was improved with keppra, suggestive of seizure. She had new edema at that point in the right frontotemporal area and area of new enhancement ant/sup temporal lobe, R frontal. This was followed by MRI. In [8-23] she had re-biopsy of temporal lobe (incr swelling) and path revealed grade II oligodendroglioma; she received temodar in [2195], underwent resection again in [12-26], and has had several more courses of radiation. Most recently, she had been on PCV chemo and underwent more radiation in [2-23]. Her last brain MRI was [2197-4-10]. -Hypothyroid -GERD -HTN -Depression -Chronic urinary incontinence -G2P2 Social History: She does smoke 1 to 1-1/2 pack of cigarettes per day. She does not drink. Family History: n/c Physical Exam: T 98.4 HR 78 BP 143/84 RR21 93-95 RA General: laying in bed, (B) upper extremity tremor, confused HEENT: pupils equal in size but pt will not cooperate with penlight exam, EOM grossly intact Heart: RRR s MRG Lungs: CTAB Abdomen: 3-4 cm well-healed scar in RUQ; soft, NABS, NT/ND Ext: no edema Neuro: CN as above, Motor strength grossly intact, Alert to person, place (knows its [Hospital1 18]), year??, month = [Month (only) 547], President is [Hospital1 1806] Pertinent Results: brain MRI [5-2]: 1. Multiple intraparenchymal masses in right frontal and temporal lobes with vasculogenic edema, overall increased in size compared to the prior study, with increased mass effect and shift of normally midline structures. Increased size of ventricle, representing developing hydrocephalus, which may contribute to the patient's symptoms. Increased enhancement along the leptomeninges surrounding the brainstem, interpeduncular cistern and left temporal lobe, representing leptomeningeal spread. New enhancing tumor in the right hypothalamus. 2. MR angiography: No flow limiting stenosis. . CXR [5-2]: Lungs are low in volume, exaggerating heart size, which is probably top normal. Retrocardiac opacity seen on the lateral view is probably hiatus hernia. Lungs are otherwise clear. No pleural effusion or evidence of central adenopathy. . CT Head [5-2]: Overall, stable appearance of the tumor and edema in the right frontal lobe as compared to [2197-4-10]. Small amount of mass effect on the suprasellar cistern is also unchanged. . EEG [5-2]: no report in computer but per ONC notes, (-) . Head CT [5-7]: Interval placement of a VP shunt through a new craniotomy in the right frontal skull with tip terminating in the anterior [Doctor Last Name 534] of the left lateral ventricle. Otherwise, no significant change compared to prior study. Again seen are some foci of hyperdensity in the inferior aspect of right frontal lobe, possibly representing hemorrhage. . Head CT [5-7]: 4.1 x 3.3 cm right frontal intraparenchymal hemorrhage with associated slight worsening in regional mass effect with shift of the falx approximately 6 mm to the left and effacement of the adjacent portion of the suprasellar cistern. . KUB [5-7]: Supine frontal views of the chest and abdomen and lateral view of the abdomen are submitted. Intact shunt catheter traverses the chest and upper abdomen ending anteriorly above the level of the umbilicus. There is no evidence of intestinal obstruction or mass effect. . Head CT [5-8]: Increased dilatation of the supratentorial ventricular system and increased intraventricular blood compared to [2197-5-7]. The overall size and configuration of a right frontal intraparenchymal hemorrhage associated mass effect are unchanged; however, the increased density of this right frontal hematoma suggests continued hemorrhage. Brief Hospital Course: #ICH/dilation of Ventricular system: Patient was transferred to the [Hospital Unit Name 153] for close monitoring. She was continued on Mannitol, anti-seizure prophylaxis with lamictal, keppra, trileptal, and Decadron. She received Q2H neurochecks and she remained stable. She was followed by her neurooncologist, Dr. [Last Name (STitle) 4253]. Due to her poor prognosis, she was made comfort measures only (CMO) after a family meeting with her, her HCP, and her entire family on [2197-5-2]. A PICC line was placed by Interventional radiology because patient has very difficult access and requires multiple IV medications for her comfort. She was left on her antiseizure medications and Decadron per the family's request to prevent ongoing seizures, but otherwise all other medications except those intended to maximize the patient's comfort were discontinued. She was sent to a hospice facility on [2197-5-12] under the care of Dr. [Last Name (STitle) ]. . # Comm: [Name (NI) ], HCP: [Telephone/Fax (1) 56708] (cel), [Telephone/Fax (1) 56709] Medications on Admission: [Doctor First Name ] 180 mg Ditropan 5 mg Decadron prn with chemo only (none recently) Exelon - pt reports that she stopped taking this months ago Prilosec 40 mg [Hospital1 ] Felodipine 5 mg [Hospital1 ] Synthroid 150/137 alternating qod Lamictal 250 mg [Hospital1 ] Keppra 1500 mg [Hospital1 ] Trileptal 300 mg [Hospital1 ] Finished Zithromax for bronchitis in [Month (only) 116] Compazine PRN . Transfer MEDS DMS 8 mg IV q 8 [Doctor First Name ] 60 mg [Hospital1 ] Hydral prn SSI Lamotrigine 250 mg po bid T4 137 alt 150 qd Keppra 1500 mg po bid Mannitol 25 mg IV q 6 Oxybutynin 5 mg PO TID Oxcarbazepine 300 mg PO BID Percocet prn Pantoprazole 40 mg IV Q12 Felodipine 7.5 mg qd MS Contin 15 mg po bid Discharge Medications: 1. Dexamethasone Acetate 8 mg/mL Suspension Sig: Eight (8) mg Injection every eight (8) hours. 2. Morphine 10 mg/mL Solution Sig: 1-5 mg Intravenous every four (4) hours as needed for pain: Please administer as needed for comfort. 3. Phenytoin Sodium 50 mg/mL Solution Sig: 100mg Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [Hospital3 35813] Center - [Location (un) 37361], RI Discharge Diagnosis: Oligodendroglioma complicated by intracranial hemorrhage Discharge Condition: stable to be discharged to hospice Discharge Instructions: Please administer medications as below for comfort. Followup Instructions: Please contact facility doctor as needed [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "4019", "2449" ]
Admission Date: [2174-8-6] Discharge Date: [2174-8-19] Date of Birth: [2138-3-26] Sex: M Service: MEDICINE CHIEF COMPLAINT/IDENTIFICATION: This is a 36-year-old male, status post right cadaveric renal transplant, who was found unresponsive at home and was admitted with acute renal failure. PAST MEDICAL HISTORY: 1. Right cadaveric renal transplant in [2163] for hypoplastic kidney. 2. Laparoscopic cholecystectomy in [2174-2-24]. MEDICATIONS ON ADMISSION: Cyclosporin 100 mg p.o. q.d. Imuran 100 mg p.o. q.a.m. Prednisone 10 mg p.o. q.d. Isradipine 2.5 mg p.o. q.d. Zestril 10 mg p.o. h.s. Furosemide 20 mg p.o. q.d. Kayexalate 15 mg p.o. q.d. ALLERGIES: There were no known allergies. HISTORY OF PRESENT ILLNESS: The patient was found unresponsive at home by his mother. [Name (NI) ] was intubated by the EMTs and was transferred to [Hospital ] Hospital with hypotension and oliguria. He was started on dopamine, bicarbonate and Lasix drip without any improvement. CT scans of the head and abdomen with contrast were negative. The patient continued to have poor urine output and was subsequently changed to phenylephrine infusion. His initial BUN and creatinine at [Hospital ] Hospital were 87 and 8.4. His pH was 7.03 with a bicarbonate of 16. The patient had a known baseline BUN and creatinine of 41 and 2.2 in [2174-5-27]. [Hospital 12145] HOSPITAL COURSE: The patient was transferred to the medical intensive care unit at [Hospital1 188]. His white blood cell count at that time was noted to be 29,600 with 70% polymorphonuclear leukocytes and 6% bands. His hematocrit was 21.4 and he had a bicarbonate of 16 and a potassium of 5.2. He was also noted to have some diarrhea with guaiac positive stools. The patient was transfused with two units of packed red blood cells. There was some note of some coffee grounds from his nasogastric tube, which cleared with lavage. The patient also had some elevated liver function tests and CPKs. On chest x-ray, the patient was noted to have right upper lobe and right lower lobe opacities. A repeat CT scan of his abdomen was done following Quinton catheter insertion and an unexplained hematocrit drop. The CT scan was found to be negative. The patient was extubated on [2174-4-7] and was discontinued from his vasopressors and Lasix. He was treated with one unit of fresh frozen plasma and vitamin K on [2174-8-8] for coagulopathy of unknown etiology. His chest x-ray showed some improvement of his right sided opacities on that date. The patient was subsequently restarted on his cyclosporin. His prednisone was tapered from 50 mg to 10 mg. PHYSICAL EXAMINATION: At the time of the [Hospital 228] transfer to the medical floor, the patient was in no apparent distress and he was afebrile. His blood pressure was 130/60 with a heart rate of 70, a respiratory rate of 20 and an oxygen saturation of 98% on room air. On neurological examination, the patient was alert and oriented. His cardiovascular examination demonstrated normal heart sounds with no S3 or S4. He had a II/VI holosystolic murmur at the left sternal border radiating to his left second intercostal space. He did not have any peripheral edema and his peripheral pulses were palpable. On respiratory examination, his chest was clear to auscultation. The abdominal examination revealed bowel sounds that were present and a soft, slightly distended and nontender abdomen. MEDICAL FLOOR HOSPITAL COURSE: Sputum cultures and stool cultures from [2174-8-7] and [2174-8-8] were negative. On [2174-8-10], the patient was transferred out of the medical intensive care unit to the floor. On [2174-8-11], his BUN and creatinine remained unchanged despite receiving no dialysis. A left Quinton catheter was inserted and dialysis was initiated. He subsequently underwent a PermCath placement by the radiology department on [2174-8-12]. The patient was continued on a course of levofloxacin and Flagyl empirically for a community acquired/aspiration pneumonia. His antibiotics were continued for a two week course and were discontinued on the day of discharge. On [2174-8-11], the patient's cyclosporin was held and his Protonix was decreased to 40 mg once a day. An ultrasound of his renal transplant was done and that showed that his transplant to be without abnormality. His cyclosporin level was checked and it came back at 82. A hemolysis screen was done to rule out the possibility of thrombotic thrombocytopenic purpura, given his low hematocrit and low platelet count. This screen was normal and a peripheral smear demonstrated no schistocytes. On [2174-8-14], the patient's diarrhea resolved completely and he continued receiving dialysis. His urine output was improved. On [2174-8-16], the patient was restarted on his cyclosporin and stopped hemodialysis on [2174-8-17]. His urine output continued to improve and his creatinine continued to decrease without the dialysis. He was noted to have an increasing white blood cell count from 12,000 to 14,000 with no focus. His chest x-ray done at that time was clear and cultures that were done were normal thus far. On [2174-8-18], the patient had the right internal jugular PermCath removed. His hematocrit at that time was noted to be 22 and he was transfused one unit of blood. On [2174-8-19], the patient's trough cyclosporin level was 33 and his hematocrit increased approximately to 26 and his white blood cell count decreased to 11.6. CONDITION/DISPOSITION: The patient was discharged home on [2174-8-19] in stable condition. His cyclosporin dose was increased from 75 to 100 mg once a day. DISCHARGE MEDICATIONS: Cyclosporin 100 mg p.o. q.d. Imuran 100 mg p.o. q.d. Prednisone 10 mg p.o. q.d. TUMS 500 mg p.o. t.i.d. with meals. Nephrocaps one p.o. q.d. Protonix 40 mg p.o. q.d. Flagyl and levofloxacin were completed on the day of discharge. He had received a two week course of levofloxacin and a ten day course of Flagyl. FOLLOW UP: The patient was instructed to follow up with his primary nephrologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 28641] at [Hospital 882] Hospital. He had been instructed to follow up in the early portion of next week. DISCHARGE DIAGNOSES: Acute renal failure, likely secondary to acute tubular necrosis from an episode of hypotension that was likely precipitated by dehydration from diarrhea. DR.[Last Name (STitle) ],[First Name3 (LF) 177] A. 11-988 Dictated By:[Name8 (MD) 26201] MEDQUIST36 D: [2174-8-19] 12:42 T: [2174-8-19] 14:00 JOB#: [Job Number 28642] cc:[Numeric Identifier 28643]	[ "5849", "0389", "51881", "486", "4019" ]
Admission Date: [2128-3-22] Discharge Date: [2128-3-27] Date of Birth: [2064-9-7] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary Artery Bypass x 1 (LIMA-LAD) [2128-3-23] History of Present Illness: 63F with a history of CAD presented to [Hospital6 3105] with chest pain and ruled in for NSTEMI. She had a myocardial infarction with subsequent stent placement in [2121-8-16]. Cardiac cath revealed multi-vessel coronary artery disease and she is referred for surgical evaluation. Past Medical History: Coronary Artery Disease Myocardial Infarction s/p stent [2120] Dyslipidemia Social History: Lives with: husband Contact: Phone # Occupation: physical therapist at [Hospital1 1501] Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [x] [12-23] drinks/week [] >8 drinks/week [] Illicit drug use, denies Family History: Premature coronary artery disease Physical Exam: Pulse: 52 Resp:18 O2 sat: 99% B/P Right: 105/60 Left: Height: 64" Weight:150lbs Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] left cheek 1cm scab with mild surrounding erythema HEENT: PERRLA [x] EOMI [] 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 + [] Extremities: Warm [], well-perfused [] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:+2 Left:+2 DP Right: +2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right: +2 Left:cath site Carotid Bruit Right:none Left:None Pertinent Results: [2128-3-23] Intra-op Echo: Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results at time of surgery. POST-BYPASS: The patient is A paced. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. Tricuspid regurgitation is unchanged. The aorta is intact post-decannulation. . Brief Hospital Course: The patient was brought to the Operating Room on [2128-3-23] where the patient underwent CABG x 1 (LIMA-LAD) 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. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Plavix was resumed for her Diagonal stent. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued and patient had complaint of right sided chest discomfort. A right pneumothorax was noted on CXR and a right pigtail catheter was placed with evacuation of air. CXr showed rigthlung re-inflation. Pigtail was removed without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Plavix 75mg daily Aspirin 81mg daily Crestor 40mg daily Niacin 1000mg daily Folic acid 1mg daily fish oil 1000mg daily Multivitamin Calcium Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 13. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:28 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Coronary Artery Disease Myocardial Infarction s/p stent [2120] Dyslipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: generalized edema. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: WOUND CARE NURSE cardiac surgery Phone:[Telephone/Fax (1) 170] Date/Time:[2128-4-1] 10:45 at [Hospital ] medical office building [Doctor First Name ]. [Hospital Unit Name ] SURGEON [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2128-4-28] 1:15 at [Hospital ] medical office building [Doctor First Name ]. [Hospital Unit Name ] Cardiologist Dr.[Last Name (STitle) 4922]- his office will call you with in appointment to be seen in [12-19] weeks. Please call to schedule the following: Primary [First Name (STitle) ] [Telephone/Fax (1) 77368] in [2-19] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2128-3-27]	[ "41071", "41401", "412", "2724" ]
Admission Date: [2145-10-11] Discharge Date: [2145-10-11] Date of Birth: [2089-9-13] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11040] Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: none History of Present Illness: This is a 56 year old female with no known past medical history who called EMS today with dyspnea. In EMS she reported SOB and feeling as if she would die then had PEA arrest. CPR was initiated in ambulance and continued in Widden Emergency Room. Had an hour plus code there during which she got 9 epi, 3 atropine, 3 bicarb, heparin, and amio boluses. Also had emergent femoral line placement. Rhythm varied from AF, to PEA, to VT. She eventually got thrombolytics with return of spontaneous circulation. Went on to have CT head, which revealed no acute process before being transferred to [Hospital1 18]. Pt was cooled en route here. In ED initial VS 100 BP:104/56 O2 Sat :99% on vent. Planned to be cooled again but patient developed an additional two PEA arrests in the ED during which she received atropine/epinephrine/bicarb and atropine/epinephrine/dopamine respectively with CPR. Therefore current plan is to postpone cooling until after patient demonstrates an hour of stability. Of note, patient has had flaccid tone on all exams and fixed dilated patients. Family reportedly updated as to patient's grim neurological prognosis. ROS: Unobtainable as patient intubated, and unresponsive Past Medical History: -Morbid Obesity -Anemia -Chronic venostasis Meds (per recent [Hospital1 2025] discharge) -Omeprazole 40 mg PO daily -Flucinolone Cream -Ondansetron -Hydrocodone-APAP Social History: Nonsmoker. Attending RN school in NY but visiting family in [Location (un) 86]. No heavy alcohol or illicit drug use per recent [Hospital1 2025] discharge Family History: Unknown Physical Exam: VS: P 125, BP 107/72, RR 15, O2 Sat 100% (AC, 500, 15, 10, 100%) GEN: Intubated, sedated, no spontaneous movements HEENT: Pupils midline, fixed and dilated, anicteric, OP not assessible due to intubation. RESP: Coarse rhonchi bilaterally anteriorly, no wheezes appreciated CV: Difficult to appreciate over coarse breath sounds, tachycardic, no obvious murmurs ABD: Obese, soft, NT, ND, BS+, no organomegaly or masses EXT: 2+ woody edema in lower extremities bilaterally NEURO: No spontaneous movements, no response to voice, pain or painful stimuli, no withdrawal to pain, pupils fixed, dilated, and midline, no gag reflex. No clonus in LE's, no appreciable lower extremity DTR's. Pertinent Results: [2145-10-11] 03:49AM WBC-18.2* RBC-4.06* HGB-11.5* HCT-35.5* MCV-87 MCH-28.3 MCHC-32.4 RDW-14.7 [2145-10-11] 03:49AM PLT COUNT-210 [2145-10-11] 02:21AM GLUCOSE-211* LACTATE-6.1* NA+-143 K+-3.9 CL--105 TCO2-24 [2145-10-11] 02:17AM UREA N-11 CREAT-1.3* [2145-10-11] 02:17AM ALT(SGPT)-73* AST(SGOT)-180* CK(CPK)-1224* ALK PHOS-102 TOT BILI-0.7 [2145-10-11] 02:17AM LIPASE-26 [2145-10-11] 02:17AM CK-MB-46* MB INDX-3.8 cTropnT-1.17* [2145-10-11] 02:17AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2145-10-11] 02:17AM FIBRINOGE-103* [2145-10-11] 03:49AM CK-MB-86* MB INDX-3.5 cTropnT-2.19* [2145-10-11] 03:49AM ALT(SGPT)-79* AST(SGOT)-229* LD(LDH)-727* CK(CPK)-2434* ALK PHOS-103 TOT BILI-0.7 [2145-10-11] 03:59AM LACTATE-5.5* [2145-10-11] 03:59AM TYPE-[Last Name (un) ] PO2-48* PCO2-68* PH-7.22* TOTAL CO2-29 BASE XS--1 [2145-10-11] 06:31AM PTT-150* [2145-10-11] CXR The lungs are low in volume and show a retrocardiac opacity. The cardiac silhouette is enlarged. The mediastinal silhouette, hilar contours, and pleural surfaces are normal. No definite pleural effusions are present. The ET tube terminates 3 cm above the carina. IMPRESSION: Left lower lobe atelectasis. ET tube in appropriate position. [2145-10-11] CT head w/o contrast There is global loss of the sulci and effacement of the lateral ventricles with only the frontal horns of the lateral ventricles visible. This is consistent with global cerebral edema. No acute large vascular territory infarct, shift of midline structure or acute large hemorrhage is present. The paranasal sinuses and mastoid air cells show bilateral maxillary mucosal thickening. IMPRESSION: Global cerebral edema. [2145-10-11] CT chest w/o contrast The thyroid gland is unremarkable. There is no axillary or mediastinal lymphadenopathy. There is mild cardiomegaly. No pericardial effusion, anterior mediastinal hematoma or evidence of aortic injury is present. There is significant soft tissue injury in the anterior chest wall. The airways are patent down to the subsegmental level. The ET tube terminates 2 cm above the carina appropriately. There is right greater than left bibasilar atelectasis. Ground-glass opacities within both lungs could represent infection, pulmonary edema, or pulmonary hemorrhage. No large hematomas are seen in the soft tissues. Although this study was not tailored for subdiaphragmatic evaluation, ascites and an unremarkable liver are noted. OSSEOUS STRUCTURES: The visible osseous structures show no fractured ribs. There is a non-displaced incomplete fracture through the mid sternum. IMPRESSION: 1. Bilateral diffuse ground-glass opacities may represent edema, infection or pulmonary hemorrhage. 2. Diffuse soft tissue subcutaneous hemorrhage anteriorly. No well marginated hematoma. 3. Non displaced partial sternal fracture. 4. Bilateral lower lobe consolidations, aspiration cannot be ruled. Brief Hospital Course: 56 year old female with past medical history mostly notable for morbid obesity presenting with shortness of breath followed by PEA arrest requiring multiple rounds of CPR. The etiology of arrest remained unclear but given dyspnea preceding event, PEA, ? RBBB, and response to lytics PE seems more likely than any other cause. She was initially transferred to [Hospital1 18] for possible cooling via post arrest protocol. Given her instability and pressor requirement, full diagnostic evaluation with CTA chest was deferred and the patient was continued on empiric therapy with heparin gtt. Given dismal neurologic prognosis following prolonged ischemic time with CT head showing diffuse cerberal edema and GCS of 3 on exam, goals of care were readressed with family. The family decided to withdraw care and the patient was terminally extubated with discontinuation of pressor support. The family declined an autopsy. Medications on Admission: -Omeprazole 40 mg PO daily -Flucinolone Cream -Ondansetron -Hydrocodone-APAP Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: s/p cardiac arrest Discharge Condition: expired Discharge Instructions: N/A	[ "2859" ]
Admission Date: [2163-8-5] Discharge Date: [2163-8-9] Date of Birth: [2097-10-18] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 33596] Chief Complaint: lethargy Major Surgical or Invasive Procedure: CT abdomen/pelvis History of Present Illness: 65 yo woman with stage III cervical cancer s/p recent admission at [Hospital1 112] for urosepsis and s/p bilateral nephrostomy tubes and course of ceftriaxone, presents today from rehab after being noted to be disoriented, confused and lethargic with SBP in 90's. Sent to ED for eval. . On arrival here had SBP in 80's with HR in 80's which quickly improved with 2L NS to 120's SBP. And then ABG of 7.23/19/125/8 was done. . Discussion with longtime partner, fiance [First Name4 (NamePattern1) ] [Known lastname 4887], she has not been eating well for a long time and had had two weeks of diarrhea and some left sided abdominal pain. She had been herself until one day prior to admission when she became confused. . Here she says she feels cold, answers questions, but not appropriately, aware of her name and at [Hospital1 112] instead of [Hospital1 18], but not oriented to time. Discussed care with partner and sister and goal of care in terminially ill patient would not be to rescusitate or intubate patient as longterm prognosis is very poor. Past Medical History: -Stage IIIb cervical ca diagnosed in [3-15] s/p carboplatin, XRT and brachtherapy, initially diagnosed with hydroureter bilateral obstructions resulting in nephrostomies -urosepsis [1-12] to infected nephrostomy tubes in [7-15] s/p 2 weeks of cefotaxime for resistant e.coli in blood and urine -CRI last creatine 3.4 after hx of recurrent obsctruction -hx of MRSA in urine -FTT -anemia -hx of sacral decub Social History: currently lives at rehab but previously living with fiance who she has been with for 19 years, smoker, denies ETOH, retired factory worker Family History: sister w/ ? ovarian/uterine cancer Physical Exam: VS:T 97.2/99.6R BP 108/58 P 83 R14 Sat 100% on RA GEN: cachetic, ill-appearing HEENT: PERRL, dry MM, clear OP, supple neck, flat JVD CHEST: CTAB no wheezes, rales or rhonchi CV: regualr, tachycardic no murmurs ABD: soft tender diffusely, guarding, +BS, guiaic positive EXT: no edema, 2+DP pulses bialterally Pertinent Results: [2163-8-5] 10:37PM URINE COLOR-Pink APPEAR-Cloudy SP [Last Name (un) 155]-1.010 [2163-8-5] 10:37PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2163-8-5] 09:53PM GLUCOSE-127* UREA N-31* CREAT-2.9* SODIUM-139 POTASSIUM-5.1 CHLORIDE-119* TOTAL CO2-10* ANION GAP-15 [2163-8-5] 09:53PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.4* [2163-8-5] 09:53PM WBC-10.3 RBC-3.32* HGB-10.0* HCT-32.5* MCV-98 MCH-30.2 MCHC-30.8* RDW-16.2* [2163-8-5] 09:53PM PLT COUNT-234 [2163-8-5] 04:50PM URINE COLOR-Straw APPEAR-Cloudy SP [Last Name (un) 155]-1.010 [2163-8-5] 04:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2163-8-5] 04:50PM URINE RBC-21-50* WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0-2 [2163-8-5] 04:02PM TYPE-ART TEMP-37.2 PO2-125* PCO2-19* PH-7.23* TOTAL CO2-8* BASE XS--17 INTUBATED-NOT INTUBA [2163-8-5] 04:02PM K+-5.2 [2163-8-5] 03:00PM URINE HOURS-RANDOM [2163-8-5] 03:00PM URINE GR HOLD-HOLD [2163-8-5] 03:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.010 [2163-8-5] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2163-8-5] 03:00PM URINE RBC->50 WBC-21-50* BACTERIA-OCC YEAST-MANY EPI-0-2 [2163-8-5] 02:27PM LACTATE-1.9 [2163-8-5] 01:20PM GLUCOSE-200* UREA N-34* CREAT-3.0* SODIUM-138 POTASSIUM-5.2* CHLORIDE-114* TOTAL CO2-10* ANION GAP-19 [2163-8-5] 01:20PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-1.6 [2163-8-5] 01:20PM ASA-NEG [2163-8-5] 01:20PM WBC-11.5* RBC-3.47* HGB-10.5* HCT-34.8* MCV-100* MCH-30.3 MCHC-30.3* RDW-16.3* [2163-8-5] 01:20PM NEUTS-88.8* BANDS-0 LYMPHS-7.5* MONOS-3.0 EOS-0.6 BASOS-0.2 [2163-8-5] 01:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2163-8-5] 01:20PM PLT SMR-NORMAL PLT COUNT-271 CTAbd/pelvis: 1. Allowing for limitations of lack of intravenous contrast, oral contrast and distention, there is bowel wall thickening involving a long segment of the distal colon, which could be consistent with a colitis, most likely infectious. 2. Urine distended bladder with subtle bladder wall thickening and a tiny focus of air. The bladder wall thickening could be potentially due to chronic outflow obstruction from the large fibroids, which extend to the deep pelvis. Clinical correlation and history of instrumentation is advised given the focus of air. 3. Bilateral percutaneous nephrostomy tubes without evidence of hydronephrosis. 4. Findings most consistent with a left adrenal adenoma. Brief Hospital Course: 65 yo woman with stage III cervical ca s/p bilateral nephrostomy tubes and recent admission for urosepsis here with fever, lethargy # Urosepsis: Recent hx of resistant e.coli infection requiring admission to [Hospital 756] Hospital, s/p 14 days cefotaxime following change in one of her nephrostomy tubes due to obstruction on presentation. BP stable after IVF w/ no further HD compromise. UA on admission w/ >1000K wbc, moderate LE, and many bacteria. Cx only grew yeast. Patient has remained afebrile and WBC trending downward on aztreonam. Blood cx from [2163-8-5] are without growth to date. Plan to continue antibx through [2163-8-18]. . # Colitis: CT w/ bowel wall thickening and stool positive for c diff. Patient is toerating po flagyl and will continue this medication through [2163-9-1]. Her abdomen is tender but no rebound/guarding. Her diarrhea is much improved and she is tolerating po without vomiting. Of note, she completed her course of xrt on [2163-6-1]. There may be a component of radiation colitis as well. . # Stage III cervical ca: Discussed with patient's outpatient oncologist, Dr. [Last Name (STitle) ], from Farber re: tx plan. Patient is scheduled to follow-up with Dr. [Last Name (STitle) ] from [Hospital1 ] gynecologic oncology department. Palliative care was consulted and family is decided to pursue hospice care at the [Hospital ]. . # Pain: Patient offered prn dilaudid but rarely uses this medication. . # Depression: Patient continued on her remeron. . # FEN: Patient on house diet w/ boost tid. On marinol to stimulate her appetite. . # Metabolic acidosis: Both gap and non-gap acidosis on initial presentation. Non-gap likley related to her diarrhea/colitis at rehab prior to admission, and gap likey secondary to lactate from sepsis. There was likely also a componant of renal insufficiency in alkali losses. Aggressive bicarb repletion was given to help correct her acidosis, as with respiratory drive has CO2 down to 19 and did not want this to drop further. Her acidosis fully resolved on her 3rd hospital day. . # Proph: pneumoboots (heparin allergy) . # Code: DNR/DNI per discussion with sister [Name (NI) ] and confirmed with fiance [Doctor Last Name ] and brother. . # Communication: Fiance [Doctor Last Name ] [0-0-], sister [Name (NI) ] h:[Telephone/Fax (1) 62771] or c:[Telephone/Fax (1) 62772] . # Dispo: patient discharged back to [Hospital3 537] Medications on Admission: remeron 15mg qhs marinol KCL 20meq [Hospital1 ] D5 0.5NS kayopectate prn vitamin c dilaudid 2mg q6h prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed): to sacral decubitus ulcer. 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 23 days: through [2163-9-1]. 4. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 9 days: through [2163-8-18]. 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Last Name (un) ] Center - [Location (un) 701] Discharge Diagnosis: primary: clostridium difficile urinary tract infection secondary: stage IIIb cervical cancer sacral decubitus ulcer Discharge Condition: BP stable, tolerating po, abdominal exam stable, no vomiting, diarrhea improved Discharge Instructions: Please monitor for temperature > 101, hypotension, worsening abdominal pain, or other concerning symptoms. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ], your gynecologic oncologist at [Hospital 756] Hospital tomorrow, as scheduled. Please follow-up with your primary care doctor within 1 week for a check-up.	[ "0389", "5990", "2762" ]
Admission Date: [2168-8-19] Discharge Date: [2168-8-23] Date of Birth: [2098-12-1] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[First Name3 (LF) 2641] Chief Complaint: PE Major Surgical or Invasive Procedure: none History of Present Illness: 69M history of colon cancer, status post resection in [Month (only) 404], complains of progressive dyspnea on exertion since Monday and severe dyspnea at rest today, as well as a vague feeling of abdominal fullness. He presented to [Hospital3 5365] where they obtained a CT torso showing extensive bilateral pulmonary emboli with suggestion of RV strain, and questionable gallbladder wall thickening. He was started on a heparin bolus and drip and transferred to [Hospital1 18] because he receives his usual care here. Patient denied fever, chills, cough, chest pain, significant abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia. Regarding prior malignancy history a lesion was found on colonoscopy on [2167-11-23]. He had an abdominal CT to evaluate extent of the lesion and was found to have incidental pulmonary embolus which was treated with lovenox then bridged to coumadin until [5-/2168] when it was discontinued per PCP. . ED course: presenting vitals: 98.5 110 119/75 94% 4L NC. He was noted to be persistently tachycardic. FAST exam notable for RV strain. He was continued on the heparin drip. Labs notable for WBC 11.6, PTT 142, normal creatinine, BNP<5, trop 0.13, and ALT/AST 53/46. Right upper quadrant ultrasound showed some GB wall thickening and possible hemangioma 1.7cm. Admitted to MICU green for management of PE. Vitals prior to transfer: 108 115/70 99% 3L NC. Access: 20g R-ac, 20g-L-ac. . On the floor he confirms the above story and hx of prior PE, anticoagulation history and recent symptomatology. Pt denied abd pain or fullness and reported that breathing was somewhat improved. He also pt reports long car trip 2 weeks ago. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or hemoptysis. 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: Hypertension Diabetes Mellitus type 2 Psoriasis High grade dysplasia on colonoscopy s/p colectomy [12/2167] Social History: Patient lives with his wife. Retired from [Name (NI) 29723] Brothers. [Name (NI) 1139]: never ETOH: none Family History: No known history of cancer. Nephew has a hypercoaguable disorder. Physical Exam: Admission Physical Exam Vitals: t96.8 hr 110 bp 116/78 rr22 O296/3L NC General: Alert, oriented, male lying flat in bed no acute distress, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: mild dry rales b/l bases, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge physical exam: Vitals: T 96 BP 121/80 HR 72 RR 18 SO2 94% RA Unchanged from above, except: General: NAD, comfortable Lungs: CTAB Pertinent Results: TTE ([2168-8-20]) The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is >=15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. Apical function is preserved ([Last Name (un) 13367] sign). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet systolic A late systolic jet of mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Mild mitral valve prolapse with mild mitral regurgitation CXR ([2168-8-19]) FINDINGS: There are no old films available for comparison. The lung volumes are slightly low. There is a patchy area of volume loss at the left base which partially obscures the left hemidiaphragm that could represent small area of infiltrate versus volume loss. Otherwise, the lungs are clear. The heart is upper limits normal in size. There is no effusion. LENIs ([2168-8-20]) IMPRESSION: 1. In right lower extremity, occlusive thrombus extending from right calf veins to the common femoral vein at the level of the greater saphenous vein, though minimal surrounding flow is noted in the right popliteal vein. 2. Chronic partially occlusive thrombus within the left popliteal vein. LIVER OR GALLBLADDER US ([2168-8-19]) IMPRESSION: 1. Mild gallbladder distention and gallbladder wall edema without stones or sludge. These findings are nonspecific and may be related to third spacing or possible hepatitis. Acute acalculous cholecystitis is considered unlikely, however, if clinical suspicion for acalculous cholecystitis is high, a HIDA scan may be obtained for further evaluation. 2. 1.5 x 1.4 x 1.7 cm echogenic lesion in the right lobe of the liver, likely a hemangioma; however, due to patient's history of colon cancer, a metastatic lesion cannot be fully excluded. As a result, MRI is recommended for further evaluation. 3. Septated cyst visualized in the left lobe of the liver. MRSA SCREEN (Final [2168-8-22]): No MRSA isolated. Labs on admission Chem: Glucose-111* Na-141 K-4.5 Cl-107 calHCO3-21 UreaN-16 Creat-1.0 CBC: WBC-11.6* RBC-4.61 Hgb-15.1 Hct-41.6 MCV-90 Plt Ct-108# Neuts-83.5 Lymphs-11.5* Monos-3.6 Eos-0.7 Baso-0.7 Coags: PT-13.7* PTT-142.2* INR(PT)-1.2* LFTs: ALT-53* AST-46* AlkPhos-58 TotBili-0.5 Lipase-27 [2168-8-19] 12:48PM BLOOD cTropnT-0.13* proBNP-<5 [2168-8-20] 04:19AM BLOOD cTropnT-0.07* Labs on discharge Chem: Glucose-93 UreaN-14 Creat-1.0 Na-144 K-4.2 Cl-104 HCO3-31 CBC: WBC-7.0 RBC-4.78 Hgb-15.6 Hct-43.5 MCV-91 Plt Ct-126* Coags: PT-12.4 PTT-28.8 INR(PT)-1.0 Pending Labs Lupus-PND ACA IgG-PND ACA IgM-PND BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND Brief Hospital Course: 69y M hx of prior PE (off anticoag since [Month (only) ]), HTN, [Hospital 88414] transferred from OSH on heparin gtt for management. . # PE: OSH report suggests extensive thrombus b/l pulmonary arteries and each lobar branch with increased exertional dyspnea over past few days. Evidence of intraventricular septum flattening on CT chest report and on FAST u/s in ED with RV dysfunction. Chest xray showed low lung volumes, no consolidation, effusion or pneumothorax. He was switched from a heparin gtt to LMWH given normal renal fxn, body habitus and malignancy history. LENIs documented new RLE DVT; TTE confirmed RV dysfunction. Pt was transfered from the MICU to the general medicine floor on [2168-8-20]. On [2168-8-21] pt had HR to the 160s and was found to be in atrial fibrillation; pt. returned to sinus rhythym with HR in 120's after 5 mg IV metoprolol. Pt placed on standing metoprolol. He remained in sinus rhythym through the rest of his hospitalization. On [8-23] pt was satting well on RA. . # HTN: We held his home atenolol in the context of a PE; given the management of the atrial fibrillation episode outlined above, we continued to hold atenolol and placed him instead on metoprolol. . # NIDDM: We held home metformin and placed on a sliding scale. Blood sugars were well controlled throughout hospitalization. . # Liver lesion: Right upper quadrant ultrasound in ED showed some GB wall thickening and possible hemangioma 1.7cm with recommended f/u by MRI. Previous MRI abd w/ w/out contrast at [Location (un) 2274] ([2168-5-11]) identified a 15 mm lesion in segment 8 consistent with hemangioma. Per radiology, there is no need for outpatient MRI to evaluate this; he should continue imaging as recommended by his outpatient [Month/Day/Year 21339]. . TRANSITIONS IN CARE -will need to continue lovenox indefintiely -will need to consider metoprolol vs. atenolol -f/u on Lupus, beta-2-glycoprotein, and anti-cardiolipin antibodies. Medications on Admission: 1.atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Medications: 1. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 2. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours). Disp:60 syringe Refills:6 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS pulmonary embolism SECONDARY DIAGNOSIS atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 88415], It was a pleasure to take care of you during your stay at [Hospital 61] [Hospital 1225] Hospital. You presented to our emergency department with a known diagnosis of bilateral extensive pulmonary embolism. This was diagnosed at at [Hospital3 5365], where you came earlier that morning with dyspnea and had a CT scan showing pulmonary embolism, a blood clot in your lungs. We gave you extra oxygen to help you breath and enoxaparin to help dissolve your clot and prevent other clots from forming. You were admitted you to the medical intensive care unit for close monitoring. While at the medical intensive care unit, you remained hemodynamically stable, and the next day ([2168-8-20]) you were transferred to the general medical service. There, we found that your heart was beating irregularly (atrial fibrillation), which we treated by giving you the beta blocker metoprolol. By [2168-8-23], you were breathing comfortably without needing any additional oxygen, and your heart at returned to its normal rhythym. We also did an ultrasound which found that the source of the clot in your lungs was a clot in your legs. We sent several laboratory tests to help evaluate possible causes of the clot; you should follow up on these with your [Month/Day/Year 21339]. MEDICATIONS TO CONTINUE -all of your home medications EXCEPT atenolol MEDICATIONS TO START -enoxaparin 90 mg injection twice a day -metoprolol 12.5 mg twice a day by mouth MEDICATIONS TO STOP -atenolol Please follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 21339] as cheduled below. Followup Instructions: Name: [Last Name (un) ],ZULFIQAR A. MD Location: [Location (un) 2274]-[Hospital1 ] Address: [Location (un) 17467], [Hospital1 ],[Numeric Identifier 10727] Phone: [Telephone/Fax (1) 68410] When: [Last Name (LF) 2974], [2167-8-27]:40AM Name: [Last Name (LF) ], [Name8 (MD) ] MD Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3468] When: Tuesday, [9-13], 1:30PM Completed by:[2168-8-23]	[ "2875", "42731", "4019", "25000" ]
Admission Date: [2175-10-5] Discharge Date: [2175-10-20] Date of Birth: [2093-12-17] Sex: M Service: CARDIOTHORACIC Allergies: Spironolactone Attending:[First Name3 (LF) 1505] Chief Complaint: worsening DOE over the past 2 days Major Surgical or Invasive Procedure: Cardiac catheterization AVR(25m CE tissue) [10-16] History of Present Illness: 81 yo M with AS([Location (un) 109] 1.0, 68/40 mmHg as of [4-3],), hypertension, DM, CAD s/p multiple coronary interventions, A fib on amiodarone admitted with worsening DOE. The patient states that for the past 2-3 days he is unable to walk more than 200 feet without getting significantly short of breath. Prior to [12-31] days ago he could walk up to 400-500 feet with minimal shortness of breath. He describes a significant weight gain based upon his admission weight (up 32 lbs from his last weight measured several weeks ago on a different scale). He denies any new edema, orthopnea, PND, CP, SOB at rest, cough or productive sputum. He describes medication and low-salt dietary compliance. . ED: 97.6 53-55 150-160/50-70 20 97% 3L NC, 94% RA. The patient had one set of negative cardiac enzymes and was admitted for further work-up. . Past Medical History: AS ([Location (un) 109] 1.0, 68/40 mmHg as of [4-3]) Acxute on chronic diastolic heart failure CAD s/p multiple coronary interventions (PCI to LAD and RCA) A fib s/p successful DC CV [8-4] and [2169] Hypertension DM Spinal stenosis BPH Basal cell cancer, s/p resection Glaucoma Bilateral Cataracts, s/p lens replacements Social History: He lives alone. He does not smoke but has one glass of wine or beer per day. He is retired from the Navy as an airplane mechanic and then drove an automobile carrier till he retired in [2153]. Family History: Father deceased from MI at 66 Physical Exam: PHYSICAL EXAMINATION: 97.4 59 190/80 20 98% 2L FS 228 102.3kg Gen: Comfortable. NAD. HEENT: PERRL. JVP 10. CV: AS murmur. RRR. Pulm: Decreased breath sounds in the left lung base. Abd: Soft, nontender. Ext: No edema. Neuro: A&Ox3. Pertinent Results: CXR ([2175-10-5]): Small bilateral pleural effusions. No evidence of focal consolidation. . EKG ([2175-10-5]) NSR, rate of 54, normal axis and intervals. Downgoing T waves in V4-6. Unchanged from prior in [2-/2175] Brief Hospital Course: During work-up Mr. [Known lastname 19841] dyspnea on exertion, PFTs were performed secondary to amiodarone use. He underwent cardiac catheterization which showed no significant coronary disease and confirmed severe AS. Dental consult recommended that some teeth be extracted. He awaited decrease in INR and creatinine, and dental extractions which were performed on [10-12]. He was taken to the operating room on [10-16] where he underwent an AVR (tissue). He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was given 48 hours of perioperative vancomycin as prophylaxis given that he was in the hospital preoperatively. His pressors were weaned and he was transferred to the floor. Mr. [Known lastname 19841] wires and chest tubes were removed. By post-operative day four he was ready for discharge to home. Medications on Admission: Amio 200', Norvasc 7.5, ASA 81', Lipitor 10', DDAVP 0.2', Doxazosin 8', Finasteride 5', HCTZ 25', Benicar 40', NPH 19U qAM, NPH 22U qhs, Labetolol 400", MVI, Coum Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Desmopressin 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:0 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Nineteen (19) units Subcutaneous before breakfast. Disp:qs units Refills:0 11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Two (22) units Subcutaneous at bedtime. Disp:qs units Refills:0 12. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO daily (). Disp:60 Tablet(s) Refills:0 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 16. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Please take 1 pill (2.5mg) every TThSS and 2 pills (5mg) every MWF or as directed by the office of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 9486] . Disp:30 Tablet(s) Refills:20 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 18. Outpatient Lab Work INR to be drawn Sunday and sent to the office of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. phone [Telephone/Fax (1) 9486] fax [Telephone/Fax (1) 19842]. Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: severe AS now s/p AVR glaucoma, HTN, IDDM, CAD-s/p PCI to LAD, RCA [2164], Afib, CRI ( baseline creat. 1.3), BPH, anemia, Bell's palsy, T+A, s/p cataract surgery, skin ca Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Please see Dr. [Last Name (STitle) ] 4 weeks ([Telephone/Fax (1) 11763]. Already scheduled appointments: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name12 (NameIs) ] INTERNAL MEDICINE (NHB) Date/Time:[2175-11-29] 10:45 Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 902] Date/Time:[2175-11-30] 4:00 INR to be drawn Sunday and sent to the office of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. phone [Telephone/Fax (1) 9486] fax [Telephone/Fax (1) 19842]. Completed by:[2175-10-20]	[ "4241", "5849", "4280", "5859", "40390", "42731", "41401", "2724", "V5867" ]
Admission Date: [2186-7-27] Discharge Date: [2186-8-1] Date of Birth: [2141-6-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3853] Chief Complaint: "nausea and vomtting." Major Surgical or Invasive Procedure: Hemodialysis CVL placement History of Present Illness: . Mr. [Known lastname ] is a 45 yo M with IDDM c/b nephropathy and ESRD HD mwf, CABG x 4 and aflutter who presented with nausea and vomtting. Started to have nausea day PTA. Then, nausea persisted the following day, which was a dialysis day for him. He presented to HD with nausea and also fevers and chills x 1 day. At HD, c/o feeling fatigued/chills/unwellness. The outpatient renal team got blood cultures and the patient was given IV cefazolin. Still felt abnormal with N/V. They did not take much fluid off at HD. Went home, got called back for Group G strep + blood cultures and proteus (pansensitive). On arrival to the ED, hypotensive received 3 Liters IVF. Transfered to the MICU was started on Vanc/Zosyn and briefly required pressor support. Abx's were narrowed to CTX [2186-7-29]. TEE was perfromed which did not show vegetations. Upon transfer from the MICU, his vitals were 98.2, 90-100/50-70s, 60-80, 18, 98% RA. He was comfortable and voiced only that he was ready to go home. He would like to have abx dosed with HD so that he does not need an additional line. . ROS: Denies fever, chills, night sweats after admission to the hospital, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: # Stage V CKD d/t diabetic nephropathy, followed by Dr. [Last Name (STitle) 4883], last seen [2182-2-6], on renal replacement for 5 yrs # Congestive heart failure with an ejection fraction of 60-70% in [10-31], mod LVH, diastolic dysfunction. # Moderate pulmonary hypertension with significant pulmonic regurgitation and markedly dilated right atrium on [10-31] # Diabetes mellitus, type 2, insulin dependent, diagnosed [2171] complicated by diabetic neuropathy, retinopathy, nephropathy and vascular insufficiency, s/p toe amputation. # Hypertension. # Obesity. # Hypercholesterolemia. # History of sickle trait. # Acid reflux. # Secondary hyperparathyroidism # s/p L vitrectomy Social History: The patient lives with wife and two children. He is a chef. No tobacco or alcohol use. Cat, fish and parrot at home. Family History: Mother with diabetes Physical Exam: ADMISISON PHYSICAL EXAM: Vitals: 99.9, 65, 18, 79-90/32-41 99% 2l General: Alert, oriented, no acute distress, lying comfortably in bed. HEENT: Sclera anicteric, MM dry 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: rt foot has 2 cm ulcer on the plantar aspect. No erythema, but blackish area surrounding it. Minimal foul smell Access:Left bracio-basilic fistula, good bruit . DISCHARGE PHYSICAL EXAM: VS: Tm 97.9, BP 80-110s/60s, HR 70-80, RR 20, O2sat>96% RA General: Alert, oriented, no acute distress, lying comfortably in bed. HEENT: Sclera anicteric, MM dry 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: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: rt foot has 2 cm ulcer on the plantar aspect. No erythema, but blackish area Access: Left bracio-basilic fistula, good bruit Pertinent Results: ADMISSION LABS: [2186-7-27] 10:00AM BLOOD WBC-4.9 RBC-3.83* Hgb-13.4* Hct-39.9* MCV-104* MCH-35.0* MCHC-33.6 RDW-16.3* Plt Ct-139* [2186-7-27] 08:08PM BLOOD PT-14.3* PTT-28.8 INR(PT)-1.2* [2186-7-27] 10:00AM BLOOD Glucose-172* UreaN-26* Creat-6.9# Na-147 K-4.4 Cl-98 HCO3-36* AnGap-17 [2186-7-27] 08:08PM BLOOD ALT-7 AST-23 LD(LDH)-299* CK(CPK)-199 AlkPhos-95 TotBili-0.4 [2186-7-27] 08:08PM BLOOD CK-MB-2 cTropnT-0.16* [2186-7-28] 04:40AM BLOOD CK-MB-2 cTropnT-0.14* [2186-7-28] 04:40AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.6 [2186-7-28] 09:22AM BLOOD Vanco-7.0* [2186-7-27] 11:27AM BLOOD Lactate-3.0* . DISCHARGE LABS: [2186-7-31] 06:27AM BLOOD WBC-4.5 RBC-3.75* Hgb-12.9* Hct-38.7* MCV-103* MCH-34.3* MCHC-33.3 RDW-16.1* Plt Ct-144* [2186-7-31] 06:27AM BLOOD Glucose-117* UreaN-62* Creat-10.7# Na-140 K-4.8 Cl-96 HCO3-30 AnGap-19 [2186-7-31] 06:27AM BLOOD Calcium-9.1 Phos-5.1 Mg-2.4 [2186-7-28] 05:03AM BLOOD Lactate-1.0 . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP G \| PROTEUS MIRABILIS \| \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S PENICILLIN G---------- 0.06 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [2186-7-27]): Reported to and read back by DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] ON [2186-7-27] AT 0710. GRAM POSITIVE COCCI IN CHAINS. Aerobic Bottle Gram Stain (Final [2186-7-27]): GRAM POSITIVE COCCI IN CHAINS. [7-27], [7-28], [7-29] BLOOD CULTURES PENDING, NO GROWTH TO DATE . [7-28] FOOT XRAY: There is no fracture or dislocation. There is a curvilinear lucency over the lateral malleolus which likely represents artifact or overlying structures. There is extensive disorganization and demineralization of the mid foot, which has increased from prior study and likely represents worsening Charcot's arthropathy. There is periostitis at the lateral portion of the fifth metatarsal, largely unchanged from prior study. There is significant soft tissue swelling, most prominent on the plantar surface. There is a small surface irregularity and radiolucency on the plantar surface inferior to the mid foot which may represent an ulcer. There is no subcutaneous emphysema. There are vascular calcifications. There is no definite radiographic evidence of osteomyelitis. IMPRESSION: 1. No definite radiographic evidence of osteomyelitis. If clinically concerned, consider MRI. Soft tissue irregularity on the plantar surface which may correspond to ulcer. 2. Worsening destruction of the mid foot consistent with progressive Charcot's arthropathy. 3. Unchanged periostitis in the lateral aspect of the fifth metatarsal. . [7-28] UPPER EXTREMITY U/S: Transverse and sagittal images were obtained of the subcutaneous tissues at the left antecubital fossa. A large patent hemodialysis fistula is identified on grayscale and color Doppler imaging. No fluid collection is seen in this region. IMPRESSION: No indication of abscess in the left antecubital fossa. A palpable mass in the antecubital fossa corresponds to the hemodialysis fistula. . [7-29] TTE: The left atrium is elongated. The right atrium is moderately dilated. 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 right ventricular cavity is dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated ascending aorta. No valvular pathology or pathologic flow identified. Compared with the prior study (images reviewed) of [2185-6-2], pulmonary artery systolic hypertension is now quantified. Right ventricular cavity size and free wall motion are similar. CLINICAL IMPLICATIONS: Based on [2181] 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. . [7-31] CT ABD/PELVIS: ABDOMEN: Visualized portion of the lung bases appears unremarkable. The liver shows no focal lesion or biliary duct dilation. The gallbladder is decompressed. The spleen is normal in size and appearance. Pancreas shows no surrounding fluid collection. The adrenal glands are normal appearing bilaterally. The kidneys enhance with and excrete contrast symmetrically without evidence of hydronephrosis or perinephric fluid collection. In the inferior pole of the right kidney is a hypodensity that is too small to characterize but likely represents a simple cyst. The small and large intestine show no evidence of obstruction or wall edema. The appendix is visualized and is normal. There is no free air, free fluid, or lymphadenopathy. PELVIS: The bladder, prostate, and rectum appear unremarkable. There is no free fluid or lymphadenopathy. BONES: There are no aggressive appearing lytic or sclerotic lesions. Moderate degenerative changes are seen throughout the lumbar spine. Anterior osteophytes are also noted throughout the lumbar spine. At the L4-L5 level, there is enplate sclerosis, likely degenerative, however there is ragged or an erosive/destructive appearance to the adjacent endplates with mild soft tissue prominence anteriorly. IMPRESSION: 1. No acute intra-abdominal or intra-pelvic process. 2. Abnormal appearance of L4-L5 level, as described above, concerning for discitis/ostemyelitis - correlate with patient's clinical condition. Brief Hospital Course: 45 yo gentleman with PMH of diabetes, diabetic neuropathy and nephropathy, ESRD on HD MWF, presented to the hospital this morning with fever and chills with GPC in chains in blood culture. . ACTIVE ISSUES BY PROBLEM: # Spesis: He initially presented with fever and hypotension and was taken care of in the MICU, requiring fluid and pressors. His blood cultures grew Group G strep and Proteus. Patient initially covered with vancomycin and piperacillin/tazobactam. This was narrowed to ceftriaxone per ID recommendations. Left Bracio-basilic fistula was imaged and no signs of infection. Foot ulcer was imaged without any signs of osteomyeltis. He had a TTE which was negative. The source of the infection was presumed to be intraabdominal and a CT abdomen was performed. CT abdomen did not show GI pathology, however, it did show a ragged edge of the L4/5 disc which might represent discitis. The patient declined an inpatient MRI to further characterize this. He preferred to have an outpatient, open MRI with the knowledge that he might have to be on 8 weeks of antibiotics if he does not get this MRI since there would have to be treatment for presumptive discitis. Per ID recommendations he was discharged on cefazolin and ciprofloxacin dosed with hemodialysis. . # HTN/Vascular: His home medications were held during his hospitalization due to sepsis-induced hypotension. He was discharged on a half-dose of home metoprolol given his multiple risk factors for cardiac disease. He was told to follow-up with his nephrologist and PCP to increase the dose again. . CHRONIC ISSUES BY PROBLEM: # Foot ulcer: Podiatry evaluated the foot infection and noted that there are no signs of osteo, but has worsening charcot neuroarthropathy of midfoot. They changed dressings and followed along in house. He will continue to follow with them outpatient. . # ESRD/HD: On HD MWF. Continued to get his dialysis and will have IV antibiotics dosed with dialysis. Will also have surveillance labs for abx drawn with HD. Fistula not suspicious for source of infection. He was started on nephrocaps. . # Anemia: Baseline anemia due to chronic renal failure. Continued to monitor. Continued sevalamer and cinacalcet. . TRANSITIONAL ISSUES: - PATIENT WILL NEED OUTPATIENT COLONSOCOPY GIVEN GROUP G STREP INFECTION. SHOULD HAVE ARRANGMENT THROUGH OUTPATIENT PCP. [Name Initial (NameIs) ] PLEASE FOLLOWUP WITH WEEKLY BLOOD TESTING OF CBC, LFTS, AND CHEM 7 WHILE ON ANTIBIOTICS, these can be drawn with dialysis - PLEASE CONTINUE ANTIBIOTICS FOR 8 WEEKS TO TREAT PRESUMED DISCITIS - PLEASE GET A REPEAT MRI TO DETERMINE WHETHER COURSE OF ANTIBIOTICS CAN BE ATTENUATED Medications on Admission: sensipar 90mg daily renagel 800mg tid simvastatin 20mg daily aspirin 325mg daily metoprolol 25mg [Hospital1 ] Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:0 7. metoprolol tartrate 25 mg Tablet Sig: one-half Tablet PO twice a day. 8. cefazolin 1 gram Recon Soln Sig: 2G MON, 2G WED, 3G FRI GRAMS Intravenous AS DIRECTED: DOSE AFTER DIALYSIS, FOR 8 WEEKS. 9. Cipro 500 mg Tablet Sig: One (1) Tablet PO MWF, AFTER DIALYSIS: FOR 8 WEEKS. Disp:24 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Sepsis from Proteus and Group G strep Chronic Kidney Disease . SECONDARY DIAGNOSIS: Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital because you were having fevers and were found to have a bacteria in your blood stream. We are not completely sure where this bacteria came from, but it may have been from the ulcer on your foot or from your abdomen. You were treated with antibiotics to kill the bacteria. . Because there was concern that the bacteria might have landed somewhere while they were in your blood, a CT of your abdomen was performed. This showed there might be an infection in the intervertebral discs of your spine. You should have this followed up with an MRI as an outpatient in a few weeks, please call [Telephone/Fax (1) 327] to book this. . Also, because you will be on antibiotics, you should have blood work checked every week. . The following changes were made to your medications: - DECREASE your metoprolol to [11-27] tab twice a day until instructed otherwise by Dr. [Last Name (STitle) 7473] - START taking nephrocaps - START taking cefazolin and ciprofloxacin (antibiotics) for the next 8 weeks . Because you have kidney failure, you should weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . It is very important that you keep all the follow-up appointments as listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: You have the following follow up appointments: . Department: INFECTIOUS DISEASE When: MONDAY [2186-8-14] at 9:30 AM With: [Name6 (MD) 14621] [Last Name (NamePattern4) 14622], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Name: [Last Name (LF) 5533],[First Name3 (LF) ] M. Location: [Hospital 3578] COMMUNITY HEALTH CENTER Address: [Hospital1 3579], [Location (un) ],[Numeric Identifier 3580] Phone: [Telephone/Fax (1) 3581] When: Tuesday, [8-15], 4:15PM . Name: [Last Name (LF) 4883], [Name8 (MD) ] MD Location: [Location (un) ] Dialysis [Location (un) ] Phone: [Telephone/Fax (1) 5972] You will see Dr. [Last Name (STitle) 4883*] at your reugular dialysis appointmnets, Monday, Wednesday and Fridays at 3:30PM.	[ "78552", "40391", "V4581", "V5867", "2720", "4280", "99592" ]
Admission Date: [2161-11-24] Discharge Date: [2161-11-26] Date of Birth: [2161-11-24] Sex: M HISTORY OF PRESENT ILLNESS: A 39-2/7 week gestation male admitted with respiratory distress. MATERNAL HISTORY: A 35-year-old gravida 2, para 1 (now 2) histories. PRENATAL SCREENS: A positive, antibody negative, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, Rubella immune, group B strep negative. PREGNANCY HISTORY: Antepartum unremarkable by report. amniotic fluid. No maternal fever or fetal tachycardia. A repeat cesarean section without labor, under spinal anesthetic. NEONATAL COURSE: The infant required no resuscitation at birth. Apgar scores were 7 at 1 minute and 8 at 5 minutes. Some transient respiratory symptoms in early neonatal period, resolving spontaneously. Neonatal Intensive Care Unit assessment requested at 3 hours of age for grunting, respirations, and tachypnea. The infant was transferred to the Neonatal Intensive Care Unit for monitoring. PHYSICAL EXAMINATION ON PRESENTATION: Birth weight was 3535 g, anterior fontanel, soft and flat, nondysmorphic. Palate was intact. Mild nasal flaring. Mild intermittent retractions, but good breath sounds bilaterally. No crackles. Well perfused. A regular rate and rhythm. Femoral pulses were normal. Normal first heart sound and second heart sound. No murmur. The abdomen was soft and nondistended. No organomegaly. No masses. Bowel sounds were active. The anus was patent. Active, alert, responsive to stimulation, moved all extremities. Tone was normal. Normal spine. Normal hips. Clavicles were intact. HOSPITAL COURSE BY SYSTEM: 1. PULMONARY SYSTEM: The infant remained on room air this hospitalization with oxygen saturations of greater than 95%. The infant initially had grunting and mild nasal flaring which resolved on day of life one, but remained tachypneic with respiratory rates in the 80s. By day of life two, the infant had comfortable respirations with a respiratory rate in the 50s to 60s. No desaturations, and continued to be stable on room air. The infant did not require any supplemental oxygen this hospitalization. 2. CARDIOVASCULAR SYSTEM: No murmur. The infant remained hemodynamically stable this hospitalization. 3. FLUIDS/ELECTROLYTES/NUTRITION: On admission, the infant was nothing by mouth and started on D-10-W at 60 cc/kg per day. Intravenous fluids were discontinued on day of life one, and the infant has done breast feeding ad lib or taking Enfamil 20 calories per ounce at a minimum of 60 cc/kg per day. Dipsticks have been 58 to 90. The infant has been voiding and stooling. The current weight on discharge was 3440 g (which was down 95 g from birth weight). 4. GASTROINTESTINAL SYSTEM: No issues. 5. HEMATOLOGY: The most recent hematocrit on the day of admission was 50.9. 6. INFECTIOUS DISEASE: Due to initial respiratory distress, a complete blood count, differential, and blood culture were drawn. The complete blood count on admission showed a white blood cell count of 15,300. Hematocrit was 50.9%. Platelets were 290,000. Differential with 66 polys and 1 band. Antibiotics were not given. The blood culture remained negative to date. 7. NEUROLOGICAL SYSTEM: No issues. 8. SENSORY: A hearing screen is recommended prior to discharge. 9. PSYCHOSOCIAL: The parents were involved. CONDITION AT DISCHARGE: A full-term male gestation, currently stable on room air. DISCHARGE DISPOSITION: To newborn nursery. PRIMARY PEDIATRICIAN: Name of primary pediatrician is Dr. [First Name (STitle) 40494] [Name (STitle) 40493] (telephone number [Telephone/Fax (1) 47013]). CARE RECOMMENDATIONS: 1. Feedings at discharge: Breast feeding or Enfamil 20 calories per ounce orally ad lib. 2. Medications: None. DISCHARGE DIAGNOSES: 1. Term gestation male. 2. Status post respiratory distress; most likely transient tachypnea of newborn. 3. Status post rule out sepsis. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern1) 47014] MEDQUIST36 D: [2161-11-26] 14:33 T: [2161-11-26] 15:04 JOB#: [Job Number 47015]	[ "V290", "V053" ]
Admission Date: [2144-5-22] Discharge Date: [2144-5-29] Date of Birth: [2075-6-27] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / IV Dye, Iodine Containing / Latex / Banana Attending:[First Name3 (LF) 6088] Chief Complaint: Cold right foot Major Surgical or Invasive Procedure: 1. Right groin exploration with aortobifemoral graft thrombectomy and femoropopliteal and tibial thromboembolectomies. 2. Right lower extremity arteriography. 3. Right four-compartment fasciotomies. History of Present Illness: 68M developed an allergic reaction to a banana and was treated with epineprhine at [Hospital 1474] Hospital. He left AMA and was later found down and intoxicated by police. Returned to [Hospital 1474] hospital complaining of L leg pain. Documented cold pulseless leg at 4:30 am. Started on heparin gtt and transferred here. He states he has had aorto-bifem and fem-fem bypasses with revision of the fem-fem twice at [Hospital3 2005]. Past Medical History: PVD, Htn, DM, COPD, Asthma, PSurg: [Month (only) ] resection ~ 25 yrs ago for rectal CA, multiple incisional hernia repairs. Heart cath with stent. Social History: N/C Family History: N/C Physical Exam: PE: Tm98 Tc98 HR72 BP154/79 RR18 95%RA Gen:No acute distress, AAOx3 CV: RRR Pulm: rhonchi and exp wheeze bilaterally Abd: soft, midline scar, ostomy site intact b/l femoral scars Ext: blanched R foot, motor & sensory deficits dp pt R Dop Dop L Dop Dop No anus Pertinent Results: [2144-5-23] 12:00AM GLUCOSE-227* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-25 ANION GAP-9 [2144-5-23] 12:00AM CK(CPK)-7661* [2144-5-23] 12:00AM CK-MB-87* MB INDX-1.1 cTropnT-<0.01 [2144-5-23] 12:00AM CALCIUM-6.8* PHOSPHATE-3.7 MAGNESIUM-1.9 OPERATIVE REPORT [Last Name (LF) ],[First Name3 (LF) 251] C. Signed Electronically by [Last Name (LF) ],[First Name3 (LF) 251] on SUN [2144-5-24] 10:33 AM Name: [Known lastname ], [Known firstname 4075] Unit No: [Numeric Identifier 79104] Service: Date: [2144-5-22] Date of Birth: [2075-6-27] Sex: M Surgeon: [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 41313] ASSISTANT: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], INT PREOPERATIVE DIAGNOSIS: Acutely ischemic right lower extremity. POSTOPERATIVE DIAGNOSIS: Acutely ischemic right lower extremity. PROCEDURE: 1. Right groin exploration with aortobifemoral graft thrombectomy and femoropopliteal and tibial thromboembolectomies. 2. Right lower extremity arteriography. 3. Right four-compartment fasciotomies. ANESTHESIA: General endotracheal. INDICATIONS: The patient is a 68-year-old male with a previous history of a femoral-femoral bypass and aortofemoral bypass graft in [2136]. He had no known active problems with claudication but within the past twelve hours he has had a recent emergency room evaluation for anaphylaxis. She subsequently then signed himself out AMA and was found intoxicated and down near his home. When he arrived again at the emergency room, he had a cold, pulseless right leg. He was heparinized and brought to [Hospital1 ] [Hospital1 ] emergently. FINDINGS: The aortofemoral graft was full of thrombus proximally, as was the common femoral, superficial femoral through the popliteal and into the tibial vessels. This was quite a large clot burden. His aortofemoral graft plugs directly into the right superficial artery and the origin of the profunda is chronically occluded. The native CFA looks to have been replaced with the ABF limb. After completing two thrombectomies, we performed an arteriogram which showed residual clot in the popliteal and re-thrombectomized the tibioperoneal trunk and tibials with a much improved result and better foot perfusion. OPERATIVE PROCEDURE: After informed consent, the patient was brought to the operating room and positioned supine on the operating table. The entire right leg and both groins were sterilly prepped and draped. A vertical skin incision was made over his previous groin incisions. There was dense scar but careful dissection was carried out to control his right aortofemoral graft limb, which appears to have been completely replaced the original common femoral artery. The graft then went directly into the superficial femoral artery. A longitudinal graftotomy was performed near the distal anastomosis and on inspecting this, there was a fresh clot within. We performed a #5 [Doctor Last Name ] proximal thromboembolectomy with resulting good inflow. Next, we performed distal thrombectomies using 3 and 4 [Doctor Last Name ] catheters. There was no evidence of any profunda orifice during the intial thrombectomy. After getting good back- bleeding from the superficial femoral artery, we restored flow and performed an arteriogram. Arteriography showed no problems with the aortofemoral graft and good flow through the proximal SFA. Upon late films, the profunda femoris could be seen reconstituted retrograde via numerous circumflexfemoral collaterals. The lower arteriographic images showed patent popliteal arteries. Below the knee, there was a high takeoff of the posterior tibial artery and there was residual thrombus in the tibioperoneal trunk and proximal anterior tibial and peroneal arteries. There was no flow down beyond the lower calf. We decided to reopen the graftotomy and redo the tibioperoneal embolectomies using a 3-[Doctor Last Name ] catheter. Doing this, we retrieved a large amount of additional clot from the tibial vessels. The back-bleeding again was very good. We again closed the graftotomy and performed an arteriogram which showed restoration of flow through the posterior tibial and anterior tibial arteries. The foot was perfused at this point and we concluded our revascularization. Next, attention was turned towards the fasciotomies which were performed via medial and lateral incisions. All four compartments were released. The muscles were pink, healthy and all contracted to electrocautery stimulation. At the end of the case the patient had easily palpable dorsalis pedis, posterior tibial and peroneal signals. The fasciotomies were dressed with VAC dressings. The wound was closed in layers with deep running Vicryl sutures and 3-0 nylons in the skin. The patient tolerated the procedure well. All sponge and instrument counts were correct at the end of the case. He was transferred to the intensive care unit in stable condition. [Name6 (MD) ] [Last Name (NamePattern4) ], MD [MD Number(2) 41315] Dictated By:[Last Name (NamePattern4) 79105] Brief Hospital Course: The patient is a 68-year-old male was found intoxicated and down near his home. When he arrived again at the emergency room, he had a cold, pulseless right leg. He was heparinized and brought to [Hospital1 ] [Hospital1 ] emergently. Patient was taken to the OR for emergent right groin exploration. The aortofemoral graft was full of thrombus proximally, as was the common femoral, superficial femoral through the popliteal and into the tibial vessels. This was quite a large clot burden. His aortofemoral graft plugs directly into the right superficial artery and the origin of the profunda is chronically occluded. The native CFA looks to have been replaced with the ABF limb. A Aortobifemoral graft thrombectomy and femoropopliteal and tibial thromboembolectomies were performed and right four-compartment fasciotomies. A VAC was placed over the medial and lateral fasciotomy sites. After completing two thrombectomies, we performed an arteriogram which showed residual clot in the popliteal and re-thrombectomized the tibioperoneal trunk and tibials with a much improved result and better foot perfusion. He had been fine since the surgery but on POD3 he became agitated and assaultive this am during dressing change. Was screaming and swearing at the same time. Nursing also noticed that the pt might have been having visual hallucinations last night. Pt received 2 mg iv of Ativan for the agitation, which occurred about 30-45 minutes ago. He is now too sedated to be examined/interviewed. Pschiatry recommended, Haldol 2.5 mg po/iv qid prn agitation and to re-evaluate the pt when he is more alert. CIWA was also recommended for the slight possibility of alcohol withdrawal. Correct all electrolyte disturbances. After re-evaluation psychiatry thought that alcohol withdrawal was unlikely, but recommended continue CIWA. And continued haldol for aggitation. Physical therapy cleared the patient to rehab on POD3. On POD5 the medial fasciotomy site was closed with intermittent mattrex and simple sutures. A smaller VAC was placed on the lateral fasciotomy site. Medications on Admission: glyburide 5', fluoxetine 40', HCTZ 25', ASA 325', metformin 500'', lisinopril 5', trazadone 50', simvastatin 20' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Insulin SLiding Scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [11-20] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 3 Units 161-180 mg/dL 4 Units 181-200 mg/dL 5 Units 201-220 mg/dL 6 Units 221-240 mg/dL 7 Units 241-260 mg/dL 8 Units 261-280 mg/dL 9 Units 281-300 mg/dL 10 Units 301-320 mg/dL 11 Units 321-340 mg/dL 12 Units 341-360 mg/dL 13 Units > 360 mg/dL Notify M.D. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Last Name (un) ] Center - [Location (un) 701] Discharge Diagnosis: Acutely ischemic right lower PMH: PVD HTN DM COPD Asthma Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [12-22] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12832] Phone: [Telephone/Fax (1) 12834] Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2144-6-10] 9:15 Completed by:[2144-5-29]	[ "4019", "25000" ]
Admission Date: [2119-7-28] Discharge Date: [2119-8-5] Date of Birth: [2033-12-16] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 3853] Chief Complaint: "R leg trauma and GI bleed." Major Surgical or Invasive Procedure: - ORIF of displaced R supracondylar oblique distal femur fracture - IVC filter placement - Upper Endoscopy with Cauterization of bleeding duodenal ulcers History of Present Illness: 85 YO F with h/o HTN, HLD, DM, asthma, who presented 7 days after slipping and falling on her leg while vacationing in [Country 3515]. She was placed in splint on return to US. In [Name (NI) ], pt found to have displaced R distal femur fx and was admitted to ortho, where she underwent ORIF and plate placement on [7-29]. Venous US done [7-28] to rule out DVT showed nonocclusive thrombus in R popliteal vein, and she was started on lovenox/coumadin. On [7-30] pt had emesis with PO and 3 episodes of maroon stools and melena. On [7-31] pt had one episode hematesis with HR 130s. Received IVF boluses and protonix drip, and lovenox/coumadin withheld. EGD showed gastritis and 2 large duodenal bulb ulcers, one actively bleeding and other with large clot. Hct 24.2 (from 34) after EGD, and pt received 4U PRBC on admission to MICU. . MICU COURSE: Pt febrile on admission, was pan-cx (urine negative, blood pending). Required bolus for low UOP and tachycardia. Received 3 separate PRBC transfusions on [2119-8-1]. IVF filter placed [2119-8-1]. PPI drip continued. On [2119-8-2] GI cauterized as much GI bleed as possible. Treated empirically for PUD (amoxicillin, clarithromycin, PPI for 14 day course that started [2119-8-2]), H. pylori Ab test was positive. She was noted to be hypertensive on [2119-8-2] to SBP 194, and treated with hydralazine, metoprolol, and HCTZ. Of note, home simvastatin was held because of clarithromycin interaction. . Today, she complains of R knee pain in surgical site, but no other complaints. Specifically denies abdominal pain, chest pain, SOB, bleeding, numbness, tingling. Past Medical History: HTN DM-2 HLD asthma Social History: Denies smoking No alcohol No illicits Born in [Country 3515] Family History: Daughter has stomach ulcers. No family history of stomach or GI cancer she is aware of. Physical Exam: On Arrival to MICU: Vitals: T: 100.1 BP:145/96 P:105 R: 21 O2: 96% RA General: Very pleasant, thin woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachcardic with hyperdynamic heart, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On Arrival to Medicine: PHYSICAL EXAM: VS: T 100.2 --> 99.2, BP 142/80, P 108, R 24, O2 sat 97% RA. GENERAL: Thin-appearing woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, OP clear. Dry mucus membranes. NECK: Supple, no thyromegaly, no cervical LAD. LUNGS: Decreased breath sounds bilaterally, + mild expiratory wheezes. HEART: RRR, no MRG, nl S1-S2. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, 1+ peripheral pulses. R knee in brace, swollen and warm to touch compared to L, but no erythema. SKIN: No rashes or lesions. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, sensation grossly intact throughout, muscle strength and gait deferred On discharge: Same as above except: CTAB on lung exam. R knee swollen but without erythema or calor. Pertinent Results: On admission: [2119-7-28] 02:00AM BLOOD WBC-8.5 RBC-3.74* Hgb-11.5* Hct-34.0* MCV-91 MCH-30.7 MCHC-33.8 RDW-14.4 Plt Ct-459* [2119-7-28] 02:00AM BLOOD Neuts-72.4* Lymphs-21.6 Monos-5.0 Eos-0.5 Baso-0.4 [2119-7-28] 02:00AM BLOOD PT-12.8 PTT-23.2 INR(PT)-1.1 [2119-7-28] 02:00AM BLOOD Glucose-319* UreaN-18 Creat-1.0 Na-134 K-4.9 Cl-96 HCO3-29 AnGap-14 [2119-7-28] 03:36PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.3 . On discharge: [2119-8-5] 06:49AM BLOOD Hct-32.6* [2119-8-4] 07:35AM BLOOD WBC-8.1 RBC-3.48* Hgb-10.7* Hct-30.6* MCV-88 MCH-30.7 MCHC-34.9 RDW-15.3 Plt Ct-280 [2119-8-4] 07:35AM BLOOD Plt Ct-280 [2119-8-4] 07:35AM BLOOD PT-11.7 INR(PT)-1.0 [2119-8-5] 06:49AM BLOOD Glucose-188* UreaN-8 Creat-0.7 Na-136 K-3.5 Cl-94* HCO3-30 AnGap-16 [2119-8-4] 07:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8 . HELICOBACTER PYLORI ANTIBODY TEST (Final [2119-8-2]): POSITIVE BY EIA. (Reference Range-Negative). . URINE CULTURE (Final [2119-8-2]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . EKG: [2119-7-28] Sinus tachycardia at rate of 102, normal axis, normal intervals, no signs of atrial or ventricular enlargement, No ST segment elevations or depressions with isolated T-wave inversion in V1. Aside from increased rate, no change from prior on [2119-7-28]. . R Knee/Pelvis/Femur XR [2119-7-28] PELVIS: The bony pelvis is intact. The hip joints are symmetric with minimal degenerative change. Degenerative changes of the lower lumbar spine is seen. RIGHT HIP: No femoral neck fractures are present. Minimal superior subchondral sclerosis is present. RIGHT FEMUR: There is an oblique displaced fracture through the right distal femur metadiaphyseal junction. The distal femur is impacted medially and posteriorly with approximately 2 cm of overriding. A moderate joint effusion is seen in the knee. IMPRESSION: Displaced distal femur fracture. . CXR [2119-7-28] FINDINGS: A single portable AP chest radiograph was obtained. The lungs are hyperinflated with flattened diaphragms consistent with emphysema. Aside from right basal calcified granuloma, the lungs are clear. No effusion or pneumothorax is present. The heart and mediastinal contours are normal. The right humeral head is severely subluxed superiorly, probably due to degeneration from longstanding rotator cuff tear. Findings are stable since [2118-9-2]. IMPRESSION: Emphysema. Apparently chronic severe right shoulder subluxation. . R shoulder XR [2119-7-28] FINDINGS: There is no acute fracture or dislocation. The humeral head is high riding, consistent with a chronic rotator cuff rupture. There are secondary degenerative changes with sclerosis, joint space narrowing and large osteophytes about the humeral head. There is narrowing of the AC joint with spurring and sclerosis. The visualized lung and ribs are unremarkable. There is no soft tissue calcification or radiopaque foreign body. IMPRESSION: No acute fracture or dislocation. Severe degenerative changes in the shoulder joint and high-riding humeral head secondary to chronic rotator cuff rupture. . Venous ultrasound [2119-7-28] FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. There is non-occlusive thrombus material seen on grayscale imaging within a segment of the right popliteal vein. At this site, the vein does not fully compress and incomplete vascular flow is identified. The remainder of the vessels of both legs demonstrate normal flow, compression, and augmentation. IMPRESSION: Nonocclusive thrombus seen within the right popliteal vein. . R leg fluo [2119-7-28] FINDINGS AND IMPRESSION: Multiple views of the right femur. Status post ORIF of the right femur. The hardware appears intact. Improved alignment of the distal femur comminuted fracture. Total intraoperative fluoroscopic imaging time 84.7 seconds. Please see operative report for further details. . CT ABD [2119-8-1]: CT ABDOMEN WITHOUT CONTRAST: There is a 4 mm calcified granuloma in the right lower lobe (2:5). Note is made of areas of linear subsegmental atelectasis in the left lower lobe overlying a fat-containing Bochdalek hernia. The heart is notable for a small amount of coronary arterial calcification. The stomach, duodenum, spleen, pancreas, right adrenal gland, kidneys and gallbladder are normal with the limits of this non-contrast examination. A hypodense nodule in the left adrenal gland is 13 x 4mm, and is hypodense, likely adrenal adenoma.The liver contains numerous hypodensities in both lobes which are incompletely characterized on this non-contrast examination, though the largest of which appears to measure 2.5 x 2.1 cm in segment VI (2:12). There is no free gas or free fluid in the abdomen. Vascular structures are notable for atherosclerotic arterial calcification. There appears to be a single normally positioned renal vein bilaterally. The distance from the confluence of the renal veins and inferior cava to the confluence of the common iliac veins is approximately 5.8 cm, though evaluation is slightly limited on this non-contrast examination. There is no evidence of a duplicated inferior vena cava. There is no retroperitoneal or mesenteric lymphadenopathy. CT PELVIS WITHOUT CONTRAST: The urinary bladder, distal ureters, rectum are unremarkable. The uterus contains calcified fibroids. There is no free gas or fluid in the pelvis. There is no pelvic sidewall or inguinal lymphadenopathy. There is a moderate amount of diffuse subcutaneous edema. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion. Severe degenerative changes are present in the lower lumbar spine as well as at the symphysis pubis. IMPRESSION: 1. Limited assessment of venous anatomy given the absence of contrast, nevertheless with apparent conventional configuration to the inferior vena cava, with a distance of roughly 5.8 cm from the confluence of the common iliac veins to the confluence of the renal veins. 2. Numerous incompletely characterized hepatic hypodensities. Recommend comparison to prior imaging if available and failing that, would correlate to ultrasound. 3. Left adrenal gland nodule. Though indeterminate on this study, this is statistically likely to be an adrenal adenoma. 4. Fat-containing Bochdalek hernia. 5. Calcified uterine fibroids. . [2119-8-1] Abd fluoro: FINDINGS: One hard copy of IVC filter placement under radiologic guidance was sent to the radiology department for assessment. An IVC filter is seen in the mid abdomen. Placement cannot be assessed as inferior ribs are excluded from the film. No gross osseous abnormalities. IMPRESSION: IVC filter in mid abdomen. Location cannot be assessed in this limited image sent to radiology. . [2119-8-2] Abd portable FINDINGS: Normal bowel gas pattern without evidence of dilatation. No free air is observed in the left lateral decubitus view. Degenerative changes are seen in the spine and hips. An IVC filter is observed just to the right of the midline in the mid abdomen. Calcifications projecting over the iliac ala are injection granulomas. IMPRESSION: No evidence of free air, ileus or small bowel obstruction. . Brief Hospital Course: Primary Reason for Hospitalization: Ms. [Known lastname 51536] is an 85 y/o F who presented with a displaced R supracondylar oblique distal femur fracture for which she underwent ORIF. The hospital course was also complicated by lower extremity DVT and bleeding duodenal ulcers. ACTIVE ISSUES: . # R supracondylar oblique distal femur fracture s/p ORIF: Patient will need rehab for PT. She was discharged with tylenol and MSIR for pain control because oxycodone has some interaction with clarithromycin. She will f/u with ortho. . # Duodenal Bulb Ulcers: The patient had extensive bleeding (Hct dropped 34 to 24, tachycardia to 130s) requiring multiple pRBC transfusions and IVF boluses in the MICU. She was H. Pylori positive and therefore was started on triple therapy with Amoxicillin, Clarithromycin, and Pantoprazole, Day 1 = [2119-8-2]. She will receive a 14 day course with last dose on [2119-8-15]. She will need f/u with GI with f/u Urea Breath Test to document eradication. The patient's aspirin was held due to bleeding. Decision to resume can be made as an outpatient with PCP. [Name10 (NameIs) ] discharge, pt's Hct stabilized to 30s, and HR to 80s-90s. Pt will f/u with PCP regarding [Name9 (PRE) 4820] anticoagulation. . # RLE DVT: Because of the active bleed she was not started on anticoagulation, therefore she had an IVC filter placed by the surgery team (heparinized Bard G2 filter). Duration of treatment will need to be decided by PCP based upon clinical circumstances. . # Hyperlipidemia: Due to increased risk of rhabdo with Clarithromycin, the patient was instructed to stop simvastatin until she finishes her course of antibiotics. . # HTN: The patient was not given any antihypertensives initially because of active bleeding. Once the bleeding was stabilized she became hypertensive (SBP 190s), likely due to pain. She was on Metoprolol and HCTZ 25mg daily. SBP stabilized to 130s. . TRANSITIONAL ISSUES: . # Patient has IVC filter, the duration will need to be decided by patient's PCP based on clinical circumstances. Please follow up with your PCP regarding future anticoagulation. . # Left Adrenal Incidentaloma: 13 x 4mm and is hypodense. Likely to be an adrenal adenoma. She may need further workup as an outpatient with PCP. . # Hepatic hypodensities seen on CT: Radiology recommended correlation with U/S since prior imaging is not available for comparison. . # Aspirin: Benefits for primary prevention will need to be weighed against risk if patient bleeds again in the future. Decision left to PCP. . # Simvastatin: Patient can restart after completing course of clarithromycin. . # HTN: Please consider starting an angiotensin receptor blocker ([Last Name (un) ]) for blood pressure control, as patient has ACE inhibitor-induced cough. . Medications on Admission: albuterol 90mcg INH q6h PRN fluticasone HFA 110mcg 1 puff [Hospital1 ] glimepiride 4mg daily (d/c'd by PCP in [Name9 (PRE) 3515]) HCTZ 12.5mg daily (d/c'd by PCP in [Name9 (PRE) 3515]) 4U of Novolog mix 70-30 100U/mL(70-30) soln @ 10am and 6pm, lisinopril 40mg daily (d/c'd due tocough) simvastatin 20mg daily ASA 81mg Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 2. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 3. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) for 10 days: Please take for 10 days (last dose [8-15]). Disp:80 Capsule(s) Refills:0 4. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days: Please take for 10 days (last dose [8-15]). Disp:40 Tablet(s) Refills:0 5. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:56 Capsule(s) Refills:2 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain. Disp:84 Tablet(s) Refills:2 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 10 days: Please take for 10 days (last dose 9/13). Disp:20 Tablet, Delayed Release (E.C.)(s) Refills:0 8. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day as needed for pain. Disp:36 Tablet Extended Release(s) Refills:0 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for breakthrough pain: if you have pain between your doses of long-acting morphine. Disp:40 Tablet(s) Refills:0 10. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Four (4) units Subcutaneous twice a day: give at 10am and 6pm. 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. metoprolol tartrate 25 mg Tablet Sig: [12-4] Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 13. INSULIN Please check fingerstick blood glucose qid. Administer regular insulin according to attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 13990] Health Care Center - [Location (un) 5110] Discharge Diagnosis: Primary - R Femur Fracture - Lower Extremity Deep Vein Thrombosis - Duodenal Bulb Ulcers - GI Bleed - Hypertension Secondary - Diabetes Mellitus Type 2 - Hyperlipidemia - Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 51536], You came to [Hospital1 18] after you broke your right leg in [Country 3515]. Our orthopedic surgeons repaired your broken leg. You also had a blood clot in one of the veins of your leg which is called a DVT (Deep Vein Thrombosis). Ordinarily we would treat this with blood thinning medications, however since you were bleeding this would only make the bleeding worse. Therefore our surgeons put in a device called an IVC filter. This device keeps the blood clot from going to the lungs which is the main risk from blood clots. This device may be able to be removed in the future. After your surgery you also developed bleeding in your digestive tract. We did an endoscopy and found that you had two ulcers in your duodenum (small intestine) that were bleeding. You received several units of blood to make up for the blood that you lost. We then did another endoscopy and cauterized your ulcers to stop them from bleeding. We then observed you in the hospital for a few days afterwards to make sure you did not bleed any more. We then felt that you were stable to go to rehab to focus on healing your broken leg. We made several changes to your medications which are detailed below. The following medication changes were made: STOP Simvastatin Simvastatin interacts with the antibiotic clarithromycin. You may resume Simvastatin after you finish your course of clarithromycin. INCREASE HCTZ to 25mg Daily START Amoxicillin 1000mg Twice Daily with last dose on [2119-8-15] START Clarithromycin 500mg Twice Daily with last dose on [2119-8-15] START Pantoprazole 40mg Twice Daily with last dose on [2119-8-15] START Metoprolol 12.5 mg every 12 hours START METFORMIN 500 mg daily at night START Oxycodone 5mg every 6 hours as needed for pain START MS-Contin 15mg every 12 hours as needed for pain Please attend all your appointments. Please take all your medications as instructed. Followup Instructions: Department: [Hospital ] MEDICAL GROUP When: WEDNESDAY [2119-8-9] at 10:00 AM With: DR. [First Name8 (NamePattern2) 507] [Name (STitle) ] [Telephone/Fax (1) 133] Building: [Street Address(2) 3375] ([Location (un) ], MA) [Location (un) 858] Campus: OFF CAMPUS Best Parking: On Street Parking Department: ORTHOPEDICS When: THURSDAY [2119-8-17] at 12:20 PM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: THURSDAY [2119-8-17] at 12:40 PM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2119-9-13] at 1 PM With: [First Name8 (NamePattern2) 4503] [Last Name (NamePattern1) 4504], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage You will see your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] ([Telephone/Fax (1) 133]), when you are sent home from your rehab center. Completed by:[2119-8-5]	[ "2851", "25000", "2724", "4019", "49390", "V5867" ]
Admission Date: [2179-8-9] Discharge Date: [2179-8-17] Date of Birth: [2113-1-23] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Weakness. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 43400] is a pleasant 66-year-old male with a history of NIDDM and PVD who complains of recent weakness with any exertion and back pain radiating to his neck. An echo performed at an outside hospital revealed aortic stenosis with a 56 mm peak gradient. He is subsequently transferred to [Hospital1 190] for cardiac catheterization which showed severe left main and LAD disease. The catheterization also confirmed aortic stenosis. Mr. [Known lastname 43400] was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: NIDDM, PVD, left leg vascular bypass, hypertension, hyperlipidemia, anemia. ALLERGIES: No known drug allergies. MEDICATIONS: Aspirin 325 mg q d, Diovan 80 mg q d. REVIEW OF SYSTEMS: Mr. [Known lastname 43400] has had several episodes of confusion. He has had no headache or vision changes. No shortness of breath, cough or wheezes. He has had no melena, urinary retention, no arthralgias or myalgias. He has had fatigue with activity. PHYSICAL EXAMINATION: Vital signs, blood pressure 130/70, heart rate 70, normal sinus rhythm. Head is normocephalic, atraumatic. Neck is supple with no bruits. His lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm with normal S1 and S2. He does have a 3/6 systolic ejection murmur. His abdomen was soft, nontender, non distended with normoactive bowel sounds. His extremities are without clubbing, cyanosis or edema. HOSPITAL COURSE: Mr. [Known lastname 43400] was taken to the operating room on [2179-8-11] for CABG times two and AVR. CABG graft included LIMA to LAD, SVG to OM. Aortic valve replacement with a #23 CE pericardial valve. The operation was performed without complication and Mr. [Known lastname 43400] was subsequently transferred to the Surgical Intensive Care Unit. On postoperative day #1 Mr. [Known lastname 43400] was followed for a falling hematocrit. It eventually reached 18 and he was transfused two units of packed red blood cells. Otherwise he did well and his hematocrit stabilized. Mr. [Known lastname 43400] was extubated and weaned off drips and adequately fluid resuscitated. By postoperative day #4 Mr. [Known lastname 43400] was felt to be hemodynamically stable for transfer to the floor. Mr. [Known lastname 43400] had an uneventful stay on the floor. He recovered well with good ambulation and oral intake. His pain was controlled with oral medications. By postoperative day #6 Mr. [Known lastname 43400] was felt to be stable for discharge home. He will receive visiting nurse to follow his recovery. Physical exam at discharge, vital signs with temperature 98.2, pulse 75, blood pressure 106/60, respirations 18, O2 saturation 92% on room air. Heart was regular rate and rhythm. Lungs were clear to auscultation bilaterally. His incision was clean, dry and intact. Abdomen was nontender, non distended with normoactive bowel sounds. Extremities were remarkable for 1+ edema. DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Docusate 100 mg [Hospital1 ] while taking Percocet, KCL 20 mEq q d times 10 days, Lasix 40 mg q d times 10 days, Metoprolol 25 mg po bid, Percocet 1-2 tablets q 4-6 hours prn for pain, Lorazepam 0.5 mg q 4-6 hours prn for anxiety. FOLLOW-UP: Mr. [Known lastname 43400] should follow-up with Dr. [Last Name (STitle) 70] in 6 weeks. He should follow-up with his primary care physician [Last Name (NamePattern4) ] [4-12] weeks. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Mr. [Known lastname 43400] is to be discharged home with visiting nurse assistance. DISCHARGE DIAGNOSIS: 1. Status post CABG and AVR. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Doctor First Name 24423] MEDQUIST36 D: [2179-8-20] 10:43 T: [2179-8-20] 10:57 JOB#: [Job Number 43401]	[ "41401", "4241", "4019", "25000", "2720" ]
