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Admission Date: [2179-10-17] Discharge Date: [2179-10-20] Date of Birth: [2133-3-20] Sex: M Service: Cardiology Dictating for: [Known firstname ] [Last Name (NamePattern1) ], M.D. HISTORY OF PRESENT ILLNESS: This is a 46-year-old male with cardiac risk factors of hypertension, hypercholesterolemia, and smoking (three to four packs per day for approximately 30 years) who presented via ambulance to [Hospital1 190] from an outside hospital for rescue cardiac catheterization after failed thrombolysis for an acute inferior myocardial infarction. The patient was in his usual state of health on [10-16], the day before admission; when, after hunting, he experienced substernal chest pain radiating to both while sitting down that did not resolve for several hours. There was some associated diaphoresis, but the patient denied shortness of breath, dizziness, or palpitations. After several hours of continuous pain, the patient went to an oxygen saturation hospital ([Hospital3 36606] Hospital) where he arrived with stable vital signs and an electrocardiogram indicative of an inferior myocardial infarction. The patient was given thrombolytics times two as well as heparin, morphine, Lopressor, nitroglycerin drip, and aspirin; all without significant improvement in the electrocardiogram or in his pain. The patient was therefore transferred, with stable vital signs, to [Hospital1 69] where he had a coronary angioplasty with two stents placed in the right coronary artery. There was stenosis in the proximal right coronary artery of 60%, and in the distal right coronary artery of 99%, with TIMI-I flow. After stent placement, TIMI-III flow was seen. Left ventriculography showed an ejection fraction of 45% with inferior hypokinesis. No mitral regurgitation and increased filling pressures. The patient was admitted to the Coronary Care Unit at [Hospital1 1444] with improvement in symptoms and electrocardiogram findings and in stable condition. REVIEW OF SYSTEMS: Review of systems was significant for occasional chest pain over the course of the past year or more that was similar to the chest pain he experienced before admission. In addition, the patient reports abdominal pain upon eating which has been occurring for several months. Otherwise, review of systems was negative. PAST MEDICAL HISTORY: Past medical history is significant for hypertension, hypercholesterolemia, hemorrhoids. No history of heart disease. At the time of admission, the patient did not regularly see a primary physician. ALLERGIES: There were no known drug allergies. MEDICATIONS ON ADMISSION: The patient took no medications at home. FAMILY HISTORY: Family history was significant for both parents who had myocardial infarctions in their 50s. SOCIAL HISTORY: Social history was significant for three to four packs per day of smoking for 30 years and approximately 10 beers per week. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Coronary Care Unit revealed vital signs with a temperature of 96.9, heart rate was 62, blood pressure was 140/88, respiratory rate was 19, oxygen saturation was 99% on 3 liters nasal cannula, a weight of 165 pounds, and a height of 5 feet 11 inches. In general, the patient was awake and alert, in no acute distress; though the patient appeared restless. Head, eyes, ears, nose, and throat examination was significant for pupils which were equal, round, and reactive to light with extraocular muscles intact. There was increased jugular venous pressure to the jaw at 15 degrees, and there was a question of bilateral carotid bruits. Cardiovascular examination was significant for a regular rate and rhythm. A soft systolic ejection murmur at the left lower sternal border. Lung examination was significant for clear lungs bilaterally. Abdominal examination revealed positive bowel sounds, nontender, mildly tensed abdomen. Extremities revealed he was moving all four extremities. There was a right femoral catheter which was nontender without hematoma, and the patient had bilateral dorsalis pedis pulses. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values from [Hospital3 36606] Hospital immediately before admission to [Hospital1 ] showed the following; a complete blood count with a white blood cell count of 9000, hematocrit was 44.2, platelets were 351. The differential showed 39 neutrophils with 49 lymphocytes. Chemistry-7 showed sodium was 143, potassium was 3.7, chloride was 104, bicarbonate was 25, blood urea nitrogen was 14, creatinine was 1.2, and blood glucose was 126. The PTT was 23.1. The creatine kinase was 104. The MB fraction was 1.5. Troponin I was less than 0.4. RADIOLOGY/IMAGING: A chest x-ray was normal. Electrocardiogram on admission to the Emergency Room at [Hospital3 36606] Hospital showed sinus rhythm with a rate of 66, an axis of -30, with 2-mm to 3-mm ST elevations in II, III, and aVF; and reciprocal changes ST changes in aVL and V1 through V4. Electrocardiogram at [Hospital1 69] after angioplasty showed a sinus rate of 90, with an axis of -30, and improved ST elevations in II, III, and aVF; as well as improved ST depressions in V1 through V4. The cardiac catheterization showed a left main, a left anterior descending, and left circumflex arteries without flow-limiting disease. The right coronary artery showed a 60% proximal stenotic lesion proximal to the acute marginal with TIMI-II flow distally and a mid distal right coronary artery with 99% stenosis. Right atrial pressures were 15. Right ventricular pressure was 35/20. Left ventricular end-diastolic pressure was 35. Pulmonary capillary wedge pressure was 27. Right atrial pressure was 35/20. The cardiac output was 4.23. The left ventricle showed inferior hypokinesis with an ejection fraction of 45%. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit in stable condition. He was started on Plavix 75 mg b.i.d., aspirin 325 mg q.d., heparin, captopril 25 mg t.i.d., and Lopressor 12.5 mg t.i.d. Because of the suspicion of alcohol withdrawal, the patient was started on oxazepam as needed as well as thiamine, folate, and multivitamins. This suspicion was based on the patient's admitted use of 10 beers per week as well as elevated AST at 237, an ALT of 52, and the patient's significant restlessness. It was also considered that this restlessness was due to withdrawal from a significant nicotine habit. The patient's cholesterol was found to be elevated with a total cholesterol of 229, a high-density lipoprotein of 29, a low-density lipoprotein of 161, with triglycerides of 196. As a result, the patient was stated on Lipitor once his abnormal liver function tests resolved. The patient's right femoral catheter was removed on hospital day one. Pressure was held on for 55 minutes without oozing and with a small hematoma. Because the patient had some increasing back pain around this time, a hematocrit was checked which was shown to be decreased to 36 from 39. On rechecking the hematocrit the next day, it remained stable at 38.5, and no further workup was felt to be necessary. SMOKING CESSATION: Because of the patient's history of three to four packs per day of smoking, the patient was started on a nicotine patch, and the importance of smoking cessation was emphasized and discussed with the patient. The patient was to follow up with his primary care physician regarding this matter. ADDENDUM: The patient's creatine phosphokinase peaked at 2588, with a MB fraction of 407, and a troponin I of greater than 50. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 44824] [Name (STitle) 25356] for primary care at [Hospital 15953] Medical Group at [Last Name (un) 44825], in [Hospital1 189], [Numeric Identifier 44826] (telephone number [Telephone/Fax (1) 24335]). In addition, the patient was to follow up with cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7208]. MEDICATIONS ON DISCHARGE: 1. Lisinopril 10 mg p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Plavix 75 mg p.o. q.d. (times 30 days total). 7. Folic acid 1 mg p.o. q.d. 8. Multivitamin. 9. Nicotine patch. DISCHARGE DIAGNOSIS: Inferior myocardial infarction with no complications. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [MD Number(1) 1014] Dictated By:[Last Name (NamePattern4) 44827] MEDQUIST36 D: [2179-10-19] 16:10 T: [2179-10-19] 16:21 JOB#: [Job Number 44828] cc: [Name6 (MD) ] [Name8 (MD) ], M.D., [Hospital 15953] Medical Group, [Last Name (un) 44829], [Hospital1 189], [Numeric Identifier 44830] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D., Cardiologist, [Hospital 15953] Medical Group, [Last Name (un) 44825], [Hospital1 189], [Numeric Identifier 41087]	[ "41401", "4019", "3051", "2720" ]
Admission Date: [2137-8-2] Discharge Date: [2137-10-1] Date of Birth: [2091-6-8] Sex: M Service: SURGERY Allergies: Haldol / Penicillins Attending:[First Name3 (LF) 5569] Chief Complaint: End stage renal disease Major Surgical or Invasive Procedure: Cadaveric renal transplant [2137-8-3] central venous access arterial line Hemodyalsis line Kidney biopsy bronchoscopy tracheostomy [2137-8-27] History of Present Illness: 46 y/o male on HD at [Hospital1 8] [Location (un) ] who has been called in for standard criteria cadaveric kidney transplant. The patient currently dialyzes T-Th-S with last HD on [8-1]. EDW is reported as 100 kg, he states off weight yesterday was 102 kg. He often has hypotension during RX and have adjusted his BP meds recently. He reports he does not make urine. The patient denies fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath. He reports no recent hospitalizations and no sick contacts Past Medical History: Past Medical History: ESRD of unclear etiology on HD x 3 years, on transplant list MSSA bacteremia [2136-10-23], treated with 6 weeks IV Vanco at HD MSSA bacteremia [8-/2136] at [Hospital 8] Hospital HTN S/p L nephrectomy late [2117] for stab wound to kidney HCV GT1 s/p 48 wks RBV/IFN ending [2-26] with HCV VL undectable [2136-8-17] Depression OCD Obesity Brachiocephalic stenosis . Social History: SOCIAL HISTORY: + tobacco 1ppd x deacdes, no ETOH, or IVDU. Orginally from [Country 651], here in US x 20 years. Lives alone in [Hospital1 8]. Son involved. Wife and children in [Country 651]. Unemployed. Family History: Family History: No FH recurrent skin infections, CAD, DM Physical Exam: VS: 98.9, 81, 126/81, 14, 96%RA WT: 103.7 kg HEENT: No oral infection or dental caries noted, no LAD, sclera anicteric Card: RRR, no M/R/G Lungs: CTA bilaterally Abd: Obese, multiple scars noted (s/p nephrectomy from stab wound 15 years ago) + BS, not taut or distended Extr: 1+ LE edema, Left femoral groin catheter in place, arms with multiple access interventions Neuro: A+O x 3, depressed somewhat flat affect Skin: moist, multiple dry scaly areas especially lower legs Pertinent Results: [2137-8-2] 05:40PM UREA N-78* CREAT-11.4# SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-20 ANION GAP-25* [2137-8-2] 05:40PM ALT(SGPT)-8 AST(SGOT)-13 [2137-8-2] 05:40PM ALBUMIN-4.0 CALCIUM-7.8* PHOSPHATE-8.5# MAGNESIUM-2.1 [2137-8-2] 05:40PM WBC-8.0# RBC-4.43# HGB-13.6# HCT-41.9# MCV-95 MCH-30.7 MCHC-32.4 RDW-16.7 [2137-8-2] 05:40PM PLT COUNT-202 [2137-8-2] 05:40PM PT-12.9 PTT-29.2 INR(PT)-1.1 [2137-8-7] 11:19 am SPUTUM GRAM STAIN (Final [2137-8-7]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2137-8-9]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- 32 S TOBRAMYCIN------------ <=1 S [2137-8-8] 6:59 am BRONCHIAL WASHINGS RESPIRATORY CULTURE (Final [2137-8-20]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SUSCEPTIBILITY TO DORIPENEM AND COLISTIN REQUESTED [2137-8-13] BY DR [Last Name (STitle) ] [Last Name (NamePattern4) 10000] ([Numeric Identifier 72184]). SENT TO [Hospital1 4534] FOR COLISTIN AND DORIPENEM SENSITIVITIES ([2137-8-15]). Colistin <= 2 MCG/ML SUSCEPTIBLE. DORIPENEM > 2 MCG/ML NOT SUSCEPTIBLE. Colistin & DORIPENEM SENSITIVITIES DONE BY [Hospital1 4534] LABS. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SUSCEPTIBILITY TO DORIPENEM AND COLISTIN REQUESTED [2137-8-13] BY DR [Last Name (STitle) ] [Last Name (NamePattern4) 10000] ([Numeric Identifier 72184]). PSEUDOMONAS AERUGINOSA #2 COMBINED WITH #1 FOR COLISTIN & DORIPEMEM SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- 16 I 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I 8 I MEROPENEM------------- =>16 R =>16 R PIPERACILLIN/TAZO----- 64 S 64 S TOBRAMYCIN------------ <=1 S <=1 S FUNGAL CULTURE (Final [2137-8-22]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2137-8-9]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [2137-8-9] 7:59 pm Immunology (CMV) Source: Line-art. CMV Viral Load (Final [2137-8-13]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. [2137-8-26] 2:48 pm BLOOD CULTURE Blood Culture, Routine (Final [2137-9-1]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- 2 I TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S [2137-8-29] 11:40 am BLOOD CULTURE Blood Culture, Routine (Final [2137-9-1]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S [2137-9-1] 4:30 pm SPUTUM PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- 16 I 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R 8 I MEROPENEM------------- =>16 R =>16 R PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ 2 S 2 S [2137-9-14] 12:58 am URINE ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| ENTEROBACTER CLOACAE \| \| CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I 64 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R [2137-9-14] 12:58 am URINE _________________________________________________________ ENTEROBACTER CLOACAE \| ENTEROBACTER CLOACAE \| \| CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I 64 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R Brief Hospital Course: Patient was admitted to Dr.