Admission Date: [2199-5-6] Discharge Date: [2199-5-10] Date of Birth: [2127-7-26] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old male with a history of ulcerative colitis who awoke from sleep with 5/10 chest pain with radiation to his right jaw, accompanied by nausea, dizziness, lightheadedness, but no vomiting. He was given two aspirins by his wife and taken to [Hospital3 3583]. In the Emergency Department, his blood pressure was 100/50. Pulse in the 50s. Electrocardiogram with ST elevations in the inferior leads with reciprocal changes in the anterior leads. Patient received one liter of normal saline, intravenous nitroglycerin, intravenous heparin, morphine, Ativan and was transferred to [Hospital6 1760] for cardiac catheterization. The patient was taken immediately to the Cardiac Catheterization Laboratory which showed a right dominant system with total occlusion of the right coronary artery, 80% proximal left anterior descending and a lesion and a 90% left circumflex lesion at the origin of the OM1. Patient had single vessel stenting of his right coronary artery with three serial stents. The patient also had elevated PA pressure of 56/38, an elevated wedge of 33. Patient's left anterior descending lesion was not intervened upon at this time. Patient was started on aspirin, Plavix, Lasix and Integrilin. Patient also had an episode of atrial fibrillation while in the Catheterization Laboratory, which was electrically cardioverted times one. Patient was enrolled in the COOL MI study. PAST MEDICAL HISTORY: 1. Ulcerative colitis. 2. Status post appendectomy. 3. Status post cholecystectomy. MEDICATIONS: Asacol, Rowasa. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No alcohol or tobacco history. Patient is married. PHYSICAL EXAMINATION: Temperature 35.8. Blood pressure 97/53. Pulse 72. In general, patient is alert in no acute distress under warmer blankets per COOL MI study. Cardiovascular: Regular rate and rhythm, no murmurs. Lungs are clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, guaiac positive. Extremities: No cyanosis, clubbing or edema. 2+ dorsalis pedis pulses bilaterally. Medium sized femoral hematoma on left at percutaneous site. INITIAL LABORATORY DATA FROM THE OUTSIDE HOSPITAL: White blood cell count 6.6, hematocrit 43, platelets 166,000. Chem-7: Sodium 139, potassium 4.2, chloride 106, bicarbonate 28, BUN 15, creatinine 1.1, glucose 119. LFTs within normal limits. Initial CK was 39. Electrocardiogram showed sinus rhythm at [Street Address(2) 43463] elevations in T3 and aVF and ST depressions in V2 through V5. Electrocardiogram after cardiac catheterization showed normal sinus rhythm at [Street Address(2) 43464] depressions in V2 through V6 and Q waves in III and aVF. HOSPITAL COURSE: Status post his initial cardiac catheterization, the patient was transferred to the Coronary Care Unit. At that time, the patient had multiple runs of non-sustained ventricular tachycardia, the longest run approximately 20 beats. Patient was initially given a small dose of intravenous Lopressor which dropped his blood pressure. Patient was then subsequently given two small intravenous boluses of normal saline with good response of blood pressure. Patient continued to have occasional episodes of left shoulder pain and nausea overnight, but without changes in his electrocardiogram. Patient was continued on aspirin and Plavix and Lipitor, status post his inferior myocardial infarction. Patient was guaiac positive from his history of ulcerative colitis, however, patient's hematocrit started to trend downwards from 43 to 39 to 35 to 32. An abdominal CAT scan was obtained which was negative for retroperitoneal hematoma, positive for diverticulosis, as well as for a small right renal cyst. Patient was transfused two units of blood with stabilization of his hematocrit. Patient's small groin hematoma remained stable. A cardiac echocardiogram was obtained to evaluate patient's left ventricular function, status post myocardial infarction. His echocardiogram showed an ejection fraction of 35-40%, a mildly dilated aortic abdominal aorta, mildly thickened mitral valve, as well as posterior akinesis and posterior lateral and inferior septal hypokinesis. As patient's blood pressure began to stabilize off of intravenous fluids, the patient was started on a low dose beta-blocker. Patient was then taken back to the catheterization laboratory for stenting of his left anterior descending. Patient was also started on a low dose ACE inhibitor. Electrophysiologic wise, patient was not anticoagulated for his brief episode of atrial fibrillation, secondary to his tendency to have lower gastrointestinal bleedings, secondary to his ulcerative colitis. Patient did not have any further episodes of atrial fibrillation during his hospitalization. Patient's non-sustained ventricular tachycardia decreased in frequency and eventually stopped as patient was further out from his ischemic event. Patient's repeat cardiac catheterization for his left anterior descending stent showed normalization of his filling pressures, an RRA of [10-19], RV 26/11, PA pressure of 26/13, wedge of 15, output 5.2, index 2.9. DISCHARGE CONDITION: Patient was discharged home in stable condition. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Plavix 75 mg po q.d. for 30 days. 3. Protonix 40 mg po q.d. 4. Lipitor 10 mg po q.d. 5. Asacol 800 mg po t.i.d. 6. Rowasa. 7. Metoprolol 12.5 mg po b.i.d. 8. Captopril 6.25 mg po t.i.d. FOLLOW-UP: Patient to get follow-up resting MIBI scan in one month per COOL MI protocol. DISCHARGE DIAGNOSES: 1. Status post inferior myocardial infarction. 2. Status post right coronary artery and left anterior descending stents. 3. Status post episode of atrial fibrillation. 4. Status post electrical cardioversion. 5. Ulcerative colitis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[First Name3 (LF) 39689] MEDQUIST36 D: [2199-6-18] 21:00 T: [2199-6-18] 21:00 JOB#: [Job Number 43465]	[ "41401", "9971", "42731", "4019", "2720" ]
Admission Date: [2146-4-10] Discharge Date: [2146-4-14] Service: [Location (un) 259] I NOTE: Date of Discharge is expected to be [2146-4-15]. CHIEF COMPLAINT: Fevers and increased white blood cell count. HISTORY OF PRESENT ILLNESS: This is an 85 year old female with multiple medical problems who was sent in to the [Hospital1 1444] Emergency Room from her nursing home for fevers and an increased white blood cell count. The patient was recently admitted to [Hospital1 346] from [2146-3-17] until [2146-4-6] initially for shortness of breath and then had a prolonged hospital course which included respiratory distress thought secondary to a chronic obstructive pulmonary disease flare from Pseudomonal pneumonia. Other etiologies were entertained including allergic bronchopulmonary aspergillosis versus Turk-[Doctor Last Name 3532]. During the patient's last admission she had intermittent shortness of breath episodes that were treated with Lasix for pulmonary edema. She had also ruled out for an myocardial infarction at that time. Her hospital course at that time was also complicated by a steroid induced myopathy, incidental thyroid nodule with biochemically sick euthyroid, acute T12 compression fracture, ataxia attributed to steroid myopathy, pancytopenia attributed to medication, and a PEG placement. Upon evaluation for the current admission, the patient's daughter stated that since her discharge, the patient's mental status has been at baseline until the day prior to admission when she became slightly more depressed. She had been calling out for her deceased mother. The patient also appeared confused and agitated. At the nursing home, her temperature was 101.1 F.; heart rate was 106 and respiratory rate was 14. She was saturating 94% on two liters and had been placed on a nonrebreather by the EMS. At the nursing home she had been given Ciprofloxacin, Azithromycin and ceftazidime for one day. Per the patient's daughter, the patient had not had any headache, chest pain, change in her vision, diarrhea. She complained of mild abdominal diffuse pain. PAST MEDICAL HISTORY: 1. Status post pseudomonal pneumonia. 2. Chronic obstructive pulmonary disease. 3. Diverticulitis. 4. Pancreatitis complicated by pseudocyst. 5. Asthma. 6. Gastroesophageal reflux disease. 7. History of eosinophilia. 8. Hypercholesterolemia. 9. Atrial fibrillation, rate controlled. 10. Alzheimer's dementia. 11. Degenerative joint disease. 12. Coronary artery disease with a history of anterior myocardial infarction and an ejection fraction of greater than 55%. 13. T12 compression fracture. 14. Bronchiectasis. 15. Pancytopenia. 16. Sick euthyroid. 17. Steroid myopathy. 18. Status post PEG placement. MEDICATIONS: 1. Albuterol nebulizers q. six hours. 2. Calcitriol 0.25 micrograms q. day. 3. Salmeterol 50 micrograms q. 12 hours. 4. Guaifenesin q. six hours p.r.n. 5. Multivitamin. 6. Tylenol p.r.n. 7. Dulcolax suppositories p.r.n. 8. Colace 100 mg p.o. twice a day. 9. Flovent 110 micrograms, six puffs twice a day. 10. Alendronate 5 mg p.o. q. day. 11. Lidocaine patch p.r.n. 12. Calcium carbonate 1500 mg twice a day. 13. Prednisone 15 mg p.o. q. day. 14. Atrovent nebulizers q. six hours. 15. Nystatin swish and swallow. 16. Paxil 10 mg p.o. q. day. 17. Risperdal 0.5 mg p.o. twice a day p.r.n. 18. Zithromax 250 mg q. day. 19. Ciprofloxacin 500 mg q. day. 20. Ceftazidine one gram intravenously q. eight hours. 21. Lasix 20 mg p.o. q. day. 22. Diltiazem. SOCIAL HISTORY: The patient has a significant history of tobacco use. She resides at the [Hospital3 2732] home for the past week since her discharge from the hospital. PHYSICAL EXAMINATION: On evaluation in the Emergency Room, the patient was febrile with a temperature of 101.8 F.; blood pressure 145/66; heart rate 110; respiratory rate 22; 99% on a non-rebreather, 93% on room air at rest. The patient appeared sedated and was becoming agitated and combative at times. Her Pupils equally round and reactive to light. Her neck was supple without any lymphadenopathy or bruits. Her oropharynx was dry and her mucous membranes were moist without exudates. She had fine crackles half way up bilaterally on her lung examination and had occasional expiratory wheezes. She had no accessory muscle use. Her heart was regular rate and rhythm with S1, S2. Her abdomen was soft, nontender to deep palpation. She had normoactive bowel sounds and no guarding. Her PEG site was clean, dry and intact without erythema or drainage. Her legs were in lambs wool boots. She had trace edema to the ankles. There were no cords or erythema present. On neurologic examination, she responded to commands by opening her eyes, but appeared sedated. She had no point tenderness over her spine. She had no sacral decubitus ulcers and no skin ulcers. LABORATORY: Her labs were as follows on admission, white blood cell count 19.8, hematocrit 29.7, platelets 671. She had 70% neutrophils and 7% bands. Her electrolytes were as follows: Sodium 139, potassium 3.8, chloride 99, bicarbonate 29, BUN 18, creatinine 0.5, glucose 143. Her lactate was 0.9. Her first set of cardiac enzymes revealed the following: A CK of 30, MB of 3, troponin of 0.13. Her second troponin was 0.15. Her INR was 1.2. Two sets of blood cultures and a urine culture were drawn. Her ALT was 25, alkaline phosphatase 82, total bilirubin 0.2, lipase 78, amylase 83. On urinalysis she had moderate leukocytes and moderate blood. She had a white blood cell count of greater than 50 in her urine and many bacteria. There were three to five epithelial cells. Chest x-ray showed increasing rounded but ill defined opacity in the left upper lobe, same as in [2146-2-17]. There was a question of cavitary worsening left upper lobe opacity. An EKG was done which showed sinus tachycardia at 108 with normal intervals and left axis deviation. HOSPITAL COURSE BY PROBLEM: 1. FEVERS: Initially, the patient's fevers were thought to be due to a urinary tract infection as seen on her urinalysis upon admission. She had been placed on Levaquin to treat for the urinary tract infection, however, when the cultures came back showing methicillin resistant Staphylococcus aureus, the patient was switched to Vancomycin. Also, blood cultures had been drawn upon admission. The first set of blood cultures ended up growth enterococcus which was resistant to Vancomycin; thus, the patient's Vancomycin was discontinued and the Levaquin was discontinued as well. She was then started on Linezolid. An Infectious Disease consultation was obtained. They recommended that the patient undergo possible transesophageal echocardiogram; however, given the patient's agitated state, this test was not done. She was kept on the Linezolid and she was also started on clindamycin. Per Infectious Disease recommendations, the patient was to be kept on the Linezolid for a total of three or four weeks. The patient continued to have occasional spikes in her temperature. Surveillance blood cultures were drawn daily. The patient daily did not complain of any sort of symptoms; however, it was difficult to obtain a history daily given that the patient has a baseline dementia. 2. PULMONARY NODULE: Given the presence of this pulmonary nodule on chest x-ray upon admission, a CT scan was recommended by a pulmonary consultation that had been obtained in the early part of the [Hospital 228] hospital course. CT scan showed that the nodule had been present on a prior CT scan but had slightly grown in size. They were unable to rule out whether this was TB versus aspergillosis. Thus, the patient was placed in isolation in order to have her ruled out for tuberculosis. Sputum was induced on multiple occasions. The first two sets of sputum cultures had no acid fast bacilli on smear. Cultures were pending. The third set at the time of this dictation has not been induced yet. The patient had initially been placed on ceftazidime and Ciprofloxacin in case this had been a recurrence of her Pseudomonal pneumonia. However, after an Infectious Disease consultation had been obtained, they thought that this was low suspicion and decided to place the patient on Clindamycin. The Pulmonary Team followed the patient throughout her hospital course. 3. ELEVATED TROPONIN: Given that the patient's CK and MBs were within normal limits, it was thought that the patient's slightly elevated troponins were likely from demand ischemia. She had no new EKG changes and the patient continued to be asymptomatic. She denied any chest pain or shortness of breath throughout her hospital course. She was placed on Telemetry throughout her hospital course. There were no events up to the time of this dictation. 4. DECREASED HEMATOCRIT: The patient had a slightly decreased hematocrit upon admission. On hospital day two, she was transfused one unit of blood. Her hematocrit remained stable throughout the remainder of her hospital course. 5. MENTAL STATUS: The patient has baseline Alzheimer's Disease dementia. Initially she appeared improved since her last admission, although at times she had periods of agitation and depression. She was placed on Risperdal twice a day p.r.n. for agitation. 6. NUTRITION: The patient was continued on her tube feeds for her PEG that had been placed at her prior admission. A swallow consultation was obtained to see if the patient was at high risk for aspiration. The patient refused to have this test done, and given that she clearly had some risk of aspiration, she was made NPO as her diet throughout her hospital course. 7. CODE STATUS; The patient was a full code during her hospital stay up until the point of this discharge summary. 8. PROPHYLAXIS: The patient was placed on Colace, Dulcolax, heparin subcutaneously for deep venous thrombosis prophylaxis, fall precautions, aspiration precautions. 9. DIABETES MELLITUS: The patient had her fingersticks checked four times a day. She was placed on a regular insulin sliding scale due to the diabetes mellitus that had developed from her long chronic use of Prednisone. Her blood sugars remained well controlled during her hospital stay. The plan is for the patient to be discharged to a rehabilitation facility after she is ruled out for tuberculosis. At the rehabilitation facility she will receive the antibiotics, Linezolid and clindamycin up to a total of three weeks. DISCHARGE STATUS: Discharged to a rehabilitation facility. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. VRE bacteremia. 2. Methicillin resistant Staphylococcus aureus urinary tract infection. 3. Severe chronic obstructive pulmonary disease. 4. Pulmonary nodule. 5. Rule out tuberculosis. 6. Asthma. 7. Gastroesophageal reflux disease. 8. Alzheimer's Disease dementia. 9. T12 compression fracture. 10. Bronchiectasis. 11. Pancytopenia. 12. Steroid myopathy. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to call her doctor or return to the Emergency Room if she experienced any further chest pain, increased shortness of breath, abdominal pain, fevers, change in mental status, or other worrisome symptoms. 2. She was also told to follow-up with the Infectious Disease Clinic. 3. She is to follow-up with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. 4. In addition, the patient had been scheduled for certain appointments during her prior hospital stay which were still pending such as her appointment with Neurology and Pulmonary. If there are any further events in the [Hospital 228] hospital course, they will be dictated at a later time. [Name6 (MD) ] [Name8 (MD) ], MD [MD Number(1) 21980] Dictated By:[Name8 (MD) 4955] MEDQUIST36 D: [2146-4-14] 14:44 T: [2146-4-14] 17:38 JOB#: [Job Number 99483] cc:[Last Name (NamePattern1) 99484]	[ "99592", "5990", "51881" ]
Admission Date: [2141-6-30] Discharge Date: [2141-7-5] Date of Birth: [2069-3-28] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Left Arm Discomfort Major Surgical or Invasive Procedure: CABGx2(SVG->LAD, OM) [2137-6-30] History of Present Illness: 72 y/o female with left arm pain and no other symptoms who had an ETT which showed ST depression. Stress Echo showed inferior and posterior hypokenesis. Cardiac Cath performed on [6-23] revealed severe 3 vessel disease. And pt was then referred for bypass surgery. Past Medical History: Hypertension Hypercholesterolemia Hypothyroidism Colon Cancer s/p colon resection 86 Breast Cancer s/p Left radical mastectomy with radiation 70 s/p Appendectomy Social History: Reitred, Lives with Husband, Quit smoking in [2122] after 35 pack year history. Denies ETOH. Family History: Mother died at afe of 60 of CHF. Physical Exam: VS: 68 142/78 Ht 5'5" Wt 148lbs General: WD/WN female in NAD Skin: R upper chest petechiae and L chest scarring HEENT: Oropharynx benign, EOMI, PERRLA Neck: Supple, -JVD Heart: RRR, +S1S2, with sodt systolic murmur at apex Lungs: CTAB Abd: Soft, NT/ND, +BS Ext: Warm, trace [Last Name (un) ], varicosity of right GSV Neuro: A&Ox3, nonfocal Pertinent Results: Pre-op CXR [6-28]: 1. No evidence of congestive heart failure or pneumonia. 2. Area of increased density overlying the left first rib at the lung apex could possibly represent a superimposition of structures, although left apical lung nodule or sclerotic lesion within the first rib cannot be excluded. Post-op [2141-7-1] CXR: No PTX with good lung expansion following removal of multiple lines and tubes. No new infiltrates and no CHF. Pre-op EKG [6-28]: Sinus rhythm 68. Non-specific ST-T wave abnormalities. [2141-6-30] 10:23AM BLOOD WBC-7.3 RBC-3.20# Hgb-9.7# Hct-27.6# MCV-86 MCH-30.2 MCHC-35.0 RDW-12.9 [2141-7-1] 03:24AM BLOOD WBC-11.4# RBC-3.21* Hgb-9.7* Hct-28.7* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.7 Plt Ct-243 [2141-7-5] 06:40AM BLOOD WBC-11.5* RBC-3.10* Hgb-9.2* Hct-27.8* MCV-90 MCH-29.7 MCHC-33.2 RDW-13.9 Plt Ct-345# [2141-6-30] 11:20AM BLOOD PT-15.5* PTT-39.0* INR(PT)-1.6 [2141-7-2] 05:10AM BLOOD PT-12.5 PTT-25.9 INR(PT)-1.0 [2141-6-30] 11:20AM BLOOD UreaN-12 Creat-0.8 Cl-103 HCO3-24 [2141-7-4] 05:50AM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-131* K-4.4 Cl-96 HCO3-28 AnGap-11 [2141-7-4] 05:50AM BLOOD Mg-1.9 [2141-7-1] 12:43PM BLOOD freeCa-1.11* Brief Hospital Course: As mentioned in the HPI, pt is a 72 y/o female with severe 3vd on cath. She was initially seen in outpatient clinic and then scheduled for surgery. On [2141-6-30] she was a same day admit and was brought to the operating room and underwent CABG surgery. Please see op note for full details. Pt. tolerated the procedure well with a total bypass time of 57 minutes and cross clamp time of 46 minutes. She was transferred to the CSRU in stable condition with a MAP of 85, CVP 10, PAD 16, [Doctor First Name 1052] 24, HR 92 A-paced being titrated on Nitro and Neo. Later on op day, pt was weaned from mechanical ventilation and propofol and was successfully extubated. Pt. was awake, alert, MAE, and following commands. On POD #1 pt appeared to be doing well. Chest tubes and swan-Ganz catheter were removed. Nitro was already weaned and pt was started on diuretic and b-blockade per protocol. He was transferred to the telemetry floor. POD #3 pt had rapid A.Fib w/ vent. response of 180 in the AM. Pt. converted with Amio/Lopressor/Mg. Po Amio started and pt. was stable. Lungs had some scattered rhonchi, 1+ edema. Pt. was slowly improving but need to get OOB and ambulate more. POD #[4-18] pt. appeared to be doing well. She had no new events the past two days nor no episodes of A.Fib. She was at level 5 and was discharged home with services. Physical Exam at d/c: VS: 98.1 71 108/59 18 Neuro: A&Ox3, nonfocal Chest: Sternum stable, -clicks or drainage Lungs: Bibasilar crackles Heart: RRR -c/r/m/g Abd: Soft, NT/ND,+BS Ext: 1+ edema Medications on Admission: 1. Vasoctec 15mg [Hospital1 ] 2. Lopressor 50mg [Hospital1 ] 3. Norvasc 5mg qd 4. Zocor 40mg qd 5. Tricor 145mg qd 6. Synthroid 50mcg qd 7. HCTZ 25mg qd 8. ASA 81mg qd 9. Ativan 0.5mg qhs 10. Calcium 500mg [Hospital1 ] Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:30 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Then decrease to 400 mg PO daily for 1 week, then 200 mg PO daily. Disp:50 Tablet(s) Refills:0 6. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days. Disp:28 Tablet(s) Refills:0 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of [Doctor Last Name ] Discharge Diagnosis: Coronary artery disease s/p Coronray Artery Bypass Graft x 2 Hypertension Hypercholesterolemia Hypothyroidism Colon Cancer s/p colon resection 86 Breast Cancer s/p Left radical mastectomy with radiation 70 s/p Appendectomy Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use powders, lotions, creams on wounds. Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 64290] for 1-2 weeks. Dr. [Last Name (STitle) 36812] in [1-15] weeks Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Call [Doctor First Name ] @ [Telephone/Fax (1) ] to schedule. Completed by:[2141-7-5]	[ "41401", "9971", "42731", "4019", "2720", "2449" ]
Admission Date: [2103-9-6] Discharge Date: [2103-9-10] Date of Birth: [2026-4-10] Sex: M Service: MEDICINE Allergies: Zithromax / Erythromycin Base Attending:[First Name3 (LF) 13541] Chief Complaint: Melena and hypotension Major Surgical or Invasive Procedure: Upper Endoscopy Duodenal ulcer biopsy and cauterization History of Present Illness: This is a 77 yo M with h/o DM II, dementia, HTN, COPD, and recent admission for cellulitis on Levo/Flagyl/Bactrim who presents from Nursing home with melena and hypotension. Patient reports one episode of melena yesterday which he describes as black loose stool. He denies any hematochezia, BRBPR, bloody or coffee ground emesis, abdominal pain, fevers, or chills. He does reports some nausea. Per report at his nursing home, BPs were noted to be in the 70s along with decreased HCT so he was transferred to [Hospital1 18]. In the ED: Temp 97.7, HR 83, BP 116/60. Patient was given 1u PRBC, NG lavage showed coffee ground emesis which cleared with 200cc lavage. On arrival to the SICU, patient denies diarrhea, melena, abdominal pain, bloody emesis, coffee ground emesis. Otherwise ROS negative. Past Medical History: Past Medical History: 1. Hypertension. 2. Type 2 diabetes. 3. Chronic renal impairment. 4. Peripheral vascular disease s/p stent to left SFA, s/p therectomy and PTA of the right 5. Atrial fibrillation. 6. Hyperlipidemia. 7. Chronic obstructive pulmonary disease. 8. [Last Name (un) 309] body dementia. 9. CAD s/p stents on Plavix Social History: Currently lives in Stone [Hospital3 ] home. He continues to smoke at least one pack of cigarettes a day. Denies etoh use, h/o IVDU. Family History: Not obtained Physical Exam: VS: BP 115/69 HR 91 RR 12 95% RA GEN: AAO X 3, lethargic, responds to verbal stimuli HEENT: EOMI, PERRLA, dry mucous membranes, OP clear NECK: Supple, no JVD appreciated CV: normal S1, S2. irregularly irregular. no m/r/g appreciated CHEST: +minor crackles at bilateral bases, +mild expiratory wheezes ABD: Soft, NT, ND, no HSM, normoactive BS EXT: no peripheral edema, +1 distal pulses SKIN: erythema noted over bilateral lower shins, warm to touch, several overlying healing skin ulcers, no pus. Rectal: +small amount black stool, guaiac +, +stage 2 ulcer of superior buttocks Pertinent Results: STUDIES: . [2103-8-31] 4:19 pm SWAB Source: R anterior LE. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Please contact the Microbiology Laboratory ([7-/2401])immediately if sensitivity to clindamycin is required on this patient's isolate. Oxacillin RESISTANT Staphylococci MUST be reported as alsoRESISTANT to other penicillins, cephalosporins, carbacephems,carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S . [2103-9-6] 01:25AM WBC-11.9* RBC-3.11* HGB-9.1# HCT-29.1 MCV-94 MCH-29.4 MCHC-31.4 RDW-14.0 [2103-9-6] 01:25AM NEUTS-74.7* LYMPHS-18.8 MONOS-5.4 EOS-0.8 BASOS-0.3 [2103-9-6] 01:25AM PLT COUNT-449# [2103-9-6] 01:25AM PT-15.6 PTT-25.6 INR(PT)-1.4* [2103-9-6] 01:25AM ALT(SGPT)-23 AST(SGOT)-25 ALK PHOS-83 TOT BILI-0.3 [2103-9-6] 01:25AM GLUCOSE-86 UREA N-51* CREAT-1.0 SODIUM-138 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-10 [2103-9-6] 01:31AM HGB-9.8* calcHCT-29 [2103-9-6] 05:45AM HGB-9.3* HCT-28.0* [2103-9-6] 08:39AM HGB-10.0* calcHCT-30 Brief Hospital Course: 77 yo M with h/o CAD, DM II, PVD, COPD, cellulitis, who presented with melena and hypotension, and underwent embolization after duodenal ulcers were identified. # Melena: Patient with melena x 1, along with hypotension at nursing home and HCT drop from 37.3 on [9-1] to 29.1. GI was consulted. GI performed an EGD on the morning of [9-7], which showed 2 duodenal ulcers, cauterized. Pt was initially transfused 1 unit PRBCs in emergency department. Hct was 28, stable at 29.9-30 while on MICU service. Pt. was treated with PPI IV BID. BP meds were held. After discussion with GI, decision was made to continue plavix given pt's CAD s/p stents, but ASA was decreased from 325 to 81 mg. Pt should discuss resumption of full dose ASA with his PCP. # Hypotension: Likely in setting of UGIB, was hemodynamically stable in MICU. Hct stable as above. Did not require fluid boluses while on MICU service or on floor. Generally maintained good pressures 110-122 systolic while on floor. The patient was discharged on Metoprolol Succinate 100 mg Tablet Sustained Release one per day. # Cellulitis: Patient with recent discharge for cellulits, on Bactrim/Levo/Flagyl PO. These antibiotics were discontinued as the wound culture showed resistance, and patient was started on Vanco IV for 14 days first dose [2103-9-6]. # CAD s/p stents - Pt s/p PCI of LAD in [6-/2103] with 2 Bare Metal Stents. Plavix continued and ASA decreased to 81 mg as above. In the context of his hypotension on presentation, his home ACEi, BB, and statin were initially held. Metoprolol was later introduced. We advise that the patient's PCP consider [Name9 (PRE) 18290] his ACE-I as outpatient if pressures remain stable. # COPD: Patient lethargic on arrival, on O2. O2 stopped, ABG taken, hypoxic to 89% transiently which improved immediately. ABG 7.39/49/68. Lethargy likely [2-24] to lack of sleep. His tiotropium was continued, and albuterol nebs were ordered. # DM II - Pt continued on half dose NPH while NPO. # Atrial fibrillation - Hx of afib, not on coumadin. Continued on ASA 81mg as above. When patient was NPO, he was continued on Digoxin IV and his digoxin level was checked. As above, his beta blocker was held, and restarted at the end of his course with good results. Patient should discuss restarting Coumadin with PCP after GI tract has had some time to heal. # PVD - History of SFA stent: Continued plavix, decreased ASA dose as above. # Dementia - Held aricept, paroxetine while NPO, these were reintroduced at the end of his course. # Sacral Ulcer: Pt was seen by wound care. Wound was dressed with wet to dry dressings. Medications on Admission: Bactrim 80-400mg 2tabs PO BID Levofloxacin 500mg daily Flagyl 500mg TID Insulin Sliding Scale NPH 36u SQ [Hospital1 ] Furosemide 20mg daily Digoxin 125mcg daily Lisinopril 20mg daily Toprol XL 150mg daily MVI Paroxetine 10mg qAM Plavix 75mg daily Spiriva 18mcg capsule daily Thiamine 1 tab daily Aricept 10mg daily Simvastatin 40mg daily Trazodone 37.5mg daily ASA 325mg daily Bisacodyl 10mg supp PRN Simethicone 30mg q6h PRN Milk of Magnesia 30mg daily PRN Acetaminophen PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:0 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [1-24] Inhalation Q6H (every 6 hours) as needed. Disp:120 Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 6. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:0 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Metoprolol Succinate 100 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. 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 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 7 days. Disp:7 Refills:0 15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous per sliding scale: According to sliding scale. Disp:30 Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: Bleeding duodenal ulcer Lower extremity ulcers and cellulitis Chronic atrial fibrillation Stable coronary artery disease Chronic systolic heart failure Diabetes type 2, controlled, with complications Hyperlipidemia Chronic obstructive pulmonary disease Hypertension Discharge Condition: Good Discharge Instructions: Please take all your medications as prescribed. Please note that you will need to complete a 7 day course of IV vancomycin adminstered through the PICC line. Please return for fever, chest pain, shortness of breath, shaking chills, blood in urine or stool, non-healing wounds or ulcers, or any other concerning symptom. Followup Instructions: Please call your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 335] [Last Name (NamePattern1) 5351] at [Telephone/Fax (1) 10688] within 24 hours to make an appointment to take place withint the next week. Please ask her to review your medications with you, as well as follow-up on those issues addressed during this hospitalization. Please see Dr. [Last Name (STitle) ] (Phone:[Telephone/Fax (1) 62]) on [2103-9-18] 9:30 Please see [Doctor First Name ] [Doctor Last Name ], DPM (Phone:[Telephone/Fax (1) 543]) on [2103-11-22] 10:20 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 13546] Completed by:[2103-9-9]	[ "2851", "4280", "25000", "41401", "V4582", "2724", "42731", "5859", "496", "40390" ]
Admission Date: [2166-4-20] Discharge Date: [2166-5-2] Date of Birth: [2109-4-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: pneumonia Major Surgical or Invasive Procedure: Intubated on ventilator [Date range (1) 13407] PICC line placed [4-24] History of Present Illness: 56 year old female with a past medical history significant for multiple sclerosis in a wheelchair, and DVT on coumadin who presented with shortness of breath. [Doctor Last Name 402], her personal care attendant, reports on Friday patient had some coughing, but no shortness of breath. She got chest physical therapy and some suctioning and felt better. On Saturday, she was slightly worse with some cough, and shortness of breath, that improved suctioning and pulmonary treatments. Today she had wheezing, short of breath, and coughing. A neighbor was somehow notified of shortness of breath and called EMS. EMS found patient 84 %, placed on NRB then was 100%. In ED, patient was alert, able to nod head to questions. [First Name8 (NamePattern2) ] [Doctor Last Name 402] baseline is limited communication, mostly non-verbal. Noted to have noisy upper respiratory sounds. Guaiac negative. Underwent nasotracheal suctioning without significant secretions, but with re-positioning appeared to throw up G-tube feeds. Placed NGtube and suctioned tube feeds. Clinically felt to aspirate. Portable CXR L basilar retrocardiac PNA. EKG sinus tach at 118. Got Levoquin 750, flagyl, tylenol and toradol. Got 2.5 L fluid. Vitals Rectal 99.0, HR 106, BP 119/63, RR 18-20, o2sat 96% 6 liters. Planned for unit transfer, then noted blood in her airway, unclear source but suspected NG tube and got intubated for airway protection. ED spoke with ENT, packed her mouth and sent to ICU for further care. Past Medical History: Multiple Sclerosis DVT on coumadin, may years ago [First Name8 (NamePattern2) ] [Doctor Last Name 402] Depression Social History: lives alone, daily care health care aid- [Doctor Last Name 402] [Telephone/Fax (1) 37057]. Brothers and sisters, and two children. Divorced. Her daughter [Name (NI) ] primary health care proxy, and [Name (NI) 402] is secondary health care proxy. Family History: NC Physical Exam: ON ADMISSION General: intubated, sedated, no acute distress HEENT: Sclera anicteric, MMdry, oropharynx with dried blood, blood in left posterior nares Neck: supple, JVP not elevated, no LAD Lungs: Coarse rhonchi throughout 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, g- tube in place Ext: cool, slight mottling but cap refill < 3 secs. dopplerable pulses, 1+ edema bilaterally. Arms with contractures at elbows and hands. ON DISCHARGE General: no acute distress HEENT: MMday, face tent humidified at 40% hiflow Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds, moving air 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, g- tube in place Ext: warm, cap refill < 3 secs. dopplerable pulses, trace edema bilaterally. Arms with contractures at elbows and hands. Pertinent Results: ON ADMISSION: CXR: Left basilar and retrocardiac opacity. Findings could represent aspiration pneumonia. Minimal atelectasis of the right base. RESPIRATORY CULTURE (Final [2166-4-24]): Commensal Respiratory Flora Absent. YEAST. RARE GROWTH. CTA [2166-4-22]: 1)No pulmonary embolism or acute aortic pathology. 2)Partial collapse of the left upper lobe is contributing the abnormal contour of the aortic knob on the recent chest radiograph 3)Multifocal pneumonia with bilateral pleural effusions and bibasilar atelectasis. 4)Multilevel wedge compression fractures of indeterminate chronicity. [2166-4-20] 02:30PM BLOOD WBC-15.4* RBC-4.70 Hgb-14.8 Hct-43.2 MCV-92 MCH-31.6 MCHC-34.4 RDW-14.9 Plt Ct-255 [2166-4-20] 02:30PM BLOOD Neuts-89.2* Lymphs-5.3* Monos-4.9 Eos-0.1 Baso-0.6 [2166-4-20] 05:42PM BLOOD PT-19.4* PTT-40.9* INR(PT)-1.8* [2166-4-20] 02:30PM BLOOD Glucose-138* UreaN-18 Creat-0.5 Na-136 K-4.0 Cl-97 HCO3-27 AnGap-16 [2166-4-20] 02:30PM BLOOD ALT-77* AST-69* AlkPhos-275* TotBili-0.3 [2166-4-20] 08:15PM BLOOD Calcium-8.1* Phos-2.0* Mg-1.4* [2166-4-20] 09:04PM BLOOD Type-ART Rates-16/ PEEP-15 FiO2- O2 Flow-40 pO2-106* pCO2-40 pH-7.40 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2166-4-20] 02:54PM BLOOD Lactate-3.0* [2166-4-20] 04:00PM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.010 [2166-4-20] 04:00PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2166-4-20] 04:00PM URINE RBC-[5-29]* WBC-[5-29]* Bacteri-MANY Yeast-NONE Epi-[2-21] TransE-0-2 ON DISCHARGE: [2166-5-2] 03:21AM BLOOD WBC-8.6 RBC-2.84* Hgb-9.3* Hct-27.1* MCV-96 MCH-32.6* MCHC-34.1 RDW-14.5 Plt Ct-806* [2166-4-27] 04:33AM BLOOD Neuts-67.0 Lymphs-21.8 Monos-10.8 Eos-0.2 Baso-0.2 [2166-5-2] 03:21AM BLOOD Glucose-99 UreaN-13 Creat-0.3* Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 [2166-4-22] 03:32AM BLOOD ALT-40 AST-27 AlkPhos-175* TotBili-0.4 [2166-5-2] 03:21AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1 Brief Hospital Course: This is a 56 year old female with advanced multiple sclerosis admitted for pneumonia. 1. Respiratory Failure: The patient required intubation related to her underlying PNA. She also developed lobar collapse versus segmental atelectasis on imaging when she was initially weaned to pressure support. Sedation was weaned off but extubation was problem[Name (NI) 115] due to weakened gag reflex, underlying muscle weakness secondary to advanced multiple sclerosis, volume overload, copious oral secretions, and lack of cuff leak. She received a course of dexamethasone given her absence of cuff leak. Further diuresis was attempted but was limited by the patient developing hypotension. She was extubated on [4-28] after a 4 day trial of PSV. After exutbation, she still had a high oxygen requirement and need for frequent suctioning of oral secretions. Her saturation would improve with repositioning, chest PT, and suctioning which suggested that she may have had intermittent mucous plugging. She also had some pleural effusions on imaging. The patient confirmed that she would not want to be re-intubated and her code status was changed to DNR/DNI. She required aggressive chest PT, scopolamine patches as needed to reduce oral secretions, as well as ipratropium, albuterol, Mucomyst, and fluticasone MDIs to improve her pulmonary status. An insufflator/exsufflator was also initiated to stimulate cough to further help to bring up secretions. She was also continued on her home biPAP of [9-23] at night. Her fluticasone MDI was discontinued prior to discharge given the association of steroids with increased incidence of pneumonia. She may benefit from intermittent scopolamine patches to help decrease her oral secretions. 2. PNA: Most likely community acquired with an aspiration component given her altered gag reflex and observation in the ED of tube feeds in her mouth. She was orginally on levofloxacin, ceftiaxone, and flagyl. Ceftriaxone was discontinued [4-23]. Flagyl was changed to clindamycin to cover for celllulitis as detailed below. She completed a 7 days course of levofloxacin and was continued clindamycin to treat both her cellulitis and aspiration. 3. Leukocytosis/Fevers: The patient developed leukocytosis on [4-29] in addition to some low-grade fevers. She has had no other localizing sources of infection other than her PNA and improving cellulitis. Her fevers may possibly be due to atelectasis, but C. diff was also ruled out given the administration of antibiotics. Her PICC was placed on [4-24]. She has not had any fevers for a few days prior to discharge and her leukocytosis has also resolved. 4. RLE Erythema: She was noted to have a rash on [4-25] which was concerning for cellulitis. Flagyl was changed to clindamycin on [4-25] with improvement of the demarcated border of erythema. She completed a 7 day course of clindamycin on [5-2]. Clindamycin was picked because it will cover both possible MRSA and aspiration PNA. 5. Atrial Fibrillation: The etiology is likely secondary to pneumonia. Her CHADS score is 1. She was started on diltiazem 30mg PO q6 which worked well for rate control initially but had to be discontinued given her hypotension. She was on metoprolol at home as well which was also discontinued due to hypotension. Aspirin was originally held given OP bleeding but was restarted on [4-25]. Her home Coumadin was not restarted. She was in sinus with tachycardia in low 100s and hemodynamically stable at time of discharge. 6. Multiple Sclerosis: She was continued on her home regimen of clonazepam, baclofen, and reglan. It was noted that she had some increased sedation which improved with halving her clonzepam dose to 0.25mg TID. 7. Elevated LFTs: Her transaminitis was likely related to her statin. It resolved off of simvastatin and her statin was not re-initiated on discharge. 8. h/o DVT: Her home Coumadin and aspirin were initially stopped secondary to oropharyngeal bleeding noted on admission. She was restarted on aspirin but not Coumadin. DVT prophylaxis was maintained with heparin SC and pneumoboots. 9. Depression: She was continued on her home dose of fluoxetine. 10. Hyperglycemia: She did not have a diagnosis of diabetes prior to admission. It may be that her sugars have been elevated in the setting of acute illness. She was maintained on a Humalog ISS, but it was discontinued on discharge as she has not had any appreciable insulin requirement in several days. 10. Code: Confirmed DNR/DNI. Medications on Admission: Klonopin 0.5 mg QHS Baclofen 10 mg 2 tabs at 8 am, 12 pm, 6pm and 1 tab at bedtime Calcium Carbonate 600 mg daily Vitamin C 500 mg [Hospital1 ] Clotrimazole 1% TID: rash: prn Prozac solution 20 mg /5ml 7.5 ml daily Hiprex 1 gm tabs [Hospital1 ] Prevacid 30 mg in apple juice [Hospital1 ] Colace 150 mg/15ml 10 ml daily Senokot 8.6mg tabs [Hospital1 ] Bisacodyl 10 mg M/Wed/Fri Reglan 5 mg/ml [Hospital1 ] Atrovent 0.03% solution neb [Hospital1 ] Pulmicort 0.25mg/2ml neb [Hospital1 ] Jevity 1.2 cal/cc 4 cans daily through g tube when upright in wheelchair BiPAP PEEP 5, inspiratory pressure 10 at night ASA 81 mg daily Lopressor 12.5 mg [Hospital1 ] Simvastatin 10 mg QHS Cerovite (MVI) 15 ml daily Coumadin unclear dosage . pills are crushed with pill crusher, mixed with water 50 cc and given through g-tube with 50 cc flush. Liquid medicines are given with 50 cc water, and flushed with 50 cc water. Discharge Medications: 1. Baclofen 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO 8 AM, 12 PM AND 6 PM (). 2. Baclofen 10 mg Tablet [Hospital1 ]: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Metoclopramide 10 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 4. Fluoxetine 20 mg Tablet [Hospital1 ]: 1.5 Tablets PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid [Hospital1 ]: Five (5) ML PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] twice a day. 7. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) ML PO BID (2 times a day). 8. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO QMOWEFR (Monday -Wednesday-Friday). 10. Ascorbic Acid 500 mg/5 mL Syrup [Last Name (STitle) ]: Five (5) ML PO twice a day. 11. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 12. Acetaminophen 650 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 13. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed for affected areas. 14. Ibuprofen 600 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 15. Acetylcysteine 20 % (200 mg/mL) Solution [Last Name (STitle) ]: Five (5) ML Miscellaneous Q4H (every 4 hours) as needed for chest congestion. 16. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) ampule Inhalation Q6H (every 6 hours). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) ampule Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Clonazepam 0.5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO TID (3 times a day). 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 20. Calcium Carbonate 600 mg (1,500 mg) Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 21. Hiprex 1 gram Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Primary Diagnosis: Community acquired pneumonia with element of aspiration requiring intubation Primary Diagnosis: new onset atrial fibrillation Secondary diagnoses: Advanced Multiple Sclerosis History of DVT many years ago Depression Discharge Condition: Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Mental Status: Clear and coherent. SBP: 90s-100s, HR 100s, stable Discharge Instructions: You were admitted to [Hospital1 69] for evaluation of shortness of breath. You were noted to have a pneumonia that required intubation. You have slowly recovered, but continue to have trouble coughing up phelgm and are going to a rehabilitation facility to help regain your strength. The following changes have been made to your home medication regimen: - You should stop your home Pulmicort - You should stop your home Coumadin - You should stop your home simvastatin - You should stop your home metoprolol - You should decrease your home clonazepam dose to 0.25mg three times daily Followup Instructions: Please follow up with the physicians at your long term care facility. Please contact your primary care practice, [Name (NI) ] Community Medical Group, to update them on your progress. [First Name4 (NamePattern1) 1743] [Last Name (NamePattern1) 37058], NP [Telephone/Fax (1) 37059] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 37060] [Telephone/Fax (1) 8454]. They can also help you transition home when you are ready. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "5070", "51881", "5180", "5990", "486", "42731", "311", "V5861" ]
Admission Date: [2153-5-27] Discharge Date: [2153-5-27] Date of Birth: [2096-12-2] Sex: M Service: Neurosurgery HOSPITAL COURSE: The patient was a 56 year old male who was transferred from an outside hospital. Apparently earlier today, he was speaking on the telephone with his niece and became unresponsive. She called 911 and the patient was found unresponsive at home in a chair. He was intubated at an outside hospital. They did see movement of his right. The patient was a known noncompliant hypertensive. He was hypertensive up to 220 and did receive a dose of mannitol 50 mg en route. PAST MEDICAL HISTORY: Hypertension. MEDICATIONS: Unknown. ALLERGIES: Unknown. PHYSICAL EXAMINATION: Blood pressure was 159/69, heart rate 81, respiratory rate 14. Patient was intubated and in a hard collar. He was unresponsive. Pupils were 3 mm bilaterally, nonreactive. He had no corneal reflexes, no gag. Did have positive doll's eyes. He had movement to deep painful stimulation in all 4 extremities. Toes were mute. LABORATORY DATA: Repeat CAT scan in the emergency room did show a large left intraventricular hemorrhage with dilatation of the left lateral ventricle, showing transfalcine herniation with midline shift of 1.4 cm as well as effacement of the sulci and uncal herniation. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit. The patient did meet all criteria for brain death. The brain declaration check list was performed. The patient's wife and daughter did arrive. They were receptive to organ donation, and consent was obtained. DISCHARGE DIAGNOSIS: Large intracranial bleed. DATE OF EXPIRATION: [2153-6-27]. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2153-7-11] 12:35:32 T: [2153-7-11] 13:01:39 Job#: [Job Number 61575]	[ "4019" ]
Admission Date: [2148-8-14] Discharge Date: [2148-8-21] Service: [Hospital1 ] MEDICINE HISTORY OF PRESENT ILLNESS: This is an 89-year-old female with history of hypertension, who is admitted postfall on her knees secondary to questionable dizzy spell with no loss of consciousness. She was admitted for dehydration and elevated CKs to rule out myocardial infarction, but now also being worked up with findings consistent with rabdo picture and treated with IV fluids. In ED her vitals were temperature of 97.0, blood pressure of 182/99, heart rate of 96, respiratory rate of 34, and O2 saturation of 92% on room air. Patient in the ED was given Aldomet 250 mg, aspirin, Lopressor, and 1.5 liters of normal saline. She also got a CT without contrast, which was negative. A chest x-ray and plain films and bilateral hips were negative. HOME MEDICATIONS: 1. Aldomet 1.5 tablet t.i.d. 2. Vasotec 5 mg q.d. 3. Maxzide half a tablet q.d. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Hypertension. 2. Eye implants in [2134]. 3. History of DVT, which she was treated for six months with Coumadin in [2142]. SOCIAL HISTORY: No tobacco, no ethanol, and no drugs. Lives alone in [Location (un) ] Senior Center. No stairs, housebound. Son and daughter live in [Name (NI) 1411] and [Name (NI) 745] respectively. He was born in [Country 4754]. On admission, her T max was 98, T current was also 98, BP was 133-145/75-77, heart rate was 76-80, respiratory rate was 16, O2 saturation was 96% on 2 liters. PHYSICAL EXAM: She was lying down in no acute distress, appeared to be comfortable. HEENT: Slightly dry membrane mucosa. Eyes: Her pupils were sluggishly reactive to light and her extraocular movements were not intact and with questionable visual changes, decreased vision in both eyes. Neck: No LAD, no JVD noted, no carotid bruits. Thyroid was not palpable. Respiratory: She had these high-pitched expiratory wheezes bilaterally, no rales or rhonchi. Cardiovascular: Regular, rate, and rhythm, normal S1, S2, no S3, S4. Abdomen: Nondistended, nontender, soft, plus bowel sounds in all quadrants, no hepatosplenomegaly. Extremities: 2+ pitting edema in the lower extremities, no clubbing or cyanosis. Pulses were palpable 1+. Neurologically, she was alert and oriented times three. Cranial nerves III, IV, and VI slow for extraocular motors, not fully intact. Other cranial nerves were intact. Her deep tendon reflexes were intact. Her motor strength was [3-23] throughout. Sensation to touch was intact. Speech was normal. LABORATORIES ON ADMISSION: Cardiac enzymes: She had a CK of 1759, CK MB of 52, index of 3.0, troponin-T of 0.21. The repeat CK was 1491, CK MB 44, index 3.0, troponin-T of 0.23 and the one after that, eight hours after was also negative. UA showed small blood, trace protein, trace ketone, occasional bacteria, 0-2 epi, 0-2 red blood cells, 0-2 white blood cells. Her PTT was 29.1. INR 1.2. Chest x-ray showed cardiomegaly, basilar bilateral linear atelectasis with a calcified aorta, no effusion and no pneumothorax. Head CT further verification still showed no evidence of intracranial hemorrhage and no acute brain infarct. Patient was admitted for evaluation of dehydration, which received normal saline since admission. Also getting normal saline secondary to presumed rhabdomyolysis with elevated CKs which were trending down with normal saline IV fluid hydration. She was ruled out for myocardial infarction given normal index of MB. HOSPITAL COURSE: Since she was admitted, her rabdo was improving daily. She was ruled out for myocardial infarction, but on day two of hospital admission, she developed shortness of breath, and she was slightly refractory to O2 treatments. An ABG was retained, which showed a CO2 of 108 with good pO2. She was then transferred to the MICU for further evaluation secondary to CO2 retention. She stayed in the MICU for three days. Patient's blood gas was repeated and over time, blood gas gradually improved. Although when readmitted to the floor, still the bicarb for ........... were a mechanism was still elevated, although decreasing each day. For the past three days, the bicarb has been decreasing. It has gone from 50 to 48 to 44 and today's is pending. Patient is still on face mask today, but says that everything is feeling better, and her extraocular motors are now back and she notes that she is going back to her old self, although still has some respiratory distress and is still currently on BiPAP machine intermittently with nasal cannula. Her lower edema, she is wearing her stockings and since wearing the stockings, had been feeling better. Her rhabdomyolysis has been improved and the last CK was dramatically improved from the over 1,000 CK that was on admission, it was 300 and today's CK pending. CONDITION ON DISCHARGE: Stable, some respiratory distress. Continues to be on O2. DISCHARGE STATUS: Patient is planning on being discharged to rehab center today. DISCHARGE MEDICATIONS: 1. Ipratropium nebulizer IH q.6h. 2. Albuterol nebulizer one inhaled q.6h. prn. 3. Bisacodyl 10 mg p.r. prn. 4. Thiamine 100 mg p.o. q.d. 5. Bacitracin ointment TP b.i.d. apply to lumbar sore. 6. Heparin 5,000 units subQ q.12h. 7. Docusate sodium 100 mg p.o. b.i.d. prn. 8. Aspirin 81 mg p.o. q.d. FOLLOWUP: Patient is to followup with PCP early next week. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4263] Dictated By:[Last Name (STitle) 109878] MEDQUIST36 D: [2148-8-21] 08:27 T: [2148-8-21] 08:36 JOB#: [Job Number 109879] cc:[CC Contact Info ]	[ "5849", "4280", "51881", "5180", "4240" ]
Admission Date: [2110-2-19] Discharge Date: [2110-2-24] Date of Birth: [2053-12-16] Sex: F Service: SURGERY Allergies: Iodine / Hydromorphone / Talwin / Talwin NX / Codeine / MS Contin / Cefazolin / Penicillins / Dicloxacillin / Prochlorperazine / Nsaids / Duragesic / Fluconazole / Fish Product Derivatives Attending:[First Name3 (LF) 1556] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 65F transfer from OSH s/p fall down 7 stairs at noon, [2-19]. She states she was climbing stairs and lost her balance. Reports loss of consciousness for approximately ten minutes. Called her son at 5pm. Next memory is of EMS. On admission, mild memory difficulties, with GCS 14. Compalaining of back and rib pain. Past Medical History: PMH: spinal cord injury, fibromyalgia, GERD, neurogenic bladder, hypothyroidism, Crohn's disease PSH: recent left shoulder surgery, hysterectomy, appendectomy, lumpectomy left breast x4, cholecystectomy, centralobular emphasyma Social History: noncontributory Family History: noncontributory Physical Exam: On presentation: PE: HEENT: PERRLA Neck: Collar in place Resp:Clear to ascultation throughout all fields, no crepitus CA:RRR GI: soft, nontender, nondistended, RUQ pain, nl tone GU/GYN/pelvis: pelvis stable Musculoskeletal: Left toes with minimal movement, Right leg moving, Right shoulder pain, thoracic and lumbar, sacral notch tenderness, no step off deformity, +pulses Neuro: GCS=15, confused Pertinent Results: [2110-2-19] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2110-2-19] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.003 [2110-2-19] 08:50PM WBC-6.4 RBC-4.49 HGB-13.4 HCT-39.9 MCV-89 MCH-29.8 MCHC-33.5 RDW-13.6 [2110-2-19] 08:50PM PLT COUNT-326 [2110-2-19] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2110-2-19] 08:50PM LIPASE-67* [2110-2-19] 08:57PM GLUCOSE-103 LACTATE-1.4 NA+-146 K+-3.3* CL--99* TCO2-28 [2110-2-19] 08:50PM UREA N-5* CREAT-0.7 CT Head: No acute intracranial abnormality. CT C-spine: 1. No acute cervical fracture or malalignment. 2. Severe centrilobular pulmonary emphysema. CT T-spine: 1. No acute thoracic spine fracture or malalignment. 2. Severe centrilobular pulmonary emphysema. R Shoulder XR: No evidence of acute fracture or dislocation. CXR: Underlying trauma board partially obscures the view, given this, no acute cardiopulmonary process. Brief Hospital Course: 56F s/p fall down stairs with loss of consciousness and was admitted for observation. Extensive CT imaging was preformed which was determined to show no acute injury. A CT of her C-spine ruled out fracture and her collar was removed, a soft collar was provided for comfort. The patient takes a large amount of narcotic medications for chronic pain which were continued during her hospital admission. On [2110-2-20] the patient was found to be unresponsive. A code blue was called and responded to appropriately, it was determine that the patient was in respiratory distress. She was given Narcan and ventilated by Ambu until she began to respond. The patient was able to breath on her own and was transferred to the TSICU for further monitoring. Social work was consulted while the patient was admitted to the TSICU and she was stable without any further respiratory events. The patient was transferred back to the floor [2110-2-21] and chronic pain was consulted. The chronic pain team recommendations included: 1) decreasing OxyContin to 60mg [Hospital1 ] or 40mg TID 2) continue oxycodone 5-10mg Q4h, 3) continue Amitriptyline 75mg qhs, 4) continue Mirtazapine 15mg qhs, 5) continue Diazepam 5 mg Q6H. DO NOT increase dose back to 10mg per home regimen, and 6) Hold doses of narcotics or benzodiazepines for any signs of sedation. These recommendations were carefully considered and the appropriate orders were written. An echocardiogram was preformed [2110-2-21] to rule out a cardiac cause of the patients fall which showed normal left ventricular function with an EF >55%. Because of the complicated social history of the patient, disorganization of thoughts during interviews, a high level of frustration and anxiety when discussing her pain regimen, and a concern for the patients safety as documented by the social work department, the patient was seen by psychiatry. Psychiatry recommended following recommendations made by chronic pain, continuing to optimize established antidepressant regimen, possible outpatient psychiatrist/therapist, and pastoral care while inpatient. Throughout the rest of the patients inpatient stay she remained stable. Her blood pressure ran in the 90's systolically however there were no episodes of hypotension or orthostasis. Because of concern of a low oxygen saturation level while the patient was in bed on [2110-2-24], her ambulating oxygen saturation level was tested and she remained stable at 93% RA. Physical therapy was consulted and she was evaluated as safe to return home. Medications on Admission: oxycontin 80''', oxycodone [3-31] QID, Hydroxyzine 25mg Q4H:PRN, valium 10 QID, amitriptyline 75 QHS, amlodipine 5', mirtazapine 15 QHS, nystatin 1tsp QID:PRN, mycelex Discharge Medications: 1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for itching. 2. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety/pain. 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 11. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for dyspnea. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 15. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 16. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 17. Valium 5 mg Tablet Sig: One (1) Tablet PO four times a day. 18. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours. Disp:qs Tablet Sustained Release 12 hr(s) Refills:0 19. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for breakthrough pain. Discharge Disposition: Home Discharge Diagnosis: s/p Fall Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You are taking multiple medications prescribed by other prescribers. Your medications were confirmed via a fax received from Dr.[Name (NI) 86128] office. These medications were added to your discharge medication list. The only medication that you received a prescription for was for the reduced Oxycontin dose that was recommneded by our Pain Service. You were evaluated after a fall down stairs. You had multiple imaging studies that do not show evidence of abnormalities. You will likely feel sore for the next few days while you are recovering from this injury. You also reported that you hit your head during the fall and a CT scan of your head did not show evidence of bleeding. IT IS BEING RECOMMENDED THAT YOUR VALIUM DOSE BE REDUCED TO HALF OF THE REGULAR DOSE. You can take your regular pain medication for the aches from this injury. You can also take tylenol every six hours and can use ice for twenty minutes at a time. It is important that you do not take to many pain medications at the same time, this puts you at risk to loose conciousness or stop breathing. You were seen by the chronic pain service for managment of your pain and sedation. Your valium was decreased from 5mg to 10mg. It is important to follow all of the instructions for your medications carefully and correctly. Followup Instructions: Follow up with your primary care providers within the next week. You will need to call for an appointment. It is being recommended that you follow up with a Psychiatrist as an outpatient for managing your psychiatric medications. Your primary care doctor can make the referral for you. Completed by:[2111-9-3]	[ "2449" ]
Admission Date: [2132-12-12] Discharge Date: [2132-12-19] Date of Birth: [2056-11-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 800] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: blood transfusions Colonoscopy EGD History of Present Illness: 76 y/o man with PMH notable for gastric cancer s/p gastrectomy ([2116]) who presents with several episodes of bright red blood per rectum. The patient was at home and felt well yesterday. He then had vague abdominal pain last night and had [5-20] grossly bloody stools starting at about 9 pm. After several bloody stools, he noted dizziness with sitting up and standing. On his way to the bathroom, he fell and may have briefly lost consciousness. His girlfriend then found him passed out in a pool of blood on the floor before making it to the bathroom. He does not believe he struck his head but cannot recall exactly what happened. He then came to the emergency room at about 1 am; his last episode of BRBPR was at home. . In the ED, initial vitals were T 96.8, HR 70, BP 123/70, RR 16, 99% on RA. He had bright red blood on rectal examination but no obvious hemorrhoids. The patient was treated with 80 mg IV protonix and 4 mg IV zofran for nausea. His hematocrit was found to be 21.6 (baseline ~ 40) and he was given 2 U PRBCs as well as 2 L NS. He did not undergo NG lavage due to h/o gastrectomy. GI was contact[Name (NI) ] and will see the patient this morning. He had a CT of his abdomen/pelvis which showed diverticulosis without diverticulitis as well as evidence of prior gastrectomy and ? roux-en-y anastomosis. . On arrival to the ICU, the patient reports that his abdominal pain has resolved. He has not had any further BRBPR since arrival at the ED. He denies any recent aspirin or coumadin use though he does take motrin about once per day on average for arthritis. He drinks beer occasionally, perhaps a few drinks yesterday during the holiday. He had some nausea with dry heaves at home but no vomiting or hematemesis. When the diarrhea started, he also had diffuse vague abdominal pain but this resolved in the ED. No headache, chest pain, difficulty breathing, or urinary symptoms. He denies any current nausea or dizziness. He has never had bleeding like this in the past. He had gastric cancer resected in [2116] at the [Hospital1 756] but tells me he is not followed there any more. Past Medical History: * h/o hypertension (not on meds) * h/o stage I gastric adenocarcinoma, diagnosed following melenotic stools in [2116-1-15] - s/p antrectomy & Bilroth I gastrojejunostomy in [1-/2116] - completion total gastrectomy in [2-/2116] due to findings of T1 adenocarcinoma * h/o diverticulosis (last colonoscopy [4-/2131] at [Hospital1 18]) * h/o left rotator cuff tear * h/o gout * h/o prostate cancer Social History: Widowed and retired. Former smoker but quit 30 years ago. Drinks a few beers per week. Family History: + for gout Physical Exam: BP: 153/72 HR: 90 RR: 12 O2 99% RA Gen: Pleasant, well appearing elderly African American male in no distress, lying in bed HEENT: Slight conjunctival pallor. No scleral icterus. MMM. OP clear. NECK: Supple, No LAD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs appreciated. LUNGS: clear bilaterally, no wheezing ABD: slightly distended but soft, hypoactive bowel sounds, diffuse mild tenderness to palpation without guarding or rebound Rectal: Small amount of thin bright red blood on perianal area, no rectal fissure appreciated EXT: warm, no peripheral edema, DP pulses 2+ bilaterally SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. Face symmetric and speech clear, moving all extremities without difficulty. Pertinent Results: [2132-12-15] Colonoscopy Multiple non-bleeding diverticula with wide-mouth openings were seen in the whole colon.Diverticulosis appeared to be severe. Impression: Severe diverticulosis of the whole colon Otherwise normal colonoscopy to cecum Recommendations: Bleeding likely secondary to diverticulosis. Routine post-procedure orders [2132-12-15] EGD Previous gastrectomy with roux en y anastomosis of the stomach Benign appearing polyp in the stomach Otherwise normal EGD to third part of the duodenum Recommendations: Routine post-procedure orders. No etiology of bleeding found. [2132-12-12] CTabd/pelvis 1. Pancolonic diverticulosis with no evidence of diverticulitis. 2. Unchanged appearance of multiple hypodense liver lesions which were previously characterized as hemangioma and simple cysts. 3. Status post gastrectomy and esophageal jejunostomy for a gastric cancer. This study is not able to evaluate tumor recurrence at anastomosis [2132-12-17] GIB study INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images show no evidence of active tracer extravasation. Dynamic blood pool images show no pooling of tracer uptake to suggest active bleeding. Tracer activity inferior to the bladder is within the penis. IMPRESSION: No evidence of active intraluminal extravasation of tagged RBC's. [2132-12-12] 03:00AM BLOOD WBC-9.9# RBC-2.13# Hgb-7.1# Hct-21.6# MCV-102 MCH-33.6* MCHC-33.1 RDW-14.4 Plt Ct-113* [2132-12-13] 04:37AM BLOOD WBC-7.6 RBC-2.48* Hgb-8.4* Hct-22.9* MCV-92 MCH-33.8* MCHC-36.7* RDW-16.9* Plt Ct-104* [2132-12-14] 06:55AM BLOOD WBC-9.7 RBC-3.16# Hgb-10.1 Hct-28.6* MCV-90 MCH-32.0 MCHC-35.4* RDW-16.7* Plt Ct-113* [2132-12-15] 06:58AM BLOOD WBC-6.7 RBC-3.09* Hgb-9.8* Hct-26.7* MCV-86 MCH-31.6 MCHC-36.6* RDW-17.6* Plt Ct-111* [2132-12-16] 06:25AM BLOOD WBC-6.5 RBC-3.11* Hgb-9.9* Hct-28.1* MCV-90 MCH-31.8 MCHC-35.2* RDW-17.9* Plt Ct-133* [2132-12-17] 06:10AM BLOOD WBC-6.4 RBC-3.26* Hgb-10.3* Hct-29.0* MCV-89 MCH-31.5 MCHC-35.3* RDW-17.6* Plt Ct-142* [2132-12-18] 07:10AM BLOOD WBC-7.0 RBC-3.99* Hgb-12.2* Hct-34.4* MCV-86 MCH-30.6 MCHC-35.5* RDW-17.4* Plt Ct-174 [2132-12-19] 07:05AM BLOOD WBC-6.2 RBC-3.91* Hgb-12.5* Hct-35.0* MCV-90 MCH-32.0 MCHC-35.8* RDW-17.6* Plt Ct-194 [2132-12-12] 03:00AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3* [2132-12-15] 06:58AM BLOOD PT-13.0 PTT-27.0 INR(PT)-1.1 [2132-12-12] 03:00AM BLOOD Glucose-196* UreaN-45* Creat-1.8* Na-140 K-5.2* Cl-116* HCO3-15* AnGap-14 [2132-12-19] 07:05AM BLOOD Glucose-92 UreaN-20 Creat-1.3* Na-141 K-4.4 Cl-108 HCO3-25 AnGap-12 [2132-12-12] 03:00AM BLOOD ALT-34 AST-23 LD(LDH)-163 CK(CPK)-85 AlkPhos-57 TotBili-0.2 [2132-12-12] 03:00AM BLOOD Lipase-48 [2132-12-12] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.01 [2132-12-12] 12:03PM BLOOD CK-MB-NotDone cTropnT-0.01 [2132-12-12] 03:00AM BLOOD TotProt-4.2* Albumin-2.5* Globuln-1.7* [2132-12-12] 12:03PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0 [2132-12-19] 07:05AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2 [2132-12-13] 04:37AM BLOOD VitB12-281 Folate-19.8 [2132-12-14] 07:04AM BLOOD %HbA1c-5.9 Brief Hospital Course: Mr. [Known lastname 634] is a 76 year old man with PMH notable for gastric CA s/p gastrectomy admitted with massive BRBPR. # LGIB: Pt. was initially kept in MICU for close monitoring and repeatedly needed transfusions after having episodes of BRBPR. He had a colonoscopy which showed diverticulosis, but no bleeding source. Bleeding scan was attempted after an episode of BRBPR but was non localizing. His Hct stabilized and he did not have anymore episodes of BRBPR so he was d/c'd w/ instructions to call 911 immediately if he developed BRBPR . # Acute on chronic renal insufficiency: Cr returned to baseline after resucitation. . # Hyperglycemia: No history of diabetes per patient. Pt. had several finger sticks greater than 200 so Dx w/ DM. Pt. was told to F/u w/ his PCP RE Tx. # Hypoalbuminemia: Likely related to prior gastrectomy and possibly diet. Nutrition consulted and started on a multivitamin with minerals and Ensure TID. . # CODE: full, confirmed with patient # COMM: With patient and girlfriend, [Name (NI) ] [Name (NI) 174], [Telephone/Fax (1) 14024] Medications on Admission: travoprost eye gtt motrin prn (once daily) tylenol prn arthritis Allopurinol 300mg PO QD Indocin Cyproheptadine 4mg Viagra 100mg PRN Discharge Medications: 1. Travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Prilosec 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:2 4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 6. Outpatient Lab Work Please have a complete blood count drawn at Dr.[Name (NI) 14025] office. 7. 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 8. Viagra 100 mg Tablet Sig: One (1) Tablet PO as needed as needed for Erection. 9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 10. Indocin Oral 11. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO once a day: We did not change this, take whatever you did before. Discharge Disposition: Home Discharge Diagnosis: Primary Diverticulosis Lower gastrointestinal bleed Secondary Diabetes Mellitus type II Hypertension Discharge Condition: Stable, not bleeding Discharge Instructions: You have been diagnosed with diverticulosis and lower GI bleed. You lost a significant amount of blood before comming to the hospital and you required several blood transfusions. You need to take one iron supplement pill daily for the next month. We are also starting you on colace to help you have softer bowel movements. We also started you on an acid pill to prevent your gastrointestinal tract from bleeding. We also gave you a vitamin B12 shot and a pneumonia vaccine. While you were here you were also diagnosed with diabetes but your blood sugars remained well controlled most of the time. You should talk to Dr. [Last Name (STitle) 1789] about whether you should start taking medication for this or whether it can be controlled with diet and excercise. You need to get your blood drawn at Dr.[Name (NI) 14025] office at 2:00 p.m. on Monday [12-22]. You should eat a diet high in fiber (you can see the amount of fiber in the nutrition information on the box). You should also avoid seeds and whole nuts, peanut butter is fine. You should not consume more than one or two alcoholic beverages per night. Please follow the diet instructions included in the included information. Please take all of your medications exactly as prescribed. If you have ANY rectal bleeding, black tarry stools, shortness of breath, fainting, chest pain, confusion or any other concerning symptoms please call your doctor immediately or go to the emergency department. Followup Instructions: You need to get your blood drawn at Dr.[Name (NI) 14025] office at 2:00 p.m. on Monday [12-22]. [Name6 (MD) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2132-12-25] 1:30 Provider [Name9 (PRE) ] GATES, [Name9 (PRE) 280] MSN Phone:[Telephone/Fax (1) 1228] Date/Time:[2133-1-6] 11:30 Dr. [Last Name (STitle) 1789] Thursday [2132-12-25] 12:00 call [Telephone/Fax (1) 1792] w/ questions. Have your blood drawn at Dr.[Name (NI) 14025] on monday [12-22] at 2:00p.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811] Completed by:[2132-12-24]	[ "5849", "40390", "5859", "2859", "2875", "25000" ]
Admission Date: [2136-11-29] Discharge Date: [2136-12-9] Date of Birth: [2063-5-3] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 73 year old woman, with a remote history of tuberculosis, status post wedge resection in [2087], and history of bronchoalveolar lung cancer, status post right upper lobe lung lobectomy and XRT in [Month (only) 958] of this year. She presented to an internist in [State 108] three to four weeks prior to admission, with a complaint of non productive cough. No fevers or shortness of breath above baseline. Cough was also associated with chest pain on the right side that was sharp and pleuritic, occurring with coughing. No sick contacts. [Name (NI) ] international travel. The patient was started on a five day course of Azithromycin for treatment of bronchitis versus viral pneumonia. The patient reports that she has had viral pneumonia six times in the past 40 years. She received Pneumo-Vax immunization two years ago. The patient flew from [State 108] to [Location (un) 86] about five days prior to admission and worsening non productive cough on antibiotics. She developed low grade fevers to 100 to 100.5 and worsening dyspnea on exertion. Chest pain was unchanged. She saw her local physician. [Name10 (NameIs) ] x-ray done per husband reports a right lower lobe pneumonia and pleural effusion. White count of 14.8. The patient was then started on Moxifloxicin. One day prior to admission, the patient's symptoms worsened and she spiked a temperature to 102 and had shaking chills. She presented to [Hospital3 3834] [Hospital3 ]. Outside hospital temperature was 98.4. Pulse was 104. Respiratory rate of 20. Oxygen saturation 94%. Blood pressure 120/54. Chest x-ray showing worsening pneumonia in right middle lobe and right lower lobe. White blood cell count of 25. The patient was started on Vancomycin and Ceftazidime. The patient underwent ultrasound guided thoracentesis for small pleural effusion, with only 3 cc of fluid aspirated, which was hazy, yellow pleural fluid; however, pH was 6.89; glucose of 46; total protein of 4.5; LDH of 388. White count to 600; red count of 20,000 with 92 neutrophils, 4 lymphs, 4 monos. Pleural fluid culture was sent and did not grow any organisms. Infectious disease was consulted and the patient's antibiotics were changed to Vancomycin and Ciprofloxacin. Given low pH of pleural fluid and concerns for empyema, patient was transferred to [Hospital1 188] for thoracic surgery evaluation. On admission, CT scan of chest obtained showed one moderate sized, multi-loculated right pleural effusion with slight thickening of pleural rind, concerning for empyema. Patchy, peripheral consolidation of right lower lobe, as well as more diffuse ground glass opacity, consistent with pneumonia. Right hilar lymphadenopathy as well as slightly enlarged nodes in the zygoesophageal recess, may be reactive peripheral ground glass opacities in left upper lobe. Two small left lower lobe lung nodules. One contains component of calcification and an empyema. Of note, the patient reports a CT of chest was obtained [11-10], prior to head surgery, and was normal. The patient underwent pig tail catheter into right thoracic space with 100 cc of straw-colored fluid removed. Catheter was maneuvered in an attempt to direct as many loculations as possible. Gram stain showing 3+ PNM's, no micro-organisms. Fluid was sent for culture. ALLERGIES: No known drug allergies. MEDICATIONS: Hydrochlorothiazide 12 mg p.o. q. day. Zestril 10 mg p.o. q. day. Multi-vitamins. Calcium 150 mg p.o. q. day. [Last Name (un) ]-Pro times 20 years for osteoporosis prevention. PAST MEDICAL HISTORY: Hypertension. History of tuberculosis in [2087], treated for two years with Streptomycin and PF. Status post wedge resection with phrenic nerve injury in [2087]. History of spondylosis, status post spinal fusion in [2109]. Hospital course complicated by meningitis and spinal leak. Bronchoalveolar lung cancer, status post right upper lobe lobectomy, [2-9], followed by XRT for three months, finished in [5-11], with reported negative chest CT on [9-10]. Bilateral hip replacements for osteoarthritis in [12-12] and [9-10]. Cutaneous porfira tarda, diagnosed in [2129], treated with phlebotomy. Status post appendectomy. SOCIAL HISTORY: Lived in [Location ], [State 350]. Moved to [State 108] about five years ago. Patient lives with husband who is a retired family physician. [Name10 (NameIs) 20282] have four children. 30 year tobacco history, quit in [2118]. Ethanol, 14 glasses of wine a week. Had walked two miles a day prior to hip surgery. The patient reports six episodes of pneumonia over the last 30 years, although one was viral. PHYSICAL EXAMINATION: On admission, the patient was afebrile, temperature 99.1; heart rate 89 to 102; blood pressure 120 to 160 over 63 to 90; respiratory rate 20 to 22; oxygen saturation 97% on two liters. Weight is 43 kilograms. General: Awake, alert, breathing comfortably, in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx moist. No buccal lesions. Neck supple. Heart regular rate, tachycardia at 100, no murmurs, rubs or gallops. Lungs: Positive bronchial breath sounds and egophony at right breast. Pigtail catheter in place on the right side. Left diffuse sub crackles. Abdomen: Soft, nontender, non distended, positive bowel sounds. Extremities: no edema or clubbing. Neurologic: Cranial nerves 2 through 12 intact. Strength 5/5 proximally and distally. Sensation grossly normal to light touch. LABORATORY DATA: White count of 20. Hematocrit of 29. Platelets of 637. 92 neutrophils, 3 lymphs, 3 monos, 3 eosinophils. Sodium of 134; potassium of 4.4 and chloride of 103. Bicarbonate of 22. BUN of 9. Creatinine of 0.7. HOSPITAL COURSE: The patient was initially admitted to the medical service, with the history as described above. However, she was then transferred to the Medical Intensive Care Unit on [2136-12-1] because of an episode of tachypnea and respiratory distress, in the context of an examination showing diffuse wheezing and prolonged inspiratory to expiratory ratio. INITIAL IMPRESSION: The initial impression was that the patient was having some component of reactive airway disease, which responded to a combined treatment. Low on the differential was a possible congestive heart failure. The patient was treated for both. She received Lasix and nitrates and had some relief of symptoms. She also was treated with nebulizers. The patient ultimately stabilized of the Neonatal Intensive Care Unit day one on [12-1]. Later in the day, the patient had worsening respiratory distress, requiring intubation. Her arterial blood gases at the time was 6.95, 76 and 102. The patient then received a bronchoscopy. It was felt that the patient had significant secretions and may have had an episode of mucus plugging and causing her desaturations and hypocarbic arrest. The patient was noted to have a very small airway and a #6 endotracheal tube was placed. Results of bronchoscopy on [2136-12-3] revealed patent trachea, main right stem and right upper lobe bronchus are patent; right bronchus intermedius was patent and there were no masses visible. Right middle lobe was patent. Minimal to moderate amounts of white secretion. Right upper lobe bronchus was patent and visualized with anterior apical and post bronchial right lower lobe was also patent. The patient was transiently on Dopamine for an episode of hypotension, though she had a brief episode of atrial fibrillation on transfer to the Intensive Care Unit. She remained hemodynamically stable and out of atrial fibrillation. The patient was weaned to pressure support ventilation by [2136-12-4] but had increased tachypnea with decreased pressor support. Chest x-rays showed persistent middle and right lower lobe infiltrates; no significant effusion and also left upper lobe infiltrate. Culture data revealed positive Strep Milleri from her pleural fluid. Antibiotics were changed to Ceftriaxone for coverage of Strep Milleri. By [2136-12-6], however, the patient had increased respiratory distress, after being extubated on [2136-12-5]. The thought was that she likely had another episode of mucus plugging. Examination was consistent with reactive airways. She was intubated again on [2136-12-6], after discussing with the patient and her husband, who is her health care proxy. From a cardiac standpoint, the patient remained hemodynamically stable, slightly hypotensive, but ruled out for a myocardial infarction, with only some "T" wave inversions on electrocardiogram. Overall picture and impression of team at this time was that the patient had underlying poor pulmonary reserve, in the context of remote tuberculosis history and wedge resection on the left; recent bronchoalveolar carcinoma on the right, status post resection, with a concurrent empyema and probably some component of restrictive disease with fibrosis, as well as an active pneumonia, requiring repeat intubation. Over the next two days, the patient remained stable but then requiring continued treatment for Strep Milleri with continuous Ceftriaxone. Vancomycin was added for Mersa which grew from a bronchoalveolar lavage done on [2136-12-7]. After extensive discussion with family and the patient's husband, who is her health care proxy, consent was achieved between the patient's family and the team regarding the fact that the patient's overall prognosis for recovery was limited and moreover, the patient and her husband had strong feelings against undergoing a tracheostomy and a prolonged wean. Given this wish not to have a tracheostomy, it was felt that the patient would be unlikely to have any significant improvement over the next several days and would ultimately require a tracheostomy and require very prolonged Intensive Care Unit and then rehabilitation course, should she recover at all. At this point, the patient's husband and family reached consensus on [2136-12-9] that the patient's care should focus on comfort care. The patient was extubated on [2136-12-9] with her family present. She remained comfortable. The patient had respiratory failure and died at 4:07 p.m. on [2136-12-9]. The patient's husband requested a post mortem examination. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 37297] Dictated By:[Name8 (MD) 37298] MEDQUIST36 D: [2136-12-9] 16:39 T: [2136-12-17] 08:28 JOB#: [Job Number 37299]	[ "51881", "42731", "5119", "49390" ]
Admission Date: [2173-2-18] Discharge Date: [2173-3-2] Date of Birth: [2105-11-25] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7299] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation [2173-2-18] Lumbar puncture [2173-2-20] History of Present Illness: 67F with end stage multiple sclerosis c/b torticollis who presents to ED from long-term care facility with AMS. Patient with chronic indwelling foley, and she finished a course of cipro on [2-14] for a UTI. She became increasing altered in the days prior to admission and became unresponsive in the ED. She was admitted to the ICU with BP of 86/40 and was intubated for airway protection. She was fluid responsive, and never on pressors. Initially she put on Vanc/Cefepime/Cipro for sepsis of unknown source. Urine cx grew Vanc-sensitive enterococcus, and abx were narrowed to Vanc alone. Due to persistent altered state, EEG was ordered which showed concern for non-convulsive status epilepticus. She was by neuro and started on Keppra with resolution of seizure activity. LP, although difficult, was negative for high OP, meningitis, and HSV. She remained intubated until [2-25]. Prior to extubation, tan secretions were noted and she was placed on VAP protocol with Vanco, Tobra (given no cipro for seizures), Zosyn. MiniBAL and sputum cx are pending. . Currently, patient denies difficulty breathing or cough. She is hungry, asking for doritos, and denies abdominal pain or nausea. She has no headache. Past Medical History: - Multiple sclerosis diagnosed at age 30, wheel chair bound since [2166] - Torticollis - Scoliosis s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 931] rod placement - Constipation - Chronic pain - Allergic rhinitis - Depression - Peripheral vascular disease - Urinary incontinence - Neurogenic bladder with chronic Foley catheter - HTN - Osteoporosis - Obstructive hydrocephalus - Insomnia Social History: Has been living in a nursing facility for about the past 2 years. Is divorced and has one son who is her only support outside the facility. No tobacco, alcohol, or drug use per son. Family History: Parents lived till mid 80s w/o major medical ailments. Father died of heart attack. Grandmother developed dementia at last year of her life. Physical Exam: FEX ON MICU ADMISSION Vitals: T: 101, BP: 130s-170s/40s-90s, P: 120s-130s, R: 15 O2: 100% on AC with TV=400, PEEP=5, FiOs=50% General: Intubated/sedated, responds to painful stimuli HEENT: Sclera anicteric, dry MM, ET tube in place, PERRL Neck: muscle contractures with rightward head deviation from torticollis CV: Tachcardic, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: Bilateral upper extremities appear mottled and cool to the touch with good pulses. Lower extremities are warm, well perfused, 2+ pulses, no clubbing or edema Neuro: intubated/sedated, responds to painful stimuli, opens eyes spontaneously, marked muscular contractures, rightward head deviation from torticollis FEX ON DISCHARGE VS - 98.8 98.3 159/77 96 20 97%RA General: Awake, alert, oriented and appropriate HEENT: Sclera anicteric, MMM Neck: Muscle contractures with rightward head deviation from torticollis CV: RRR, no murmurs, rubs, gallops Lungs: Appears comfortable on RA. Limited posterior ausculatation clear. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: No CCE, no joint swelling or pain, RLE with anterior bruising, no increased swelling or pain. Neuro: awake, alert, and oriented. Good attention and follows commands. Marked muscular contractures, rightward head deviation from torticollis. Strength unchanged Pertinent Results: PERTINENT MICROBIOLOGY: [2173-2-25] 12:04 pm Mini-BAL FINAL REPORT [2173-2-27] GRAM STAIN (Final [2173-2-25]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2173-2-27]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. Time Taken Not Noted Log-In Date/Time: [2173-2-18] 11:54 am BLOOD CULTURE FINAL REPORT [2173-2-22] Blood Culture, Routine (Final [2173-2-21]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. ENTEROCOCCUS FAECALIS. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin = 2.0 MCG/ML SENSITIVE Sensitivity testing performed by Etest. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [2173-2-19]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 0503 ON [2-18] - [Numeric Identifier 85530]. GRAM POSITIVE COCCI. PAIRS AND SHORT CHAIN. Aerobic Bottle Gram Stain (Final [2173-2-19]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by DR. [Last Name (STitle) ] [2173-2-19] 12:18PM. Time Taken Not Noted Log-In Date/Time: [2173-2-18] 11:11 am URINE FINAL REPORT [2173-2-20] URINE CULTURE (Final [2173-2-20]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S . . PERTINENT STUDIES: [2173-2-27] Radiology CHEST PORT. LINE PLACEM Rotated positioning. Previously seen left IJ catheter has been removed. Left subclavian PICC line is present. The tip may be partially obscured by the spinal hardware. However, I suspect it is unchanged in position and likely lies at the SVC/RA junction. No pneumothorax is detected. Again seen is obscuration of the left diaphragm and increased retrocardiac density. There is more pronounced patchy opacity at the right base. Suspect mild pulmonary vascular plethora. [2173-2-26] Radiology CHEST (PORTABLE AP) Interval extubation. Stable bilateral pleural effusions, large on the left and small on the right. Possible minimal pulmonary edema. [2173-2-21] Neurophysiology EEG This is an abnormal continuous ICU monitoring study because of frequent bifrontal and parasagittal generalized periodic epileptiform discharges. Although some of the bifrontal discharges have triphasic features but, given their evolution, these are most likely related to earlier epileptiform activity. These findings are indicative of focal cortical irritability and potential epileptogenicity predominantly in the bifrontal regions. In addition, the background is diffusely slow and disorganized indicative of moderate to severe encephalopathy. Compared to the prior day's recording, there is improvement with fewer blunted discharges and longer periods of disorganized theta activity without bifrontal discharges. [2173-2-20] Radiology MR HEAD W & W/O CONTRAS 1. Unchanged ventriculomegaly with associated cerebellar atrophic changes, with no evidence of transependymal migration of CSF. Scattered foci of high signal intensity are identified in the subcortical and periventricular white matter, likely consistent with chronic microvascular ischemic changes. 2. Chronic hydrocephalus, possibly communicating, is a consideration, there is no evidence of leptomeningeal enhancement to suggest arachnoiditis, the possibility of a Dandy-Walker variant is also a consideration. 3. Unchanged opacity of the ethmoidal air cells and sphenoid sinus suggesting an ongoing inflammatory process. [2173-2-20] Cardiovascular ECHO Poor image quality. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The RV is not well seen but overall normal free wall contractility is probably 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([12-28]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. [2173-2-20] Neurophysiology EEG This is an abnormal continuous ICU monitoring study because of frequent generalized periodic epileptiform discharges (GPEDs) at times as frequent as one to two per second. These do not evolvefurther into non-convulsive status epilepticus. However, these findings are indicative of severe cortical irritability and potential epileptogenicity in a generalized distribution. The backgroundtowards the later portion of the recording is diffusely slow and disorganized indicative of moderate to severe encephalopathy. [2173-2-19] Radiology BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in either lower extremity. The study and the report were reviewed by the staff radiologist . [2173-2-18] Radiology CT HEAD W/O CONTRAST 1. No evidence for intracranial hemorrhage or other definite acute process. 2. Moderate enlargement of all ventricles, more striking than background cerebral atrophic changes, although cerebellar atrophy is substantial. There is no hypodensity about the ventricles to suggest transependymal edema. Correlation with clinical history is recommended and comparison to prior head CT, if available, may be helpful to assess for chronicity. Major differential considerations include chronic hydrocephalus, probably communicating, associated with a prior inflammatory process such as arachnoiditis or perhaps in association with a congenital lesion such as Dandy-Walker variant. 3. Opacification of the left sphenoid sinus with bony thickening suggesting longer chronicity and hyperdense material suggestive of fungal colonization. Blood: [2173-2-18] 12:54PM BLOOD WBC-20.3* RBC-4.26 Hgb-13.0 Hct-38.2 MCV-90 MCH-30.4 MCHC-33.9 RDW-12.6 Plt Ct-242 [2173-2-20] 01:15PM BLOOD WBC-15.5* RBC-3.44* Hgb-10.1* Hct-29.0* MCV-84 MCH-29.5 MCHC-35.0 RDW-13.1 Plt Ct-210 [2173-2-23] 03:09AM BLOOD WBC-15.3* RBC-3.38* Hgb-9.8* Hct-28.3* MCV-84 MCH-29.0 MCHC-34.6 RDW-13.1 Plt Ct-272 [2173-2-26] 02:15AM BLOOD WBC-17.6* RBC-3.55* Hgb-10.3* Hct-30.6* MCV-86 MCH-29.0 MCHC-33.7 RDW-13.1 Plt Ct-457* [2173-2-28] 05:20AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-26.5* MCV-82 MCH-29.1 MCHC-35.5* RDW-13.5 Plt Ct-456* [2173-3-2] 05:16AM BLOOD WBC-13.9* RBC-3.29* Hgb-9.9* Hct-27.5* MCV-84 MCH-30.1 MCHC-36.1* RDW-14.0 Plt Ct-485* [2173-2-20] 01:15PM BLOOD PT-13.3* PTT-31.9 INR(PT)-1.2* [2173-2-22] 04:31AM BLOOD PT-12.1 PTT-37.4* INR(PT)-1.1 [2173-2-18] 12:54PM BLOOD Glucose-149* UreaN-30* Creat-0.8 Na-145 K-3.7 Cl-112* HCO3-18* AnGap-19 [2173-2-21] 03:41AM BLOOD Glucose-125* UreaN-10 Creat-0.2* Na-142 K-3.2* Cl-106 HCO3-29 AnGap-10 [2173-2-23] 03:09AM BLOOD Glucose-131* UreaN-9 Creat-0.3* Na-144 K-3.7 Cl-101 HCO3-35* AnGap-12 [2173-2-25] 03:40AM BLOOD Glucose-135* UreaN-15 Creat-0.4 Na-137 K-4.2 Cl-100 HCO3-24 AnGap-17 [2173-2-28] 05:20AM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-141 K-2.9* Cl-104 HCO3-27 AnGap-13 [2173-3-2] 05:16AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-141 K-3.8 Cl-105 HCO3-29 AnGap-11 [2173-2-18] 12:54PM BLOOD ALT-18 AST-30 LD(LDH)-367* CK(CPK)-171 AlkPhos-92 Amylase-111* TotBili-0.4 [2173-2-20] 01:15PM BLOOD ALT-18 AST-29 LD(LDH)-360* AlkPhos-94 Amylase-57 TotBili-0.5 [2173-2-18] 12:54PM BLOOD Lipase-26 [2173-2-18] 12:54PM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-0.06* [2173-2-19] 03:57PM BLOOD Calcium-9.1 Phos-1.2* Mg-1.8 [2173-2-23] 03:09AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 [2173-2-27] 05:39AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7 [2173-3-2] 05:16AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 [2173-2-21] 03:41AM BLOOD Cortsol-8.3 [2173-2-19] 03:57PM BLOOD TSH-0.84 [2173-2-20] 09:09PM BLOOD Vanco-8.0* [2173-2-25] 03:40AM BLOOD Vanco-32.0* [2173-2-26] 02:15AM BLOOD Tobra-1.8* [2173-2-27] 08:53PM BLOOD Vanco-14.5 [2173-2-18] 10:49AM BLOOD Type-ART pO2-160* pCO2-53* pH-7.31* calTCO2-28 Base XS-0 [2173-2-19] 09:06AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.34* calTCO2-23 Base XS--3 [2173-2-24] 02:25PM BLOOD Type-ART PEEP-5 pO2-141* pCO2-40 pH-7.48* calTCO2-31* Base XS-6 Intubat-INTUBATED [2173-2-18] 11:08AM BLOOD Lactate-4.4* [2173-2-18] 12:51PM BLOOD Lactate-1.8 [2173-2-19] 09:06AM BLOOD Glucose-148* Lactate-2.5* Na-143 K-4.4 Cl-115* [2173-2-20] 01:24PM BLOOD Lactate-0.7 [2173-2-24] 02:25PM BLOOD Lactate-1.8 URINE: [2173-2-18] 04:14PM URINE Color-AMBER Appear-Cloudy Sp [Last Name (un) ]-1.012 [2173-2-18] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [2173-2-18] 04:14PM URINE RBC-121* WBC-62* Bacteri-MANY Yeast-NONE Epi-1 [2173-2-18] 04:14PM URINE CastHy-8* [2173-2-25] 10:07AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 [2173-2-25] 10:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CSF: [2173-2-20] 03:46PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-1 Lymphs-70 Monos-29 [2173-2-20] 03:46PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-85 [2173-2-20] 03:46PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-NEGATIVE [2173-2-20] 2:09 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [2173-2-20]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2173-2-23]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION 67 year old female with PMH of multiple sclerosis and torticollis presenting from a long term care facility for further evaluation of altered mental status and being transferred to the ICU for likely urosepsis after intubation for airway protection. ACTIVE PROBLEMS # Urosepsis: The patient has a known neurogenic bladder from her underlying multiple sclerosis with a chronic indwelling Foley. On admission, she was noted to be in septic shock with positive UA, BP of 86/40 and altered mental status. Due to her unresponsive state, she was intubated and placed on a vent in the ED. Her septic shock was initally treated broadly with vanco/cefepime/cipro; as further cultures came back, she was discovered to have a Vancomycin sensitive enterococcus growing from blood and urine. She did not require any pressors during her hospitalization. The day prior to her discharge from the ICU she was noted to have increased tan secretions, increasing WBC count, and low grade fever concerning for VAP. She was initated on VAP protocol with Tobramycin and Zosyn in addition to her Vancomycin for VSE. However, she was rapidly extubated and transferred to the floor with improving clinical status. All BAL/sputum Cx returned negative for growth and decision was made to discontinue VAP coverage. Pt was switched to ampicillin alone to complete a 14 day course for VSE urosepsis, last dose [3-4] PM, then PICC line may be pulled. # Respiratory Failure/VAP: She was intubated until 1 day prior to her discharge from the ICU for concerns regarding her mental status, as well as secretions. She was also a very difficult intubation due to her torticollus. Given concern for VAP on [2-25] in setting of with new tan secretions and leukocytosis, she was started on tobramycin and zosyn in addition to vanco on [2-25]. She was also started on hyoscyamine for secretions. Following discharge from the ICU, patient's respiratory status was greatly improved and she was satting well on room air. Given clinical improvement and negative BAL cultures, VAP coverage antibiotics were discontinued. Pt was monitored clinically on Ampicillin alone for an additional 48hrs and remained afebrile with no new respiratory symptoms, maintaining sats on RA. # Altered Mental Status/Seizures: Patient noted on EEG suggestive of non-convulsive status. Unclear how long patient has been having seizures. An LP was performed, which was predominately negative. Patient was started on acyclovir, empirically. MRI showed chronic hydrocephalus and ventriculomegaly with periventricular white matter changes. Acyclovir was discontinued once CSF was negative for HSV. Patient became much more alert and interactive following extubation. She was maintained on Keppra and Risperdal was stopped. On transfer to the floor, patient was alert and oriented x3. She was discharged at her baseline mental status. # Goals of care: Patient a DNR/DNI, confirmed in discussion with patient once extubated and lucid; son and HCP [Name (NI) ] expressed interest in the patient being made do not hospitalize with palliative care. As of now, patient may be rehospitalized, but the facility should contact [Name (NI) ] prior to transferring her to hospital. [Doctor First Name ] was advised to follow up with facility if the patient decides those are her wishes. #. Sinus Tachycardia. Patient had sinus tachycardia into the 120s while in the ICU. Patient was placed on lower dose Metoprolol 37.5 mg TID while in the ICU. Prior to discharge, metoprolol was increased to her home dose of 150mg daily and HR remained in the 80s. # CT read of fungal sinusitis: Per ENT, CT was suggestive of a chronic process and not invasive fungal disease. ENT recommended an outpatient follow-up for possible resection if symptomatic. Currently, fungal ball is not symptomatic. CHRONIC PROBLEMS # Hydrocephalus: Chronic, no changes during hospitalization. #. Multiple Sclerosis. The patient has severe multiple sclerosis with resultant muscle contractures; she has been wheelchair bound since [2166], and has a neurogenic bladder requiring chronic Foley. We continued her on some of her home medications, but not all given concerns for her mental status. Her baclofen was decreased to 5mg tid, and her bethanechol was discontinued. #. Chronic pain. Seemingly related to contractures from underlying multiple sclerosis. Patient denied pain during her stay. We continued her on a lidoderm patch prn but have been holding her home ibuprofen, MS Contin, tramadol, gabapentin and voltaren gel. She was doing well on this minimized regimen and may not need this additional medications going forward. #. HTN. Held home lisinopril while in ICU in setting of urosepsis. After transfer to the floor, her home dose of lisinopril was restarted. Metoprolol was also started at a lower dose (37.5 mg TID) until uptitration to her home dosing of 150mg Toprol daily prior to discharge. #. Osteoporosis. Held home alendronate. Continued Calcium supplementation. #. Constipation. Continued home docusate, senna, miralax. #. Depression: Had been holding home medications given intubation and altered mental status. Discontinued risperdol and Tramadol given they can lower seizure threshold. We also held her abilify and trazadone. We continued her citalopram. MEDICATION CHANGES Start Keppra 750mg po bid Start ampicillin 2 IV q4 to complete 2 weeks Decrease baclofen to 5mg tid Stop bethanechol Stop morphine Stop Tramadol Stop gabapentin Stop Risperdal Stop trazodone Stop voltaren TRANSITIONAL ISSUES -Made a number of adjustments to her psychiatric and pain medications. Would monitor closely -Will need to complete 14 days of ampicillin to treat urosepsis -Patient with apparent fungal ball in sinus on CT. Currently asymptomatic. Would continue to monitor. -Please talk to HCP and son [Name (NI) ] before any major changes to patient's goals of care *If patient becomes febrile, develops productive cough or worsening respiratory status, low threshold to initiate Vancomycin and Pip/Tazo for 7 day course for HCAP treatment.* Medications on Admission: - Alendronate 70mg weekly on Monday - ASA 81mg daily - Baclofen 10mg TID - Bethanechol 50mg QID - Calcium carbonate 500mg TID - Cranberry 475mg daily - Docusate 200mg [Hospital1 ] - Fish Oil daily - Fleet enema rectally every day PRN constipation - Loratadine 10mg daily - Fiber daily - Metoprolol succinate 150mg daily - Multivitamin daily - Miralax 17 grams twice daily - Selenium 200mcg - Senna 4 tabs twice daily every other day - Vitamin B complex daily - Vitamin C 500mg daily - Vitamin D 1000 units daily - Ibuprofen 600mg TID - Lidoderm 5% patch topically to sternum (12 hrs on/12 hrs off) - Tylenol 1000mg three times daily - Morphine ER 30mg [Hospital1 ] - Tramadol 75mg every 6 hours prn pain - Abilify 2.5mg at bedtime - Citalopram 40mg daily - Gabapentin 100mg every morning - Gabapentin 300mg at 2PM and 8PM - Risperdal 0.5mg [Hospital1 ] prn agitation - Trazodone 100mg at bedtime - Voltaren 1% gel to chest every 4 hours PRN pain - Lisinopril 10mg daily - Flaxseed oil 1000mg daily Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: on Monday. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 5. cranberry 475 mg Capsule Sig: One (1) Capsule PO once a day. 6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Fish Oil Oral 8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 10. Fiber Supplement Powder Oral 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 12. multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Miralax 17 gram/dose Powder Sig: One (1) pack PO twice a day as needed for constipation. 14. selenium 200 mcg Capsule Sig: One (1) Capsule PO once a day. 15. senna 8.6 mg Capsule Sig: Four (4) Capsule PO every other day. 16. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 17. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 21. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three times a day. 22. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 23. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day. 25. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln Intravenous every four (4) hours for 3 days: Last dose 3/8 PM. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 3075] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for living Discharge Diagnosis: Sepsis from a urinary source Status epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted because you had a severe urinary tract infection which led to persistent seizures. You were treated in the intensive care unit, and you were intubated for several days. You were started on IV antibiotics to treat your infection and started on levetiracetam (Keppra) to control the seizures. Once these were controlled, you were transferred to the floor, and we watched you for a few days while we adjusted your medications. At this time, it is safe for you to return home. You should follow up with your neurologist as scheduled below. Please note the following changes to your medications: Start Keppra 750mg po bid Start ampicillin 2 IV q4 to complete 2 weeks Decrease baclofen to 5mg tid Stop bethanechol Stop morphine Stop Tramadol Stop gabapentin Stop Risperdal Stop trazodone Stop voltaren Followup Instructions: Location: [Hospital3 3765], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Bldg Address: 131 ORNAC [Apartment Address(1) 85531], [Location (un) 1514], MA Phone: [Telephone/Fax (1) 85532] Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], Neurology Appt: [3-9] at 11am	[ "51881", "78552", "99592", "5990", "4019", "42789" ]