[Name (NI) 8584] surgical service and underwent a cadaveric renal transplant on [2137-8-2]. Prior to procedure, patient required re-positioning of his tunneled HD line as this is also his only vascular access. Please refer to operative note for more details. He was taken directly to the intensvie care unit after his surgery. The remainder of his hospital course can be summarized by the following review of systems. Neuro: Patient's sedation and pain was appropriately controlled with fentanyl and versed while he remained intubated. The patient had multple episodes of agitation requiring increased boluses of fentanyl and versed. On POD 16, patient's fluoextine was restarted for concerns for SSRI withdrawal. In addition, PO Zyprexa and Ativan were also started. On [8-24], the patient was started on PO methadone to improve pain control and anxiety. On [8-31], librium was started for a longer acting anxiolysis. Fentanyl and Versed were weaned off. By [9-5], methadone and ativan were being weaned. Patient continued to have episodes of agitation. On [9-10], the patient had suicidal ideations and pyschiatry was reconsulted. The patient was started on Cogentin for concern for akathisia and the Zypexa was d/c'ed for suspected EPS. The patient was started on prn seroquel for agitation. A 1:1 sitter was recommended. He received intermittent propofol at night to prevent deline/detubing. The patient's suicidal ideation improved with the start of eating and being in contact with his family in [Name (NI) 651] (via telephone). The patient's neuro status improved with an improvement in his suicidal ideations. The 1:1 sitter was d/c'ed. Ativan and clonidine were weaned per psychiatry recommendations. Patient is awake, alert, oriented and cooperative on discharge. Pulm: The patient was transferred to the SICU intubated. Esophageal balloon used to determine optimal PEEP. The patient was on an ARDS protocol. Patient bronched on [8-8], cultures sent. Cefepime and fluconazole started. Patient was growing psuedomonas from sputum. Tobramycin Inh and Cefepime started for VAP. By POD15, PEEP decreased to 5 and started a CPAP trial on POD16. Since the patient has a history of tracheal stenosis (trach placed in [2117]), Thoracic surgery was consulted for trach placement. On POd 16, the patient was on CPAP 5/5. On [8-27], the patient was brought to the OR by thoracic surgery for trach placement, which was subequently exchanged for a longer size. The patient was weaned to PS with trach mask trials. On [9-16], speech and swallow was consulted. He did not tolerate a Passy-Muir valve. On [9-17], he tolerated trach collar all day with CPAP overnight. The patient had episodes of tolerating trach collar and then required CPAP support. On [9-26], IP assessed the patient for possible desizing trach to allow for a PMV. However, since he wasn't tolerating trach collar, it was decided to not manipuate the trach. On the evening of [9-26], the patient had a acute desaturation episode and became agitated. He had severe hypercarbia on ABG and was restarted on CMV with gradual improvement. The patient was bronched during this event, which showed a normal exam: all airways patent, no mucus or erythema. Since this, he is tolerating intermittent trach mask but still requiring vent support when tires. He has been OOB to chair and has ambulated on his own from bed to chair. Cardio: Patient had massive fluid resuscitation immediately post-op and required Levophed for hypotension. Cardiac enzymes were negative x 3. TEE on [8-8] and [8-9] showed hyperdynamic with evidence of low intravascular volume. Patient was intermittently bolused with crystallioid,albumin, and PRBCs for volume replacement. Pressors were weaned, but needed to be restarted/increased for hypotension if too much fluid was removed via CVVHD or if the patient needed more sedation. Patient continued volume resuscitation with albumin. The patient's BP stabilized and he was able to tolerate fluid removal via HD. He has been hemodynamically stable even while off HD for past few days. GI: Dobhoff was placed by IR and Novasource Renal was started on [8-12] and advanced. On [8-22], Tf were held for increased abominal distention (noticeable at his known hernia site). On [8-22], Relistor was given, which improved bowel function, and TF were restarted. On [9-17], the patient passed his swallowing evaulation. The patient was started on pureed solids and thin liquids with ensure supplements and has been tolerating them while on trach mask. Renal: Patient with delayted graft function. Patient started on CVVHD post-op. Renal u/s on [8-5] showed patent vessels and good flow. Patient received 2 doses of ATG and Tacorlimus was started POD3. On [8-7] tPa was added to HD line clotting. HD line was replaced by IR on [8-8] Tacrolimus, Cellcept, and solumedrol restarted on [8-10]. Right groin HD catheter was replaced on [8-14]. Renal biopsy on [8-16] showed no acute rejection. By POD 14, the patient tolerated aggressive diuresis on CVHD, with daily diuresis up to 2- 3L daily. By, [8-22], the patient had a profound diuresis, and CVVHD was run even. However, since his BP was labile, intermittent HD was not recommended. On [8-28], the patient had a renal biopsy, which was negative for rejection. On POD 31 ([9-1]), the patient tolerated HD. Patient tolerated 1-2L negative on HD. On [9-7], 160mg lasix given, with no change in urine output. The patient has qdaily straight caths, with urine outputs upwards of 100-150cc/daily. On [9-21], the patient's ureteral stent was d/c'ed by urology. On [9-25], the patient was given 100mg IV Lasix with an increase in urine output. Overall, his urine output continued to improve up to 400-500cc/day. With the improvement in his urine output and return to pre-op weight, HD was held. Given improving renal function (i.e. decreasing Cr), he was not requiring HD from [9-28] and was given intermittent lasix with good response. On [9-30], his