Admission Date: [2178-1-20] [Month/Day/Year ] Date: [2178-1-28] Date of Birth: [2112-1-5] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: Closed reduction and traction pin R hip [1-20] ORIF acetabulum [1-22] ORIF 5th metacarpal [1-22] History of Present Illness: 66M restrained driver s/p motor vehicle crash with +LOC GCS15 +airbag deployment and +windshield crack. Past Medical History: HTN, Gout, MI s/p CABG, Left femur surgery Social History: Married, lives with wife Family History: Noncontributory Physical Exam: Upon admission: 98.2 47 120/40 NAD, AAOx3, Pleasant Sclera clear. NCAT. EOMI, PERRLA MMs pink/moist Non-labored respirations Brady, RR Left hand with obvious swelling/bruising over the ulnar aspect of the palm. + ulnar and radial pulses. Sensation intact in median, ulnar, and radial sensory nerve distributions. Left little finger rotated and scissors with flexion into the ring finger, slight (2-3 mm) shortening compared to opposite side. Superficial skin avulsion measuring 1.5 cm round over the apex of this fracture on the dorsum of the hand. Small open area of dermis in the center of the soft tissue defect with no obvious exposed bone. Pertinent Results: [2178-1-20] 06:15PM WBC-12.1* RBC-4.02* HGB-13.6* HCT-38.3* MCV-95 MCH-33.7* MCHC-35.5* RDW-13.9 [2178-1-20] 06:15PM PLT COUNT-104* [2178-1-20] 06:15PM PT-12.6 PTT-20.2* INR(PT)-1.1 [2178-1-20] 06:15PM ALT(SGPT)-145* AST(SGOT)-218* CK(CPK)-478* ALK PHOS-44 AMYLASE-128* TOT BILI-1.0 DIR BILI-0.3 INDIR BIL-0.7 [2178-1-20] 06:15PM GLUCOSE-151* UREA N-33* CREAT-1.4* SODIUM-134 POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-23 ANION GAP-12 [2178-1-20] 06:15PM LIPASE-165* Cardiology Report ECG Study Date of [2178-1-20] 6:10:10 PM Supraventricular bradycardia. The P wave is atypical for sinus. Intraventricular conduction delay. Late R wave progression with lateral ST-T wave abnormalities. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 50 166 126 494/476 -63 77 -148 [2178-1-22] CTA CHEST W&W/O C&RECONS, NON- IMPRESSION: 1. Negative examination for pulmonary embolism. 2. Complete collapse of the right lower lobe and incomplete collapse of the left lower lobe probably due to hypoventilation and microatelectasis. 3. Small amount of bilateral pleural effusion. 4. Small contusions in the right middle lobe, adjacent to rib fractures. 5. Minimal aneurysm, aortic arch. 6. Right rib fractures (fourth, fifth, and sixth). [2178-1-26] RIGHT LOWER EXTREMITY ULTRASOUND IMPRESSION: No evidence of DVT. Brief Hospital Course: 66M presented from a referring hospital s/p motor vehicle crash complaining of right hip pain and was found to have dislocation with right acetabular fracture and left 5th metacarpal fracture. Reduction attempts at the referring hospital were unsuccessful. He was transferred to [Hospital1 18] for further management. Upon arrival repeat reduction attempts at bedside were also unsuccessful. He was then taken to the OR for reduction under general anesthesia and traction pinning. He was taken back to OR [1-22] for ORIF acetabular fracture by orthopaedics and ORIF left 5th MCP fracture by plastics. Postoperatively he did well initially and was extubated, however required reintubation for desaturation thought to be secondary to mucous plugging. A CTA of the chest was obtained showing no PE. He also underwent bronchoscopy and was extubated [1-12]. He was later transferred to the floor and developed respiratory distress and was transferred back to the Trauma ICU. A right thoracentesis was performed with return of 350 cc of fluid. On post procedure films patient was noted to have a small pneumothorax. Patient was started on Mucomyst/Ipratropium and Albuterol nebs q 6 hours along with aggressive chest PT with improvement in respiratory status. Pneumothorax was noted to decrease in size on serial CXRs. On [1-26] RLE LENI was performed demonstrating no DVT. Patient was transferred to the floor. Room air sats 93-95%. His hematocrit was noted to drift downward postoperatively. Given his cardiac history and recent CABG the decision was made to transfuse him with 2 units packed cells for a Hct of 21. Post transfusion Hct was 25.6. Hemodynamically he remained stable with this anemia. Physical therapy was consulted early during his hospital stay and recommended that he go to rehab after his acute hospitalization. Medications on Admission: Atenolol 50', Cardiazem 30 QID, allopurinol 100', ASA 81' [Month/Year (2) ] Medications: 1. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 0.5 ML's Subcutaneous DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) NEB Miscellaneous Q6H (every 6 hours): Give with Ipratropium. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for acute SOB/wheezing. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) DOSE Injection four times a day as needed for PER SLIDING SCALE: See attached sliding scale. 12. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). [Month/Year (2) ] Disposition: Extended Care Facility: [Hospital1 ] Cape & Islands [Hospital1 ] Diagnosis: s/p Motor vehicle crash Right acetabular fracture with posterior dislocation Left hand 5th metacarpal fracture Rib fractures Respiratory distress secondary to mucous plugging Acute blood loss anemia [Hospital1 ] Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Followup Instructions: Follow up in 2 weeks with Dr. [Last Name (STitle) 1005], orthopedics. Call [Telephone/Fax (1) 1228] for an appointment. Follow up in 2 weeks with Dr. [Last Name (STitle) ], Trauma Surgery. Call [Telephone/Fax (1) 6429] for an appointment. Follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] from rehab. You will need to call for an appointment. Completed by:[2178-1-28]	[ "51881", "5180", "5119", "2851", "4019" ]
Admission Date: [2108-12-7] Discharge Date: [2108-12-18] Date of Birth: [2036-10-9] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: inability to respond to questions Major Surgical or Invasive Procedure: (IV tPA administration at OSH) PEG placement on [2108-12-17] History of Present Illness: The pt is a 72 year old right-handed female history of a.fib off coumadin, and HTN, who presents from an outside hospital with a likely MCA stroke after being given tPA at [Hospital 4068] hospital and transferred here for possible intra-arterial intervention. The patient was at home with her husband returning from a [Holiday ] dinner. They went to bed at 21:30. At around 22:15 the husband was [Name2 (NI) 83992] by a gurgling sound coming from his wife. He looked over and asked her questions but she was unable to respond. Her daughter came over and noted that her face was asymmetric, but could not remember which side. She also noted that the patient did not appear to comprehend. EMS arrived on 22:50, and she was taken to [Hospital 4068] hospital. She had a CT, which was reportedly read as normal (but on our read here has a hyperdense MCA) and she was noted to have global aphasia, right sided weakness and left gaze deviation. He put the NIH scale at least 16 but he was not able to do a full scale secondary to aphasia. She was bolused with tpA at 23:50 and started on the infusion. She had finished the infusion by the time she arrived at [Hospital1 18]. On arrival the patient was initial not responsive to voice and commands per ED team. On arrival the patient was able to open her eye to sternal rub, was spontaneously moving the left arm and had a leftward gaze deviation. The patient was globally aphasic, with no comprehension, and was not following commands. She was intubated for airway protection. She then had a CTA/P, and it was noted that there were new hemorrhages on the CT, and any further intervention was deferred. NIH Stroke Scale score was 32: 1a. Level of Consciousness: 2 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 2 3. Visual fields: 2 4. Facial palsy: 2 5a. Motor arm, left: 3 5b. Motor arm, right: 3 6a. Motor leg, left: 3 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 3 10. Dysarthria: 2 11. Extinction and Neglect: 2 On neuro [Last Name (LF) ], [First Name3 (LF) ] family the patient had not complained of a headache. They noted that she had an episode of right leg weakness 3 days prior which seemed to resolve on its own. She had chronic back pain, and had some mild difficult walking at baseline. No No bowel or bladder incontinence or retention. On general review of systems, the family did not believe there were any recent fever or chills, or infectious symptoms. No cough/SOB, chest pain. No N/V. Past Medical History: - Atrial Fib, was on coumadin for 2 weeks ~ 1 year prior but per family cardiologist stopped it for unknown reason - HTN - Sciatica Social History: Lives at home with husband. [Name (NI) 23835] nearby. [Name2 (NI) ] in all ADLs. Very active per family. No etoh/tob/drug use. HCP [Name (NI) ] [Name (NI) 83993]: [Telephone/Fax (1) 83994] Family History: Multiple members of family with stroke and CAD. Physical Exam: Exam on admission: Physical Exam: (done pre-intubation) Vitals: T:98.3 P:134 R: 16 BP:114/112 SaO2:100% General: Opens eyes to nox stim, does not follow commands HEENT: NC/AT, no scleral icterus noted, Neck: Supple, Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: [Last Name (un) 3526] and tachy, slight flow murmur heard Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, Skin: no rashes, mild bruising on legs bilaterally Neurologic: -Mental Status: Will open eyes to loud voice and nox stimulation. Completely mute, does not follow commands. Does not appear to attend to R side -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2.5mm and brisk. Appears to have right field cut III, IV, VI: Left [Hospital1 ] gaze deviation, eyes do not cross midline to right V: did not test VII: R facial droop, VIII: Not tested IX, X: Gag intact [Doctor First Name 81]: not tested XII: not tested -Motor: Normal bulk, slight decreased tone on right. Patient was moving left arm and leg spontaneously, not moving right. Small amount of movement on right leg elicited with nox stim, trace movement on right arm with nox stim -Sensory: Sensation to pain intact at all 4 extremities -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 3 3 2 3 2 R 3 3 2 3 3 Toes, upgoing bilaterally, more on R Did not test coordination and gait. Pertinent Results: Labs on admission: [2108-12-7] 01:20AM BLOOD WBC-12.7* RBC-4.41 Hgb-13.7 Hct-39.7 MCV-90 MCH-31.1 MCHC-34.5 RDW-14.8 Plt Ct-217 [2108-12-8] 02:18AM BLOOD WBC-10.9 RBC-4.12* Hgb-12.8 Hct-38.0 MCV-92 MCH-31.0 MCHC-33.6 RDW-14.5 Plt Ct-188 [2108-12-7] 01:20AM BLOOD PT-14.5* PTT-31.9 INR(PT)-1.3* [2108-12-7] 01:20AM BLOOD Glucose-152* UreaN-28* Creat-0.8 Na-143 K-4.3 Cl- 107 HCO3-24 AnGap-16 [2108-12-11] 07:25AM BLOOD Na-139 [2108-12-11] 01:47AM BLOOD Glucose-121* UreaN-19 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-27 AnGap-11 [2108-12-8] 02:18AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 [2108-12-8] 04:48PM BLOOD Calcium-8.6 Phos-2.6* Mg-2.3 [2108-12-8] 06:22PM BLOOD Osmolal-296 [2108-12-9] 07:11AM BLOOD Osmolal-294 [2108-12-10] 09:13AM BLOOD Osmolal-300 [2108-12-11] 07:25AM BLOOD Osmolal-304 Imaging: CTA/P of head [12-7]: IMPRESSION: 1. Findings consistent with an acute left MCA infarct, with loss of [Doctor Last Name 352]- white matter differentiation in the left middle cerebral artery territory, including the insular region and left basal ganglia. There is thrombus in the supraclinoid segment of the left internal carotid artery extending into the bifurcation and into the left middle cerebral artery. There is marked asymmetry in the flow of the left middle cerebral artery territory, with corresponding perfusion abnormalities as detailed above. 2. Curvilinear hypodensity within the carotid bulb on the left, which may represent atherosclerotic disease versus an artifact. A dissection flap is considered less likely given that curvilinear hypodensity is localized to the carotid bulb. 3. There is subarachnoid hemorrhage in the left hemisphere, new since the outside head CT from [Location (un) 620] done only a short time prior to the current study. 4. Endotracheal tube in position. Orogastric tube incompletely visualized. 5. Old right temporal infarct with encephalomalacia. CTP: Image quality is degraded by poor signal to noise. There is suggestion of asymmetric decreased cerebral blood volume and blood flow, without definite asymmetry on the mean transit time. This correlates with the asymmetry on the CTA images in terms of the enhancement, with the left decreased compared to the right. CTH [12-7] 1.30pm IMPRESSION: Unchanged acute ischemia in the left MCA territory and foci of subarachnoid and subdural hemorrhage CTH [12-10] IMPRESSION: 1. Evolving left MCA distribution infarct with stable mass effect on the left lateral ventricle. 2. Stable multifocal subarachnoid hemorrhage, with no new foci of acute hemorrhage. CTH [12-11]: Again seen is a large area of hypodensity within the left MCA territory, consistent with expected evolution of infarct. The degree of mass effect on the left lateral ventricle and overlying sulcal effacement remains unchanged. The hyperdense left MCA is again noted. Foci of subarachnoid hemorrhage are also stable in extent and resolving. No new areas of hemorrhage are seen. The ventricles remain stable in size. IMPRESSION: Little change since prior study with evolving left MCA distribution infarct with stable mass effect. Stable extent of multifocal subarachnoid hemorrhage with no new areas of acute hemorrhage. The study and the report were reviewed by the staff radiologist. [12-16] KUB xray: The colon is gas-filled. There are no dilated loops of small bowel. There is no evidence of obstruction. The side port of the endogastric tube is within the stomach. There is no obvious pneumoperitoneum, although the lack of a decubitus view limits assessment of pneumoperitoneum. Degenerative changes are noted throughout the spine. IMPRESSION: No evidence of obstruction. Brief Hospital Course: 72 year old LEFT-handed woman with atrial fibrillation (off Coumadin) and HTN who presented from OSH with an MCA stroke and after receiving IV tPA was transferred to [Hospital1 18] for question of an intra-arterial intervention. On initial examination she was noted to be globally aphasic with R sided weakness and hemianopia, and L gaze deviation. She appeared to not have improved significantly after IV tPA and in the ED and became drowsy, with minimal eye opening to voice and sternal rub. She was eventually intubated for airway protection. On follow up CTA/P she was noted to have SAH in the cortical left frontal and left parietal lobes, felt to be due to tPA as well as a thrombus in the supraclinoid segment of the left ICA extending into the bifurcation and into the left MCA. CT imaging here showed a dense MCA sign, along with a CTP showing L decreased BV and BF. Due to new SAH, she was not a candidate for intraarterial tPA and was admitted to Neuro-ICU to complete post CVA care. NEURO. Patient's BP was maintained < 180, goal of -500 cc I/O, ASA and all anticoagulation were held due to concern for SAH, which was confirmed on a subsequent CT. CT on [12-8] also showed mass effect due to increasing edema at the frontal [Doctor Last Name 534] of the left lateral ventricle due to evolving infarct. At this time, she was started on mannitol, HOB elevation and fluid restriction w/ goal of -500 cc/day. With this treatment she slowly became more alert and was extubated. Serial head CTs showed stable SAH and evolving left MCA distribution infarcts with mass effect on the left lateral ventricle without herniation. Mannitol was weaned starting on [2108-12-11]. She was transferred to the floor an completely weaned off the mannitol. Given the size of the infarct it was decided not to start her an a heparin drip. Coumadin was restarted on [12-18] and she will be titrated for a goal INR of [2-14]. Here LDL was noted to be 111 and she was started on a statin at a low dose. Her blood sugar tests were normal. She will be discharged to a rehab facility to continue working on her weakness and speech deficits. CV. Patient remained in atrial fibrillation and had an episode of afib with RVR to 170s. She was treated with diltiazem gtt and started on PO diltiazem in addition to atenolol (she did not respond to IV metoprolol). Her final dosage of diltiazem was 90mg QID. She has been scheduled for outpatient cardiology follow up to help determine a suitable treatment for her atrial fibrillation. PULM. Patient was extubated on HD#3 without complications. RENAL. No issues. GI. She was treated with famotidine and TFs. She was noted to aspirate with all consistencies of nutrition thus was maintained on NGT and TFs. She repeatedly failed speech and swallow evaluations and required the placement of a PEG feeding tube. This was placed on [2108-12-17] without complications and tube feeds were started the next morning. Adjust PEG bumper in [2-14] days, with care not to over-tighten, as fat necrosis can occur Medications on Admission: - Atenolol 50 [Hospital1 ] - Simvastatin 20mg QD stopped taking a few weeks prior as she heard it can cause weakness - Tylenol/Codiene PRN Discharge Medications: 1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for apply between skin fold for yeast infection. 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 4 days. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): check INR for goal of [2-14]. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever, pain. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: Left Middle Cerebral Artery Stroke - likley embolic Discharge Condition: MS: Globally aphasic, does not follow commands, will mimic some actions, CN: R facial droop, EOM nearly intact, does not fully abbdict to the right, will attend to both sides but has a right sided gaze preference. Motor: No spontaneous movement of R hemibody, withdraws very slightly at RLE, Left upper and lower extremity move spontaneously and do not appear to be impaired. Sensory: grimaces to pain at all 4 ext Gait: deferred Coordination: could not evaluate Discharge Instructions: You were admitted as a transfer from an outside hospital for a large stroke of the left side of your brain. You were initially seen at an outside hospital were it was determined that you had a large stroke of a blood vessel in your brain called the left middle cerebral artery. You could not move your right side and could not speak or understand language. You were given a clot busting [Doctor Last Name 360] called tPa. You were not noted to improve significantly and were transferred to [Hospital1 18] to see if there were any other interventions that could be done. At [Hospital1 18] a follow up CT scan of your brain showed that there was some small amount of bleeding and it was determined that it was not safe to give any other interventions, which could increase the bleeding. You were transferred to the ICU, and were started on mannitol because of concern of swelling of your brain. This was slowly weaned off and you were transfered to the floor. You were weaned of the mannitol. On the floor your exam has remained largely unchanged but you have occasionally been able to make an occasional sound. Physical therapy was able to have you bear weight on your right leg. As you were not able to swallow a PEG feeding tube has been placed and your were started on tube feeds. You will be transfered to a rehab facility to continue to work on improving your strength. Please take all medications as prescribed, please make all follow up appointments. If you experience any of the symptoms listed below please call your doctor or return to the nearest emergency room. Followup Instructions: 1) Dr. [First Name (STitle) 162], MD, Neurology, Phone:[Telephone/Fax (1) 44] [2109-1-18] 9:30 2) Please see Dr. [Last Name (STitle) ], MD, Division of Cardiology, Phone: [Location (un) 83995], RW-453 [Location (un) 86], [Numeric Identifier 718] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2109-1-14] 8:00 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "42731", "4019" ]
Admission Date: [2133-3-30] Discharge Date: [2133-4-6] Date of Birth: [2062-4-4] Sex: M Service: VSU CHIEF COMPLAINT: A nonhealing right foot ulceration and rest pain. HISTORY OF PRESENT ILLNESS: This is a 71-year-old male, with a 30-pack year history of smoking and insulin dependent diabetes, coronary artery disease status post coronary artery bypasses x 4 with peripheral vascular disease, who underwent a left BKA and a left fem-[Doctor Last Name ] bypass graft which failed, who comes in with a nonhealing right foot ulcer on the fifth digit, and a history of rest pain in the right calf. He is a longstanding patient of Dr.[Name (NI) 1392], and has been seen for these symptoms. He is here for an arteriogram and vascular work-up. He has had an ulcer for three to four weeks. He has not been treated with antibiotics. He has been exuding purulence and sanguineous material, and is painful on ambulation. The patient also complains of one episode of rest pain of the right calf (cramping pain at night alleviated with standing). These symptoms occur in a leg status post fem-[Doctor Last Name ] bypass and femoral endarterectomy. The patient's left leg was amputated after multiple revascularization procedures. The patient has a long history of coronary artery disease. Denies any chest pain, shortness of breath. The patient now is admitted for IV hydration prior to undergoing diagnostic arteriogram. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Metformin 1,000 mg [Hospital1 ]. 2. Hydrochlorothiazide 25 mg once daily. 3. Avapro 75 mg once daily. 4. Lisinopril 40 mg once daily. 5. Lipitor 10 mg once daily. 6. Metoprolol 100 mg [Hospital1 ]. 7. Insulin, Humalog 70/30, 55 units q am and 30 units q pm. PAST MEDICAL HISTORY: Coronary artery disease. Type 2 diabetes, insulin dependent x 5 or 6 years. Peripheral vascular disease. Hypercholesterolemia. Renolithiasis. Hypertension. PAST SURGICAL HISTORY: Left BKA with revision in [2127-10-24]. Left internal carotid artery ligation with a carotid endarterectomy of a common carotid with a patch angioplasty in [2130-7-24]. Right common femoral endarterectomy and Dacron patch in [2130-8-24]. Coronary artery bypasses x 4 in [2121]. Bilateral fem-popliteal bypasses in [2122]. Left fem-popliteal bypass in [2125]. Cholecystectomy. Colon resection for cancer. PHYSICAL EXAM: VITAL SIGNS: 97.7, 120/70, 74, 80, fasting glucose 98. GENERAL APPEARANCE: Alert, cooperative white male in no acute distress. CHEST EXAM: Lungs are clear to auscultation. Heart has a regular rate and rhythm without murmur, gallop or rub. ABDOMINAL EXAM: Benign. VASCULAR EXAM: There is a right carotid bruit. The femoral pulse is palpable bilaterally. The graft pulse on the right is palpable, 1 plus. The popliteal is faint by palpation. The DP has dopplerable triphasic. The PT is a dopplerable signal only on the right. The right fifth toe plantar aspect shows a 2 x 1 cm ulceration with erythematous margins and tender to palpation. HOSPITAL COURSE: The patient was admitted to the hospital, vascular service, and placed on bed rest. Wound cultures were obtained, IV antibiotics were instituted, and IV hydration for anticipated arteriogram. The patient's white count on admission was 8.9, hematocrit 42.3, BUN 17, creatinine 1.0. Chest x-ray was no acute disease, status post open heart surgery. Ultrasounds of the carotids were obtained which showed a totally occluded left internal carotid artery. The right internal carotid artery showed 40- 59 percent. The patient underwent arteriogram on [2133-3-31] which was uncomplicated. The films were reviewed, and Dr. [Last Name (STitle) 1391] felt the patient was revascularable. His post angio labs remained stable with BUN of 17, creatinine 0.4, hematocrit 44.5. [Last Name (un) ] followed the patient during his hospitalization for glycemic management. The patient was preopped on [2133-4-1] for anticipated surgery. The patient underwent on [2133-4-2] a right common femoral endarterectomy with a patch angioplasty, a right superficial femoral artery to peroneal bypass using nonreversed saphenous vein, angioscopy and valve lysis. She tolerated the procedure well and was transferred to the PACU in stable condition. In the recovery room, the patient had an episode of hypotension, systolic, to the 60s. He was given Neo- Synephrine with good response. The patient denied any chest pain, although he was diaphoretic. He denied nausea or vomiting. EKG showed no changes from previous EKG. Cardiac enzymes were sent. The patient's total CK's peaked at 382, and over the next 72 hours returned to baseline of 169. The patient's CK-MB's rose gradually from 3, peaked at 7, and returned to baseline at 72 hours to 2. The patient's troponin levels were 0.3. On postoperative day 1, there were no overnight events, and the patient's exam was unremarkable. Pulse exam showed dopplerable monophasic DP, PT and peroneal. His diet was advanced as tolerated. IV fluids were Hep-Locked. His Lopressor was increased for rate control, and his insulin dosing was increased. He continued to be followed by [Last Name (un) ]. On postoperative day 2, there were no overnight events. T- max was 100.4-99.2. Exam was unremarkable. Lungs were clear to auscultation. Wounds were clean, dry and intact. Pulse exam remained unchanged. Ambulation to chair was begun. PT was requested to see the patient for touchdown weightbearing essential distances only. He required adjustment in his Lopressor dosing for systolic hypertension of 161. Heart rate was 86. Physical therapy did see the patient. They felt initially that the patient would benefit from [Hospital 3058] rehab to improve compliance with touchdown weightbearing. The remaining hospital course was unremarkable. Physical therapy would assess the patient prior to discharge and determine whether or not he would be safe to be discharged to home. An addendum will be dictated at that time. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg once daily. 2. Irbesartan 75 mg once daily. 3. Atorvastatin 10 mg once daily. 4. Aspirin 325 mg once daily. 5. Metformin 1,000 mg [Hospital1 ]. 6. Lisinopril 40 mg once daily. 7. Darvocet N 100, 1-2 tablets q 4 h prn pain. 8. Metoprolol 75 mg [Hospital1 ]. 9. Insulin 70/30, 55 units at breakfast and 30 units at dinner. 10. Humalog sliding scale. FOLLOW UP: The patient should follow-up with Dr. [Last Name (STitle) 1391] in 2 weeks time. He should ambulate essential distances only. He is to keep the foot elevated when not ambulating. He should not drive a car until he is seen in follow-up. He is to continue stool softeners until he is finished with his narcotics. DISCHARGE DIAGNOSES: Peripheral vascular disease, tibial disease, with a nonhealing right heel ulcer and rest pain, status post a right common femoral endarterectomy with patch angioplasty, status post right superficial femoral to peroneal bypass with nonreversed greater saphenous vein. Type 2 diabetes, insulin dependent, controlled. Coronary artery disease, status post coronary artery bypass graft x 4 in [2121], stable. Hypertension, controlled. Carotid disease with totally occluded left and a 40-59 percent right carotid stenosis, asymptomatic. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2133-4-6] 11:06:17 T: [2133-4-6] 11:54:43 Job#: [Job Number 29521]	[ "9971", "V4581", "42789", "4019", "25000", "V5867" ]
Admission Date: [2163-3-17] Discharge Date: [2163-3-22] Date of Birth: [2120-9-25] Sex: F Service: KURLIND CHIEF COMPLAINT: Shaking chills. HISTORY OF PRESENT ILLNESS: This is a 42 year-old woman with a history of type 1 diabetes who was recently discharged from [Hospital3 ] a little over a week ago after an admission for returns to the Emergency Room complaining of a two day history of shaking chills. She has not measured any fever at home. She denies chest pain, shortness of breath, cough, urinary symptoms, diarrhea, nausea, vomiting. She does admit to recently manipulating her Lasix dose to decrease her weight. significant for insulin dependent diabetes for thirty years with several episodes of diabetic ketoacidosis. She has nephropathy and is status post living related renal transplant in [2150] complicated by chronic rejection and therefore she has chronic renal insufficiency with a baseline creatinine of 2.6 to 3.5. She has diabetic neuropathy, hypertension, eating disorder, hydradenitis, recurrent urinary tract infections and she had a negative stress thallium test in [Month (only) 205] of last year. MEDICATIONS: Aspirin 325 mg q.d., Cyclosporin 100 mg b.i.d., Imuran 50 mg q.d., Diovan 80 mg q.d., Metoprolol 50 mg b.i.d., Zocor 20 mg q.d., Neurontin 100 mg b.i.d., Renagel one tablet three times a day, Bethanechol 25 mg t.i.d., Procrit 4000 units subcutaneous biweekly, Lentis 12 to 14 units every evening and Humalog sliding scale with one unit for every 15 grams of carbohydrate in a meal and 1 unit of 50 points of blood sugar over 150 before each meal. She takes Lasix 80 mg q.d. She also recently started Clonidine .1 mg b.i.d. and Bactrim DS one tablet every other day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: This is an emotionally upset woman in no acute distress. Temperature 97.8. Pulse 72. Respiratory rate 20. Blood pressure 116/68. Oxygen saturation is 100% on 2 liters nasal cannula. Examination of head, eyes, ears, nose and throat revealed pupils are equal, round and reactive to light with a surgical pupil on the right. Extraocular movements intact. Oropharynx is benign. Neck was supple without adenopathy or bruit. There was no JVD. Lungs were clear to auscultation bilaterally. Examination of the heart revealed a regular rate and rhythm with a grade 1 out of 6 systolic ejection murmur. Examination of the abdomen revealed it was soft, normoactive bowel sounds, nontender. There was on mass or organomegaly. Examination of the extremities revealed no rash or edema. On neurological examination the patient was alert and oriented times three. Cranial nerves II through XII were intact. Strength and sensation were equal and symmetric bilaterally. Deep tendon reflexes were 2+ and symmetric. There were no focal findings. INITIAL LABORATORY STUDIES: Significant for a white blood cell count of 14.8, hematocrit of 31, platelets 387, sodium 134, potassium 6.2, chloride 103, bicarb 13, BUN 95, creatinine 3.5, glucose 537. This gave her an anion gap of 18. A total CK was 120 with an MB fraction of 9.2, troponin [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] .3, calcium 8.3, phos 8.0, magnesium 2.6. Urinalysis showed trace ketones, 3 to 5 white blood cells, moderate bacteria and contaminated with 6 to 10 squamous epithelial cells. A chest x-ray showed no infiltrates. An electrocardiogram showed peaked T waves, poor R wave progression and slight ST elevations in V2 and V3 and ST depressions in V5 and V6 that were not significant from previous electrocardiograms. HOSPITAL COURSE: The patient was felt to be in diabetic ketoacidosis based on her laboratory work. She was begun on an insulin drip at 10 units an hour. She was also begun on intravenous fluids and she was treated with Levofloxacin for questionable bacteremia. She was admitted to the Medical Intensive Care Unit and the insulin drip was continued. Her blood sugar decreased on the insulin drip and she became hypoglycemic at 2:00 in the morning on the night of admission with a blood sugar of 21. This occurred approximately an hour and a half after the insulin drip was shut off. A central line was also placed in the right IJ at that time. When the patient's blood sugar was 21 she also became hypotensive and bradycardic. She was treated with 3 amps of D50 and also received copious amounts of intravenous fluid as well as Atropine to maintain her heart rate and blood pressure. Her glucose then increased back to as high 547 at which a low dose insulin drip was restarted. An arterial blood gas at this time revealed a pH of 7.16, CO2 42, PO2 of 186. An arterial line was also placed at this point. A repeat chest x-ray showed a question of a right lower lobe infiltrate versus asymmetric congestive heart failure. Due to the patient's decreased mental status and metabolic acidosis she was intubated at this time and placed on a ventilator. She was changed to D5 half normal saline. Her insulin drip was carefully managed to maintain her blood glucose at acceptable levels. The next morning the patient was noted to have increased BUN/creatinine with a BUN of 93 and a creatinine of 5.6. This was felt to be acute on chronic renal failure secondary to volume depletion with a question of ATN and her Cyclosporin was held. She received more intravenous hydration. Her Diovan and Lasix were also held. Her hematocrit was noted to have decreased from 31 to 23. She had no gross blood in her stool, but was guaiac positive. She was transfused with 2 units of packed red blood cells and subsequently had an appropriate increase in her hematocrit back to 31. The patient's blood sugars remained more stable subsequent to her intubation and she did not show signs of going back into diabetic ketoacidosis, although she did have a persistent low bicarb level between 14 and 17. She became more alert and responded to commands while on the ventilator and as her mechanics and oxygen saturation were good she was extubated and tolerated this well. She had no further respiratory problems. Her urine culture was positive for greater then 100,000 units of staph aureus, however, contaminants were present as well. She was given a single dose of Vancomycin, however, subsequent to this as there was no clinical evidence of systemic infection no further doses were given. The Levaquin was also discontinued as the official [Location (un) 1131] on the chest x-ray was not suggestive of a pneumonia. The patient was able to come off the insulin drip on hospital day number two and she was stable for transfer to the regular floor. The patient was noted to be very belligerent and confrontational after being extubated. The patient was also seen by cardiology consultation, because she had a slightly elevated MBCK of 11 with a total CK of 120. At this point a bedside echocardiogram was performed, which showed left atrial dilation, but a normal left ventricular that was hyperdynamic with an ejection faction of greater then 70%. No wall motion abnormalities were noted and no significant valvular abnormalities were noted except for 2+ tricuspid regurgitation, moderate pulmonary hypertension was seen. It was felt that no evidence of any ischemia or myocardial infarction. On hospital day three the patient's arterial blood gas was 7.35 pH, PCO2 of 29, PO2 113, and bicarb of 17. Her creatinine had decreased slightly to 5.2. At this time her Cyclosporin level was 81. She remained afebrile and hemodynamically stable. She was noted to have significant lower extremity edema bilaterally probably as a result of intravenous fluid during her hemodynamic resuscitation. By hospital day number four the patient's hematocrit was 31 and stable. Her creatinine had decreased to 4.6. She was extremely hostile and confrontational overnight threatening to leave and refusing to cooperate with the psychiatric consultation and therefore required security sitter. However, she was more cooperative although still somewhat hostile subsequent to this. The patient's blood sugars remained somewhat labile after she was resumed on her Lantus and sliding scale Humalog, however, her blood sugars did improve somewhat when a slightly more aggressive Lantus and sliding scale dosage was substituted. She remained afebrile with a normal white blood cell count and no further antibiotics were administered. The patient was begun on lasix as she was felt to be total volume overloaded. She had no evidence of further GI bleeding by hematocrit and she had no gross blood per rectum. The patient did eventually see the attending psychiatrist who felt that she might be depressed, however, the patient refused antidepressant medication and was not receptive for recommendations on an outpatient psychiatric treatment. On hospital day number six the patient had elevated blood sugar in the morning, however, this decreased by lunch time and was between 100 and 200 during the late morning and afternoon. Urine ketones were negative. It was felt that she was sufficiently stable in terms of her insulin regimen and blood glucose to be discharged. In terms of her other medical problems she continued to be afebrile with any antibiotics. She showed no clinical evidence of pneumonia or urinary infection. She remained total body volume overloaded and Lasix was increased to 80 mg twice a day. It was felt that this could also be managed as an outpatient. Her creatinine continued to slowly decrease and was 4.0, which is similar to her regular level. She had been restarted on Cyclosporin and the level was monitored. It is felt that she could be discharged on a dose of 50 mg twice a day as compared to her 100 mg twice a day. It was felt that her psychiatric status was stable and the patient did eventually agree to see psychiatric specialists associated with the [Hospital ] Clinic. The patient was self administering insulin and performing calorie counts at the time of discharge. FINAL DIAGNOSIS: Diabetic ketoacidosis. DISCHARGE PLAN: The patient was discharged to home. DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg q.d., cyclosporin 15 mg b.i.d., Imuran 50 mg q.d., Metoprolol 50 mg b.i.d., Zocor 20 mg q.d., Neurontin 100 mg b.i.d., Renagel two tablets three times a day, bethanechol 25 mg t.i.d., Lentis 14 units q.h.s. and the patient will resume her previous sliding scale. Lasix 80 mg b.i.d. Clonidine .1 mg b.i.d. She was instructed not to resume her Diovan at this time. She will follow up in the renal clinic in three days to have Cyclosporin and electrolyte levels checked. She will also follow up with the diabetic nurse educator and dietitian and she will see her primary care physician and diabetologist Dr. [Last Name (STitle) ] within two weeks and she will see her renal physician [Last Name (NamePattern4) ]. [First Name (STitle) 1313] within two weeks. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 17186], M.D. [MD Number(1) 16896] Dictated By:[Doctor Last Name 16885] MEDQUIST36 D: [2163-3-22] 16:22 T: [2163-3-23] 08:43 JOB#: [Job Number 104075] cc:[Last Name (NamePattern4) 104076]	[ "5845", "40391" ]
Admission Date: [2151-5-25] Discharge Date: [2151-5-28] Date of Birth: [2128-3-28] Sex: F Service: SURGERY Allergies: Augmentin Attending:[First Name3 (LF) 2534] Chief Complaint: s/p fall from bike Major Surgical or Invasive Procedure: Intracranial Pressure Monitoring Bolt History of Present Illness: 23F s/p fall from bike AM of DOA with helmet on. Patient seen at Nedham, intubated for agitation, and transferred to [Hospital1 18]. Past Medical History: Sinusitis Social History: no tobacco no etoh Family History: non-contributory Physical Exam: O: T: afebrile BP: 100-170/50-90's HR: 40's - 100's R vented O2Sats 98-100% Gen: WD/WN, agitated at times HEENT: Pupils: 3-2mm bilaterally / right is slightly ecentric / pupils midposition with 2 beat nystagmus to Right approx every 10-20 seconds EOMs unable to assess Neck: in cervical collar Neuro: Mental status: GCS 3 Orientation: unknown. Recall: unkown. Language: none/ intubated. Naming intact.unknown. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. midposition III, IV, VI: 2 beat nystagmus to the right intermittently V, VII: unable to assess Facial strength and sensation VIII: Hearing unknown IX, X: unkown Palatal elevation [Doctor First Name 81]: unkown Sternocleidomastoid and trapezius. XII: unknown if Tongue midline without fasciculations. Motor:No localization or withdrawal to noxious. noted are some clonic jerks to arms/legs and shoulders. No purposeful movements Toes downgoing bilaterally No clonus No decorticate or decerebrate posturing noted Pertinent Results: [2151-5-25] 08:59PM HCT-29.9* [2151-5-25] 07:18PM TYPE-ART TEMP-38.9 RATES-0/18 O2-30 PO2-216* PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 INTUBATED-INTUBATED [2151-5-25] 03:08PM TYPE-ART TEMP-38.3 TIDAL VOL-500 PO2-261* PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [2151-5-25] 02:52PM GLUCOSE-100 UREA N-8 CREAT-0.6 SODIUM-138 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10 [2151-5-25] 02:52PM CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-2.0 [2151-5-25] 02:52PM OSMOLAL-291 [2151-5-25] 10:09AM GLUCOSE-167* UREA N-12 CREAT-0.7 SODIUM-137 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14 [2151-5-25] 10:09AM estGFR-Using this [2151-5-25] 10:09AM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.9 [2151-5-25] 10:09AM WBC-17.4* RBC-3.51* HGB-11.7* HCT-31.3* MCV-89 MCH-33.3* MCHC-37.4* RDW-14.3 [2151-5-25] 10:09AM PLT COUNT-237 [2151-5-25] 10:09AM PT-12.1 PTT-23.3 INR(PT)-1.0 [2151-5-25] 09:23AM PO2-417* PCO2-31* PH-7.42 TOTAL CO2-21 BASE XS--2 COMMENTS-SPECIMEN T [2151-5-27] 04:42AM BLOOD WBC-11.2* RBC-3.10* Hgb-10.4* Hct-28.0* MCV-90 MCH-33.5* MCHC-37.2* RDW-14.6 Plt Ct-208 [2151-5-26] 02:31AM BLOOD WBC-11.5* RBC-3.29* Hgb-10.8* Hct-29.4* MCV-89 MCH-32.8* MCHC-36.8* RDW-14.6 Plt Ct-228 [2151-5-27] 04:42AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-139 K-3.3 Cl-108 HCO3-21* AnGap-13 [2151-5-26] 02:31AM BLOOD Glucose-119* UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-110* HCO3-24 AnGap-10 [2151-5-25] 02:52PM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-138 K-4.1 Cl-108 HCO3-24 AnGap-10 [2151-5-27] 04:42AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9 [2151-5-26] 02:31AM BLOOD Albumin-3.5 Calcium-8.1* Phos-3.1 Mg-2.2 [2151-5-25] 02:52PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 RADIOLOGY Final Report CT PELVIS W/CONTRAST [2151-5-25] 9:22 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: acute process [Hospital 93] MEDICAL CONDITION: 23 year old woman s/p fall from bike REASON FOR THIS EXAMINATION: acute process CONTRAINDICATIONS for IV CONTRAST: None. CHEST CT WITH CONTRAST, CT ABDOMEN WITH CONTRAST, CT PELVIS WITH CONTRAST, [2151-5-25] AT 09:35 HOURS HISTORY: Status post fall from bicycle. TECHNIQUE: Serial transverse images were acquired sequentially through the chest, abdomen, and pelvis following the uneventful administration of 130 mL of Optiray 350. Oral contrast was not administered per protocol. Transverse sections were reconstructed at stacked 5-mm increments. Coronal and sagittal reformatted images were also generated. COMPARISON: None. FINDINGS: CT OF THE CHEST: The endotracheal tube terminates at the ostium of the right main stem bronchus and should be retracted 3-5 cm. A nasogastric tube is coiled within the esophagus and needs repositioning. There is no pneumomediastinum or mediastinal hematoma. The aorta is intact with normal contour, caliber, and course. A normal branching pattern is observed of the great vessels. The heart is normal in size with no pericardial effusion. No significant underlying coronary artery disease is identified. Atelectatic changes are noted in the dependent aspects of both lung bases. There is no pneumothorax. An ovoid opacity is noted in the juxta-fissural position in the superior segment of the left lower lobe, reference series 2, image #25. No consolidation is seen. There are no effusions. CT ABDOMEN/PELVIS: The liver is intact with no gross traumatic lesion. There is no intrahepatic biliary dilatation. The gallbladder is present, minimally distended, but otherwise unremarkable. The spleen is intact also with no traumatic lesion. There is a small splenule at the inferior pole. The remaining solid abdominal organs likewise are unremarkable. Symmetric renal enhancement and contrast excretion is noted. Stomach is mildly distended with air. Proximal small bowel loops are collapsed without dilatation or frank bowel wall thickening. Stool is seen throughout the colon again with no obvious wall thickening noted. The bladder is distended with an intraluminal Foley catheter. Trace free fluid is seen in the pelvic cul-de-sac. Uterus and bilateral ovaries are present and otherwise unremarkable. There is no free intraperitoneal air. The abdominal aorta is normal in contour, course, and caliber. Incidental note is made of a retroaortic left renal vein with a low insertion on the proximal left common iliac vein. There is a minimally displaced transverse fracture of the mid diaphysis of the left clavicle. There is a nearly nondisplaced fracture of the scapular body with no clear extension to the glenoid fossa on the left as well. No rib fractures are noted. The thoracic and lumbar spine are intact with normal anatomic alignment. IMPRESSION: 1. Left clavicle and scapular fracture as detailed above. 2. No traumatic injury in the chest, abdomen, or pelvis. 3. Small quantity of intrapelvic fluid, likely physiologic given reproductive age status. 4. Incidental nodule in the superior segment of the left lower lobe. A followup CT scan in six months is recommended to assess for stability. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7411] Approved: TUE [2151-5-25] 4:43 PM RADIOLOGY Final Report CT C-SPINE W/O CONTRAST [2151-5-25] 9:21 AM CT C-SPINE W/O CONTRAST Reason: fracture [Hospital 93] MEDICAL CONDITION: 23 year old woman s/p fall from bike REASON FOR THIS EXAMINATION: fracture CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 23-year-old status post fall from bike rule out fracture. COMPARISONS: None. TECHNIQUE: Axial MDCT images of the cervical spine with coronal and sagittal reformats. FINDINGS: C1 through T1 are well visualized. There is normal alignment of the cervical vertebral bodies without acute fracture. Patient is intubated and NG tube is in place which appears coiled in the nasopharynx. Posterior elements are intact. Seen on the inferiormost images but only partially imaged is the patient's known fracture extending through the left greater [Doctor First Name 362] of the sphenoid and entering the sphenoid sinus. Again there is partial opacification of the left mastoid and inner ear suspicious of an occult temporal bone fracture, though none is directly visualized. There is smooth septal thickening at the lung apices suggestive of some volume overload. No pneumothorax. IMPRESSION: 1) No acute cervical spine fracture. 2) Patient's known left skull base fracture is only partially imaged, see accompanying head CT report. 3) NG tube appears coiled in the nasopharynx. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name (STitle) ] [Name (STitle) 12563] Approved: TUE [2151-5-25] 5:44 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2151-5-25] 9:20 AM CT HEAD W/O CONTRAST Reason: progression of bleed [Hospital 93] MEDICAL CONDITION: 23 year old woman s/p fall from bicycle REASON FOR THIS EXAMINATION: progression of bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 23-year-old status post fall from bicycle. Evaluate for progression of bleed. COMPARISONS: None; history suggests there is prior imaging, however, this is not available to us. TECHNIQUE: Axial MDCT images through the brain without IV contrast. FINDINGS: There is extensive hemorrhage bilaterally within the brain. Specifically, there is extensive right-sided subarachnoid hemorrhage, most prominent in and adjacent to the sylvian fissure. Small hyperdense right convexity subdural hematoma is noted along the parietal and temporal convexity. There are bilateral inferior temporal hemorrhagic contusions. On the left, there is a small hyperdense extra-axial collection, likely a subdural hematoma along the left parietal calvarium, adjacent to a nondisplaced calvarial fracture which extends through the left parietal and temporal skull through the greater [Doctor First Name 362] of the sphenoid and into the sphenoid sinus. This fracture appears to stay clear from the major vascular foramina. Blood is noted within the sphenoid sinus. There is opacification of portions of the left mastoid and left middle ear, however, no definite temporal bone fracture is visualized, though these findings raise the suspicion for an occult fracture. There is a nondisplaced fracture of the left zygomatic arch. Finally, in the left parietal lobe, there is a small focus of approximately 7 mm of hemorrhage which appears intraparenchymal and may be related to diffuse axonal injury. There is no shift of normally midline structures at this time; however, the right lateral ventricle appears mild to moderately effaced. No evidence of hydrocephalus contralaterally. IMPRESSION: 1) Extensive right-sided subarachnoid hemorrhage and bilateral subdural and hemorrhagic contusions as described above. The possibility of diffuse axonal injury is not excluded, and could be more sensitively assessed by MRI. Mild effacement of the right lateral ventricle, but no shift of midline structures at this time. 2) Nondisplaced fracture extending from the left calvarium into the left skull base. Left zygomatic arch fracture. 3) Opacification of portions of the left mastoid and left inner ear, raise the suspicion for an occult temporal bone fracture, though none is directly visualized on this study. These findings were discussed with the trauma resident, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 72147] after the study. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name (STitle) ] [Name (STitle) 12563] Approved: TUE [2151-5-25] 5:39 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2151-5-26] 8:35 AM CT HEAD W/O CONTRAST Reason: sp fall head injury [Hospital 93] MEDICAL CONDITION: 23 year old woman with sp trauma REASON FOR THIS EXAMINATION: sp fall head injury CONTRAINDICATIONS for IV CONTRAST: None. STUDY: CT of the head without contrast. INDICATION: 23-year-old female status post bicycle accident and head trauma. COMPARISONS: [2151-5-25]. TECHNIQUE: Non-contrast head CT. FINDINGS: Compared to the CT examination from approximately 24 hours prior, there has been interval development of a small subdural hematoma located posteriorly at the level of the foramen magnum. Diffuse subarachnoid hemorrhage within the right parietal lobe along the superior aspect is relatively unchanged compared to the previous examination. A small right subdural hematoma located along the parietal and temporal convexities is largely unchanged compared to the previous examination. Bilateral inferior temporal hemorrhagic contusions on today's examination are surrounded by slightly more hypodensity consistent with evolving edema but otherwise are largely unchanged. A small left parietal subdural hematoma is also unchanged compared to the previous examination. Just adjacent to this area, a large superficial left subgaleal hematoma is unchanged. There is associated nondisplaced fracture of the temporal bone at this level as well. A left- sided fracture through the sphenoid [Doctor First Name 362] which is nondisplaced is overall unchanged in appearance. This fracture is contiguous with a fracture through the left portion of the squamosal temporal bone. A left-sided zygomatic arch fracture is unchanged in appearance. Once again, there is partial opacification within the mastoid air cells of the left temporal bone, but no definitive fracture is identified. Overall, there is no shift of normal midline structures or hydrocephalus. There has been interval placement of a cerebral bolt entering from a left frontal approach. A punctate area of hyperdensity within the left parietal lobe is unchanged. The visualized portions of the soft tissues, osseous structures, and paranasal sinuses are otherwise unremarkable with the exception of the findings described above. IMPRESSION: Evolving intracranial hemorrhage. New small subdural hematoma noted posteriorly at the level of the foramen magnum compareed to [2151-5-25]. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 2618] [Doctor Last Name ] DR. [First Name (STitle) ] [Name (STitle) 12563] Approved: WED [2151-5-26] 11:14 PM Brief Hospital Course: Patient was initally evaluated in the [Hospital1 18] ED. After initial CT scans she was transferred immediately to the TICU where Neurosurgery evaluated and placed an ICP bolt. Due to inital elevated ICP she was started on mannitol, however she responded well and was taken off the mannitol after approx 12hrs. Patient had a repeat head CT which was stable, and on HD2 she was extubated. She continued to improve neurologically and was transferred to the floor on HD3. Patient was evaluated by PT and OT and was deemed stable for discharge with Neurosurgical follow-up. Medications on Admission: OCP's Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day) for 1 months. Disp:180 Tablet, Chewable(s) Refills:0 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p fall from bicycle, SDH, SAH L zygomatic arch fracture L clavicle/scapula fracture Discharge Condition: Stable Discharge Instructions: Please call physician or return to ED if any of the following occur: 1. Fever >101.5 2. Change in mental status 3. Increased pain not controlled with medication 4. Dizziness, Shortness of [Last Name (un) ], Chest Pain 5. Increased redness, swelling, or drainage from wound 6. Any other concerning symptoms Continue to wear your sling for LUE comfort. Followup Instructions: Please follow-up in 4 weeks with Dr. [Last Name (STitle) 548] (Neurosurgery). Call ([Telephone/Fax (1) 88] for appointment. For your calvicle fracture/scapula fracture you may follow-up with Dr. [Last Name (STitle) 1005]. Call ([Telephone/Fax (1) 2007] for appointment. Completed by:[2151-5-28]	[ "5180" ]
Admission Date: [2138-9-8] Discharge Date: [2138-9-26] Date of Birth: [2057-5-1] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Codeine / Darvocet-N 100 / Vancomycin / Lactose / Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Levofloxacin / Prilosec Attending:[First Name3 (LF) 14689] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Left hip total arthroplasty [2138-9-18] History of Present Illness: 81-year-old woman with history of colon cancer and CML presents with worsening abdominal pain for the past several weeks. Patient complains of epigastric and RLQ abdominal pain that had been intermittent, usually exacerbated after eating, until the day prior to admission when the pain became almost constant. The pain is sharp, not associated with nausea, vomiting, or changes in bowel habits. Denies fevers or chills. She has experienced poor appetite and reports losing 5 lbs in the past few months. . In the ED, T 98.2, HR 93, BP 138/73, RR 16, 100%RA. Her exam reportedly revealed mild tenderness at RUQ and RLQ without any rebound tenderness. She underwent an abdominal/pelv CT, with PO contrast but without IV contrast due allergy, which showed increased masses throughout her abdomen. She was administered morphine 15 mg PO x 1 and a total of 8 mg of morphine IV for her pain. She was then admitted to OMED for further management. On arrival to the floor, she was pain free. Of note, Ms. [Known lastname 100416] was recently admitted from [2138-8-18] to [2138-8-22] at [Hospital1 18] for a UTI and pneumonia, treated with cefpodoxime adn azithromycin, as well as worsening hip pain, treated with increased amounts of narcotics and a plan for orthopedics follow-up. She saw Dr. [Last Name (STitle) ] on [2138-8-25], who planned to schedule a total hip replacement as soon as possible. For her colon cancer, she underwent right hemicolectomy with primary reanastomosis in 09/[2135]. She was treated for a short time with capecitabine, but due to side effects treatment was stopped after after two and a half cycles. PET scan on [2135-7-30] showed new FDG uptake in retroperitoneal lymph nodes in the left abdomen area with elevated CEA concerning for progression of her metastatic colon cancer. Was planning to follow up with Dr. [Last Name (STitle) ]. She saw Dr. [Last Name (STitle) ] and NP[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2138-9-4], for her CML. Her BRC-ABL level was re-checked, and a bone marrow biopsy was done. Dr. [Last Name (STitle) ] plans to switch her imatinib to dasatinib once insurance coverage for the medication is assured. . REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other review of systems negative. Past Medical History: ONCOLOGIC HISTORY: # Stage III colon cancer: status post right hemicolectomy with primary reanastomosis in 09/[2135]. She was treated for a short time with capecitabine, but due to side effects treatment was stopped after after two and a half cycles. PET scan on [2135-7-30] showed new FDG uptake in retroperitoneal lymph nodes in the left abdomen area with elevated CEA concerning for progression of her metastatic colon cancer. Planning to follow up with Dr. [Last Name (STitle) ]. # CML: on imatinib since [3-/2131] # Lymphoma. (Diagnosed in early [2098]; in remission) # Bladder cancer related to cyclophosphamide; s/p cystectomy and left nephrectomy, with ileal loop reconstruction OTHER MEDICAL HISTORY: # Pulmonary fibrosis secondary to bleomycin # Recurrent UTIs # Chronic anemia # S/p left knee replacement in [3-23] # Hypothyroidism # GERD Social History: Home: Married; lives with her husband in apartment in the [Location (un) 100419] Occupation: previously employed as an actress, producer, and director - primarily worked in theater but also worked in television and film EtOH: ~ 1 glass of wine per night Drugs: Denies Tobacco: ~20-30 PPY smoking history ([1-18] PPD x30-40 yrs); quit > 20 yrs ago Family History: Sister - died of lung cancer Mother - coronary artery disease, stroke Father - coronary artery disease, diabetes mellitus, stroke Physical Exam: Vitals: T 98.2, BP 142/74, HR 82, RR 19, 97%RA Gen: elderly woman, oriented x 3, pleasant, in no acute distress HEENT: extraocular movements intact, conjunctivae clear, sclerae anicteric, oropharynx moist and without lesion Neck: supple, no LAD CV: no jugular venous distention, normal rate, regular rhythm, normal S1/S2, no murmur Lungs: clear to ascultation bilaterally, no crackles or wheezes Abd: soft, nontender, nondistended, bowel sounds present, no hepatosplenomegaly, surgical scars well-healed, urostomy bag in place Back: no CVA tenderness bilaterally Ext: warm, well-perfused, no cyanosis or edema Neuro: oriented x 3, answering all questions appropriately Pertinent Results: Admission Labs: [2138-9-8] 04:24PM BLOOD WBC-15.9* RBC-3.29* Hgb-9.4* Hct-30.7* MCV-93 MCH-28.5 MCHC-30.6* RDW-16.7* Plt Ct-672* [2138-9-8] 04:24PM BLOOD Neuts-90.6* Lymphs-4.6* Monos-3.0 Eos-1.0 Baso-0.9 [2138-9-8] 09:43PM BLOOD PT-12.7 PTT-35.9* INR(PT)-1.1 [2138-9-8] 04:24PM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-136 K-4.0 Cl-101 HCO3-26 AnGap-13 [2138-9-8] 04:24PM BLOOD ALT-11 AST-21 LD(LDH)-361* AlkPhos-114* TotBili-0.4 [2138-9-8] 04:24PM BLOOD Lipase-41 [2138-9-8] 04:24PM BLOOD Albumin-3.1* Calcium-8.5 [2138-9-8] 04:24PM BLOOD CEA-425* . WBC Trend: [2138-9-8] WBC-15.9, [2138-9-11] WBC-12.5, [2138-9-12] WBC-11.3, [2138-9-13] WBC-10.8 [2138-9-13] WBC-38.9, [2138-9-14] WBC-48.4, [2138-9-15] WBC-25.2, [2138-9-16] WBC-15.5, [2138-9-17] WBC-11.3, [2138-9-18] WBC-12.5, [2138-9-19] WBC-12.5, [2138-9-20] WBC-16.2, [2138-9-21] WBC-21.1, [2138-9-22] WBC-24.7, [2138-9-23] WBC-24.1, [2138-9-24] WBC-27.6, [2138-9-25] WBC-39.8, [2138-9-26] WBC-33.7 . Discharge Labs: [2138-9-26] 08:00AM BLOOD WBC-33.7* RBC-3.14* Hgb-9.2* Hct-28.8* MCV-92 MCH-29.2 MCHC-31.9 RDW-16.7* Plt Ct-515* [2138-9-26] 08:00AM BLOOD Neuts-56 Bands-6* Lymphs-3* Monos-3 Eos-1 Baso-3* Atyps-0 Metas-15* Myelos-12* Promyel-1* [2138-9-26] 08:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL Bite-1+ [2138-9-26] 08:00AM BLOOD Glucose-78 UreaN-18 Creat-0.8 Na-137 K-4.0 Cl-105 HCO3-24 AnGap-12 [2138-9-26] 08:00AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.7 . CT Abd/Pelvis [2138-9-8]: 1. Interval increase in size and number of intraperitoneal metastases. New small amount of pelvic fluid and mesenteric stranding, suspicious for malignant involvement. Recommend followup CT with intravenous contrast (with premedication) or MRI to assess patency of abdominal vasculature and better assess tumor burden. 2. Increase in paraaortic lymphadenopathy, also consistent with disease progression. 3. Right ileal conduit, with unchanged parastomal hernia. 4. Severe osseous degenerative changes. . Bone Scan [2138-9-11]: 1. Increased uptake in the left femoral head and acetabulum is consistent with avascular necrosis. No definite evidence of metastatic disease. 2. New asymmetric increased uptake in the right shoulder. Would recommend correlative radiographs for further evaluation. 3. Focal increased uptake in the right knee consistent with degenerative changes seen on prior radiograph. . CXR [2138-9-13]: In comparison with study of [8-19], there is extensive patchy opacification involving much of the left lung, consistent with the clinical diagnosis of widespread pneumonia. The right lung remains essentially clear. . Left Hip X-Ray [2138-9-18]: Limited examination due to body habitus. Multiple surgical clips project over the pelvis. Right lower quadrant ostomy projects over the right greater trochanter. Degenerative changes of the pubic symphysis. The right hip is not well visualized due to overlying soft tissue structures. Status post left total hip arthroplasty. The hardware appears intact. No definite fracture or dislocation on this single AP view. Subcutaneous emphysema and edema, post-surgical. Skin staples present. IMPRESSION: Status post left total hip arthroplasty, as above. . CXR [2138-9-22]: There has been interval partial clearing of the infiltrate in the left mid lung. However, there continues to be dense retrocardiac opacity consistent with a combination of both volume loss and consolidation. . CXR [2138-9-25]: official read pending at time of discharge . Bilateral lower ext vein ultrasound [2138-9-26]: prelim read at time of discharge - no evidence of DVT in bilateral lower ext veins Brief Hospital Course: 81yo female with history of colon cancer and CML who presented with worsening abdominal pain for the past several weeks. #. Abdominal pain: Pain likely secondary to worsening tumor burden from known colon cancer that had been seen imaging studies prior to admission. CT on admission confirmed interval increase in size and number of intraperitoneal metastases, as well as increase in paraaortic lymphadenopathy, consistent with disease progression. Her pain was controlled with narcotic pain medications during the admission. She will follow-up with Dr. [Last Name (STitle) ] after discharge from rehab. . #. Pneumonia: During the [Hospital 228] hospital course, she developed acute hypoxia, and was transferred to the ICU. CXR showed a left-sided infiltrate, and the patient was started on broad coverage for hospital-acquired PNA vs. aspiration pneumonia. She was thought to have possibly aspirated in setting of increased sedation while receiving pain control via dilaudid PCA. She was started on vancomycin, aztreonam, and ciprofloxacin. Her oxygen was weaned, and the patient was transferred back to the floor in stable condition. Her PCA dosing was adjusted accordingly. She completed a 9-day course of antibiotics for her pneumonia. At time of discharge, she was afebrile, without chest pain, SOB, or cough, and CXR showed improvement in left lobe consolidation. . # Colon cancer: CT abdomen showed increased size and number of intraperitoneal metastases, as well as increase in paraaortic lymphadenopathy masses throughout abdomen. CEA noted to be increasing as well. Her abdominal pain, likely due to to increasing tumor burden, was well controlled at time of discharge. She will follow-up with Dr. [Last Name (STitle) ]. . # CML: The patient has been followed by Dr. [Last Name (STitle) ] as an outpatient, and was on imatinib at time of admission. Per notes, her WBC was 15.9 at baseline. She was initially continued on imatinib, then switched to dasatinib once she had insurance approval. Her dasatinib was held in setting of pneumonia and hip surgery, and restarted on [2138-9-24] at 70mg daily. Her WBC had previously peaked at 48.4 in setting of her pneumonia, then trended down to as low as 11.3 on [2138-9-17]. However, WBC was noted to rise again, peaking at 39.8 on [2138-9-25]. She did have a left shift/bandemia, but no infectious source was indentified. There was no evidence of infection at her surgical site, no clinical evidence of pneumonia, blood cultures were negative, and the patient remained afebrile. Her stool tested negative for C. diff x2. She had a decrease in WBC on the day of discharge, from 39.8 to 33.7, in setting of starting dasatinib. She will follow-up with Dr. [Last Name (STitle) ] following discharge. #. Left hip pain: Pain was secondary to avascular necrosis of the hip, and the patient underwent a left total hip arthroplasty on [2138-9-18]. She tolerated the procedure well. Pain control was difficult, as the patient required high doses of narcotics to control her pain, but was very susceptible to respiratory depression and lethargy in setting of increased narcotic dosing. Ultimately, her pain was brought under control after a 3-day course of toradol in addition to methadone 2.5mg TID, with oxycodone for breakthrough pain. Her pain also steadily improved following her hip replacement surgery. She will be discharged on a pain regimen of acetaminophen 1000mg PO TID, gabapentin 400mg [Hospital1 ], methadone 2.5mg PO TID, naproxen 375mg [Hospital1 ] (to be continued through [2138-10-1]), with oxycodone 15-30mg Q3 prn breakthrough pain. After [2138-10-1], she should only receive naproxen as needed for pain. Her renal function should be closely monitored in setting of NSAID use. Regarding her hip surgery, she should have staples removed on [2138-10-10] with steri-strips placed, and will follow-up with ortho on [2138-10-17]. . #. Diarrhea: The patient did develop some loose stools during her hospital stay. Given her rising white count and antibiotic use, she was tested for C. diff infection, but testing was negative x2. Her diarrhea may be secondary to the dasatanib. Her symptoms improved with Lomotil. . #. Hypothyroidism: The patient was continued on her home dose of levothyroxine 125 mcg daily. . #. Insomnia: The patient was given zolpidem 5 mg QHS prn insomnia. . #. Anxiety: The patient was seen by palliative care during the admission, and per their recommendations was started on olanzapine for increased anxiety. Medications on Admission: docusate sodium 100 mg [Hospital1 ] gabapentin 400 mg [Hospital1 ] mirtazapine 30 mg qhs omeprazole ER 20 mg [Hospital1 ] levothyroxine 125 mcg daily imatinib 400 mg daily zolpidem 10 mg qhs prn insomnia oxycodone SR 30 mg q12h acetaminophen 1000 mg tid diphenoxylate-atropine 2.5-0.025 mg q6h prn diarrhea oxycodone 15 mg q4-6h prn senna prn Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for dry skin. 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS PRN () as needed for insomnia. 5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 7. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Naproxen 375 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 14. Dasatinib 70 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 15. Oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 16. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for diarrhea. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 18. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 19. Outpatient Lab Work Please check twice weekly CBC with diff, chemistries (Na, K, Cl, HCO3, BUN, Cr, Ca, Mag, Phos) Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Colon cancer CML Pneumonia Left hip replacement surgery [2138-9-18] Diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with worsening abdominal pain, which is likely due to your colon cancer. Your pain was better controlled after we increased your pain medications. You developed some shortness of breath and low oxygen levels, and were found to have a pneumonia. You were briefly treated in the ICU, but then were stable to be transferred back to the general oncology floor. We treated you with antibiotics, and your pneumonia resolved. You had left hip replacement surgery on [2138-9-18]. You tolerated this procedure well. Your staples should be removed in 2 weeks, and you will follow-up with the orthopedics team on [2138-10-17]. It was difficult to control your pain during your hospital stay. You tried many different narcotic medications, including morphine, oxycodone, and dilaudid. A medication called toradol was very effective, but you can only take this medication for 3 days at a time. You will be discharged on a medication called naproxen, which is in the same family as toradol. You can take this medication for one week, and you can also continue to take the oxycodone as needed for pain. While you were here, you stopped taking imatinib and were started on a medication called dasatinib. This medication was held while you were treated for the pneumonia and surgery. We noticed your white blood cell count was increasing again after the surgery, and we re-started the dasatinbib. Followup Instructions: Department: HEMATOLOGY/BMT When: THURSDAY [2138-10-16] at 11:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], [Last Name (NamePattern1) 280] [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: THURSDAY [2138-10-16] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], MD [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: FRIDAY [2138-10-17] at 2:20 PM With: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], PA [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You should also follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. You should follow-up with your primary care doctor, Dr. [First Name (STitle) ] [First Name8 (NamePattern2) ] [Doctor Last Name ]. The clinic number is [Telephone/Fax (1) 133]. [Name6 (MD) ] [Name8 (MD) 10341] MD [MD Number(2) 14690]	[ "5070", "2859", "2449", "53081" ]
Admission Date: [2165-11-2] Discharge Date: [2165-11-13] Date of Birth: [2081-6-10] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2071] Chief Complaint: Congestive Heart Failure, Non-ST elevation Myocardial Infection, Urinary Tract Infection Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old female per record has a history of colon cancer recent diagnosis of pneumonia presenting from an outside hospital with congestive heart failure, NSTEMI, and urinary tract infection. Patient is confused and unable to answer questions, history obtained from chart from [Hospital3 ] and from husband. She was recently admitted to [Hospital3 ] [2165-10-25] for lethargy and PNA, had been hospitalized prior to that for R colectomy for colon Ca c/b cholecystitis s/p cholecystecomty and also had G tube placement. PNA treated with oral abx and dc'ed to rehab with anticipation that G tube would be removed in near future. . She was sent to [Hospital3 ] again on [2165-11-2] from rehab for shortnss of breath, nasal congestion and desat to 70s, improved to 93% with O2 by NC. the onset was 2 days prior to presentation. The patient characterizes increased shortness of breath at rest. SOB is exacerbated by activity; relieved with rest. At the outside hospital, her room air saturation was noted to be in the 70s and she was tachypneic, placed on O2 by NC. . In regard to associated symptoms, the patient denies chest pain, cough, headache or change in vision, neck stiffness, abdominal pain, focal numbness tingling or weakness, dysuria or urinary frequency although patient appears to be altered and knows she is in a hospital but does not know why, thinks she lives at home with her husband and is not sure of the year. . In the ED, noted to have physical exam with stigmata of CHF including symmetric lower extremity edema, crackles in the bases bilaterally, +JVD. Give 40 mg IV lasix at outside hospital ED and received vanc and zosyn for evidence of UTI on UA. Troponin noted to be elevated at 0.15, Cr 1.9, Hct 33.3. She was given heparin bolus and gtt for concern for NSTEMI as well with EKG showing a flutter at 85 and TWI in lateral leads, no prior. BNP ordered in ED and is pending. Also received duonebs with some improvmeent in dyspnea. Initial ED VS 96.1 86 113/71 24 98% 2l at [Hospital1 18]. . Currently, patient denies any complaints although she is breathing very quickly and appears uncomfortable. Husband notes that she has been increasingly forgetful over the last few months but has been confused in that she is not sure entirely of what day it is, where she is at all times. She also has occasinally been very agitated and angry while at rehab. After first operation in [9-22] for colon cancer, she started getting more confused. Per husband, mental status at baseline today. He thought she had been improving, denied any complaints in the last couple of days, but while he was vistiting her today she suddenly started breathing very hard. No fevers, but has had cough and congestion for the last about 7 days, was recently admitted for PNA and had been on a course of keflex. Lower extremity edema has been presented since [9-22] and has not worsened. Husband denies any other symptoms. Past Medical History: Hyperlipidemia, Hypertension, Hypothyoridism, Vertigo, Anemia (on B12 and iron), history of MRSA, Colon CA s/p R colectomy c/b cholecystitis s/p cholecystectomy in [9-/2165], Anorexia with G-tube placed [2165-10-28], Anxiety, "only one kidney works" per husband Social History: -Tobacco history: former smoker quit 30 yrs ago, started as teenager 1 ppd until 40 years old -ETOH: denies -Illicit drugs: denies lives at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] Healthcare Center ([Telephone/Fax (1) 91474], but lived at home prior to [9-22] Family History: [Name (NI) ] brother died of MI at 71, brother with pancreatic cancer in 70s. Mother died of pernicious anemia at 44, fathr died 57 from strokes. Sister died at 59 died of kidney failure. Has a living and brother and sister. [Name (NI) ] family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 95.6 146/75 85 40 100% 2L GENERAL: WDWN F breathing heavily. Oriented to hospital, [Month (only) 359], self but not to year or president. 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 elevated JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Appears to be working hard to breathe, +bilateral crackles at bases, wheezes throughout ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits, G tube in place with no drainage EXTREMITIES: 3+ pitting edema to knees, +venous stasis changes on shins. No femoral bruits. SKIN: No 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: Admit Labs: [2165-11-2] 08:00PM BLOOD WBC-7.8 RBC-3.79* Hgb-10.6* Hct-33.3* MCV-88 MCH-28.0 MCHC-31.9 RDW-17.7* Plt Ct-230 [2165-11-2] 08:00PM BLOOD Neuts-69.8 Lymphs-24.6 Monos-3.9 Eos-1.5 Baso-0.2 [2165-11-2] 08:00PM BLOOD PT-12.8 PTT->150 INR(PT)-1.1 [2165-11-2] 08:00PM BLOOD Glucose-98 UreaN-22* Creat-1.9* Na-139 K-4.6 Cl-108 HCO3-20* AnGap-16 [2165-11-2] 08:00PM BLOOD CK(CPK)-48 [2165-11-2] 08:00PM BLOOD Albumin-2.2* Calcium-7.7* Phos-4.7* Mg-1.4* . CXR [2165-11-2]: UPRIGHT AP VIEW OF THE CHEST: The heart size is mildly enlarged. There is mild-to-moderate pulmonary edema with perihilar haziness and vascular indistinctness. Additionally, small-to-moderate sized layering bilateral pleural effusions are present, greater on the left than on the right. Dense opacification in the retrocardiac region may reflect compressive atelectasis. Infection, however, is not excluded. Diffuse calcification of the aorta is present. There is no pneumothorax. Right PICC tip terminates within the mid SVC. No acute osseous abnormalities are seen. IMPRESSION: Mild-to-moderate pulmonary edema. Small-to-moderate sized bilateral pleural effusions, left greater than right. Retrocardiac opacity may reflect compressive atelectasis though infection cannot be excluded. . EEG [2165-11-6]: FINDINGS: CONTINUOUS EEG: The initial part of this recording (eight minutes) is performed on the Natus EEG system. This shows continuous bilateral frontally maximal high voltage sharp and slow wave discharges at 2 Hz. The discharges are of higher amplitude over the right hemisphere. EEG is then continued on the Apropos system at 1 a.m. The patient had received intravenous lorazepam in the interim. The recording shows a [6-18] Hz posterior dominant rhythm with diffuse frontally maximal semi-rhythmic delta activity. There are frequent high voltage bilateral sharp and slow wave discharges, sometimes in brief periodic runs at 0.5-1 Hz. EEG is disconnected between 2 and 3 a.m. At 4:30 a.m., there is recurrence of the 2 Hz high voltage sharp and slow wave discharge pattern in bursts lasting three to five minutes. This then resolves until 5 a.m. when the high voltage sharp and slow wave discharges recur at 1.5 Hz lasting until 6:50 a.m., resolving for several minutes and then continuing until the end of the study at 7 a.m. SPIKE DETECTION PROGRAMS: There are 1,009 automated spike detections predominantly for the high voltage spike and slow wave discharges described above, as well as EMG and electrode artifact. SEIZURE DETECTION PROGRAMS: There are 11 automated seizure detections predominantly for electrode and movement artifact. There are several prolonged electrographic seizures, as described above. PUSHBUTTON ACTIVATIONS: There are no pushbutton activations. SLEEP: The patient progresses from wakefulness to stage II, then slow wave sleep at appropriate times with no additional findings. CARDIAC MONITOR: Shows a generally regular rhythm with an average rate of 60-70 bpm. IMPRESSION: This is an abnormal continuous ICU monitoring study because of initial continuous 2 Hz high voltage sharp and slow wave discharges consistent with generalized nonconvulsive status epilepticus. There is slight predominance of the ictal rhythm over the right hemisphere. This pattern improved after intravenous lorazepam and intravenous levetiracetam, but then recurred several hours later and lasted until the end of the study. Between electrographic seizures, background showed a slow posterior dominant rhythm and diffuse delta activity indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. There were frequent bifrontal sharp and slow wave discharges. . MRI of the brain w/o contrast ([2165-11-9]) CLINICAL INFORMATION: Patient with CHF and myoclonic status which is now settled following medication adjustment, confused but otherwise nonfocal exam, question evidence of hypoperfusion accounting for seizures. TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial images of the brain were acquired. FINDINGS: FLAIR images demonstrate multiple foci of T2 hyperintensity in the periventricular and subcortical white matter. There is moderate ventriculomegaly seen with mild dilatation of the temporal horns. The findings are indicative of brain atrophy. The diffusion images demonstrate no evidence of acute infarct. In addition, the diffusion images demonstrate no evidence of areas of restricted diffusion to indicate watershed infarcts or global cerebral hypoperfusion. IMPRESSION: No acute infarcts are seen. Brain atrophy and small vessel disease are noted. . Discharge Labs: [2165-11-13] 05:15AM BLOOD WBC-10.2 RBC-3.10* Hgb-9.1* Hct-27.9* MCV-90 MCH-29.3 MCHC-32.6 RDW-18.5* Plt Ct-354 [2165-11-13] 05:15AM BLOOD Glucose-126* UreaN-54* Creat-2.1* Na-146* K-3.7 Cl-106 HCO3-38* AnGap-6* [2165-11-9] 06:10AM BLOOD ALT-17 AST-23 AlkPhos-122* TotBili-0.1 [2165-11-13] 05:15AM BLOOD Phos-2.3* Mg-2.0 [2165-11-7] 02:32AM BLOOD T4-3.4* T3-48* calcTBG-0.87 TUptake-1.15 T4Index-3.9* [2165-11-7] 02:32AM BLOOD TSH-25* [2165-11-6] 08:45PM BLOOD Ammonia-8* [2165-11-12] 04:53AM BLOOD Valproa-49* Brief Hospital Course: Primary Reason for Hospitalization: Mrs. [Known lastname ] is an 84 year old female with a history of HTN, colon cancer s/p colectomy c/b cholecystitis s/p laparascopic cholecystectomy, HLD, p/w dyspnea, UTI, elevated troponin, evidence of fluid overload on physical exam and who developed status epilepticus. . # Goals of Care: Several days into the hospitalization a family meeting was held with patient's husband and daughter present. They expressed that the patient would want to be at home rather than repeatedly hospitalized as she has been for the past 2 months. Currently the plan is to get the patient to rehab for a fixed amount of time (2 weeks maximum) to see whether the patient can gain any strength to be more functional. The secondary purpose would be for the family to get a better idea of how to care for the patient at home. After a week or so of rehab the patient would go home with hospice. She will continue to receive medical care but interventions will focus on things that will improve her comfort and ability to interact with the environment. Therefore controlling seizures and avoiding pulmonary edema will be tantamount. If her care transitions to hospice, we recommend discontinuing Atrovastatin, multivitamins, ferrous sulfate. We also recommend only giving free water and food by gastric tube for comfort. . # Status Epilepticus: On [11-6] patient became more encephalopathic, not interacting when her family visited on [11-6]. Thus a head CT and EEG were performed with the latter demonstrating polyspike and wave discharges at 1Hz with evidence of status epilepticus (myoclonic encephalopathic type). The patient was treated with IV lorazepam and Keppra with delayed hypotension into the 70s systolic and maintained pressures in the 80-90s resulting in transfer to the ICU under neurology on [11-7]. Her hypotension settled on transfer and she did not require pressor support. She improved initially from a behavioral and EEG perspective after cessation of cefepime and initiation of Keppra however had persistent epileptiform discharges and episodic seizures on [11-7]. She was loaded with IV sodium valproate, changed AEDs to IV and started standing dose and gave additional dose overnight into [11-8] due to persistent seizures. No seizures on [11-8] and keppra increased to 1g [Hospital1 ]. The etiology is likely multifactorial. An MRI was performed which showed many nonspecific findings but no clear etiology for the seizures. . # NSTEMI vs Demand Ischemia: Patient is a poor historian due to dementia and delirium so it was difficult to illicit if patient was having CP sysmptoms prior to transfer from OSH. Patient at OSH had troponin elevation 0.43 prior to transfer with EKG changes. On Presentation to [Hospital1 18] ED, trops were 0.15 to 0.14, CKMB 8->6. In the setting of renal failure and fluid overload with CHF exacerbation patient thought to have NSTEMI. Patient had dynamic EKG changes upon evaluation of OSH EKG and EKG taken [Hospital1 18] ED. She was noted to have new TWI in V4-V6, and ST elevation in V3 in comparison to previous EKG on the [10-25]. Patient was treated with maximal medical therapy including heparin drip. The plan originally was for possible outpatient cath when patient's overall medical condition improved however that plan changed as goals of care changed. . #Pneumonia: Patient was being treated at OSH prior to admission for Pneumonia. She was noted to have evidence of fluid overload but concern for LLL infiltrate per OSH CXR. Patient had productive cough, but no elevation in WBC or fever. She was placed on Vanc/Cefpimie (D1 [2165-11-3]). After several days the patient's presentation appeared more consistent with CHF exacerbation rather than PNA therefore antibiotics were dicontinued. In addition there was concern that cefepime could have lowered the seizure threshold. . # Acute systolic CHF exacerbation (EF=40%): Patient was hypervolemic on exam with elevated JVP, lower extremity edema, and dypsnea also with concerning CXR with pulm edema. She did not have previously have documented CHF, but per rehab notes was recently started on lasix 20mg daily. Her BNP was 70,000 on presentation. She was diuresed aggresively with IV lasix before being transitioned to PO torsemide. She was also treated with Metoprolol, lisinopril, and spironolactone. . # CKD: Cr was 2.0 prior to discharge which was at recent Baseline per OSH records. . # Anemia: Patient has an unclear baseline, but patient on presentation was hemodynamically stable. Her HCT was trended and she was continued on her home B12 and iron supplementation . # HTN: Patient's medications were changed to lisinopril, metoprolol, spironolactone, and torsemide as above. . # Dementia: Pt on presentation from OSH had altered mental status and was A&Ox1 (only to person). Per family report patient has had memory issues over the last year but did not carry a diagnosis of dementia. Pt had a CT head [2165-10-25] at OSH which demonstrated no acute intracranial process, atropy and mircovascular leukoencephalopathy (proogresed from [2162-1-18]). She also had an MRI during this admission that showed many nonspecific findings. The patient's med list was reconciled to reduce deliriogenic meds including stopping meclizine and ativan (unless needed for status epilepticus). Seroquel was stopped because patient's agitation was able to be controlled adequately with redirection and comforting. . # HLD: Patient was on simvastatin at home, changed to atorvastatin 80mg given possible NSTEMI. . # Vertigo: Patient had no symptoms therefore meclizine was stopped to avoid inducing delirium . # Anorexia: Patient had history of poor PO intake, recent G tube placed at OSH. She was taking mirtazapine however this was discontinued when it appeared to be worsening her mental status and possible also her seizures. . # Hypothyroidism: Patient's levothyroxine was increased because of very elevated TSH and low T4 and T3. . . TRANSITIONAL ISSUES: - TSH should be rechecked in [4-17] wks after increase in levothyroxine dose if consistent with goals of care at that point Medications on Admission: Keflex 500 mg TID (last day to be [11-4]) lactobacillus [Hospital1 ] Kcl 20 mEq daily levothyroxine 75 mcg daily simvastatin 20 mg daily vitamin B12 250 mcg daily lorazepam 0.5 mg Q6H PRN ferrous sulfate 325 mg daily heparin 5000 units TID meclizine 12.5 mg Q8H PRN dizziness tramadol 50 mg Q6H PRN remeron 15 mg QHS albuterol nebs PRN multivitamin hctz 25 mg daily labetolol 200 mg [Hospital1 ] lasix 20 mg daily seroquel 25 mg [Hospital1 ] seroquel 25 mg Q6H prn nitropaste PRN Tube feeds: free water flush 200 mL Q6H, jevity 1.2 cal 50 mL/hr, on at 8 pm of at 6AM, hold durng the day Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for Dizziness. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: One (1) PO Q8H (every 8 hours). 11. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Tube feeds Tubefeeding: Nepro Full strength; Starting rate:35 ml/hr; Do not advance rate Goal rate:35 ml/hr Residual Check:q4h Hold feeding for residual >= :200 ml Flush w/ 50 ml water q6h Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] Continuing Care Center - [Hospital1 392] Discharge Diagnosis: Primary Diagnoses: Acute on Chronic Diastolic Heart Failure Healthcare Associated Pneumonia Non convulsive seizure Secondary Diagnoses: hypothyroidism pneumonia vertigo anemia, unclear etiology, on B12 and iron supplements HTN MRSA hx Colon Ca s/p R colectomy c/b cholecystitis s/p cholecystectomy in [9-/2165] G tube placed [2165-10-28] Discharge Condition: Mental Status: Confused - always. 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 because you were found to have a pneumonia. You were also found to have increased fluid buildup around your lungs, thought to be secondary to problems with your heart. Your hospital course was complicated by seizure activity. We treated you with medication to control the seizures, you will need to continue to take these medications to prevent seizures in the future. You also suffered a heart attack and were taken for cardiac catheterization. There was stent placed, and optimal medical management was started. The following changes were made to your medications: START Aspirin INCREASE Levothyroxine DISCONTINUE Simvastatin DISCONTINUE Lorazepam DISCONTINUE Tramadol DISCONTINUE Remeron DISCONTINUE Hydrochlorothiazide DISCONTINUE Labetalol DISCONTINUE Furosemide DISCONTINUE Seroquel START Atorvastatin START levetiracetam START Valproic Acid START Torsemide START Lisinopril START Metoprolol START Spironolactone Followup Instructions: Please follow up with your primary care provider as needed [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 2073]	[ "41071", "486", "5990", "5849", "4280", "5859", "40390", "2724", "2449" ]