urine output was ~100-200cc/hr without lasix. His last FK level on discharge was 10.2 (from 11.5) and he was sent on FK 12mg [Hospital1 ]. He is to have his FK level checked at rehab and his medication dosed accordingly. Heme: Patient has been on heparin gtt post-op with a PTT goal 50-60 to protect the graft. On [9-3], the patient was started on coumadin. Once the patient had a therapeutic INR, the hep gtt was stopped. The patient received intermittent PRBCs transfusions with HD. He was transfused for low HCT as needed with lasix after he was off HD. His HCT at discharge was stable 29.5. His INR on discharge was 2.5 (from 1.8 on coumdain 7.5mg) and his coumadin dose was dropped to 1mg. He is to have his INR checked tomorrow AM at rehab. ID: VAP sepsis, vancomycin/cipro/flagyl started on [8-7], improved and kept on cefepime and inhaled tobramycin. ID was consulted on [8-9] for pseudomonas aeruginoas pneuomia, plan to continue Vanco, cefepime, d/c ciprofloxacin, cont micfungin, d/c fluconazole, start inh tobramycinPatient is on valgancyclovir and bactrim for post-transplant prophylaxis. On [8-29], blood cultures from R. femoral catheter grew GPC, coag negative Staph. Vancomycin was restarted, in addition to vanco lock in the HD line for a 14 day course. Surveillance blood cultures were drawn, which were consistently negative. Sputum culture on [9-1], positive for pseudomonas, treatment held since patient had normal WBC, afebrile, tolerating trach mask. HD line vanc lock continued. On [9-16], the patient was started on cipro for urine culture positive for enterobacter ([9-14]). On [9-23], the cipro was stopped. His valcyte was increased to 450mg three times per week on date of discharge. Endo: maintained on RISS, random cortisol level was 30, confirming appropriate adrenal function. Medications on Admission: ALLERGIES: PCN - unknown. Has never had a reaction but had a skin test decades ago in [Country 651] that was positive. Haldol- cramps. Meds prior to admission: Fluoxetine 40mg PO daily, Renal cap daily, Lisinopril 40mg PO daily, Renagel 1600mg PO TID Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) dose PO Q6H (every 6 hours) as needed for Pain. 4. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q2 PRN () as needed for SOB/wheeze. 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q4H (every 4 hours) as needed for thick secretions. 9. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: 1000 (1000) mg PO BID (2 times a day). 10. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR ASDIR Injection ASDIR (AS DIRECTED). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Sulfamethoxazole-Trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 13. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation: Hold for hypotension/oversedation. 14. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation: Hold for SBP<110. 15. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) SC Injection Injection QMOWEFR (Monday -Wednesday-Friday). 16. Tacrolimus 1 mg Capsule Sig: Twelve (12) Capsule PO Q12H (every 12 hours): Tacrolimus level to be checked in AM tomorrow and then 3 times a week, adjust dose accordingly. 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for PRN anxiety/agitation: Hold for over-sedation. 18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Please check INR in AM tomorrow and then 3 times per week, adjust dose accordingly. 19. Valganciclovir 50 mg/mL Recon Soln Sig: Four [Age over 90 1230]y (450) mg PO 3X/WEEK ([Doctor First Name ],TU,TH). 20. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting 21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 22. Vancomycin Lock Sig: One (1) Vancomycin Lock ASDIR: Combine: 12,500 Units heparin sodium & 12.5mg Vancomycin in 5mL Normal Saline -Please administer via sterile syringe each time after using the femoral dialysis line -If any questions, please call [Telephone/Fax (1) 72185] for [Hospital1 18] Pharmacy. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: ESRD s/p Cadaveric Renal Transplant with extended criteria complicated by VAP sepsis s/p percutaneous tracheostomy 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 going [Hospital1 ]/[Hospital ] [Hospital 8] Rehab. Please call Dr. [Last Name (STitle) ]/[Hospital 1326] clinic if any of the warning signs listed below appear or if you have any concerns/questions. You have a tracheostomy and are tolerating trach mask. Followup Instructions: Please follow-up in 1 week at the transplant clinic with Dr. [Last Name (STitle) ] - please call [Telephone/Fax (1) 673] to schedule an appointment.	[ "40391", "78552", "5845", "99592", "5990" ]
Admission Date: [2192-2-17] Discharge Date: [2192-2-28] Date of Birth: [2123-1-15] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain with exertion Major Surgical or Invasive Procedure: [2192-2-20] Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery [2192-2-20] Mediastinal re-exploration and evacuation of a clot status post coronary artery bypass surgery History of Present Illness: This 69 year old male was seen by his primary care physician [Name Initial (PRE) ] 3-4 weeks of exertional chest pressure that radiates down left arm. He was seen at an urgent care center for evaluation and an EKG showed new deep T wave inversions in I,AVL,V1-6.Pt. was admitted and ruled out for an MI by enzymes and EKG. CXR showed no acute changes. Chest CT showed no evidence of pulmonary embolism. He was started on Plavix and ASA yesterday and transferred for cardiac catheterization with Dr. [Last Name (STitle) 66097] ti [Hospital1 18]. Past Medical History: diet controlled diabetes mellitus Hypertension Hyperlipidemia Cervical disc disease Sciatica Depression Social History: [2-15] yr hx of cig smoking in his 20's. Former cigar smoker after that. -ETOH: prior alcoholism, sober for 9 months -Illicit drugs: none Family History: Mother with cirrhosis, both parents have ETOH abuse. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse: 63 Resp:16 O2 sat:97% RA B/P Right:125/79 Left:136/78 Height: 5ft 9" Weight:210lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []crackles in bases Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]protruberant Extremities: Warm [x], well-perfused [x] Edema [] No edema____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:+1 Left:+1 DP Right: trace Left:trace PT [Name (NI) 167]:trace Left:trace Radial Right: Cath site Left:+2 Carotid Bruit Right: None Left:None Pertinent Results: [2192-2-26] 05:30AM BLOOD WBC-10.4 RBC-3.53* Hgb-10.8* Hct-32.1* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt Ct-134* [2192-2-25] 04:16AM BLOOD WBC-8.2 RBC-3.32* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.4 Plt Ct-126* [2192-2-26] 05:30AM BLOOD Glucose-94 UreaN-43* Creat-1.2 Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 [2192-2-25] 04:16AM BLOOD Glucose-81 UreaN-44* Creat-1.0 Na-140 K-3.3 Cl-102 HCO3-26 AnGap-15 [2192-2-24] 08:36PM BLOOD Glucose-162* UreaN-48* Creat-1.1 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-17 TTE [2192-2-20] PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. POST-CPB: On infusion of phentylephrine. AV pacing for slow sinus rhythm. Preserved biventricular systolic function. MR remains 1+. No AI. Aortic contour is normal post decannulation. [2192-2-20] TTE Exploration for Bleeding. 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. There is no sign of tamponade physiolo9gy. [2192-2-26] 05:30AM BLOOD WBC-10.4 RBC-3.53* Hgb-10.8* Hct-32.1* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt Ct-134* [2192-2-27] 04:30AM BLOOD UreaN-39* Creat-1.2 Na-140 K-4.8 Cl-103 Brief Hospital Course: Mr. [Known lastname 91857] was admitted under cardiology and underwent cardiac catheterization which showed total occlusion of the proximal LAD, 70% proximal LCx lesion, 40% prox RCA lesion, and 50% RPDA lesion, with right to left collaterals. He remained chest pain free after cardiac catheterization. Cardiac surgery was consulted and routine preoperative evaluation was performed. Given his recent Plavix dose, surgery was delayed for several days. On [2-20], Dr. [Last Name (STitle) ] performed three vessel coronary artery bypass with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. She had increasing amount of chest tube drainage in the first 2 hours after surgery totaling nearly 1 liter in 2 hours and hence, he was taken back to the Operating Room for exploration. He was hemodynamically stable with no signs of tamponade. There was a large amount of old clot and blood in the mediastinum as well as in the left pleura. After this was cleared, all the surgical sites were inspected. No sign of any surgical site bleeding was found and the bleeding was thought to be due to the Plavix which he was on preoperatively. He was kept intubated on POD 1 and ventilator and vasoactive support was weaned. POD 2 found the patient extubated to BIPAP. He was aggressively diuresed with Lasix three times a day. He had several days on BIPAP and when taken off and desaturated quickly. He was weaned from BIPAP on POD 4 to nasal canula and progressed well from a respiratory standpoint. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. He went into a rapid atrial fibrillation and was started on an Amiodarone drip. He converted to sinus rhythm and remained in sinus for the remainder of his hospital course. 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 8 the patient was ambulating freely, the wounds were 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: Neurontin 300 mg twice daily Plavix 75 mg daily Lipitor 80 mg daily Atenolol 50 mg daily Celexa 20mg daily was taking for over 1yr but stopped taking this [Month (only) ] Motrin 600mg prn back pain Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks. Disp:14 Tablet, ER Particles/Crystals(s) Refills:0 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg (two tablets) twice a day for two weeks, then 200mg(one tablet twice a day for two weeks then 200mg daily(one tablet) until directed to stop. Disp:120 Tablet(s) Refills:2 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day as needed for shortness of breath or wheezing for 4 weeks. Disp:1 Refills:1 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease noninsulin dependent diabetes mellitus Hypertension Hyperlipidemia Cervical disc disease Sciatica Depression Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait and walker Incisional pain managed with oral medications 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) ]([Telephone/Fax (1) 170]) on [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2192-3-28] 1:00 in the [Hospital ] medical office building [Doctor First Name ] [Hospital Unit Name ] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 12997] in [5-17] weeks ([Telephone/Fax (1) 86132]) Cardiologist: Dr. [Last Name (STitle) ] will call with appointment 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:[2192-2-28]	[ "41401", "42731", "2851", "25000", "4019", "311", "2724", "V5861" ]
Admission Date: [2147-7-24] Discharge Date: [2147-7-28] Date of Birth: [2124-11-2] Sex: F Service: ADMISSION DIAGNOSES: 1. Upper gastrointestinal bleed. 2. History of pulmonary embolus. 3. History of deep vein thrombosis. 4. Morbid obesity, status post gastric bypass surgery. 5. Asthma. 6. Hypertension. 7. Migraine headaches. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Blood loss anemia. 3. History of pulmonary embolus. 4. History of deep vein thrombosis. 5. Morbid obesity, status post gastric bypass surgery. 6. Asthma. 7. Hypertension. 8. Migraine headaches. HISTORY OF PRESENT ILLNESS: The patient is a 22 year old female who underwent an open gastric bypass on [2147-7-5], at [Hospital6 1708] for morbid obesity. The patient had a relatively uneventful postoperative course. Approximately seven to ten days ago, she was diagnosed with pulmonary embolism and was readmitted to the [Hospital6 8866] and started on anticoagulation. The patient was discharged on Lovenox and Coumadin. On the day of admission, her INR was found to be 4.1. The patient was advised to skip her dose of Coumadin where she was monitored. On the same day, the patient felt some epigastric pain and had four episodes of coffee ground emesis. Notably, she also had two black stools. The patient presented to the Emergency Department at [Hospital1 69]. Initially when the patient presented, her hematocrit was 35.5 and as noted, her INR was 4.1. The patient was admitted and started on gastrointestinal bleed protocol and started on intravenous Protonix, given fresh frozen plasma to reverse her anticoagulation and had plans to follow her coagulation studies. The patient was admitted initially to the Medicine service. PHYSICAL EXAMINATION: Notably on her admission examination, temperature was 98.8, heart rate 124, blood pressure 150/80, respiratory rate 16, oxygen saturation 99% in room air. She was alert and oriented in no acute distress. Sclera were anicteric. The oropharynx was without erythema. The neck was supple without adenopathy. The lungs were clear bilaterally. The heart was tachycardic but it was normal in rhythm with S1 and S2 and no murmurs, rubs