Admission Date: [2101-1-12] Discharge Date: [2101-1-21] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2101-1-14] Mitral Valve Replacement utilizing a 33 millimeter CE Perimount Mitral Bioprosthetic Valve History of Present Illness: This is an 82 year old male with known mitral regurgitation and dilated cardiomyopathy. He also suffers from chronic atrial fibrillation. He complains of worsening fatigue and shortness of breath. Cardiac catheterization in [2100-11-21] confirmed 3+ mitral regurgitation and an LVEF of 35%. Coronary angiography showed no flow limiting disease. His most recent ECHO was from [2100-5-21] which revealed moderate to severe mitral regurgitation, 1+ aortic insufficiency, and an LVEF of 45%. Based on the above results, he was referred for cardiac surgical intervention. He will be admitted for reversal of Warfarin and heparinization. Past Medical History: Mitral regurgitation, Dilated Cardiomyopathy, Congestive Heart Failure, History of Myocardial Infarction, Chronic Atrial Fibrillation, Hyperlipidemia, History of Cerebrovascular Accident, Trigeminal Neuralgia, Testicular Tumor - s/p Orchiectomy, s/p Right Shoulder Surgery Social History: Lives with wife. Retired chief probation officer. Denies tobacco. Occasional EtOH - averges out to one drink a day. Family History: No premature CAD. Brother and mother died of MI in their 70's. Physical Exam: Vitals: T 98.7, BP 139/72, HR 66, RR 16, SAT 100% on room air General: elderly male in no acute distress HEENT: oropharynx benign, sclera anicteric, PERRL, EOMI Neck: supple, no JVD, no carotid bruits Heart: irregular rate, normal s1s2, systolic murmur noted Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 1+ edema, chronic venous stasis changes, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [2101-1-12] 03:04PM BLOOD WBC-6.1 RBC-3.75* Hgb-12.6* Hct-35.4* MCV-94 MCH-33.6* MCHC-35.6* RDW-13.5 Plt Ct-148* [2101-1-12] 03:04PM BLOOD PT-15.1* PTT-24.6 INR(PT)-1.4* [2101-1-12] 03:04PM BLOOD Glucose-88 UreaN-23* Creat-1.1 Na-142 K-4.2 Cl-107 HCO3-25 AnGap-14 [2101-1-12] 03:04PM BLOOD ALT-20 AST-25 AlkPhos-103 Amylase-57 TotBili-0.6 [2101-1-20] 06:30AM BLOOD WBC-7.3 RBC-3.10* Hgb-10.0* Hct-30.3* MCV-98 MCH-32.3* MCHC-33.1 RDW-14.2 Plt Ct-135* [2101-1-21] 09:30AM BLOOD PT-21.1* INR(PT)-2.0* [2101-1-21] 06:35AM BLOOD UreaN-39* Creat-1.7* [2101-1-20] 06:30AM BLOOD Glucose-103 UreaN-39* Creat-1.9* Na-138 K-4.8 Cl-104 HCO3-25 AnGap-14 [2101-1-19] 03:23AM BLOOD Glucose-109* UreaN-34* Creat-1.8* Na-135 K-4.2 Cl-103 HCO3-23 AnGap-13 [2101-1-18] 04:51AM BLOOD Glucose-108* UreaN-33* Creat-2.0* Na-134 K-4.2 Cl-102 HCO3-24 AnGap-12 Brief Hospital Course: Mr. [Known lastname 95715] was admitted and underwent routine preoperative evaluation. He was concomitantly heparinized for his chronic atrial fibrillation. Workup was otherwise unremarkable and he was cleared for surgery. On [1-14], Dr. [Last Name (STitle) 1290] performed a mitral valve replacement utilizing a 33 millimeter CE perimount mitral bioprosthetic valve. The operation was uneventful and he transferred to the CSRU in stable condition. Within 24 hours, he awoke neurologically intact and was extubated. He initially required atrial pacing for an underlying junctional rhythm. He otherwise maintained stable hemodynamics and successfully weaned from inotropic support. Over several days, his native heart rate improved and low dose beta blockade was resumed. Given his bradycardia and long standing history of atrial fibrillation, Amiodarone was not recommended. He was noted to have a slight decline in renal function but continued to maintain adequate urine output. His creatinine peaked to 2.0 on postoperative day four. Diuretics were titrated accordingly. His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day five. His renal function continued to improve. Warfarin was dosed daily for a goal INR between [12-24]. He transiently required Heparin for a subtherapeutic prothrombin time. Over several days, he continued to make clinical improvements and made steady progress the physical therapy. He was cleared for discharge to rehab on postoperative day 7. All surgical wounds were clean without signs of infection. His creatinine continued to improve, and was 1.7 on the day of discharge.INR on [1-21] was 2.0 after several doses of 5 milligrams. Medications on Admission: Lipitor 20 qd, Lasix 20 qd, Warfarin 5 qd, KCL, Aspirin 81 qd, Toprol XL 12.5 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Warfarin 5 mg Tablet Sig: Five (5) Tablet PO ONCE (once) for 1 doses: check INR [2101-1-22] and prn and redose coumadin, . 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: On [Location (un) ] - [Location (un) ] Discharge Diagnosis: Mitral regurgitation - s/p MVR, Dilated Cardiomyopathy, Postoperative Acute Renal Insufficiency, Congestive Heart Failure, Chronic Atrial Fibrillation, Hyperlipidemia, History of Cerebrovascular Accident, Trigeminal Neuralgia, Testicular Tumor - s/p Orchiectomy, s/p Right Shoulder Surgery Discharge Condition: Good Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Weigh daily, call with weight gain 2 pounds in one day or five in one week. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [2-23] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 12646] in [12-24] weeks - call for appt. Local cardiologist, Dr. [Last Name (STitle) ] in [12-24] weeks - call for appt. Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [2-23] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 12646] in [12-24] weeks - call for appt. Local cardiologist, Dr. [Last Name (STitle) ] in [12-24] weeks - call for appt. Completed by:[2101-1-21]	[ "4240", "42731", "4280" ]
Admission Date: [2110-8-20] Discharge Date: [2110-8-26] Date of Birth: [2062-7-3] Sex: M Service: MEDICINE Allergies: Demerol / Metronidazole Attending:[First Name3 (LF) 34452] Chief Complaint: CC - nausea, vomiting, fever, diarrhea x 24 hrs Major Surgical or Invasive Procedure: Colonoscopy [2110-8-25] with normal results History of Present Illness: 48 yo man w/ h/o HIV (last CD4 59, recently taken off HAART due to [Month/Day/Year 500] marrow suppression), Hep C, ESLD, and chronic ascites who presents nausea, vomiting, fever, and diarrhea x 24 hours. The patient was seen by Dr. [Last Name (STitle) 497] in the Liver Center [8-15], who performed a therapeutic paracentesis. On the night prior to admission, he developed acute onset nausea, non-bloody emesis x 1, fever (100.4 or 104, cannot remember), crampy abdominal pain, and non-bloody diarrhea. He denied chills, night sweats, SOB, cough, mental status changes, headache, or rash. Last BM was at 8 am. Reports compliance with all medications; however, lasix/aldactone were stopped on [8-15]. His friend brought him to the ER for evaluation. . In the ED, he was febrile to 102.5, tachy at 119, BP 119/77, RR 28, 97%RA. Then BP subsequently dropped to 94/58. He was given 1.5 liters NS, levofloxacin 500 mg IV x 1, vanco 1 gm IV x 1, Flagyl 500 mg IV x 1. Lactate was 5.2. He also received 2 units FFP in anticipation of possible paracentesis; however, abdominal u/s showed no pockets of peritoneal fluid for tap. Past Medical History: 1. HIV, diagnosed in [2092]. Previously on Trizivir, stopped 2 months ago [2-26] leukopenia, started on Neupogen. Last CD4 248 on [2110-6-16] off HAART. VL <50 on [2110-5-5]. History of + IVDU. 2. Hepatitis C/cirrhosis: Complicated by ascites and varices. HCV VL 2,660,000 IU/mL on [2110-5-5]. Listed for transplant. 3. Chronic back pain and leg pain secondary to spinal stenosis. 4. Peripheral neuropathy 5. History of compression fracture Social History: Positive tobacco [1-26] ppd X years. No EtOH. Past history of IVDU, nothing X more than 15 years. He lives alone. Family History: Non-contributory Physical Exam: 100.8 - 104 - 110/52 - 16 - 94% RA Gen: cachectic man, jaundiced, awake and alert, NAD HEENT: PERRL, icteric, dry MM, erythematous MM, temporal wasting Neck: supple, no LAD Lungs: course bilaterally, +wheezes diffusely, no crackles Heart: RRR, normal s1s2, no M/R/G Abd: NABS, distended, TTP RLQ and mid-lower abdomen, no palpable masses. +caput medusae Ext: 1+ pitting edema bilaterally, +venous stasis changes Neuro: A&Ox3, CN II-XII intact; strength grossly intact bilaterally; +asterixis Rectal: guaiac negative per ER . Brief Hospital Course: Shortly after admission, the patient became hypotensive and was transferred to the MICU for pressure management. In the MICU, the patient was bolused to keep MAP > 60 and empiric Abx treatment for SBP, PNA/PCP/MAC, and meningitis was started: Ceftriaxone 2 gm IV Q24H, Levofloxacin 500 mg IV Q24H, Flagyl 500 mg IV Q8h, and Bactrim. 4/4 bottles BCx grew GNR. BP stabilized overnight, and pt became afebrile. ID consulted, recommended continuing antibiotic coverage and tailoring after speciation/sensitivities came back. CMV viral load and extensive stool studies were sent. Liver service consulted and recommended lactulose and rifaximin for hepatic encephalopathy, restarting Lasix/aldactone when hemodynamically stable, and considering tapping the ascites. Hyponatremia, probably [2-26] cirrhosis, was managed w/ free water restriction. RUQ U/S showed cholelithiasis but no cholecystitis. Abd CT showed diffuse wall thickening of ascending and transverse colon likely representing infectious or inflammatory colitis. After the patient was stabilized, he was transferred back to the floor for further management. A colonscopy done showed no abnormalities. He was continued on Flagyl for a course of 7 days for the ascending colitis, and on ceftriaxone for E.coli sepsis 2g IV. At the time of discharge, the patient was no longer having any diarrhea and asymptomatic. He deferred having a therapeutic paracentesis multiple times and preferred to wait until his appointment with Dr. [Last Name (STitle) 497] to have the tap done. He was discharged with a midline to complete his 2-week course of Ceftriaxone therapy and was to follow with his ID physician for results of the stool studies, as they were all pending at the time of discharge. Medications on Admission: 1. Aldactone 30 mg TID 2. Bactrim 1 tablet daily 3. Lactulose 30 ml TID 4. Lasix 20 mg QID 5. Rifaximin 200 mg TID 6. Truvada 200-300 mg daily 7. MS Contin 240 mg TID Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 3. Rifaximin 200 mg Tablet Sig: 1.5 Tablets PO tid (). Disp:135 Tablet(s) Refills:2 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ceftriaxone Sodium in D5W 40 mg/mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 7 days. Disp:14 grams Refills:0 7. Morphine 60 mg Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO three times a day. Disp:168 Tablet Sustained Release(s) Refills:0 8. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary - colitis of unknown etiology Secondary - HIV/AIDS ([2092]), Hep C/cirrhosis/ESLD, chronic diarrhea, ascites, chronic back pain and leg pain, spinal stenosis, peripheral neuropathy Discharge Condition: Fair Discharge Instructions: -continue with medications as prescribed -please follow-up in clinic as scheduled -if diarrhea returns or worsens, or any other concerning symptoms arise, please seek medical attention -weigh yourself daily Followup Instructions: Provider: [Name10 (NameIs) 454],SIX DAY CARE [Hospital Ward Name ] 8 Where: DAY CARE [Hospital Ward Name ] 8 Date/Time:[2110-8-29] 12:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 5628] Phone:[Telephone/Fax (1) 673] Date/Time:[2110-9-4] 11:00 Provider: [Name10 (NameIs) 454],SIX DAY CARE [Hospital Ward Name ] 8 Where: DAY CARE [Hospital Ward Name ] 8 Date/Time:[2110-8-29] 12:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 5628] Phone:[Telephone/Fax (1) 673] Date/Time:[2110-9-4] 11:00 Provider: [Name10 (NameIs) ] [Name8 (MD) 9406], MD Where: LM [Hospital Unit Name 4337] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2110-9-8] 11:30 Completed by:[2110-9-1]	[ "2761", "5180", "2875" ]
Admission Date: [2159-5-26] Discharge Date: [2159-5-29] Date of Birth: [2117-5-16] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 42 yo female restrained driver s/p sigle motor vehicle crash. + airbag deployment with no rpeorted LOC. She was taken to an rea hsopital where found to have significant spleen injury and was then transferred to [Hospital1 18] for further care. Past Medical History: Hypertension Depression Family History: Noncontributory Physical Exam: Upon admission: T 96.9 HR 74 BP 132/70 RR 20 O2 Sat 100% Gen: No acute distress HEENT: NCAT; PERRL at 4mm Chest: CTA bilat; no crepitus Cor: RRR Abd: soft, NT FAST +; TTP RUQ Neuro: A & O x3, MAE x4 Pertinent Results: [2159-5-26] 03:30PM GLUCOSE-109* UREA N-20 CREAT-1.4* SODIUM-138 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12 [2159-5-26] 03:30PM ALT(SGPT)-31 AST(SGOT)-34 ALK PHOS-35* TOT BILI-0.5 [2159-5-26] 03:30PM WBC-16.1* RBC-3.38* HGB-11.0* HCT-32.1* MCV-95 MCH-32.7* MCHC-34.3 RDW-12.6 [2159-5-26] 03:30PM PLT COUNT-335 [2159-5-26] 03:30PM PT-12.4 PTT-22.5 INR(PT)-1.0 [2159-5-26] 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2159-5-26] 11:20PM HCT-25.1* [2159-5-26] CT Chest/Abd/Pelvis: IMPRESSION: 1. Grade IV multifocal splenic lacerations with active extravasation/traumatic pseudoaneurysm formation, subcapsular hematoma and moderate hemoperitoneum, concurrent with apparent initial interpretation. 2. Normal aorta without traumatic injury. No other solid organ injury. 3. No fractures. 4. 2 mm right middle lobe nodule. In the absence of risk factors for lung cancer, no followup is needed. 5. Several tiny renal hypodensities, too small to characterize. Cardiology Report ECG Study Date of [2159-5-26] 3:50:44 PM Sinus rhythm. Short P-R interval. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 94 94 420/428 33 79 51 Brief Hospital Course: She was admitted to the Trauma Service and transferred to the Trauma ICU for serial abdominal exams and close monitoring of her hematocrits. She was placed on bedrest initially and given IV fluids. Her hematocrits were as follows: HCT: 39> 32> 28> 25> 25.5> 25.3> 25.3> 25.6> 24.1 (26.6 on day of discharge). She remained hemodynamically stable and was then transferred to the regular nursing unit where she continued to do well. Her pain was managed effectively with Vicodin prn. Her diet and activity were advanced and her home medications were restarted. She was discharged to home on hospital day 4 with instructions for follow up in Trauma clinic and with her primary care provider. Medications on Admission: Welbutrin 200 mg [Hospital1 ], Nifedipine 10 mg [Hospital1 ], Flexeril prn, Naproxysyn prn Discharge Medications: 1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): Both eyes. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 6. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Grade III splenic laceration Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: AVOID any contact sports or any activity that may cause injury to your abdominal area because of your spleen injury. Go to the nearest Emergency room immediately if you suddenly become weak/dizzy, feeling as though you may pass out and/or develop left shoulder pain. These are signs that you may be having internal bleeding from your spleen. Followup Instructions: Follow up with Dr. [Last Name (STitle) ], Trauma Surgery next week in clinic for your spleen injury. Call [Telephone/Fax (1) 6429] for an appointment. Follow up with your primary care providers within the next [2-16] weeks for a general physical. You will need to call for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2159-6-15]	[ "2851", "2449", "4019" ]
Admission Date: [2180-3-24] Discharge Date: [2180-4-1] Date of Birth: [2125-7-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: Left Empyema Major Surgical or Invasive Procedure: [2180-3-27] Left thoracoscopy and partial decortication of left lung. [2180-3-30] Flexible bronchoscopy History of Present Illness: The patient is a 54-year-old male with an approximately 12 cm loculated empyema in the left chest. He was treated initially with a chest tube that evacuated over a liter of frank pus. A post chest tube CT scan demonstrated markedly improved expansion of the left lung but there were some residual fluid collections within the pleural space. He was taken to the operating room for debridement and decortication. Preoperatively, we reviewed the risks of the operation with the patient and his sister. We discussed the risk of bleeding, reoperation, recurrence of the pleural effusion and death. Past Medical History: Obesity Social History: Lives alone Never smoked. ETOH once a week Family History: non-contributory Physical Exam: T 98.3, HR 86, BP 130/82, RR 18, O2Sa 95%RA GEN - NAD, A&O HEENT - NCAT, EOMI, MMM, trachea midline, neck supple CVS - RRR, nl S1 and S2 PULM - CTAB, no W/R/R, no respiratory distress ABD - S/NT/ND, no massess EXTREM - warm/dry Pertinent Results: [2180-3-31] WBC-16.6* RBC-2.76* Hgb-8.0* Hct-24.6 Plt Ct-661* [2180-3-30] WBC-21.2* RBC-2.88* Hgb-8.1* Hct-25.7* Plt Ct-713* [2180-3-24] WBC-23.3* RBC-3.35* Hgb-9.4* Hct-28.3* Plt Ct-578* [2180-3-29] Neuts-84.5* Lymphs-10.8* Monos-3.2 Eos-1.1 Baso-0.4 [2180-3-31] Glucose-112* UreaN-22* Creat-2.8* Na-143 K-3.3 Cl-107 HCO3-26 [2180-3-30] Glucose-114* UreaN-21* Creat-3.1* Na-142 K-3.6 Cl-107 HCO3-25 [2180-3-29] Glucose-120* UreaN-20 Creat-2.9* Na-139 K-4.1 Cl-104 HCO3-24 [2180-3-29] Glucose-101* UreaN-18 Creat-2.6# Na-136 K-4.0 Cl-105 HCO3-24 [2180-3-28] Glucose-88 UreaN-12 Creat-1.2 Na-135 K-3.7 Cl-102 HCO3-24 [2180-3-24] Glucose-99 UreaN-13 Creat-0.8 Na-130 K-3.8 Cl-94* HCO3-27 [2180-3-31] Calcium-8.2* Phos-4.2 Mg-2.3 [2180-3-25] calTIBC-122* Hapto-472* Ferritn-GREATER TH TRF-94* [2180-3-25] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2180-3-27] IgG-1611* IgA-390 IgM-96 Micro: [2180-3-30] BAL G/S -> no orgs [2180-3-29] renal u/s No hydro, bladder appears nl [2180-3-28] DFA Negative for Influenza A & B [2180-3-27] Pleural Tissue Final- no growth [2180-3-25] Urine Cx Negative [2180-3-25] Pleural Fluid Strep Milleri, GNR [2180-3-24] Blood Cx Negative CXR: [2180-3-31] FINDINGS: In comparison with the study of [5-29], the right IJ catheter has been removed. Post-surgical changes are again seen on the left with two chest tubes in place. Little overall change in the extent of the left pleural thickening or residual effusion. Chest CT [2180-3-26] IMPRESSION: 1. Marked decrease in the size of multiloculated left pleural fluid collections following placement of a left pleural drain. Small amount of loculated fluid and extensive pleural thickening persists. 2. Slight interval increase in the size of pericardial effusion. These findings should be closely followed clinically for the possibility of developing tamponade physiology. 3. Persistent left lobe dependent consolidation. 4. Mild gallbladder mural thickening. Would correlate this finding to physical examination for upper abdominal pain. If absent, could correlate to an outpatient abdominal ultrasound [2180-3-29] Renal US: 1. Patent hepatic vasculature. 2. No significant ascites is seen. 3. Multiple gallbladder calculi and moderately thickened gallbladder wall as identified on prior ultrasound scan [2180-3-24]. Brief Hospital Course: 54M admitted on [2180-3-24] from the ED after as a transfer from [Hospital3 3583] ED where he was found to have six weeks of fatigue, decreased energy. At [Hospital1 18] he was found to have a leukocytosis and on CT had a large left sided empyema occupying >50% of the left chest cavity. He was immediately started on Vanc and Zosyn and on HD 2 he underwent placement of a left sided pigtail catheter with the immediate outflow of thick pus > 1L. The patient did complain of some abdominal pain and was found to have cholelithiasis with thickening of the gallbladder wall on ultrasound, but there was no intrahepatic or extrahepatic biliary dilatation. An MRCP was performed because of the ultrasound findings and the patient's elevated biliruben to 3.4 at the time of admission, but his pain had begun to subside by HD 2 and his LFTs were all down trending. There was much less of a concern for acute cholecystitis. He was otherwise stable and tolerating a regular diet. On HD 3 a repeat CT of the chest confirmed that much of the empyema had drained but there was a persistent left lobe dependent consolidation and and extensive pleural thickening. On HD 4 he was taken to the operating room for a L VATS decortication, washout and chest tube placement. This procedure went well without surgical complication; for more information please see separate op note. During extubation the patient did become agitated and resultantly pulled out his IV access and dislodged the ET tube. The tube was promptly replaced but becuase the patient remained agitated, IM sedation was given including 5mg midazolam and 60mg ketamine. He was also hypertensive into the 200s systolic and given 10 labetolol. A central line was placed in the PACU and the patient remained intubated. His pressures then began to drift downward with MAPs 60-65. He was then started on phenylephrine drip up to 2mcg/kg/min. He was transferred to the ICU for monitoring, weaning of the pressors and respiratory managment. Overnight POD 0 he required a 500cc bolus of LR and 250 of 5% albumin as his Urine output was borderline low. On the morning of POD 1 he was alert, responsive to commands and down on his pressor to 0.8mcg/kg/min of phenylephrine. At 5pm his pressors were weaned off and he was extubated without event. He was comfortable and tolerating a regular diet On POD 2 he transferred to the floor. Renal was consulted for ATN pk CRE 3.1 base 0.8. They felt his acute renal failure was secondary to ischemic ATN during his period of hypotension requiring pressors. His creatinine continued to improve and on POD#5 it was 2.4. It was decided that since the patient had no insurance and was paying out of pocket for his hospital stay that it would be ok to discharge him home. The nephrology team was comfortable with sending him home with a Cr of 2.4 as well as long as the patient was set for follow-up soon after discharge where a chem panel could be checked. Therefore, his chest tubes were switched out for pneumostats. He and his sister received [Name2 (NI) 84856] teaching and home VNA was set up for him since he started an application for Mass Health. On the day of discharge, he was afebrile with stable vital signs. He was tolerating a regular diet. He had no complaints of pain, shortness of breath, cough, or chest pain. He was able to get out of bed and ambulate independently. Medications on Admission: None Discharge Medications: 1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day: Continue antibiotics until seen in [Hospital ] clinic on [2180-4-28]. Disp:30 Tablet(s) Refills:0 2. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO four times a day: Continue taking this medication until seen in [Hospital ] clinic on [2180-4-28]. Disp:360 Capsule(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Left empyema Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or sputum production -Chest tube site: ([Telephone/Fax (1) ]) change dressing daily -Drain [Telephone/Fax (1) ] daily and keep a record of output. -If the chest tube falls out cover site with dressing and call immediately -Continue to take the antibiotics as directed until you are seen in infectious disease clinic Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2180-4-13] 3:00 in the [Hospital Ward Name 121] Building Chest Disease Center [Location (un) 24] Chest X-Ray at 2:30 (before your appt) in the [Location (un) 861] Radiology Deparment Blood draw ground floor [Hospital Ward Name 516] Shapior Clinical Center (behind the information desk) You have an appointment for follow-up in the Infectious Disease clinic on [2180-4-28] at 9:30am. Call [Telephone/Fax (1) 457] to confirm or reschedule your appointment as needed. The [Hospital ] clinic is located on the ground floor of the [Hospital ] Medical Office Building, which is located on [Last Name (NamePattern1) ]. Please call ([Telephone/Fax (1) 10135] to schedule an appointment with Dr. [First Name (STitle) 30217] [Name (STitle) 28760] in nephrology clinic within 2 weeks of discharge.	[ "486", "5845", "2761", "2859" ]
Admission Date: [2189-7-10] Discharge Date: [2189-7-20] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: 88 year old white female with DOE Major Surgical or Invasive Procedure: [7-13] [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] removal, CABG x 1 (SVG->LAD) History of Present Illness: This 88 year old white female has a h/o diastolic dysfunction with an LVEF of 55% and SSS with permanent pacer, and was doing well until 3 days prior to admission. She developed increasing DOE and PND and presented to [Hospital3 45967] where she was in CHF. A cardiac echo revealed a 3.5x2 cm mass in the LA and she was transferred to [Hospital1 18] for surgical evaluation. Past Medical History: s/p MI [2164] Complete heart block- s/p PPI [2164], [2173], [2184] Vertigo Hyperparathyroidism s/p appy s/p cataract removal NIDDM Social History: Lives alone. Does not smoke cigarettes or drink ETOH Family History: Unremarkable Physical Exam: Elderly WF in NAD AVSS HEENT: NC/AT, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. with R bruit Lungs: Bibasilar crackles CV: RRR without R/G/M, nl s1, s2 Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bilat. except bil. DP non-palpable, bilat. superficial varicosities. Neuro: A+Ox3, nonfocal. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2189-7-18] 06:30AM 7.7 3.37* 10.2* 28.9* 86 30.1 35.2* 16.2* 171 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2189-7-20] 09:00AM 16.0* 27.3 1.7 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [2189-7-13] 12:38PM 185 CALL TO [3-/3266] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2189-7-18] 06:30AM 481 18 0.9 136 3.9 100 292 11 Brief Hospital Course: The patient was admitted and was seen by cardiology and endocrine. She had a cardiac cath which revealed an 80% mid vessel LAD lesion and a 60% distal RCA stenosis. On [2189-7-13] she underwent a L atrial mass removal and CABGx1 w/ SVG->LAD. She tolerated the procedure well and was transferred to the CSRU in stable condition on Neo, Epi, and Propofol. Cross clamp time was 43 mins., total bypass time was 60 mins. She had a stable post op night and was extubated. She was started in coumadin on POD#1 and was weaned off her drips. On POD#2 she was transferred to the floor and her chest tubes and wires were d/c'd. She continued to do well and the pathology on the atrial mass was thrombus. She was discharged to rehab in stable condition on POD#7. Medications on Admission: Digoxin 0.125 mg PO daily Isosorbide 60mg PO daily Cardizem 180 mg PO daily Ecotrin 81 mg PO daily Vasotec 5 mg PO daily Lasix 60 mg PO daily Glyburide 10 mg PO daily KCL 20 mg PO BID 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 Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. 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 7. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: INR 1.7 on [7-20], goal 1.5-2, check INR wednesday [7-22]. Disp:30 Tablet(s) Refills:0 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] Nursing and Rehab Center Discharge Diagnosis: LAA Clot, CAD CHF PPM s/p AWMI s/p APPY Type 2 DM s/p L cataract removal hypercalcemia, elevated PTH Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 2 lbs in one day or five in one week. Adhere to 2 gm sodium diet [Known firstname 116] shower, no baths, wash incision with mild soap and water, call with temperature more than 101.5, or redness or drainage from incision PT q Mon., Wed., Fri. INR goal of [1-21].5 Followup Instructions: Dr. [Last Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 36812] in [12-21] weeks. Completed by:[2189-7-20]	[ "4280", "2760", "41401", "25000", "412" ]
Admission Date: [2138-10-7] Discharge Date: [2138-10-21] Date of Birth: [2061-6-24] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3556] Chief Complaint: Resp failure, intubated Major Surgical or Invasive Procedure: Intubation with mechanical ventilation (x2) Tracheostomy placement Right Internal Jugular vein line placement Arterial line placement PICC line placement [10-11] History of Present Illness: 77F with COPD, significant smoking hx who was initially admitted to [Hospital6 18346] last wednesday for RLE cellulits, discharged home on Friday on a course of Augmentin. Per the family and OSH notes, patient had a new O2 requirement on discharge of 2L NC. Per her family, patient's cellulitis improved but she began to act "wacky;" was saying strange things, hallucinating, and was increasingly somnolent. She also had decreased PO intake and activity, ? due to SOB. Presented to her pcp's office today, and reportedly had an O2 sat in the 60s (74-78 % on 2L), so was sent to the ED. In the ED in [Hospital1 6687], initial VS were BP 167/110, HR 112, RR 28, SaO2 53% on RA, which increased to 94% on 4L. Initially, she c/o nausea [3-11] Augmentin and was given zofran 4 mg IV. She became obtunded and minimally responsive; CXR reportedly showed Pulm edema and ABP showed 7.19/113/52/42 and the patient was intubated. She was also given albuterol nebs and Lasix 60 IV, Ativan 2 mg IV and Morphine 5 mg IV, and transferred to [Hospital1 18]. During [Location (un) ], was started on peripheral Dopamine at 10 mcg/kg/min (no vitals recorded). . In the ED, T 100.8, BP initially 130/56, HR initially 60s but increased to 140s transiently per nursing report (although HRs recorded only to max of 120s). Consequently, patient was changed from dopamine to levophed, and HR improved to 110s. During this changed, BP reportedly dropped (again not recorded, and patient bolused 2 liters). She was given vanco/levo to cover leg and pulm sources, 10 mg IV dexamenthazone and admitted to the MICU for further management. Past Medical History: COPD: MICU admission [2136] for hypercarbic/hypoxic respiratory failure [3-11] strep pneumo infectsion - underwent trach and peg and d/c'd to [Hospital ] [Hospital ] hospital MICU admission in [Name (NI) 108], pt intubated x 2 weeks ?CHF - last TTE [2136] showed normal EF Glaucoma Social History: Quit tobacco 16years ago, previously has approximately 80 pack year smoking history. No EtOH nor other illicits. Formerly worked in parking permit department at the police dept. Has 9 children (7 daughters, 2 sons). Lives alone on [Hospital1 6687], part of the year in Fla. Family History: Family History: non-contributory Physical Exam: Discharge Physical Exam Vitals: T: 97.7 BP: 90/44 P: 85 R: 31 O2: 93% General: trached, arousable, oriented x3 HEENT: Sclera anicteric, moist MM Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds anteriorly b/l CV: Regular rate and rhythm, normal S1 + S2, [3-15] soft systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place draining yellow urine Ext: warm, well perfused, [2-8]+ pitting edema b/l Pertinent Results: [2138-10-7] 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2138-10-7] 09:59PM GLUCOSE-121* LACTATE-0.9 NA+-144 K+-4.4 CL--86* TCO2-41* [2138-10-7] 09:50PM UREA N-17 CREAT-0.7 [2138-10-7] 09:50PM ALT(SGPT)-140* AST(SGOT)-95* LD(LDH)-246 ALK PHOS-159* TOT BILI-0.4 [2138-10-7] 09:50PM LIPASE-18 [2138-10-7] 09:50PM proBNP-3654* [2138-10-7] 09:50PM ALBUMIN-3.6 [2138-10-7] 09:50PM WBC-7.9 RBC-4.06* HGB-12.4 HCT-37.7 MCV-93 MCH-30.6 MCHC-32.9 RDW-14.0 [2138-10-7] 09:50PM NEUTS-82.9* LYMPHS-10.0* MONOS-4.5 EOS-1.6 BASOS-0.9 [2138-10-7] 09:50PM PT-11.6 PTT-21.0* INR(PT)-1.0 [2138-10-7] 09:50PM PLT COUNT-385 [2138-10-7] 09:49PM TYPE-ART PO2-75* PCO2-70* PH-7.36 TOTAL CO2-41* BASE XS-10 ___________________________________ IMAGING: ECHO [10-8] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary gradient is identified. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient 12 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. [10-8] CTA- IMPRESSION: 1. Moderate pulmonary edema with bilateral pleural effusions and bibasilar consolidations which could be compressive atelectasis in the setting of effusions. Superimposed infection is not excluded. 2. Mediastinal adenopathy, unchanged since the prior study. This could also be related to cardiac decompensation/heart failure. Alternatively, this could be reactive to a generalized infectious process. 3. Coronary artery disease, evidence of pulmonary hypertension, significant mitral annular calcifications are all unchanged. 4. Unchanged left hepatic lobe lesion could represent a cyst or a hemangioma. 5. Suboptimally visualized previously seen left adrenal mass. This could represent an adenoma, however is incompletely imaged, As indicated previously, this should be further evaluated with an adrenal protocol CT or an MRI. The study and the report were reviewed by the staff radiologist. CXR [10-20] IMPRESSION: Pulmonary anatomic detail in the lungs is obscured by respiratory motion. Chest configuration indicates substantial COPD. Moderate right pleural effusion unchanged since [10-19]. Left lower lobe opacification is probably atelectasis, but pneumonia cannot be excluded. Pulmonary vascular congestion is definitely present, and there may be mild pulmonary edema. Heart size top normal. Tracheostomy tube in standard placement. Feeding tube passes into the stomach and out of view. _______________________________________________ LABS DURING ADMISSION: CBC [10-7]: 7.9 > 12.4/37.7 < 385 CHEM 7 [10-7]: 143/4.3 - 105/32 - 18/0.6 < 130 Ca: 7.3 Phos: 3.3 Mg: 1.7 ALT: 140 AST: 95 _______________________________________________ LABS AT DISCHARGE: CBC [10-21]: 10.0 > 8.3/24.9 < 238 CHEM 7: 141/4.1 - 96/40 - 21/0.7 < 125 Ca: 8.3 Phos: 4.2 Mg: 2.4 ALT: 65 ([10-10]) AST: 27 ([10-10]) TSH: 5.3 Free T4: 0.92 Galactomannan - negative beta-glucan - negative Final cultures pending: [2138-10-18] 4:39 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2138-10-18]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. HEAVY GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. Blood cultures from [10-18] and [10-19] pending - no growth to date URINE CULTURE (Final [2138-10-19]): YEAST. >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). SPARSE GROWTH. Brief Hospital Course: 77 yo F with Hx of COPD with multiple past intubations, now presenting with hypercarbic respiratory failure and hypotension concerning for sepsis in the setting of several possible sources of infection. . # Respiratory failure - The patient presented to the [Hospital1 18] ED intubated and sedated. CXR suggestive of pulmonary edema versus interstitial infectious process. CTA of the chest showed no pericardial effusion, unchanged mediastinal adenopathy, no PE, dilated main PA, normal aorta, moderate bilateral pleural effusions, and moderate pulmonary edema. Patient has been exposed to hospital pathogens with recent hospital admission for cellulitis. She was started on levophed, vancomycin, cefepime and admitted to the MICU. She was able to extubated after being intubated overnight and was transitioned to bilevel airway ventilation. She was on this for 1.5 days, however when it was attempted to wean her off, she became tachypneic, confused, and hypercarbic and was re-intubated. On [10-13] pt was extubated again , however she quickly became hypertensive and tachypneic and required re-intubation. Trach and PEG option discussed with pt and family. On [10-16] pt underwent trach (not PEG per patient decision) with CT surgery and a dobhoff was placed. Pt tolerated the procedure well with no complications other than residual pain at the site. On [10-17], she had an episode of tachypnea and fever and CXR showed possible infiltrate. Her Tv decreased and peak pressures increased during this time. She also had increased WBC and fever, she was started on empiric therapy for Ventilator-associated on [10-18] with vanco/zosyn for a planned 8 day course to finish on [2138-10-25]. Additionally, during this period she was requiring more pressure support, and was diuresed with 20 mg IV lasix daily with good output. She can continue to receive lasix prn if patient appears clinically volume overloaded. At the time of discharge, the patient's ventilator settings were: Pressure support at 20/5 with 50% FiO2, breathing at a rate of 35, with tidal volumes 300-350cc. . # Hypotension/Shock: Unclear if septic etiology, or secondary to combination of medication administration and positive pressure ventilation. However, given RLE cellulitis as a known source of infection and significant hypoxia pt was treated empirically for sepsis. Central line placed (IJ). Cultures at OSH showed no growth and cultures at [Hospital1 18] show NGTD. Vanco and cefepime courses were completed. Hypotension resolved. However, on [10-18], her worsening Tv, WBC and fevers led to empiric VAP coverage with Vanc-Zosyn for an 8 day course, to end on [2138-10-25]. # Anxiety - The patient frequently became very anxious, becoming hypertensive to the 200s/100s and tachcardic to the 120s. She was able to be talked down/reoriented from her anxiety, but frequently required an anxiolytic as well to calm her down. Pt was initially treated with ativan and at times required versed. On [10-16] pt was started on seroquel QHS. EKG was checked and showed no QT prolongation. The patient did well with seroquel at night, but continued to require small doses of prn ativan for anxiety. # SVT - The patient had episodes of tachycardia, her longest being a run of approximately 30 seconds, which reached a peak of 200 beats per second before spontaneously breaking. She was started on metoprolol tartrate that was titrated up to 37.5mg TID before discharge. The SVT was thought to be multifocal atrial tachycardia and her beta blocker can be titrated up to suppress the ectopic atrial activity as tolerated. # Adrenal Mass - Per final CTA read, patient needs follow up CT or MR [First Name (Titles) ] [Last Name (Titles) ] known adrenal mass (not needed in ICU). # Transaminitis - This was thought to be secondary to hypotension and hypoperfusion of his liver. These values improved with time and were not trended during the hospitalization after normalization. # Guaiac pos, slow Hct decline - The patient's Hct remained stable throughout admission, but she needs a colonoscopy as an outpatient. Ms. [Known lastname ] was full code throughout admission. Communication was with her HCP [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 77111] (cell), home [Telephone/Fax (1) 77112]. Medications on Admission: Augmentin Combivent Symbicort Vitamins D and C Folic Acid Flonase ASA . Discharge Medications: 1. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 2. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) mL PO twice a day. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) puffs Inhalation four times a day. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO qHS:PRN as needed for anxiety. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Vancomycin 750 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) mg Intravenous every twelve (12) hours for 4 days. 9. Zosyn 4.5 gram Recon Soln Sig: 4.5 g Intravenous every eight (8) hours for 4 days. 10. Chloraseptic Throat Spray 1.4 % Aerosol, Spray Sig: One (1) sprays Mucous membrane every four (4) hours as needed for throat pain. 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three times a day. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day: Discontinue when patient appropriately ambulatory. 13. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for anxiety. Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Primary: COPD exacerbation, pneumonia, anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you during your hospitalization. You were admitted with acute respiratory failure, and needed to be intubated to help you breathe. Your respiratory failure was thought to be caused by a flare of your COPD as well as a possible infection. We treated you with antibiotics that treated possible lung infections as well as the cellulitis of your right leg. We tried to remove the breathing tube twice, however each time you had progressive difficulty breathing so we had to replace the breathing tubes. Because of this, we decided to place a tracheostomy to give your lungs more time to recover. After speaking with you and the surgical team, it was decided not to place a PEG tube into your stomach. Instead, a Dobhoff feeding tube was placed through which you are getting your tube feeds. During your hospitalization, you had several episodes where your heart began beating very fast. We started a medication, metoprolol, that helps control this. You also became anxious, especially at night. We gave you anti-anxiety medication and started a medication called seroquel that helped reduce your night time anxiety and let you sleep. We started a new medication regimen for you. Please continue to take these as prescribed unless instructed otherwise by one of your physicians. 1. Bisacodyl 5 mg Two Tablet PO once a day as needed for constipation. 2. Colace 60 mg/15 mL Syrup Twenty Five mL PO twice a day. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Six puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six puffs Inhalation four times a day. 5. Metoprolol Tartrate 25 mg 1.5 Tablet PO three times a day. 6. Senna 8.6 mg One Tablet PO twice a day. 7. Quetiapine 25 mg One Tablet in the evening as needed for anxiety. 8. Famotidine 20 mg One Tablet PO twice a day 9. Vancomycin 750mg IV q12 hours for 4 more days (8 day course) 10. Zosyn 4.5g IV q8 hours for 4 more days (8 day course) 11. Ativan 0.5-1mg po BID prn for anxiety Followup Instructions: Please have your tracheostomy stitches removed on [10-23] ([10-23]). Follow-up with your PCP as needed after discharge from rehab. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560]	[ "0389", "78552", "51881", "5849", "5990", "99592", "4019", "42789", "4280" ]
Admission Date: [2178-8-10] Discharge Date: [2178-8-20] Date of Birth: [2117-4-8] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Irbesartan Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2178-8-11] Cardiac catheterization [2178-8-13] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to RCA) History of Present Illness: Mr. [Known lastname 73352] is a 61 y/o male w/ h/o HTN, DM, CKD, and 1 episode of CP pain ~1 wk prior to admission who presented to PCP for routine [Name9 (PRE) 73353], where EKG obtained which showed TWI and ?STE in V1-2. He was sent to OSH and given Heparin and Plavix and transferred to [Hospital1 18] for cardiac cath. Past Medical History: Hypertension Diabetes Mellitus - Insulin Dependent Hypercholesterolemia Chronic Renal Insufficiency Gastroesophageal Reflux Disease Gout Social History: Social history is 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: 97.7 137/67 57 20 98%2L Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm. 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: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2178-8-11] Cardiac Cath: R dom., 50% LM, 99% mLAD involving diag, 70% prox. LCX, 70% prox RCA, calcified aorta [2178-8-11] RENAL ULTRASOUND: Right kidney measures 11.0 cm. Left kidney measures 11.9 cm. No stone, mass, or hydronephrosis is seen on either side. Renal cortical thickness is preserved bilaterally. [2178-8-12] CT Chest: 1. Marked coronary artery calcifications. 2. Calcifications of the aorta and great vessels, consistent with atherosclerotic disease. 3. Cholelithiasis. [2178-8-12] CXR: FINDINGS: The cardiac silhouette is minimally prominent. The aorta is within normal limits aside from some calcifications of the knob. Lungs are grossly clear. Bony structures are intact. IMPRESSION: No signs for acute cardiopulmonary process. [2178-8-13] Carotid US: FINDINGS: Minimal calcific plaque involving the carotid bulbs bilaterally, peak systolic velocities are normal bilaterally as are the ICA to CCA ratios. There is normal antegrade flow involving both vertebral arteries. [2178-8-13] Echo: PRE-BYPASS: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. 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 phenylepherine. Patient is Atrially paced. Preserved biventricular function LVEF >55%. MR remains mild. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2178-8-11] 12:29AM BLOOD WBC-7.3 RBC-3.45* Hgb-11.7* Hct-33.0* MCV-96 MCH-33.8* MCHC-35.3* RDW-14.0 Plt Ct-156 [2178-8-19] 07:15AM BLOOD WBC-10.2 RBC-3.01* Hgb-9.7* Hct-28.3* MCV-94 MCH-32.1* MCHC-34.2 RDW-15.2 Plt Ct-168 [2178-8-20] 06:50AM BLOOD PT-15.2* INR(PT)-1.4* [2178-8-19] 07:15AM BLOOD PT-12.6 INR(PT)-1.1 [2178-8-18] 06:35AM BLOOD PT-11.8 PTT-25.6 INR(PT)-1.0 [2178-8-20] 06:50AM BLOOD Glucose-90 UreaN-28* Creat-1.8* Na-135 K-4.6 Cl-97 HCO3-32 AnGap-11 [2178-8-17] 06:45AM BLOOD Glucose-98 UreaN-29* Creat-1.9* Na-141 K-4.3 Cl-101 HCO3-31 AnGap-13 [2178-8-16] 08:45AM BLOOD Glucose-145* UreaN-28* Creat-1.8* Na-136 K-4.5 Cl-103 HCO3-25 AnGap-13 [2178-8-15] 04:41AM BLOOD UreaN-32* Creat-2.0* Na-136 Cl-106 HCO3-23 [2178-8-12] 06:55AM BLOOD Glucose-121* UreaN-26* Creat-1.7* Na-143 K-4.5 Cl-108 HCO3-27 AnGap-13 [2178-8-11] 06:40AM BLOOD Glucose-67* UreaN-31* Creat-1.7* Na-145 K-4.0 Cl-114* HCO3-22 AnGap-13 [2178-8-11] 12:29AM BLOOD Glucose-106* UreaN-34* Creat-2.2* K-4.0 Cl-113* HCO3-24 [2178-8-17] 06:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 [2178-8-11] 04:00PM BLOOD %HbA1c-7.8* Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 73352] was transferred for cardiac cath. Cath revealed severe three vessel coronary artery disease. He was appropriately worked-up prior to coronary revascularization surgery - please see result section. On [2178-8-13] he was brought to the operating room where he underwent a coronary artery bypass grafting by Dr. [Last Name (STitle) ]. See operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. By post-op day two all inotropes were weaned off and he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. All chest tubes were removed without complication and he was transferred to the telemetry floor for further care. On post-op day three he went into rapid atrial fibrillation which was appropriately treated and converted to sinus rhythm. Also on this day he required a blood transfusion for a postoperative anemia. On post-op day four his epicardial pacing wires were removed. During the rest of his post-op course he continued to recover well but had additional episodes of paroxsymal atrial fibrillation. He was eventually started on Amiodarone and Coumadin. He otherwise continued to make clinical improvments with diuresis and was eventually medically cleared for discharge on post-op day seven. Prior to discharge, arrangements were made with Dr. [Last Name (STitle) 5017] to monitor Coumadin as an outpatient. At discharge, he was in a normal sinus rhythm in the 60's with a blood pressure of 120/60 and 96% oxygen saturation on room air. Blood sugars were well controlled on Lantus and Humalog sliding scale. Discharge chest x-ray showed small bilateral pleural effusions with bibasilar atelectasis. Medications on Admission: Allopurinol - has not started yet. Colcihicine 0.6mg po qdaily - has not started yet Alphagan 1 drop leeft eye Aspirin 81 mg po qdaily Atenolol 25mg po qdaily Diltiazem (cartia) 360mg po qhs Claritin 1 tab qd prn Cosopt 1 drop left eye Cozaar 100mg [Hospital1 ] Humalog sliding scale Hyralazine 50mg po BID Lantus 55 QPM Lasix 20mg QMWF, 40mg QTThSatSun Pravachol 80mg po qdaily Prilosec 20mg po qdaily Xalatan 0.005% left eye Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Hospital1 ]: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). [Hospital1 ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). [Hospital1 ]:45 Tablet(s) Refills:1 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed. [Hospital1 ]:40 Tablet(s) Refills:0 5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). [Hospital1 ]:1 Refills:1 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). [Hospital1 ]:1 Refills:1 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). [Hospital1 ]:1 Refills:1 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: Then drop to 1 tab(200mg) twice daily for 7 days, then drop to 1 tab(200mg) daily. Continue 1 tab(200mg)daily until followup with MD. [Last Name (Titles) ]:50 Tablet(s) Refills:2 9. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO QPM: Take as directed by MD. Daily dose may vary according to PT/INR. [Last Name (Titles) ]:60 Tablet(s) Refills:2 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). [Last Name (Titles) ]:180 Tablet(s) Refills:2 11. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. [Last Name (Titles) ]:30 Tablet(s) Refills:2 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Last Name (Titles) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Lantus 100 unit/mL Cartridge Sig: Fifty Five (55) units Subcutaneous at bedtime. [Last Name (Titles) ]:1 month supply Refills:2 14. Humalog 100 unit/mL Cartridge Sig: 0-8 sliding scale Subcutaneous four times a day: Take as directed by sliding scale. [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) ] greater than 280. [Last Name (Titles) ]:1 month supply Refills:2 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. [Last Name (Titles) ]:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-op Atrial Fibrillation PMH: Hypertension, Diabetes mellitus, Hypercholesterolemia, Chronic kidney disease, Gastroesophageal Reflux Disease, Gout Discharge Condition: Good Discharge Instructions: Shower daily and pat incisions dry. No lotions, creams, powders or ointments on any incision. No driving for at least one month. No lifting greater than 10 pounds for 10 weeks. Please call surgeon for fever greater than 100.5 or drainage from sternal incision. *** Take Coumadin as directed. Dr. [Last Name (STitle) 5017] will be managing your Coumadin. PT/INR should be drawn within 48-72 hours of discharge. Initial blood draws performed by VNA with results faxed to Dr. [Last Name (STitle) 5017] @ [Telephone/Fax (1) 73354].* Followup Instructions: Dr. [Last Name (STitle) ] in [5-14] weeks, call for appt [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 5017] in [3-14] weeks, call for appt [Telephone/Fax (1) 5424] [Hospital Ward Name 121] 2 in 2 weeks for wound check Completed by:[2178-8-20**]	[ "41401", "41071", "9971", "42731", "25000", "4019", "2720", "2859", "53081" ]
Admission Date: [2198-12-13] Discharge Date: [2198-12-23] Service: CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is an 86 year old man with a history of coronary artery disease, myelodysplastic syndrome, aortic stenosis, aortic regurgitation, who presents with acute onset of midepigastric pain without radiation to his back. The pain was constant and ten out of ten. The patient came to the Emergency Department for further evaluation and he had dry heaves but without vomiting. He denies fever or chills at home. He has no history of postprandial pain. No recent changes in his medications. The patient denies chest pain and currently he has no palpitations. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft of four vessels in [2189], at [Hospital6 2121]. 2. Hypertension. 3. Myelodysplastic syndrome with thrombocytopenia. 4. Gout. 5. Basal cell carcinoma. 6. History of dysplastic colonic polyps. 7. Glaucoma. 8. Cataract. 9. Anxiety. 10. Degenerative joint disease with disc herniation at L4-L5. 11. Parkinson's disease. 12. Aortic stenosis with moderate aortic insufficiency. Echocardiogram in [2196], demonstrated an ejection fraction of greater than 55% with aortic valve of 1.0 square centimeters and moderate aortic stenosis and moderate to severe aortic regurgitation. MEDICATIONS ON ADMISSION: 1. Isosorbide 20 mg once daily. 2. Potassium Chloride 20 meq once daily. 3. Lasix 40 mg twice a day. 4. Tricor 60 once daily. 5. Allopurinol 300 mg once daily. 6. Paxil 20 mg once daily. 7. Sinemet one tablet twice a day. 8. Protonix 40 mg once daily. ALLERGIES: The patient is allergic to Ciprofloxacin, Morphine, Demerol that causes nausea and vomiting. FAMILY HISTORY: Brother with muscular dystrophy. SOCIAL HISTORY: He is a retired fireman who lives alone in a duplex with his daughter living nearby. PHYSICAL EXAMINATION: Vital signs revealed temperature 102, blood pressure 148/80, heart rate 106, respiratory rate 24, oxygen saturation 87% in room air and 90% on two liters oxygen. In general, the patient is an elderly man, slightly uncomfortable. Head, eyes, ears, nose and throat - Extraocular movements are intact. The left pupil is surgical. No jugular venous distention. Mucous membranes are dry. Cardiovascular - S1 and S2 irregularly irregular and are obscured by systolic ejection murmur at the right upper sternal border that is III/VI. The lungs are clear to auscultation bilaterally. Abdomen is soft, nondistended with decreased bowel sounds and midepigastric tenderness. No rebound or guarding. There is no costovertebral angle tenderness. Rectal examination is guaiac negative per Emergency Department. Extremities are without edema. Neurologically, there is no gross deficit. LABORATORY DATA: On admission, white blood cell count 9.1, hematocrit 44.1, baseline around 37.0, platelet count 55,000, MCV 101. Blood urea nitrogen 22 and creatinine 1.9. ALT was 11, AST 131, LDH 293, amylase 287, lipase [2211], total bilirubin 3.1, alkaline phosphatase 69, CK 67, troponin 0.09. Right upper quadrant ultrasound showed common bile duct of [9-16] millimeter diameter and gallbladder containing gallstones. There was moderate gallbladder distention but no wall edema. No pericholecystic fluid. There was also fatty infiltration of the liver and some splenomegaly. HOSPITAL COURSE: Following the results of the right upper quadrant ultrasound, it was felt that the patient had a dilated common bile duct secondary to obstruction by gallstone and the patient was treated with Ampicillin, Ceftriaxone and Flagyl and given intravenous fluids. An endoscopic retrograde cholangiopancreatography was attempted but cannulation of the biliary duct was unsuccessful despite multiple attempts because the patient became very agitated and uncooperative and therefore, the procedure was aborted. It was decided to attempt another endoscopic retrograde cholangiopancreatography, this time under anesthesia. However, in the meantime, the patient was found to have rising troponin T which gradually reached the 0.6 level. Original impression was that this elevated troponin represented demand ischemia imposed on the heart by the pancreatitis and the cholestatic picture in the setting of aortic stenosis/aortic regurgitation. Given the rising trend in the troponin, as well as need for general anesthesia to perform the endoscopic retrograde cholangiopancreatography, it was decided that the patient should be evaluated by cardiac catheterization. The cardiac catheterization showed severe native three vessel coronary artery disease, as was known from before. Severe but not critical aortic stenosis with moderate aortic regurgitation, severe pulmonary arterial hypertension, systemic systolic arterial hypertension, severe left ventricular diastolic heart failure, patent left internal mammary artery - left anterior descending, patent saphenous vein graft OM and saphenous vein graft posterior descending artery, presumed occluded saphenous vein graft - diagonal and severe disease in unusual OM4 to AV groove with complex OM lesion arising from bifurcation and distal lesion with limited runoff. It was decided that most of the perioperative cardiac risk is related to the severe aortic stenosis/aortic regurgitation and diastolic heart failure. Stenting of the OM4 would be associated with increase of stent thrombosis given poor runoff. It is doubtful that balloon angioplasty of this OM which supplies only a small area of myocardium would significantly improve his perioperative risk of cardiac events. Decision first was made to defer PCI on this OM. These results confirmed the results of a transthoracic echocardiogram that had been done on [2198-12-14], and had shown an aortic valve area of 0.7 square centimeters, left ventricular ejection fraction of 40% and symmetric left ventricular hypertrophy. Following these results, it was decided that the patient could have the endoscopic retrograde cholangiopancreatography and as of the time of this dictation, the patient is scheduled for an endoscopic retrograde cholangiopancreatography in the morning of [2198-12-24]. As of [2198-12-23], the pancreatic enzyme levels as well as the total bilirubin level have returned towards normalization, and the patient is free of abdominal pain. However, a MRCP demonstrated persistence of gallstones in the common bile duct, necessitating an endoscopic retrograde cholangiopancreatography procedure and sphincterotomy. During the hospitalization and at the time that the patient was in a pancreatitis abdominal pain picture, intravenous fluids were given resulting in an increase in total body weight and fluid retention. The patient is recommended to be gently diuresed following the next few days, to remove a goal of ten pounds in fluid. This diuresis is complicated by the elevated creatinine which currently is 1.8 as of [2198-12-23]. Hematology - The patient has an underlying myelodysplastic syndrome which manifests with chronic thrombocytopenia. The patient's platelet count on admission was 55,000 and remained in the 40,000 to 50,000 range until the patient was transfused platelets prior to the endoscopic retrograde cholangiopancreatography procedure. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient as of [2198-12-23], is expected to be discharged to home pending endoscopic retrograde cholangiopancreatography on [2198-12-24], and with recommended follow-up by primary care physician as well as by his primary cardiologist, Dr. [First Name4 (NamePattern1) 1399] [Last Name (NamePattern1) 17915] and it has been recommended that he follow-up with Dr. [Last Name (Prefixes) ] of cardiothoracic surgery for an outpatient evaluation and potential consideration of an aortic valve repair. Also during this hospitalization and while the patient was on telemetry, he demonstrated frequent premature ventricular contractions as well as runs of ventricular tachycardia. It is recommended that the patient's primary care physician consider [Name9 (PRE) 702] with an Electrophysiology specialist. Medications and discharge information will be dictated by the intern taking over the service on [2198-12-24]. Again, the finalization of this discharge summary will be done through an addendum by the intern taking over the service on [2198-12-24]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Last Name (NamePattern1) 17916] MEDQUIST36 D: [2198-12-23] 14:39 T: [2198-12-23] 15:09 JOB#: [Job Number 17917]	[ "2875", "4241", "4280", "5849" ]
Admission Date: [2191-2-21] Discharge Date: [2191-3-5] Date of Birth: [2107-11-7] Sex: M Service: MEDICINE Allergies: Keflex / Avandia / Aldactone / Levofloxacin Attending:[First Name3 (LF) 4760] Chief Complaint: hypoxia at rehab Major Surgical or Invasive Procedure: bronchoscopy and [First Name3 (LF) ] [2191-3-3] History of Present Illness: This is a 83 year-old male with MMP including afib on coumadin, CAD, cardiomyopathy s/p ICD/pacer, T2DM, HTN, hyperlipidemia, and CKD who presents to the ED from rehab with weakness and hypoxia. Pt was recently admitted to [Hospital1 18] [Location (un) 620] from [2191-2-2] to [2191-2-8] for weakness and was found to have multifocal PNA. He was initially treated with azithromycin and ceftriaxone. He worsened clinically and continued to have fevers and he was switched to vancomycin and zosyn. He was discharged to rehab to complete his course of ABx. Hospital course was c/b rhabdomyolysis, supratherapeutic INR, transaminitis, and ARF on CRI. . In the ED, vitals on presentation were T 100.6 HR 74 BP 143/74 RR 18 89%2L NC. He was given 1L of NS. He was given levofloxacin 750 mg IV x 1, vancomycin 1 gram IV x 1, and ceftriaxone 1 gram IV x 1. In addition, he was given Tylenol 1 gram PO x 1 and an amp of D50 for a BG of 44. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: CAD, s/p MI, s/p PTCA to the LAD in [2178] Cardiomyopathy with ventricular tachycardia, status post ICD placement in [2185], status post VT ablation of VT foci in [2185] (inferior scarring). History of biventricular bigeminy. Status post CVA in [2178] without residual effect Transient Ischemic Attacks Diabetes mellitus type 2, insulin dependent. Obesity. Hypertension. Hypercholesterolemia. Status post right hip replacement in [2188]. C-Diff colitis. Status post cholecystectomy. Asthma. AFib - on Coumadin CHF (EF of 35%-40%) Chronic kidney disease, Stage III, with baseline creatinine of 1.9 Question of a TIA in [2190-4-10] Early vascular dementia Social History: The patient lives at home. The patient quit smoking 50 years ago. The patient is dependent for his ADLs and walks with a walker. He denied any alcohol or illicit drug use. Family History: Father with coronary disease and diabetes mellitus. Physical Exam: Vitals: T:96.7 BP:145/57 HR:73 RR:28 O2Sat:93% GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2191-2-21] 08:55PM WBC-12.2* RBC-3.79* HGB-11.3* HCT-33.2* MCV-88 MCH-29.9 MCHC-34.1 RDW-14.2 [2191-2-21] 08:55PM NEUTS-70.2* LYMPHS-17.4* MONOS-3.7 EOS-8.2* BASOS-0.5 [2191-2-21] 08:55PM PLT COUNT-670# [2191-2-21] 08:55PM PT-20.9 PTT-29.2 INR(PT)-2.0* [2191-2-21] 08:55PM GLUCOSE-43* UREA N-20 CREAT-1.6* SODIUM-138 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [2191-2-21] 09:20PM GLUCOSE-44* UREA N-20 CREAT-1.6* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [2191-2-21] 09:20PM CK(CPK)-51 [2191-2-21] 09:20PM CK-MB-NotDone [2191-2-21] 10:59PM cTropnT-0.02* [2191-2-21] 10:34PM PT-21.7* PTT-32.3 INR(PT)-2.1* Portable CXR, [2191-2-21]: The study is limited secondary to profoundly diminished lung volumes and patient positioning. Despite these limitations, there is significant opacification and a patchy distribution throughout the aerated right lung. The findings are most compatible with a pneumonia likely involving the right lower lobe. There is a more hazy linear opacity at the left lung base, likely atelectasis. The remaining left lung is clear. A dual-lead pacemaker is stable in course and position. There is atherosclerotic disease of the aorta again identified. The cardiac silhouette is difficult to assess, but grossly stable. Degenerative changes are noted throughout the thoracic spine. IMPRESSION: Patchy opacities throughout the right lung, presumably the right lower lobe, most compatible with pneumonia. If clinically feasible, consider PA and lateral views to establish a baseline early in treatment. CT CHEST W/O CONTRAST [2191-2-22]: COMPARISON: CT of the chest obtained on [2191-2-7] in [Location (un) 620] and chest radiograph obtained on [2191-2-21]. TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm collimation axial images reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Compared to the prior chest CT obtained two weeks ago, there is interval worsening of the involvement of the right upper lobe and right middle lobe extensive areas of consolidation containing air bronchogram with some slight interval improvement of the right lower lobe consolidations. There is also increase in size of the left lower lobe consolidations with interval development of bilateral small pleural effusions. Several mediastinal lymph nodes are enlarged including right paraesophageal lymph node, 2:32, measuring 13 mm; right lower paratracheal lymph node measuring 14 mm as well as several scattered mediastinal lymph nodes, not pathologically enlarged. Compared to the prior study, this lymph nodes have increased in size in the interval, most likely being reactive. There is no pericardial effusion. The heart size is increased. The position of the pacemaker lead terminating in the right ventricle is unchanged. The imaged portion of the upper abdomen is unremarkable except for calcified splenic artery. There are no bone lesions worrisome for malignancy. Several healed anterior fractures of the lower left rib are noted, unchanged. IMPRESSION: 1. Interval worsening of the multifocal pneumonia, in particular in the right upper and left lower lobes. 2. Small bilateral pleural effusion. 3. Interval additional increase in mediastinal lymphadenopathy, most likely reactive, but should be evaluated with subsequent following study after injection of IV contrast. 4. Status post cholecystectomy. ECHO [2191-2-23]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is probably moderately depressed (LVEF= 35-40 %) with inferior and infero-lateral akinesis. There is no ventricular septal defect. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CT Chest [2191-2-28]:FINDINGS: Extensive parenchymal abnormality in the contracted right lung, characterized by widespread ground-glass opacification and multiple areas of peribronchial infiltration and septal thickening predominantly in the lower lung is very little changed since [2-22]. In the anterior segment of the right upper lobe there is less peribronchial infiltration. More focal regions of consolidation in the left lung predominantly in the lower lobe have improved a little but not resolved, but the left lung is free of the generalized ground- glass opacification. Moderate narrowing of the basal trunk of the right lower lobe bronchus and secretions at the origin of the superior segment are new, but I doubt that they are contributing to respiratory insufficiency. Small nonhemorrhagic bilateral pleural effusions layering posteriorly have decreased. There is no pericardial effusion. Moderate multi-chamber cardiomegaly is stable; marked enlargement of the pulmonary arteries (intrapericardial right PA) measures 30 mm and is unchanged. Atherosclerotic calcification is heavy in the proximal head and neck vessels, all major coronary branches and the descending thoracic aorta but there is no aneurysm. Borderline enlarged central lymph nodes in the right lower paratracheal station at 11 mm were 14.1 mm on [2-22]; in the right paraesophageal station nodes have increased to 16 mm from 11 mm at one location, and remain stable at 20 mm in another( 2:26). IMPRESSION: 1. Very little change since [2-22] aside from minimal improvement in small peribronchial component of the diffuse infiltrative abnormality in the right lung, and some improvement in more focal consolidation at the left lung base. Findings are not consistent with pulmonary edema, instead suggest organizing pneumonia, either postinfectious or cryptogenic. Since patient has a pacer defibrillator system in place this raises the question of amiodarone toxicity, which can produce widespread pulmonary abnormality, but I do not see the increased attenuation in the liver generally seen with amiodarone administration. 2. Severe atherosclerotic calcification, particularly in the coronary arteries. Stable global cardiomegaly and pulmonary hypertension. . [2191-3-3] 8:30 am BRONCHOALVEOLAR LAVAGE RML. GRAM STAIN (Final [2191-3-3]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. ACID FAST SMEAR (Final [2191-3-4]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2191-3-3]): NEGATIVE for Pneumocystis jirovecii (carinii).. . [2191-3-3] 8:30 am BRONCHOALVEOLAR LAVAGE HSV AND VZV DFA NOT PERFORMED ON BRONCH LAVAGE. CMV VIRAL LOAD NOT PERFORMED ON BRONCH LAVAGE.. Rapid Respiratory Viral Antigen Test (Final [2191-3-3]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for the direct detection of respiratory viruses in specimens; interpret negative result with caution.. Refer to respiratory viral culture for further information. Respiratory Viral Culture (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Virus isolated so far. VARICELLA-ZOSTER CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: 83 year-old male with MMP including afib on coumadin, CAD, cardiomyopathy s/p ICD/pacer, T2DM, HTN, hyperlipidemia, and CKD who presents to the ED from rehab with weakness and hypoxia. Pt was found to have interstitial lung disease, likely due to amiodarone toxicity. . # Hypoxia/Interstitial Lung Disease/Amiodarone Toxicity: Initially, it was unclear if the patient had truly failed treatment of his prior multifocal pneumonia diagnosed at [Hospital1 18] [Location (un) 620] and from where he was discharged on [2191-2-8] on a total 10 day course of vanc and zosyn or if there was another process occurring. WBC was elevated at 12.8 on admission however the patient was afebrile with a cough without sputum production. Other possible etiologies for the patient's hypoxemia in the setting of his chest CT findings included post-pneumonic inflammatory changes/scar, BOOP. Of note, the pt required 2 L NC prior to admission here. On admission, the patient's acid-base status on ABG looked good 7.43/42/73 on NRB. Although the patient did receive vanc, CTZ, and levo in ED, he was s/p 10 day course of vanc and zosyn and afebrile, without substantial change in radiographic (CT images reviewed with ICU attending Dr [Last Name (STitle) ] appearance of multifocal opacities, so no antibiotics were administered after the ED doses. The MICU team felt that diuresis initially improved hypoxia somewhat, even though CXR/CT did not look grossly volume overloaded and the patient went into subsequent mild acute on chronic renal failure. On the medicine floor, the patient still required 4 liters O2 by nasal cannula. The patient was not volume overloaded and was not diuresed. He received nebs given history of asthma and noted wheeziness at times. Given possible chronic aspiration ( bilateral lower lobe infilrations), speech and swallow evaluation was obtained which did not show any clear evidence of aspiration. Video swallow eval showed no silent aspiration either. A repeat CT of his chest on [2191-2-28] was done (performed due to persistent 4 L O2 requirement). This showed continued multilobular opacities, diffuse ground glass opacities with peribronchial nodular opacities, somewhat more peirpherally based, sparing LUL, with posterior RUL confluence. There was concern for COP or amiodarone toxicity. Pulmonary was consulted and it was felt that the leading diagnostic possibility was BOOP/COP either idiopathic or due to amio. With elevated INR, alveoloar hemorrhage also in differential. Infection and malignancy were felt to be less likely. Felt unlikely that all of his parenchymal opacities, some peripheral and upper zone, were due to aspiration. His eosinophilia was felt to be more c/w drug toxicity or hypersensitivity process. [Date Range ] was recommended to rule out infection and hemorrhage and assess for pulmonary eosinophilia or lymphocytosis. Amiodarone was stopped due to potential toxicity. This was discusssed with pts cardiologist, Dr. [Last Name (STitle) ]. Bronchoscopy with [Last Name (STitle) ] was performed on [2191-3-3] and this showed no evidence of [First Name8 (NamePattern2) 691] [Last Name (un) ] or infection. Following bronchoscopy the patient had mild hypotension (requiring 250 cc NS bolus) and mild increase in hypoxia (needing 6 L NC) which resolved after 24 hours (back to 4 LNC). [Last Name (un) ] sent for for cell count and diff, gram stain and culture, fungal stain and Cx, AFB, mycobacterial Cx, PCP stain, cytology. PCP smear was negative, and fungal stain neg. Rapid respiratory viral antigen test was negative. He had only 15% eosinophils, so not indicative of eosinophilic PNA. Given that staph aureus (sensitivities not yet back) grew out from the bronch, we decided to treat the patient with an 8 day course of Vancomycin (although the staph may just be a colonizer or from subtle aspiration). Vancomycin was started on [3-4]. In addition, we started the pt on prednisone 40 mg daily (to be given for 2 weeks and then tapered to 30 mg daily for another 2 weeks until follow up with Dr. [Last Name (STitle) 575] of pulmonary in 1 month) to treat for amiodarone toxicity. The pt will need his Vancomycin trough checked on [3-6] and redosing of his vancomycin if trough<15. The patient was also started on Ca, VIt D, and prophylactic bactrim theraphy while on steroids. He will need to follow up with Dr. [Last Name (STitle) 575] of pulmonary in 1 month from now with a CT scan of the lungs prior to his appointment. . # Weakness/Lethargy: Unclear etiology, likely related to COP/amiodarone toxicity. TSH/CK normal. UA negative for infection. PT and rehab recommended. . # Afib on coumadin: rate controlled. He was on amiodarone for both atrial and ventricular arrhythmias, started in [11-16] for PAF. INR therapeutic 2.1 on admission, but after pt had 1-2 days of diarrhea, INR up to 8. He was given 5 mg of Vitamin K on [2-28] and again on [3-1]. Coumadin was held in setting of need for bronch/[Last Name (LF) ], [First Name3 (LF) ] pt was bridged with Lovenox once subtherapeutic (after bronch) given his high risk (h/o TIA, DM, HTN, age). As per above, the pts amiodarone was stopped due to potential toxicity. Case discussed with pts cardiologist Dr. [Last Name (STitle) ], and per notes it seems pt had been started on amio in [11-16] for PAF. INR was 2.2 at discharge, so lovenox was stopped. Pt should have his INR checked at least weekly. . # CAD/Chronic Systolic CHF (EF 35-40%): Continued home regimen of metoprolol and isosorbide; had not been on standing diuretics since recent PNA, but we did diurese total ~2L negative (net) over 2 consecutive days for clinical volume overload, at which point Cr bumped to 2.3; Creatinine trended down to 1.8. Baseline creatinine is documented at 1.9. Given his poor po intake, his home dose of lasix (held since last admission) was not resumed. Given his supratherapeutic INR, his ASA and Plavix were held until his INR trended down. His [Last Name (un) ] was restarted when his creatinine stabilized, but stopped again when creatinine trended back up to 2.2. Would hold [Last Name (un) ] currently in setting of poor po intake. . # Delirium on early vascular dementia: Pt with new onset delirium following bronchoscopy on [3-3]. He became sleepier and more confused. Suspect this was due to sedation received. At baseline pt knows the year and where he is, but he did not at this time. 24 hours later the pt was still sleepy but able to answer questions appropriately. B12, TSH, and folate were normal. UA was normal. Pt currently is closer to his baseline (less sleepy although still very fatigued, did state year was [2181] prior to discharge but able to correct himself, knew he was in the hospital), but with initiation of his steroids his delirium may worsen. . # Type II Diabetes Mellitus, controlled/Hypoglycemia: Had low fs at 44 in ED here, got 1 amp D50. Likely [3-14] to poor po intake and continued home insulin dosing. Pt was noted to have poor po intake, so his 70/30 was decreased from 42 U in the AM and 27 U at night to 22 U in the AM and 14 U at night which resulted in hyperglycemia. Ultimately he was placed on 70/30 40 U units in AM and 40 U in PM. Given initiation of steroids, his 70/30 will need to be titrated further. . # Eosinophilia: Pt had an absolute eosinophilia here up to [2182]. Felt to be likely due to amiodarone toxicity. Amiodarone was stopped. O and P was negative x1. Differential for his eosinophilia included eosinophilic PNA, drug toxicity (ie amiodarone), Churg [Doctor Last Name 3532]. ABPA unlikely given no bronchiectasis. No known malignancy. [Doctor Last Name ] showed only 15% eos, so not diagnostic for eosinophilic PNA. ANCA was negative. Should continue to trend eosinophils as outpatient. . # Acute Kidney Failure on CKD, Stage III: Cr 1.6, near baseline, on admission. However, his creatinine rose up to 2.3 after diuresis. His creatinine improved to 1.7 after cessation of lasix. Cozaar was reinitiated and creatinine again bumped to 2.2. He was given further IVF and cozaar again held with creatinine trending back down to 2.0 prior to discharge. . # Recent rhabdomyolysis: Off statin and zetia after last hospitalization. CK normal on admission here. . # Hyperlipidemia: Off statin/zetia due to recent rhabdo.His LFTs and CK was normal here. His LDL was 99 (goal less than 70 given his h/o CAD), with HDL of 23. He was started on pravastatin 20 mg daily, and his LFTs/CK should be rechecked in 1 month. . # FULL CODE: Discussed with pt and his family . # ACCESS: Midline placed [3-5] prior to discharge (L arm) Medications on Admission: Amiodarone 100 mg PO daily Aspirin 81 mg PO daily Plavix 75 mg PO daily Imdur 20 mg PO daily Cozaar 100 mg PO daily Metoprolol 25 mg PO TID MVI Coumadin 5 mg PO QHS Novolin 70/30 42 units in am and 27 units in pm Vancomycin 1 gm UV q24 hours x 9 days, Zosyn 3.378 gram q6h x 9 days (completed [2-20]) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: For FS of: 150-199 give 2U, 200-249 give 4 U, 250-299 give 6 U, 300-349 give 8 U, 350-400 give 10 U. 15. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 16. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO Monday, Wednesday, Friday. 17. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous q48 hr for 8 days: First dose was evening of [3-4]. 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO as directed: Take 40 mg daily (4 tablets) for 2 weeks, then take 30 mg daily (3 weeks) until you follow up with pulmonary in a month from now. 19. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 20. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Forty (40) units Subcutaneous qam and qpm. 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Interstitial Lung Disease Amiodarone Toxicity Eosinophilia Hypoxemia Generalized Weakness Delirium Supratherapeutic INR Acute on Chronic Kidney Failure Discharge Condition: stable, satting 95% 4 L NC Discharge Instructions: You were admitted with shortness of breath and weakness. You were noted to have continued changes on your chest imaging which we feel is consistent with an interstitial lung disease. You underwent a bronchoscopy while you were here. We have stopped your amiodarone due to concern that this could be causing some of your symptoms. You were started on steroids, and you will be on these for a long time. Steroids can cause worsening of your diabetes/sugar control, confusion, agitation, and other symptoms. You were also started on an antibiotic called bactrim because steroids can predispose to infections. Due to a bacteria growing from your bronchoscopy, we will treat you with a 8 day course of Vancomycin again. . You were treated with lasix while here to try to remove fluid from your lungs. This resulted in acute kidney failure. Your kidney function has now returned to baseline. . You were also noted to have a high INR. Your coumadin, plavix, and aspirin were held. You were treated with Vitamin K to try to lower your coumadin levels in order to decrease your risk of bleeding. Your coumadin, plavix, and aspirin have all been restarted. . Your cozaar was stopped as you have intermittently had acute renal failure. . Call your doctor or go to the ER for any worsening shortness of breath, wheezing, increased sputum production, fever, chest pain, confusion, dehydration, bleeding, or any other concerning symptoms. Followup Instructions: 1. You need to have a repeat CT scan in 4 weeks from now and follow up with pulmonologist Dr. [Last Name (STitle) 575]. Please call his office at ([Telephone/Fax (1) 513] to make sure that these are arranged. You should have a CT scan prior to your appointment with Dr. [Last Name (STitle) 575] earlier on the same day. If you have any difficulty, please ask to speak with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11622]. I have already emailed her in advance to try to arrange for these appointments. . 2. [Hospital ] clinic: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2191-3-15] 2:30 PM, [Hospital1 18] [Hospital Ward Name 5074], [Hospital Ward Name 23] Building [Location (un) 436], [Telephone/Fax (1) 62] . 3. Please call Dr. [Last Name (STitle) ] [Last Name (STitle) ] to arrange for follow up after your discharge from rehab . 4. Please call Dr. [Last Name (STitle) ], your cardiologist, after your discharge from rehab to arrange for follow up.	[ "5849", "40390", "4280", "42731", "41401", "2720", "49390", "V4582", "V5867", "412", "V5861" ]
Admission Date: [2132-4-2] Discharge Date: [2132-4-9] Date of Birth: [2050-9-26] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 32612] Chief Complaint: Ampullary mass Major Surgical or Invasive Procedure: [2132-4-2]: 1. Diagnostic laparoscopy. 2. Exploratory laparotomy. 3. Lysis of adhesions. 4. Pylorus-preserving pancreaticoduodenectomy with harvest of pedicled omental flap for protection of pancreatic and duodenal anastomoses. 5. Placement of gold fiducials for possible postoperative CyberKnife therapy. History of Present Illness: Mr. [Known lastname 449] is a very nice 81-year-old gentleman with newly diagnosed ampullary adenocarcinoma. Mr. [Known lastname 449] presented approximately a year ago with right-sided abdominal pain. He was referred for endoscopy and found to have adenomatous polyps. Most of these were resected endoscopically. On [2132-3-6], he underwent a repeat upper endoscopy. This demonstrated recurrent adenomas. Biopsy this time showed poorly differentiated adenocarcinoma. He continues to have persistent abdominal pain and anorexia. He states he has lost 35 pounds over the last year. He did have a CT scan done today which demonstrated large mass lesion in the second portion of the duodenum. The patient was evaluated by Dr. [Last Name (STitle) ] in her [Hospital 79163] clinic and after discussion with the patient, he was scheduled for elective Whipple resection on [2132-4-2]. Past Medical History: TIA Afib BPH CHF . PSH CCY Social History: smokes 1 ppd, 60 PY hx, occa etoh, no drugs, worked as engineer w/ GE, lives w/ 44 yo son Family History: non contributory Physical Exam: On Discharge: VS: 98.1, 60, 110/56, 14, 98% RA GEN: Very thin man in no acute distress CV: Irregularly irregular rate and rhythm PULM: CTAB ABD: Midline abdominal incision opent to air and c/d/i, old RLQ JP site with occlusive dressing and c/d/i. EXTR: Warm, no c/c/e Pertinent Results: [2132-4-6] 07:38AM BLOOD WBC-8.9 RBC-3.54* Hgb-10.9* Hct-30.6* MCV-87 MCH-30.9 MCHC-35.7* RDW-14.0 Plt Ct-201 [2132-4-8] 01:00PM BLOOD PT-11.3 INR(PT)-1.0 [2132-4-6] 07:38AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-140 K-3.6 Cl-104 HCO3-32 AnGap-8 [2132-4-6] 07:38AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6 Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 79164],[Known firstname 1569] [2050-9-26] 81 Male [Numeric Identifier 79165] [Numeric Identifier 79166] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mtd SPECIMEN SUBMITTED: WHIPPLE SPECIMEN. Procedure date Tissue received Report Date Diagnosed by [2132-4-2] [2132-4-2] [2132-4-7] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mn???????????? Previous biopsies: [Numeric Identifier 79167] GI BX'S (2 JARS) [-1/3358] GI BX'S (2 JARS) DIAGNOSIS: Whipple resection, pylorus-sparing pancreaticoduodenectomy (A-AC): 1. Invasive adenocarcinoma of the periampullary duodenum, poorly differentiated, arising from an adenomatous precursor lesion with high grade dysplasia, with invasion into subserosal adipose tissue (pT3); lymphovascular and perineural invasion is present; see synoptic report. 2. Seven of thirteen lymph nodes with involvement by adenocarcinoma ([8-8]- pN2). 3. Extrahepatic bile duct segment and ampulla, within normal limits. 4. Pancreatic parenchyma with focal changes of low grade intraepithelial neoplasia (PanIn-1), focal dilation of pancreatic ducts, and squamatization of duct epithelium. Small Intestine: Segmental Resection, Pancreaticoduodenectomy (Whipple Resection) Synopsis AJCC/UICC TNM, 7th edition Protocol web posting date: [2129-10-27] MACROSCOPIC Specimen Type: Duodenum. Other organs Received: Head of pancreas, Ampulla, Common bile duct. Tumor Site: Duodenum. Tumor configuration: Infiltrative. Tumor Size: Greatest dimension: 4.2 cm. MICROSCOPIC Macroscopic Tumor Perforation: Not identified. Histologic Type: Adenocarcinoma (not otherwise characterized). Histologic Grade: G3: Poorly differentiated. EXTENT OF INVASION Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into the subserosa or into the nonperitonealized perimuscular tissue (mesentery or retroperitoneum) with extension 2 cm or less. Regional Lymph Nodes (pN): pN2: Metastasis in 4 or more regional lymph nodes. Lymph Nodes Number examined: 13. Number involved: 7. Distant metastasis: pMX: Cannot be assessed. MARGINS Segmental Resection or Pancreaticoduodenectomy (Whipple) Proximal Margin: Uninvolved by invasive carcinoma. Distal Margin: Uninvolved by invasive carcinoma. Circumferential (Radial) or Mesenteric Margin : Uninvolved by invasive carcinoma (tumor present 1 mm from margin; see Slide N). Pancreaticoduodenectomy (Whipple) Bile Duct Margin: Margin uninvolved by invasive carcinoma. Pancreatic Margin: Margin uninvolved by invasive carcinoma. Lymphovascular Invasion: Present Perineural Invasion: Present Additional Pathologic Findings: Adenoma(s). Comments: Adenomatous precursor of the duodenum is present in multiple sections, but is shown best on Slide K. No dysplastic precursor is found within the ampullary region itself, arguing against the tumor origin from this site. Clinical: Ampullary mass. [2132-4-9] 06:20AM BLOOD PT-13.9* INR(PT)-1.3* Brief Hospital Course: The patient with ampullary mass was admitted to the Surgical Oncology Service on [2132-4-2] for elective Whipple procedure. On [2132-4-2] , the patient underwent pylorus-preserving pancreaticoduodenectomy and placement of gold fiducials for possible postoperative CyberKnife therapy, which went well without complication (reader referred to the Operative Note for details). Inraoperatively patient was transfused with 2 units of RBC for low HCT, he was extubated post operatively and transferred in ICU for observation. The patient was hemodynamically stable. In ICU patient was hypotensive with low urine output, which was treated with fluid boluses. On POD # 2, patient was transferred on the floor in stable condition. The [Hospital 228] hospital course was uneventful and followed the Whipple Clinical Pathway without deviation. Post-operative pain was initially well controlled with epidural catheter and Dilaudid PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#2, and the foley catheter discontinued at midnight of POD# 3. The patient subsequently voided without problem. The patient was started on sips of clears on POD# 3, which was progressively advanced as tolerated to a regular diet by POD# 5. JP amylase was sent in the evening of POD# 5; the JP was discontinued on POD#7 as the amylase level were low and output continue to decrease. Patient was started on home dose of Coumadin on POD # 6, and he was bridged with SC Lovenox prior discharge as his INR was subtherapeutic. Patient will continue on SC Lovenox and Coumadin until his INR reach therapeutic level, INR will be motinored by [Hospital ] Hospital [Hospital 197] Clinic as outpatient. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [2132-4-9], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: coumadin (held since [2-/2049], on lovenox bridge prior to OR), alendronate 70' qweek, amiodarone 200', lisinopril 2.5', methimazole 7.5', metoprolol 12.5', simvastatin 20', Discharge Medications: 1. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day for 2 weeks. Disp:56 Tablet(s) Refills:0 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 4. methimazole 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. 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:5 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow up with [Hospital 197] clinic on [2132-4-10] at 11:30 to check INR level. 11. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 12. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous [Hospital1 ] (2 times a day). Disp:10 injection Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Locally advanced ampullary adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please continue to follow up with [Hospital 197] clinic as outpatient to adjust you Coumadin doses. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-5] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Department: SURGICAL SPECIALTIES When: TUESDAY [2132-4-15] at 3:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 79168], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please follow up with Dr. [Name (NI) 70277] (PCP) in [2-29] weeks after discharge. . [Hospital 197] Clinic. Thursday [4-10] at 11:30 am. Completed by:[2132-4-9*]	[ "2762", "496", "42731", "2724", "3051", "40390", "5859", "V5861" ]
Admission Date: [2158-8-30] Discharge Date: [2158-9-5] Service: MEDICINE Allergies: digoxin / Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 16115] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo F with PMH of HTN and question TIA presenting to ED with fever and weakness. Patient reports not feeling well the day prior to admission. On the day of admission, she had shaking chills and episodes of nausea and dry heaves and 2 non-bloody soft stools in the morning. Blood pressure at the [Hospital 4382] 80/60. She was recently on Keflex for folliculitis, finished course on Friday. The patient denies chest pain, dyspnea, cough, abdominal pain, dysuria. In the ED, initial VS were: 101.8, 80, 112/56, 16, 97% RA. Labs were notable for WBC 19.8 with 22% bands, HCT 32.3, lactate 1.8. The patient was given acetominophen 325 mg, zofran, metronidazole 500 mg and ceftriaxone 1 g, 3 L IVF. On arrival to the MICU, patient's VS 98.7, 75, 107/41, 96%RA Past Medical History: Past Medical History: Hypertension, glaucoma, cataracts, question of a TIA and skin cancer of the right upper extremity. Past surgical history: Right arm skin cancer excision, ankle surgery for osteoarthritis, and cataracts. Social History: Retired nurse. Lives in [Hospital3 ] and is independent. ETOH- 3 glasses of wine or port per week. Denies smoking or illicit drug use. Family History: Breast cancer in daughter and sister. Mother had high blood pressure and TIA. Denies FH of heart disease. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge exam: 98.4 HR 65 153/79 RR 18 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 1+ pitting edema improving over past two days Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [2158-8-30] 02:45PM BLOOD Glucose-131* UreaN-18 Creat-0.7 Na-131* K-4.0 Cl-95* HCO3-25 AnGap-15 [2158-8-30] 02:45PM BLOOD WBC-19.8* RBC-3.83* Hgb-10.6* Hct-32.3* MCV-84 MCH-27.5 MCHC-32.7 RDW-13.7 Plt Ct-260 [2158-8-30] 02:45PM BLOOD Neuts-58 Bands-22* Lymphs-3* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-4* Promyel-1* [2158-8-31] C. difficile DNA amplification assay (Final [2158-8-31]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [7-/3270] [2158-8-31] 11:45AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.6 3.79* 10.3* 31.0* 82 27.3 33.3 13.9 332 Glucose UreaN Creat Na K Cl HCO3 AnGap 110 4 0.5 131 3.3 97 29 8 Brief Hospital Course: MICU COURSE # CDIFF COLITIS: Patient presented with hypotension, which was initially thought to be multifactorial with contributing factors of hypovolemia, risk of sepsis. Given CXR with potential retrocardiac opacity (which may have been resolution of prior infection), patient was started on levofloxacin and ceftriaxone, as well as flagyl for coverage of c diff given potential c diff in context of abdominal pain, diarrhea, and recent Keflex use. Patient remained without respiratory complaint. C diff study was positive, and patient's antibiotic coverge was narrowed to IV flagyl alone, then to PO Flagyl. Symptoms continued to improve on the floor, and Flagyl 500 mg PO Q8H will finish on [2158-9-13]. # HYPOTENSION: Patient with fluid-responsive hypotension, with pressures improved after several liters of IVF resuscitation. Cardiac troponins were sent, which were negative x2. # HYPONATREMIA - Na slightly low at 131 on presentation, likely secondary to hypovolemia, low solute intake, and GI losses. Potential contributor of acute illness, particularly nausea, contributing to SIADH. Patient does appear to be persistently hyponatremic to 129-131, however. Sodium remained at baseline throughout course. # HTN- continued atenolol and Diovan # Glaucoma- continued eye drops. Patient discharged to home facility on [2158-9-5], with intent to continue aggressive physical therapy to return to prior level of functioning. She has an appointment with her PCP [Last Name (NamePattern4) ] [2158-9-13] at 11 a.m. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Valsartan 80 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. calcium NF unknown Oral [Hospital1 ] 5. Centrum Silver NF (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tab Oral daily 6. cyanocobalamin (vitamin B-12) NF 2,000 mcg Oral daily 7. Istalol NF (timolol maleate) 0.5 % OU daily each eye 8. Systane Ultra NF (peg 400-propylene glycol) 0.4-0.3 % OU 1 drop TID prn 9. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Atenolol 25 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Valsartan 80 mg PO DAILY 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days last day [2158-9-13] 6. calcium NF 500 mg ORAL [Hospital1 ] 7. Centrum Silver NF (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tab Oral daily 8. cyanocobalamin (vitamin B-12) NF 2,000 mcg Oral daily 9. Istalol NF (timolol maleate) 0.5 % OU daily each eye 10. Systane Ultra NF (peg 400-propylene glycol) 0.4-0.3 % OU 1 drop TID prn Discharge Disposition: Extended Care Facility: [Location (un) ] - [Location (un) 620] Discharge Diagnosis: Clostridium difficile Hypertension Glaucoma 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 low blood pressures and fevers, and were found to have an infectious diarrhea called C.difficile. You were treated with IV fluids and antibiotics with improvement in your symptoms. You will need to take the antibiotic for one more week. No other changes were made to your medications. Please see below for your follow up appointment. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) ] on [2158-9-13] at 11 a.m.	[ "2761", "4019" ]
Admission Date: [2114-4-6] Discharge Date: [2114-4-11] Date of Birth: [2045-8-10] Sex: M Service: [Location (un) 259] HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old male with cirrhosis presumed due to alcohol use, diabetes type 2, coronary artery disease, and chronic renal insufficiency who was admitted to [Hospital3 ] Hospital on [2114-3-28] due to worsening renal failure and increased weight gain. The patient's laboratory data is currently remarkable for a creatinine of 4.3 from a baseline of 2. The patient transferred to [Hospital1 18] on [2114-4-6] for evaluation of acute renal failure and for consideration of TIPS. Paracentesis was performed to rule out spontaneous bacterial peritonitis. Since admission, the patient was started on Levofloxacin for pneumonia. He was transfused 2 units of packed red blood cells. He underwent thoracentesis of right hemithorax fluid consistent with a transudate. He was treated with albumin and was started on midodrine and Octreotide. With the administration of albumin, packed red blood cells, and IV fluids, the patient became volume overloaded and experienced worsening respiratory distress. The patient was transferred to the MICU for further monitoring. HOSPITAL COURSE: In the MICU, the patient continued to be treated for pneumonia with levofloxacin and was noted to have worsening bilateral alveolar infiltrates and bilateral effusions, all consistent with pulmonary edema. His oxygenation remained adequate on 100% nonrebreather. Since aggressive diuresis would further worsen the patient's renal function, he was placed on noninvasive positive pressure ventilation. The patient had worsening delirium and worsening acidosis. A family meeting was held to determine the plan of care. The family decided to pursue comfort measures. The patient was started on a morphine drip and was transferred to the Medical Service. The patient passed away on the night of [2114-4-11]. DIAGNOSIS: 1. Chronic renal insufficiency with concomitant hepatorenal syndrome. 2. Cirrhosis secondary to alcohol use. 3. Type 2 diabetes mellitus with retinopathy. 4. Hypotension. 5. Peptic ulcer disease. 6. Osteoarthritis. 7. Spinal stenosis, status post laminectomy. 8. Pancreatitis. 9. History of myocardial infarction. 10. Cholelithiasis, status post cholecystectomy. As noted above, the patient was transferred to the Medical Service for comfort measures and was maintained on a morphine drip. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], M.D. [MD Number(2) 22654] Dictated By:[Dictator Info ] MEDQUIST36 D: [2114-4-11] 02:09 T: [2114-4-11] 14:42 JOB#: [Job Number 48926]	[ "486", "5849", "51881", "40391", "5990", "5119" ]
Admission Date: [2172-6-1] Discharge Date: [2172-6-25] Date of Birth: [2102-11-16] Sex: M Service: CARDIOTHORACIC Allergies: Vytorin Attending:[First Name3 (LF) 165] Chief Complaint: increasing SOB; hypoxia intubation at cath Major Surgical or Invasive Procedure: s/p cabg x 3 /MV repair/aortic endarterectomy and pericardial patch [2172-6-5] (LIMA to LAD, SVG to OM and PDA with Y graft, 28 mm [Company 1543] annuloplasty ring) History of Present Illness: 69 yo male with history of CAD presented to [Hospital 1474] Hospital with increasing SOB. Noted to have inferior ST elevations and taken to cath. Emergently intubated there for hypoxia. Cath revealed 100% RCA, 70% CX/OM, 90-95% prox. LAD. Echo showed EF 55% and transferred here for surgery. Past Medical History: NSTEMI PVD with AAA 4.7 cm chronic A fib CAD HTN elev. chol. elevated PSA Social History: married, lives with wife [Name (NI) ]. ETOH 100 pack-year history- quit 2 yrs. ago Family History: CAD present prematurely Physical Exam: sedated , intubated on ventilator CTAB anteriorly RRR, no murmur noted abd benign extrems cool; + distal pulses 68" 75 kg Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2172-6-24] 03:36AM 11.7* 2.88* 9.2* 27.4* 95 31.8 33.4 16.3* 340 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2172-6-16] 03:09AM 76.8* 11.9* 4.7 5.9* 0.8 Source: Line-aline RED CELL MORPHOLOGY Hypochr Macrocy [2172-6-16] 03:09AM 1+ 1+ Source: Line-aline BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2172-6-24] 03:36AM 340 [2172-6-24] 03:36AM 20.2* 63.0* 1.9* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2172-6-24] 03:36AM 117* 42* 1.3* 141 3.8 108 27 10 RADIOLOGY Final Report CHEST (PORTABLE AP) [2172-6-24] 7:41 AM CHEST (PORTABLE AP) Reason: evaluate effusion - page [Numeric Identifier 72690] with concerns [Hospital 93] MEDICAL CONDITION: 69 year old man with history of cad awaiting CABG REASON FOR THIS EXAMINATION: evaluate effusion - page [Numeric Identifier 72690] with concerns AP CHEST 8:27 A.M. ON [6-24] HISTORY: Awaiting CABG. IMPRESSION: AP chest compared to [6-19] through 14: Moderately severe pulmonary edema which improved on [6-22] has recurred accompanied by small bilateral pleural effusions. Heart size is normal and unchanged. No pneumothorax. Tracheostomy tube in standard placement. Findings were discussed by telephone with Dr. [Last Name (STitle) 72691] at the time of dictation. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Cardiology Report ECHO Study Date of [2172-6-5] * Report not finalized * PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Congestive heart failure. Coronary artery disease. Hypertension. Left ventricular function. Mitral valve disease. Murmur. Myocardial infarction. Shortness of breath. Valvular heart disease. Status: Inpatient Date/Time: [2172-6-5] at 08:41 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW5-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] [Name (STitle) ] MEASUREMENTS: Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Overall normal LVEF (>55%). LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in ascending aorta. Complex (mobile) atheroma in the ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. Complex (mobile) atheroma in the descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate (2+) 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 for the patient. Conclusions: Prebypass: 1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are complex (>4mm), mobile atheroma in the descending thoracic aorta. Given degree of descending disease an epiaortic scan was performed. There are simple atheroma in the ascending aorta. There is a single complex (mobile) atheroma 0.5 cm on the posterior surface of the prox ascending aorta on epiaortic scan. There are simple atheroma in the aortic arch. There are complex (>4mm), mobile atheroma in the descending thoracic aorta. Aortic canullation and cross clamping were guided by the epiaortic scan 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 7. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. (3+) was evoked with provacative maneuvers (fluid, elevated BP, Trendelenberg) Vena contracta measured as 0.6 cm. 8. There is no pericardial effusion. Postbypass (on Phenylphrine ggt): 1. Preserved biventricular systolic function 2. There is a ring prosthesis in the mitral position. MR is now trace/mild eccentric valvular MR. 3. Study otherwise unchanged from prebypass. [Location (un) ] PHYSICIAN: ([Numeric Identifier 72692]) Brief Hospital Course: Admitted [6-1] and pre-op workup completed with cardiology consult obtained. Carotid US was negative and plavix washout continued for a few days.Extubated on [6-2]. Heparin continued while enzymes peaked. Diuresis for CHF also done prior to CABG x 3/MV repair/aortic endarterectomy on [6-5] with Dr. [First Name (STitle) ]. Transferred to the CSRU in stable condition on a titrated porpofol drip. Extubated that evening and reintubated within 30 minutes for respiratory distress/ hypoxia. Dobutamine drip continued for low cardiac output. Amiodarone loaded for recurrent A fib with DC cardioversion to sinus brady on POD #2. Heparin also restarted. Dermatology consult done for evaluation of warts on hands and feet. He may follow up with derm. as an outpt. Extubated again on [6-9], but reintubated again the next morning for hypoxic resp. failure with bilat. infiltrates. Bronchoscopy done [6-10] for bloody mucus plugs right lung. CT chest showed CHF, infiltrates, and ? PNA vs. pneumonitis. Vanco and zosyn started. He failed to wean from vent and underwent trach and PEG on [6-16]. He continued to diurese and wean from vent slowly. He had intermittent AF and was comadinized. He developed diarrhea and was found to be c. diff positive on [6-23] and was started on Flagyl. On POD#18 he stayed on trach mask for 8 hours and did well with a Passey-Muir valve. He passed a swallowing study. On POD# 20 he was discharged to rehab in stable condition. Medications on Admission: ASA 81 mg daily plavix 75 mg daily (300 mg given [6-1]) crestor 5 mg daily atenolol 50 mg daily coumadin daily cardizem CD 120 mg daily lisinopril/HCTZ daily cartia daily Discharge Medications: 1. Acetaminophen 325 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [Month/Year (2) ]: One (1) Inhalation [Hospital1 ] (2 times a day). 3. Nystatin 100,000 unit/mL Suspension [Hospital1 ]: Five (5) ML PO QID (4 times a day). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Rosuvastatin 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Two (2) PO BID (2 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Hospital1 ]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 13. Diltiazem HCl 90 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QID (4 times a day). 14. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [Last Name (STitle) ]: Five (5) ML PO DAILY (Daily). 15. Hydralazine 10 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q6H (every 6 hours). 16. Carvedilol 6.25 mg Tablet [Last Name (STitle) ]: Six (6) Tablet PO BID (2 times a day). 17. Amiodarone 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 18. Potassium Chloride 40 mEq Packet [Last Name (STitle) ]: One (2) PO twice a day for 10 days. 19. Lasix 80 mg Tablet [Last Name (STitle) ]: One (2) Tablet PO twice a day for 10 days. 20. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 21. Sertraline 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 22. Coumadin 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime: INR goal 2-2.5. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: s/p cabg x 3 /MV repair/aortic endarterectomy and pericardial patch repair AAA PVD A fib HTN elev. chol. right fem. stent Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision no driving for one month or until visit with surgeon no lfting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [Last Name (STitle) 72693] in [2-11] weeks see Dr. [Last Name (STitle) ] in [3-14] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] see dermatology as an outpt. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2172-6-25]	[ "4280", "486", "5845", "4240", "41401", "42731", "4019", "2724", "V5861" ]
Admission Date: [2153-7-20] Discharge Date: [2153-7-22] Date of Birth: [2094-4-5] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Left Carotid Stenosis Major Surgical or Invasive Procedure: Left Carotid Angiogram and Stent History of Present Illness: Pt. is a 59 yo male with history of PVD, HTN, hypercholesterolemia, and CAD who presented for a left carotid stent placement secondary to severe left carotid stenosis. Pt. has long standing CAD. Cardiac cath. from [10-26] showed 60-70% stenosis of left main coronary artery. Pt. subsequently underwent 3-vessel CABG (LIMA-LAD, SVG-OM1, SVG-RPDA). Recent cardiac cath. ([2153-7-11]) showed patent LIMA-LAD, SVG-RPDA and occluded SVG-OM1. Pt. had carotid ultrasound on [2153-6-7] demonstrating 80-99% stenosis of bilateral ICA's. Pt. denies any recent dizziness, syncope, chest pain, slurred speach prior to admission. Past Medical History: CAD PVD HTN Hypercholesterolemia Social History: Pt. is a current smoker with a hisory of smoking 1/2-1 ppd for >50 years. Questionable history of ETOH abuse. Patient currently denies any abuse. States last drink was over 1 week ago. Currenly lives at home and able to perform ADL's Family History: Brother died in 40's from CAD Physical Exam: Vitals: BP: 129/37 HR: 73 RR: 15 O2sat: 97% RA HT: 5'[60]" WT: 168 lbs. Gen.: Awake, alert, NAD HEENT: wnl Heart: Irregular rhythm, +S1/S2, no murmurs/rubs/gallops Vasculature: no bruits, 1+ DP in rt foot Lungs: CTA bilaterally, good aeration Abd: NT, no masses, +BS, no HSM Skin: wnl Neuro: no deficits noted Ext: no edema/cyanosis, Lt BKA Pertinent Results: [2153-7-20] 12:00PM WBC-7.6 RBC-4.17* HGB-13.0* HCT-37.9* MCV-91 MCH-31.1 MCHC-34.2 RDW-12.7 [2153-7-20] 12:00PM PLT COUNT-220# [2153-7-20] 12:00PM CALCIUM-8.9 MAGNESIUM-1.9 [2153-7-20] 12:00PM CK(CPK)-141 [2153-7-20] 12:00PM GLUCOSE-84 POTASSIUM-4.3 [2153-7-20] 09:28PM HCT-33.6* [2153-7-20] 09:28PM POTASSIUM-3.8 [2153-7-20] 09:28PM UREA N-11 CREAT-0.7 POTASSIUM-3.9 Brief Hospital Course: Pt. was referred to the cardiac cath. lab for a left carotid stent placement by Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ]. A AccuNet 6.5 mm was placed in the left carotid without difficulty. The patient tolerated the procedure well and was admitted to the CCU for post procedural monitoring. The patients SBP was maintained between 140-160 with Neo-synephrine and three bolusses of 250 NS. Pt. had serial neurological checks with no notable changes. After 24 hours the Neo was slowly weaned off and the pt maintained a SBP>120. Pt. was without complaints on the floor and was stable for discharge on [2153-7-22]. Medications on Admission: Lipitor 10mg Qday Lopressor 50mg [Hospital1 ] Plavix 75mg Qday Aspirin 325mg Qday Discharge Medications: Lipitor 10mg Qday Plavix 75mg [Hospital1 ] x 30 days, then switch to one tablet once a day Aspirin 325mg Qday Discharge Disposition: Home Discharge Diagnosis: Bilateral Internal Carotid Stenosis Discharge Condition: Pt. was stable and in good condition on discharge. Discharge Instructions: Pt. is to resume all previous medications except for his blood pressure medication, metoprolol (Lopressor). If the patient experiences any weakness, numbness, slurred speech, or chest pain he is to go to the emergency room. Followup Instructions: Pt. has an appointment for next Tuesday with Dr. [Last Name (STitle) 11493]. At that time his blood pressure will be taken and meds adjusted accordingly. He is to follow up with the [Hospital ] clinic in one month. Dr. [First Name (STitle) ] will call to set up the time. At this visit, the patient will be scheduled for his right carotid stent.	[ "2720", "4019", "V4581" ]
Admission Date: [2140-9-13] Discharge Date: [2140-9-26] Date of Birth: [2060-5-6] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 598] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2140-9-22] ERCP BILIARY&PANCREAS History of Present Illness: 80 F recently admitted for gallstone pancreatitis s/p perc chole tube [2140-9-1] now presents from OSH w/ 1 day history of worsening abdominal pain. Her pain began this morning in the RUQ, has been crampy, non-radiating, [10-21]. She has had associated nausea and dry heaves without emesis. She was transferred from an OSH after her lipase was found to be elevated and a CT abd revealed peri-pancreatic fluid collections. Past Medical History: HTN, HLD, Anxiety, COPD, Hypothyroid, Diverticulitis Social History: Resides at [Hospital3 78668] Facility. Denies tobacco, alcohol, and drug use. Family History: Noncontributory Physical Exam: VS: 96.6 96 155/72 16 100 Gen: uncomfortable, alert and oriented but not cooperative. CVS: reg Pulm: No resp distress Abd: + Distended. TTP throughout LE: trace edema bilaterally Pertinent Results: [2140-9-13] 05:52PM GLUCOSE-158* UREA N-23* CREAT-1.0 SODIUM-136 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14 [2140-9-13] 05:52PM WBC-25.8* RBC-3.59* HGB-9.9* HCT-31.3* MCV-87 MCH-27.7 MCHC-31.7 RDW-16.7* [2140-9-13] 05:52PM PLT COUNT-614* [2140-9-13] 05:52PM PT-14.3* PTT-29.2 INR(PT)-1.2* Imaging: [9-13] CXR: Bilateral pleural effusions have minimally improved. Left lower lobe atelectasis persists. Otherwise, no new focal consolidations. . CT ABD [2140-9-12] (OSH): Peripancreatic fluid collection. Pancreatitis. Not much change from prior CT scan. . TTE [9-13]: mild symmetric left ventricular hypertrophy. LVEF 70%. The left ventricular inflow pattern suggests impaired relaxation . Brief Hospital Course: She was admitted to the ICU and on HD 1, she developed respiratory distress and was intubated for ~10 hours. A central line was placed for hemodynamic monitoring. She was extubated later in the evening without issue. She likely had decreased respiratory drive, became hypercarbic and developed respiratory distress. Her white count was in the 20's with worsening abdominal pain and empiric vancomycin and Zosyn were started. GI was consulted for ERCP for presumed cholangitis. They deferred ERCP given her acute respiratory distress. On HD 2 Cipro was added for worsening white count (30's) for double coverage. ERCP was planned but aborted in the evening given ERCP's concern for another process other than cholangitis. CT scan of the abdomen revealed a peripancreatic fluid collection. However by HD 3, her white count, amylase and lipase were decreasing so ERCP was again deferred. After discussion between the surgery and GI attending the decision was made to proceed with ERCP. She has required nasal oxygen during her hospital stay, her saturations on [3-16] liters/min have been 96-98%. She is receiving scheduled nebulizer treatments and her home medications were restarted. Geriatric medicine also followed along during her stay given her age and other comorbidities. Several medications recommendations were made pertaining to her medications. It was felt that Megace and Marinol were contributing to her drowsiness and so these were stopped. She would later be started on a diet, advancing slowly and her TPN was stopped. She is now tolerating a regular diet with minimal abdominal pain. Her antibiotics were eventually stopped and her PICC line removed. She was evaluated by Physical therapy and is being recommended to return to rehab after her acute hospital stay. Medications on Admission: simvastatin 10', tylenol, ducolax 10' prn, milk of mag, lasix 20', synthroid 50', metoprolol 50", advair, iron, oxycodone, senna, lisinopril 20', HCTZ 12.5', Xanax 1', lactulose Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal EVERY 6 HOURS AS NEEDED () as needed for hemorrhoids. 11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Alprazolam 1 mg Tablet Sig: [2-13] Tablet PO BID (2 times a day) as needed for anxiety. 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 78668] and Rehabilitation Center - [Location (un) 4047] Discharge Diagnosis: Recurrent gallstone pancreatitis 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 hopsitalized with a recurrence of your gallstone pancreatitis. You were treated with intravenous fulids and given special nutrition through a PICC cathether called TPN. Once your abdominal pain decreased your diet was advanced slowly for whcich you are currently tolerating a regular diet. The drainage catheter that you have will remain in place for another [2-13] weeks; you will follow up in [Hospital 2536] clinic at that time. Followup Instructions: Follow up in [Hospital 2536] clinic in [2-13] weeks, call [Telephone/Fax (1) 600] for an appointment. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2140-9-26]	[ "51881", "4019", "2724", "2449", "496", "2859" ]
Admission Date: [2166-11-11] Discharge Date: [2166-11-17] Date of Birth: [2094-11-29] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / adhesive tape Attending:[First Name3 (LF) 2972] Chief Complaint: dyspnea, chest pain, need for BiPAP Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 8467] is a 71y/o lady with DM2, poorly controlled HTN, CAD s/p NSTEMI&CABG [1-22], s/p MV annuloplasty, and systolic/diastolic CHF (EF 55%) who presented with chest pain&dyspnea and is admitted to the CCU due to CHF exacerbation requiring BiPAP. At her recent baseline, she can walk in the mall and do housework as well as going up and down stairs without symptoms of either chest distress or undue dyspnea. Per ED report, she was doing fine until yesterday when she felt acutely short of breath. Then she developed left-sided chest pain that radiated to her arm and back. Patient reports that she has had similar chest pain before but it has never radiated and never was associated with shortness of breath. Her family brought her to the ED. In the ED, initial VS were: pain [8-22], T 99.2, HR 88, BP 146/47, RR 24, POx 80% RA. Was having difficulty completing sentences and was sleepy. Had rales to mid-lung and CXR confirmed pulmonary edema. Labs were notable for WBC 12.1, Hct 29.5 (baseline 30), BUN 42/Cr 1.5 (which is baseline), glucose 276, Anion gap 16. Lactate not checked. Troponin was 0.04 and BNP was 8300. EKG revealed SR, rate 88 w/LBBB, negative Sgarbossa's. She was started on BiPAP on arrival with improvement of her sats to 100%. She continued to appear tired but VBG did not suggest that she was retaining CO2. She was started on a NTG drip (currently at 5), as well as receiving Lasix 80mg with 250cc urine output over the next 2 hours. She also received ASA 325mg PO. She was unable to be weaned from BiPAP so she was admitted to the CCU. VS prior to transfer were pain 0/10, T 98.0, HR 78, BP 126/51, RR 19, POx 97%. On arrival to the floor, she is on BiPAP, somnolent but arousable to loud voice. Follows commands but then dozes off. Denies chest pain currently. REVIEW OF SYSTEMS Unable to assess due to somnolence and BiPAP use. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -diastolic CHF - CABG [2165-1-16]: LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA)/MV repair 3. OTHER PAST MEDICAL HISTORY: -Hypothyroidism -Squamous cell carcinoma of left forearm. - h/o varicella zoster - basal cell carcinoma on back [2166] - vitreous hemorrhage- R and L eye. - L hemispheric stroke [4-21] - chronic lower back pain secondary to spinal stenosis - depression - hemorrhoids Social History: Married, lives at home with husband, denies tobacco, alcohol, illicits. Ambulates independently, occasionally uses walker. Family History: No early CAD, DM, or HTN. Physical Exam: Admission Physical Exam: Weight: 97kg Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 71 (71 - 84) bpm BP: 120/42(61) {120/42(61) - 146/73(88)} mmHg RR: 18 (18 - 18) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) GENERAL: obese lady with BiPAP on, lethargic but arousable to loud voice HEENT: MMM, no scleral icterus NECK: Supple with JVD to angle of the mandible CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur best heard at RUSB. No thrills, lifts. No S3 or S4. LUNGS: Scattered rales, worse throughout lower lung fields ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Trace edema of ankles. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge Physical Exam: VS: Wt 95.2kg, T 97.7, P 59, BP 145/61, RR18, 99% 2L NC Gen: AxOx3 NECK: unable to assess JVD [2-13] habitus CV: distant heart sounds, RRR, no m/r/g PULM: CTAB ABD: BS+, soft, minimally TTP EXT: no edema Pertinent Results: Admission Labs: Troponins: [2166-11-11] 05:20PM CK(CPK)-190 [2166-11-11] 05:20PM CK-MB-4 cTropnT-0.10* [2166-11-11] 05:50AM CK(CPK)-222* [2166-11-11] 05:50AM CK-MB-4 cTropnT-0.08* [2166-11-11] 12:35AM CK(CPK)-220* [2166-11-11] 12:35AM cTropnT-0.04* [2166-11-11] 12:35AM CK-MB-3 proBNP-8300* Chemistry: [2166-11-11] 05:20PM GLUCOSE-102* UREA N-56* CREAT-1.8* SODIUM-137 POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18 [2166-11-11] 10:14AM GLUCOSE-289* UREA N-51* CREAT-1.7* SODIUM-139 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [2166-11-11] 05:50AM GLUCOSE-342* UREA N-47* CREAT-1.7* SODIUM-135 POTASSIUM-5.4* CHLORIDE-98 TOTAL CO2-20* ANION GAP-22* [2166-11-11] 05:50AM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.0 [2166-11-11] 12:35AM GLUCOSE-276* UREA N-42* CREAT-1.5* SODIUM-137 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-21* Hematology: [2166-11-11] 05:50AM WBC-9.1 RBC-2.81* HGB-9.0* HCT-28.1* MCV-100* MCH-31.9 MCHC-31.9 RDW-13.9 [2166-11-11] 05:50AM PLT COUNT-194 [2166-11-11] 12:35AM WBC-12.1# RBC-2.98 HGB-9.6* HCT-29.5* MCV-99* MCH-32.3* MCHC-32.6 RDW-13.9 [2166-11-11] 12:35AM NEUTS-90.0* LYMPHS-5.4* MONOS-4.2 EOS-0.2 BASOS-0.2 [2166-11-11] 12:35AM PLT COUNT-200 [2166-11-11] 12:35AM PT-12.3 PTT-31.5 INR(PT)-1.1 Urine: [2166-11-11] 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2166-11-11] 03:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD Imaging: [2166-11-11] TTE: -> LVEF 50%. Septal motion is abnormal. minimal aortic valve stenosis. Trace AR. Mild (1+) MR. Moderate [2+] TR. The tricuspid regurgitation jet is eccentric and may be significantly underestimated. There is moderate pulmonary artery systolic hypertension. Compared with the findings of the prior study (images reviewed) of [2166-1-31], the findings are grossly similar, but the technically suboptimal nature of both studies precludes definitive comparison. [11-11] CXR: IMPRESSION: New moderate-to-severe pulmonary edema with probable bilateral pleural effusions. [11-14] CXR: IMPRESSION: AP chest compared to [11-11]: Previous moderate pulmonary edema has largely cleared. Residual opacification at the right lung base could be edema and atelectasis. Moderate cardiomegaly is improved. Pleural effusions are minimal, if any. No pneumothorax. [11-15] RUQ U/S: IMPRESSION: Distended gallbladder with positive [Doctor Last Name 515] sign raises concern for acute cholecystitis in the appropriate clinical setting. There is however no evidence of stones, pericholecystic fluid, or gallbladder wall thickening. Correlate with laboratory values and consider HIDA if clinically indicated. Discharge Labs: [2166-11-17] 06:59AM BLOOD WBC-6.2 RBC-2.70* Hgb-8.7* Hct-26.5* MCV-98 MCH-32.1* MCHC-32.8 RDW-13.9 Plt Ct-285 [2166-11-17] 06:59AM BLOOD Glucose-151* UreaN-79* Creat-1.9* Na-137 K-4.6 Cl-98 HCO3-32 AnGap-12 [2166-11-17] 06:59AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.2 Brief Hospital Course: Ms. [Known lastname 8467] is a 71y/o lady with DM2, poorly controlled HTN, CAD s/p NSTEMI&CABG [1-22], s/p MV annuloplasty, and systolic/diastolic CHF (EF 55%) who presented with dyspnea and chest pain in the setting of CHF exacerbation. ACTIVE ISSUES # Decompensated CHF: She was continued on a nitroglycerin drip and home antihypertensives. She was also continued on home BiPAP and was diuresed with a goal of negative 1-2L per day. She briefly became hypertensive off the nitro drip and was placed back on the drip while her home antihypertensives were uptitrated but was soon able to be weaned off again. # Hypertension: poorly controlled. She was weaned off of the nitroglycerin drip and continued on her home antihypertensives which were uptitrated to goal BPs in the 120s/80s. # Somnolence: unclear etiology. Initially concerning for CO2 retention but none per VBG and then ABG on arrival to the floor. Might be related to sedating medications at home (Oxycodone-Acetaminophen, Gabapentin dose higher than recommended for her renal function). This improved throughout her stay. # CAD s/p CABG: chest pain w/mildly elevated troponin, likely demand. Troponins continued to trend down and no EKG changes were observed. # Leukocytosis: Patient had leukocytosis on admission and was started on ceftriaxone for UTI. She was febrile to 100.4 on HD2 and azithromycin was added to cover for community acquired pneumonia. # Abdominal pain: Patient complained of mild abdominal pain on [11-15]. RUQ U/S was obtained which was unremarkable and LFTs were entirely unremarkable. Patient treated symptomatically with good effect. # Anion gap 16: likely from ketones. The patient was started on an insulin drip and treated for DKA. [Last Name (un) ] was consulted and made recommendations to stop the insulin drip, start glargine 20 units at bedtime and use high-dose insulin sliding scale. Her anion gap gradually closed with treatment. # CKD: Cr 1.5 which is baseline. Creatinine was monitored daily and medications were renally dosed. # DM II: poorly controlled. HbA1c 8.5% earlier this month. She was placed on a sliding scale and standing lantus. INACTIVE ISSUES # Anemia: Stools were guaiaced and hematocrits were monitored daily. # Gout: Continued on Allopurinol, Colchicine (renally dosed) # Hypothyroidism: Continued on home levothyroxine # Chronic pain: Gabapentin and Oxycodone-Acetaminophen were held while somnolent and gabapentin was restarted when mental status improved. # Depression: Continued on home Fluoxetine TRANSITIONAL ISSUES: -[Month (only) 116] need cath vs stress test as outpatient -Needs to wear CPAP at night Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol 400 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Fluoxetine 10 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. HydrALAzine 50 mg PO Q6H 9. insulin detemir NF 20 Subcutaneous at bedtime 10. HumaLOG NF (insulin lispro) inject per sliding scale Subcutaneous twice a day 11. Levothyroxine Sodium 150 mcg PO 3X/WEEK (TU,TH,SA) 12. Levothyroxine Sodium 225 mcg PO 4X/WEEK ([Doctor First Name ],MO,WE,FR) 13. Lorazepam 1 mg PO BID:PRN anxiety 14. Losartan Potassium 100 mg PO DAILY 15. Metoprolol Tartrate 25 mg PO BID 16. Oxycodone-Acetaminophen (5mg-325mg) [1-13] TAB PO Q6H:PRN pain 17. Zolpidem Tartrate 5 mg PO HS 18. Aspirin 81 mg PO DAILY 19. Cyanocobalamin 1000 mcg PO DAILY 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Amlodipine 10 mg PO DAILY RX amlodipine 10 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fluoxetine 10 mg PO DAILY RX fluoxetine 10 mg one capsule(s) by mouth daily Disp #30 Capsule Refills:2 6. Gabapentin 300 mg PO Q12H 7. Levothyroxine Sodium 150 mcg PO 3X/WEEK (TU,TH,SA) 8. Levothyroxine Sodium 225 mcg PO 4X/WEEK ([Doctor First Name ],MO,WE,FR) 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Lidocaine 5% Patch 1 PTCH TD DAILY pain 11. Nitroglycerin SL 0.4 mg SL PRN chest or arm pain RX nitroglycerin 0.4 mg one tablet sublingually as needed for chest pain Disp #25 Tablet Refills:0 12. Torsemide 20 mg PO DAILY RX torsemide 20 mg two tablet(s) by mouth daily Disp #60 Tablet Refills:2 13. Allopurinol 400 mg PO DAILY 14. Oxycodone-Acetaminophen (5mg-325mg) [1-13] TAB PO Q6H:PRN pain 15. Lorazepam 1 mg PO BID:PRN anxiety 16. Metoprolol Tartrate 12.5 mg PO BID 17. Colchicine 0.6 mg PO PRN gout take only when the gout is active 18. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX isosorbide mononitrate 60 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 19. Levofloxacin 250 mg PO Q24H Duration: 3 Days RX levofloxacin 250 mg one tablet(s) by mouth daily Disp #3 Tablet Refills:0 20. Detamir 32 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 21. HydrALAzine 50 mg PO Q6H Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CHF exacerbation Pneumonia Urinary tract infection Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 8467], It was a pleasure caring for you during your hospitalization at [Hospital1 18]. You were admitted for increased shortness of breath and were found to have a congestive heart failure exacerbation. You were given medications to reduce fluid and blood pressure and improved. You developed a fever and were treated for pneumonia and a urinary tract infection. Please take all medications as prescribed and attend all follow-up appointments as indicated. It is very important that you wear your mask at night to prevent increased pressure in your lungs that can make your heart work harder. Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days Followup Instructions: Department: DERMATOLOGY When: THURSDAY [2166-11-27] at 2:00 PM With: [Name6 (MD) 2975] [Name8 (MD) 2976], MD [Telephone/Fax (1) 2977] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DERMATOLOGY When: THURSDAY [2166-11-27] at 2:30 PM With: [Name6 (MD) 2975] [Name8 (MD) 2976], MD [Telephone/Fax (1) 2977] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: THURSDAY [2166-12-25] at 1:30 PM With: [Name6 (MD) 251] [Last Name (NamePattern4) 252], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Dr. [Last Name (STitle) 1147] Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: 1000 [Last Name (LF) ], [First Name3 (LF) ], MA Phone: [Telephone/Fax (1) 6662] Date/Time: [11-20] at 9:30	[ "486", "5990", "4280", "V5867", "V4581", "412", "2724", "40390", "5859", "2449", "311" ]
Admission Date: [2149-9-26] Discharge Date: [2149-10-4] Date of Birth: [2089-6-7] Sex: M Service: CARDIOTHORACIC Allergies: Bee Sting Kit Attending:[Known firstname 922] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p coronary artery bypass grafting x 4 (Left internal mammary artery grafted to the left anterior descending artery/saphenous vein grafted to posterior descending artery/obtuse Marginal/diagnal) on [2149-9-30] History of Present Illness: 60 year old male with history of Coronary artery disease s/p stents in [2142]. He reports progressive chest pain with activity over the previous 3 weeks, and occasional rest chest pressure. Cardiac Cath revealed left main/multi vessel coronary disease. Cardiac surgery was consulted for coronary revascularization. Past Medical History: Coronary artery disease s/p stent to LAD, RCA and Cx [2142] Hypertension Hypercholesterolemia GERD Asthma Past Surgical History: Abdominal surgery r/t injury in [Country 3992] @ age 19 (Shrapnel) Social History: Race: Caucasian Last Dental Exam: 1yr. ago Lives with: alone Occupation: retired fire fighter Tobacco: quit age 19 ETOH: 12 beers/week Family History: mother died of MI 62yo father died MI 82yo Physical Exam: Admission Physical Exam Pulse: 64 Resp: 24 O2 sat: 98% 2L B/P Right: Left: 131/78 Height: 5'1" Weight: 212lb General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] well healed mid-line scar Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [2149-9-30] PREBYPASS 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 descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Epiaortic scan showed no significant atheromatous disease of the ascending aorta. POSTBYPASS Biventricular systolic function remains preserved. There are no other changes from the prebypass exam. [2149-10-2] 04:45AM BLOOD WBC-10.2 RBC-3.25* Hgb-10.3* Hct-30.2* MCV-93 MCH-31.6 MCHC-34.0 RDW-12.7 Plt Ct-129* [2149-10-2] 04:45AM BLOOD Glucose-104* UreaN-13 Creat-1.2 Na-133 K-4.4 Cl-98 HCO3-31 AnGap-8 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [2149-9-30] where the patient underwent coronary bypass grafting x4 with left internal mammary artery to the left anterior descending coronary, reverse saphenous vein single graft from aorta to first diagonal coronary artery, reverse saphenous vein single graft from aorta to second obtuse marginal coronary artery, as well as reverse saphenous vein graft from the aorta to the posterior descending coronary artery. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. he was on Plavix preoperatively for stents to LAD, RCA and Cx and this was resumed. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Plavix 75mg daily enalapril 5mg daily Toprol XL 100mg daily omeprazole 40mg daily simvastatin 20mg daily aspirin 325mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. omeprazole 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:2 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass grafting x 4 on [2149-9-30] PMH: s/p stent to LAD, RCA and Cx [2142] Hypertension Hypercholesterolemia GERD Asthma 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. Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [Last Name (STitle) 914] on [10-21] at 2pm Cardiologist:Dr. [Last Name (STitle) 8579] on [10-28] at 9:30am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 8522] in [12-21] weeks [Telephone/Fax (1) 8577] 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:[2149-10-4]	[ "41401", "2875", "V4582", "4019", "2720", "53081", "49390", "2859" ]
Admission Date: [2131-6-21] Discharge Date: [2131-6-27] Date of Birth: [2051-9-27] Sex: M Service: SURGERY Allergies: Lipitor Attending:[First Name3 (LF) 4111] Chief Complaint: Right flank pain Major Surgical or Invasive Procedure: Abscess excision, right flank History of Present Illness: 79 year-old gentleman who presents with a 30-pound weight loss over 4 years duration and some feeling of fatigue and lack of function in addition to a mass, which has now become quite prominent. This first came to attention when he presented with an enlarging mass of the right flank approximately twelve months ago. He had a CT scan on [2130-4-11] which reported a subcutaneous mass and/or collection of 2.7 x 3.9 cm overlying the posterior lateral subcutaneous fat. He noted the mass enlarging in size for the past 6 months. He has slight discomfort when he sits. He denies fever, chills, and redness. Past Medical History: * CAD * CABG x 2 * anterior MI at age 37 * CHF, EF 25% s/p cardiac resynchronization and biv pacer placement * hypertension * dyslipidemia * ccy [2127] * remote motor vehicle accident Social History: retired sales officer, lives along in [Location (un) 11790], remote tobacco, occasional ETOH Family History: diabetes, hypertension on both sides of the family Physical Exam: Well appearing male in no acute distress Chest is clear Regular sinus rhythm, grade 3-4/6 mitral valve murmur Abdomen soft, non-tender, non-distended, well healed small laparoscopic scar at umbilicus. On the right flank, there is a 12 x 13 cm mass, which is bulging upward and feels somewhat cystic. No hernias Pertinent Results: Admission/Post-op Labs [2131-6-21] 02:10PM BLOOD WBC-12.1* RBC-3.87* Hgb-10.7* Hct-32.5* MCV-84 MCH-27.8 MCHC-33.1 RDW-15.7* Plt Ct-233 [2131-6-21] 02:10PM BLOOD Glucose-133* UreaN-24* Creat-1.1 Na-137 K-4.7 Cl-102 HCO3-28 AnGap-12 [2131-6-21] 02:10PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 MICROBIOLOGY~~~~~~~~~~~~~~~~~ #1 [2131-6-21] 12:40 pm TISSUE CONTENTS OF ABSCESS. GRAM STAIN (Final [2131-6-21]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2131-6-24]): NO GROWTH. ANAEROBIC CULTURE (Final [2131-6-27]): NO GROWTH. #2 [2131-6-21] 11:50 am ABSCESS RT FLANK. GRAM STAIN (Final [2131-6-21]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2131-6-23]): NO GROWTH. ANAEROBIC CULTURE (Final [2131-6-27]): NO GROWTH. PATHOLOGY~~~~~~~~~~~~~~~~~~~~~ SPECIMEN SUBMITTED: ABSCESS RIGHT FLANK, CAVITY STONES, AND GALLSTONES (1). DIAGNOSIS: I. Skin, right flank (A-C): Skin with subcutaneous abscess formation. II. Abscess cautery stones: Gross examination only. III. Gallstones: Gross examination only. RADIOLOGY~~~~~~~~~~~~~~~~~~~~ CAROTID SERIES COMPLETE [2131-6-26] 1:24 PM FINDINGS: Duplex evaluation was performed of both carotid arteries. Moderate plaque was identified on the right. On the right, peak systolic velocities are 136, 62, 75 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 2.1. This is consistent with a 40-59% stenosis. On the left, peak systolic velocities are 95, 57, 66 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.6. This is consistent with less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: On the right, there is moderate plaque with a 40-59% carotid stenosis. On the left, there is a less than 40% stenosis. Brief Hospital Course: The patient was admitted on the day of surgery. Due to his significant cardiac history a pulmonary artery catheter was placed in the OR for hemodynamic monitoring post-operatively. He was extubated easily and transferred to the recovery room. He was monitored in the intensive care unit post-operatively for fluid management and cardiology was involved for recommendations. He was maintained on antibiotics throughout his hospital stay, however the culture from the operating room failed to reveal a pathogen. He tolerated a regular diet POD1. The PA catheter was removed on POD3. He was transferred to the floor on POD4. A carotid duplex ultrasound was obtained to evaluate a soft left carotid bruit heard during his hospital stay. (see results section). Dr. [Last Name (STitle) ] of vascular surgery was consulted and will follow-up with the patient as an outpatient for further monitoring. The patient had [Location (un) 1661]-[Location (un) 1662] drains placed during the surgery and these remained in for his hospitalization. The output of each was less than 30cc of serosanguinous fluid at discharge. He was instructed as to care and emptying of the drains and will record outputs regularly. He will also have visiting nursing care to aid in his wound and drain care. He was discharged to home on Augmentin for another week and will follow-up with Dr. [Last Name (STitle) 957] in clinic. Medications on Admission: Lasix 10mg po bid Lopressor 50mg po bid Lanoxin 0.25mg po bid Fosinopril 10mg po qday Aspirin 325 po qday (held) Zetia 10mg po qday Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO daily (). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [First Name8 (NamePattern2) 40133] [Last Name (NamePattern1) 32495] Discharge Diagnosis: Dropped gallstone abscess, right flank Discharge Condition: Good Discharge Instructions: Please call if you are experiencing fevers (>101.5), are having a significant increase in pain or discomfort, notice increasing redness, swelling, or drainage from your wound. Followup Instructions: please call Dr.[Name (NI) 6275] office for your follow-up appointment in 2 weeks. Follow-up with your outpatient cardiologist. You may make an appointment with Dr. [Last Name (STitle) 11255] at ([Telephone/Fax (1) 7236] if you wish to remain under his care for cardiology. Follow-up with Dr. [Last Name (STitle) ] will be arranged through Dr. [Last Name (STitle) 957] after your follow-up visit.	[ "4280", "V4581", "4019" ]
Admission Date: [2176-7-22] Discharge Date: [2176-7-30] Date of Birth: [2101-9-5] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Gemfibrozil Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: coronary artery bypass graft x3 Coronary artery bypass grafting x3 with the left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the obtuse marginal artery, and the diagonal artery. 2. Left atrial appendage resection. for chronic afib History of Present Illness: Mr. [Known lastname ] is a 74 yo M with CAD s/p MI, anxiety, HTN, Hyperlipidemia and chronic AFib, who presented to OSH on [2176-7-19] with NSTEMI, and was transferred to [Hospital1 18] on [2176-7-22] for cardiac cath. Cath demonstrated complex LAD and diagonal disease, and was evaluated by cardiac surgery for revasularization after plavix washout. . Mr. [Known lastname ] presented initially on [2176-7-19] after developing substernal chest pain. The pain was associated with mild SOB and radiated to his left shoulder. In the OSH ED, he was given SL nitro and aspirin and the pain subsided. He was loaded with plavix. .At OSH, his troponin peaked at 0.40 on [2176-7-19] @ [2120]. . Past Medical History: - CAD, h/o MI - Hypertension - Hyperlipidemia - Gout - Atrial fibrillation, chronic - anxiety - Bilateral TKR. -right hip replacement Social History: The patient lives with his wife and a son. [Name (NI) ] quit smoking in [2147], after smoking 3 ppd for 15 years. He drinks 4-5 beers per day. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION: VS - 96.9 157/82 79 16 99%2L Gen: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. MMM. Neck: Supple with no elevation of JVP. CV: Irregular, normal S1, S2. No m/r/g. No S3 or S4. Chest: Nasal cannula in place. Resp were unlabored, no accessory muscle use. Lung exam limited by patient's inability to move post-procedure. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. No hematoma. c/d/i. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: Echo PREBYPASS The left atrium is moderately dilated. The left atrium is elongated. Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded due to presence of spontaneous echo contrast and difficulty visualizing tip of appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POSTBYPASS The patient is A-V paced and is not on any inotropes. The left atrial appendage has been ligated. We are unable to identify any remnants of the appendage and there is no flow in the area of the appendage on color Doppler. Left ventricular systolic function continues to be normal (LVEF>55%). Trace aortic regurgitation and trivial mitral regurgitation remain. The thoracic aorta is intact. Pre-op [2176-7-22] 11:25AM PT-18.4* PTT-33.8 INR(PT)-1.7* [2176-7-22] 11:25AM PLT COUNT-118* [2176-7-22] 11:25AM WBC-4.0 RBC-4.21* HGB-13.8* HCT-39.7* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.6 [2176-7-22] 11:25AM TRIGLYCER-74 HDL CHOL-58 CHOL/HDL-2.9 LDL(CALC)-93 [2176-7-22] 11:25AM %HbA1c-5.3 eAG-105 [2176-7-22] 11:25AM ALBUMIN-3.8 CHOLEST-166 [2176-7-22] 11:25AM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-67 TOT BILI-0.7 [2176-7-22] 11:25AM GLUCOSE-219* UREA N-9 CREAT-0.6 SODIUM-129* POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-12 Discharge [2176-7-29] 05:55AM BLOOD WBC-6.9 RBC-3.01* Hgb-10.1* Hct-27.7* MCV-92 MCH-33.6* MCHC-36.5* RDW-14.2 Plt Ct-118* [2176-7-29] 05:55AM BLOOD Plt Ct-118* [2176-7-29] 05:55AM BLOOD Glucose-108* UreaN-15 Creat-0.6 Na-132* K-3.5 Cl-97 HCO3-31 AnGap-8 Radiology Report CHEST (PORTABLE AP) Study Date of [2176-7-28] 10:06 AM [Hospital 93] MEDICAL CONDITION: 74 year old man with removal of chest tubes REASON FOR THIS EXAMINATION: eval for PTX Final Report In comparison with the study of [7-26], all of the monitoring and support devices other than the right IJ catheter have been removed. No definite evidence of pneumothorax. Bibasilar changes of atelectasis persist, more prominent on the left, where there is some associated pleural effusion. DR. [First Name11 (Name Pattern1) 1569] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11006] Brief Hospital Course: The patient was admitted to the hospital and after a plavix washout was brought to the operating room on [2176-7-25] for a coronary artery bypass graft x 3 and left atrial appendage ligation. See operative report for details, in summary he had: Coronary artery bypass grafting x3 with the left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the obtuse marginal artery, and the diagonal artery, Left atrial appendage resection. His CROSS-CLAMP TIME was 70 minutes with a bypass PUMP TIME of 83 minutes. Overall he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis. On the day of surgery he woke neurologically intact, was weaned from the ventilator and extubated. Beta blocker, statin and diuresis was initiated and he was gently diuresed toward his preoperative weight. Initially Mr. [Known lastname ] was sensitive to lopressor and became bradycardic to the 40's after receiving one dose of 25mg lopressor. Lopressor was held temporarily and resumed at a lower dose and gently increased. Coumadin therapy was resumed for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery on POD1. All tubes lines drains and pacing wires were discontinued per cardiac surgery protocol without complication. Mr. [Known lastname ] has chronic hyponatremia and was placed on a fluid restriction, serum sodium levels were monitored. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 Mr. [Known lastname ] was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He was discharged in good condition with appropriate follow up instructions. Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] was contact[Name (NI) ] to follow his coumadin dosing. Medications on Admission: HOME MEDICATIONS: - Aspirin 325 mg - Allopurinol 300 mg daily - Imdur 60 mg daily - Zestril 40 mg daily - amlodipine 5 mg daily - Xanax 0.125mg - Coumadin 2.5 mg daily - Tamsulosin 0.4 mg daily - Docusate 100 mg [Hospital1 ] ADDED AT OSH: - Plavix 75 mg daily (Plavix 300 mg load on [2176-7-21]) - Solumedrol 40 mg IVP [2176-7-21] and [2176-7-22] a.m. - Heparin 1000 units/hr Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Alprazolam 0.25 mg [Month/Day/Year 8426] Sig: One (1) [Month/Day/Year 8426] PO BID (2 times a day) as needed for anxiety. 3. Ezetimibe 10 mg [Month/Day/Year 8426] Sig: One (1) [Month/Day/Year 8426] PO DAILY (Daily). 4. Allopurinol 300 mg [Month/Day/Year 8426] Sig: One (1) [Month/Day/Year 8426] PO DAILY (Daily). 5. Aspirin 81 mg [Month/Day/Year 8426], Delayed Release (E.C.) Sig: One (1) [Month/Day/Year 8426], Delayed Release (E.C.) PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 325 mg [Month/Day/Year 8426] Sig: Two (2) [Month/Day/Year 8426] PO Q4H (every 4 hours) as needed for pain. 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 9. Metoprolol Tartrate 25 mg [Month/Day/Year 8426] Sig: 0.5 [Month/Day/Year 8426] PO BID (2 times a day). Disp:30 [Month/Day/Year 8426](s) Refills:2 10. Warfarin 1 mg [Month/Day/Year 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] DAILY (Daily) as needed for AFIB: INR goal >2.0 for AFib. Disp:60 [Last Name (Titles) 8426](s) Refills:0 11. Furosemide 20 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO BID (2 times a day) for 3 days. Disp:6 [Last Name (Titles) 8426](s) Refills:0 12. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 3 days. Disp:6 Tab Sust.Rel. Particle/Crystal(s) Refills:0 13. Warfarin 5 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO ONCE (Once) for 1 doses. Disp:1 [Last Name (Titles) 8426](s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary artery disease s/p CABG x3 PMH: Gout, Myocardial infarction, Hypertension, Anxiety - takes xanax every night and wakes at times in panic, Hyperlipidemia, Atrial Fibrillation (on coumadin), s/p total hip arthroplasty right - [2172], s/p bilateral knee replacement - both in [2173] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: trace bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [8-15] @2:30 Cardiologist:Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [8-30] @3:15P Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) ] [Telephone/Fax (1) 29248] in [3-4] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation Goal INR 2-2.5 First draw [2176-7-31] Results to Dr [Doctor Last Name 86963] [Telephone/Fax (1) 8725] fax [Telephone/Fax (1) 8719] Completed by:[2176-7-30]	[ "41071", "2761", "41401", "42731", "412", "4019", "2724", "V5861" ]
Admission Date: [2132-6-27] Discharge Date: [2132-7-2] Date of Birth: [2048-2-18] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: sudden weakness in her LEFT side of the body and inability to speak Major Surgical or Invasive Procedure: intubated and extubated History of Present Illness: 85 yo RH woman with a PMH remarkable for HTN and AF off AC (unknown reasons) p/w sudden weakness in her LEFT side of the body and inability to speak. Yesterday, she was evaluated by her PCP and diagnosed with a UTI. She was started on cefuroxime. At the time her MS was at baseline. She went to bed without problems. Today, she was last seen at her USOH at 8:30 am. This [Last Name (un) 44550] she was "off". Drooling on the left side , leaning to left and not moving her left limbs. At baseline she requires an assistant with eating and preparing meals. Walks with a walker. Able to communicate with simple sentences. Per son, she is off coumadin and ASA because she had a severe LGIB 18 months ago. At [Hospital1 18] ED: FSBS 105 , SBP 184. ETT in the ED for airway protection. Past Medical History: AF (+) off coumadin HTN DAT Hypothyroidism Pertinent negatives: Strokes (-) Procoagulant conditions (-) CAD (-) , DM (-), HLD (-), OSA (-) Seizures (-), migraine (-), CNS tumors (-) Social History: Lives at Emeritus Senior building [Telephone/Fax (1) 47057]: [Hospital3 ] Exercises (-) Tobacco (-) ETOH (-) Drugs (-) Family History: NC Physical Exam: PE: Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Irregular S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. . MS: General: stuporous, responsive to verbal command. Squeezes with right hand, she does wiggle right/ left toes. Speech/Language: non-fluent, comprehension intact for simple apendicular commands. . Not Blinking ot threat on the LEFT. There is a rigth gaze deviation, but she crosses the midline without problems. [Name (NI) 2994] 3mm to 2mm, . III,IV,VI: EOMI, no ptosis. No pathological nystagmus. V: sensation intact V1-V3 to LT. VII: left Facial droop IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [5-28] bilaterally XII: tongue protrudes midline, . . Deep tendon Reflexes: . Bicip: Tric: Brachial: Patellar: Achilles Toes: Right 2 2 2 2 0 UPGOING Left 2 2 2 2 0 UPGOING 1a LOC =0 1b Orientation = (severe dysarthria: 1) 1c Commands = 1 2 Gaze =0 3 Visual Fields =0 4 Facial Paresis = 1 5a Motor Function R UE = 0 5b Motor Function L UE= 3 6a Motor Function R LE= 0 6b Motor Function L LE= 1 7 Limb Ataxia = 0 8 Sensory perception = 0 9 Language = 0 10 Dysarthria = 1 11 Extinction/Inattention = 0 TOTAL = 8 Pertinent Results: [2132-7-1] 06:24AM BLOOD WBC-9.4 RBC-4.29 Hgb-11.7* Hct-37.2 MCV-87 MCH-27.4 MCHC-31.5 RDW-15.2 Plt Ct-281 [2132-6-30] 05:40AM BLOOD WBC-11.9* RBC-4.38 Hgb-12.0 Hct-37.6 MCV-86 MCH-27.4 MCHC-31.9 RDW-15.3 Plt Ct-275 [2132-7-1] 06:24AM BLOOD Plt Ct-281 [2132-7-1] 06:24AM BLOOD PT-16.8* PTT-33.2 INR(PT)-1.5* [2132-6-30] 11:25AM BLOOD PT-18.5* PTT-54.3* INR(PT)-1.7* [2132-6-30] 05:40AM BLOOD PT-18.3* PTT-58.9* INR(PT)-1.7* [2132-7-1] 06:24AM BLOOD Glucose-105* UreaN-29* Creat-0.8 Na-145 K-3.5 Cl-110* HCO3-26 AnGap-13 [2132-6-30] 05:40AM BLOOD Glucose-112* UreaN-20 Creat-0.9 Na-139 K-3.5 Cl-105 HCO3-26 AnGap-12 [2132-7-1] 06:24AM BLOOD ALT-32 AST-31 AlkPhos-122* TotBili-0.2 [2132-7-1] 06:24AM BLOOD Calcium-9.5 Phos-1.8* Mg-2.0 [2132-6-30] 05:40AM BLOOD Calcium-9.9 Phos-1.9* Mg-2.0 [2132-6-28] 03:18AM BLOOD %HbA1c-5.7 eAG-117 [2132-6-28] 03:18AM BLOOD Triglyc-122 HDL-38 CHOL/HD-4.5 LDLcalc-110 [2132-6-28] 03:18AM BLOOD TSH-2.1 [2132-6-28] 03:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: Brief Hospital Course: The patient was a admitted with left sided weakness and difficulty speaking. left-sided weakness at ~ noon. The time of symptom onset is unclear. She was last seen at 8:30 AM, but she was "off - drooling". She was intubated after arrival to our ED. In the ED a head CT, CTP, and CTA showed white matter disease, , no ICH, prolonged MTT in the right parietal region w/o obvious abnormalities on blood volume maps. CTA showed slight decrease in the collateral flow in right MCA territory and possible flow signal drop in one of the cortical branches. No major arterial occlusion was seen in the neck or circle of [Location (un) 431]. She was thought to have a presentation that was consistent with a embolic infarct but she was not a candidate for IV t-[MD Number(3) 6360] unknown time of onset. She was admitted to the neuro-ICU for frequent neuro checks and allowed her BP o autoregulate. She was not initially started on heparin given the concern of the increased risk of ICH. Neuro - She was able to be extubated in the neuro-ICU. She initially did not pass the speech and swallow evaluation and an NGT was placed and tube feeds were started. A repeat head CT was stable and she was transferred out of the ICU. On the floor the patient eventually passed the swallow eval and was started on a dysphagia diet. - she was started on aspirin and coumadin. The aspirin can be stopped when the patient reaches an INR of [2-27] ID - the patient had 6 days of ceftriaxone in addition two days of oral antibiotic before she presented. All UCx here have been negative. CV - her home blood pressure medications were re- added and she was started back on her atenolol and amlodipine Endo - her synthriod was continued Patient was discharged to a skilled nursing facility Medications on Admission: ASA (-) Coumadin (-) Amlodipine, atenolol Levothyroxin Aricept and namenda Ambien Discharge Medications: 1. Aspirin 325 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily). 3. Warfarin 2 mg Tablet [Date Range ]: Two (2) Tablet PO Once Daily at 4 PM: for goal INR [2-27]. 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 5. Amlodipine 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 25 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. Aricept 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 9. Multivitamin Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. Magnesium Oxide 400 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. 11. Tums 500 mg Tablet, Chewable [Last Name (STitle) ]: Two (2) Tablet, Chewable PO twice a day. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Doctor Last Name 5749] [Doctor Last Name ] Village - [Location (un) ] Discharge Diagnosis: Right middle cerebral artery infarct Discharge Condition: MS: awake, alert, oriented to self, occasionally year, but not reliably, inattentive, slightly slurred speech, no recall, intermittently follows midline and appendicular commands. CN: EOMI (crosses midline), obvious left sided neglect, possible L field cut, L facial droop, [Location (un) 2994] Motor: moves right upper and lower ext spontaneously and seems near full strength. Slight withdrawal on left UE/LE clearly weaker, although neglects left side [Last Name (un) ]: grimaces to pain at all 4 ext Non ambulatory Discharge Instructions: You were admitted with left sided weakness and difficulty speaking. You were found to have a right MCA stroke. You initially required admission to the neuro-ICU and were intubated for airway protection. Your CTA showed the the stroke and the clot in the MCA. You had an echo which did not show any evidence of a source of embolus. It was assumed that this was caused by a clot from your atrial fib. You were extubated and then transferred to the floor. You were initially fed through a [Last Name (un) ]-gastric tube. You eventually passed a speech and swallow evaluation and you will need to be observed if you can take in enough food or will need supplementation. You were restarted on aspirin and will be bridged to coumadin. You were also continued on cefriaxone for 5 days (continuing your treatment of 2 days that you had received as an outpatient before admission) You will be discharged to a skilled nursing facility Please make all follow up appointments. Please take all medications as prescribed. If you experience any worsening of your symptoms, or any of the signs listed below please call your doctor or return to the nearest emergency room. Followup Instructions: Please follow up with your PCP [Name9 (PRE) ],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 250] Neurology: Please follow up with: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2132-8-12] 3:00 on [Hospital Ward Name ] [Location (un) ] or [Hospital1 18] [Hospital Ward Name ] [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023]	[ "5990", "42731", "4019", "2449", "311" ]
Admission Date: [2121-3-31] Discharge Date: [2121-4-10] Date of Birth: [2072-1-21] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2836] Chief Complaint: abdominal pain and distention Major Surgical or Invasive Procedure: [2121-4-3] Exploratory laparotomy with left salpingo-oophorectomy, [Last Name (un) ] gastrostomy tube placement, and placement of a vacuum dressing. [2121-4-7] Re-exploration with washout and placement of large vacuum-assisted closure dressing. [2121-4-10] Re-exploration with washout, GJ tube placement, tracheostomy, [State 19827] patch placement History of Present Illness: This is a 49 year-old female with a history of EtOH dependence who presents with abdominal pain and distention. Unfortunately, she is not able to clearly recall the sequence of her symptoms. She reports 3 days of increasing abdominal distention, abdominal discomfort, loose non-bloody, non-melenic stools, and occasional nausea/vomitting. She denies any increase in the amount she drinks (fifth of vodka daily). Denies any urinary symptoms. Denies any fevers, chills, sick contacts, or recently consuming potential food triggers of gastrointestinal illness. Past Medical History: EtOH abuse Social History: + History of EtOH. Denies any tobacco, IVDU, illicit drug use, ethylene glycol or mouthwash consumption. Lives with mother. Family History: non-contributory Physical Exam: Vitals: T:97.5 BP:125/75 HR:110 RR:23 O2Sat:100% on RA GEN: Thin female, NAD HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, trachea midline COR: Tachycardic, III/VI systolic murmur, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, Distended, +BS, TTP diffusely, no rebound or guarding, tympanitic throughout, no shifting dullness. EXT: No C/C/E, no palpable cords NEURO: alert, oriented to [Hospital1 18], name, and month but not year. CN II ?????? XII grossly intact. Moves all 4 extremities. Struggling to pull NG tube but in restaraints. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ADMISSION LABS [2121-3-31] 04:15PM BLOOD WBC-2.0* RBC-2.18* Hgb-7.4* Hct-22.2* MCV-102* MCH-34.0* MCHC-33.4 RDW-16.1* Plt Ct-95* [2121-4-1] 03:55AM BLOOD Neuts-75.3* Bands-0 Lymphs-18.4 Monos-5.6 Eos-0.6 Baso-0.2 [2121-4-1] 03:55AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-1+ Burr-1+ Stipple-1+ Tear Dr[Last Name (STitle) ]1+ [2121-3-31] 04:15PM BLOOD PT-15.8* PTT-28.9 INR(PT)-1.4* [2121-3-31] 04:15PM BLOOD Gran Ct-1300* [2121-3-31] 04:15PM BLOOD Glucose-172* UreaN-52* Creat-1.1 Na-138 K-3.1* Cl-103 HCO3-22 AnGap-16 [2121-3-31] 04:15PM BLOOD ALT-12 AST-39 LD(LDH)-371* AlkPhos-110 TotBili-1.4 DirBili-0.7* IndBili-0.7 [2121-3-31] 04:15PM BLOOD Calcium-9.0 Phos-1.9* Mg-2.5 Iron-16* [2121-3-31] 04:15PM BLOOD calTIBC-338 VitB12-1550* Folate-14.3 Ferritn-143 TRF-260 [2121-3-31] 04:15PM BLOOD Osmolal-306 [2121-3-31] 05:52PM BLOOD Ammonia-34 [2121-4-1] 03:55AM BLOOD TSH-1.9 [2121-3-31] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2121-3-31] 10:46PM BLOOD Lactate-2.2* RESULTS [3-31]-head CT w/o contrast-negative [3-31]-CT abdomen-1. Diffuse small bowel dilatation with no evidence of obstruction. The presence of air-fluid levels raises the possibility of enteritis. Clinical correlation is advised. Ascites. 2. Leiomyomatous uterus. 3. Small hepatic hypodensity too small to adequately characterize. 4. Left renal cyst. 5. Extensive pancreatic calcification and atrophy compatible with chronic pancreatitis. 6. Cholelithiasis. 7. Sclerotic focus in the right iliac bone abutting the SI joint of uncertain clinical significance. Recommend clinical correlation. Bone scan may be obtained for further evaluation as clinically warranted. [3-31]-KUB-1. Dilated small bowel, which is concerning for small-bowel obstruction. 2. Pancreatic calcifications suggesting chronic pancreatitis. Recommend clinical correlation. [4-1]-cXR-No previous images. The cardiac silhouette is within normal limits and there is no vascular congestion or pleural effusion. Specifically, no convincing evidence of acute pneumonia. Nasogastric tube extends to the lower body of the stomach, then coils back on itself to lie in the upper body of the stomach. Brief Hospital Course: In the ED, patient underwent bedside ultrasound that did not demonstrate any ascites amenable to bedside paracentesis. Abd CT showed diffuse small bowel dilatation with no evidence of obstruction or free air. She was also noted to be pancytopenic with a hematocrit of 22, baseline unknown. She was given 1 unit PRBC while in the ED. For bordeline hypotension of systolic of 95, patient was given 2 litres normal saline. Incidentally, she was also noted to have progressive delerium and was given diazepam 5mg IV, and started on thiamine/folate intravenously. Head CT was performed given mental status changes and was unremarkable. She was admitted to MICU for further monitoring of mental status, and borderline hypotension. At this point, the etiology was still unclear given the workup. In the MICU, NGT was placed for decompression. The patient was kept NPO. On the following morning, the patient had a clear mental status and was able to answer questions appropriately. She was kept on CIWA scalenad required diazepam x 2. She was aggressively hydrated with a total of 3L of IVF and continued to be tachycardic, likely either to dehydration or to withdrawal from alcohol. She reported resolution of her nausea and pulled her own NGT. It was not replaced since she was no longer nauseated. She was called out to the floor for further management. On arrival to the medical floor she was tachycardic at 110, other vitals stable and similar to those on arrival to the ED. She had [7-20] RUQ pain, and her abdomen was found to be distended. She had a RUQ ultrasound that did not show cirrhosis, or cholecystitis. She remained afbrile, and did not have leukocytosis, or jaundice, or a cholestatic picture in her LFTs thus cholangitis was not felt to be likely. She was given IV fluids for her volume depletion. On the first day she had four bowel movements that were guaiac positive and watery. Stool cultures were collected to evaluate for c.diff. She remained stable until [4-2], when her abdomen became increasingly distended. An NGT was placed, which did not provide the patient relief, drained a total of 600cc of yellow fluid. Her abdomen became increasingly distended, and she had a new O2 requirement and her tachycardia increased from 110 to 140's, sinus. An ABG was done that was unremarkable, a CXR showed hazyness at the right base. Surgery was consulted and they recommended a CTA chest and CT abdomen. Her chest CTA showed a large right sided pleural effusion, no PE and her CT abdomen was unchanged. She was given 20mg IV lasix for her pleural effusion. She continued to be uncomfortable, with increasingly distended bowel that was rigid and there was an abscence of bowel sounds. In addition she became slightly confused, but was still oriented times three. A repeat ABG showed an increased lactate to 2.2. Surgery raised concern for ischemic bowel and she was transferred to the ICU for closer monitoring as well as possible intubation as she required volume resuscitation. Given her worsening condition and concerning abdominal exam, the patient was taken to the operating [2121-4-3] for an exploratory laparotomy and found to have diffuse peritonitis and fibrinous coating of the bowel with clearly purulent ascites, ileus, and ruptured left tubo-ovarian abscess. She had a left salpingo-oophorectomy, [Last Name (un) ] gastrostomy tube placement, and placement of a vacuum dressing since her abdomen was unable to be closed. [Name (NI) ], pt was transferred to the SICU for further management. She did develop sepsis and was started on pressors and broad spectrum antibiotics. Since she was a Jehovah's witness, she only received crystalloid and hespan for volume resuscitation. She remained intubated and sedated. On post-op day 4, she was taken back to the OR for re-exploration with washout and placement of large vacuum-assisted closure dressing. She was started on TPN for nutrition and was able to be weaned off pressors on post-op day 6. She continued to require volume resuscitation. She returned to the OR the following day for a re-exploration with washout, GJ tube placement, and tracheostomy. During the surgery, pt became hemodynamically unstable, had increased pressor requirement for hypotension, and had diffuse intra-abdominal oozing of blood. No specific bleeder could be identified and the bleeding could not be stopped. Pt transferred back to the SICU for further management. Contact was made with the pt's mother regarding the dire situation and she reiterated that no blood products be given. She also expressed that she did not want further escalation of care or cardiopulmonary resuscitation. The pt expired shortly thereafter. Medications on Admission: none Discharge Disposition: Expired Discharge Diagnosis: Ruptured tubo-ovarian abscess Discharge Condition: Expired	[ "51881", "5119", "5180" ]
Admission Date: [2154-1-20] Discharge Date: [2154-2-18] Date of Birth: [2094-9-26] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Attending:[Known firstname 922] Chief Complaint: Ruptured thoracoabdominal aneurysm Major Surgical or Invasive Procedure: [2154-1-20] - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm with a 34-mm Dacron tube graft using deep hypothermic circulatory arrest. [2154-1-22] - Chest and abdomen exploration, Removal of packs, Chest closure. [2154-1-25] - abdomen closure/ feeding jejunostomy [2154-2-4] tracheostomy History of Present Illness: 59 M transferred from [Hospital3 15402] with ruptured TAA. Presented to OSH with back pain - CT scan done-> intubated and transferred here.Taken directly to OR for surgery for ruptured TAA. Past Medical History: hypertension Social History: lives with fiance Family History: Unknown Physical Exam: PE: 120/65 HR 85 Intubated, sedated RRR decreased BS on left soft NT, distended obese abdomen no edema, feet warm, 1+ PT and DP B/L Pertinent Results: Admission: [2154-1-20] 11:45AM FIBRINOGE-260 [2154-1-20] 11:45AM PT-13.8* PTT-29.3 INR(PT)-1.2* [2154-1-20] 11:45AM PLT COUNT-405 [2154-1-20] 11:45AM WBC-21.4* RBC-3.30* HGB-9.6* HCT-30.5* MCV-92 MCH-29.1 MCHC-31.5 RDW-13.0 [2154-1-20] 11:53AM GLUCOSE-366* LACTATE-3.4* NA+-137 K+-5.5* CL--110 [2154-1-20] 12:35PM GLUCOSE-358* LACTATE-4.1* NA+-141 K+-4.8 CL--111 [2154-1-20] 08:05PM ALT(SGPT)-34 AST(SGOT)-88* ALK PHOS-37* TOT BILI-1.8* [2154-1-20] 08:05PM GLUCOSE-187* UREA N-15 CREAT-1.2 SODIUM-152* POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-31 ANION GAP-11 Discharge: [2154-2-18] 02:58AM BLOOD WBC-10.1 RBC-3.05* Hgb-8.7* Hct-26.9* MCV-88 MCH-28.5 MCHC-32.3 RDW-15.2 Plt Ct-399 [2154-2-18] 02:58AM BLOOD Plt Ct-399 [2154-2-18] 02:58AM BLOOD PT-25.1* PTT-33.0 INR(PT)-2.4* [2154-2-18] 02:58AM BLOOD Glucose-111* UreaN-53* Creat-1.4* Na-135 K-4.3 Cl-103 HCO3-24 AnGap-12 [2154-2-18] 02:58AM BLOOD ALT-82* AST-59* AlkPhos-131* Amylase-100 TotBili-1.1 [2154-2-18] 02:58AM BLOOD Albumin-2.8* Calcium-8.5 Phos-4.2 Mg-2.3 Cholest-99 [2154-1-22] 03:13AM BLOOD %HbA1c-6.0* eAG-126* ECHO -[1-20] This is a directed and limited study to assess the aorta. The patient was booked as a Type A dissection. On placement of the TEE, it is clear that there is no ascending dissection and no AI. The descending aorta and mediastinum are distorted by clot. It is not possible to discern an aortic lumen or to fairly assess the heart's fxn. It is possible to see the aortic valve well. No AI or ascending dissection seen. Other intracardiac structures are too distorted to assess. TEE was used to help place the venous cannula in the right atrium. Aortic wire could not be seen. Pre-CPB: The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is a small pericardial effusion. After Circ Arrest and CPB: There were several instances when the right heart ceased to function because the lungs were full of blood and he could not be ventilated. With frequent pulmonary lavage and high dose epi, we were able to regain some cardiac fxn. No AI was seen. After heroic resuscitation, he had good biventricular systolic fxn on moderate doses of norepi and epinephrine by infusion. The patient was taken to the ICU for further care. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 86264], [Known firstname 177] [Hospital1 18] [Numeric Identifier 86265]Portable TTE (Complete) Done [2154-1-28] at 3:07:53 PM FINAL Interpret MD: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.8 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.6 m/s Right Atrium - Four Chamber Length: 5.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 59 ml/beat Left Ventricle - Cardiac Output: 5.00 L/min Left Ventricle - Lateral Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 4.0 cm <= 3.6 cm Aorta - Ascending: 4.3 cm <= 3.4 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 13 Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 175 ms 140-250 ms TR Gradient (+ RA = PASP): 38 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta. AORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[11-24]+] TR. Moderate PA systolic hypertension. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is elongated. 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. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild -moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Pulmonary artery systolic hypertension. Mild right ventricular cavity enlargement. Dilated ascending aorta. These findings are c/w a primary pulmonary process (COPD, bronchospasm, pulmonary embolism, obstructive sleep apnea, etc.). CLINICAL IMPLICATIONS: Based on [2150] 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) ] [2154-1-28] 17:47 CHEST (PORTABLE AP) Study Date of [2154-2-15] 7:25 AM Final Report INDICATION: 59-year-old male with thoracic aneurysm repair and fever. COMPARISON: [2154-2-7]. CHEST, AP: Mediastinal widening is roughly stable, measuring 14 cm in greatest transverse measurement. Left lower lobe atelectasis is unchanged. The right lung is clear. There are no large pleural effusions. Cardiac and hilar contours are normal. Surgical clips are noted in the left upper quadrant. IMPRESSION: 1. Cardiomediastinal silhouette appears stable, but evaluation should ideally be performed by transesophageal echocardiography, CT, or MR. 2. No acute pulmonary process. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 10307] HO DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] MR HEAD W/O CONTRAST Study Date of [2154-2-3] 2:42 PM [Hospital 93] MEDICAL CONDITION:59 year old man s/p TAA, chest/abd closure now blind REASON FOR THIS EXAMINATION: ischemic vs hemmorrhagic event Final Report:MRI OF THE BRAIN AND MRA OF THE HEAD AND NECK CLINICAL HISTORY: 59-year-old man status post TAA, chest, abdomen closure, now blind. TECHNIQUE: MRI of the brain was performed without the use of intravenous contrast. MRA of the head was obtained utilizing time-of-flight technique (no intravenous gadolinium contrast). MRA of the neck was performed both before and after the administration of intravenous gadolinium contrast, utilizing bolus triggering and subtraction technique. Complex multiplanar reformatted images were obtained of the MRA of the head and MRA of the neck. MR BRAIN: Multiple foci of decreased diffusion are noted in the brain, the largest of which is in the right occipital lobe, with corresponding T2 and FLAIR hyperintensity, consistent with acute infarcts. There is also gyriform T1-hyperintensity in the right occipital lobe, likely representing cortical laminar necrosis. Additional smaller foci of decreased diffusion are noted in the frontal and the parietal lobes, bilaterally, with involvement of the left precentral gyrus. There is no mass effect, shift of midline structures, or evidence of a space-occupying lesion. There is no extra-axial fluid collection. Scattered foci of susceptibility artifact are noted within the brain, which do not appear to correlate with these foci of decreased diffusion. The flow-voids of the major vessels are present. Mild mucosal thickening is noted in the ethmoid air cells. Fluid is noted layering in the nasal cavities and in the right maxillary sinus, likely related to the patient being intubated. There is also fluid within the mastoid air cells bilaterally, also likely related to the intubation. The visualized orbits and soft tissues are otherwise unremarkable. The bone marrow signal on the sagittal T1 image appears heterogeneous with foci of decreased T1 signal intensity. MRA HEAD: There is normal flow-related enhancement of the intracranial internal carotid arteries, the anterior, middle and posterior cerebral arteries, the anterior and posterior communicating arteries, the vertebral arteries, and the basilar artery. There is a slightly patulous basilar tip, with a prominence to the origin of the left superior cerebellar artery which may have an infundibular origin. Otherwise, there is no evidence of a hemodynamically significant stenosis, dissection, or aneurysm (within the limitations of this MRA technique). MRA NECK: Image quality is degraded by patient motion and the timing of the contrast bolus injection. However, allowing for this limitation (and using both initial and delayed acquisitions), the common, internal and external carotid arteries demonstrate normal enhancement, without evidence of hemodynamically significant stenosis or dissection. The vertebral arteries are grossly normal in caliber and enhancement, again without evidence of hemodynamically significant stenosis. IMPRESSION: 1. Multiple acute infarcts, bilaterally, the largest of which is in the right occipital lobe. Given that (by DWI, ADC map and FLAIR sequences) these lesions appear to be of the same age, the distribution as well as the history, these are likely embolic in nature, related to a single event. 2. A few foci of susceptibility artifact, appearently unrelated to the foci of acute infarction, may be represent prior microhemorrhage, perhaps related to underlying hypertension or, less likely, prior embolic disease or underlying cavernous malformations. 3. MRA of head and neck is unremarkable, without evidence of hemodynamically significant stenosis, dissection, or aneurysm (within the limitations of the MRA technique). 4. Heterogeneous bone marrow signal with foci of T1-hypointensity in the bone marrow of the calvaria and the visualized spine. In a male patient of this age, this raises the possibility of a marrow-replacing process, and close correlation with laboratory data is recommended. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Name (STitle) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7593] Brief Hospital Course: Mr. [Known lastname ] was transferred to the [Hospital1 18] on [2154-1-20] for emergent repair of his ruptured thoracoabdominal aortic aneurysm. He was taken immediately to the operating room where he underwent an emergent salvage repair of ruptured thoracoabdominal aortic aneurysm with a 34-mm Dacron tube graft using deep hypothermic circulatory arrest. Please see operative note for details which included cardiac arrest x2. Postoperatively he was taken to the intensive care unit for monitoring with an open chest. He remained intubated and sedated on pressors and inotropes. On [2154-1-22], he returned to the operating room where he underwent exploration and chest closure. On [1-25] he returned to the OR for abd closure JP/ drain placement/ feeding jejunostomy placed at that time for nutritional support. Neurology consult done [1-26]. Pressors slowly weaned. ID consult obtained on [1-27] for fever,leukocytosis, and recomendations for antibiotic management. Multiple bronchoscopies were performed for secretions/ pulm. hemorrhage. Developed intermittent A Fib on [1-28] and treated with amiodarone and cardioversion x4, has had several episode of going in and out of atrial fibrillation since that time. EEG done [1-29] revealed severe encephalopathy for continuing neurologic deficits including bilat. LE paralysis and right arm paralysis. MRI revealed multiple acute infarcts, with the largest in the right occipital lobe. When the patient woke it was found that he had developed blindness. Ophthalmology was consulted and stated that the patient likely had posterior ischemic optic neuropathy bilaterally due to hypotension, in addition to occipital infarcts. Electrophysiology was consulted and recommended titration of beta blocker and observation of rhythm. Tracheostomy was performed on [2154-2-4]. On [2154-2-11] BC were + for GPC treated with-IV vanco. Coumadin was titrated for afib. with target INR being 2-2.5. His tube feeds have been at goal rate for past several weeks. By system: Neuro: Moves all extremities and follows commands. Still not able to tolerate Passy-Muir so unable to assess orientation. At times becomes restless and agitated, has history of benzo use preoperatively and has responded well to PRN ativan during post-op course. Pulmonary: s/p tracheostomy on [2-4], has tolerated long periods of trach collar over past week however tires and has been on CMV or PSV overnight to rest. Continues to have moderate to large amount of secretions daily. CV: Intermittant Atrial Fibrillation treated with Bblockers and Amiodarone and now in sinus rhythm. Also anticoagulated for afib. Hemodynamically stable since initial recovery from surgery. Renal: ARF in initial post-op period now largely resolved, never requiring HD. Continues to be diuresed with Lasix Abdm: soft/NT/+BS. Tube feeds at goal rate (NovaSource Renal) Ext: warm with palpable pulses, 1+ edema bilat ID: +BC wcoag neg staph tx with Vanco last level on [2-18] 27.2-course completed Wounds: thoracoabdominal wound healing well with exception of very small open area mid wound that is @1cm around and 1/2cm deep, no surrounding erythema. Packed with dry gauze and covered w/DSD-[Hospital1 ] Medications on Admission: benicar Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [11-24] Drops Ophthalmic PRN (as needed) as needed for dryness. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezes. 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily for 7days then 200mg daily. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for groin yeast. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation/anxiety. 14. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: 3mg on [2-18] target INR 2-2.5 (received 5mg last 4 days) . 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital Discharge Diagnosis: Type A aortic dissection with rupture s/p thoracoabdominal repair Hypertension atrial fibrillation blindness respiratory failure s/p Trach and G-J tube Discharge Condition: alert and responsive, at times agitated/restless moving all extremities, follows commands new blindness, needs assistance with ambulation and ADL Thoraco-abdominal wound healing well with exception of mid wound 1cm are that is about .5cm deep/packed with dry gauze and covered with DSD Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Surgeon Dr. [Last Name (STitle) 914] [2154-2-26] 1:00 pm [Telephone/Fax (1) 170] Please call to schedule appointments Primary Care Dr. [Last Name (STitle) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 86266] in 2 weeks Referral for a cardiologist needed from Dr. [Last Name (STitle) ] and please make appt in [11-24] weeks Completed by:[2154-2-18*]	[ "5849", "486", "9971", "5990", "5180", "5119", "2760", "4019", "2859", "42731" ]
Admission Date: [2102-1-17] Discharge Date: [2102-1-31] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: Nausea, distention Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 6249] is a [Age over 90 ] year-old male with a history of diverticulitis, s/p Hartmann's procedure in [5-11], and who, most recently is s/p exploratory laparotomy with LOA in [11-12], which has been complicated by prolonged ileus, and presented to [Hospital1 18] on [2102-1-17] for evaluation and treatment. Past Medical History: As above, including: htn, diverticulitis, sigmoid volvulus, SBOs, COPD PSH: likely L colectomy, hartmanns [5-11], ostomy takedown [8-11], internal hernia w/ SBO 1 week later s/p exlap, loa, repair, incisional hernia repair [4-11] Social History: Married with four children. Former owner of restaurant. Former smoker. Physical Exam: Alert, no distress Decreased [Last Name (un) 6250] sounds at lung base RRR Abd distended, soft, nontender Brief Hospital Course: Mr. [Known lastname 6249] is a [Age over 90 ] year-old male with a history of diverticulitis, s/p Hartmann's procedure in [5-11], and who, most recently is s/p exploratory laparotomy with LOA in [11-12], which has been complicated by prolonged ileus, and presented to [Hospital1 18] on [2102-1-17] for evaluation and treatment. He was admitted to the surgery service. A rectal tube was placed. On [1-18], Mr. [Known lastname 6249] was found to be in respiratory distress and was intubated. CXR revealed atelectasis and infiltrate. A CT torso revealed no evidence of sbo, but a fluid filled sigmoid. He was continued on antibiotics. He was started on neostigmine. He was extuabated two days later, and would remain stable from a respiratory standpoint. He was transferred to the floor in stable condition. Success was achieved with a combination of prokinetics and dulcolax, and his bowel functioned returned. He was started on oral pyridostigmine and reglan. He began tolerating a regular diet, and by the time of discharge, he was taking in an adequate amount of oral intake. The rectal tube was removed. He was discharged to rehab in good condition on [2102-1-31], tolerating a regular diet, having bowel movements, and with less abdominal distention. He should receive dulcolax for constipation or abdominal distention. A rectal tube, as well, should be placed for marked distention. Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 100. Tablet(s) 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): 75 mg PO BID. 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily (). 10. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Reglan 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Dulcolox 10 mg, PR [Hospital1 ] prn 15. Colace 100 mg, PO BID. 16. MOM 30 cc, PO BID Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) ] & Islands - [Location (un) 6251] Discharge Diagnosis: Ileus Discharge Condition: Stable Discharge Instructions: Please call Dr. [Last Name (STitle) 957] or return to the local ER if: * You experience new chest pain, pressure, squeezing or tightness. * If you are nauseous and 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. A large amount of swelling or bruising Difficulty passing stool * Unable to tolerate oral intake * An increase redness or drainage of the incision * Bright red blood or foul smelling discharge coming from the incision * Difficulty urinating * Dislocation of j-tube * Any serious change in your symptoms, or any new symptoms that concern you. Additional Instructions Dressings: If the dressing from the operating room is still on, you should leave it on until it is removed by Dr. [Last Name (STitle) 957] in the office. Activity: You can start getting back to your routine as soon as you feel able. Just take it easy at first. The following tips may help:Take short walks to improve circulation. If you were able to climb stairs before your surgery, you may continue to climb stairs; this will not harm your incision. You may start some light exercise when you feel comfortable. Lifting: For a period of six weeks, please do not lift anything heavier than ten (10) pounds, which is as large as [Initials (NamePattern4) ] [Last Name (NamePattern4) 86] telephone book. It will take about six (6) weeks for your incision to heal.; at the end of six (6) weeks your incision will be as strong as it will be a year from now. Fatigue: It is normal to experience fatigue for 2-3 weeks days after your surgery. The more exercise and activity you re involved in, the better you will be and the quicker you will recover. J-Tube: This tube (located on your left abdomen) will remain clamped until you see Dr. [Last Name (STitle) 957] in clinic. Call the clinic if this tube is dislocated or accidently removed. It should be secured to your abdomen. Abdominal Binder: Please wear this binder for support while you are out of bed ambulating. Please continue to take your home medications as listed. Please continue to take the new medications as prescribed. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 957] in 2 weeks. Please call [Telephone/Fax (1) 2359] to schedule an appointment.	[ "5180", "4280", "4019", "V1582", "42731" ]
Admission Date: [2140-4-3] Discharge Date: [2140-4-8] Date of Birth: [2074-2-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2195] Chief Complaint: Nausea, vomiting, and chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 66F with PMH of DM2 not on insulin, HL, depression and alcohol abuse who initially presented with nausea and vomit. She was in her prior state of health until ~5 days prior to admission when she started feeling very depressed and the voices she normally hears started to tell her to injure herself. She denies any plan or thoughts of harming others. Then, she started feeling very nauseous and within 24 hours she started having yellow-green vomit, leading to decreased PO intake. Then 3 days ago she started drinking abour 8 oz of Vodka daily for three days. She states she was hydrating herself adequately during this time. Denies any blurry vision, double vision, lightheadedness, dizziness, chest pain, shortness of breath, palpitations, abdominal pain, diarrhea, constipation, skin rashes, fever, chills, rigors or any focal signs of infection. On the day of admission she started having sub-sternal chest pain of [8-16], sharp in quality, lasting 30 sec to 5 minutes, not associated with activity, without radiation, may worsen with inspiration. Therefore, she decided to come to the [Hospital1 18] for evaluation. In the ER her initial VS were T 99.4, HR 117 BPM, BP 131/79 mmHg, SpO1 100% on 2L NC. She was tachycardic throughout the ED admission with otherwise stable VS. Her initial BS was 273. She was guaiac positive with an otherwise normal exam. Her ECG showed sinus tachycardia with TWI in the infero-lateral leads. She initially was found to have a gap of 47 with bicarbonate of 5, creatinine of 2.5 with BUN of 44, WBC 14 with 1% bands and 83% PMNs. Her CK was 981, MB 45, Trop-T 0.02, Lypase 546. Her serum alcohol level was 84 and her urine was positive for opioids. Otherwise negative tox screen. Her CXR was clean as well as her UA. Patient received 2 L NS, a Banana bag, folate, thiamine, MVI, Aspirin 325 mg and was started on Insulin gtt, Vanc/Zosyn for a leukocytosis. She also received Zofran 4 mg IV and morphine 4 mg IV for chest pain. Her gap started to close up to 27. At that time her ABG was: 7.27/27/102 with a lactate of 4.2. She was admitted to the ICU for further management of the gap and insulin drip. Her VS prior to admission were HR 105 BPM, BP 160/125 mmHg, RR 24 X', SpO2 98% 2 L. Past Medical History: #DM, dx [2134], last HbA1C 6.3% ([3-/2139]), not on any medications for this at this time, performs fingersticks QAM, BS usually 88-174 #Hypercholesterolemia. #Depression. #Alcohol use. #Alopecia areata, [2129] #History of GI bleeding in [2128]. Colonoscopy demonstrated diverticuli of the sigmoid colon. Has not had recent bleeding. #Alcoholic hepatitis. #Colonic polyps, last colonoscopy [3-/2139] Social History: Receptionist in psychiatry department at [Hospital6 ]. Married twice, second husband died 10yrs ago of massive MI while lifting heavy-object, and depression began around his death. She has one adult son who lives in [Name (NI) 1468]. Patient lives alone in [Location (un) 686] in basement apartment. Used to live with brother who died 2 years ago, also contributing to depression. Has a nephew. Denies any current or past history of tobacco. She has chronic alcohol. Denies any illegal drug use. Screening: negative [Last Name (un) 3907] ([9-15]), colonoscopy ([3-15]). Family History: Son, 47, well, but benign heart murmur. Sister, 30, died of cirrhosis. Sister, 43, died of MI. Brother, 45, died of MI. Brother, 65, died of liver failure, "heart problems." Mother, age 50, died of pneumonia . Physical Exam: VITAL SIGNS - Temp 99.7 F, BP 154/79 mmHg, HR 105 BPM, RR 22 X', O2-sat 100% RA GENERAL - sick-appearing woman in distress secondarely to pain, uncomfortable, appropriate, not jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, pin-point pupils bilateraly with full range of motion of both eyes NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no RG, nl S1-S2, systolic bar-like murmum on apex radiating towards axila [2-13] ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions Pertinent Results: Admission Results: CXR: The cardiac silhouette is normal in size. The mediastinal and hilar contours are unremarkable. The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is present. No acute skeletal abnormalities seen. . ECG: NSR 1:1 conduction at 100 BPM with mild sings of atrial enlargement, PR isoelectric and 180 ms, QRS axis 60 degrees with 80 ms [First Name (Titles) ] [Last Name (Titles) 101514], TWI in III, aVF, V2-V5 with normal ST-segment. QT 400 ms. [2140-4-3] 07:25PM WBC-14.0# RBC-3.60 Hgb-10.6* Hct-33.4* MCV-93 Plt Ct-208 Neuts-83* Bands-1 Lymphs-12* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Glucose-257* UreaN-44* Creat-2.5# Na-132 K-5.0 Cl-81* HCO3-5* AnGap-51* ALT-46* AST-108* CK(CPK)-981* AlkPhos-70 TotBili-0.7 Lipase-546* CK-MB-45* MB Indx-4.6 cTropnT-0.02* CK-MB-47* MB Indx-4.3 cTropnT-0.04* CK-MB-42* MB Indx-2.7 cTropnT-0.04* Calcium-7.3* Phos-1.3# Mg-1.5 pO2-102 pCO2-27* pH-7.27* calTCO2-13* Base XS--12 Discharge Labs: [2140-4-8] 06:22AM WBC-6.7 RBC-3.26* Hgb-9.9* Hct-30.4* MCV-93 Plt Ct-188 Glucose-115* UreaN-4* Creat-0.8 Na-143 K-3.7 Cl-102 HCO3-31 AnGap-14 Calcium-8.6 Phos-3.3 Mg-2.3 Brief Hospital Course: 66F with PMH of DM2 not on insulin, HL, depression and alcohol abuse presenting with acute renal failure and metabolic disarray in the setting of recent decreased PO intake and binge drinking. #. Anion Gap Metabolic Acidosis - Likely secondary to ketoacidosis in the setting of decreased PO intake and alcohol abuse with a potential small contribution from diabetic ketoacidosis. Resolved with IV fluid hydration and Insulin therapy. #. Pancreatitis - Patient with recent increase in alcohol intake, now coming with nausea, vomit and lipase of 546. Patient was initially made NPO, and had her diet slowly advanced. She was tolerating a regular diet for two days prior to discharge. #. Acute kidney failure - Initial creatinine of 2.5 from her baseline of 1. Likely secondary to volume depletion in the setting of decreased PO intake and vomiting. Resolved with fluid hydration. #. Chest pain: Troponin stable at 0.02, 0.04, and 0.04. Chest pain symptoms more consistent with epigastric pain, thought to be secondary to alcoholic pancreatitis +/- alcoholic gastritis. #. Depression: Patient was continued on her home regiment. She spoke over the phone with her outpatient psychiatrist and plans to follow-up with her after discharge. The dangers of decreased PO intake and alcohol were reviewed several times, and patient was urged to contact a family member, her psychiatrist, or her PCP if she felt her depression worsening or her appetite decreasing in the future. #. Alcohol abuse - Patient with chronic alcohol use and abuse with last drink on the day of discharge. She showed no signs of withdrawal throughout her stay. Medications on Admission: Citalopram 40 mg PO Daily Hydrochlorothiazide 25 mg PO Daily Trazodone 100 mg PO QHS Aspirin 325 mg PO Daily Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Insomnia. 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Acute renal failure Hypophosphatemia Hypomagnesemia Hypokalemia Hypocalcemia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with acute renal failure and very low levels of potassium, calcium, phosphorous, and magnesium. This was likely caused by not eating and drinking a lot of alcohol. This can be a life-threatening combination, and I encourage you to call your Psychiatrist or Dr.[Last Name (STitle) ] if you ever feel like you are in danger of doing this again. No changes have been made to your home medication regiment. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2140-4-11] at 1:20 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "2762", "2720", "25000", "2859", "311" ]
Admission Date: [2174-3-15] Discharge Date: [2174-3-22] Date of Birth: [2105-8-18] Sex: F Service: CT SURGERY CHIEF COMPLAINT: Aortic insufficiency HISTORY OF PRESENT ILLNESS: History of rheumatic fever at age 12, resulting in such. PAST MEDICAL AND SURGICAL HISTORY: Tympanoplasty, tonsillectomy and adenoidectomy, pacemaker in [2173], bladder suspension, total abdominal hysterectomy. MEDICATIONS AT HOME: Levoxyl .75 mg once a day, enalapril 20 mg once a day, Norvasc 2.5 mg once a day, lasix 20 mg once a day, Zoloft 100 mg once a day, potassium, and aspirin 325 mg once a day. FAMILY HISTORY: Sister had coronary artery bypass graft in her 60s after a myocardial infarction. SOCIAL HISTORY: The patient lives with her husband. She denies ethanol abuse. PHYSICAL EXAMINATION: Significant for a diastolic murmur. LABORATORY DATA: On admission, 142/4.1/102/27/18/1.2/85. CBC was 6.9/38.2/259. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic service as a same day admission. She was taken to the operating room on [2174-3-15] with Dr. [Last Name (STitle) ], with assistants [Doctor Last Name 14968] and Hamey. Please see the operative note for full details. The patient postoperatively was transferred to the Cardiothoracic Intensive Care Unit. Her blood pressure was labile, and she was treated with intravenous fluids and vasopressors. She was continued on pressors until postoperative day number one, on [3-16], when her pressors were weaned. She had already been extubated. The patient was transferred to the floor on postoperative day number one after her chest tubes had been discontinued without incident. On postoperative day number two, the patient had desaturation down to the 80s, with a respiratory rate of 22 to 26. Physical examination was not significant for anything, however, her hematocrit for that day came back at 19.4, not up from the 20 the day before, and the decision was made to transfuse the patient two units of blood after consultation with the senior nurse-practitioner [First Name (Titles) ] [Last Name (Titles) 37798] of the attending. Her electrolytes were repleted, and a repeat CBC the next morning showed the patient's hematocrit had increased appropriately to 28.2. The Foley was discontinued. Her wires were discontinued, and the patient was doing well. On [2174-3-19], the nurse informed the physician on call towards the evening that the patient was desaturating to 88% on 2 liters nasal cannula. Physical examination showed lung crackles two-thirds of the way up her lung fields after her blood transfusion the day before. She was given 20 mg of intravenous lasix every six hours on Tuesday, and then returned to her normal dose. She responded, and felt better. The decision to discontinue the Foley, as mentioned, was not performed until the next day. The next day, the patient was much more comfortable subjectively, and chest x-ray done on this day showed no fluid overload, and the decision was made not to put her back on her standing dose of lasix. At no time was the patient hemodynamically unstable. On [2174-3-21], the patient was doing well, however, still having some difficulty ambulating, however, she had saturations of 97% on 3 liters nasal cannula, and was able to walk quite well. The patient was discharged on [2174-3-22] with the following medications: Calcium carbonate 500 mg by mouth three times a day, Zoloft 100 mg by mouth once daily, lasix 20 mg by mouth once daily, potassium chloride 20 mEq by mouth once daily, Lopressor 12.5 mg by mouth twice a day, percocet one to two tablets by mouth every four to six hours as needed, aspirin 325 mg by mouth once daily, Levoxyl 75 mcg by mouth once daily, Colace 100 mg by mouth twice a day. The patient is to follow up with her primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 37799], regarding all medical and cardiac issues, and is to follow up with Dr. [Last Name (STitle) ] with regards to cardiothoracic issues. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2174-3-21] 23:00 T: [2174-3-22] 00:40 JOB#: [Job Number ]	[ "4280", "5990", "4019", "2449" ]