or gallops. The abdomen was soft, tender in the epigastrium, midline incision was well healed. LABORATORY DATA: As noted previously. HOSPITAL COURSE: The patient was admitted to the Medicine service and underwent an endoscopy by Gastroenterology which showed some blood which could have been secondary to an ulcer or at staple line. The patient had serial hematocrit levels followed as noted previously. Her next hematocrit after the initial one drawn dropped to 27.6. The patient was transfused with two units of blood and also given fresh frozen plasma as previously noted for this. The patient remained on the Internal Medicine service but was subsequently transferred over to surgery where her conservative management continued with proton pump inhibitors, intravenous fluids, and serial hematocrit checks. Essentially the patient's course subsequent to her initial episode of bleeding was unremarkable. She no longer had any episodes of bleed and her hematocrit stabilized between 26.0 and 27.0. She underwent placement of a temporary inferior vena cava filter which was without complications for her history of deep vein thrombosis and as the patient could no longer be anticoagulated. She tolerated the procedure well. Again, as noted, the patient was transferred to the surgery service where conservative management with keeping her NPO and following serial hematocrit checks continued. By hospital day number five, the patient was started on a diet and was able to take a Stage III diet without any difficulty. Her hematocrit was stable and last recorded at 27.9. Her coagulation studies had returned to within normal limits. IT was determined the patient should follow-up for endoscopy with gastroenterology in five days and also follow-up with Dr. [Last Name (STitle) ] next week. She was discharged to home in good condition on Zantac Elixir, take 10 mg p.o. twice a day. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[Last Name (NamePattern1) 13262] MEDQUIST36 D: [2147-7-28] 18:05 T: [2147-7-29] 14:23 JOB#: [Job Number 22788]	[ "4019", "49390" ]
Admission Date: [2122-5-19] Discharge Date: [2122-6-12] Date of Birth: [2051-10-4] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Tape Attending:[Last Name (NamePattern4) 290] Chief Complaint: cc: Respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This 70 year old female with a history of COPD with trach, HTN, and CAD was transfered from [Hospital1 ] with difficulty breathing/broncospasm. She was noted to have elevated PIP (40s), HR 110-120, BP 166/73, given Lasix/Morphine for presumed COPD exacerbation and transfered to [Hospital1 18]. Here she was treated with Albuterol/Atrovent nebs and IV Solumedrol. She had been initially admitted to [Hospital1 18] on [2122-4-11] after transfer from [Location (un) 60966] for failure to wean. She had a tracheostomy and G-tube placement. Her course was complicated by MAT, steroid induced hyperglycemia, bronchitis, and c.diff colitis. Past Medical History: 1. [Name (NI) 3672] Pt has had COPD for 10 to 15 years. She has required multiple intubation inthe last 5 years. 2. HTN 3. CAD 4. GERD 5. S/P TIAs 6. S/P vertebral fractures 7. Osteopenia Social History: Pt is married and lives with her husband, she comes from [Name (NI) ] at this time. He is her primary care giver. They have seven children who are very involved. She quit smoking 20 years ago after smoking 1 PPD for many years. Occasional ETOH. No drugs. Family History: [Name (NI) 1094] father had a CVA at age 38. Her mother died from complications of ovarian cancer. Physical Exam: VS General alert, responsive trached patient in NAD HEENT Pupils unequal, reactive Pertinent Results: [2122-5-19] 11:00PM BLOOD WBC-18.8# RBC-3.19 Hgb-10.0* Hct-29.1* MCV-91 MCH-31.4 MCHC-34.4 RDW-14.7 Plt Ct-307# [2122-5-19] 11:00PM BLOOD Neuts-89.5* Lymphs-7.1* Monos-2.8 Eos-0.3 Baso-0.2 [2122-5-19] 11:00PM BLOOD PT-11.8 PTT-28.3 INR(PT)-0.9 [2122-5-19] 11:00PM BLOOD Plt Ct-307# [2122-5-24] 04:46AM BLOOD Fibrino-269 [2122-5-19] 11:00PM BLOOD Glucose-129* UreaN-33* Creat-1.0 Na-129* K-5.3* Cl-90* HCO3-29 AnGap-15 [2122-5-19] 11:00PM BLOOD ALT-17 AST-18 LD(LDH)-285* CK(CPK)-29 AlkPhos-69 Amylase-38 TotBili-0.4 [2122-5-19] 11:00PM BLOOD Lipase-27 [2122-5-20] 08:08AM BLOOD CK-MB-2 cTropnT-0.01 proBNP-9437* [2122-5-19] 11:00PM BLOOD Albumin-3.4 Calcium-8.7 Phos-6.0# Mg-1.7 [2122-5-24] 04:46AM BLOOD calTIBC-192 VitB12-667 Folate-15.4 Ferritn-854* TRF-148* [2122-5-23] 05:18PM BLOOD Vanco-55.7* [2122-5-19] 10:53PM BLOOD Type-ART pO2-472* pCO2-62* pH-7.31* calHCO3-33* Base XS-3 [2122-5-19] 10:53PM BLOOD Glucose-140* Lactate-1.0 Na-127* K-5.6* Cl-91* [2122-5-23] 10:13AM BLOOD TRYPTASE-Test Brief Hospital Course: 1. Respiratory failure - This 70 year old female with severe COPD s/p trach was transfered from Rehab with respiratory failure most likely secondary to COPD exacerbation. Her respiratory failure was felt to be most likely bronchospastic secondary to severe COPD and superimposed infection. She might also have some component of fluid overload. She was started on broad spectrum antibiotics given high risk since she was coming from a nursing home. She was started on Vancomycin for possible MRSA and Zosyn for broad coverage including Pseudomonas. On [5-20] she grew Stenotrophomonas in her sputum and Timentin was added for coverage. On [5-26] the Zosyn was discontinued, the Vanco was discontinued once a 14 day course was complete. The Timentin was continued for a 5 day course. Throughout her hospital stay attempts were made to wean her off the ventilator. She was able to tolerate pressure support however every occasion when the PEEP was decreased below 8 she had episodes of desaturation and respiratory difficulty. On [5-22] a bronchoscopy was performed on which she was noted to have posterior membrane collapse on exalation with agitation. Numerous further attempts to wean her off the ventilator were unsuccessful. She was continued on steroids and nebs as treatment for her COPD. In addition she was treated briefly with IV Aminophyline which she tolerated without complication. Based upon this she was started on PO Theophyline which was titrated up to obtain levels between 8 and 12. She was also diuresed aggressively for possible fluid overload as a cause of increased respiratory failure. On [5-27] she began to have copious bloody secretions per her trachostomy. These were initially felt to be due to trauma and it they were monitored. These bloody secretions continued for several days and repeat CXR showed increased nodular densities. Given concern for vasculitis vs. trauma vs. other cause of hemoptysis. On [5-29] a bronchoscopy was performed which showed diffuse oozing blood in all airways, no focal bleeding source. Otherwise the airways were normal and BAL was performed. A chest CT was also performed which showed bilateral upper love consolidation with nodular opacification. She was briefly treated with Voriconazole and cyclophosphamide with concern for fungal infection vs. vasculitis. These were d/cd given low clinical suspicion as well as a normal ESR and CRP. It was felt that the most likely cause of bleeding was still trauma for suctioning and the frequency of suctioning was decreased. Pt continued to be intubated, in discussion with family, her code status was changed to comfort measures only and she was started on a morphine drip. Pt died on [6-12] from respiratory failure. . 