Admission Date: [2124-12-9] Discharge Date: [2124-12-12] Date of Birth: [2053-5-30] Sex: M Service: BLUE SURGERY HISTORY OF PRESENT ILLNESS: This is a 71-year-old male with a past medical history of duodenal ulcer bleeding, who presented with a chief complaint of two days of orthostasis, fatigue and malaise with dark and tarry stools on [2124-12-9] to the [Hospital1 69] Emergency Room. The patient reportedly denied nausea, vomiting, hematemesis, bright red blood per rectum, or syncope. The patient, however, did note fatigue, weakness and orthostasis. The patient reportedly contact[Name (NI) ] Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2124-12-9], after realizing that his symptoms were consistent with a prior episode of duodenal ulcer bleeding. The patient was subsequently referred to the [Hospital1 69] Emergency Room and admitted on [2124-12-9], for workup of suspected upper gastrointestinal bleed. PAST MEDICAL HISTORY: Polycythemia [Doctor First Name ], coronary artery disease, hypertension, gout, depression, basal cell and squamous cell carcinoma, duodenal ulcer with repeated bleeds, status post splenectomy, status post right coronary artery stent, status post multiple skin biopsies, status post appendectomy. MEDICATIONS AT HOME: Protonix, aspirin, hydroxyurea, Procardia, fexofenadine, allopurinol. ALLERGIES: Tetracycline. PHYSICAL EXAMINATION: Temperature 97.2, blood pressure 112/51, heart rate 57, respiratory rate 16, oxygen saturation 95% on room air. The patient was noted to be normocephalic, atraumatic, pupils equal, round and reactive to light and accommodation. The patient had moist mucous membranes and a clear oropharynx, no lymphadenopathy or jugular venous distention was noted, and no carotid bruits were noted bilaterally. Heart examination demonstrated a regular rate and rhythm, normal S1 S2, and a II/VI systolic murmur. Respiratory examination demonstrated lungs clear to auscultation bilaterally, with diminished sounds at the bases. Abdominal examination was soft, with minimal protuberance, nontender, no palpable masses. Rectal examination demonstrated brown stool, strongly guaiac positive, no palpable masses, and normal tone. Extremities were warm and well perfused, with no cyanosis, clubbing or edema. Neurologic examination was alert and oriented x 3, appropriate. LABORATORY DATA: White blood cell count 9.1, hematocrit 23.6, platelet count 780. Sodium 134, potassium 5.4, chloride 103, bicarbonate 20, BUN 47, creatinine 1.6, glucose 46. A previously-drawn Helicobacter pylori test was antibody negative. PT 12.7, PTT 29.2, INR 1.1. HOSPITAL COURSE: The patient was admitted to the Blue Surgery service on [2124-12-9], under the direction of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], with a presumptive diagnosis of upper gastrointestinal bleeding. The patient was admitted to the Surgical Intensive Care Unit for close hemodynamic monitoring, and was immediately transfused two units of packed red blood cells. An endoscopy conducted the evening of admission demonstrated a normal esophagus, melena in the antrum and stomach body, and a single acute cratered bleeding 7 mm ulcer in the distal bulb of the duodenum, with edema of the surrounding walls and a narrowing of the lumen. Ten 1 cc epinephrine 1:10,000 injections were applied for hemostasis, with success. [Hospital1 ]-cap electrocautery was applied for hemostasis successfully. The patient was followed with serial hematocrits every four hours through the evening of admission, into hospital day number one, during which time the patient required two additional units of packed red blood cells to be transfused, resulting in a hematocrit of 27.3 on the morning of hospital day number one. Given this inappropriate response to four units of packed red blood cells transfused, the patient received continuous every four hour hematocrit checks through hospital day number three. The patient subsequently required two additional units of packed red blood cells and was noted to demonstrate a stable hematocrit of 31.8 on hospital day number three. Given the stabilization, the patient was subsequently transferred out of the Intensive Care Unit on the evening of hospital day number three, with instructions for continued hematocrit monitoring. Serial studies conducted throughout the course of hospital day number three and four demonstrated stabilization of the patient's hematocrit at approximately 31.7. On hospital day number four, the patient was advanced to a regular diet. His intravenous fluids were discontinued, and he was transitioned to oral medications. A follow-up evaluation by the Gastroenterology service noted the patient to be doing well, in stable condition, and advised continued oral Protonix therapy twice daily for at least eight weeks, with once daily therapy thereafter. The patient was subsequently cleared for discharge to home, with instructions for follow up. CONDITION AT DISCHARGE: Patient to be discharged to home, with instructions for follow up. DISCHARGE STATUS: Stable. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg by mouth twice a day 2. Sucralfate 1 gram by mouth four times a day DISCHARGE INSTRUCTIONS: The patient is to observe a planned non-acidic diet, Sucralfate 1 gram by mouth four times a day, pantoprazole 40 mg by mouth every 12 hours. The patient is to limit physical exercise, no excessive exertion. The patient is to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the outpatient surgical clinic three to four weeks following discharge. The patient is to call [Telephone/Fax (1) 18052] to schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 28881] MEDQUIST36 D: [2124-12-12] 21:45 T: [2124-12-13] 00:17 JOB#: [Job Number 104961]	[ "2851", "41401", "4019", "V4582" ]
Admission Date: [2174-5-10] Discharge Date: [2174-5-28] Date of Birth: [2105-5-6] Sex: F Service: MEDICINE Allergies: carbamazepine Attending:[First Name3 (LF) 9160] Chief Complaint: Chief Complaint: fall, leg weakness Reason for MICU transfer: intubation, percutaneous transhepatic cholangiogram Major Surgical or Invasive Procedure: - ERCP - IR percutaneous transhepatic cholangiogram with placement of 10F left internal/external drain - R CVL placement by IR - L CVL Removal - IR placement of IVC filter - IR placement of stent and removal of biliary drain History of Present Illness: 69F h/o developmental delay, seizures, OSA on CPAP, GERD, who initally presented to [Last Name (un) 4199] with LE weakness and fall, as well as blood in stools. She was found to have an increased troponin, anemia, and hyponatremia. She was given 2U RBC's and may have had a transfusion reaction although this is unclear from [Name (NI) 4199] documentation. She is being transferred to [Hospital1 18] from Wooden (admitted [5-4] for weakness and anemia). During a prep for cscopy, had afib with RVR, then developed hypotension briefly requiring pressors while on dilt gtt. She was rate controlled with dilt gtt thereafter and was volume resuscitated. She was electively intubated for increased work of breathing and respiratory distress at the OSH. She was given vanc, CTX, flagyl for GPC's and GNR's in BCx (initially was on CTX and gent, but after speciated as klebsiella, gent was d/c'd). She was found to have increased Tbili to 4, and RUQ US was unrevealing but CT scan showed abnl gallbladder with markedly thickened gallbladder wall and dilated CBD. On arrival to the MICU, patient is intubated and sedated. Review of systems: (+) Per HPI Past Medical History: Developmental Delay Seizures - since a child OSA on CPAP COPD GERD Osteoporosis Glaucoma ?CHF and ?CAD [First Name8 (NamePattern2) ] [Last Name (un) 4199] notes Social History: Lives in [Hospital3 ] with partner [Name (NI) ]. Mobile and functional at baseline with help of a PCA. No smoking, drinking, drugs. Family History: [First Name8 (NamePattern2) ] [Last Name (un) 4199] note: Mother: heart dz Physical Exam: Admission Physical Exam: General: easily awakens to voice, no acute distress, intubated but not sedated. SKIN: Jaundiced HEENT: Sclera icteric, EOMI Neck: supple, JVP not elevated, no LAD. Left CVL in place. CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds with scattered rhonchi bilaterally, no wheezes Abdomen: soft, obese and distended, bowel sounds present GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge VS: 99.5 99.3 123-146/61-75 89-112 22-24 95% 2L BG 121-134 I/O: 1000/inc + 2BM 400/inc + 2BM GEN: appears older than stated age. Comfortable but not alert. CV: RRR, distant heart sounds, no m/r/g LUNGS: +rhonchorous breath sounds anteriorly, crackles at bases but only left lung examined in posterior position. ABD: soft, distended, biliary drain in place with dressing c/d/i capped, +tenderness to palpation in RUQ and epigastrium EXT: palmar erythema and redness under right upper arm, left forearm noticeably large and more edematous than right arm, trace pitting edema in upper and lower extremities GU: incont NEURO: eyes open and tracking shakes head "no" in response to "do you have pain?" She is not having shaking or pursing her lips. She does squeeze her right hand and lift it off the bed, she also wiggles her right toes on command. She does not follow commands on the left. Left leg is held in external rotation and left toe is up going. Pertinent Results: ADMISSION LABS: [2174-5-10] 10:36PM BLOOD WBC-22.1* RBC-4.08* Hgb-11.0* Hct-34.0* MCV-83 MCH-26.9* MCHC-32.3 RDW-16.4* Plt Ct-130* [2174-5-10] 10:36PM BLOOD Neuts-91.3* Lymphs-5.1* Monos-3.1 Eos-0.3 Baso-0.2 [2174-5-11] 03:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-1+ Ellipto-OCCASIONAL [2174-5-10] 10:36PM BLOOD PT-39.5* PTT-36.7* INR(PT)-3.9* [2174-5-10] 10:36PM BLOOD Glucose-141* UreaN-22* Creat-0.5 Na-133 K-3.6 Cl-107 HCO3-20* AnGap-10 [2174-5-10] 10:36PM BLOOD ALT-85* AST-132* LD(LDH)-277* AlkPhos-175* TotBili-7.1* [2174-5-11] 06:08AM BLOOD cTropnT-0.13* [2174-5-12] 04:05AM BLOOD cTropnT-0.13* [2174-5-10] 10:36PM BLOOD Calcium-7.4* Phos-1.3* Mg-2.0 [2174-5-10] 10:30PM BLOOD Type-ART pO2-116* pCO2-26* pH-7.46* calTCO2-19* Base XS--2 -ASSIST/CON Intubat-INTUBATED [2174-5-11] 11:07AM BLOOD Lactate-3.0* [2174-5-11] 06:09PM BLOOD Lactate-1.3 [2174-5-12] 04:26AM BLOOD Lactate-1.1 [2174-5-11] 01:30PM URINE Color-DkAmb Appear-Cloudy Sp [Last Name (un) ]-1.044* [2174-5-11] 01:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-LG Urobiln-2* pH-6.0 Leuks-SM [2174-5-11] 01:30PM URINE RBC-41* WBC-21* Bacteri-FEW Yeast-NONE Epi-2 TransE-1 [2174-5-11] 01:30PM URINE CastGr-2* CastHy-2* . PERTINENT LABS: [2174-5-15] 06:16AM BLOOD Ret Aut-3.2 [2174-5-19] 06:25AM BLOOD CEA-7.5* AFP-5.7 [2174-5-15] 06:16AM BLOOD calTIBC-165* Ferritn-361* TRF-127* [2174-5-22] 06:50AM BLOOD CA [80]-9 -50 [Date range (1) 102374]; [Date range (1) 82130] Blood cultures negative [5-13] blood culture: yeast . RADIOLOGY: -[5-5] TTE from [Last Name (un) 4199]: Summary: LV size and wall thicknesses are nl; LVEF is ~75%. -[5-10] CT abd/pelvis from [Last Name (un) 4199]: Two gallbladder-to-distal small bowel fistulas with associated severe gallbladder wall thickening. This is highly suspicious for gallbladder carcinoma with possible local invasion of the adjacent liver and adjacent loop of colon. Alternatively, and probably less likely, this could be due to chronic inflammatory process of the gallbladder. Severe extrahepatic and intrahepatic biliary ductal dilatation with pneumobilia. Dilatation tapers at the level of the distal CBD without obvious obstructing mass lesion visualized. Debris or sludge ball may be present in the distal CBD. No bowel obstruction. Mild ascites and small b/l pleural effusions. -[5-10] CXR Bibasilar opacities are largely attrributible to small effusions and atelectasis, as seen on recent CT. A small opacity in the lingula could represent a small focus of pneumonia. - [5-12] RUQ U/S 1. Limited study. Irregularity in the gallbladder region as expected. No targetable liver lesion identified. 2. No intrahepatic bile duct dilation. Borderline common duct dilation. PTBD in place. -[5-13] Abdominal MRI 1. Circumferential gallbladder cancer erodes into a small bowel loop in the right upper quadrant (21: 24) and also possibly into the liver. Two hepatic lesions are most consistent with bilomas. 2. No intrahepatic duct dilatation, the common bile duct is dilated within its central portion measuring up to 1.2 cm but tapers distally. 3. Moderate ascites. 4. Small bilateral pleural effusions - [5-14] CXR AP chest compared to [5-10] through 18: There are now more discrete areas of consolidation in the right mid and lower lung zones, which could be due to pneumonia. Aeration in the left lower lobe is compromised but unchanged since [5-10], probably atelectasis. The heart is moderately enlarged. Small bilateral pleural effusions are presumed. A right jugular line ends deep in the right atrium. No pneumothorax. - [5-15] LUE U/S: There is an occlusive clot in a short segment of the left cephalic vein. No evidence of deep vein thrombosis or hematoma. - [5-17] Lower extremity U/S: Non-occlusive thrombus involving the distal left superficial femoral vein. No evidence of deep vein thrombosis in the right lower extremity deep veins. - [5-18] echo The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. IMPRESSION: No echocardiographic evidence of endocarditis. Small LV cavity size with hyperdynamic LV systolic function. Consequently there is a mild left ventricular outflow tract gradient during systole. No significant valvular abnormality seen. Mildly elevated pulmonary artery systolic pressure. If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. - [2174-5-20] IR 1. Biopsies and brushings of the area of stricture in the CBD. 2. Placement of 12 mm x 8 cm Luminexx metal stent in the CBD across the stricture, with post-stent placement balloon dilatation. 3. Placement of 10 French pigtail catheter with its tip in the duodenum to secure access. 4. The tube is currently capped. The patient can be brought in a few days for repeat cholangiogram and removal of the catheter, if there is no evidence of cholestasis or cholangitis. [2174-5-20] Gallbladder Brushings: Scant glandular epithelium with atypia, see note. Note: There is noticeable atypia in this scant glandular epithelium. Given the scant material, additional evaluation should be considered if clinically appropriate. [2174-5-20] Gallbladder Cytology pending - [2174-5-25] CT HEAD No acute intracranial process. - EEG [2174-5-25] (24 hour): This is an abnormal continuous ICU monitoring study because of mild diffuse background slowing indicative of mild diffuse cerebral dysfunction with non-specific etiology. No epileptiform discharges or electrographic seizures are present. Compared to the prior day's recording, there are no significant changes. Note is made of an irregular heart rhythm with intermittent borderline tachycardia and occasional wide complex premature beats. - [2174-5-27] CXR Lung opacities likely due to multifocal pneumonia. DISCHARGE LABS [2174-5-27] 05:23AM BLOOD WBC-14.0* RBC-3.18* Hgb-9.1* Hct-29.5* MCV-93 MCH-28.7 MCHC-31.0 RDW-22.4* Plt Ct-282 [2174-5-27] 05:23AM BLOOD PT-23.9* PTT-32.8 INR(PT)-2.3* [2174-5-27] 05:23AM BLOOD Glucose-104* UreaN-20 Creat-0.5 Na-149* K-3.3 Cl-110* HCO3-25 AnGap-17 [2174-5-27] 05:23AM BLOOD ALT-9 AST-24 AlkPhos-323* TotBili-1.6* [2174-5-27] 05:23AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8 Brief Hospital Course: 69F h/o developmental delay, seizures, OSA on CPAP, GERD, who initally presented to [Last Name (un) 4199] with weakness and fall, as well as blood in stools. There she was found to have an increased troponin, anemia, and hyponatremia. She was noted to have rising liver enzymes and a CT scan that showed an abnormal gallbladder with markedly thickened gallbladder wall and dilated common bile duct and possible gallbladder carcinoma. She was initially admitted to the [Hospital Unit Name 153] as she was intubated for respiratory distress at the OSH. She was then transferred to IR for biliary drainage, and findings were suspicious, but not diagnostic, for gallbladder cancer. At this point, the patient's HCP and partner, [Name (NI) ], made the decision to transfer to hospice care, despite no definitive diagnosis of cancer. ACTIVE ISSUES: # Goals of Care: meetings were held with HCP/partner, [Name (NI) ] to discuss patient's likely diagnosis of cancer, for which the patient is not a surgical or chemo candidate. Pt was transitioned to CMO/hospice on [2174-5-27], with plan to discontinue vital signs and IV fluids. She was continued only on her anti-epileptics and pain medication as needed. She was given small doses of morphine for persistent right upper quadrant pain. She was originally on oral keppra, but was observed to choke/gargle even with minimal quantity of the liquid; thus she was transitioned to standing lorazepam that could be absorbed orally. She was discharged to hospice on [2174-5-28]. INPATIENT ISSUES: # Cholangitis, bacteremia: At OSH, pt had GPC's and GNR's in blood cultures. She was found to have increased Tbili to 4, and CT scan showing abnormal gallbladder with markedly thickened gallbladder wall and dilated common bile duct, suggesting biliary tract was likely source. In the ICU, she was treated with cefepime, vancomycin, and flagyl. Patient had gallbladder drain placed, which was discontinued on [2174-5-27]. Following this, patient's over clinical condition improved. She was weaned off pressors, and her white count improved. She was narrowed to unasyn on [2174-5-22] to complete a 2-week course of antibiotics. # Fungemia: [12-29] blood cultures positive for yeast from [5-13], though subsequent surveillance culture were negative. Felt to be from gallbladder source. ECHO evaluation for endocarditis and ophthalmology evaluation for endopthalmitis were negative. Patient was started on micafungin (day 1: [5-15]) and completed a 13-day course on [2174-5-27]. # Likely GB malignancy: MRCP suggestive of malignancy with formation of enteric fistulas and some sign of hepatic involvement. ERCP was unsuccessful in entering CBD so patient underwent biliary stenting and biopsy by IR. Per hepatobiliary surgery, patient is poor surgical candidate. Hem/Onc also feels chemotherapeutic options are limited. Final pathology from brushings/biopsy revealed glandular atypia but no definitive carcinoma. The option of biopsy was presented to the patient's HCP and partner, [Name (NI) ], as the patient was not able to communicate her own desires at this point. [Doctor Last Name ] opted for comfort measures and declined the biopsy, wishing to focus on hospice care. # Anemia: Had Hct in high 20's upon admission to OSH but was 34.0 upon admission to ICU. Reportedly had blood in stools recently. Was going to undergo evaluation with colonoscopy and EGD at OSH, but this could not be completed due to patient instability. Iron studies revealed anemia of chronic inflammation and some hypoproliferation. Her stools remained guaiac positive while here but without frank blood. She received 1U pRBC transfusion in the setting of coffee-ground emesis (see below) but was otherwise stable. # Left lower extremity DVT: Non-occlusive thrombus found in left leg after patient complained of some leg pain. Heparin drip started on [5-18], which was later stopped after patient developed coffee-ground emesis. Patient underwent IR-guided IVC filter placement on [5-19]. # UGIB: Developed coffee ground emesis on [5-18], though maintained stable vitals and hematocrit. Her heparin drip was discontinued. NG tube placement was attempted but not tolerated. KUB was negative for obstruction. She received 1U pRBC transfusion. She was started on IV PPI [Hospital1 ] and GI was made aware, who felt there was no need for urgent intervention at this time as she was hemodynamically stable. She had no further episodes. She was kept NPO as she was not able to swallow. # Extremity weakness: Per chart, patient has history of left-sided weakness, though at baseline is able to walk with a cane. Weakness, left side greater than right, is notable on physical exam. Likely worsened by her deconditioning due to critical illness. The patient's weakness worsened as her overall clinical status worsened. # Hypoxia/intubation: Pt was not intubated at the OSH for respiratory failure, but rather acidosis and increased work of breathing. She did not require any sedation. After her IR-guided biliary drain placement, she remained intubated for MRCP. She was later extubated without event and did well. She was saturating well on 2L O2 on the floor. Her persistent hypoxia on the floor was felt due to a combination of ventilator-associated pneumonia, COPD, OSA, pulmonary edema, and possible aspiration events in setting of upper GI bleed. She completed a course for VAP and was diuresed daily to help with volume overload. She was continued on CPAP nightly for OSA. She was initially NPO and kept on aspiration precautions until time of discharge, at which time it was felt that tube feeds were not in keeping with her goals of care. # Afib with RVR: This appears to be new onset and began at [Last Name (un) 4199] during colonoscopy prep. There, she was maintained on Diltiazem drip and then transitioned to oral Diltiazem. In the ICU, she entered into A fib with RVR, and eventually needed to be put back on a Diltiazem drip when boluses did not break the RVR. Patient converted into sinus rhythm and was weaned off the Diltiazem drip. She was transitioned to her home dose of metoprolol. On the floor, she had intermittent bursts of supraventricular tachycardia but no further atrial fibrillation while hospitalized. # Previous hypotension: Pt was normo- to hypertensive on admission, but she had lower BP's to the 100's after being started on a Diltiazem drip. This was similar to what happened at [Last Name (un) 4199], where she developed hypotension briefly requiring pressors while on Diltiazem drip. She was started on pressors after her drain was placed, and her blood pressure continued to improve. She was weaned off pressors and did not require any further pressors while in ICU. Her blood pressures remained in the 130-140 range on the floor. # Elevated INR to 3.9 upon admission: Remained elevated throughout despite improvement of LFTs. Likely due to hepatic involvement of malignancy and poor nutrition. CHRONIC ISSUES: # OSA on CPAP: was initially intubated, and then continued on CPAP at night while on the floor. # GERD: Continued PPI. # Seizure disorder: History of complex partial seizures, none during her current stay, confirmed on 24h EEG. Continued keppra, which was transitioned to Lorazepam at time of discharge. # Developmental delay/Paranoia: Held risperidone while NPO # Chronic pain: Held gabapentin while NPO TRANSITIONAL ISSUES: # CODE STATUS: DNR/DNI . # ISSUES OF CARE: - hospice, focus on comfort. PO lorazepam dissolving, instead of PO keppra given pt's gargling/choking on even 2cc's of liquid keppra. . # CONTACT: HCP & long term partner [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 102375] Medications on Admission: Nystatin powder aspirin 81 mg daily calcium/vitamin d combivent inhaler QID PRN docusate 100 mg [Hospital1 ] flunisolide 2 sprays [Hospital1 ] fosamax 35 mg weekly kenalog 0.1% [Hospital1 ] PRN keppra 1500 [Hospital1 ] lisinopril 10 mg daily metoprolol 50 mg [Hospital1 ] neurontin 400 mg [Hospital1 ] omeprazole 20 gm daily risperdal 1 mg qPM risperdal 0.25 mg qHS spectazole 1% [Hospital1 ] to breast rash acetaminophen PRN zocor 40 mg daily dilantin 200 mg [Hospital1 ] Discharge Medications: 1. collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2-10 mg PO Q2H (every 2 hours) as needed for pain or shortness of breath. Disp:200 mL Refills:2 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): apply to skin folds. 6. diazepam 12.5-15-17.5-20 mg Kit Sig: Twenty (20) mg Rectal q1h as needed for seizure. Disp:100 Refills:2 7. Lorazepam Intensol 2 mg/mL Concentrate Sig: 1-2 mg PO q30min as needed for seizure. Disp:100 Refills:2 8. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) mg PO every six (6) hours: As antiepileptic. Disp:120 Refills:2 Discharge Disposition: Extended Care Facility: [Hospital ] Rehab Discharge Diagnosis: PRIMARY ?cholangiocarcinoma Cholangitis Bacteremia DVT SECONDARY Seizure disorder Developmental delay Discharge Condition: Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear [Known firstname ], You were admitted to [Hospital1 18] because you had a serious infection of your gallbladder and bloodstream likely due to an underlying cancer. You were initially in the intensive care unit on medications to help support your blood pressure. When you moved to the floor, your infection improved. A blood clot was found in a vein in your leg so a filter was placed in your vein to help prevent it from moving. A drain and stent were also placed in your gallbladder to open up blockages, help relieve pain and help drain the infection. A sample of tissue was taken from the gallbladder which showed a very advanced cancer. Unfortunately, our surgeons and cancer doctors did not feel there was a safe treatment for this disease. At this point, you were transitioned to hospice care. It was a pleasure taking care of you and we wish you all the best. Please note the medication list which is attached as there have been many changes to your medications in order to make you comfortable. Followup Instructions: None [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162]	[ "0389", "78552", "2762", "2851", "2761", "99592", "496", "42731", "4280", "32723", "53081", "2875" ]
Admission Date: [2163-11-6] Discharge Date: [2163-11-11] Date of Birth: [2096-10-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital6 ] . CHIEF COMPLAINT: Fever. REASON FOR MICU ADMISSION: Sepsis, mechanical ventilation. Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [Known lastname 1557] is a 67 y.o. M from [Hospital3 537] with recent history of pneumonia, presented with fever, tachycardia, and increased lethargy. History from RN at [Hospital3 537] and faxed medical records. The patient lives at [Hospital3 537] and was recently hospitalized at [Hospital1 2177] from [10-31] to [11-4] and diagnosed with aspiration pneumonia. He completed a course of cefpodoxime and Flagyl. Around 8 PM, the patient was noted to be lethargic and did not open eyes with name calling, moaning. He desat'ed to 88% on RA and improved to 92% on 2 L NC He was also noted to be febrile. MD was called and referred patient via ambulance to [Hospital1 2177]. VS at [Last Name (un) ]: 140/69 HR 121 RR 28 T 100.6. Ambulance diverted to [Hospital1 18]. Of note, patient was to complete hospice referral on [2163-11-7]. . In the ED, initial VS: T 101.6 HR 122 BP 127/70 RR 33 O2 96% on 10 L NRB. Labs, blood cultures x 2, and urine culture were sent. Portable CXR was completed. EKG completed, noted with some lateral changes so Cards consulted. The patient was intubated with etomidate and succinylcholine, then sedated with fentanyl and midazolam. ABG performed. Placed OG tube and noted thick green coating on dry tongue. NG lavage with some thick black looking material, ? coffee grounds, but cleared quickly. Rectal with guiaic + brown stools, so GI consulted. He was given levofloxacin 750 mg IV x 1 and Zosyn x 1. Acetaminophen 1300 mg PR x 1, IV Protonix 40 mg IV x 1 then gtt at 8/hour, and Vitamin K 10 mg IV x 1 were given. He was also given 3.5 L IVFs. Discussed CVL but deferred given supratherapeutic INR. . Currently, the patient is sedated and intubated. . ROS: Unable to obtain due to sedation and intubation Past Medical History: Per [Hospital3 537] Records Type 2 DM HTN Hyperlipidemia s/p R nephrectomy due to renal cancer PVD (s/p RLE bypass, s/p AAA repair) L carotid artery occlusion h/o alcohol withdrawal sz in [2134] Positive PPD with negative CXR Incisional hernia Severe pharyngeal dysphagia Embolic CVA at [Hospital1 2025] in [2145-4-16] (left superior frontal, posterior parietal and temporal-occipital) Stage 4 CKD with R arm fistula (not useD) CAD with positive dobutamine stress in [6-25] Atrial fibrillation on coumadin History of aspiration pneumonia (on nectar thickened liquids) Social History: Lives at [Hospital3 537] Family History: DM in 2 brothers. Aneurysms - mom in brain, fatal; brother in heart. Brother with melanoma. Physical Exam: Vitals - T: 98.7 BP: 110/57 HR: 85 RR: 14 02 sat: 100% on AC 500 x 16, PEEP 5, FiO2 100% GENERAL: sedated, intubated, appears older than stated age HEENT: eyes not reactive to light, but equal, no cervical LAD CARDIAC: III/VI SEM best heard at LLSB, no r/g LUNG: on anterior exam, breath sounds bilaterally, no w/r/r ABDOMEN: NDNT, soft, NABS EXT: no c/c/e, R knee with ecchymoses NEURO: sedated DERM: sacral decub stage II Pertinent Results: [Hospital3 537]: INR 5.01 on [2163-11-1] [Hospital3 537]: WBC 10.7, Hgb 8.8, Hct 28.5, Plt 307, Neut 75.3, L 15, Monos 6, Eos 3.1, Baso 0.4 . MICROBIOLOGY: Blood Culture x 2 - pending Urine Culture - pending . STUDIES: EKG: tachy at 100 bpm, LAD; II-III-aVF with Qwaves, [Street Address(2) 4793] depression in V4-V6. No prior to compare to. . PORTABLE CXR [2163-11-6]: ETT tube 2 cm above carina. NGT over LUQ in stomach. Dense opacity at LLL with diffuse nodular consolidation in mid and upper lungs. Air bronchograms in retrocardiac space. R lung clear. Worrisome for pneumonia. Impression: Extensive pna in left lung. Brief Hospital Course: 67 y.o. M from [Hospital3 537] with recent history of pneumonia, presented with fever, tachycardia, and increased lethargy, found to have pneumonia, admitted to ICU s/p intubation for respiratory failure. 1. Respiratory Failure: Secondary to dense pneumonia that was seen on portable CXR. Intubated in ED for tachypnea and work of breathing. Pt was admitted to the ICU. Treated with broad spectrum antibiotics, vancomycin / cefepime / ciprofloxacin, for hospital acquired pneumonia given recent hospitalization and living in [Hospital3 537]. Pt was rapidly weaned from ventilator and extubated on [11-7]. Sputum culture without pseudomonas, so ciprofloxacin was stopped. Course of antibiotics for 8 days. 2. Sepsis: Secondary to pneumonia on CXR. Treated with antibiotics as above. Pan-cultured. Lactate was not elevated. No pressors needed. 3. Altered mental status: On admission to ICU, pt's eyes noted to be non-reactive to light. ? cataract surgery, but unable to get history. CT head negative for acute bleed. Per family, pt's baseline is "yes" and "no". Likely altered mental status due to infections, R arm pain (RSD). 4. ? GI bleeding: + guiaic positive in ED with supratherapeutic INR. GI was consulted. Followed patient's Hct which was stable. Active T&S maintained, Guiaiced all stools. 2 large bore PIVs. IV PPI gtt initiated in the ED, then changed to IV PPI [Hospital1 ]. 5. Elevated troponins: Elevated Troponin may be secondary to renal failure, ruled out MI with serial enzymes and EKGs. Cards evaluated EKG in ED and believed it was demand ischemia. By report, EKG with old inferior Qs. . 6. Coagulopathy: PT, PTT, INR all elevated. Likely interaction between recent flagyl use and coumadin. But also may be secondary to DIC, although platelets within normal limits. Also likely nutritional deficiency. DIC labs negative. Held coumadin. Given 10 IV K in ED with decrease in INR. Restarted low dose coumadin but stopped given goals of care. 7. CKD, stage 4: Recently discharged with Cr 2 from [Hospital1 2177]. Likely pre-renal as pt appeared intravasculary dry on admission. Fluid resuscitated with D5W given hypernatermia. Cr trended down. 8. Hypernatremia: Na 155 on admission. D5W @ 120 cc / hour for 20 hours for correction. Na serially monitored and normalized during ICU stay. 9. Type 2 DM: Fingersticks and labs were discontinued as per family wishes for patient to receive comfort measures only. 10. Hyperlipidemia: Zetia and Lipitor were discontinued as per family wishes for patient to receive comfort measures only. 11. HTN: Beta blocker and amlodipine were initially held in setting of questionable GI bleed, but discontinued as per family wishes for patient to receive comfort measures only. 12. Stage 2 Sacral Decub: Patient received wound care. Cleaned with normal saline, duoderm gel, and gauze dressing daily. 14. R arm pain: X ray negative. From OSH records, may be RSD. Continued low dose neurontin and lidocaine patch. 15. Goals of care: On [11-8], family meeting was held and patient was made DNR/DNI/comfort measures only by HCP. [Name (NI) ] was transferred to the floor on [11-9]. Antibiotics were continued as he was clinically improving, but they were discontinued on discharge. Morphine for pain. Palliative care was consulted. Patient is discharged with hospice care. CONTACT: [First Name8 (NamePattern2) 32000] [Last Name (NamePattern1) 32001] [Telephone/Fax (1) 32002] Medications on Admission: Vitals - T: 98.7 BP: 110/57 HR: 85 RR: 14 02 sat: 100% on AC 500 x 16, PEEP 5, FiO2 100% GENERAL: sedated, intubated, appears older than stated age HEENT: eyes not reactive to light, but equal, no cervical LAD CARDIAC: III/VI SEM best heard at LLSB, no r/g LUNG: on anterior exam, breath sounds bilaterally, no w/r/r ABDOMEN: NDNT, soft, NABS EXT: no c/c/e, R knee with ecchymoses NEURO: sedated DERM: sacral decub stage II Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please apply to right arm. 12 hours on, 12 hours off. 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for pain, turning. 10. Wound Care Sacral decubitus ulcer - please clean with Duoderm gel and cover with 4 x 4 Mepilex border dressing daily Discharge Disposition: Extended Care Facility: Sachem Skilled Nursing & Rehabilitation - [Location 21318] Discharge Diagnosis: Primary Diagnosis: Pneumonia Discharge Condition: Afebrile, minimal pain, saturating well on room air. Discharge Instructions: You were admitted to [Hospital1 69] for pneumonia. You required intubated and an ICU stay during this admission because of respiratory failure. The pneumonia was treated with antibiotics during your admission. You do not need any further antibiotics after discharge. The decision was made by your health care proxy to only pursue comfort measures. You are being discharged with hospice care. Your medications have changed, please take only the medication listed on your discharge medication list. Followup Instructions: Follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], as needed. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "0389", "486", "51881", "5849", "2761", "5180", "99592", "40390", "42731", "41401", "2724", "25000", "V5861" ]
Admission Date: [2188-5-20] Discharge Date: [2188-6-3] Date of Birth: [2123-7-18] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 603] Chief Complaint: Felt Bad Major Surgical or Invasive Procedure: Right Sided Subclavian CVL History of Present Illness: 64YoM with history of HTN, GERD, HEP C, polysubstance abuse, brought from friends house because he was confused and did not know where he was, generally "feeling terrible." Per his report, this has been an acute change. He also stated that for the past day or so, he has had worsening low back pain radiating to his buttocks, which is new. In the ED, he gave a history of possible syncopal episode following heroin use. He is not complaining of any abdominal pain, nausea, changes in bowel habits, dysuria, chest pain, SOB, headache, neck pain/stiffness. He apparently gets all of his care at [Hospital1 2177]. . In ED, initial vitals were 97.6 91 185/132 14 94%. He was c/o epigastric pain and had 2 episodes of bloody to [Last Name (un) 30212]-colored emesis. He was started on octreotide and pantoprozole gtt. Hct was 48.8. Utox positive for opiates; he states he has not used in months . GI was consulted and recommended EGD. . On the floor, patient is hypertensive to SBPs 170s-180s. He is not oriented to place or time, and also denies any recent drug use. NG lavage done by GI was negative. . 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: GERD HTN Hep C Heroin abuse Gunshot wound to abdomen s/p ex-lap 20 years ago Social History: He is homeless and has been living at shelter. History of heroin use. - Tobacco: 1 ppd for about 30 years - Alcohol: Denies any recent alcohol use; "does not like it" - Illicits: IV Heroin last use: "months ago" Family History: NC Physical Exam: Admission: General: Alert, not oriented to place or time, NAD HEENT: Sclera anicteric, Dry MMM, conjunctiva injected Neck: supple, JVP 7-8 cm, no LAD Lungs: Dry bibasilar crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: protuberant, soft, normoactive bowel sounds, no shifting dullness to percussion, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, PERRLA, no asterexis, no focal motor deficits, tender ness to palpation over right lower paraspinal musculature Discharge: Gen: Pleasant, middle aged male in NAD. AAOx3 HEENT: NCAT. Sclera anicteric. Left eye clouded without vision. EOMI. MMM, OP benign. No sinus tenderness to palpation Neck: Supple, full ROM. No visible JVP. No cervical lymphadenopathy. CV: RRR with normal S1, S2. No M/R/G. No S3 or S4. Chest: Respiration unlabored. Mild crackles at RLL base, otherwise CTAB without crackles, wheezes or rhonchi. Abd: Bowel sounds present. Soft, protuberant, NT/ND. No organomegaly or masses appreciated Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, PT 2+. Skin: No rashes, ulcers, or other lesions noted. Neuro: CN II-XII grossly intact. Normal speech. Pertinent Results: ADMISSION LABS: ================= [2188-5-20] 06:00PM WBC-18.2* RBC-4.58* HGB-14.0 HCT-40.0 MCV-87 MCH-30.5 MCHC-34.9 RDW-14.7 [2188-5-20] 06:00PM NEUTS-85.5* LYMPHS-9.3* MONOS-4.0 EOS-0.8 BASOS-0.3 [2188-5-20] 06:00PM PLT COUNT-179 [2188-5-20] 05:20PM URINE HOURS-RANDOM UREA N-299 CREAT-166 SODIUM-43 POTASSIUM-71 CHLORIDE-22 [2188-5-20] 05:20PM URINE HOURS-RANDOM [2188-5-20] 05:20PM URINE GR HOLD-HOLD [2188-5-20] 02:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2188-5-20] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2188-5-20] 02:00PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-<1 [2188-5-20] 02:00PM URINE HYALINE-4* [2188-5-20] 02:00PM URINE MUCOUS-RARE [2188-5-20] 12:52PM LACTATE-2.0 K+-3.3* [2188-5-20] 11:33AM PT-12.9 PTT-24.3 INR(PT)-1.1 [2188-5-20] 11:28AM AMMONIA-20 [2188-5-20] 11:04AM GLUCOSE-127* UREA N-50* CREAT-5.2* SODIUM-148* POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-24 ANION GAP-22* [2188-5-20] 11:04AM estGFR-Using this [2188-5-20] 11:04AM ALT(SGPT)-119* AST(SGOT)-168* CK(CPK)-[Numeric Identifier 100019]* ALK PHOS-63 TOT BILI-0.7 [2188-5-20] 11:04AM LIPASE-58 [2188-5-20] 11:04AM cTropnT-0.05* [2188-5-20] 11:04AM CK-MB-67* MB INDX-0.5 [2188-5-20] 11:04AM ALBUMIN-4.3 [2188-5-20] 11:04AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2188-5-20] 11:04AM WBC-20.0* RBC-5.46 HGB-16.3 HCT-48.2 MCV-88 MCH-29.9 MCHC-33.8 RDW-14.7 [2188-5-20] 11:04AM NEUTS-88.4* LYMPHS-7.2* MONOS-3.7 EOS-0.5 BASOS-0.3 [2188-5-20] 11:04AM PLT COUNT-196 [2188-5-20] 12:00AM URINE HOURS-RANDOM [2188-5-20] 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG DISCHARGE LABS: ================== [2188-6-3] 05:55AM BLOOD WBC-9.8 RBC-3.72* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.6 MCHC-33.3 RDW-14.2 Plt Ct-358 [2188-6-3] 05:55AM BLOOD Plt Ct-358 [2188-6-3] 05:55AM BLOOD Glucose-100 UreaN-16 Creat-1.7* Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 [2188-5-31] 08:35AM BLOOD ALT-22 AST-28 CK(CPK)-132 AlkPhos-50 TotBili-1.0 [2188-5-29] 06:35AM BLOOD Lipase-21 [2188-6-3] 05:55AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0 [2188-5-27] 05:14AM BLOOD HIV Ab-NEGATIVE [2188-5-26] 05:33AM BLOOD Free T4-1.4 [2188-5-26] 05:33AM BLOOD Triglyc-115 CT Abdomen [2188-5-26] COMPARISON: [2188-5-25] CT abdomen and pelvis and chest radiograph of [5-26], [2187]. TECHNIQUE: MDCT axial images were obtained through the chest without IV contrast. Coronal and sagittal reformats were displayed. FINDINGS: The imaged thyroid gland is normal. There is no axillary, mediastinal, or hilar adenopathy meeting CT criteria for pathologic enlargement. A left-sided central venous line follows a normal course terminating at the junction of the brachiocephalic vein with the SVC. The heart is enlarged with trace pericardial fluid. Small hiatal hernia is present. There is a new right-sided pigtail catheter terminating at the base of the right lung. Loculated pleural effusion is slightly increased compared to the prior study. For example, a collection of fluid at the base measures 2.6 cm in maximal width compared to 2.1 cm previously. Gas within the pleural fluid is presumably secondary to placement of the pigtail catheter. A loculated component of fluid anteriorly measures 5.6 x 11.2 cm. A third component of fluid along the right lateral chest measures approximately 4.4 x 2.1 cm. A small collection of gas within a consolidation at the right lung base adjacent to the effusion is similar to prior and concerning for pneumonia or necrotizing pneumonia. There is peribronchial thickening. A 5-mm nodule in the right lower lobe is not appreciably changed from the prior study (2:26). A second nodule measuring 3 mm is seen at the right lung base (2:33). There is a small left pleural effusion. In the visualized upper abdomen, the gallbladder is distended up to 4.5 cm with sludge. a fat-containing abdominal wall hernia is incompletely evaluated. Hypodensity in the upper pole of the left kidney is better evaluated on the prior CT abdomen. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified. IMPRESSION: 1. Interval placement of a right-sided pigtail catheter with slight increase in the loculated pleural effusion which could reprsent empyema. Persistent area of loculated gas surrounded by lung parenchyma could represent pulmonary abscess or necrotizing pneumonia. 2. Gallbladder distension up to 4.5 cm with sludge. Recommend right upper quadrant ultrasound for further evalaution. 3. Small left-sided pleural effusion. 4. Small pulmonary nodules measuring up to 5 mm on the right. The study and the report were reviewed by the staff radiologist. RUQ/Liver US [2188-5-28] FINDINGS: Normal liver echotexture without focal liver lesion. No intrahepatic biliary dilatation. The common bile duct measures 3 mm. Incidental 3-mm polyp noted within the gallbladder. The gallbladder wall measures 3 mm. Gallbladder is only mildly distended. There is a trace of peri-cholecystic fluid. The patient was son[Name (NI) 5326] [Name2 (NI) 6416]. No son[Name (NI) 493] features of acute cholecystitis. Findings in the gallbladder are likely related to underlying liver disease and third spacing from renal failure and low albumin. The main portal vein is patent and demonstrates hepatopetal flow. Pancreas is partially visualized in the midline, the distal tail is not seen in its entirety. The visualized IVC is unremarkable. The spleen measures 12cm. There is a non-obstructing 6-mm calculus in the interpolar region of the right kidney. This is stable. No evidence for ascites in the visualised upper abdomen. IMPRESSION: 1. Minimally distended gallbladder with mild gallbladder wall edema and pericholecystic fluid. No gallstones seen. The patient was son[Name (NI) 5326] non-tender. Findings most likely represent sequelae of liver disease and third spacing from acute renal failure and low albumin. 2. Incidental 3-mm gallbladder wall polyp. 3. Stable non-obstructing 6-mm right renal calculus. CXR [2188-6-1] CLINICAL HISTORY: Hypertensive HCV status post VATS. CHEST: Since the prior chest x-ray, the left chest tube has been removed. There is no evidence of a pneumothorax. Atelectasis of the left lower lobe is present. Left effusion is seen. Upper zone redistribution to the right side is present though not to the left, third degree of failure is probably present. IMPRESSION: Chest tubes removed. No pneumothorax. Brief Hospital Course: The patient is a 64 year old male with a history of HCV infection, GERD, HTN, and polysubstance abuse admitted for UGIB and [Last Name (un) ] from rhabdomyolysis, while hypertensive to 170s-180s systolic. He was admitted to the MICU and later transfered to the floor. On the floor he had no subsequent upper GI bleeding, and his acute kidney injury and rhabdomyolysis slowly resolved. While on the floor, he was found to have a RLL necrotizing PNA/empyema, which was treated with IV antibiotics and a VATS decortication. Active issues: # Upper GI Bleed On presentation, the patient complained of epigastric pain and had two episodes of bloody to [Last Name (un) 30212]-colored emesis. He was started on Octreotide and Pantoprozole gtt. Hct was 48.8. GI was consulted and recommended EGD. He was admitted to the MICU after his maroon-colored emesis in the ED while hypertensive to 170s-180s systolic. In the MICU, he remained hemodynamically stable overnight. He had negative NG lavage, and his hematocrit was stable. He received IVFs and maintained good urine output. RUQ ultrasound with doppler showed a normal appearing liver without a nodular appearance, not suggestive of cirrhosis. The patient was transfered to the general medicine floor where he had no further episodes of emesis. He had an EGD which was negative for any source of bleeding, but positive for gastritis, as well as esophagitis and duodenitis. Subsequent H. Pylori testing was positive. On discharge, the patient was started on PPI with instructions to follow-up with his PCP for treatment of the H. Pylori once he finished his course of antibiotics begun in-hospital. # [Last Name (un) ] / Rhabdomyolysis: On presentation, the patient had been brought in by his friends who did not know how long he had spent unconsious, raising suspicion of rhabdomyolysis. On admission, his Cr was 5.2 with baseline 1.4 based on [Hospital1 2177] discharge summary in [2185]. CK elevated to [Numeric Identifier 100019] on admission, likely secondary to rhabdomyolysis as a major contributor. Renal ultrasound demonstrated no obstructive cause for the [Last Name (un) ]. Over the course of his admission, the patient received regular IVF treatment, and his CK trended downward to 132 at his final measurement before discharge. Although his Cr also downtrended steadily with the length of his admission, he had a brief bump in his Cr. After he received IV lasix, his urine output steadily improved, and his Cr at discharge remained at 1.7 its nadir for this admission. He was not continued on Lasix due to his continued urine output. While in the hospital, every possible effort was made to renally dose medications and avoid nephrotoxins. # Necrotizing Pneumonia/Empyema Shortly after the patient was transfered from the MICU to the floor, the patient began to report some discomfort at the right upper quadrant/lower right costal margin. At this time, he had a few brief fluctuations in mental status. The discomfort increased over two days, and began radiating to his back. Given the finding of a non-obstructing kidney stone on his initial ultrasound, and a mild pancreatitis, a CT abdomen was ordered (both kidney and RUQ U/S were recently negative for obstruction). The patient was found to have a loculated effusion in the RLL, which was initially tapped by interventional pulmonology. The patient was started on IV Vanc/Zosyn. Thoracic surgery performed a right VATS decortication on [2188-5-28]. Subsequent to the surgery, the patient ran a low temperature on several nights, likely due to atelectasis (cultures sent during these spikes were negative), which quickly resolved. During this period, the patient received aggressive chest PT, and had a progressive decrease in his requirement of supplemental O2. Due to the low suspicion for MRSA, the patient's antibiotics were changed to levofloxacin and clindamycin, and his improvement was sufficient that ID recommended that he could be switched to PO antibiotics for his remaining course, which will end on [2188-6-16]. Chronic Issues: # Hypertension: The patient was initially 170s-180s systolic on arrival to the ED. His SBP continued to remain high in the MICU and was in the 160-180s just prior to transfer to the floor. On the floor, he received labetalol, hydralazine, and amlodipine, where his pressures generally remained within the 120-140 range. On discharge, he was prescribed once daily metoprolol and amlodipine in order to increase compliance. # Drug Abuse: The patient initially denied recent drug use in several months, but had UTox positive for opiates in the ED. He has smoked 1 PPD for many years. In the hospital, the patient received a prn nicotine patch. Given his history of IVDU, an HIV test was performed which was negative. Social work also consulted, and confirmed that the patient had been off drugs for one year, with occasional lapses and was now living independently after years of struggling to get housing. The patient was kept in contact with his social supports in order to help him maintain his progress as an outpatient and to ensure that he remains connected to social services. Transitional Issues: - Follow up H. Pylori treatment - Follow up L inf renal mass with outpatient u/s Medications on Admission: HCTZ -- patient unsure of dose Diltiazem -- patient unsure of dose Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 13 days: end date [6-18]. Disp:15 Tablet(s) Refills:0 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. Outpatient Lab Work Please draw chemistry panel (CHEM 7) 2 days after discharge to assess renal function 5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 13 days: end date [6-18]. Disp:52 Capsule(s) Refills:0 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Upper GI bleed Acute Kidney Injury due to Rhabdomyolysis Right Lower Lobe Pneumonia complicated by empyema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital because you were found unconscious. When you were admitted, you were vomiting blood and you had a severe injury to your kidneys. You were placed in the medical intensive care unit (MICU) in order to be monitored very carefully. . When your condition improved, you were transferred to the general medicine [Hospital1 ]. However, when you were on the general medicine [Hospital1 ], it was discovered that you had an infection in your right lung. A CT scan was performed which showed that the infection was so severe that it had to be treated with surgery. You had surgery on [2188-5-27], after which two tubes were placed in your chest to drain fluid and to keep your lung inflated. These tubes were removed a few days after the surgery and your respiratory status was monitored carefully. You were started on oral antibiotics with a plan to complete a 4 week course. During your stay, you were also found to have an infection with an organism called H. Pylori. It is important for you to follow up with your primary care doctor in order to treat H. Pylori once you finish your treatment for pneumonia. The following changes were made to your medications: To treat infection: * START taking Levofloxacin 750mg tablets. Take one tablet every 48 hours for 13 days * START taking Clindamycin 300mg tablets. Take one tablet four times daily. . For your stomach: * Start Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Take One (1) Tablet, Delayed Release (E.C.) by mouth twice a day . To treat your high blood pressure: * START taking METOPROLOL XL 200mg tablet. Take one tablet daily. * Start Amlodipine 10 mg Tablet Take One (1) Tablet by mouth daily. . Again it was pleasure taking care of you. * Again it is of the utmost importance to abstain from drinking and drug use Followup Instructions: You will need to follow-up with thoracic surgery department; they will plan on contacting you; if you don't hear from them please call [Telephone/Fax (1) 3020] for an appt. . You will plan to follow-up with your PCP at [Hospital3 9947] or the at the VA. You will need to schedule an appt for 1-2 weeks. . Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2188-6-10] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2188-7-1] at 9:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4091], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Completed by:[2188-6-10**]	[ "486", "5849", "40390", "5859", "3051", "2875" ]
Admission Date: [2173-12-17] Discharge Date: [2173-12-22] Date of Birth: [2111-12-10] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Re-do sternotomy , AVR (23mm porcine) History of Present Illness: This is a 61yo male s/p AVR in [2162-6-17] for aortic valve endocarditis. He has known bioprosthetic aortic valve stenosis which has been followed by serial echocardiograms. He has also had worsening symptomatology. Current symptoms inlude dyspnea on exertion, fatigue and peripheral edema. His most recent echocardiogram showed severe aortic bioprosthetic stenosis with a peak of 74mmHg and a mean of 44.mmHg. His aortic root and ascending aorta were dilated with both measuring 4.3cm. Given the progression of his disease, he has been referred for surgical management. Recent liver workup by Dr. [Last Name (STitle) 497] showed no evidence to suggest advanced chronic liver disease. He was previously seen in [Month (only) ] and [Month (only) 359] and now presents for PATs. He has been cleared to proceed for redo operation. Past Medical History: Past Medical History: - Congestive Heart Failure(chronic, diastolic) - History of aortic valve endocarditis(Enterococcus) - History of IV drug abuse, on Methadone maintenance - Hepatitis B and C - History of Hepatitis A - Dyslipidemia - Hypertension(resolved with bariatric surgery) - Diabetes Mellitus(resolved with bariatric surgery) - History of Splenic Infarct(endocarditis) - Low Testosterone - Nephrolithiasis - Ventral Hernia Past Surgical History: - s/p AVR(25mm tissue) [2162-6-17] - [Hospital1 18] Dr. [Last Name (STitle) 1537] - Excision of a neurofibroma on the thoracic spine - s/p Bariatric surgery with Roux-en-Y bypass [2171-2-17] - Right total knee replacement Past Cardiac Procedures: Surgery: Aortic Valve Replacement [2162-6-17] Type of valve: 25mm [Last Name (un) 3843]-[Doctor Last Name ] bovine valve Social History: Race: Caucasian Last Dental Exam: Edentulous Lives with: Wife in [Name2 (NI) 47] Occupation: Carpenter Cigarettes: Smoked no [X] yes [] Hx: ETOH: None Illicit drug use: former IV drug abuser with heroin 25 years ago Family History: Denies premature coronary artery disease Physical Exam: Pulse: 65 O2 sat: 100% B/P 109/64 Height: 68" Weight: 200lb General: WDWN male in no acute distress Skin: Warm, dry and intact. Keloid scarring noted in sternotomy and prior thoracotomy incision HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Edentulous. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X]; healed back scars Heart: RRR, Nl S1-S2, IV/VI harsh holosystolic murmur Abdomen: Soft [X], bowel sounds + with large ventral hernia and healed scar Extremities: Warm [X], well-perfused [X] 1+ LE Edema on L with faint erythema, trace edema on R; healed Right knee scar Varicosities: None [X] Neuro: Grossly intact [X],nonfocal exam;MAE [5-20] strengths Pulses: Femoral Right:2 Left:1 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit Pertinent Results: Due to patient's history of gastric bypass surgery, only mid-esophageal window images were obtained. No transgastric views were attempted. PRE-CPB: The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve is present. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results at time of study. POST-CPB: There is a porcine prosthetic valve in the aortic position. The valve appears well seated with normal leaflet mobility. There is no evidence of aortic stenosis or aortic insufficiency. There are no paravalvular leaks. Biventricular function is preserved. The tricuspid regurgitation remains moderate. There is no evidence of aortic dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Name8 (MD) 17792], MD, Interpreting physician [Last Name (NamePattern4) ] [2173-12-17] 14:48 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [2173-12-17] where the patient underwent re-do sternotomy AVR (23Porcine). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. he developed a junctional rhythm and hos lopressor dose was held then decreased without further episode of junctional rhythm. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Lovastatin 10mg daily, Lisinopril 10mg daily, Aldactone 50mg daily, Methadone 80mg 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:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 4. methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 5. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 8. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: Re-do sternotomy /AVR (23 porcine)[2173-12-17] Congestive Heart Failure(chronic, diastolic), History of aortic valve endocarditis(Enterococcus), History of IV drug abuse, on Methadone maintenance, Hepatitis B and C, History of Hepatitis A, Dyslipidemia, Hypertension(resolved with bariatric surgery), Diabetes Mellitus(resolved with bariatric surgery), History of Splenic Infarct(endocarditis), Low Testosterone, Nephrolithiasis, Ventral Hernia s/p AVR(25mm CE tissue) [2162-6-17] - [Hospital1 18] Dr. [Last Name (STitle) 1537], Excision of a neurofibroma on the thoracic spine, Bariatric surgery with Roux-en-Y bypass [2171-2-17], Right total knee replacement Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage 1+ lower extremity Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] Phone:[Telephone/Fax (1) 170] Date/Time:[2174-1-19] 1:30[Hospital 31652] [Hospital ] medical office building [Last Name (NamePattern1) ], [Hospital Unit Name ] WOUND CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2173-12-30] 10:30 [Hospital ] medical office building [Last Name (NamePattern1) ], [Hospital Unit Name ] Cardiologist: Dr. [First Name8 (NamePattern2) 3924] [Last Name (NamePattern1) 20222] [Telephone/Fax (1) 6256] - the office will call you with an appointment Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 3658] in [4-20] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2173-12-21]	[ "4280", "2724", "42731" ]
Admission Date: [2108-2-28] Discharge Date: [2108-3-9] Date of Birth: [2053-12-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: DOE and LLE edema. Major Surgical or Invasive Procedure: bronch during pea arrest [3-8] History of Present Illness: [2108-3-7] MICU Resident Accept Note . cc: Transferred to MICU for acute on chronic respiratory failure. . HPI: 54 yo male with Crohn's disease c/b PSC and cirrhosis awaiting Liver transplant, pulmonary sarcoid, recent sinusitis, admitted [2-28] with cc: fever, SOB, hemoptysis and calf pain. He was amditted to the medical service He had CTA and LENI which was negative for PE but CT showed intersitital and bronchial opacties. His ANC was 530 and he was started on Cefepime, azitrho, vancomycin and admitted to the medical service on the floor. Hospital course notable for: . 1. PNA: Seen by pulmonary consult who felt likely bacterial PNA. Sputum cultures were normal. Urine legionella, serum galactomanon, cryptococcal negative. IgG positive for mycoplasma, but IgM negative ruling out acute mycoplasma. Fungal Cx neg. Pt's Vanco and Azithro d/c'd on [3-5]. . 2. PANCYTOPENIA: He was seen by heme consult for pancytopenia. DAT was positive on surface but not eluate, so he was felt to NOT be hemolyzing (this can occur in hypergammaglobulinemic states.) BM showed cellular BM- they felt liekly due to splenic sequestration vs (less likely) MDS. . 3. BRBPR: Had episode of BRBPR overnight on [3-3]. Colonoscpy normal [8-2] (inactive chrons and polyp.). Hct stable so observed, and c.diff checked. . 4. Hyponatermia:NA 128 on [3-5]. Was felt to be due to siADH and fluid resricted and diuresed with improvement to 132 on [3-8]. . 5. ID was consulted [3-3] who rec dc azithro, vanc. Capsofungin was added for candidiasis. . 6. FEN: Was not taking pos due to thrush. TFs were started on [3-6] and patient was started on pos. . Called by NF team on [3-7] at 11pm to see patient for increasing respiratory distress. VS 75%RA to 96%NRB breathing at 30 with accesory muscle use. ABG on NRB: 7.5/39/74. CXR shows worsenig bialteral infiltrates vs. failure. He was given lasix 40iv x 1, MsO4 1mg, vanco 1 g, flagyl 500 and started on mask-ventilation and transferred to the ICU team. Past Medical History: 1. IBD (Chrons) c/b PSC awaiting OLT 2. Pancytopenia, NOS 3. PSC cirrhosis 4. Recent sinusitis s/p ENT drainage on levofloxacin x 2 weeks 5. Pulmonary sarcoid diagnosed by lung biopsy x 19 years (off steroids x 10 years) 6. Thrush . Meds on Transfer: Acetaminophen Albuterol 0.083% Neb Soln Albumin 25% (12.5gm) Benzonatate Caspofungin Cefepime Cetylpyridinium Chl (Cepacol) Chlorhexidine Gluconate Clotrimazole Dolasetron Mesylate Ferrous Sulfate Furosemide Guaifenesin-Dextromethorphan Ipratropium Bromide Neb Maalox/Diphenhydramine/Lidocaine Mesalamine Multivitamins Neutra-Phos Nystatin Oral Suspension Oxycodone Pantoprazole Phenaseptic Throat Spray Promethazine HCl Senna Ursodiol Zinc Sulfate traZODONE HCl Social History: Lives with wife, no alcohol, no tobacco (quit 25 years ago). Engineer on disability. Family History: NC Physical Exam: 101.8 Tc; 111/39 ; 126 ; 37 ; 100% on mask ventilation with PS [10-3] GEN: With mask ventilation on HEENT: PERRLA, + scleral icterus NECK: JVP 1cm above sternal notch LUNGS: Bilateral basilar rales; no wheezes COR: Tachy, no murmurs ABD: Soft, NT + palpable spleen tip, no fluid wave, ND EXT: 2+ edema NEURO: Moving all 4 extremities equally, no asterixis SKIN: 1cm purpuric lesions on dorsum of feet Pertinent Results: [3-7] at 0600: WBC 2.7, hct 26.6, plt 111, mcv 106 50%PMNs, 12%bands, 28%lymphs . 132/97/11 -------- < 108 4.0/32/0.8 . Ca 7.3/ Mg 1.7/ P 2.4 . CXR:Worsening bibasilar infilatrates Brief Hospital Course: 1. Respiratory Failure: History of pulmonary sarcoid and now with worsening pneumonia. Pt was just recently started on Tube feeds and pos-- aspiration is possible. Given fever, worsening bibasilar infiltrates PNA likely although worsening sarcoid cannot be ruled out. Was given Lasix/MsO4/NTG with no diuresis by NF team. Had negative CTA/LENI on admission. Patient was intubated for respiratory failure on am of [3-8]. Very hypoxic requiring Fio2 100%, high peep. Even so, he began to desat to 40% and had a PEA arrest subsequent to this. His O2 sats were improved after about 45 minutes of coding the patient with very high PEEPs and continued Fio2 100%. AFter patient continued to decline, an esophageal baloon was used to measure pleural pressures and pt. was tried on nitric oxide to vasodilate pulm arteries without success. . 2. CVS. Does not appear to be in pulmonary edema. Was given lasix/MsO4/NTG without effect. Echo [6-2] shows normal EF. Echo during code with big RV but . 3. Hepatology: PSC with cirrhosis awaiting Liver transplant. . U/S shows diffusely heterogeneous and nodular liver, consistent with the given history of PSC and cirrhosis, minimal ascites, patent portal vein. Patient developed shock liver after pea arrest. . 4. Renal. Creatinine Stable. ABG shows metabolic alkalosis, likely due to intravascular volume depletion. Continue to monitor. After arrest, pt. had significantly elevated lactate and metabolic and resp acidosis. The resp acidosis was eventually resolved but patient continued to be more and more acidotic with a rising lactate to a max of 30. . After PEA arrest, patient was as mentioned above VERY difficult to ventilate and oxygenate with a rising lactate (to a max of 30 prior to his death). He was very volume overloaded and requiring at times 4 pressors to maintain adequate MAPS. He had multiorgan dysfunction with anuric renal failure, shock liver, possible anoxic brain injury with fixed, dilated fluids, respiratory failure. He also had rising INR and possible DIC with some bleeding from the ETT tube. Renal felt HD or CVVH would NOT be tolerated. As the patient continued to decline and was heading towards another cardiac arrest despite broad specturm antibiotics including antifungals, pressors, bicarbonate drips and boluses, a family meeting was held and it was decided that patient would be made comfort measures only. Patient was not, however extubated and pressors were continued per family request. Patient died several hours later at 8:35 PM. The family agreed to a Post with the exclusion of the brain. Medications on Admission: Mesalamine 1200mg qd MVI Mylanta Zinc Ursodiol 1200mg [Hospital1 ] Levaquin 500mg qd Tussin DM Chlorhexidine Mouthwash Codeine Tylenol Discharge Medications: none, expired Discharge Disposition: Expired Discharge Diagnosis: respiratory failure shock liver renal failure pea arrest crohns sepsis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "486", "5849" ]
Admission Date: [2178-2-23] Discharge Date: [2178-3-5] Date of Birth: [2108-10-16] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6736] Chief Complaint: Renal subcapsular hematoma Major Surgical or Invasive Procedure: Embolization of renal artery branch (inferior branch of a duplicated renal artery) [2178-2-26] History of Present Illness: 69M w/ severe vasculopathy, on Coumadin for mechanical aortic valve being followed by Dr. [Last Name (STitle) ] [Last Name (STitle) ] a stable 2.8 cm RLP enhancing renal mass suspicious for carcinoma who presented to OSH with new onset right flank pain. A CT scan was performed, which per report demonstrated a subcapsular hematoma with associated stranding in the perinephric space and within the retroperitoneum. The patient was noted to have minor abdominal tenderness and positive psoas sign. He is on Coumadin for a mechanical aortic valve. He has had nausea and vomiting associated with this episode. Prior to this episode, the patient had a syncopal episode with a fall of a ladder approximately one month ago. At that time, the patient's Hct was 38. He does not recall if he hit his right flank during that fall. Past Medical History: PMH: TIA ([2158], [2163], [2165]), CVA ([2164], [2166]) now on coumadin (goal 2.5-3.5), asc. aortic aneurysm (6.2cm), severe HTN, anti-Fy(a) antibodies, hypercholesterolemia, arthritis PSH: AVR ([2146]--mechanical), redo AVR with R subclavian to carotid bypass with asc. aortic replacement, s/p aoritc arch endovascular stent on [2175-8-8], LCFA to L axillary bypass graft [2175-11-21]; RIHR; PVP with TURP [2174]; lipoma excision ([2170]) Meds: coumadin 6-7.5mg [Last Name (LF) ], [First Name3 (LF) ] 81mg, diovan 80mg [Hospital1 ], norvasc 5mg [Hospital1 ], IC bisoprolol fumarate 2.5mg [Hospital1 ], meloxicam 15mg, citalopram 20mg, zytrec [Hospital1 ], vytorin [9-14] [Month/Year (2) ], APAP prn All: NKDA Social History: Lives with wife. [Name (NI) 4084] smoked. Occasional alcoholic beverage. Family History: Mother died in her 60's of heart disease Physical Exam: General: comfortable Abd: non tender, softly distended, flank ecchymosis Void: clear yellow urine Pertinent Results: [2178-3-5] 06:30AM BLOOD Hct-26.9* [2178-3-5] 06:30AM BLOOD PT-28.9* PTT-38.6* INR(PT)-2.9* [2178-3-5] 06:30AM BLOOD Glucose-124* UreaN-33* Creat-1.5* Na-135 K-4.2 Cl-94* HCO3-29 AnGap-16 Brief Hospital Course: Mr. [Known lastname 63903] renal bleed was initially managed conservatively with bedrest and transfusion for hematocrit goal 30. He was anticoagulated throughout his stay for INR 2.5-3.5 goal, given his mechanical aortic valve. On [2178-2-25], he had acute back and chest pain, emergent CT scan identified no dissecting aneuysm and cardiac enzymes and serial EKG identified no myocardial infarction. He required daily transfusions for 5 days and had increased right flank pain and shortness of [Last Name (LF) 1440], [First Name3 (LF) ] underwent embolization of a branch of one of his right renal arteries supplying the inferior pole [2178-2-26]. Patient tolerated procedure without complications, no infections of hematoma, monitored in ICU before transfer to the floor. He has been hemodynamically stable since embolization. At discharge patient's pain well controlled with no narcotics, tolerating regular diet, ambulating without assistance, and voiding; Hct 27, INR 2.9. Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 8PM (): Titrate for INR 2.5-3.5. Disp:0 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:0 Tablet, Chewable(s) Refills:0 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:0 Tablet(s) Refills:0 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 5. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO at bedtime. Disp:0 Tablet(s) Refills:0 6. Meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day. Disp:0 Tablet(s) Refills:0 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 8. Zyrtec Oral 9. Vytorin [9-14] 10-20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:0 Tablet(s) Refills:0 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 weeks. Disp:20 Capsule(s) Refills:0 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 1 weeks. Disp:60 Tablet(s) Refills:0 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Renal subcapsular bleed Discharge Condition: Stable Discharge Instructions: Resume all of your home medications, NO CHANGES in your home medications including doses. Continue your coumadin, check with your coumadin team for INR check within 3 days of discharge. Call Dr.[Name (NI) 10529] office to schedule a follow-up appointment AND if you have any questions. If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: 1. Call Dr.[Name (NI) 10529] office to schedule a follow-up appointment. 2. Continue your coumadin, check with your coumadin team for INR check within 3 days of discharge.	[ "5849", "2851", "V5861", "4019", "2724" ]
Admission Date: [2103-6-9] Discharge Date: [2103-6-26] Date of Birth: [2055-11-14] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female, with a history of COPD and asthma, schizoaffective disorder, hypertension, hypercholesterolemia, hypothyroidism, ETOH and benzodiazepine abuse, who was admitted [6-9], status post fall prior, with some associated resulting leg weakness, found to have a T8 radiculopathy and mild myelopathy secondary to retropulsion and cord compression. CT scan of the spine showed T8 retropulsion with possible cord compression. HOSPITAL COURSE: The patient underwent a T8 vertebrectomy and T7-9 stabilization that was done [2103-6-11] by neurosurgery, with no complications. The patient was continued on a Solu-Medrol drip postoperatively, and changed to hydrocortisone on [6-12]. The patient was sent to the Surgical Intensive Care Unit postoperatively and was extubated on [6-13]. On [6-13], she was also noted to have bright red blood per rectum with no associated nausea, vomiting, or any abdominal pain, tachycardic to 120s, with hypotension, blood pressures 160-100. The patient received, at that time, 4 units of packed red blood cells, as well as 4 units of FFP. Hematocrit noted to drop from 34-24 after the bleed, but then increased back to 34 with transfusion during that time. The patient had a GI consult, with a colonoscopy that was recommended, but deferred given the patient's recent stabilization of bleeding and recent postoperative neurosurgery. The patient progressed reasonably well until [6-15], when the patient was transferred to a regular medical floor, 98% on nasal cannula. On [6-17], in the morning the patient had an increasing episode of respiratory distress with O2 saturations noted to be 90-92% on 3 liters nasal cannula, in spite of receiving albuterol and aggressive chest physical therapy. Noted was thick green sputum that was suctioned. The patient was started on PO Levaquin. A CTA that was done was negative for pulmonary embolism. A chest x-ray, as well as the CTA, noted a left lower lobe consolidation consistent with pneumonia, as well as bilateral ground glass opacities. The patient was still coughing up green sputum with saturations 88-92% on [3-27] liters nasal cannula. On [6-19], the patient received some lasix 20 mg IV for respiratory distress with no change in respiratory status. On [6-20], a pulmonary consult was recommended. The consult was done. Recommendations included a change for broader antibiotic coverage to include gram-positive rods, as well as gram-negative rods, and anaerobes. Therefore, Zosyn and vancomycin IV were started, and Levaquin was DC'd during that time. Later that afternoon, the patient had another episode of respiratory distress with tachypnea and O2 saturations in the 80s. Therefore, it was decided that the patient would be transferred to the Medical Intensive Care Unit at that time. PHYSICAL EXAM: Vitals - 98.8, blood pressure 169/90, respirations between 22-30, pulse 100-112, satting 92% on O2 nonrebreather. The patient is an obese female in moderate respiratory distress, speaks [4-28] words before pause. Pupils are equal and reactive to light and accommodation. Extraocular movements intact. Oropharynx clear. Neck - no JVD. Respiratory - is wheezing bilaterally with coarse breath sounds, symmetrical. Heart - regular rate and rhythm, S1, S2 noted, II/VI systolic ejection murmur. Abdomen is nontender and nondistended, positive bowel sounds. Extremities - no cyanosis, clubbing, or edema. Neurological exam - alert and oriented, moving all extremities. LABORATORIES: White count 24.2, hematocrit 32.4, platelets 169, sodium 140, potassium 4.0, chloride 99, bicarbonate 27, BUN 23, creatinine 0.7, glucose 101, calcium 9.1, PT 24.9, PTT 28.8, INR 4.1. ABG - pH 7.45, PCO2 47, PO2 57, bicarbonate 34. Chest x-ray showed bilateral consolidation, done on the [6-20]. The [6-16] CT angiogram of the chest showed no evidence of pulmonary embolism, with left lower lobe consolidation, and bilateral ground glass opacities. A [6-18] stool cultures were negative for Clostridium difficile. A [6-17] sputum was negative. For respiratory distress, the patient received albuterol and Atrovent nebulizers as needed. Hydrocortisone 100 mg IV q 8 h was started, as well as aggressive chest PT, suctioning, and elevation of head of bed with aspiration precautions. Etiology of respiratory distress likely due to pneumonia, possible hospital acquired. Therefore, the patient was started on Zosyn and vancomycin. Sputum cultures would be checked serially. Because of the recent lower GI bleed, serial hematocrits were checked. Protonix was given. If decreasing hematocrits noted, then a bleeding scan would be needed. The patient was started NPO and given intravenous fluids of D5 [1-25] normal saline started. Hypotension was treated with patient's hydralazine 10 mg q 6 h as needed. Over the course of the hospital stay, results of sputum cultures showed gram-positive cocci in pairs and clusters, with noted moderate oropharyngeal flora and presence of yeast. Urine cultures done serially all showed negative results. Hematocrits during the rest of the hospital stay to time of discharge were stable with no hematocrit ever going below a target value of 30 despite fear of hematocrit measurements. PSYCHIATRIC ISSUES: The patient was continued on all prehospital psychiatric medications. A psychiatric consult was done on [6-24] with recommendations that the patient stay on psychiatric medications, and ativan be administered as a standing dose instead of prn. During the first day in the ICU, the patient had continuing respiratory distress with hyperventilation, despite being on pressure support with biphasic positive airway pressure. Therefore, the decision was made to intubate the patient on [6-21]. The patient was also started on tube feeds for a question of aspiration on PO. Noted was continuous suctioning of thick secretions, but changing in consistency to white from a previous color of yellowish-green. The patient was ventilated on assisted control with a tidal volume of 550, rate of 16, PEEP of 5, and a FIO2 of 0.4 on initial settings which she tolerated well per serial ABGs. On [6-22], the patient was started on a trial of pressure support ventilation from assisted control which she tolerated well. Therefore, later on on that day on [6-22], the patient was extubated successfully and started on albuterol and Atrovent nebulizers standing dose q 3 h, tube feeds were held, and the patient was kept NPO due to aspiration precautions. Left lower extremity ultrasounds were negative for DVT. Also, the patient's vancomycin on [6-23] was DC'd, since sputum culture showed no evidence of Methicillin resistant Staphylococcus aureus. Serial urinalysis done showed no evidence UTI throughout the rest of the hospital stay. On [2103-6-24], psychiatry was consulted given patient's multiple episodes of respiratory distress, status post extubation. They noted that the patient's anxiety was a large component of her respiratory distress. Psychiatry's recommendations were that the patient would continue with all of her preadmission medications, and that ativan should be considered as a standing dose of 0.5 mg tid. Recommendation was also to check a TSH for possible hyperthyroidism as a source of her anxiety. The patient's hydralazine was discontinued, and diltiazem was started at 30 mg po qid, given patient's unresponsiveness to hydralazine and recent clonidine trial of 0.1 mg po. It was thought that hydralazine was causing a reflex tachycardia which would be contributing to the patient's anxiety component. The patient was also switched to an oral steroid dose of prednisone 60 mg po qd during that same time. Over the rest of the hospital course, the patient's respiratory status improved remarkably. The patient's high blood pressure was improved slightly. The patient's respirations rate decreased from high-30s, to low-40s, to the 20s. Physical therapy tried evaluating the patient on [2103-6-25] and recommended that the patient would be a good candidate for improvement, but patient did not comply with all physical therapy exercises. Today, on [2103-6-26], the patient has been stable and has improved throughout hospital stay. Therefore, the decision was made to discharge the patient to rehabilitation for continued PT therapy. The patient is to be discharged in stable status. DISCHARGE MEDICATIONS: 1) clonazepam 250 mg po q hs, 2) clomipramine 150 mg po qd, 3) nicotine patch 40 mg TD qd, 4) thiothixene 20 mg po q am, thiothixene 10 mg po q pm, 5) doxepin 50 mg po qd, 6) Combivent inhaler 3 puffs qid, 7) fluticasone inhaler MDI 4 puffs [Hospital1 ], 8) Protonix 40 mg po qd, 9) diltiazem 30 mg po qid, 10) heparin subcu 5,000 U, may DC once patient is able to tolerate physical therapy and is ambulating well, 11) ativan 0.5 mg po tid, 12) Zosyn 4.5 gm IV q 8 for 3 days postdischarge. TREATMENTS: The patient must have TLSO brace on at all times. The only time patient can have off is when patient is lying flat in bed. The patient is started on diabetic diet with aspiration precautions. DISCHARGE DIAGNOSES: 1) Chronic obstructive pulmonary disease exacerbation with left lower lobe pneumonia. 2) Status post T8 vertebrectomy. 3) Schizoaffective disorder. 4) Hypothyroidism. 5) Hypertension. 6) Hypercholesterolemia. FOLLOW-UP WITH THE FOLLOWING PHYSICIANS: Neurosurgeon - [First Name8 (NamePattern2) ] [Name8 (MD) 1327], MD, follow-up within 2 weeks, ([Telephone/Fax (1) 88]. The patient is to follow-up with primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24564], within 2-3 weeks, ([Telephone/Fax (1) 24565]. Finally, the patient is to follow-up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], Psychiatric NP, within 2-3 weeks at ([Telephone/Fax (1) 24566]. She should also follow-up with a pulmonologist. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 17322] MEDQUIST36 D: [2103-6-26] 11:49 T: [2103-6-26] 10:51 JOB#: [Job Number 24567]	[ "51881", "486", "2449", "2720", "4019" ]
Admission Date: [2200-11-24] Discharge Date: [2200-12-2] Date of Birth: [2147-9-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3043] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: -Temporary HD catheter placement and removal -hemodialysis 1 History of Present Illness: Mr. [Known lastname 83881] is a 53 year old man with recent THR, HTN, and diabetes on insulin who was found unresponsive sitting in a chair in his halfway house by his superintendent. He was reportedly sitting in a chair and was completely unresponsive. When EMS arrived they found him unresponsive and non-verbal but with stable vital signs. He was given 0.4mg naloxone with no response. On route to the hospital he vomited a small amount. In the ED he was unresponsive but was moving his head around. His vital signs in the ED were T 98.8 HR 88, BP 124/66 RR 11 saturating at 97% on room air. Ct head and spine were unremarkable. Chest xray was also unremarkable. Urine tox was positive for opiates. Serum tox was negative. UA was negative for leukocytes and nitrites; WBC [11-28], large blood, RBC negative. Patient had a leukocytosis with a WBC of 22. He was given 1 dose of vancomycin. His creatinine was elevated to 8.9 (baseline 0.8) and he had a potassium of 6.3 with peaked T waves. Patient was given bicarb, insulin, and glucose and his potassium decreased to 5.1. No kayexelate was given due to patient's altered mental status. Nephrology was consulted and recommended rehydration at 125cc/hr, potassium checks, renal US with doppler, and PTH level. Patient was given a total of 2L NS in the ED and then admitted to the intensive care unit where he was moving all four extremities but only rarely followed commands and was not reliably responsive to voice. Past Medical History: -Hypertension -Diabetes mellitus on insulin (A1C 6.3% on [2200-10-29]) -Hypertensive cardiomyopathy (last ECHO 35% EF with septal/inferior hypokinesis) -Hepatitis C Virus (never treated) -h/o cholecystitis -s/p hip replacement -Gambling addiction -h/o EtOH and cocaine abuse, sober since [2195] Social History: Patient has lived at the [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] House where he has lived for the past three years. He reports that he stopped drinking and cocaine several years ago. He receives health care through health care for the homeless. Patient has long standing history of smoking and continues to smoker. Family History: Non-contributory Physical Exam: ADMISSION EXAM: T 98.8 HR 88, BP 124/66 RR 11 saturating at 97% General: easily awaked and startled, non-verbal HEENT: NC/AT, will not allow me to open eyes well but pupils appear 2mm and symmetric Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally but difficult to assess with rhonchorous upper airway sounds Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted, no fistula, no medical patches Neurologic: limited exam -mental status: drowsy but arousable with follow a few commands: smiled symmetrically once, squeezed right hand but then would not follow further commands, when arm raised above head patient does not allow arm to fall on his face, when turned patient grabbed out to stabalize himself -cranial nerves: unassessable but symmetric smile -motor: normal bulk, strength and tone throughout. not moving extremeties -DTRs:1+ biceps, brachioradialis, 2+ patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. +myoclonus Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-22.1 RBC-3.95* Hgb-13.1* Hct-39.0* MCV-99* RDW-13.6 Plt Ct-191 ---Neuts-77.3* Lymphs-16.1* Monos-6.0 Eos-0.3 Baso-0.2 PT-13.8* PTT-23.4 INR(PT)-1.2* Fibrino-353 UreaN-51* Creat-9.0* ALT-54* AST-81* LD(LDH)-506* AlkPhos-148* TotBili-0.5 Albumin-4.2 Calcium-8.7 Phos-7.9* Mg-1.9 Osmolal-317* On Discharge: WBC-12.4* RBC-3.12* Hgb-10.3* Hct-32.6* MCV-99* RDW-13.2 Plt Ct-220 Glucose-239* UreaN-22* Creat-1.2 Na-137 K-4.1 Cl-101 HCO3-27 ALT-35 AST-28 CK(CPK)-614* AlkPhos-96 TotBili-0.8 Calcium-9.1 Phos-2.9 Mg-1.6 Other Important Labs: CK Trend [2200-11-24] 04:20PM CK(CPK)-5015* [2200-11-24] 11:20PM CK(CPK)-6561* [2200-11-25] 04:28AM CK(CPK)-6445* [2200-11-25] 08:34PM CK(CPK)-4367* [2200-11-26] 06:03AM CK(CPK)-3207* [2200-11-26] 05:07PM CK(CPK)-[2191]* [2200-11-29] 11:06AM CK(CPK)-614* Cardiac Enzymes: [2200-11-24]: cTropnT-0.05* [2200-11-25]: cTropnT-0.07* Serum Tox:ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine Studies: -------------- Tox Screen [2200-11-24]: bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [2200-11-24] Osmolal-521 [2200-11-24] Color-Amber Appear-Clear Sp [Last Name (un) ]-1.026 Blood-LG Nitrite-NEG Protein-75 Glucose-1000 Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG UreaN-398 Creat-327 Na-33 CastGr-0-2 CastHy-[6-18]* RBC-0-2 WBC-[11-28]* Bacteri-MOD Yeast-NONE Epi-0 TransE-0-2 [2200-12-1] Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 Blood-MOD Nitrite-NEG Protein-TR Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-31* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 CastHy-1* ============= MICROBIOLOGY ============= Blood Cultures 3: No growth Nasal MRSA Screen: Positive for MRSA Urine Culture2:NGTD =============== OTHER STUDIES =============== EKG ([2200-11-24]): Normal sinus rhythm, rate 98, with probable left atrial abnormality. Delayed precordial R wave progression, possibly a normal variant, possibly anterior myocardial infarction of indeterminate age. Non-specific inferolateral repolarization changes. CT Head and C-spine ([2200-11-24]): 1. No acute fracture or misalignment of the cervical spine. Multi-level posterior osteophytes which increases risk of spinal cord injury. MRI is more sensitive for evaluation of spinal cord or ligamentous injury. 2. Mild paraseptal likely bullous changes of bilateral lung apices. Miniscule left apical pneumothorax can not excluded. Follow-up suggested. 3. 1.6 cm right thyroid nodule. Ultrasound on a non-emergent basis is suggested. CXR ([2200-11-24]): Severely limited study due to obscuration of the lung apices by the head, otherwise no acute intrathoracic abnormality. Abd U/S ([2200-11-25]): 1. Stones and debris in the gallbladder. 2. No evidence of stones or hydronephrosis bilaterally. CT Head w/o Contrast ([2200-11-26]): 1. No acute intracranial hemorrhage. No significant change since the prior study. 2. No soft tissue stranding or any significant abnormalities seen within the subcutaneous tissues to explain etiology of drainage. Left Foot Radiograph ([2200-11-29]): REASON FOR EXAM: Pain in the lateral aspect. There is a question of a fracture in the distal phalanx of the fifth digit. There is no evidence of dislocation, sclerotic lesions or soft tissue calcifications. There is edema in the soft tissues adjacent to the base of the fifth metatarsal. The fifth metatarsal is normal. There is a small enthesophyte at the insertion of the Achilles tendon. Chest Radiograph ([2200-12-1]) IMPRESSION: Improving bibasilar opacities with residual right infrahilar opacity likely due to atelectasis. No definite new source of infection. Brief Hospital Course: Mr. [Name13 (STitle) 83882] is a 53 year old gentleman with past medical history notable for HTN, diabetes mellitus, and recent total hip replacement found unresponsive in his halfway house with rhabdomyolysis and acute kidney injury. 1. Altered Mental Status: The patient presented with altered mental status of unclear etiology. He was moving all four extremities and hemodynamically stable and afebrile but minimally responsive to commands. Particularly given his leukocytosis occult infection was a major concern but he remained afebrile, chest radiograph and urinalysis were not consistent with infection, and patient never had meningismus or clinical signs of acute bacterial meningitis. He received one dose of vancomycin at presentation for unclear reasons. Blood cultures remained sterile. Toxicology screen was only notable for opiates, which the patient had been prescribed as he recovered from his hip surgery and he had not responded to naloxone on EMS arrival. There was no osmolar gap and the patient's head CT was essentially benign. Given acute kidney injury uremia was thought to be a possible cause of encephalopathy and he was dialyzed 1 with rapid improvement of his mental status and increased responsiveness. The patient dramatically improved over the ensuing day and returned to baseline. He remained with poor memory of the events leading to his presentation but could recall other events and converse in a reasonable manner. Unfortunately, due to the patient's habitus an initial attempt at an LP was unsuccessful and given his dramatic resolution with dialysis, decreasing leukocytosis, lack of fever, and ability to deny headache it was not considered necessary to reattempt. Likely cause of somnolence/delirium at presentation is thought to be uremia though the initial insult that caused patient to be immobile and develop rhabdomyolysis leading to [Last Name (un) ] and uremia is unclear. At the time of discharge patient's mental status was at baseline. Oliguric Acute Kidney Injury: On presentation the patient had a Cr of 9 up from a baseline reported at 0.8. Given urinalysis findings of large blood on dipstick without cells and grossly elevated CK most likely etiology was thought to be rhabdomyolysis and myoglobinuria causing acute kidney injury. Obstruction and postrenal insult was essentially ruled out by normal ultrasound. Nephrology was involved in course from the ED where they recommended fluids. The patient eventually put out very poor urine and given this, his metabolic abnormalities (including hyperkalemia and hyperphosphatemia), and his continued alteration of mental status he had a temporary dialysis catheter placed and received HD 1 with rapid resolution of his metabolic abnormalities and mental status. Shortly after that he began a brisk diuresis and required no further HD sessions or acute management of electrolyte abnormalities. Therefore, his HD catheter was removed. His Cr was down to 1.2 at the time of discharge. Rhabdomyolysis At presentation the patient had clear rhabdomyolysis and resulting kidney injury with elevated CK's and urine dipstick with large blood but few RBC's on microscopy suggestive of myoglobinuria. It was suspected the patient's rhabdomyolysis was secondary to prolonged immobilization in his chair and over his hospitalization he developed skin and tissue breakdown also suggestive of a prolonged immobilization. The reason for this prolonged immobilization is unclear. The patient's CK fell with fluids and improvement in his renal function and the last time it was checked it was slightly more than 600. * Left Foot Vesicle The patient had hyperkeratotic, cracked skin on his feet and was noted to develop a large vesicle on his left lateral sole. This was evaluated by podiatry who lanced it yielding serous material without frank purulence. They did not recommend antibiotics and these were not started. The patient was discharged with outpatient podiatry follow-up. * Skin Breakdown The patient was noted to have skin breakdown with what looked like a friction ulcer in his gluteal cleft. This was evaluated by wound care who also noted areas of deep tissue injury and other ulcers on his lower body. These were thought consistent with a prolonged immobilization with some friction injury from sliding or unintentional movements while unconscious in a chair. These were all evaluated and showed no signs of acute infection. Wound care was implemented and the patient will have VNA to help continue this care as an outpatient. Hypertension The patient became hypertensive on his second hospital day and thus was restarted on his metoprolol and nifedipine at home doses. His lisinopril was held given he had acute kidney injury. As his Cr was close to baseline (down to 1.2) and he was becoming more hypertensive again (SBP's in the 140's) his lisinopril was restarted at half dose (20 mg daily) on the day of discharge. He will follow up with his PCP to discuss when to increase this back to his standard home dose. Diabetes The patient was continued on his home insulin glargine dose as well as insulin sliding scale. His AC doses and metformin were held in the context of hospitalization and he was given sliding scale with reasonable control of his blood sugars. His AC humalog and metformin were restarted at discharge. Given the patient evidenced minimal understanding of his diabetes or its management he received diabetes education in house and was set up to receive more as an outpatient. As he ran quite hyperglycemic in general it was considered safe to discharge him on his home scheduled insulin regimen with greater understanding required to start sliding scale at home. * Slightly elevated LFT's: On day of admission patient had elevated LFTs with an ALT 54, AST 81, Alk Phos 148, Tbili 0.5. Patient had gall stone on abdominal US. With improvement of mental status patient had benign abdominal exam with no nausea or vomiting. LFTs were followed and normalized. Most likely etiology of * Diabetes Patient has insulin dependent diabetes. He was started on an insulin sliding scale here in the hospital. An outpatient podiatry appointment was set up for him. Hypertensive Cardiomyopathy The patient remained without signs of volume overload or clinical heart failure. He was continued on his beta blocker and ACEi was restarted prior to discharge. The patient was kept on subcutaneous heparin for DVT prophylaxis. There was no indication for GI prophylaxis so this was not started. He was full code. He tolerated a full diet prior to discharge. Medications on Admission: toprol XL 200mg QD nifedipine 120mg QD lisinopril 40mg qd aspirin 81mg qd naproxen 500mg [Hospital1 ] lantus 58 units/day metformin 500mg [Hospital1 ] humulog 6u AC nitrostat prn tramadol 50mg 1-2 tabs q6h prn pain citalopram 20mg qd Discharge Medications: 1. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Nifedipine 60 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO once a day. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s)* Refills:0 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lantus 100 unit/mL Solution Sig: Fifty Eight (58) units Subcutaneous once a day. 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous TID w/ meals. 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for fever or pain. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnoses: Altered Mental Status Rhabdomyolysis Oliguric Acute Kidney Injury Secondary Diagnosis Hypertension Diabetes Mellitus Discharge Condition: Stable, tolerating PO Discharge Instructions: You came into the hospital because you were found unresponsive in your home. No cardiac, neurological, infectious, or toxic reason was found for your unresponsiveness. When you came into the hospital you were found to have damaged your kidneys and you were started on intravenous fluids. You also had one session of hemodialysis to remove some of the toxins from your blood that had accumulated given your poor kidney function. During your stay in the hospital your kidney function improved dramatically and returned to near baseline on your discharge from the hospital. To keep your kidneys healthy, we recommend that you continue to drink over 1L of water each day. While your kidneys recover we held and then restarted at a lower dose your lisinopril. Otherwise please continue to take your medications as previously prescribed. Should you develop any concerning symptoms, including shortness of breath, chest pain, severe abdominal pain, nausea/vomiting, fever, blurry vision, headache, you should seek immediate medical attention. Followup Instructions: PODIATRIST Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 7749] Tueday, [12-9], 1:45pm [Location (un) 83883], [Location (un) ] [Telephone/Fax (1) 83884] PRIMARY CARE Dr. [Last Name (STitle) 11435] [2201-12-12]:30am [Street Address(1) ] Clinic [Telephone/Fax (1) 83885]	[ "5849", "2762", "25000", "2859", "V5867" ]