2. Hypotension - She had some hypotension post diuresis which resolved with fluid. She had no further hypotension on admission. Her blood pressure was monitored closely. . 3. Throughout admission she had episodes of tachycardia, diaphoresis, hypertension, and hypoxia. These episodes were felt to be due to agitation. However other possible causes were ruled out. A Triptase was normal indicating no allergic reaction. Her pain was controlled with morphine. Psychiatry was involved in controlling her agitation. They felt that she might have some level of delerium and held all benzos. In addition she was weaned off her Paxil, however she seemed more depressed and it was restarted. She was treated with Haldol as needed for agitation. She was continued on calcium channel blockers for tachycardia. - Urine Metanephrines pending to evaluate for pheo. 5HIAA pending to evaluate for carcinoid. . 4. C.diff - On admission she had just completed a course of PO Vanco for C.diff. A repeat sample was sent for c.diff assay which was negative. She was monitored for diarrhea given the inititation of antibiotics, and had no further diarrhea. . 5. Klebsiella UTI (based on cultures from [Hospital1 ] - [5-8]). She was treated with Zosyn on admission which covered the Klebsiella UTI. Repeat urine cultures here were negative. 6. She had some Hyponatremia on admission which resolved with NS IV fluid. 7. CAD/HTN - She was continued on Diltiazem for a.fib and BP control. Her Captopril was D/Cd on admission given hypotension. . 8. Anemia. Her HCT dropped at which time she was noted to have some guiaic positive stool. NG lavage was negative. She will need colonoscopy/EGD once active issues resolved. Her HCT was also noted to be dropping at the time of the bloody hemoptysis. Her HCTs were checked [Hospital1 ] and she was transfused to keep her HCT greater than 30. . 9. Access - On this admission a second PICC line was placed as her single lumen PICC on the left was inadequate for IV antibiotics and her multiple other IV medications. . 10. FEN - She was continued on tube feeds via her g-tube on this admission. Her lytes were repleted as needed. . 11. PPx - She was treated with Heparin SC for DVT prophylaxis. She was also treated with a PPI. 13. Social work and Case Management were involved in her care and further dispo. 14. Code: DNR 15. Rt LE swelling - LENIs were performed for some LE swelling, they were negative for DVT. Medications on Admission: Seroquel, Zanax, Pulmicort, Oscal, Capoten, Cardizem, [Doctor First Name ], Heparin SC, Atrovent, Prevacid, Xopenex, Mg Oxide, Vit D, RISS, Reglan, MVI, Paxil, Simethicone, Cefotaxime, Vanco PO (just completed course) Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2122-11-26]	[ "51881", "486", "2875", "25000", "4019", "41401", "53081" ]
Admission Date: [2114-3-26] Discharge Date: [2114-4-19] Date of Birth: [2037-3-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: constipation w/ inability to void- developed chest pain in ER Major Surgical or Invasive Procedure: [2114-4-2] urgent CABG x2 (LIMA to LAD, SVG to PDA) [2114-4-11] PEG [2114-4-16] Trach History of Present Illness: 76M h/o Diabetes, HTN, hypercholesterolemia, h/o CVA, elevated PSA, on warfarin arrives with 5 days of inability to void and 7day h/o constipation. Poor historian with reported poor follow up history in chart and unclear about what meds he takes at home. Tried suppositories and laxatives without effect initially but then states that he had small BM yesterday at home. Last colonoscopy was over 10 yrs ago per pt. Arrived in ED because he states Dr. [Last Name (STitle) 5717] was not in office - he mainly arrives with c/o urinary retention. Of note, it appears that he was on flomax in past and has been referred to urology for w/u with elevated PSA around 6, but he states he is no longer taking this med. He also failed to f/u with urology for prostate bx. Denies abd pain, n/v, or any other sx. In ED, vitals were 98.8, 57, 124/61, 16, 97% RA. KUB consistant with constipation, no stool in rectum. Foley was placed and urine relieved. Given enema with another small BM, pt states that now his bowels are relieved. Labs notable for Cr 1.5 (baseline 1.1), Na slightly elevated to 146 c/w dehydration. On transfer from ED to floor, pt was comfortable, without pain, and only concerned for urinary retention. During the course of his hospitalization, he experienced chest pain and shortness of breath. His pain was reported to radiate from to his throat and resolved with sublingual nitroglycerin and oxygen administration. ECG demonstrated LBBB with ST depressions in II and AVF which resolved. CE Tn 0.02 -> 0.08 -> 0.14. CK 174 -> 178 -> 138. Cardiac cath deferred until INR decreased from 3.3. He was clopidogrel loaded with 300mg. Cardiac cath demonstrated severe 3 vessel CAD with single remaining vessel with 90% left main supplying LAD and collateralized RCA. PCI deferred for surgical evaluation. On arrival to the CCU the patient is resting comfortably. He currently denies shortness of breath, lower extremity edema, PND or orthopnea. He denies palpitations, lightheadedness, dizziness or syncope. All other review of systems were negative. Cardiac cath done [3-29] with 3VD and referred for surgery. Past Medical History: HTN; hypercholesterolemia; type 2 DM since [2095], insulin-requiring prior TIA [2096]; L MCA CVA with expressive aphasia [7-/2104]; seizure disorder; chronic warfarin anticoagulation; ? RHM Social History: [1-27] ppd x 20 yrs no etoh. Lives at home with wife. Retired school Spanish teacher. Family History: Noncontributory Physical Exam: 66" 74.8 kg VS - Temp 98.1, BP 146/64, HR 88, R 22, O2-sat 92% 2L GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear 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 