Admission Date: [2102-1-18] Discharge Date: [2102-1-19] Service: MEDICINE Allergies: Aleve Attending:[First Name3 (LF) 1145] Chief Complaint: cc:[CC Contact Info 65637] Major Surgical or Invasive Procedure: cardiac catheterization s/p 2 DES History of Present Illness: HPI: Patient is an 83 year-old woman with HTN, Hyperlipidemia who was getting pain with exertion in her left chest for the past year, worse for the past 2-3 months. Also increasing DOE after exterion, stress. Stress test done 2 months ago showed fixed inferior posterior perfusion defect with EF 64% and upsloping ST depressions -- Patient developed exhaustion and substernal chest discomfort after walking only a short distance on the treadmill ([2101-11-9]). Patient delayed cath until now. On ROS, denied abdominal pain, urinary complaints. Reports occasional DOE, occasional PND. . Cath on [2102-1-18] showed Right Dominant System with 2 vessel disease: diffusely diseased RCA with 90% mid-RCA stenosis, 70% proximal Cx stenosis, and 50% mid-Cx stenosis --> DES to RCA, DES to LCX. Given history of possible aspirin allergy (patient broke out in hives several years ago after taking Alleve and was told by an alergist that she should avoid ASA), patient was admitted to CCU for desensitization while under Integrillin and Plavix therapy. Past Medical History: 1. HTN 2. Hyperlipidemia 3. CCY 4. Kidney stones in [2076] 5. Benign R lumpectomy [2076] 6. Bilateral arthroscopic knee surgeries 7. Inactive TB? Social History: Married for 58 years. Retired broker. Son and daughter in law live in area. Lives with husband at home. Family History: CAD: Sister had bypass at age 89. Mother had MI at age 63. Brother had Mi at age 52. Another brother with CVA in 50s. Physical Exam: VS: T 96.6; BP 128/44; HR 49; RR 16; 99% RA GEN: Pleasant, NAD, comfortable HEENT: MMM. JVP 8 cm. CV: S1S2 RRR. loud s2 ? click. No MRG LUNGS: CTA B/L ABD: soft, NT/ND. +BS. No femoral bruits. EXT: 2+ DPs, full. Trace ankle edema. NEU: AO x 3. Pertinent Results: Cardiac catheterization [2102-1-18]: 1. Selective coronary angiography in this right dominant patient revealed two vessel coronary artery disease. The LMCA was normal. The LAD had diffuse minor disease. The LCx had a proximal ulcerated 70% lesion and a proximal OM1 lesion of 50%. The RCA had a tight mid 90% lesion. 2. Limited resting hemodynamics revealed a blood pressure of 186/74 with mean of 102 which was treated with nitro drip. 3. Successful placement of 2.5 x 28 mm Cypher drug-eluting stent in mid-RCA postdilated with a 2.75 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 4. Successful placement of 3.0 x 8 mm Cypher drug-eluting stent in proximal LCx. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Aspirin desensitization in the intensive care unit today. 6. Successful placement of 6 French Angioseal device in right femoral arteriotomy without complications. FINAL DIAGNOSIS: 1. Two vessel CAD 2. Moderate severe systemic hypertension. 3. Successful placement of drug-eluting stent in mid-RCA. 4. Successful placement of drug-eluting stent in proximal LCx. 5. Successful placement of Angioseal in right femoral arteriotomy. 6. Aspirin desensitization today in intensive care unit. Brief Hospital Course: Patient is an 83 year-old female with HTN, Hypercholesterolemia, and recent +Myoview ([10-17]) who was admitted for cardiac catheterization. Patient was taken to the catheterization laboratory where 2 vessel CAD was seen. Patient received 2 drug eluting stents to RCA and LCx, respectively (see Pertinent Results section for full details); she tolerated procedure well. Given history of Aspirin allergy, patient was subsequently admitted to the CCU for staged desensitization. Patient was successfully desensitized and outpatient medications were restored. Patient to continue ASA indefinitely and Plavix for minimum 6 months. Patient was discharged home the following day on her routine medications to follow-up with her PCP and cardiologist. Medications on Admission: Isosorbide 30mg PO qd Toprol 50mg PO qd Plavix 75mg PO qd Lipitor 10mg PO qd Diovan 160mg PO qd Tylenol PRN headaches Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: CAD s/p DES to RCA and LCx Discharge Condition: hemodynamically and clinically stable Discharge Instructions: 1. Please take all medications as prescribed 2. If you develop chest pain, shortness of breath, or any other concerning signs/symptoms, please contact your PCP or report to the Emergency Room immediately. 3. Please make all follow-up appointments Followup Instructions: Please make an appointment to see your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 58201] in [8-21] days. The number is [Telephone/Fax (1) 65012]. Please make an appointment to see your cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 26191] in 1 month. The number is [Telephone/Fax (1) 65638] Completed by:[2102-1-19]	[ "41401", "4019", "2724" ]
Admission Date: [2130-7-26] Discharge Date: [2130-8-2] Date of Birth: [2058-11-17] Sex: F Service: MEDICINE Allergies: Shellfish / Percocet / Zosyn / Amiodarone Attending:[First Name3 (LF) 398] Chief Complaint: Fever/hypotension Major Surgical or Invasive Procedure: Placement of rt subclavian central venous catheter Placement of rt antecubital PICC line History of Present Illness: 70yoF with h/o influenza A infection c/b ARDS s/p trach, afib, and tracheocutaneous fistula now presents with hypotension and fever. Pts initially presented to [Hospital6 ] in [4-10] with influenza A infection complicated by ARDS and prolonged ventilator course requiring tracheostomy and was discharged to [Hospital1 ] with tracheostomy tube but off ventilatory support. She returned with hypercarbic respiratory failure requiring mechanical ventilation through ET tube. She was found to have a LLL PNA, paroxysmal rapid AFib (hr 180s) and pneumomediastinum, upper esophageal dilatation, and UTI. She underwent bronchoscopy which was apparently unremarkable, and was treated empirically with vancomycin and ceftazidime for pneumonia, and flagyl (for diarrhea). Her course had been complicated by hypotension requiring levophed and rapid AFib for which chemical cardioversion was attempted unsuccessfully with ibutilide. Cultures revealed MRSA PNA/bacteremia, and pseudomonas UTI, and treatment was initiated with vancomycin and zosyn. She was then admitted to [Hospital1 18] [5-30] after short stay at OSH for workup of pneumomediastinum. Bronch at OSH revealed no defects in the tracheal wall, and an esophageal gastrograffin study was negative as well. Multiple imaging studies did not reveal any pneumomediastinum. Repeat EGD/Rigid bronchoscopy did not show any TE fistula, but the evidence for pneumomediastinum is that respiratory symptoms (hypercarbic failure) and AF with RVR became worse when ET tube was in higher position, and resolved when ET tube was repositioned lower, presumably below the site of a fistula. Her tracheostomy was revised and she had no recurrence of afib with RVR. The may many attempts for pressure support wean unsuccessfully so PEG was placed and she was discharged to a chronic vent facility. Of noted she was also found to be Cdiff positive and completed a 14 day course of flagyl on [6-20] as well as a 2 week for ciprfloxacin for sensitive pseudomonal UTI. At rehab, the patient was noted to be hypotensive and tachycardic aafter blood transfusion last night. Of not she also recently had increasing thick secretions suctioned from trach. She was being treated with Linizolid for MRSA line sepsis changed to vancomycin [7-24] and Imipenem for GNR in urine and possible urosepsis, as well as PO vancomycin for potential resistent C.diff. She was given 600cc bolus with minimal improvement and was given another 1L NS en route to hospital. In ED here she was febrile to 102 and persistently hypotensive despite wide open fluids so levophed was initiated. She transiently had HR of 150 and SBP in 200's requiring them to hold levophed. In total she received 5 L total of NS in ED and was given a dose of levofloxacin for suspected sepsis. Past Medical History: 1. Influenza A in [4-10] complicated by ARDS eventually leading to intubation, ventilatory support, and tracheostomy. 2. Remote history of pneumonia. 3. Status post left eye cataract surgery. 4. Anxiety 5. DMII Social History: no significant tobacco or alcohol use. Family History: non-contributory. Physical Exam: VS: 99.8 \| 110/75 \| 75 \| AC with TV 400 RR 14 Fio2 50% PEEP 5 gen: intubated, somnolent but arousable, appears younger than stated age HEENT: pupils ERRL, MMM, no JVD, no carotid bruit neck:supple, no LAD, CV: RRR, nl s1s2, no murmurs. chest: mild diffuse rhonchi but no crackles or wheeze abd: soft, nt/nd, +bs, no organomegaly. extr: warm well perfused, 2+ dp pulses, no cyanosis, diffuse anasarca neuro: pt not cooperating with exam, moving UE and LE to command. Pertinent Results: BNP [7-24] 1100 proBNP: [Numeric Identifier 28323] Lactate:0.7 Urine Color: Yellow Appear: Clear SpecGr: 1.012 pH: 6.0 Urobil: neg Bili:Neg Leuk: Tr Bld: Lg Nitr: Neg Prot: Tr Glu: Neg Ket: 15 RBC: [7-15] WBC:0-2 Bact: Occ Yeast: None Epi: 0-2 Lactate:0.7 Hem 7 143 \| 102\| 69/ 88 AGap=8 4.7 \| 38 \| 0.6\ CK: 12 MB: Notdone Trop-T: 0.03 Ca: 6.8 Mg: 2.0 P: 4.5 D ALT: 105 AP: 195 Tbili: 0.2 Alb: AST: 108 LDH: Dbili: TProt: [Doctor First Name ]: 74 Cortsol: 33.0--> 49 MCV 94 WBC 8.5 Hgb 8.2 Plt 177 Hct 25.4 N:86.3 L:9.0 M:3.3 E:0.9 Bas:0.6 Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ PT: 29.6 PTT: 30.7 INR: 3.1 Micro: Blood cx [5-27]: MRSA. Blood cx [5-29]: NGTD.Urine cx [5-27]: Pseudomonas. Sputum cx [5-28]: MRSA. [2130-7-26] 3:02 pm SPUTUM GRAM STAIN (Final [2130-7-26]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. AZTREONAM Susceptibility testing requested by DR.[Last Name (STitle) ],[First Name3 (LF) ] ([Numeric Identifier 67021]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 8 I MEROPENEM------------- 4 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R ECG-NSR at 71, nl axis, LVH, mildly peaked tw in precordium, TW flat in avl, no other ST or T changes CXR-IMPRESSION: Right-sided central line is seen with tip overlying SVC. Poorly defined opacity is seen in the left mid lung, appears more apparent on current study, possibly representing focal consolidation. Evidence of increased mild-to-moderate pulmonary edema superimposed on chronic edema or chronic interstitial lung abnormalities. CT chest [7-26]: The previously demonstrated pneumomediastinum has been completely resolved. The mediastinal lymph nodes are markedly enlarged measuring 13 mm in the right supracarinal area instead of 8 mm. The aorta is dilated measuring up to 4.5 cm in the ascending part unchanged. The density of the blood in the cardiac [Doctor Last Name 1754] is diminished, suggesting anemia. The heart size is enlarged with no pericardial effusion. Esophagus is dilated predominantly in its proximal part with air-fluid level suggesting esophagitis. Bilateral pleural effusions are slightly increased. The bilateral widespread consolidations with prominent most probably infectious bronchiectasis are slightly diminished, especially in lower lobes and in left upper lobe. The ET tube tip is 3 cm above the carina. The tip of the right and left central venous lines are at the level of cavoatrial junction. The images of the upper abdomen demonstrate normal liver, spleen, kidneys and pancreas. Gallbladder with no evidence of acute cholecystitis is unchanged. The patient has prominent prominent subcutaneous fat stranding, most probably due to hypoalbuminemia. IMPRESSION: 1. Slight improvement of bilateral consolidation representing ARDS or widespread infection. 2. Mild increase in bilateral pleural effusions. 3. Cardiomegaly. 4. Anemia. 5. Gallbladder with no evidence of cholecystitis. 6. Status post feeding gastrostomy insertion Echo [2130-7-27]: 1. The left atrium is dilated. The right atrium is dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. 3. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 4. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. 5. No aortic dissection is seen up to 40 cm of probe insertion. Brief Hospital Course: 70 year old woman with a history of influenza A infection complicated by ARDS s/p trachestomy, afib, and tracheocutaneous fistula now presents with hypotension and fever. 1) Respiratory failure: Appeared stable from oxygenation standpoint with worsening respiratory and metabolic acidosis over the past few days. CXR was unchanged from previous in regards to infiltrate but suggests some superimposed volume overload on underlying interstitial disease. Patient's sputum culture grew pseudomonas sensitive to cefepime, ceftazidime, meropenem and zosyn. She had been started empirically on aztreonam and levofloxacin and as she improved clinically on this regimen it was continued. We requested add on sensitivities to aztreonam and these are pending at the time of this dictation. Pseudomonas was resistant to Ciprofloxacin. While in hospital she also developed a cuff leak despite elevated trach cuff pressures of 38. We discussed the issue with interventional pulmonary who recommended leaving this same trach in place as long as she continued to oxygenate and ventilate well since there was more risk of tracheomalacia in increasing the size of the trach or moving to a longer trach. Under no circumstances should the cuff pressures be increased to >25-30. . 2) Hypotension-There was possibility of transfusion reaction as hypotension occured in the setting of transfusion. Fever suggested infectious etiology. Possible sources included GNR from [7-22] growing in urine at rehab, VAP, and line sepsis with recent coag neg staph bacteremia although only [2-8] culture bottles were positive, and this may have be a contaminant. Pt had anemia with hx of dilated ascending aorta and ther was concern for dissection although she had equal BP in UE. TEE was performed which showed no dissection. Three sets of cardiac enzymes were negative. A cortisol stimulation test was negative. Patient improved with antibiotics and pressors were weaned by day two of hospitalization. Initially vancomycin was continued due to report of coag neg staph in blood culture at rehab, however, this was discontinued as it grew in only 1/4 bottles and was likely a contaminant. The urine culture from rehab grew enterobacter resistant to all antibiotics except gentamicin. As patient was improving with treatment for her pneumonia, did not change coverage to treat UTI as likely not the pathogen in this situtation. She will continue on Aztreonam. At the time of discharge she had completed 7 of 14 days. Her left PICC line was d/c'd. A rt PICC line was placed prior to discharge. During her hospitalization she was treated through a right subclavian line which removed on day of discharge. . 3) Anemia-Pt had colonoscopy 2 years ago with only polps removed but has fam hx of colon CA. EGD as part of TE fistula workup was not full study but did not comment on source of UGIB. Iron studies were consistent with anemia of chronic inflammation. As patient did not have evidence of renal failure, darbopoetin was held. . 4) C. diff- As patient did not have diarrhea during this hospital stay po vancomycin was discontinued. . 5) Afib: On coumadin with PAF which she is not tolerating well with possible leaky capillary syndrome. Patient had several runs of rapid afib during this hospital stay with resulting hypotension, therefore, despite risk of pulmonary toxicity, we loaded her with an amiodarone drip and then started 400 [Hospital1 ] to be followed by 400 daily and then 200 daily. At the time of discharge she requires 2 more days of 400mg [Hospital1 ], then wean to 200mg [Hospital1 ] mg daily and she should continue 200mg qd thereafter. Electrophysiology was consulted and recommended amiodarone rather than sotalol. Coumadin was restarted once hematocrit was stable. INR was therapeutic at the time of discharge. . 6) Elevated LFT's-Likely due to sepsis and hypoperfusion. Improved without intervention. She developed some nausea on HD4 which responded well to anzemet. It was unclear if this was med related but LFT's were normal and no further workup was initiated since it cleared. . 7) Psych - Initially held citalopram since recently started, but patient complained of depressed mood and family wanted to start SSRI so started zoloft with ativan prn for anxiety. . 8) FEN: Continued on tube feeds per PEG. Pt underwent metabolic cart which revealed respiratory quotient of 0.9 suggesting that her carbohydrate intake exceeded her need. Her carbohydrate intake was decreased and her protein intake was increased to meet her caloric needs. Her family raised the issue of Borage oil supplementation but after discussion with nutrition it was felt this would be unhelpful and may cause problems with the PEG tube so it was not started. . 9) Ppx: bowel regimen, PPI, coumadin, pneumoboots, . 10) Access: Rt PICC . 11) Code: Full Code Medications on Admission: Vancomycin 125mg q6h Vancomycin 1g IV bid Imipenem 500 q6h Darbepoetin Diltiazem 60mg q6h Colace 100mg [Hospital1 ] Atrovent MDI Lactinem Prevacid 30mg qd Magnesium gluconate 1g [Hospital1 ] MVI Zoloft 12.5mg qhs stopped [7-24] ASA 325mg qd tylenol Ativan 0.5mg q6h prn coumadin 3mg qd sotalol 120mg bil Albuterol MDI Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation QID (4 times a day). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Starting on [8-3] and finishing on [8-9]. 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: To be started on [2130-7-13] and continued thereafter. 11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lorazepam 0.5 mg IV Q8H:PRN 15. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 7 days: Ending [2130-8-9]. 16. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Trasfusion reaction Pneumosepsis Discharge Condition: Vital signs stable on ventilator Discharge Instructions: If you experience any fevers, chills, increasing sputum production, nausea or vomiting you should notify the rehab staff. Followup Instructions: Please continue to follow-up with the doctors [First Name (Titles) ] [Last Name (Titles) ] rehab including Dr. [Last Name (STitle) ] for further management of your ventilator wean and response to the antibiotics for pneumonia.	[ "0389", "42731", "2762", "99592" ]
Admission Date: [2147-4-3] Discharge Date: [2147-4-12] Date of Birth: [2072-1-21] Sex: M Service: CARDIOTHORACIC Allergies: Levaquin Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Asymptomatic left lower lobe mass- was bronched to have atypical cells. Admitted for left VATS Major Surgical or Invasive Procedure: left video assisted thoracoscoy for a left upper lobectomy History of Present Illness: Found to have left upper lobe mass on baseline CXRAY to follow AAA. Past Medical History: Abdominal Aortic Anerysm, PVD s/p L fem [Doctor Last Name ] '[16], COPD, ^chol, s/p Zenker's diverticulum repair x2 Social History: Employment [Doctor Last Name 360]. Married, lives w/ wife. 3 children, 3 grandchildren smoker 1ppd for 45 years, quit [2117]. Family History: Father died age 64- ?MI Mother healthy until 84-died stroke Sister- DM 3 children, 3 grandchildren healthy. Physical Exam: General-Well appearing male, NAD HEENT- PERLA, sclera anicteric Neck-no supraclavicular or cervical adenopathy Lungs-Clear bilat Heart- RRR, no murmur Thorax- symetrical w/o lesions. Left CT dressing, thorax incision upon d/c. Abd- + BS, sl distended. No masses or tenderness Ext- no edema or clubbing Neuro- grossly non-focal, intact and appropriate mental status Pertinent Results: [2147-4-3] 11:30PM HCT-40.7 [2147-4-3] 08:10PM GLUCOSE-148* UREA N-18 CREAT-0.8 SODIUM-134 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-10 [2147-4-3] 08:10PM WBC-14.4* RBC-4.08* HGB-12.8* HCT-37.7* MCV-92 MCH-31.3 MCHC-33.9 RDW-13.9 Brief Hospital Course: 75 yr old male admitted [2147-4-3] for elective video assisted thoracoscopy for asymptomatic left upper lobe mass. Post-op course was complicated by low urine output which responded to small boluses of IVF. Foley was subsequently found to have a large clot upon irrigation-CBI was initiated. Pt experienced urinary retention once foley was removed necesitating foley replacement. At that time was restarted on his hytrin and flomax. POD#1 : Tacycardic despite fluid boluses and adeq pain control. Given low dose beta blocker w/ good results. CBI continued. Chest tube to SXN w/ air eak. POD#2 : Tacycardia improved. Chest tube w/ small air leak-remains on sxn w/ resolution by later in day- chest tube to water seal. Progessing w/ OOB and reg diet. CBI d/c'd. Pt experienced urinary retention once foley was removed necesitating foley replacement. POD#3: tacycardia resolved. progessing w/ activity. Foley remains in place and pt was restarted on his hytrin and flomax. POD#4: Able to spont void after foley removed. Chest tube to water seal w/ leak. POD#[6-3] chest tubes d/c'd on POD#7. post pull CXR w/p PTX. FOUND TO HAVE AFB IN PATHOLOGY REPORT OF APICAL LUL from [2147-4-3].Placed on resp isolation until further identification. Pathology report also positive for lung cancer; all nodes negative for cancer. Sputum induction for AFBx3 initiated. Infectious disease and infection control following for treatment recommendations. Pt remained in hospital until AFB smears were negative. Pt was d/c'd to home with follow up with his pulmonologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22882]. Medications on Admission: claritin, advair, ASA, Pletal, Hctz 25', Zocor 20, Hytrin, Klonopin prn Discharge Medications: 1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID prn. Disp:90 Tablet(s) Refills:0 8. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 14. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a day) as needed. Discharge Disposition: Home Discharge Diagnosis: left upper lobectomy for left lingular mass on [2147-4-3] Discharge Condition: good Discharge Instructions: Resume all medications that you were taking prior to this hospitalization. Call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] if you experience shortness of breath, chest pain, fever, or chills or redness, swelling or drainage from your incision site. You can expect a small amount of pink or clear drainage form your chest tube site. You may remove the chest tube dressing and shower 2 days after the chest tubes are removed. Cover the site w/ a bandaid if necessary. Followup Instructions: Call Dr.[Name (NI) 1816] office for a follow up appointment in [11-10] days. Arrive 45 minutes prior to your scheduled appointment for a follow up chest XRAY- [Hospital Ward Name 23] Clinical Center [Location (un) ] Radiology dept. Pt will follow up with his Pulmonologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22882] Completed by:[2147-4-13]	[ "496", "2720" ]
Admission Date: [2139-8-30] Discharge Date: [2139-9-8] Date of Birth: [2060-12-12] Sex: F Service: MEDICINE Allergies: sulfa Attending:[First Name3 (LF) 7651] Chief Complaint: Vomiting/Diarrhea Major Surgical or Invasive Procedure: Cardiac Cath, s/p DES to RCA History of Present Illness: 78 y/o woman with a PMH significant for DM and HTN who was transferred from [Hospital3 ] for STEMI. She states that shortly after awaking at 0800 the morning of admission she experienced sudden onset nausea, vomiting and non-bloody non melanotic diarrhea with associated diaphoresis. She called her PCP, [Name10 (NameIs) 1023] urged her to go to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], where she was found to have ST elevations in II/III/AVF and reciprocal ST depressions in V2. VS at the time were: T 97.4 BP 131/61 HR 61 RR 18 O2 Sat 100% RA. She was given ASA 325, Heparin 60U/kg, Atorvastatin 80 and Plavix 600 and transferred to [Hospital1 18] for PCI. Cardiac cath showed total mid RCA occulsion (R dominant) and a DES was placed with restoration of flow to the distal RCA and PDA. Labs on arrival were CKMB 61 Trop 1.81 and Cr 1.7 (baseline unknown). On arrival to the CCU she denied CP/SOB/N/V/HA, palpitations or lightheadedness. She has had no sick contacts and states she can walk ~30 minutes before becoming SOB. She does not frequently climb stairs due to degenerative disc disease. She denies PND/orthopnea and states that she has noticed occasional swelling in her ankles over the past few months. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: - cataracts - GERD - osteoporosis - spinal stenosis - gastric ulcer - asthma - hysterectomy - cholecystectomy - multiple back surgeries Social History: Lives alone in [Location (un) 26671], retired office worker. - Tobacco history: 45 years of second hand smoke exposure, never smoked herself - ETOH: Denies - Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. - Mother: Died at age 87, unclear history of CAD - Father: Stroke at age 65 Physical Exam: ADMISSION EXAM: VS: T 98 BP 93/48 HR 63 RR 17 O2 Sat 97% 2L NC Wt 153 lbs GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP 3cm above the clavicle, thyroid non tender, mobile. No LAD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. II/VI harsh holosystolic murmur best heard at the apex. Normal S1/S2, no S3/S4. No lifts of heaves. No carotid bruits. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTA anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: WWP, scant pedal edema to the medial malleolus. 2+ pulses bilaterally. Cath site c/d/i, no hematoma or femoral bruits. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ DISCHARGE EXAM: GEN: NAD CV: RRR, III/VI holosystolic murmur heart throughout the precordium, JVP flat. Normal S1/S2, no S3/S4 PULM: Crackles in dependent lung fields L>R, no increased WOB, no cyanosis. ABD: NTND, NABS, no rigidity or rebound. EXT: WWP, no c/c/e, pulses 2+ NEURO: A/Ox3, non focal. Pertinent Results: [2139-8-30] 06:27PM GLUCOSE-131* UREA N-44* CREAT-1.6* SODIUM-131* POTASSIUM-3.9 CHLORIDE-88* TOTAL CO2-28 ANION GAP-19 [2139-8-30] 12:22PM CK-MB-102* cTropnT-5.04* [2139-8-30] 05:48AM CK-MB-120* cTropnT-5.18* [2139-8-30] 05:48AM TRIGLYCER-77 HDL CHOL-54 CHOL/HDL-2.9 LDL(CALC)-90 [2139-8-30] 01:00AM CK-MB-61* MB INDX-7.5* cTropnT-1.81* [2139-8-30] 01:00AM WBC-11.0 RBC-4.12* HGB-12.2 HCT-34.4* MCV-84 MCH-29.5 MCHC-35.3* RDW-15.5 [2139-8-30] 01:00AM NEUTS-86.8* LYMPHS-9.8* MONOS-3.1 EOS-0.1 BASOS-0.1 RELEVANT STUDIES: Cardiac Cath ([2139-8-30]): 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA, LAD, and LCx were free of angiographically significant disease. There was a thrombotic total occlusion of the mid-RCA with no collateralization. 2. Limited resting hemodynamics revealed normal resting systemic arterial pressure. [Month/Day/Year ] ([2139-8-30]): The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls. There is a focal defect in the basal inferior septum on 2D and color Doppler with continuous left-to-right flow c/w a post infarction ventricular septal defect (VSD). The remaining left ventricular segments contract normally. (LVEF 50%). Intrinsic left ventricular systolic function may be more depressed given the interventricular flow). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([2-8]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CXR ([2139-8-30]): Current study demonstrates top normal heart as well as bilateral hilar enlargement and pulmonary edema. The findings might potentially represent a new acute mitral regurgitation with increasing pulmonary venous pressure and presence of newly developed pulmonary edema. Small bilateral pleural effusions are noted. There is no pneumothorax. [Month/Day/Year ] ([2139-8-31]): The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 50-55 %). There is a ~1cm basal inferoseptal post infarction ventricular septal defect (VSD) with prominent left-to-right flow. Right ventricular cavity size is normal with free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. [Month/Day/Year ] ([2139-9-3]): The left atrium is normal in size. There is mild regional left ventricular systolic dysfunction with hypokinsis of the basal and mid inferior and inferolateral segmets . There is a post infarction ventricular septal defect (VSD). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. MRI ([2139-9-7]) 1. Normal left ventricular cavity size with normal global LVEF of 65% albeit severely depressed effective forward LVEF of 20%. Severe hypokinesis to akinesis of the mid to basal inferoseptal and inferior walls. 2. Transmural of late gadolinium enhancement in the inferoseptal wall, and 45% non-transmural late gadolinium enhancement in the inferior wall extending into the inferolateral wall, consistent with myocardial infarction and low (inferoseptal wall) to intermediate (inferior wall) likelihood of functional recovery after revascularization. The late gadolinium enhancement demonstrates a microvascular obstruction-type pattern. The infarct size was quantified at 18.2 g, which represents 21% of the total myocardial mass. 3. Increased T2 signal in these segments, consistent with edema/inflammation and acute/subacute timing of infarction (within 2 weeks). 4. Myocardial salvage index, representing the difference between the area at risk (T2) and the infarct size (late gadolinium enhancement) divided by the area at risk, calculated at 53%. 5. Infarct-related muscular ventricular septal defect in the mid to basal inferoseptal wall measuring 7 mm in the long-axis direction, and 6-9 mm in the short-axis direction (9 mm at the mouth on the left ventricular size of the septum, and slightly tapering to 6 mm on the right ventricular side of the septum). 6. Ischemic mitral regurgitation with mild posterior leaflet tethering. 7. Normal right ventricular cavity size with depressed RVEF of 39%. Global right ventricular hypokinesis with dyskinesis of the distal segments. Late gadolinium enhancement in the inferior right ventricular wall, consistent with right ventricular myocardial infarction. Systolic flattening of the interventricular septum, consistent with elevated right ventricular systolic pressure. 8. The indexed diameters of the ascending and descending thoracic aorta were normal. The indexed diameter of the main pulmonary artery was normal. 9. Left atrial enlargement. 10. A note is made of dependent patchy areas of consolidation are identified in the lung bases, right greater than left, with a focal area of nodularity in the right mid lung measuring 2 cm in craniocaudal dimension. However, there is no correlate on prior chest radiograph. Findings are likely the sequelae of pulmonary edema, though aspiration or pneumonia should be considered in the appropriate clinical circumstance. Recommend follow-up chest radiograph after acute illness to document resolution. A note is also made of punctate non-enhancing lesions in both kidneys, likely small simple cysts. Brief Hospital Course: 78 y/o woman with STEMI and total RCA occlusion s/p DES complicated by post-infarct ventricular septal perforation. # STEMI: Pt had 100% RCA occlusion just distal to the acute marginal takeoff, now s/p DES with restoration of flow to the distal RCA and PDA (R dominant). She was started on ASA, Plavix, Atorvastatin, metoprolol and lisinopril during her hospital course. [Year (4 digits) ] showed mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. Immediately following PCI she was in 2:1 heart block, which subsequently evolved to Wenckebach and 1:1 conduction. She remained hemodynamically stable throughout and was discharged home with cardiology and PCP follow up. # VSD: Physical exam on admission to the CCU revealed a new III/VI systolic murmur heard thoughout the precordium concerning for new VSD/MR. [Name14 (STitle) ] showed VSD, cardiac MRI later showed 3:1 shunt fraction, normal RV size with free wall hypokinesis and elevated PA pressures. Her O2 sat remained >93% on RA throughout her course and she was given diuresis for reducing pulmonary edema and shunt, and minimizing pulmonary hypertension. Blood pressure was also optimized to decrease afterload and maximize forward flow. The definite treatment will require surgical repair of the interventricular septum defect. Percutaneous VSD closure may also be an option. OUTPATIENT ISSUES: - F/U WITH CT SURGERY/INTERVENTIONAL CARDIOLOGY - Adjust lasix 80 mg po qd - Should have RHC to assess shunt function which could help decide whether patient needs to have her shunt fixed # A-fib: Pt was found to have a period of unsustained symptomatic A-fib, lasting ~30 mins. This could be a result of changes in RA volume and dynamics. Given patient's already compromised CO, atrial kick is necessary to maintain adequate MAP. Amiodarone was started for rhythm control. She was continued on metoprolol for rate control. CHRONIC DIAGNOSES: DM: Pt has documented hx of diabetes, controlled by Pioglitizone prior to admission. She was covered with ISS during this hospitalization. She was restarted on pioglitizone prior to discharge. # HTN - Her home Verapamil was held and she was started on Metoprolol and Lisinopril with SBP goal in the 90s given the lack of mortality benefit of CCB (especially verapamil) # GERD - Patient has a documented history of GERD, and takes omeprazole at home. Omeprazole was stopped in setting of plavix while ranitidine was started at 150 mg po qhs. # HLD: She was started on atorvastatin 80 mg po qdaily (PROVE trial) but it was decreased to 40 mg po qdaily given she was on multiple medications (amiodarone) which would uptitrate her statin dose putting her at risk for rhabdomyolysis. TRANSITIONAL ISSUES: - Pt maintained a full code during this admission - Pt has follow up with Dr.[Doctor Last Name 3733] in one week and CT surgery in 2 weeks Medications on Admission: - Vit D 50,000U every other sunday - Verapamil 240mg qday - Omeprazole 20mg qday - Clonazepam 0.5mg po qhs - Pioglitizone 30mg qday - Pregalbin 25mg qday - Ultram 50mg prn back pain Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 5. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. pregabalin 25 mg Capsule Sig: One (1) Capsule PO once a day. 8. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every other Sunday or as directed. 15. Benefiber Sugar Free (dextrin) Oral 16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical ASDIR. Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: PRIMARY: 1. Acute Myocardial Infarction 2. Ventricular-Septal Rupture SECONDARY: 1. Hypertension 2. Diabetes 3. Asthma 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: It was a pleasure participating in your care during your admission to [Hospital1 69]. You were transferred to our hospital for treatment of a heart attack. The blockage in your arteries was opened and a stent was placed in one of your coronary arteries to help keep it open. We also treated you with several medications to reduce the risk of both another heart attack and of your heart becoming weak from having had a heart attack. Your heart also suffered a complication from your heart attack in which one of the walls between the different [Doctor Last Name 1754] of your heart ruptured, allowing blood to flow in a direction it normally would not flow. This is a serious complication and requires repair. You were evaluated by our interventional cardiologists as well as our cardiac surgeons who felt that it would be best to postpone correcting this problem until you have had a bit more time to recover from your heart attack. We have changed some of your medications and started you on several new medications. Please take all of your medications exactly as prescribed. In terms of new medications, we have started you on the following medications: -Aspirin, 325mg daily to prevent another heart attack -Plavix, 75mg daily to keep the stent open. Do not stop taking your aspirin and plavix together unless Dr.[Doctor Last Name 3733] tells you it is OK. -Lisinopril, 5mg daily to lower your blood pressure -Atorvastatin, 40 mg daily to lower your cholesterol -Amiodarone, 200mg once daily to keep your heart in a regular rhythm. -Furosemide (Lasix), 80mg daily to prevent fluid overload -Metoprolol 25mg twice daily to lower your heart rate and help your heart recover from the heart attack. -Ranitidine, 150mg, at bedtime to prevent stomach upset You should STOP taking the following medications: -Omeprazole (instead you should take the Ranitidine listed above) -Verapamil (this is no longer necessary because of the other medications we have started you on) . Weigh yourself every day, Call Dr.[Doctor Last Name 3733] if you notice your weight increase more than 3 pounds in 1 day or 5 pounds in 3 days. Followup Instructions: Department: Cardiology Name: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: Friday [2139-9-18] at 2:40 PM Location: [Hospital1 18] - CARDIAC SERVICES Address: [Location (un) ], [Hospital Ward Name ] 7, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 62] Department: CARDIAC SURGERY When: MONDAY [2139-9-21] at 2:15 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE	[ "2761", "5849", "25000", "42731", "53081", "2724", "49390", "41401", "40390", "5859", "4280", "4240" ]
Admission Date: [2102-9-25] Discharge Date: [2102-10-4] Date of Birth: [2048-1-14] Sex: F Service: CHIEF COMPLAINT: Motor vehicle crash HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female who was an unrestrained driver in a motor vehicle crash going roughly 40 miles an hour head on into a tree. There was a question of whether or not the patient had fell asleep at the wheel. There was positive loss of consciousness at the scene. It was assumed by EMS that the patient did hit the windshield with her head because of the damage to the car and the significant injuries to her forehead. The extrication at the scene did last greater than 15 minutes, but the patient was hemodynamically stable. The patient at the scene complained of chest pain, upper abdominal pain and right leg/ankle pain. PAST MEDICAL HISTORY: None MEDICATIONS: None PAST SURGERIES: None ALLERGIES: None INITIAL PHYSICAL: VITAL SIGNS: T-max 100??????, pulse 94, blood pressure 102/49, 20, 97 on room air. GENERAL: No acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and reactive to light and accommodation. Tympanic membranes were clear. GCS of 15 at the scene and on arrival to the Emergency Department. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. No jugular venous distention. ABDOMEN: Soft, nontender, nondistended. CHEST: Chest wall positive ecchymosis over the left chest. EXTREMITIES: No peripheral edema, +2 DP and PT, positive ecchymosis over the right leg and right arm. Positive deformity to the right lower leg with tenderness and decreased sensation. C-spine no tenderness. Back no tenderness. INITIAL LABS: Hematocrit of 31, chem-7 of 140/3.7, 108/19, 13/0.5, 157, amylase of 27, calcium 1.03, lactate of 2.8, negative urinalysis. RADIOLOGY: CT scan of the abdomen which showed a grade 4 liver laceration at the prominent pancreatic tail. Right ankle showed a distal tibia fibula fracture which was status post reduction at that time by orthopedics. The x-ray also showed good alignment following the reduction. CT of the lower limbs included the common medial malleolar and talar neck fracture. Right tibia fibula films showed a distal fibula and tibia fracture on the right and no fractures of the right knee. CT of the C-spine was negative. CT of the head was also negative. Chest x-ray and pelvis negative. The major injuries to the patient included a right distal tibia fibula fracture and a grade 4 liver laceration. HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit on the [1-25] and was followed with serial hematocrits due to the grade 4 liver laceration. The patient also had a significant laceration to the forehead which ran superior to inferior over the right eye. Plastic surgery was consulted and the wound washed with copious amounts of normal saline prior to a primary closure. The incision was roughly 7 to 8 cm long and there was also a second smaller 2 cm laceration at the temporal area. The patient's Intensive Care Unit stay was fairly uneventful, but she did receive 2 units of packed red blood cells for a hematocrit that slowly dropped from 33 to 26. After the 2 units of packed red blood cells, the patient's hematocrit bumped appropriately and remained stable. Orthopedics recommendations were to have the leg fixed with open reduction internal fixation after the patient was stabilized (1 to 2 weeks). After the patient was deemed to be clinically stable with stable hematocrit, the patient was transferred to the floor. The patient continued to have an uneventful stay interrupt the hospital. Physical therapy and occupational therapy saw the patient and helped with ambulation. The patient had a fair deal of difficulty with movements and it was decided at that time the patient would be discharged to rehabilitation services prior to her [Month (only) ] surgery. During her stay on the floor, the patient's liver function tests bumped on the 15th to an ALT of 333, AST of 79 and alkaline phosphatase of 195, total bilirubin of 7.1 and direct bilirubin of 3.8. Over the 16th and 17th, the patient's ALT decreased to 278, but AST increased to 90 and alkaline phosphatase was at 268. Total bilirubin and direct bilirubin continued to 4.8 and 2.2. On the 18th, it was decided the patient could be discharged to rehabilitation services in stable condition. DISCHARGE PHYSICAL: VITAL SIGNS: T-max 98.4??????, 84, 106/72, 16, 98 on room air, in 1000, out 1600. GENERAL: Alert and oriented. HEAD, EARS, EYES, NOSE AND THROAT: Dressing on forehead was intact. Clean, dry and intact suture line. CARDIOVASCULAR: Regular rate and rhythm. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: Right lower extremity splint. LABS: Liver function tests from the 17th: ALT 278, AST 90, alkaline phosphatase 268, total bilirubin 4.8, direct bilirubin 2.2. DISCHARGE DIAGNOSES: 1. Status post motor vehicle crash, unrestrained drive with polytrauma 2. Distal tibia fibula fracture requiring open reduction internal fixation on the [2-8]. Grade 4 liver laceration 4. Forehead laceration DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q 24 hours 2. Percocet 5/325 1 to 2 tablets po q 4 to 6 hours prn 3. Tylenol 650 mg po q 4 to 6 hours prn TREATMENTS: The patient will require Venodynes at all times when in bed. The patient will also require physical therapy and occupational therapy designed appropriately by the rehabilitation services. The patient will continue on a regular diet. The patient will be non weight bearing in the right lower extremity and should have physical therapy to reflect the restricted activities. The patient will be scheduled for the open reduction internal fixation of the right tibia fibula fracture on the 23rd by [Hospital1 ] [Hospital1 ] Department. The patient should have her liver function tests checked on the 19th and also 21st to continue to trend the grade 4 liver laceration. DISCHARGE CONDITION: Good and stable to rehabilitation services. FOLLOW UP: The patient will follow up with Dr. [Last Name (STitle) ] in the trauma clinic, phone number ([Telephone/Fax (1) 24484]. The patient will also need to be transported back to [Hospital1 ] either on Sunday or Monday, the 22nd or 23rd for the open reduction internal fixation of the right tibia fibula. The patient will be admitted to the [Hospital1 ] service at that time. The attending in orthopedics will be Dr. [Last Name (STitle) ] at the [First Name (Titles) ] [Last Name (Titles) ] Department. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern4) 959] MEDQUIST36 D: [2102-10-4] 15:29 T: [2102-10-4] 15:35 JOB#: [Job Number ]	[ "2851" ]
Admission Date: [2161-12-8] Discharge Date: [2162-1-21] Date of Birth: [2084-1-29] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2597] Chief Complaint: bilateral lower extremity disabling claudication Major Surgical or Invasive Procedure: [2161-12-8]-B/l femoral endarterectomies and patch profundoplasties, removal R ileofemoral bypass, B/l common and external ileac stenting, R EIA to distal CFA dacron bypass [2161-12-9]- ileocecectomy and 15 cm distal small bowel resection, left open, mesenteric angiogram, thrombectomy with patch angioplasty SMA with stenting [12-10]-ex lap, resection proximal R colon, cholecystectomy, resection distal ileum, liver biopsy [2161-12-11]-abdominal exploration, washout, ileocecostomy [12-13]-ex lap, abdominal washout, gastrojejunostomy tube, LLE fasciotomies [12-28]-permcath History of Present Illness: 77 yF with disabling claudication s/p R ileofemoral bypass in [2153]. She was having progressive difficulty ambulating over the past 5 years. Non invasives done at an OSH suggest severe aortoiliac and superficial femoral disease. Past Medical History: HTN MVP osteoporosis PVD DJD gout Social History: quit smoking 10 years ago Physical Exam: HR 72, BP 150/80 Gen-NAD HEENT-soft b/l cervical bruits Cor-RRR Lungs-CTA Abd-soft nt/nd R femoral pulse diminished compared to left, all distal pulses are nonpalpable Brief Hospital Course: Patient underwent B/l femoral endarterectomies and patch profundoplasties, removal R ileofemoral bypass, B/l common and external ileac stenting, R EIA to distal CFA dacron bypass on [12-8]. Postoperatively she remained hypotensive, had a rising lactate and worsening abdominal pain. Dr. [First Name (STitle) ] from the hepatobiliary service took the patient to the OR and performed an ileocectomy and temporary abdominal closure. At the same time, the SMA was stented and a patch angioplasty was performed for severe stenosis and mesenteric ischemia. Postoperatively, the patient was critically ill in the surgical ICU. She was taken back to the OR on [12-10] for ex lap, resection proximal R colon, cholecystectomy, resection distal ileum, liver biopsy due to worsening hepatic function. She was brought back to the OR for ileocecostomy and washout on [12-11] and had LLE fasciotomies. She was on significant vent support and pressor support as well as on broad spectrum antibiotics. A gastrojejunostomy tube was place on [12-12] and a vicryl mesh abdominal closure was performed - a vac type dressing was placed. The patient was initiated on CVVHD in consultation with the renal service. TPN was initiated. She was eventually extubated on [12-23]. Tube feeds was initiated and the patient no longer required CVVH or hemodialysis. A vac type dressing was placed on the fasciotomy wounds. She then began to have LGIB for which the GI service was consulted. A colonoscopy was performed -showed anastomotic ulcers. She continued to having maroon stools (about 200-300 cc/day)for about 2 weeks with continued PRBC requirement. A CT angiogram revealed patent SMA and hypogastrics with an occluded celiac. A tagged red cell scan revealed no source for bleeding. In early [Month (only) 404] her pulmonary status began to decline with worsening pleural effusions for which thoracentesis was performed. The patient was unable to tolerate TF due to abdominal pain. On [1-19] she developed an SVT for which adenosine was required;during this time she was hypotensive and re-intubated for respiratory distress. A meeting with the family and surgical attendings was performed and it was decided to withdraw care. The patient expired on [2161-1-21]. Medications on Admission: lisinopril ASA Zocor Discharge Disposition: Expired Discharge Diagnosis: [2161-12-8]-B/l femoral endarterectomies and patch profundoplasties, removal R ileofemoral bypass, B/l common and external ileac stenting, R EIA to distal CFA dacron bypass [2161-12-9]- ileocecectomy and 15 cm distal small bowel resection, left open, mesenteric angiogram, thrombectomy with patch angioplasty SMA with stenting [12-10]-ex lap, resection proximal R colon, cholecystectomy, resection distal ileum, liver biopsy [2161-12-11]-abdominal exploration, washout, ileocecostomy [12-13]-ex lap, abdominal washout, gastrojejunostomy tube, LLE fasciotomies Patient expired Discharge Condition: patient expired	[ "2762", "5845", "4240", "5119", "4019" ]
Admission Date: [2156-11-23] Discharge Date: [2156-12-30] Date of Birth: [2156-11-23] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [Known lastname 44135] [Known lastname ] was born at 36 and 2/7 weeks gestation by repeat cesarean section for vaginal bleeding. The mother is a 30 year old, Gravida II, Para I now II woman. Her prenatal screens are blood type AB positive, antibody negative, Rubella immune, RPR nonreactive, Hepatitis B surface antigen negative and group B strep unknown. This pregnancy was uncomplicated until the day of delivery when the mother presented with vaginal bleeding. The infant emerged vigorous on the abdomen. Apgars were eight at one minute and eight at five minutes. PHYSICAL EXAMINATION: The admission physical examination reveals a pink, well perfused infant, anterior fontanel open and flat. Palate intact. Positive inspiratory crackles. Positive grunting, flaring and retracting. Normal S1-S2 heart sound. Pulses that were full, soft. Abdomen: No hepatosplenomegaly. Normal female external genitalia. Stable hip examination. Age appropriate tone and reflexes. The birth weight was 2,760 grams. The birth length was 18.5 inches and the birth head circumference was 34.5 cms. [Known lastname 44135] [Known lastname ] is now a 36 day old infant who is being transferred to [Hospital3 1810] for further neuro-imaging and EEG. HOSPITAL COURSE: Respiratory status. The infant was intubated soon after admission to the Neonatal Intensive Care Unit. She received three doses of Surfactant for respiratory distress syndrome. She was extubated to nasopharyngeal continuous positive airway pressure on day of life #4 and then weaned to nasal cannula oxygen on day of life #6 and then to room air on day of life #12 where she remained until day of life #25 when she developed a new oxygen requirement which has persisted. At this time, a chest x-ray showed normal lung volume with no consolidation and normal lung parenchyma and normal heart size. She currently is requiring 200 cc per liter flow of 21 to 30% oxygen at rest and then requiring increase to 60 to 100% oxygen during feedings. She has one to two episodes in each day of bradycardia associated with periodic breathing or apnea with accompanied desaturation. We are considering caffeine treatment once neurology feels it will not interefere with their work up. On examination, her respirations are comfortable. Her lung sounds are clear and equal. She has never received any methylxanthine treatment. Cardiovascular status. The infant received a fluid bolus soon after admission for blood pressure support and has remained normotensive since that time. She did pass a hyperoxia test on day of life #3 with a PAO2 of 272. On examination, she has a normal S1 and S2 heart sounds, no murmur. She is pink and well perfused. Fluids, electrolytes and nutrition: Enteral feeds were begun on day of life #5 and advanced to full volume by day of life #9 and then to an increased calorie enhancement of 28 calories per ounce to attain weight gain. She currently is eating 26 calories per ounce of Enfamil. She had a four day trial of Alimentum formula at the parent's request to rule out their concern for possible allergy to Enfamil. The total fluids are currently 130 cc per kg per day. The infant takes approximately one-third to one-half of the volume orally. At the time of transfer, her weight is 3,315 grams. Her length is 55 cms. Her head circumference is 35.5 cms. LABORATORY DATA: On [2156-12-23], sodium was 136; potassium of 5.5; chloride of 100; bicarbonate 26; BUN 5; creatinine 0.6. On [2156-12-27] her calcium was 10.7; magnesium of 2.2; phosphorus of 6.6. Gastrointestinal: The infant was treated with phototherapy for hyperbilirubinemia from day of life #2 to day of life #5. Her peak bilirubin occurred on day of life #2 and was total of 11.2, direct of 0.4. The infant has demonstrated consistently a weak suck and oxygen saturations with p.o. feedings and inability to take the expected p.o. volume for her age. This has been occurring since the time that oral feedings were initiated. Several different nipples have been tried, including the Dr. [Last Name (STitle) 174] bottle system and [Last Name (un) 38296] feeder. None have proved to make any significant difference in her oral intake. She was first seen by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of [Hospital3 1810] feeding team/swallowing disorder program on [2156-12-14]. Her evaluation revealed a negative rooting reflex, negative transverse tongue, negative phasic bite, reduced oral muscular tone and strength and discoordination of respiration and swallowing with immature sucking pattern. On [2156-12-15], the infant had a video fluoroscopic swallow study which revealed significant discoordination of sucking skill with poor initiation of suck, poor fluid extraction and difficulty coordinating suck, swallow, breathing sequence. Significant nasopharyngeal reflux was present due to reduced velopharyngeal elevation/closure. However, there was no evidence of aspiration. A re-evaluation on [2156-12-28] showed that there had been no significant improvement and the recommendation was to consult the gastrointestinal service for possibility of a gastrostomy tube placement. Hematology status. The patient has never received any blood product transfusion during her Neonatal Intensive Care Unit stay. Her last hematocrit on [2156-12-27] was 26.7 with reticulocyte count of 3.5%. Her hematocrit previous to that on [2156-12-20] was 27.8. She is receiving supplemental iron of 5 mg per day of elemental iron. Infectious disease status. The infant was started on Ampicillin and Gentamycin at the time of admission for sepsis suspected. She completed a ten day course of antibiotics for presumed sepsis. Blood and cerebrospinal fluid cultures from that time have remained negative. She has remained off antibiotics since that time. The infant was evaluated by [Hospital3 1810] genetics, Dr. [First Name4 (NamePattern1) 622] [Last Name (NamePattern1) 46935] and chromosomes were sent with a karyotype of 46XX. A Fish for Prader-Willi syndrome (15 Q11 - Q13) was negative. Further studies for this defect with DNA methylation studies were sent on [12-10] and are normal. Follow-up with Dr. [Last Name (STitle) 46935] is recommended as an outpatient. Neurology. The infant has presented with marked generalized hypotonia and jitteriness which has been persistent. She has been followed by [Hospital3 1810] neurology service since [2156-12-1] and most recently by Dr. [Last Name (STitle) 36469]. A magnetic resonance scan on [2156-12-2] showed no evidence of infarct or hemorrhage; however, the study was limited by motion artifact. The following neurologic studies have been sent: Urine organic acids on [2156-12-2] were normal. Serum amino acids on [2156-12-2] were within normal limits. Lactate on [2156-12-20] was 0.9. [2156-12-10] Pyrubate 0.21. Aldolase on [2156-12-10] 7.3. CPK on [2156-12-2] was 46. Acylcarnitine sent on [2156-12-10] was normal. State screen sent on [12-9] was completely within normal limits. E electromyelographic study done on [2156-12-21]: The results showed that the electrophysiologic findings were not consistent with a generalized myopathy nor with a generalized disorder of motor neurons. The nerve conduction study data suggested the possibility of a mild, primarily axonal, generalized sensory motor poly neuropathy, although further evidence of this could not be clearly identified on the electromyelography. The infant is being transferred to [Hospital3 1810] for further neural imaging and EEG study. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. Psychosocial status: The family has been followed by [Hospital1 1444] social worker, [Name (NI) ] [Last Name (NamePattern1) 6861], [Hospital1 69] beeper #[Numeric Identifier 36451]. The parents are [Known firstname ] and [Doctor First Name ]. They have been very involved in the infant's care throughout her Neonatal Intensive Care Unit stay. There is one two year old female sibling who is well. The infant is discharged in good condition. The infant is being transferred to [Hospital3 1810]. Primary pediatric care will be provided by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of [Hospital 47] Pediatrics, telephone #[Telephone/Fax (1) 43144]. CURRENT RECOMMENDATIONS AT DISCHARGE: Feeding: Enfamil 26 calories per ounce, made with 4 calories per ounce by concentration and 2 calories per ounce from medium change high triglyceride oil. Total fluids are 130 cc per kg per day. The infant has attempted to feed orally at each feeding and the remainder is fed by gavage. MEDICATIONS: Ferinsol 0.2 cc (5 mg) p.o. q. day. The infant has not yet passed a car seat position screen test. The last state newborn screen was sent on [12-9] and was within normal limits. The infant received her first hepatitis B vaccine on [2156-11-28]. IMMUNIZATIONS RECOMMENDED: Synagis-RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1.) Born at less than 32 weeks. 2.) Born between 32 and 35 weeks with plans for day care during the RSV season, with a smoker in the household or with preschool siblings. 3.) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: Prematurity, 36 weeks gestation. Status post respiratory distress syndrome. Status post presumed sepsis. Status post physiologic hyperbilirubinemia. Anemia of prematurity. Discoordinated suck and swallow reflex. Rule out genetic abnormality. Hypotonia, etiology? Oxygen requirement due to ineffective respiratory effort. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Last Name (NamePattern1) 43006] MEDQUIST36 D: [2156-12-29] T: [2156-12-29] 05:26 JOB#: [Job Number ]	[ "V053" ]
Admission Date: [2167-7-21] Discharge Date: [2167-7-31] Date of Birth: [2094-9-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic Ascending Aortic Aneurysm Major Surgical or Invasive Procedure: [2167-7-23] - Redo Sternotomy, Replacement of Ascending Aorta (32mm gelweave tube graft) History of Present Illness: Mr. [Known lastname ] is a 72-year-old male who in [2146] underwent an aortic valve replacement with a mechanical Bjork-Shiley valve. He has been followed for an enlarging ascending aorta and his most recent echo showed it to be now at 6 cm. He is now presenting for repair of the ascending aortic aneurysm Past Medical History: s/p AVR (Bjork-Shiley) [2146] s/p ICD [2161] MI at age 46 Cardiomyopathy CHF AAA Colorectal Cancer UTI Colostomy [2144] Hyperlipidemia HTN Social History: Retired lift truck operator. 60 pack year history of smoking. He quit over 10 years ago. Lives with his wife. [Name (NI) ] does not drink alcohol. He is edentulous. Family History: Noncontributory Physical Exam: GEN: NAD NECK: Supple, FROM LUNGS: Clear HEART: RRR, Crisp valve click, Nl S1-S2 ABD: Soft, NT/ND/NABS EXT: Warm, well perfused, 1+ edema. NEURO: Nonfocal. No carotid bruits. Pertinent Results: [2167-7-23] ECHO PRE CPB The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). There is moderate global right ventricular free wall hypokinesis. The ascending aorta is markedly dilated. This dilation appears to taper down near the arch but limited views prevent full assessment. There are simple atheroma in the aortic arch. There are focal calcifications in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. A single tilting disk type aortic valve prosthesis is present. The aortic valve prosthesis appears to be well seated. The disk is poorly seen but appears to be moving appropriately. Some fibrinous echodensities are seen on the LVOT side of the valve and are likely evidence of some degeneration. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is a trivial/physiologic pericardial effusion. POST CPB The patient is receiving epinephrine by infusion. The left ventricle continues to display moderate to severe global dysfunction, but now with slightly more hypokinesis of the inferior wall. The EF is about 30%. The right ventricle displays somewhat improved function from pre-bypass study - now mildly globally hypokinetic. The ascending aortic graft is only poorly seen. The thoracic aorta appers intact distal to the graft. Mitral regurgitation is now trace. No other changes from pre-cpb study. [2167-7-30] 07:00AM BLOOD WBC-7.1 RBC-3.02* Hgb-9.9* Hct-28.8* MCV-95 MCH-32.8* MCHC-34.5 RDW-13.9 Plt Ct-288 [2167-7-31] 06:45AM BLOOD PT-25.8* PTT-46.2* INR(PT)-2.6* [2167-7-30] 07:00AM BLOOD Glucose-118* UreaN-21* Creat-1.7* Na-137 K-3.8 Cl-100 HCO3-28 AnGap-13 [2167-7-21] 08:55PM BLOOD ALT-17 AST-23 LD(LDH)-153 AlkPhos-61 Amylase-47 TotBili-1.3 RADIOLOGY Final Report CHEST (PA & LAT) [2167-7-28] 2:36 PM CHEST (PA & LAT) Reason: evaluate for effusion [Hospital 93] MEDICAL CONDITION: 72 year old man with s/p asc aorta replac REASON FOR THIS EXAMINATION: evaluate for effusion CHEST X-RAY HISTORY: Status post ascending aorta repair, evaluate for effusion. Two views. Comparison with [2167-7-24]. The patient is status post median sternotomy and MVR, as before. Mediastinal structures are unchanged. An ICD remains in place. A right internal jugular catheter has been withdrawn. Allowing for differences in technique, there is no other significant change. IMPRESSION: No significant interval change. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4392] Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2167-7-21] for surgical management of his dilated ascending aorta. Heparin was started as he had been off his coumadin for 5 days in aticipation of surgery. On [2167-7-23], Mr. [Known lastname ] was taken to the operating room where he underwent a redo sternotomy with replacement of his ascending aorta. An intraopertaive vascular surgery consult was obtained as it was decided to use his right axillary artery for arterial cannulation. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. By postoperative day one, Mr. [Known lastname ] had awoke neurologically intact and was extubated. Aspirin, beta blockade and a statin were resumed. The electrophysiology service was consulted for interrogation of his pacemaker and it was reprogrammed to function appropriately. Haldol was used for some mild postoperative aggitation. Coumadin was resumed for his mechanical valve. Mr. [Known lastname ] developed atrial fibrillation for which amiodarone was started. Mr. [Known lastname ] remained in the intensive care unit for a few extra days due to agitation and confusion however this slowly cleared. On postoperative day three, he was transferred to the 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. His mental status cleared and on POD 7 he was discharged to rehab in stable condition. Medications on Admission: Aldactone 25mg QD Captopril 25mg TID Coreg 12.5mg [Hospital1 ] Coumadin Lasix 80mg QD Lovastatin 40mg QD Multivitamin Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): Dose for INR goal of 2.5-3.0. 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for UTI for 3 days. 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 12564] Health Network Discharge Diagnosis: Mild AI/Dilated ascending aorta s/p Replacement s/p AVR [2146] s/p ICD s/p Colostomy AF MI at age 46 Cardiomyopathy CHF UTI Colorectal Cancer AAA Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with cardiologist Dr. [Last Name (STitle) 5017] in 2 weeks. Follow-up with pcp [Last Name (NamePattern4) ]. [First Name (STitle) 745] in [1-31] weeks. [Telephone/Fax (1) 68885] Call all providers for appointments. Completed by:[2167-7-31]	[ "9971", "42731", "4280", "4019", "2859" ]
Admission Date: [2118-6-7] Discharge Date: [2118-6-9] Date of Birth: [2054-1-15] Sex: F Service: MEDICINE Allergies: Penicillins / Cozaar / Ace Inhibitors / Lipitor Attending:[First Name3 (LF) 20146] Chief Complaint: Hypertensive emergency Major Surgical or Invasive Procedure: none History of Present Illness: 64F with longstanding history of poorly controlled HTN and s/p hemorrhagic stroke presumably from HTN emergency at [Hospital1 2177], CAD s/p MI, CHF witH EF 35%, DM A1c 7.3%, who was seen at PCP's office with chest pain and intermittent 'gasping' over the last few days. Notes has had chest and back pain (cardiac equivalent in her) on and off for several days, as well as "gasping" particularly bothersome at night. Stable 2 pillow orthopnea. Shortness of breath and headache progressed over the past day, prompting her to keep a scheduled appt with her PCP. [Name10 (NameIs) ] her visit earlier today, SBP found to be 220-235 and she was sent to the ED for further management. . In the ED, initial VS: 96 97 189/62 18 100% RA. CXR showed mild volume overload. She was given po hydral and metoprolol with no effect and started on a nitro gtt. She also received lasix 40mg iv once without much UOP. Her pressure came down to the 150's on the nitro gtt and it was decreased as goal bp 160-170. Her labs were remarkable for trop<0.01 and negative CK with creatinine at baseline. EKG showed sinus rhythm with TWI in the precordial leads. She denied any chest pain while in the ED and refused ASA. CT head wet read showed no evidence of any acute intracranial pathology but showed a large region of encephalomalcia in the right hemisphere suggestive of old right MCA infarction. . CXR final read showed engorged pulmonary hilar vasculature, with diffuse pulmonary vascular congestestion, no effusion. . On evaulation on the floor patient reports CP and SOB have resolved, HA present, but improved. She notes she has not been taking her diovan as prescribed, but maintains compliance with her other medications, including her beta blocker, hydralazine, coumadin, and CCB. . On review of systems, she notes some back pain and left-sided pruritis. Reports recent hospitalization at [Hospital1 2177] for "dizziness, feeling like she was going to black out." Denies any prior history pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, diarrhea black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for positive features as above. Denies any current chest pain, ankle edema, palpitations, or syncope. Past Medical History: 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: Cath [1-23]: 100% pLCx. STEMI Cath [7-24]: 20% LM, 30% D1, 100% in-stent pLCx, 50% mRCA. Cath [8-27]: chronic 30% LMCA, 50% LAD, 100% in stent LCx, 50% RCA. Cath [5-1]: LCx 100% (chronic), D1 50%, 30% prox 50% mid RCA, PTCA to mid RCA -PACING/ICD: none . 3. OTHER PAST MEDICAL HISTORY: Poorly controlled HTN Diabetes on insulin sCHF EF 45% (ischemic) H/O hemorrahgic CVA [12/2117] at [Hospital1 2177] Hypothyroid CKD baseline 1.2-1.3 Severe pulm HTN by R heart cath [8-/2113] ? H/o anoxic brain injury after prolonged ICU stay Anxiety Social History: SOCIAL HISTORY: Lives with her son and future daughter in law since her stroke in [12-31]. Tob: 2.5 pack year history; quit EtOH: Used to drink on the weekends. Quit. Drugs: Denies Family History: Father with CAD, siblings with 'heart problems'. Grandfather died of MI. Physical Exam: PHYSICAL EXAMINATION: VS: BP= 186/86 HR= 71 RR= 23 O2 sat= 96% on RA GENERAL: obese AA woman slumped in stretcher. 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, JVD difficult to appreciate [2-23] habitus. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Distant breast sounds, no obvious crackles or rhonchi appreciated. ? faint expiratory wheezing. ABDOMEN: Soft, obse NTND. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+; Left: DP 2+ PT 2+ Neuro: alert and oriented x3; Left sided facial droop, otherwise cranial nerves II-XII intact. Left upper extremity hemiplegia. Decreased light touch sensation of left lower extremity. [5-26] motor in RLE, 5-/5 in LLE; [5-26] in RUE. brisk biceps reflex on L>R, unable to elicit b/l patellar reflexes Pertinent Results: ADMISSION LABS: [2118-6-7] 01:39PM GLUCOSE-154* UREA N-12 CREAT-1.3* SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [2118-6-7] 01:39PM WBC-6.5 RBC-4.33 HGB-12.5 HCT-38.4 MCV-89 MCH-28.8 MCHC-32.4 RDW-14.8 [2118-6-7] 01:39PM cTropnT-<0.01 LABS/STUDIES [6-7] EKG: Sinus at 66 bpm. TW normalization in leads I, II, AVF, V4-6 compared to prior in [5-1]. . [6-7] CT HEAD: Encephalomalacia in the region of the right middle cerebral artery territory compatible with the sequela of old infarct. No evidence of any acute intracranial pathology. . 2D-ECHOCARDIOGRAM: [4-/2117] The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) secondary to hypokinesis of the inferior septum, inferior free wall, and posterior wall. The right ventricular cavity is dilated with depressed free wall contractility. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . ETT: [4-/2117] This was a 63 year old DM woman with a known history of CAD/CHF (MI's, stents '[13]/'[16]) who was referred to the lab from the ED after negative serial cardiac enzymes for an evaluation of increasing shortness of breath and chest discomfort with exertion. She exercised for only 3.5 minutes of a Modified [Doctor Last Name 4001] protocol (~1.7 METs) and had to stop due to fatigue and shortness of breath. This represents a limited functional capacity. She denied any chest, arm, neck or back discomfort throughout the study. In the setting of diffuse T wave inversion on baseline ECG, there was T wave normalization noted during exercise, which returned to baseline morphology by 7 minutes of recovery. The rhythm was sinus with rare APB's and one PVC during exercise. There was hypertension noted at rest with an appropriate blood pressure response to the level of exercise performed. Hear rate response was blunted due to the patients limited functional capacity. . IMPRESSION: Non-specific T wave changes noted in the presence of uninterpretable baseline ECG abnormalities. No anginal type symptoms reported. Limited functional capacity demonstrated. Resting hypertension. Brief Hospital Course: 64 yo F with poorly controlled HTN, ischemic sCHF, DM, CAD s/p MI admitted to MICU with hypertensive emergency with SBP >220, chest pain, and mild pulmonary edema. . # Hypertensive Emergency: SBP >220 with report of chest pain and CXR with acute pulmonary edema. On review of CXR, appears similar to prior, without significant worsening. Per patient, has not been taking meds as prescribed ("diovan leaves a bad taste in my mouth"). SBP down to 150s on nitro gtt. Once transitioned to PO meds her blood pressures stabilized in the 150s-160s systolic. In an effort to simplify her regimen and provide control with agents she would take, we adjusted her outpatient medication regimen to - Carvedilol 12.5 mg [Hospital1 ], Losartan 100 mg daily, Lasix 20 mg [Hospital1 ], Isosorbide Mononitrate ER 90 mg daily, and Spironolactone 25 mg once daily. She met with Social Work to discuss barriers to complaince and was discharged home with services to help with medication administration and vitals monitoring. . # Chest Pain: CP likely in setting of HTN emergency, less likely ACS. Cardiac enzymes were cycled and were negative. No evidence of acute ischemia on EKG. . # Acute on Chronic Systolic Congestove Heart Failure: Known systolic dysfunction 45% on last echo. Acutely worsened with HTN emergency and improved with control of blood pressure. Lasix was restarted at home dose and the patient was breathing comfortably on room air. Continued on ASA 81 mg daily, [Last Name (un) ], Beta-blocker, and Spironolactone. . # Chronic Renal Insufficiency: Baseline creatinine as of [5-1] appears to be between 1.2 and 1.4. Creatinine remained around baseline at 1.3. . # Prior CVA: Ischemic. Treated at [Hospital1 2177] 12/[2117]. CT head on admission with no acute bleed. She was continued on Coumadin 5 mg daily. She was also give a script for outpatient Occupational Therapy to improve function of her left arm, which has residual weakness. . # DM: Continued home lantus and SSI, last A1c 7.3%. . # HLD: Continued home Simvastatin 20 mg daily. . # Hypothyroidism: Continued home Levothyroxine 50 mcg daily. . # GERD: Reported history of, not taking PPI or H2 blocker currently. . # ACCESS: PIV's . # PROPHYLAXIS: -DVT ppx with coumadin -Pain management with tylenol -Bowel regimen with colace, senna . # CODE: Full . # COMM: [Name (NI) ] Medications on Admission: albuterol inh prn furosemide 20 mg [Hospital1 ] hydralazine 30 mg tid glargine 55 units QAM lispro SSI isosorbide mononitrate ER 90 mg qd levothyroxine 50 mcg qd metoprolol tartrate 25 mg [Hospital1 ] omeprazole 20 mg qd ? not taking simvastatin 20 mg qhs spironolactone 25 mg qd valsartan 320 mg qd ? not taking warfarin 5 mg qd aspirin 81 mg Tablet Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous at bedtime. 4. insulin lispro 100 unit/mL Solution Sig: as directed by sliding scale Subcutaneous four times a day. 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day: for a total of 90 mg daily. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: please continue to have your INR monitored for Coumadin dose adjustments as needed. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 12. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Outpatient Occupational Therapy please perform occupation therapy for left arm Discharge Disposition: Home With Service Facility: At home VNA Discharge Diagnosis: Hypertensive Emergency Coronary Artery Disease Acute on Chronic Systolic Congestive Heart Failure Chronic Kidney Injury Diabetes Mellitus Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 13014], You were admitted to the Intensive Care Unit for treatment of dangerously high blood pressures. We provided you with medications and you improved. You were then transferred to the Medicine floor. You were seen by Social Work and will be having a Visiting Nurse Assistant come to help you with your medications and blood pressure monitoring at home. It is very important that you take your prescribed medications as directed and follow up with your Primary Care Physician for further evaluation. . The following changes were made to your current medication regimen: -Please STOP taking Hydralazine -Please STOP taking Metoprolol -Please STOP taking Diovan (Valsartan) -Please START Carvedilol 12.5 mg by mouth TWICE daily -Please START Cozaar (Losartan) 100 mg by mouth ONCE daily -Please CONTINUE Lasix (Furosemide) 20 mg TWICE daily, Isosorbide Mononitrate (Extended Release) 90 mg ONCE daily, and Spironolactone 25 mg ONCE daily . Please weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2118-6-16] at 1:30 PM With: [First Name4 (NamePattern1) 2184] [Last Name (NamePattern1) 2185], MD. [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Department: [Hospital3 249] When: WEDNESDAY [2118-7-13] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16163], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23*] Garage	[ "25000", "412", "2859", "4280", "5859", "41401", "V5867", "2449", "53081", "2724", "V5861", "311" ]
Admission Date: [2164-7-16] Discharge Date: [2164-7-24] Date of Birth: [2089-2-27] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion, chest pain Major Surgical or Invasive Procedure: [2164-7-19] - Coronary artery bypass grafting to four vessels.(Left internal mammary->Left anterior descending artery, Left lesser saphenous vein->Diagonal artery, Left Radial artery->Obtuse marginal artery, Right internal mammary->Distal right coronary artery) [2164-7-16] - Cardiac Catheterization History of Present Illness: 75 yo F with history of MI [74] years ago with exertional angina- chest pressure, dypnea, weakness, and dizziness. Pt had an abnormal stress test and was referred for cardiac catheterization to further evaluate. Now asked to evaluate for surgical revascularization. Past Medical History: Hypothyroidism Osteoporosis Hypertension MI in her early 50s, treated medically Arthritis Gall stones Depression ?TIA- facial numbness 6 yrs ago Social History: Occupation: Retired Last Dental Exam: 3 weeks ago, needs 2 fillings Lives with: alone Race:Caucasian Tobacco:denies ETOH:denies Family History: Family History: (parents/children/siblings CAD < 55 y/o):denies Physical Exam: Pulse:65 Resp: 16 O2 sat: 98%RA B/P Right:162/79 Left: 161/82 Height: 5'2" Weight:128 lbs General:Alert & oriented Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] No Murmur or gallops. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: s/p vein stripping Neuro: Grossly intact Pulses: Femoral Right:+2 Left:+2 DP Right:+2 Left:+2 PT [Name (NI) 167]:+2 Left:+2 Radial Right:+2 Left:+2 Pos. Allens test on left wrist. Carotid Bruit Right:None Left: None Pertinent Results: [2164-7-16] Cardiac Catheterization: 1. Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had no angiographically apparent disease but tapered distally. The LAD had 90% proximal and mid stenoses. The LCx had a long proximal stenosis up to 90%. The RCA had a proximal 90% stenosis and a long 70% mid stenosis. 2. Limited resting hemodynamics revealed SBP of 134 mmHg and a DBP of 64 mmHg. [2164-7-18] Vein Mapping Surgically absent greater saphenous veins. Patent left lesser saphenous vein with small diameters. [2164-7-18] Arterial Duplex Ultrasound Patent radial arteries bilaterally with normal flow and diameters as noted above. [2164-7-17] Carotid Duplex Ultrasound Right ICA stenosis less than 40%. Left ICA stenosis less than 40%. [2164-7-19] ECHO PRE BYPASS The left atrium is elongated. 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 are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST CPB The patient is being A paced. There is normal biventricular systolic function. Valvular function is unchanged. The thoracic aorta appears intact. [2164-7-24] 04:50AM BLOOD WBC-9.6 RBC-3.93* Hgb-12.4 Hct-34.9* MCV-89 MCH-31.6 MCHC-35.6* RDW-13.9 Plt Ct-203# [2164-7-16] 11:20AM BLOOD WBC-5.1 RBC-3.73* Hgb-11.3* Hct-33.5* MCV-90 MCH-30.3 MCHC-33.8 RDW-13.1 Plt Ct-206 [2164-7-19] 01:56PM BLOOD PT-17.2* PTT-60.4* INR(PT)-1.5* [2164-7-16] 11:20AM BLOOD PT-13.0 PTT-28.5 INR(PT)-1.1 [2164-7-24] 04:50AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-136 K-4.3 Cl-99 HCO3-26 AnGap-15 [2164-7-16] 11:20AM BLOOD Glucose-172* UreaN-19 Creat-0.7 Na-139 K-3.6 Cl-107 HCO3-25 AnGap-11 [2164-7-19] 10:10PM BLOOD ALT-27 AST-62* AlkPhos-32* Amylase-17 TotBili-1.5 Brief Hospital Course: Ms. [Known lastname 82908] was admitted to the [Hospital1 18] on [2164-7-16] for a cardiac catheterization. This revealed severe three vessel disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical management. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed a less then 40% bilateral internal carotid artery stenosis. As she had past vein stripping, a venous ultrasound and arterial duplex ultrasound were obtained. These revealed a patent but very small lesser saphenous vein and patent left radial artery. Ciprofloxacin was started for treatment of a urinary tract infection. Plavix was allowed to wash out. On [2164-7-19], Ms. [Known lastname 82908] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Cross Clamp time= 84minutes. Cardiopulmonary Bypass time= 129 minutes.Please see Dr[Doctor Last Name 14333] operative note for further details. She tolerated the procedure well and was transferred in critical but stable condition to the CVICU. A very mild rash was noted which was thought to be related o the vancomycin. Within 24 hours, Ms. [Known lastname 82908] [Last Name (Titles) 5058] neurologically intact and was extubated. All lines and drains were discontinued in a timely fashion. Beta-blocker, statin and aspirin initiated. On postoperative day one, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She developed some confusion overnight which was treated with Haldol. The confusion resolved by the next morning. She continued to progress and Dr.[Last Name (STitle) ] cleared her for discharge on POD#5. All follow up appointments were advised. Medications on Admission: Actonel 35mg once weekly on Saturday Flonase nasal spray once in the am Temazepam 30mg daily at hs Unithroid 75mcg daily Atenolol 50mg daily Tramadol 50mg four times daily PRN for arthritis pain Aspirin 325mg daily Plavix 75mg daily Isosorbide MN 30mg daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Isosorbide Mononitrate 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 months. 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Metoprolol Tartrate 37.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). *Please do not dispense Metoprolol/Isosorbide Mononitrate /and Lasix at the same time->may cause hypotension if taken at the same time Discharge Disposition: Home With Service Facility: n/a Discharge Diagnosis: CAD s/p CABGx4 Hyperlipidemia Hypertension MI in early 50's Arthritis Gallstones Depression Osteoporosis Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact your [Name2 (NI) 5059] at ([Telephone/Fax (1) 4044] for all wound issues. 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) You may wash incision and pat dry. No lotions, creams or powders to incision until after 6 weeks. No swimming or bathing for 6 weeks. 5) No driving for 1 month. 6) No lifting more then 10 pounds for 10 weeks from date of surgery. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) ] in [2-1] weeks. Please follow-up with Dr. [Last Name (STitle) 3321] in [1-31] weeks. Please call all providers for appointments. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2164-7-24**]	[ "41401", "5990", "2449", "4019", "412", "311" ]
Admission Date: [2132-11-13] Discharge Date: [2132-11-21] Date of Birth: [2068-2-16] Sex: M Service: VSU CHIEF COMPLAINT: Acute onset of painful, cold, right leg. HISTORY OF PRESENT ILLNESS: This is a 54 year old male with known peripheral vascular disease who underwent a right fem- popliteal bypass graft in [2132-3-20], now here complaining of significant leg pain times two weeks, now with increasing intensity which is describes as a [9-28]. He also has noted onset of coolness of the foot and mottling of the skin today. The patient had been on Plavix which he discontinued two months ago. Patient was initially evaluated in the emergency room and he was begun on intravenous heparin at a bolus of 6200 units and infusion started at 1400 units per hour with monitoring of coags. Morphine sulfate was administered to the patient for analgesic control. The patient was seen by the Vascular Service in the emergency room. Patient was prepared for emergent arteriogram with possible surgical exploration. PAST MEDICAL HISTORY: Is significant for tobacco use and peripheral vascular disease, hypertension. PAST SURGICAL HISTORY: As indicated in the history of present illness. The bypass graft that was done was a PTFE. The patient has had an open cholecystectomy and a Dupuytren contracture repair. He denies any drug allergies. MEDICATIONS ON ADMISSION: Lopressor 25 mg B.I.D, aspirin which he does not take on a regular basis and Plavix 75 mg daily which he stopped several weeks ago. SOCIAL HISTORY: Denies alcohol use but has excessive tobacco use. PHYSICAL EXAMINATION: Vital signs: 98.2, 80, 174/80, 16, 97 percent oxygen saturation on room air. General appearance: Alert male with moderate distress. HEENT examination was unremarkable. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdominal examination was benign. Extremity examination showed left lower extremity was warm with palpable pulses and 1 plus ankle edema. The right lower extremity was with erythema to the knee, was cool with 2 plus edema with diminished sensation and weak flexion extension of the ankle and toes. The pulse examination shows palpable radial pulses bilaterally 2 plus, femoral pulses on the right were 1 plus and distal to the right femoral artery pulse all remaining extremity pulses on the right side were absent. On the left his popliteal, posterior tibial and dorsalis pedis pulses were palpable 2 plus. HOSPITAL COURSE: The night of admission the patient underwent a retrograde left common femoral artery access and had an AngioJet of the right femoral-[Doctor Last Name ] graft, followed by angioplasty of the proximal and distal anastomosis and angioplasty of the popliteal artery. Infusion of 2 mg of tPA and placement of a thrombolysis infusion catheter into the right fem-[Doctor Last Name ] graft was done at the end of the procedure. The findings were normal aorta and iliacs. The common femoral was occluded. There is a patent profunda femoris. The graft was occluded. There was thrombus and plaque in the popliteal and peroneal arteries with a stenosis of greater than 50 percent present in the mid popliteal artery. The anterior tibial and posterior tibial were occluded. There was a reconstitution of the posterior tibial artery distally. The peroneal was the main run-off vessel to the foot. Stenosis was present and moderately severe at the distal anastomosis. The patient tolerated the procedure well, was continued on tPA infusion and was transferred to the Surgical Intensive Care Unit for continued monitoring and care. The patient remained hemodynamically stable. Aspirin and Plavix were started on [11-14]. Intravenous heparinization with tPA was continued for a goal PTT of 60 to 80. Regular vascular checks were continued and his coagulations and hematocrits were monitored and fibrinogen levels were monitored q 4 hours. Adjustments in tPA and heparin were made at that time. The patient did well overnight and returned to the angio suite on [2132-11-14]. At that time he underwent a right leg run- off with angioplasty of the knee, popliteal and distal anastomosis of the fem-AK-[Doctor Last Name ] graft and profunda femoris. There was an angioplasty of the native posterior tibial with rheolytic AngioJet thrombectomy of the right profunda femoris artery. The femoral artery was closed with Perclose. Patient tolerated the procedure and returned to the Vascular Intensive Care Unit for continued monitoring and care. Patient had required intravenous nitroglycerin during the angio procedure for systolic hypertension. This was weaned off by the time he was transferred to the Vascular Intensive Care Unit. The examination showed a groin with serosanguineous drainage but no hematoma and the right foot was warm. Extremity was warm and there was a biphasic DP signal and a monophasic PT signal. Patient did have some ST changes during the procedure. He was treated with nitroglycerin and Lopressor and electrocardiogram was examined. There were no ischemic changes noted. Serial enzymes times one were obtained. Post angio total CPK was 4100. The MB and troponin levels were flat. The patient did well overnight in the Vascular Intensive Care Unit. He remained hemodynamically stable. His examination remained unchanged. There was no groin hematoma. The ST changes resolved with the Lopressor. He was continued on Lopressor, aspirin and Plavix. Coumadinization of 7.5 mg at bedtime was instituted. Intravenous heparinization was continued during the conversion period. His Foley was discontinued. The patient was transferred to the regular nursing floor on [2132-11-15]. [Hospital ] hospital course otherwise was unremarkable except for some mental status changes which occurred on hospital day number 4. Psychiatry was consulted. They felt that the mental status changes were secondary to delirium which was multifactorial in etiology. The patient underwent a chest x-ray which was unremarkable for acute pulmonary process or infiltrates. A head CT was done which was negative for any intracranial bleed or mass. The patient was continued on Haldol for agitation. His narcotics were minimized as necessary and he was begun on vitamin B12. Over the next 48 hours his mental status improved. By hospital day nine patient remained without complaint but was very much interested in returning to rehabilitation for continued therapy. The remaining hospital course was unremarkable. The patient's heparin was discontinued on [2132-1-31]. The patient's INR was greater than 2.0 and therapeutic. Discharge planning was instituted. At the time of discharge the patient was stable. Mental status was cleared. Vascular examination was with a warm foot with a triphasic DP and PT bilaterally. DISCHARGE DIAGNOSES: 1. Ischemia of the right extremity secondary to graft occlusion secondary to thrombus status post thrombectomy angioplasty and tPA. 2. Post procedure delirium, resolved. 3. History of alcohol use. 4. History of nicotine abuse. Patient was placed on nicotine patch. DISCHARGE MEDICATIONS: 1. Plavix 75 mg daily. 2. Aspirin 325 mg daily. 3. Nicotine 14 mg patch q 24 hours. Patient to follow up with the primary care physician regarding continuation of smoking cessation program. 4. Metoprolol 75 mg q.i.d. 5. Oxycodone/acetaminophen 5/325 tablets one to two q 4 to 6 hours PRN for pain. 6. Vitamin B12 100 mcg daily. 7. Pentamidine 20 mg tablets B.I.D 8. Coumadin 75 mg at bed time. INR should be monitored at least twice a week. The goal INR is 2.0 to 3.0. These results should be called to Dr.[Name (NI) 7446] office. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(2) 6039] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2132-11-20] 18:05:51 T: [2132-11-20] 18:56:47 Job#: [Job Number 56331]	[ "3051" ]
Admission Date: [2198-10-30] Discharge Date: [2198-11-19] Date of Birth: [2136-12-23] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Right sided weakness Major Surgical or Invasive Procedure: Ventricular drain placement Intraventricular t-PA Left subclavian central line [11-5] PEG [11-7] History of Present Illness: Patient is a 61 year old male with hypertension, hypercholesterolemia, diabetes who we are asked to evaluate for right-sided weakness. Patient was in his usual state of health until around 14:30 today. He was at the Elks lounge when he was noted to have acute onset right-sided weakness, right facial droop and slurring of speech. When EMS arrived, noted right side flaccid, bilateral pinpoint pupils, sluggishly reactive, somnolent. Fingerstick blood glucose 248. Given 1mg Narcan and vomited. He was transferred emergently to [Hospital1 ] Hospital. Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. Diabetes Social History: Lives with his mother, unemployed. Toxic habits not known. Physical Exam: Tc: 99.0 BP: 224/88 HR: 90 RR: 18 Gen: WD/WN male, comfortable-appearing on vent, NAD. HEENT: NC/AT. Anicteric. MMM. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: Coarse anterolaterally. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Off of sedation x 20 minutes. Follows commands intermittently to squeeze hand, wiggle toes on left side. Does not open eyes spontaneously nor to stimuli. Moves to nasal tickle. No speech output. Cranial Nerves: Pupils unequal, fixed. Right pupil 1.5 mm, left pupil 5-6 mm, fixed. Unable to appreciate right fundus. Left disc margin blurred. No blink to threat. No oculocephalic reflex. +Corneal reflexes bilaterally. Right droop. No gag. Motor: Moves left leg spontaneously. Left arm flexed, increased tone. Withdraws x 4 with L>R. Sensation: Withdraws x 4 with L>R. Reflexes: B T Br Pa Ac Right 1 1 1 0 1 Left 1 1 1 0 1 Grasp reflex absent. Toes upgoing bilaterally. Coordination: Unable to assess. Gait: Unable to assess. Pertinent Results: [2198-11-19] 04:20AM BLOOD WBC-9.1 RBC-3.35* Hgb-10.5* Hct-29.9* MCV-89 MCH-31.4 MCHC-35.1* RDW-12.9 Plt Ct-461* [2198-11-17] 03:21PM BLOOD WBC-10.1 RBC-3.47* Hgb-10.9* Hct-31.1* MCV-90 MCH-31.6 MCHC-35.2* RDW-13.1 Plt Ct-474* [2198-11-19] 04:20AM BLOOD Plt Ct-461* [2198-11-19] 04:20AM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.0 [2198-11-18] 04:45PM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1 [2198-11-17] 03:21PM BLOOD Plt Ct-474* [2198-11-19] 04:20AM BLOOD Glucose-161* UreaN-24* Creat-0.6 Na-135 K-4.6 Cl-98 HCO3-30* AnGap-12 [2198-11-18] 04:45PM BLOOD Glucose-118* UreaN-24* Creat-0.6 Na-137 K-4.6 Cl-98 HCO3-32* AnGap-12 [2198-11-19] 04:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8 [2198-11-18] 04:45PM BLOOD Calcium-9.1 Phos-4.3 Mg-1.9 Brief Hospital Course: Arrived at ED at 15:00. Initial vitals were 175/66, 71, 16, 100%. GCS 3. Pupils unequal, reactive initially. Seen by acute stroke team member at 15:15. CT ordered by 15:15. CT with large left thalamic hemorrhage. Not a candidate for IV-tPA. Intubated after Vecuronium, Etomidate, Succhinylcholine. Loaded with 1 gram Dilantin. Received 70 grams of Mannitol. OGT and A-line placed in ED. Started on Nitroprusside for goal SBP 120-140. He was then admitted to the ICU for continued management. 1. NEURO: Because of ventricular extension of bleed and impending obstruction of the 3rd ventricle, a vent drain was placed by neurosurgery on [10-30]. He was given cefazolin while the drain was in place. Initial ICPs were in the 20's. He was given factor VII. To prevent hydrocephalus, he was given intraventricular t-PA. He was also treated with mannitol. Rpt CT scans showed decrease in intraventricular blood. On [11-3] he was noted to have rhythmic shaking activity of the right upper extremity. He was tx'd with ativan and re-loaded with dilantin. Seizure activity resolved. Neurologically, he remained stable and showed some signs of improvement, with spontaneous movement of his left upper and lower extremities, and intermittent following of basic commands. On [2198-11-5], ventricular drain was d/c'ed. Cefazolin was maintained. On [11-10], the patient showed decreased responsiveness (eyes not opening to voice, no response to command - had previously held up 2 fingers). A head CT showed interval decrease in hemorrhage and surrounding edema, and decrease in traventricular blood. Dilantin level was 10.9 and the patient was given 500mg IV dilantin. CXR showed no new infiltrate. On [2198-11-11], the patient was transferred to the floor. Neurological exam was stable after transfer to floor. Dilantin level was sub-therapeutic on [11-14] and t was given an additional 200mg po and dose was increased from 200/100/200 to 200/130/200. Please follow up dilantin level this week and adjust dose to maintain corrected level 15-17. 2. PULMONARY: The patient was intubated on admission and extubated without complication on [2198-11-9]. CXR on [2198-11-5] showed a focal opacity in right upper lobe centrally. He was pancultured and begun on levoflox on [2198-11-6]. Flagyl was added on [11-7] for presumed aspiration PNA, then d/c'ed after 3d. CXR on 113/04 showed no infiltrate. On the floor, the patient again had a T to 101.2 on 111/04 and was pancultured. CXR showed no infiltrate, but pt was continued on levo and flagyl was started on [11-12]. The patient had significant secretions throughout his hospital course and required significant suctioning, approximately q2 hours. On [11-15], the pt's low grade temps resolved and he required less frequent suctioning. On [11-15], tracheostomy was discussed with the patient's mother as a means of controlling his secretions and preventing mucous plugging in the future. On [2198-11-16], trach was placed by thoracic surgery service without complication. 3. CV: Pt was started on Nitroprusside initially to maintain SBP 120-140, and was later changed to labetalol with goal SBP 140-160. He ruled out for MI. On [2198-11-9], his lopressor was increased and he was started on lisinopril and HCTZ for elevated BP's. From [11-12] to [11-15], his SBP was 140's-150's. On [11-15], his hydral was increased to maximum dose, with good effect. A lipid panel was done (TG 160, HDL 35, LDL 78), and the patient was placed on lipitor 10mg qd. He was maintained on telemetry in the step-down unit (for nursing purposes) and no events were seen. 4. ID: PNA as described above. On [2198-11-12], after T spike, the pt had 2/4 bottles with coag negative Staph. He wa given one dose of vanc on [11-13], but as [11-13] surveillance cultures were negative and he did not spike again, these were considered to be contamination. On [2198-11-15], the pt's low grade temps resolved. He was maintained on a 14d course of levo and flagyl (started [11-7]). He has remained afebrile and WBC decreasing. Will finish 14 day course of flagyl in 3 days. 5. GI: Pt was fed by NGT and then by PEG, placed [11-6]. Tolerated feeds without difficulty. . 6. Endo: The patient was initially placed on an insulin gtt, and prior to transfer to the step-down, was placed on NPH and RISS. NPH was titrated up repeatedly for adequate control. 7. Code: The ICU and neurology teams had many conversations with the patient's mother and aunts re: code status. On [11-15], the pt was made DNR but not DNI. . 8. Ppx: Hep SC, bowel regimen, HOB>30 degrees, famotidine . 9. Dispo: To extended care facility Medications on Admission: Lisinopril Atenolol HCTZ Metformin Hydralazine Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. Disp:30 Tablet(s) Refills:2 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD () as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 150 mg/15 mL Liquid Sig: [1-12] PO BID (2 times a day). Disp:300 ml Refills:2 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:2 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). Disp:30 injection Refills:2 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 tube Refills:0 8. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:60 ML(s) Refills:2 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:90 Tablet(s) Refills:2 12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 container Refills:3 15. Ipratropium Bromide 0.02 % Solution Sig: [1-12] Inhalation Q6H (every 6 hours). Disp:1 container Refills:2 16. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO HS (at bedtime). Disp:240 ml Refills:2 17. Phenytoin 100 mg/4 mL Suspension Sig: Five (5) ml PO DAILY (Daily): please give at 2pm. 18. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) ml PO QAM (once a day (in the morning)). 19. Hydralazine HCl 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:240 Tablet(s) Refills:2 20. Insulin Regular Human Subcutaneous 21. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 12.5-25 mcg Injection Q2H (every 2 hours) as needed for pain/. Disp:30 mcg Refills:3 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Left thalamic hemorrhage with intraventricular extension 2. Intracranial hypertension 3. Hypertension 4. Pneumonia 5. Anemia Discharge Condition: stable Discharge Instructions: Please montitor neurologic status. If decreased responsiveness, new weakness or other neurologic deficits develop, please notify his primary care doctor or send him to the emergency room for evaluation. Followup Instructions: 1. [Hospital 4038] Clinic: Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2574] within [2-13] months. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "5070", "486", "4019", "25000", "2720" ]
Admission Date: [2171-4-11] Discharge Date: [2171-7-12] Date of Birth: [2171-4-11] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ], #2, is a former 750 gram Twin B, product of a 26 week gestation, pregnancy, born to a health 35 year old primigravida mother. This baby delivered via cesarean section after vaginal delivery of Twin A. Mother was admitted to [Hospital1 69] the day prior to delivery after being treated with bedrest for preterm labor and cervical shortening for the previous four weeks. She received betamethasone and magnesium sulfate. Progression of labor and cervical dilatation led to delivery on [2171-4-11]. PRENATAL SCREENS: 1. GBS unknown. 2. She is A positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative. She delivered with decreased tone and respirations, heart rate always greater than 100. Received positive pressure ventilation and intubated in the delivery room due to worsening work of breathing. Apgar five at one minute and seven at five minutes. Transferred to the Newborn Intensive Care Unit after visiting briefly with parents. PHYSICAL EXAMINATION: On admission, pink, nondysmorphic, premature infant, blood pressure good range, eyes fused. Heart regular rate and rhythm, S1 and S2, no murmur. The lungs crackly bilaterally, breath sounds equal. Abdomen benign, three vessel cord. Skin without bruising with abdomen and normal female genitalia. Low birth weight infant. Moro decreased with tone and spontaneous activity. No focal activity. Hips normal. Spine intact. Patent anus. HOSPITAL COURSE: 1. Respiratory - The patient received three doses of surfactant and required intubation until day of life 28 when she transitioned to continuous positive airway pressure. She was started on Diuril for her chronic lung disease on day of life 17 and also on potassium chloride supplement. She required CPAP until day of life 50 when she transitioned to nasal cannula oxygen until day of life 86. She has remained in room air since then with no further oxygen requirement. She was loaded with maintenance caffeine and started on maintenance dose on day of life two which required until day of life 66 for apnea and bradycardia of prematurity. This has been discontinued and she has been free of apnea and bradycardia for greater than five days at the time of discharge. 2. Cardiovascular - Initially, the baby required a normal saline bolus for marginally low blood pressure. She did not require pressor support. On day of life one, she was presumed to have a patent ductus arteriosus based on clinical presentation. She received one course of indomethacin with improvement of symptoms. She did not have an echocardiogram. At this time, she has a soft intermittent PPS murmur. She is cardiovascularly stable with blood pressure systolic 70 to 80s and diastolic 40 to 50s and means in 50 to 60s. 3. Fluids, electrolytes and nutrition - The baby initially had a double lumen UVC line inserted. She was started on peripheral and central parenteral nutrition on day of life one. A PICC line was placed on day of life six and enteral feedings were started on day of life four. She advanced to full enteral feedings by day of life eleven and then had her caloric density increased to 32 calories per ounce of mother's milk with ProMod. Her growth demonstrated adequate gain and her calories were decreased at the time of discharge. She is eating breast milk 24 calories, breast feeding when mother is available with supplemental four calories per ounce of Enfamil powder at each breast milk. This is one teaspoon of Enfamil powder per 100cc of breast milk. She has also received supplemental Vitamin E which has been discontinued. She remains on ferrous sulfate 0.2cc which equals 2 mg/kg/day. Her early days, she did require sodium supplement when she was hyponatremic with a low sodium being 124. She responded nicely to the supplementation and that has also been discontinued. Her last electrolytes on [2171-6-11], were sodium 136, potassium 3.8, chloride 104, bicarbonate 26, calcium 11.0, phosphorus 5.3 and alkaline phos 260. She had a repeat calcium on [2171-7-6], which is 10.5. The baby is currently feeding ad lib breast and bottle and voiding and stooling with no further issues. 4. Gastrointestinal - The baby had demonstrated physiologic jaundice with peak bilirubin of 4.4/0.8 on day two to three, responded nicely to phototherapy. She had her phototherapy lights discontinued and rebound bilirubin on day of life eight of 2.2/0.4/1.9. 5. Hematology - The baby's blood type is O positive, Coombs negative. She received three blood transfusions during admission, the last one being on [2171-5-7]. Her last hematocrit on [2171-6-30], was 29.4. 6. Infectious disease - The baby initially had a sepsis evaluation because of her prematurity and respiratory distress. She had an initial white blood cell count of 9.2 with 18 polys, 0 bands, and platelet count of 234,000, hematocrit 45.0. She received one week of ampicillin and gentamicin. Gentamicin levels were within range with a peak of 5.8 and a trough of 1.9. She had a lumbar puncture prior to antibiotics being discontinued with a white blood cell count of 278,000, red blood cells [Pager number ],000. Antibiotics were discontinued at one week. She has had no further issues with infection. 7. Neurology - She has had serial head ultrasounds which have all been within normal limits, the last one being on [2171-6-18], at a corrected gestational age of 36 weeks. Her physical examination is appropriate for gestational age. 8. Sensory - Hearing screen was performed with an automated auditory brain stem response. The baby passed and this was done on [2171-6-18]. 9. Ophthalmology - The baby has had serial eye examinations with progression of retinopathy of prematurity to Threshold disease with plus disease requiring laser surgery which was performed on [2171-7-1], OU. Follow-up on [2171-7-17] revealed regression of her ROP. Follow-up will be in 2 weeks with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36137]. Discharge diagnoses: 1. Prematurity Twin #2 2. R/O sepsis 3. Patent ductus arteriosus 4. Severe retinopathy of prematurity post laser therapy 5. Chronic lung disease Discharge status: Baby is being discharged to home with parents. Follow-up with Dr. [First Name8 (NamePattern2) 1743] [Last Name (NamePattern1) 37517] on Monday [2171-7-22]. Ophthalmology FU with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36137] in [2-18] weeks. Feedings - ad lib breastmilk 26 - breastmilk supplemented with corn oil 2kcal/oz and Enfamil powder 4kcal/oz. Meds - Fe - 0.5cc po QD Polyvisol 1.0cc QD Nystatin 2cc QID for 2 more days. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]	[ "2761", "7742" ]
Admission Date: [2197-4-11] Discharge Date: [2197-4-24] Date of Birth: [2134-3-10] Sex: F Service: MEDICINE Allergies: Tegretol Attending:[First Name3 (LF) 759] Chief Complaint: transferred from [Hospital3 ] per family preference Major Surgical or Invasive Procedure: intubation, mechanical ventilation, R IJ central line placement, L radial arterial line placement History of Present Illness: 63 yo F who is transferred from [Hospital3 ], after presenting on [2197-4-7] with 3 weeks of "cold symptoms" and one week of body ache and malaises with R-sided chest and abdomal pain and hand swelling. Patient was found to have CAP with r-sided effusion. She was admitted to the ICU and a chest tube was placed [2197-4-9] for drainage of parapneumonic effusion (see labs below) when her WBC was 22.3. Patients initial blood cx showed [2-18] growing step pneumo resistent to levaquin. Her respiratory status worsened and her O2 requirement increased. She developed 10cc of hempotysis, She was intubated [2197-4-11] for increased work of breathing and respiratory distress, and it was noted the intubation may have been complicated by aspiration. ABG prior to intubation was 7.37/45/76 on 100% nonrebreather. Per report, was hypotensive peri-intubation but responded to fluid bolus. . Patient's family requested transfer of care to [Hospital1 18]. Past Medical History: Htn, hyperchol, arthritis, GERD, s/p appu, s/p tonsillectomy, neck disk surgery x2 with fusion, s/p R breast bx of benign lesion, s/p open removal of kidney stones, Social History: Smoked ppd x30 years, quit 12 years ago. No EtOH or drug use. Married, lives with husband and son. [Name (NI) ] exposure hx. Had flu shot in [2196]. Has not had pneumovax. Works at Princess House. Family History: Fam Hx: Cardiac disease, brother with MI at 43. Colon cancer. Physical Exam: 98.9 111/60 108 87 98% Vent Settings: AC 450 12 5 .5 Gen: Intubated and sedated, appears comfortable, chest tube draining serous fluid HEENT: mmm, et tube in place, neck supple, OG tube with bilious contents CV: rrr I/VI SEM Pulm: Decreased breath sounds R base, few crackles R upper lung fields, L side fairly clear Abd: slightly distended, tympanic, few bowel sounds, soft Ext: non-pitting edema, well perfused Nuero: sedated Pertinent Results: OSH labs: WBC 12.5 2% bands, 75% segs, Hct 26.1, Plts 185, INR 1.29, Cr .9 Pleural fluid [4-9]: WBC 7062; 96% polys, 4% monocytes. Total protein<2.5, glucose 80, amylase and triglyceride low, LDH 1024. Ph 7.27. . Influenza pharyngeal swab negative for type A and B . Blood Cx [4-7]: S. pneumoniae resistent to Levaquin, . [4-7]: CT abd/pelvis: no acute pathology . [4-7]: abd US: no cholelithiasis [2197-4-11] 11:30PM PLT COUNT-191 [2197-4-11] 11:30PM WBC-9.8 RBC-2.81* HGB-9.1* HCT-26.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-14.3 [2197-4-11] 11:30PM CALCIUM-7.9* PHOSPHATE-1.2* MAGNESIUM-1.2* [2197-4-11] 11:30PM GLUCOSE-80 UREA N-11 CREAT-0.4 SODIUM-144 POTASSIUM-3.2* CHLORIDE-114* TOTAL CO2-25 ANION GAP-8 . CT Chest [2197-4-12] IMPRESSION: 1. Multifocal pneumonia, may be bacterial with bilateral pleural effusions and mediastinal lymphadenopathy. If this does not fit the clinical scenario, then lymphoma is a consideration. 2. Right small apical pneumothorax. 3. Tiny pericardial effusion. 4. High-density material in the gallbladder. [Month (only) 116] be sludge or contrast from prior procedure. . ECHO [2197-4-20] Conclusions: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Physiologic mitral regurgitation is seen (within normal limits). 6.There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Brief Hospital Course: Ms. [Known lastname 67167] is a 63 yo woman transferred from OSH with R-sided pneumonia, para pneumonic pleural effusion, chest tube, and recent bacteremia with Levofloxacin resistant organisms, Penicillin/CTX resistant (intermediate) strep pneumonia. She was intubated and a chest tube was placed at [Hospital3 ]. She was initially started on vancomycin pending sensitivities, and once they returned she was continued on this course, however the patient appeared to be worsening, so Zosyn was added for broader coverage. She was transferred to [Hospital1 18] for family preference. At [Hospital1 18] all cultures of blood, sputum, stool, and urine remained negative. The patient continued to spike fevers for the first few days of her stay but eventually this resolved. She was continued on [Doctor Last Name ] co and Zosyn and completed a 14 day course. She was also treated with a 6 day course of steroids for possible underlying COPD (pt has no history, but has a 30py smoking history). The patient had labile blood pressure in the unit, requiring metoprolol which was slowly increased to her home atenolol dose equivalent, however on several occasions she had hypotension requiring fluid boluses. This resolved for the last three days the patient spent in the ICU and she was kept on her beta blocker without problem. The patient was sedated with fentanyl and versed, as well as Haldol for agitation while on the ventilator. Initial trial of extubation was quickly failed, as the patient began wheezing almost immediately. She was quickly reintubated and follow up CXR showed pulmonary edema. The pt was noted to have a small right apical pneumothorax. The patient was positive 8 L during her stay in the unit, and this was then aggressively diuresed. After diuresis the patient was again extubated, with nitroglycerin drip used for 30 minutes peri-extubation, this time successfully and she remained on shovel mask, follow by NC and saturations remained consistently in the mid to high 90s. She was called out of the ICU to the floor. On the floor, the pt's pneumothorax was noted to resolve on repeat CXR, she remained afebrile and did not have a significant oxygen requirement. She was given a Pneumovax vaccine. The pt was discharged with instructions to follow-up with her primary care provider for evaluation of her anemia and was recommended a colonoscopy and was recommended to avoid air travel for 1 week after discharge. Medications on Admission: Home Meds: Atenolol. Zetia, Zantac . Meds on Transfer: Zantac 50mg IV q24, Vancomycin 1g q12h, Protonix 40mg daily, KCl, Versed gtt, Zosyn, Dilauded, Ativan, tylenol. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. Disp:30 Tablet(s) Refills:0 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash for 7 days: apply to afected areas as needed. Disp:1 bottle Refills:0 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation every 4-6 hours as needed for shortness of breath or wheezing: until resolution of shortness of breath. Disp:2 inhalers Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 ] home care Discharge Diagnosis: Primary: Pneumonia . Secondary: Hypertension Hypercholesterolemia Arthritis GERD S/p appendectomy S/p tonsillectomy Neck disk surgery x2 with fusion S/p R breast bx of benign lesion S/p open removal of kidney stones Discharge Condition: Stable, able to ambulate and maintain oxygen saturation on room air. Discharge Instructions: Please report to then nearest emergency department if you have fever, chills, nausea, vomiting, diarrhea, or difficulty breathing. If you have any problems between the time of discharge and your appointment with your primary care provider, [Name10 (NameIs) ] call [Hospital6 733] ([Company 191]) at [Telephone/Fax (1) 250]. . There has been a change in your medications. . You have been scheduled for a follow-up appointment with your new primary care physician, [Name10 (NameIs) 3] indicated below. Please ask your PCP to work up your anemia or low blood count. You will likely need also need a colonoscopy. . You have requested a transfer of your care to [Hospital1 771]. You will need to call your insurance company and update your primary care provider. . You will need to call [Telephone/Fax (1) 250] to verify your demographics on file prior to your appointment. . We have discussed your case with cardiothoracic surgery. They recommend that you avoid flying in an aeroplane for at least another week after discharge. Followup Instructions: PRIMARY CARE PHYSICIAN: [Name Initial (NameIs) 2169]: [Name10 (NameIs) ] [Name11 (NameIs) 67168] [Name12 (NameIs) ], MD (works with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216])Phone:[Telephone/Fax (1) 250] Date/Time:[2197-5-1] 2:30 Completed by:[2197-6-6]	[ "51881", "5119", "496", "4019" ]
Admission Date: [2151-12-6] Discharge Date: [2151-12-15] Date of Birth: [2085-10-29] Sex: F Service: CARDIOTHORACIC Allergies: Lisinopril / Oxycodone Attending:[First Name3 (LF) 1505] Chief Complaint: DOE Major Surgical or Invasive Procedure: [2151-12-6] Aortic valve replacement with a [Street Address(2) 6158]. [Hospital 923] Medical mechanical valve History of Present Illness: 66 year old female who complains of shortness of breath with activities. Presented to OSH ED with allergic reaction and vocal cord spasms. Further work up and echocardiogram showed aortic stenosis and is now referred for surgical eval. Past Medical History: Hypertension Hyperlipidemia Osteoporosis Angioedema secondary to lisinopril Loss of vision in right eye 7 years ago with resolution d/t TIA Anxiety Arthritis TIA Social History: Last Dental Exam:2 weeks ago Lives with:Husband Occupation:retired Tobacco:quit 10-12 years ago, 60 PYH ETOH:2-3 beers/day Family History: Father had CVA's Physical Exam: Pulse:98 Resp:16 O2 sat:96/RA B/P Right:175/92 Left: 159/90 Height:5'4" Weight:71.7 kgs General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anteriorly Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: left side facial paralysis, alert and oriented x3 MAE [6-2] Pulses: Femoral Right: cath site Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: murmur vs bruit Left: no bruit Pertinent Results: [2151-12-15] 05:13AM BLOOD WBC-5.7 RBC-3.47* Hgb-10.7* Hct-31.9* MCV-92 MCH-30.8 MCHC-33.6 RDW-13.8 Plt Ct-530* [2151-12-15] 05:13AM BLOOD Plt Ct-530* [2151-12-15] 05:13AM BLOOD PT-31.2* PTT-33.7 INR(PT)-3.1* [2151-12-15] 05:13AM BLOOD Glucose-91 UreaN-13 Creat-0.4 Na-131* K-4.4 Cl-96 HCO3-30 AnGap-9 [2151-12-15] 05:13AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.2 Conclusions The left atrium is mildly dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. A mechanical aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small partially echodense pericardial effusion. There are no echocardiographic signs of tamponade. Electronically signed by [First Name11 (Name Pattern1) 553] [Last Name (NamePattern4) 4133], MD, Interpreting physician [Last Name (NamePattern4) ] [2151-12-9] 14:47 PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-cm2). The non coronary cusp is immobile. The left and right coronary cusps however have good excursion. Mild to moderate ([1-30]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning bileaflet mechanical prosthesis in the aortic position. There is most likely trace paravalvular regurgitation. Ascending aortic contours appear intact. The remaining study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [Last Name (NamePattern4) ] [2151-12-6] 11:04 Brief Hospital Course: Admitted [12-6] and underwent surgery with Dr. [Last Name (STitle) ]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated later that day. Transferred to the floor on POD #1 to begin increasing her activity level. Coumadin started that evening for mechanical valve. Beta blockade titrated. INR rose rapidly to 12.9 and pt transferred back to CVICU for monitoring and FFP. Repeat INRs done with additional FFP given. Gently diuresed toward her preop weight. PICC placed POD #6 for poor IV access and transferred back to the floor. Coumadin titrated and INR at discharge 3.1. Cleared for discharge to home with VNA on POD # 9. Target INR 2.5-3.0 for mechanical AVR. Coumadin dosing will be followed initially by cardiac surgery team and then will be transitioned to her provider when INR is stable. All f/u appts were advised. Medications on Admission: ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - one Tablet(s) by mouth weekly on Wednesday HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - one Tablet(s) by mouth daily CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] - (Prescribed by Other Provider) - 315 mg-200 unit Tablet - 2 (Two) Tablet(s) by mouth daily MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - one Capsule(s) by mouth daily Tylenol PRN 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 BID (2 times a day). Disp:60 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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 10. warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a day: dose to be adjusted based on INR results by Cardiac surgery office [Telephone/Fax (1) 170]. Disp:100 Tablet(s) Refills:2 11. Outpatient [Name (NI) ] Work PT/INR for coumadin Dosing - daily PT/INR Results to Cardiac Surgery [Telephone/Fax (1) 170] - please call results to office thank you 12. coumadin/warfarin You have been given a prescription for 1 mg tablets of coumadin to allow the dose to be adjusted - please have INR drawn daily until directed differently and the Cardiac surgery office will call you with dosing - if you do not hear from anyone by 4 pm each day - please call the office - [Telephone/Fax (1) 170] Please have INR drawn in the am 13. Outpatient [Name (NI) ] Work PT/INR for coumadin Dosing - daily PT/INR Results to Cardiac Surgery [Telephone/Fax (1) 170] - please call results to office thank you Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Aortic Stenosis s/p AVR Hypertension Hyperlipidemia Osteoporosis Angioedema secondary to lisinopril Loss of vision in right eye 7 years ago with resolution d/t TIA Anxiety Arthritis TIA Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram prn Incisions: Sternal - healing well, no erythema or drainage Edema trace bilateral lower extremities 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] Date/Time:[2151-12-30] 3:00 Dr [Last Name (STitle) ] office will call you with appointment arranged with your cardiologist Dr [Last Name (STitle) ] Please call to schedule appointments with your Primary Care Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2405] in [5-3] weeks [Telephone/Fax (1) 87801] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.0 Daily draws for 1 week and then will reevaluate Cardiac Surgery office will follow and dose coumadin until stable regimen and then will set up coumadin coverage with cardiologist/PCP Results to Cardiac Surgery Office phone [Telephone/Fax (1) 170] Completed by:[2151-12-21]	[ "4241", "2851", "4019", "2724" ]
Admission Date: [2111-8-19] Discharge Date: [2111-9-2] Date of Birth: [2032-7-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional chest discomfort, abnormal ETT Major Surgical or Invasive Procedure: [2111-8-20] Three vessel coronary artery bypass grafting - LIMA to LAD, vein graft to diagonal, vein graft to PDA History of Present Illness: This is a pleasant Cantonese-speaking gentleman whounderwent an ETT on [2111-7-10] here at [Hospital1 18]. The patient exercised for 5.5 minutes of [Initials (NamePattern4) ] [Last Name (NamePattern4) 4001] protocol to an APHR of 94%. Patient experienced anginal symptoms with uninterpretable EKG changes at the achieved workload. Images showed severe inferior and inferolateral wall perfusion defect with a small amount of reversibility. Mild, reversible distal anterior wall and apical perfusion defect. Transient increased dilatation of LV cavity with stress. Global hypokinesis with calculated EF of 19%. The patient reports that this past winter, he developed a chest discomfort that radiated to both shoulders when walking outside. To relieve the discomfort he would go indoors and take one sublingual NitroQuick with good results. Since this time, he has continued to experience chest and bilateral shoulder discomfort with walking or when he becomes nervous. The patient also reports occasionally experiencing SOB and mild diaphoresis with these episodes. He denies any associated nausea or vomiting. The patient is now referred for a cardiac cath to further evaluate. Past Medical History: Stomach surgery [2075] gynecomastia, L breast lump by u/s Social History: Married. Came from [Country 651] in [2105]. Worked in [Country 651] for an herbal pharmacy. Family History: No premature CAD. Physical Exam: Vitals: BP 150/ 58, P 56, Sat 100% General: WDWN male in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD. + left carotid bruit Heart: RRR, no rub or murmur Lungs: clear bilaterally Abdomen: benign Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented otherwise nonfocal Pertinent Results: [2111-8-27] 06:50AM BLOOD Hct-30.6* [2111-8-26] 06:40AM BLOOD WBC-9.4 RBC-4.02* Hgb-11.5* Hct-35.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-13.5 Plt Ct-296 [2111-8-27] 06:50AM BLOOD UreaN-23* Creat-1.0 K-4.3 [2111-8-26] 06:40AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent cardiac cath which revealed severe three vessel disease and depressed LV function. Angiography showed a 50% left main lesion; the LAD had proximal and mid 80% lesions; the first diagonal had a 90% stenosis; the circumflex was diffusely diseased; the obtuse marginal had a 90% lesion; and the dominant RCA had a proximal 90% stenosis. Left ventriculography showed no mitral regurgitation and a LVEF of 25%. Based on the above results, cardiac surgery was consulted and further evaluation was performed. A carotid ultrasound found a significant left-sided plaque with a 70-79% carotid stenosis. On the right, there was less than 40% carotid stenosis. A transthoracic echocardiogram showed that the overall left ventricular systolic function was moderately depressed. There posterolateral and posterior walls were thinned and akinetic. The LVEF was estimated at 40%. There was only mild MR. Workup was otherwise unremarkable and he was cleared for surgery. On [8-20], Dr. [Last Name (STitle) ] performed three vessel coronary artery bypass grafting with repair of LV aneurysm. After the operation, he was brought to the CSRU. On POD#1, he was noted to have left sided paralysis for which a head CT scan was obtained. Neurology was concomitantly consulted. The CT scan showed findings consistent with a right middle cerebral artery territory infarction which was likely in an early subacute phase and involved the right posterior frontal and anterior parietal lobes. Given the history, anticoagulation was not recommended by neurology as this stroke did not appear to be embolic. He was kept somewhat hypertensive and transfused with PRBCs to maintain hematocrit over 30%. He was weaned from his drips and extuated by POD#2, and transferred to the floor by POD #5. Swallow evaluation showed aspiration of thin liquids. Diarrhea was cdiff negative. He was transferred to the telemetry floor, and has remained hemodynamically stable. His lasix and potassium were discontinued since he appears to now be euvolemic. He is ready to begin rehabilitation. Medications on Admission: ecasa, lisinopril, lipitor, lopressor, nitroquick Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Coronary artery disease with history of inferior myocardial infarction; postoperative stroke; elevated cholesterol; carotid disease Discharge Condition: Good Discharge Instructions: No driving for one month. Patient may shower, no baths, creams or lotions. No lifting more than 10 lbs for at least 10 weeks. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [First Name (STitle) ] in 2 weeks(cardiologist) Dr. [Last Name (STitle) ] in 2 weeks(PCP) Completed by:[2111-9-2]	[ "41401", "4019", "2724" ]
Admission Date: [2105-12-31] Discharge Date: [2106-1-9] Date of Birth: [2023-8-5] Sex: M Service: SURGERY Allergies: Percocet Attending:[First Name3 (LF) 2534] Chief Complaint: Traumatic fall from roof with head injury Major Surgical or Invasive Procedure: None History of Present Illness: Pt is an 83 y/o male who presented to the [Hospital1 18] ED as an unparalyzed field-intubated stat trauma following a fall from his roof while hanging [Holiday ] lights with head impact. He was able to crawl to his porch and was then found unresponsive by a neighbor. GCS at scene was 3. GCS at [Hospital1 18] was 3. Past Medical History: CAD CHF PVC's CA Stroke, TIA's Social History: Married, lives at home with wife. [Name (NI) ] recent tobacco use, occasional EtOH. Family History: Non-contributory Physical Exam: Vitals 101.4/100.1 HR 86 BP 128/64 RR 17 SAT 96/RA NAD, Ecchymoses NEURO Arouses to voice, GCS 8, (+)Gag/cough, (+)commands and purposeful movement CV RRR, no m/r/g PULM Coarse BS Bilat ABD (+)BS, Soft, NT, ND Ext Warm and well perfused Pertinent Results: CT HEAD [1-4]: IMPRESSION: 1) No new hemorrhage. 2) Resolution of left lenticular extra-axial hematoma. 3) Other subdural, subarachnoid, intraventricular, and intraparenchymal hemorrhages appear essentially unchanged. 4) Dense material within sphenoidal sinus may represent blood or inspissated mucus. . CT HEAD [1-1]: IMPRESSION: 1.3 cm diameter new focus of intraparenchymal hemorrhage in the right temporal lobe posteriorly in an otherwise essentially unchanged Head CT demonstrating subdural, subarachnoid, intraventricular, and intraparenchymal and epidural hemorrhage. . CT HEAD [12-31]: IMPRESSION: 1. Large left parietooccipital parenchymal hematoma with surrounding edema and small pneumocephalus. 2. Contre-coup contusion of the right frontal lobe and right temporal pole. 3. Thin layering subdural hematoma on the left and possibly also on the right. 4. Bifrontal subarachnoid hemorrhage. 5. Left occipital subgaleal hematoma with subcutaneous gas, laterally. 6. Left parietal bone fracture that extends to involve the occipital and temporal bones. The temporal bone fracture extends through the middle ear cavity, mastoid air cells and the bony plate of the external auditory canal. Associated disruption of the inner ear structures (eg. ossicular chain, facial nerve) cannot be excluded, and dedicate thin-section temporal bone CT should be considered (with clearing of blood from these compartments), when feasible. 7. Well-defined hypodensity of the left occipital pole, most likely represents established encephalomalacia, secondary to prior infarction (concordant with the vague h/o "stroke," though in unknown distribution. Less likely, this may represent acute infarction secondary to injury to the transverse venous sinus, given the fracture component and ill-defined hemorrhage in this region. . [12-31] CT C-SPINE: IMPRESSION: No acute fracture or malalignment in the cervical spine. . [12-31] CT PELVIS: IMPRESSION: Nondisplaced fracture of the right L4 transverse process, otherwise no acute traumatic injury in the chest, abdomen or pelvis. . [2105-12-31] 11:31PM TYPE-ART PO2-205* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 [2105-12-31] 11:31PM GLUCOSE-148* LACTATE-2.4* [2105-12-31] 11:31PM freeCa-1.03* [2105-12-31] 06:41PM PT-15.8* PTT-30.4 INR(PT)-1.4* [2105-12-31] 06:38PM TYPE-ART PO2-312* PCO2-29* PH-7.42 TOTAL CO2-19* BASE XS--3 [2105-12-31] 06:26PM CK(CPK)-196* [2105-12-31] 06:26PM CK-MB-6 cTropnT-<0.01 [2105-12-31] 05:22PM GLUCOSE-227* UREA N-24* CREAT-1.1 SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15 [2105-12-31] 05:22PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.1 [2105-12-31] 05:22PM WBC-28.9* RBC-3.82* HGB-11.9* HCT-33.8* MCV-89 MCH-31.1 MCHC-35.1* RDW-14.1 [2105-12-31] 05:22PM NEUTS-87* BANDS-7* LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2105-12-31] 05:22PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2105-12-31] 05:22PM PLT SMR-NORMAL PLT COUNT-158 [2105-12-31] 02:43PM TYPE-ART O2-100 PO2-275* PCO2-54* PH-7.23* TOTAL CO2-24 BASE XS--5 AADO2-386 REQ O2-68 [2105-12-31] 02:43PM GLUCOSE-240* LACTATE-4.4* NA+-136 K+-3.9 CL--103 [2105-12-31] 02:35PM UREA N-24* CREAT-1.0 Brief Hospital Course: [12-31] Pt was admitted directly to the Trauma ICU following stat trauma code with non-paralyzed field intubation for GCS of 3 following fall from roof with direct head impact. Pt was paralyzed and reintubated in the [Hospital1 18] for a Right mainstem bronchus field intubation. Pt received CT scans of his head, c-spine, abdomen, and pelvis with findings as described above, as well as a chest xray. An arterial line was placed, mechanical ventilation was started, IV hydration was given, an seizure prophylactic dose of Dilantin was given. . [1-1] A repeat head CT was performed with the above findings. The patient's neuro exam improved somewhat with purposeful movements and spontaneous eye opening, no following of commands, with positive gag and cough. A standing Dilantin dose was started. He remained intubated and on mechanical ventilation. His arterial line was changed. Tube feeds were started via NG tube. . [1-2] There was no change in the pt's neuro exam. He remained intubated and on mechanical ventilation. He was started on NPH for better blood sugar control. . [1-3] Neuro exam unchanged. Moves all extremities with purpose, eyes open spontaneously, not following commands. Dilantin continued, still intubated and on vent. Serum creatinine increasing, with subsequent increase in fluid resuscitation by ICU team. Family notified of poor overall prognosis by Neurosurgery. . [1-4] Follow-up Head CT obtained with above findings. No change in neuro exam. Family meeting held with discussion of trach/PEG, poor overall prognosis conveyed. N/S signed off of patient. . [1-5] Pt febrile to 102.8, WBC 11.4. IV Cipro started. Neuro exam unchanged. . [1-6] Family declines trach/peg and decides on extubation when other family members can be present. . [1-7] No changes in management. Pt intubated and on vent, stable. Pt still febrile to 102.3 and continues on Cipro IV. . [1-8] Pt extubated with family present. Family decides on CMO for patient based on his pre-accident wishes. Support meds withdrawn. . [1-9] Pt continues to be febrile to 101.4. IV Cipro withdrawn. Pt discharged to [Hospital1 656] Family House and Hospice for palliative care. Medications on Admission: None Discharge Medications: 1. Morphine (PF) in D5W 100 mg/100 mL Parenteral Solution Sig: 0.5-7 mg/hr Intravenous INFUSION (continuous infusion). 2. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg PO Q6H (every 6 hours) as needed for fever. 3. Acetaminophen 650 mg Suppository Sig: [1-27] Suppositorys Rectal Q6H (every 6 hours) as needed. 4. Glycopyrrolate 0.2 mg/mL Solution Sig: 0.2 mg Injection Q8H (every 8 hours) as needed. 5. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital 1121] Rehab Skilled Nursing Center - [Location (un) 4047] Discharge Diagnosis: Subarachnoid hematoma, subdural hematoma, intraventricular hemorrhage, epidural hematoma, multiple brain contusions, multiple skull and facial fractures, R L4 transverse process fracture Discharge Condition: Fair, to hospice for palliative care. Discharge Instructions: Please report to the ED for fever > 101.5, persistent nausea and vomiting, abdominal pain, obvious signs of infection, changes in vision, or tingling in your extremities. Followup Instructions: Pt is being discharged to hospice. There will be no presumable follow-up.	[ "51881", "2859", "4280" ]
Admission Date: [2136-3-19] Discharge Date: [2136-3-30] Date of Birth: [2073-12-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: lower extremity swelling Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Enteroenterostomy of afferent pancreaticobiliary drainage limb. 3. Placement of a feeding jejunostomy tube into the afferent limb distal to the stomach. History of Present Illness: 62 yo F w/ metastatic pancreatic cancer s/p Whipple procedure in [2131] currently C1D19 Gemcitabine presenting with 2-3 weeks of leg swelling. She reports ~3 weeks of lower extremity swelling. Per her oncologist, the swelling preceded initiation of gemcitabine chmotherapy. She denies pain but feels that her legs are heavy and she is having difficulty ambulating. She denies redness, warmth, fevers, chills, sweats. She reports that the amount of swelling has remained stable but over the past day her legs have been blistering and weeping so she came to the ED. She denies trauma. She denies shortness of breath, chest pain, palpitations, PND, orthopnea, cough. She denies change in urinary output, hematuria. . In the ED, she was HD stable with O2 Sats 100% RA. She was given 40 mg IV lasix. Past Medical History: Ms. [Known lastname 14840] has chronic pancreatitis with exocrine and endocrine insufficiency, status post Whipple surgery by Dr. [Last Name (STitle) 468] in [9-22]. Pathology from this surgery revealed chronic pancreatitis as well as low-grade dysplasia, pancreatic intraepithelial neoplasm. Prior to surgery, her CA-19.9 was measured at 13. She was doing fairly well until [2-24], when she noted weight loss and abdominal pain similar to her previous pancreatitis pain. At that time, MRI abdomen was notable for an irregular duct but no stricture at the pancreaticojejunostomy site. By [5-25], her CA [47]-9 has risen from 13 to 143 as well as her CEA was elevated at 4.6. She had an EGD/[Last Name (un) ] on [2135-6-14], notable for gastritis. She continued to note weight loss and pain, so she had a CTA abd in [9-25] notable for a pancreatic tail mass extending into the mesentery, occluding the splenic vein and encasing the splenic artery. She underwent an EGD and EUS which showed a 3 cm hypoechoic mass in the body of the pancreas in [10-25]. FNA was c/w adenocarcinoma. She was seen by Dr. [Last Name (STitle) 468] who felt she was not a surgical candidate. She started C1 Gemcitabine on [2136-3-1]. Her first cycle has been c/b low counts, thrush treated with fluconazole and lower extremity edema. She received C1D15 Gemcitabine on [2136-3-15]. . PMH: 1. Chronic Pancreatitis as above. S/P Whipple in [9-22]. Now with exocrine and endocrine dysfunction. 2. HTN Social History: (+) tobacco use - 20 pack year - currently [4-26] cigarettes per day. She has no h/o alcohol use. She lives alone in [Location (un) 2498]. Family History: Her mother and sister had breast cancer. Her mother's mom had stomach cancer and her mother's brother had liver cancer. Physical Exam: VITAL SIGNS: Blood pressure 132/79 , pulse 76 , temperature 96.6, O2 sat 100 RA, respirations 12. GENERAL: cachectic, NAD, alert and oriented x3. HEENT: Pupils are equal and reactive to light. Extraocular movements are intact bilaterally. dry MM. [12-24] pearly nodules on tongue. NECK: Supple. JVP - flat. NODES: No supraclavicular, submandibular, cervical, axillary, or inguinal lymphadenopathy. LUNGS: Clear to auscultation bilaterally. No w/c/r. HEART: Regular rate and rhythm. nl s1, s2. No S3, S4. no m/g/r. ABDOMEN: Thin, Soft, nondistended. No hepatosplenomegaly. Mild pain to palpation LUandLLQ. No masses palpated. No rebound/guarding. EXTREMITIES: Cool, 3+ edema feet and ankles, symmetric, pitting. No palpable cords or calf tenderness. 2x3cm macular rash on left foot and Weeping blisters on tops of feet. No redness, warmth. SKIN: Otherwise without lesions except ecchymoses on UE. Neuro: CN 2-12 intact. UE [3-24]. LE - quads/hamstrings/DF/PF - [3-24] if isolate and support feet which she reports are too heavy. Unable to wiggle toes due to swelling. Pertinent Results: CXR - The cardiomediastinal silhouette is within normal limits, and there is no pulmonary vascular congestion, pleural effusion, or other evidence of CHF. Evidence of hyperinflation. . CT ABDOMEN/PELVIS [2136-3-20]: 1. Dilated loop of excluded jejunum (s/p Whipple), which may be due to the necrotic pancreatic tail mass, an adhesion, or stricture/ swelling at the anastomotic site. This loop does appear to be compressing the IVC at the level of the aortic bifurcation, though no significant venous collaterals are seen suggesting that there is not complete occlusion. 2. Mild right hydronephrosis and hydroureter of unknown etiology. 3. Necrotic pancreatic tail mass which appears slightly smaller than the prior exam, however, this may be due to distortion of abdominal contents due to the dilated small bowel loops. 4. Persistently thrombosed splenic vein with heterogeneous enhancement of the spleen. 5. Multiple hypodensities within the liver are poorly evaluated due to contrast timing, however remain worrisome for metastases. . CXR [2136-3-28]: There has been further improved aeration in the left lower lobe since the recent chest radiograph of [2136-3-26] and more marked improvement when compared to the earlier radiograph of [3-21]. Right lung is clear. Bilateral pleural effusions are present, left greater than right. IMPRESSION: Continued improved aeration in left lower lobe. Bilateral pleural effusions, left greater than right. . [2136-3-29] CT ABDOMEN/PELVIS: 1. No definite thrombosis is noted within the IVC to suggest thrombosis; however, the infrarenal IVC is being pressed by a dilated loop of jejunum, which is unlikely to cause IVC obstruction since there is no collateral formation and no distal dilatation of iliac veins. 2. New interval development of moderate bilateral pleural effusion and massive ascites and anasarca suggest volume overload state/heart failure as the cause of lower extemity edema . 3. Unchanged appearance of mild right hydronephrosis and hydroureter of unknown etiology. 4. Unchanged appearance of necrotic pancreatic tail mass. 5. Small hypodense liver lesion within the dome of the liverthat is too small to characterize. Brief Hospital Course: A/P: 62 yo F w/ pancreatic cancer on C1D19 Gemcitabine with several weeks of LE swelling. Following admission, patient underwent work-up for lower extremity edema. Ultrasound of the lower extremities was performed and negative for DVT. CT of her abdomen and pelvis revealed IVC compression by obstructed afferent loop due to necrotic adenocarcinoma in tail of the pancreas. EGD was performed but not amenable to stent across obstruction. Following discussion with patient and family regarding pursuing comfort measures care versus surgical decompression, patient opted to undergo surgical intervention. Enteroenterostomy of afferent pancreaticobiliary drainage limb was performed, along with placement of a feeding jejunostomy tube into the afferent limb distal to the stomach. IVC filter was placed on the firt post-operative day. Her post-operative course was complicated by hypothermia, hyponatremia, and hypoglycemia. She was treated with a 7-day course of peri-operative prophylactic anbtibiotics. She was transferred back to the Oncology service on post-op day 5. The following is an outline of her ongoing medical issues: . 1) Hyponatremia: Serum sodium nadired at 126 in the post-operative course. Calculated FeNa 0.7 points to effective intravascular volume depletion. She was treated with normal saline, NaCl tablets and free water restriction. On day of discharge, her sodium serum was stable at 131. . 2) Generalized anarsarca: She developed new pleural effusions, ascites, and generalized anasarca in the post-operative period, likely the result of her hypoalbuminemia. She also had some intermittent and persitent lower extremity edema post-operatively, likely the result of dependent edema. She was treated with albumin infusion with concomitant lasix x 3 days with good result. Leg edema was complicated by 4 areas of stage II skin breakdown over her distal lower extremities. Leg edema improved with elevation of her extremities. . 3) Thrombocytopenia - Patient's platelets trended down from >500 on admission to 114. Lovenox was temporarily discontinued and heparin dependent antibody was sent. Heparin dependent antibody returned with negative result. A second test was pending at the time of discharge, and Lovenox was resumed. . 4) Pancreatic insufficiency - Patient is s/p whipple with insulin dependence. Prior to her surgical intervention, she was found unresponsive with a blood glucose of 11; it is unknown how long she had been hypoglycemic. This event occurred after receiving Lantus 3 units. Her mental status improved with D50 infusion. All insulin was discontinued following this event. She continued to have interval hypoglycemia post-operatively. Following transfer back to the Oncology service, her blood glucoses were persistently between 300-500, and she was restarted on a Humalog sliding scale. Prior to discharge, [Last Name (un) ] Diabetes was consulted and recommended that she resume Lantus 2 units qAM plus the prescribed sliding scale. . 5) Pancreatic cancer - Further chemotherapy deferred until completion of wound healing and pending further discussion with her Oncologist. . . 6) Pain control - She was managed with PRN Dilaudid in the peri-operative period. She was later transitioned to her previous regimen of MScontin once able to swallow pills. . 7) Prophylaxis - Patient with hypercoagulable state with underlying malignancy. Given her minimal subcutaneous tissue for medication administration, she was maintained on Lovenox at prophylaxis dosing. Lovenox was temporarily held with concern for HIT but was resumed prior to discharge. She is was maintained on PPI as GI prophylaxis and Acyclovir as HSV prophylaxis given her immunocompromised status. . 8) FEN - Patient is chronically malnourished. During her surgical procedure, placement of a feeding jejunostomy tube into the afferent limb distal to the stomach was accomplished. Per recommendations from Nutrition consultant, she was titrated to tube feed goal of full-strength Impact at 35 cc/hour. She also continues to tolerate a regular PO diet. . 9) Skin breakdown: Wound care consultant recommends foam dressing to partial-thickness breakdown of coccyx with change q 3 days. She also has 4 small areas of skin breakdown over distal lower extremities, secondary to profound edema. Recommend Adaptic non-adherent dressing, covered with dry gauze and Kerlex wrap, no tape on skin. Recommend daily changes to lower extremity dressing. Advise pressure relief and good skin moisturization. 10) Code status: DNR/DNI. Medications on Admission: MSCONTIN 30 [Hospital1 ] Percocet for breakthrough Lantus 3 qhs Humalog [2141-3-29] Compazine Creon Fluconazole 200 daily Acyclovir 400 tid Nystatin Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 7. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Lantus 100 unit/mL Solution Sig: Two (2) units Subcutaneous qAM. 10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 11. Humalog 100 unit/mL Solution Sig: Per sliding scale Subcutaneous qACHS. 12. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO Q6 (). 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 14. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [Hospital1 ] Senior Healthcare - [Location (un) 7168] Discharge Diagnosis: 1. Metastatic pancreatic cancer 2. Chronic pancreatitis 3. Pancreaticobiliary limb obstruction with closed loop obstruction causing vena caval compression. 4. Post-op Hypoglycemia 5. Post-op Hypothermia 6. Pancreatic insufficiency 7. Hyponatremia Discharge Condition: Guarded Discharge Instructions: Please call your doctor or return to the ER for any of the following: * New chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . Continue to ambulate several times per day. . When you're resting, it is helpful to keep your legs elevated to limit the swelling. . YOUR STAPLES CAN BE REMOVED ON [2136-4-10]. Followup Instructions: You are scheduled to follow-up with Dr. [Last Name (STitle) ] in the Deparment of Surgery on [2136-4-20] at 9 a.m. His office is located on the [Location (un) ] of the [Hospital Ward Name 23] Building on the [Hospital1 18] [Hospital Ward Name 516]. Please call ([Telephone/Fax (1) 2828] with any questions or concerns. . You are scheduled to follow-up with Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] and Dr. [First Name4 (NamePattern1) 5557] [Last Name (un) ] on [2136-4-11] at 1 p.m. Please call [Telephone/Fax (1) 22] if you have questions.	[ "2761", "496", "2875", "3051", "4019" ]
Admission Date: [2163-7-4] Discharge Date: [2163-7-6] Date of Birth: [2114-4-20] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient had undergone a workup out of state for a left PCom aneurysm. During her angiogram she developed an iatrogenic vertebral artery dissection for which she was placed on oral coumadin. She is now admitted to undergo endovascular coiling of her aneurysm after verification of the status of her vertebral artery dissection. PHYSICAL EXAMINATION: On admission, the patient is 5 feet and 2 inches, weight is 110 pounds, 49 years old, blood pressure is 121/66, heart rate is 79, SpO2 97 percent on room air. She had a perforation of the cerebral artery during an angiogram, [1-23], with visual blurring. She has been on Coumadin since. She denies chest pain, pressure. Denies dyspnea, asthma, COPD. CURRENT MEDICATIONS: 1. Levothroid 88 mcg. 2. Coumadin 5 mg to 10 mg. 3. Tylenol. 4. She is also on Lovenox b.i.d. PAST SURGICAL HISTORY: She had breast surgery in [2162], angiogram in [2163], and an appendectomy and salpingo- oophorectomy when she was 12 years old. ALLERGIES: MORPHINE AND CT SCAN DYE. HOSPITAL COURSE: On [2163-7-5], the patient underwent angiography which showed that the vertebral artery dissection had been healed and accordingly underwent succesful treatment of her left PCom aneurysm. The procedure went without difficulty. She was discharged to the PACU in stable condition. Postprocedure, the patient was alert and oriented. Temperature was 96.5 degrees, blood pressure was 134/74, heart rate was 57, respiratory rate was 16. Her SpO2 was 100 percent on room air. She was awake and alert, oriented x3, complained of mild right groin pain. She was PERRLA. Pupils were briskly reactive to 0.5 to 2 mm. Extraocular movements were intact. Visual fields, all intact. She had no drift. Groin intact without hematoma or bleeding. Her strength was full throughout. At that time, her assessment was, she was neurologically stable status post coiling. The plan, advanced diet, neurologic checks every 1 hour. On [2163-5-5], all vital signs were stable. She was afebrile. All labs were normal. Symmetric smile, no drift. Strength was full throughout. No hematoma, positive pedal pulse. Deep tendon reflexes were 2 plus. Her assessment, she was neurologically stable. Plan, she was transferred from the PACU to the floor in stable condition. At that time, we were to discontinue the A-line, discontinue the Foley, and we maintained blood pressure less than a 140 systolic. On [2163-7-6], blood pressure was running between 92 and 100 systolic. She was afebrile, awake, and alert, asking questions appropriately, no drift. Strength full throughout. She was neurologically stable and her plan was to be discharged home. The patient was discharged on [2163-7-6]. DISCHARGE MEDICATIONS: 1. Levothyroxine sodium 88 mcg tablets, 1 tablet p.o. q.d. 2. Hydromorphone hydrochloride 2 mg tablets, 1-3 tablets p.o. q.4 h. p.r.n. She was discharged home with discharge instructions. Monitor for change in mental status, dizziness, severe headache not relieved with medication. FINAL DIAGNOSIS: Status post coiling of a left Pcom cerebral aneurysm and healed vertebral artery dissection. RECOMMENDED FOLLOWUP: Follow up with Dr. [Last Name (STitle) 1132] in 1 month. DISCHARGE CONDITION: Neurologically stable. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 23079] MEDQUIST36 D: [2163-7-6] 14:17:10 T: [2163-7-7] 01:46:08 Job#: [Job Number ]	[ "2449" ]
Admission Date: [2162-5-6] Discharge Date: [2162-5-10] Date of Birth: [2112-8-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x5(LIMA-LAD,SVG-diag,SVG-OM1-OM2,SVG-pda) [2162-5-6] History of Present Illness: This 49 year old white male presented to his primary care doctor with progressive fatigue and dyspnea. Work up demonstrated coronary artery disease and catheterization previously revealed triple vessel disease. he is admitted now for elective revascularization. Past Medical History: End stage renal disease on hemodialysis hypertension hyperlipidemia s/p left arm ACV fistula insulin dependent diabetes mellitus Hepatitis C Social History: Married, lives with spouse and 3 children. Works in building maintenance at a hotel. Denies tobbaco, etoh. No hx of IVDU. No tattoos. Family History: Father with type I DM Physical Exam: Admission: Pulse:80 Resp:16 O2 sat:98%RA B/P Right:183/86 Left: Left wrist AVF Height:5'6" Weight:140lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur ESM II/VI LUSB, HSM III/VI RUSB Abdomen: Soft, non-distended, non-tender [x] Extremities: Warm, well-perfused [x] Edema mild pedal Neuro: Grossly intact Pulses: Femoral Right: nd Left: nd DP Right: 1+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 1+ Left: nd Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2162-5-10] 05:30AM BLOOD WBC-6.2 RBC-2.54* Hgb-8.4* Hct-24.0* MCV-94 MCH-33.0* MCHC-35.0 RDW-16.9* Plt Ct-163 [2162-5-9] 04:00AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.3* Hct-28.3* MCV-94 MCH-30.9 MCHC-32.9 RDW-16.6* Plt Ct-148* [2162-5-6] 11:28AM BLOOD WBC-5.1 RBC-2.26# Hgb-6.8# Hct-21.1# MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4 Plt Ct-101* [2162-5-10] 05:30AM BLOOD Glucose-118* UreaN-72* Creat-7.4# Na-135 K-4.6 Cl-95 HCO3-28 AnGap-17 [2162-5-6] 12:36PM BLOOD UreaN-22* Creat-4.0* Cl-110* HCO3-24 [2162-5-7] 03:25AM BLOOD Glucose-108* UreaN-29* Creat-5.0* Na-138 K-4.9 Cl-107 HCO3-23 AnGap-13 Brief Hospital Course: Following admission he went to the Operating Room where revascularization was performed. See operative note for details. He weaned from bypass on Propofol,Insulin and neoSynephrine infusions. He remained stable and weaned from the ventilator and pressors with out incident. He was dialyzed on POD 1 and remained stable. He required reinsertion of the Foley on POD 3 for urinary retention(800cc) and was sent to rehab with the ctaheter to remain until he is a bit more mobile. Wounds are clean and healing well at discharge. Physical Therapy saw the patient for mobility and strength, however, he required a stay at rehabilitation prior to return home. He was transfered to [Location (un) 511] Siai-[Location (un) 86] on [5-10]. Medications and restrictions are as outlined elsewhere. Medications on Admission: Doxazosin 2mg po BID Lisinopril 40mg po daily Hydralazine 50mg po TID Metoprolol 50 mgpo [Hospital1 ] Amlodipine 5 mg po BID Simvastatin 20mg po daily ASA 81mg po daily Humalog SS with meals and at bedtime Lantus 100units/ml 10units [Hospital1 ] Peginterferon weekly Nephrocaps Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: One (1) ml Subcutaneous 1X/WEEK ([Doctor First Name ]). 13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous twice a day. 16. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital1 685]- [Location (un) ] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts end stage renal disease on hemodialysis Insulin dependent diabetes mellitus hypertension Hepatitis C Right carpal tunnel syndrome s/p left arm AV fistula 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 absent Discharge Instructions: 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. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([Telephone/Fax (1) 170]). Please call cardiac surgery office with any questions or concerns ([Telephone/Fax (1) 170]). Answering service will contact on call person during off hours. Followup Instructions: Dr. [First Name (STitle) ] ([Telephone/Fax (1) 170]on [Last Name (LF) 766], [6-7] at 1:30. Please schedule appointments with: primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 21566]) Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Renal as scheduled for dialysis (Dr. [Last Name (STitle) ] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2162-5-10]	[ "41401", "40391" ]
Admission Date: [2124-3-12] Discharge Date: [2124-3-30] Date of Birth: [2056-11-30] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1148] Chief Complaint: Respiratory failure. Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: 67 yo M w/PMHx sx for COPD and tobacco use who presented to an OSH today after a neighbor found him to be very dyspneic. Per report, pt had been sick for three weeks with weakness and fever, with a productive cough with yellow sputum production, chills, sore throat, nasal congestion, and difficulty breathing. He also noted chest pressure. Per family friend, patient had lost 20 lbs over this time course, and was using only [Last Name (un) 18774] Vaporub for relief, and Tylenol PM for sleep. . Patient was brought today to the OSH by his girlfriend. [Name (NI) ] report, patient had temperature to 101, with HR 120s, with O2 sats of 96% on 6L, with progressively increasing tachypnea and cyanosis on presentation to the OSH. Patient was intubated at OSH for hypercarbic respiratory failure thought to be [2-18] pneumonia. His ABG was initially 7.19/110/278 on a nonrebreather, then 7.24/96/67 on 2L NC prior to intubation. Patient was also noted to have a leukocytosis with WBC of 24, with left shift and 1% bandemia, and a CXR which per report showed a LLL PNA. With the intubation patient received propofol, which resulted in hypotension, for which he was started on dopamine. At the OSH, patient also received one dose of levofloxacin. A subclavian line was placed as well. Patient was also noted to have dark emesis/hemoptysis with NGT placement, and protonix was started. . In the ED, patient had repeat CXR performed. His initial BPs were 70/50s. A FAST scan was performed, and was negative. He was transitioned off propofol and dopamine and started on levophed. Patient has received 4L IVF as well, as well as CTX/azithromycin, and dexamethasone 10 mg x 1 dose. . ROS: Unable to obtain as patient intubated. Past Medical History: COPD Tobacco use Alcoholism Abdominal hernia Depression Social History: Lives at home. Has a girlfriend. [Name (NI) ] no family nearby. Smoked for many years. Quit one year ago. Extensive alcohol use - drinking beer recently. Marijuana use in the past. Family History: Mother with CVA, died of hip fracture. Father with MI in 80s. Physical Exam: PE: VS: 97.1 BP 117/96 HR 98 RR 18 100% O2 sat on A/C 550x20 FiO2 0.40 PEEP 5 Gen: intubated, sedated. HEENT: MM dry. ET tube in place. No scleral icterus. Hrt: Distant heart sounds. No MRG. Lungs: No wheezes. Poor air movement throughout. No rales or rhonchi. Abd: Soft/NT/ND. No fluid wave. No organomegaly. Ext: Cool. 1+pulses. Neuro: Intubated and sedated. Pupils equally reactive. Reflexes symmetric. Withdraws to pain. Pertinent Results: [2124-3-12] 07:00PM URINE MUCOUS-FEW [2124-3-12] 07:00PM URINE GRANULAR-0-2 HYALINE-21-50* [2124-3-12] 07:00PM URINE RBC-[12-5]* WBC-[6-25]* BACTERIA-FEW YEAST-NONE EPI-[3-20] TRANS EPI-0-2 [2124-3-12] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [2124-3-12] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2124-3-12] 07:00PM RET AUT-0.9* [2124-3-12] 07:00PM FIBRINOGE-474* [2124-3-12] 07:00PM PT-20.2* PTT-31.6 INR(PT)-1.9* [2124-3-12] 07:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2124-3-12] 07:00PM NEUTS-77* BANDS-0 LYMPHS-8* MONOS-11 EOS-1 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 [2124-3-12] 07:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . [2124-3-15] CT chest/abd/pelvis: IMPRESSION: 1. Densely calcified pancreas, consistent with chronic calcific pancreatitis. 2. Poorly-defined multifocal patchy, nodular opacities seen distributed throughout the lungs bilaterally, with upper lobe predominance. Findings are nonspecific but could be of infectious or possibly inflammatory etiology. 3. Emphysema. 4. Enlarged left adrenal gland, incompletely evaluated on this single-phase study. 5. Small low attenuation lesion seen within the left kidney, possibly representing cyst but too small to characterize by CT. 6. Low attenuation lesion seen in the anterior subcutaneous soft tissue, possibly representing sebaceous cyst. Clinical correlation recommended. 7. No definite evidence malignancy identified on this study, however, this study was only performed with a single phase of contrast, limiting assessment for more subtle lesions, especially within the liver. . LIVER AND GALLBLADDER ULTRASOUND: Liver is of normal echogenicity and echotexture and no focal lesions are identified. No intra- or extra-hepatic bile duct dilatation. The CBD measures 4 mm and is normal. All the hepatic vessels are patent including the hepatic arteries, portal veins, and hepatic veins. The gallbladder is normal without evidence of stones. . [3-21] CT chest: FINDINGS: As compared to the prior study, there has been interval worsening of the multifocal areas of peribronchial consolidation in the upper lobes bilaterally. Mild peribronchial infiltration in the lingula, right middle lobe, and lower lobes, and two more discrete nodular focal opacities in the right lower lobe (3A: 44) are unchanged. Bibasal posterior subsegmental atelectasis are new. A focal area of consolidation in the superior segment of the left lower lobe posteriorly is new. The airways are patent through the segmental level. There has been interval increase in size and number of multiple mediastinal lymph nodes, for instance, an 11-mm right lower paratracheal lymph node was 9 mm previously; a 9-mm left lower paratracheal lymph node was 6 mm in the past. Bilateral mildly enlarged hilar lymph nodes are stable. Cardiac size is normal. Dense calcification is seen in the right brachiocephalic artery. There is no pericardial effusion. A small layering left pleural effusion is new. There are no bone findings of malignancy. In the upper abdomen, the liver, gallbladder, spleen, and right adrenal gland are unremarkable. The left adrenal gland remains enlarged measuring up to 26 mm. Dense calcifications through the pancreas are again noted. Previously described small cortical lesions in the kidneys are not seen on this nonenhanced study. There is a trace of ascites. Diffuse increase in density of the mesentery and subcutaneous fat in the abdomen could be due to anasarca. The 25 x 30 mm low-attenuation oval-shaped lesion in the anterior subcutaneous abdominal wall is unchanged. IMPRESSION: Worsening multifocal pneumonia. Brief Hospital Course: 67 yo with h/o COPD, alcoholism, prsented to OSH with several weeks of fever, productive cough, hemoptysis and weight loss. In the OSH intubated for hypercarbic resp failure and transferred here. He got solumedrol and levaquin. He self-extubated [3-13] but did well and was transferred to floor. Despite improvement he still had a leukocytosis with immature forms. A chest CT was notable for diffuse bronchiolitis. Of note a tracheal aspirate grew aspergillus. Patient had multiple AFBs sent that remained negative (cultures can be followed up later but no growth now) and negative PPD so taken off TB precautions. Patient HIV negative, HCV negative, HBV negative. Patient started empirically under the guidance of ID and pulmonary on voriconazole. Also given albuterol/atrovent nebs. Also given 10 days of levofloxacin empirically. Patient also had persistent diarrhea with multiple negative c diffs. . # Pneumonia: Seen by pulmonary and ID. Believe to have aspergillous bronchiolitis. Started on voriconazole and began to improve. Unclear how long course should be. Should be seen by ID consult at [Hospital1 1501] and can contact ID group here at [Hospital1 18] for further discussion. Cont pulmonary PT. With concern for cirrhosis (although none seen on ultrasound) should get weekly LFTs (have been normal here). Recommend repeat CT scan chest in 3 weeks to watch progression of disease. . # COPD: Patient breathing improved significantly once started on steroids. Cont advair and nebs prn. Steroid taper now on discharge. Close follow up with pulmonary. . # Alkalosis: Patient has mixed acid-base with metabolic alkalosis (contraction) with chronic respiratory acidosis. Bicarb on discharge is 38. Should get repeat checks and continue to encourage oral fluid intake aggressively, especially with diarrhea. Can give lomotil prn for diarrhea. . # Melena: Patient with episode here. With question of liver disease might still consider outpatient EGD, especially if repeat bleeding. Should get screening colonoscopy. . # Leukocytosis: Improved with treatment but should continue to monitor. . # Adrenal gland: Possibly enlarged on CT scan. Should consider repeat imaging as outpatient. . # Chronic pancreatitis: Found to have calcifications of pancreas on CT scan without elevation amylase/lipase. Started on creon empirically. Likely alcohol related. Continue to monitor as outpatient. . #. Communication. Patient with close friend [Name (NI) 1328] [Name (NI) 71967] [Telephone/Fax (1) 71968]. Need to contact PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 6930], North Central Human Services, [Doctor Last Name 71969], [Location (un) 976] MA in AM. Medications on Admission: Inhalers prn Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q8H PRN (). 6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day). 9. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 10. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): Use with fingersticks qachs with sliding scale. 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 16. Prednisone 5 mg Tablet Sig: As directed in taper Tablet PO once a day for 9 days: Take 4 tabs daily for 4 days, then 2 tabs daily for 3 days, then 1 tab daily for 3 days then stop. 17. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 ] Discharge Diagnosis: Aspergillos bronchiolitis Steroid induced hyperglycemia COPD exacerbation Melena Chronic pancreatitis with calcifications Discharge Condition: Good Discharge Instructions: You have a history of COPD. You appear to have developed an aspergillus bronchiolitis. You are getting treated for this but will need close infectious disease and pulmonary follow up. You are also being treated with steroids for your COPD flare. . You have had intermittent diarrhea here and have become dehydrated. You need to continue to be aggressive with your fluid intake. . You had an episode of melena (blood in your stool). This may have been stress related but if it recurs you will need to get an endoscopy. If you have not had a colonoscopy in the last 5 years we recommend that for routine screening as well. . You were found to have heavy calcifications in your pancreas suggestive of possible chronic pancreatitis. You were started on creon with meals. This can be reevaluated as an outpatient. Followup Instructions: You need to establish a primary care doctor and have regular appointments. You should seen both a pulmonary and infectious disease doctor in the next 2-3 weeks. They can contact our staff here with detailed questions. Dr. [Last Name (STitle) 67369] [Name (STitle) 3394] from infectious disease (([Telephone/Fax (1) 4170]) and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20063] from pulmonary (([Telephone/Fax (1) 514]).	[ "51881", "2762", "3051", "311" ]
Admission Date: [2147-1-2] Discharge Date: [2147-1-14] Date of Birth: [2092-8-16] Sex: M Service: VASCULAR CHIEF COMPLAINT: Ischemic left foot rest pain. HISTORY OF PRESENT ILLNESS: Obtained from the patient's wife and computer records. She was a reliable historian. The patient is a 54 year-old white male with known coronary artery disease, angioplasty and stent placement in [Month (only) 216] of this year with diabetes, hypertension and history of SIADH. He has known peripheral vascular disease and underwent a right femoral AT bypass with flap in [Month (only) ] of this year who returns now with increasing left calf claudication and rest pain times one week. The patient was seen by Dr. [Last Name (STitle) 1391] and Dr. [Last Name (STitle) ] podiatry on [2146-12-30]. The patient is scheduled for an outpatient arteriogram on [2147-1-3], but because of increasing symptoms the patient is now admitted for further evaluation and treatment. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lantus 6 units q.h.s., Prandin 2 mg t.i.d. with meals, Humalog sliding scale at lunch, Atenolol 25 mg q.d., aspirin 325 mg q.d. last dose was stopped prior to his arteriogram. PAST MEDICAL HISTORY: Coronary artery disease. He had a stress test done in [Month (only) 216] of this year, which was positive. He underwent angioplasty with stent placement times two to the left anterior descending coronary artery and angioplasty with stent to the right coronary artery in [Month (only) 216] of this year. He was recatheterized on [2146-9-20] for elevated cardiac enzymes. He had patent stents at that time. He has been a diabetic since the age of 32 with triopathy. Hypertension, history of hip fractures secondary to motor vehicle accident in [2140], osteomyelitis of the right fifth metatarsal head in [Month (only) ] of this year. Hyponatremia, SIADH in [Month (only) ] of this year treated. Peripheral vascular disease. PAST SURGICAL HISTORY: Open reduction and internal fixation of hip in [2140], right superficial femoral artery to posterior tibial with right saphenous vein graft in [Month (only) ] of this year. Right fifth metatarsal head resection in [Month (only) ] of this year. Right foot primary closure with advancement flap in [Month (only) ] of this year. SOCIAL HISTORY: He is a fisherman, lobsterman. He has had transfusions in the past. He has never smoked. Occasional beer. He is married and lives with his wife. PHYSICAL EXAMINATION: Temperature 100.7. Pulse 90. Respirations 16. Blood pressure 140/90. O2 sat 97% on room air. General appearence, alert, cooperative male in no acute distress. HEENT examination is unremarkable. Pulse examination shows intact carotids bilaterally. The right radial pulse is palpable. The left is palpable, but diminished in intensity. The abdominal aorta is nonprominent. The femoral pulses are palpable bilaterally. There are no carotid or femoral bruits. Popliteals are absent. The dorsalis pedis and posterior tibial on the right have dopplerable signal. On the left absent signal. Chest examination lungs are clear to auscultation. Heart is a regular rate and rhythm without murmur. Abdominal examination is unremarkable. Bone joint examination shows no ankle edema. The right foot is warm, pink with a yield fifth metatarsal head incision. The left foot is significantly cooler from ankle distally with multiple red skin discolorations on the dorsum of the foot. There is severe dependent ruber. There is a dry gangrenous lesion on the medial aspect of the first metatarsal head. HOSPITAL COURSE: The patient was prehydrated and Mucomyst protocol was begun. He underwent arteriogram on [2147-1-3], which demonstrated normal aorta, iliac without significant disease on the left, mild diffuse disease of the superficial femoral artery and PFA. The superficial femoral artery occludes at the adductor canal, reconstitutes as AK popliteal with moderate disease, BK popliteal has moderate disease with significant proximal AT disease. There is no proximal PT or peroneal. The AT occludes at the calf. The PT reconstructs above the ankle and continues at the arch. Pulmonary consult was placed prior to surgery to assess pulmonary risks with chest x-ray findings of left lower lobe pneumonia. They felt that he had appropriate coverage with Levofloxacin and Flagyl and there was a low suspicion for pulmonary embolus and there was an effusion that should be tapped and cultured otherwise was to proceed with planned surgery. [Last Name (un) ] was consulted to follow the patient for his diabetic management during his perioperative period. The Prandin was discontinued and his Lantus insulin was increased to 6 to 8 units at h.s. and sliding scale premeals and at supper time were written for. The patient's admitting sodium was 127, which was stabilized, but he was covered perioperatively with Dexamethasone 4 mg pre 2 mg post surgical procedure. His insulin requirements continued to require adjustment. The patient underwent on [2147-1-6] a right common femoral artery to posterior tibial bypass graft in situ saphenous vein and angioscopy. He underwent an intraoperative TE, which showed global right ventricular and left ventricular hypokinesis, moderate MR to severe MR [First Name (Titles) 151] [Last Name (Titles) 13223]. The patient was transferred to the PACU with a monophasic dorsalis pedis pulse in stable condition. His immediate postoperative electrocardiogram was without changes, but cycled CKs were obtained. The patient's total CK peaked at 271 and defervesced in the next 48 hours to 123. His MB fractions were flat and were not done, but his troponin levels peaked at 45 and defervesced 48 hours later to 20.4. During this period of time the patient required inotropic support and nitroglycerin for after load reduction. Cardiology was consulted regarding elevated enzymes and diminished cardiac index. Their recommendations were to diurese to keep the pulmonary wedge pressure less then equal to 18. Titrate dobutamine to maintain an adequate cardiac output and index, hold beta blockers while on Dobutamine, aspirin, continue intravenous heparin, cycle electrocardiograms and CPK MBs. Postoperative hematocrit was 37.2, BUN 47, creatinine 1.4, K 4.2. The patient was transferred to the CICU for continued hemodynamic inotropic support. He required 2 units of packed cells perioperatively. He maintained his hematocrit above 30. He is continued on perioperative Vancomycin, Levo and Flagyl. He remained in the CICU. He was extubated on postoperative day two. His blood gas was 7.4, 42, 83, 27 and 0. Hematocrit remained stable at 36.3 after transfusion. BUN and creatinine remained stable. The patient was transferred to the regular nursing floor on [2147-1-11], antibiotics were discontinued. He was slow with ambulation limited for weight bear. He required adjustment in his heparin dosing and Lopressor for adequate blood pressure control and anticoagulation. Prednisone was instituted 10 mg q.a.m. and 5 q.p.m. Anticoagulation was continued. Coumadinization was begun on [2147-1-11]. The patient required 3 to 6 months of anticoagulation secondary to his myocardial events. He will require an echocardiogram in three months. He was started on Lisinopril 2.5 mg q.d. for after load reduction. Physical therapy saw the patient. At the time of discharge the patient was in stable condition. Wounds were clean, dry and intact. The patient is to follow up with Dr. [Last Name (STitle) 1391] in two weeks time. He should follow up with his endocrinologist for continued management of his adrenal insufficiency and his cardiologist regarding his cardiac follow up. Echocardiogram was done on [1-10], which demonstrated ejection fraction of 20 to 25%. Left atrium was elongated, the right atrium and intraatrial septum was moderately dilated. The left ventricle was mild, symmetric left ventricular hypertrophy, overall left ventricular systolic function is severely depressed. There is a large thrombus seen in the left ventricle. The resting regional left ventricular wall motion abnormalities are seen in the basilar anterior, which is hypokinetic, mid anterior, which is hypokinetic. Basal anteroseptal, which is hypokinetic. Mid anteroseptal, which is hypokinetic. Basal inferior septal, which is hypokinetic. Mid inferior septal, which is hypokinetic. Basal inferior, which is akinetic. Mid inferior was akinetic. Basal infralateral, which is akinetic. Mid infralateral, which is akinetic. Septal apex is akinetic, inferior apex is akinetic, lateral apex is akinetic and apex is dyskinetic. Right ventricle shows severe global right ventricular free wall hypokinesis. DISCHARGE MEDICATIONS: Lisinopril 2.5 mg q.d., Miconazole powder 2% to peri area b.i.d. and prn. Prednisone 5 mg po q.p.m. 10 mg q.a.m., Propofol 50 mg b.i.d., insulin sliding scale and fixed insulin please see enclosed flow sheet. Slugrocortisone acetate 0.1 mg b.i.d., Darvocet N 100 one q 6 hours prn for pain, acetominophen 325 to 650 mg q 4 to 6 hours prn for pain, aspirin 325 mg q.d., Warfarin dose will be adjusted and maintain an INR between 2.5 and 3.5. DISCHARGE DIAGNOSES: 1. Ischemic left foot status post left common femoral to posterior tibial bypass in situ saphenous vein. 2. Perioperative myocardial infarction treated, ejection fraction 20 to 25%. 3. Adrenal insufficiency treated on maintenance minimal corticosteroids. 4. Diabetes insulin dependent, stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2147-1-13] 08:55 T: [2147-1-13] 09:06 JOB#: [Job Number 43866]	[ "9971", "41401", "4019", "V4582" ]
Admission Date: [2101-3-3] Discharge Date: [2101-3-31] Date of Birth: [2066-10-31] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old woman with a history of [Doctor Last Name 73] encephalitis at age 8, status post left hemisphere resective surgery at the age of 19 with residual right hemiparesis and language deficit with at the age of 8. She has been wheelchair bound since the resective surgery. She lives in a group home, and at baseline can communicate somewhat with gestures and limited language. She was admitted to [Doctor Last Name 40277] Hospital two times in [2101-2-4] for recurrent pneumonia, the first time requiring an the outside hospital her seizure frequency increased. Her medications were adjusted at that time, and she became supratherapeutic on Dilantin. Her seizure medications were then held, and she subsequently presented to the [Hospital1 ] [First Name (Titles) 875] [Last Name (Titles) ] on [3-3] with very frequent partial seizures, witnessed to be up to five per hour. Her seizures consisted of head and eye deviation to the right, eyelid blinking bilaterally, eye movement to the right, and left arm elevating tonically. These episodes lasted between 30 seconds and 60 seconds. Also, at the time of her presentation to the [Month (only) ], she was found to be tachypneic with decreased responsiveness. She was sent to the Emergency Department at that time. PAST MEDICAL HISTORY: 1. [Doctor Last Name 73] encephalitis at the age of 8; status post left hemisphere resective surgery at the age of 19 with residual right hemiparesis and language deficits, wheelchair bound since the time of the resective surgery. 2. Seizure disorder since the [Doctor Last Name 73] encephalitis. 3. She is status post vagal nerve stimulator implantation in [2099-12-7] with fairly good response. 4. Recurrent pneumonia including methicillin-resistant Staphylococcus aureus pneumonia in the past. 5. Multiple urinary tract infections. 6. Adenoidectomy. MEDICATIONS ON ADMISSION: ALLERGIES: An allergy to PENICILLIN has been recorded, but her mother has stated that she thinks this is a mistake. FAMILY HISTORY: There is no history of seizures or febrile seizures in the family. There is no history of mental retardation or other developmental problems in the family. Her father died of brain cancer. SOCIAL HISTORY: She lives in a group home, which she moved to in [2100-9-6]. She graduated from high school before the resective surgery was done, and went to a special school after that. She has been wheelchair bound since the resective brain surgery. She enjoys watching television and doing crafts in her day program. She is able to move herself. At baseline, prior to admission, she was able to use utensils to feed herself. She required help to transfer to a toilet and was able to move herself slowly in her wheelchair. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on initial admission on [3-3] revealed the patient's temperature was 99, blood pressure of 103/60, heart rate was in the 90s, respiratory rate was 24. The patient was initially unresponsiveness with labored breathing. Heart was regular in rate and rhythm. Lungs with diffuse upper airway noises. The abdomen was benign. Extremities were without edema. On neurologic examination, the patient had intermittent right facial, eye, and mouth twitching but was still able to follow some commands on the left. Pupils were 5 mm and reactive. Extraocular movements were full. Formal visual fields could not be tested, but the patient seemed to acknowledge all fields. There was a right facial droop. On motor examination, there was no spontaneous movement on the right. Arm was held in flexed position with fingers flexed. The right lower extremity was externally rotated with flexion response to pain. The left upper extremity was without asterixis and had full strength. There was some difficulty maneuvering the left lower extremity, and strength was about 4+/5 throughout. Reflexes could not be elicited. The left toes were downgoing. The right toes were upgoing. Sensation was intact to light touch on the left. RADIOLOGY/IMAGING: A chest x-ray on admission showed no infiltrate. PERTINENT LABORATORY DATA ON PRESENTATION: Dilantin level was 9. Phenobarbital level was 25. White blood cell count was 4 (with 42% neutrophils), hematocrit was 33, platelets were 203. Electrolytes, blood urea nitrogen, and creatinine were within normal limits. HOSPITAL COURSE: After receiving 1 mg of Ativan in the Emergency Department, her responsiveness and respiratory status improved. She was admitted to the Neurology Service and treated with Ativan, Topamax, Dilantin, and phenobarbital for seizure control. On [3-7], she was transferred to the Neurology Intensive Care Unit for decreased responsiveness, fever, and increasing respiratory distress. On [3-9], she was intubated for airway protection. She continued to have frequent seizure activity intermittently with clinical episodes and by electroencephalogram. Over the next several days her seizure frequency improved, and her respiratory status improved as well. A tracheostomy was placed on [3-16]. The patient was found to have tracheomalacia, and a percutaneous endoscopic gastrostomy tube was placed on [3-21]. Her respiratory status continued to improve, and she was weaned off the ventilator. She did continue to have right eye blinking and facial twitching episodes intermittently which did not seem to have electroencephalogram correlation. She was transferred to the Neurology floor out of the Intensive Care Unit on [3-25]. By that time, her seizures were well controlled with only the intermittent facial twitching and eye blinking, and she had completed a full antibiotic course for aspiration pneumonia. Her respiratory status remained stable while on the floor. She did begin to complain of abdominal pain on the floor and also developed a low-grade temperature. She was found to have a urinary tract infection and started on antibiotics for this. A CT of the abdomen was done which found no evidence of abscess, a small hematoma around the site of the percutaneous endoscopic gastrostomy tube insertion, and significant constipation. The percutaneous endoscopic gastrostomy tube was checked by Interventional Radiology and found to be placed correctly and functioning correctly. She received laxatives, and her constipation resolved after an enema. She does continue to gesture and show some discomfort around the site of the percutaneous endoscopic gastrostomy tube; however, there remained no sign of infection or dysfunction of the percutaneous endoscopic gastrostomy tube, and a KUB done on [3-30] showed no obstruction or impaction. Neurologically, she had remained stable with an unchanged right hemiparesis that is longstanding secondary to her left hemisphere resective surgery. Her level of arousal and responsiveness has been normal over the last several days. She remained nonverbal, but followed commands, and gestures appropriately. The remainder of the hospital course by system: 1. NEUROLOGY: As stated above, the patient was initially admitted and started on an increased dose of Dilantin, continued on her phenobarbital, and started on Topamax, as well as Ativan for seizure control. She continued to have right facial and eye twitching intermittently throughout her entire hospital course. She had multiple electroencephalograms which showed widespread background slowing focally on the left but also on the right and with frequent sharp wave discharges in the left parasagittal region. There were occasional electrographic seizures seen by electroencephalogram, but the eye twitching and facial movements did not seem to have electroencephalogram correlation. She remained on phenobarbital, Dilantin, and Topamax throughout her hospital course; and the seizures were relatively well controlled on these medications. Her goal levels for the phenobarbital was around 26 and for the Dilantin around 18 with a free Dilantin around 3. She was on olanzapine and Zoloft on admission. These medications were discontinued as they were thought to be contributing to her decreased level of responsiveness. 2. PULMONARY: The patient has a history of recurrent pneumonias, for which she was admitted to [Doctor Last Name 40277] Hospital in [2101-2-4]; including methicillin-resistant Staphylococcus aureus, which was found in her sputum. During this admission, she was treated for aspiration pneumonia and methicillin-resistant Staphylococcus aureus. She is status post methicillin-resistant Staphylococcus aureus which required intubation. She is status post tracheostomy on [3-16] and has been doing well. She has been off the ventilator since [3-24], and respiratory status has been stable. She was seen by Speech and Swallow on [3-30] for placement of a Passy-Muir valve to enable her to speak; however, she was unable to tolerate this secondary to coughing when the tracheostomy cuff was deflated and continued coughing with the Passy-Muir valve in place. She was found to have tracheomalacia, and therefore any placement of the Passy Muir valve must be done under bedside supervision. She should have the cuff deflated prior to Passy-Muir valve placement, and it should not be placed while she is asleep. She will follow up for management of the tracheostomy with Dr. [Last Name (STitle) ] in four to six weeks. 3. INFECTIOUS DISEASE: The patient is status post an antibiotic course for pneumonia, as above. She is currently receiving ceftriaxone for treatment of Morganella urinary tract infection that is resistant to Levaquin. She will complete a 10-day course of the ceftriaxone. She has been afebrile for over 48 hours. 4. GASTROINTESTINAL: The patient is status post percutaneous endoscopic gastrostomy tube placement on [3-21]. She has been tolerating tube feeds without complications. She does motion discomfort around the percutaneous endoscopic gastrostomy tube site. This was worked including an abdominal CT which showed a small hematoma around the site of the percutaneous endoscopic gastrostomy tube and constipation. The patient constipation was relieved after enema. She does still complain of some abdominal pain, but the percutaneous endoscopic gastrostomy tube is functioning well and has been checked by Interventional Radiology, and a Gastrointestinal consultation was obtained who had no further recommendations at this time. MEDICATIONS ON DISCHARGE: 1. Topamax 125 mg per G-tube b.i.d. 2. Phenobarbital 40 mg per G-tube at 8 a.m. and 60 mg per G-tube at 4 p.m. and 12 a.m. 3. Ceftriaxone 1 g intravenously q.24h. (for a 7-day course; this was started on [3-29]). 4. Dilantin 150 mg intravenously t.i.d. 5. Colace 100 mg per G-tube t.i.d. 6. Epogen 40,000 units subcutaneous every week. 7. Miconazole powder p.r.n. 8. Zinc sulfate 220 mg per G-tube q.d. 9. Vitamin C 500 mg per G-tube b.i.d. 10. Iron sulfate 325 mg per G-tube t.i.d. (in elixir form). 11. Heparin 5000 units subcutaneous b.i.d. 12. Dulcolax 10 mg p.o./p.r. p.r.n. 13. Fleet enema p.r. p.r.n. 14. Prevacid 30 mg per G-tube q.d. DISCHARGE DIAGNOSES: 1. Increased seizure frequency. 2. Aspiration pneumonia. 3. Status post tracheostomy. 4. Status post percutaneous endoscopic gastrostomy tube. 5. Old right hemiparesis secondary to left hemisphere resective surgery. 6. Seizure disorder and mental retardation secondary to [Doctor Last Name 73] encephalitis. She will see Drs. [First Name (STitle) 437] and [Name5 (PTitle) ] in follow-up for management of her [Name5 (PTitle) ]. [First Name8 (NamePattern2) 7495] [Name8 (MD) ], M.D. [MD Number(1) 7496] Dictated By:[Last Name (NamePattern1) 19315] MEDQUIST36 D: [2101-3-31] 10:40 T: [2101-3-31] 11:06 JOB#: [Job Number 40278]	[ "5070", "5990" ]
Unit No: [Numeric Identifier 66133] Admission Date: [2134-11-2] Discharge Date: [2135-2-28] Date of Birth: [2134-11-2] Sex: F Service: NB HISTORY: Baby girl [Known lastname 66134] was the 696 gram product of a 25- 4/7 weeks gestation, born to a 34 year old G2, P1 to 2 mother. Prenatal screens: blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and GBS unknown. FAMILY HISTORY: Notable for prior delivery of a 26 weeks female infant in [2127] who is currently alive and generally healthy. Pregnancy noted for prophylactic cerclage placed at 12 weeks and also complicated by spontaneous premature rupture of membranes on [10-25] prompting maternal admission and monitoring. She was treated with magnesium for several days for contractions which were discontinued on [10-26]. Course of betamethasone was complete on [10-27] and 7 days of ampicillin and erythromycin were completed on [11-1]. She was having intermittent low grade fevers and developed painful uterine contractions. She was also noted to have uterine tenderness with elevated white blood cell count and fetal tachycardia and fever to 100.3. Therefore she was taken for repeat cesarean section due to increasing concerns for chorioamnionitis. Infant emerged with moderate tone and weak cry. Responded well to stimulation and positive pressure ventilation She was intubated in the delivery room and was transferred to the newborn intensive care unit for further management. PHYSICAL EXAMINATION: Weight 696 grams, length was 32.5 cm, head circumference 23 cm, all approximately 25th percentile. Physical examination was consistent with a 25 and 4/7 weeks infant. This was a small premature female. Active and vigorous on examination. Skin was warm and pink with capillary refill of 1.5 seconds. Fontanel soft and flat. Ears and nares patent. Palate intact. Eyes fused. Neck supple. Chest with coarse tight breath sounds. Moderate aeration. Significant retractions. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. ABDOMEN: No hepatosplenomegaly. Three- vessel cord. GENITOURINARY: Premature genitalia. Anus patent. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [Known lastname ] was intubated in the delivery room for management of prematurity and respiratory distress. She is status post surfactant therapy, status post right chest tube placement on day of life 1 secondary to pneumothorax. She extubated to CPAP on day of life 51 and to nasal cannula oxygen on day of life 78 where she continues on nasal cannula 125 cc per minute of 100% oxygen. Her most recent blood gas was obtained on [2135-2-21] and was a venous gas. Her pH was 7.36. Her PCO2 was 64, her PO2 was 25, her calculated bicarbonate was 38, and her base excess was 6. The infant was started on caffeine early on in her course. Her caffeine citrate was discontinued on [12-30]. She was started on Diuril on [11-5]. She was started on Lasix every other day. On [1-31] she was started on aldactone on [2-10]. She continues on her Diuril, Lasix and aldactone. A pulmonary consult was obtained with Dr. [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) 37305] at [Hospital3 1810], pulmonology. Recommend follow up 1 week post discharge. His telephone No. [Telephone/Fax (1) 54198] and his [Hospital3 1810] beeper number is [Pager number ]. CARDIOVASCULAR: She was treated with indomethacin for a patent ductus arteriosis on day of life 2.An echocardiogram on [2135-2-25], per pulmonary request revealed no patent ductus arteriosus, a small patent foramen ovale, no pulmonary hypertension, and a structurally normal heart. FLUIDS, ELECTROLYTES AND NUTRITION: Her discharge weight is 4.060 kg, head circumference is 35.5 cm and her length is 50 cm. Enteral feedings were started on day of life 8 and advaned to full enteral feedings by day of life18. She is currently demonstrating good weight gain on breast milk 24 calorie concentrated with 4 calories of Similac powder. She was started on potassium supplementation secondary to losses due to diuretic therapy. She continues on potassium supplements. Her most recent set of electrolytes drawn on [2-27] were: sodium 137, potassium 4.6, chloride 94, and a total CO2 20. GASTROINTESTINAL: She was started on Zantac on [2-15] due to gastroesophageal reflux symptoms and continues on Zantac to date. HEMATOLOGY: The patient's blood type is A positive. She had multple packed red blood cell transfusions, most recently on [2135-1-19]. Her most recent hematocrit was 29.7 with a reticulocyte count of 4% on [2-13]. She continues on ferrous sulfate supplementation. INFECTIOUS DISEASE: She was started on ampicillin and gentamycin at the time of admission for sepsis risk factors. She completed seven days for presumed sepsis. Her blood and CSF cultures from that time were negative. [Known lastname ] has had no other infectious disease concerns during her hospital course. NEUROLOGIC: A small left grade 3 IVH was noted on head ultrasound on day of life 10. Her most recent head ultrasound was on [2135-1-13] demonstrating resolution of her IVH. No evidence of periventricular leukomalacia, normal ventricular size. SENSORY: Hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. OPHTHALMOLOGY: [Known lastname ] is status post bilateral laser therapy for retinopathy of prematurity. Her most recent eye examination was on [2-23] revealing stage 1, zone 2 ROP, 2 to 3 o'clock hours in her left eye and stage 4A, zone 2, 1 o'clock hour in her right eye. This is considered a stable eye examination by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 36137], the ophthalmologist who has been following her. Recommended follow up is 2 weeks from [2-23]. Her telephone number is [Telephone/Fax (1) 36249]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home to the parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Her telephone No.: [Telephone/Fax (1) 38703]. CARE RECOMMENDATIONS: 1. Feeds at discharge: Continue ad lib breast milk 24 calorie concentrated with 4 calories of Similac powder. 2. Medications: Ferrous sulfate(25 mg/ml)0.4 ml once daily Zantac7.6 mg q 8 hours Lasix 3.8 mg every other day Diuril 76 mg q12 hours Aldactone 7.6 mg once daily Potassium Chloride supplementation 4 mEqs q12 hours. 3. Car seat position screening was performed and [Known lastname ] passed a 90 minute screening. 4. State newborn screens have been sent per protocol and had been within normal limits. 5. Immunizations received: Synagisn [2-3], and [2-26] Hepatitis B vaccine on [2134-12-2] Pediarix on [2135-1-2] HIB on [2135-1-2], Pneumococcal vaccine on [2135-1-2]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria. A) Born at less than 32 weeks. B) Born between 32 and 35 weeks with two of the following: 1. daycare during the RSV season. 2. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 3. with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments recommended: 1. Follow appointment with pulmonology, Dr [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) 37305]. Telephone No. [Telephone/Fax (1) ]. Beeper No. 1415. Recommended time frame is 1 week after discharge. 2. Follow up appointment in 2 weeks for the week of [3-9], [2134] with Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 36137] at [Hospital1 62374]. Telephone No. [Telephone/Fax (1) 36249]. 3. [Hospital3 28900] Infant follow up Program 4. Early Intervention 5. Visiting Nurse DISCHARGE DIAGNOSES: 1. Premature infant born at 25-4/7 weeks gestation. 2. Status post respiratory distress syndrome. 3. Status post presumed sepsis . 4. Status post right pneumothorax. 5. Status post patent ductus arteriosus. 6. Status post grade 3 intraventricular hemorrhage. 7. Status post bilateral laser therapy for retinopathy of prematurity. 8. Hemangioma in groin. 9. Chronic lung disease 10. Anemia of prematurity 11. Status post hyperbilirubinemia of prematurity 12.Gastro-esophageal reflux 13, Status post apnea of prematurity [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2135-2-27] 22:16:11 T: [2135-2-28] 01:53:47 Job#: [Job Number 66135]	[ "7742", "V053" ]

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