MRG, nl S1-S2 ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - Warm well profused, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-30] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . CCU admission exam: VS: T 97.7, HR 59, BP 145/60, RR 16, O2 100% RA. General: well-appearing in NAD Neck: no carotid bruits, flat JVP CV: RRR, nl S1/S2, no MRG Resp: CTAB, no W/R/R Abd: soft, NT/ND, NABS Ext: no edema, 2+ PT/DP Neuro: A&Ox3, speech spontaneous with mild expressive aphasia Pertinent Results: [2114-3-26] 11:39AM BLOOD WBC-10.6 RBC-4.46* Hgb-13.5* Hct-40.3 MCV-90 MCH-30.2 MCHC-33.4 RDW-13.7 Plt Ct-176 [2114-3-26] 11:39AM BLOOD PT-35.2* PTT-30.0 INR(PT)-3.6* [2114-3-26] 11:39AM BLOOD Glucose-84 UreaN-33* Creat-1.5* Na-146* K-4.1 Cl-105 HCO3-31 AnGap-14 [2114-3-28] 01:10PM BLOOD CK(CPK)-126 [2114-3-28] 05:46AM BLOOD CK(CPK)-138 [2114-3-27] 07:15PM BLOOD CK(CPK)-178 [2114-3-27] 10:06AM BLOOD ALT-18 AST-26 LD(LDH)-163 CK(CPK)-174 AlkPhos-58 TotBili-0.7 [2114-3-28] 01:10PM BLOOD CK-MB-5 cTropnT-0.11* [2114-3-28] 05:46AM BLOOD CK-MB-6 cTropnT-0.14* [2114-3-27] 07:15PM BLOOD CK-MB-7 cTropnT-0.08* [2114-3-27] 10:06AM BLOOD CK-MB-5 cTropnT-0.02* [2114-3-26] 11:39AM BLOOD PSA-10.9* COMPARISON: [2109-10-11]. FINDINGS: Evaluation is limited due to diffuse bowel gas. Within these limitations, the liver shows no focal or textural abnormalities. There are gallstones, but no evidence of acute cholecystitis. Incidental note is made of several tiny probable cholesterol polyps. Pancreas is completely obscured by bowel gas. Spleen is not well visualized. The right kidney measures 11.4 cm, left kidney measures 13.8 cm. Though partially obscured by bowel gas, neither kidney shows evidence of stone or solid mass. Abdominal aorta is obscured by bowel gas. Main portal vein is patent, with appropriate antegrade flow. IMPRESSION: Limited exam due to diffuse bowel gas. Cholelithiasis, without evidence of cholecystitis. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5718] DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: WED [2114-3-28] 9:28 AM Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. 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. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results on [Known lastname 5719] before surgical incision POST-BYPASS: Patient is AV paced and receiving an infusion of epinephrine and milrinone. LVEF = 35%. RV function is normal. Mild mitral regurgitation present. Aorta is intact post decannulation. Dr [Last Name (STitle) ] aware of post bypass findings. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD, Interpreting physician [Last Name (NamePattern4) ] [2114-4-3] 16:03 [2114-4-19] 02:22AM BLOOD WBC-9.1 RBC-2.96* Hgb-8.6* Hct-26.3* MCV-89 MCH-28.9 MCHC-32.6 RDW-15.1 Plt Ct-224 [2114-3-26] 11:39AM BLOOD WBC-10.6 RBC-4.46* Hgb-13.5* Hct-40.3 MCV-90 MCH-30.2 MCHC-33.4 RDW-13.7 Plt Ct-176 [2114-4-19] 02:22AM BLOOD PT-14.5* PTT-63.3* INR(PT)-1.3* [2114-3-26] 11:39AM BLOOD PT-35.2* PTT-30.0 INR(PT)-3.6* [2114-4-19] 02:22AM BLOOD Glucose-105* UreaN-62* Creat-1.8* Na-136 K-5.0 Cl-100 HCO3-29 AnGap-12 [2114-3-26] 11:39AM BLOOD Glucose-84 UreaN-33* Creat-1.5* Na-146* K-4.1 Cl-105 HCO3-31 AnGap-14 [2114-4-16] 02:58AM BLOOD ALT-52* AST-48* LD(LDH)-371* AlkPhos-84 Amylase-36 TotBili-0.3 [2114-3-27] 10:06AM BLOOD ALT-18 AST-26 LD(LDH)-163 CK(CPK)-174 AlkPhos-58 TotBili-0.7 Brief Hospital Course: Mr. [Known lastname 5719] was admitted to the [Hospital1 18] on [2114-3-26] for further management of his non-ST-elevation myocardial infarction. He was taken to the cardiac catheterization lab and found severe three vessel disease. Given the severity of his disease, the cardiac surgical service was [Date Range 4221] and he was worked-up in the usual preoperative manner. The urology service was [Date Range 4221] as he had recent progression of his voiding difficulty over last week. He was on flomax in the past and seen by urology for irregularly nodular prostate concerning for cancer, but he never followed-up for biopsy. He had an elevated PSA 6.7 in [2112-6-26] and now 10.9 although may be falsely elevated due to urinary retention and foley placement. It was recommended that his foley in and followup in clinic for further evaluation. Flomax was resumed. On [2114-4-1] Mr. [Known lastname 5719] was subsequently transferred to the CCU where he had chest pain, initially controlled on nitro drip and subsequently developed angina refractory to nitroglycerin and morphine. The cardiac surgical service was called and he went emergently to the operating room where he underwent coronary artery bypass grafting to two vessels on [2114-4-2]. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, diminished right arm and bilateral leg movement was noted. The neurology service was [Date Range 4221] and a CT scan was performed which showed No acute intracranial hemorrhage or edema but sequelae of remote left MCA territory infarct was noted. Aspirin and statin were recommended and started along with betablockade and diuresis. An MRI was performed that showed wide spread cortical areas of restricted diffusion involving all lobes, and more extensive cortical and subcortical areas of restricted diffusion within the left occipital lobe and bilateral cerebellar hemispheres, are compatible with laminar necrosis and acute embolic disease. Heparin was started with bridge to coumadin. The vascular surgery service was [Date Range 4221] for ischemic fingers and recommended topical nitrates and to continue heparin for likely microemolic events. He was extubated on POD#2 but required re-intubation due to impaired gag and inability to clear secretions. He was started on broad spectrum IV antibiotics for GNR in sputum and +U/A. Chest tubes and pacing wires were removed per protocol on POD#3. The general surgery service was [Date Range 4221] for placement of a PEG feeding tube for long term nutrition. PICC line was placed under floroscopy w/ tip in upper SVC on [2114-4-8]. He developed atrial fibrillation which was treated w/ betablocker and amio- he is now in SR. On [2114-4-11] percutaneous endoscopic gastrostomy tube placement was performed. As he continued to have Respiratory failure on mechanical ventilation with questionable aspiration pneumonia requiring almost daily bronchosocopy for secretion management, the thoracic surgery service was [Date Range 4221] for placement of a tracheostomy. This was performed on [2114-4-16] along with rigid bronchoscopy, flexible bronchoscopy and therapeutic aspiration of tracheobronchial tree. On [2114-4-15] Mr. [Known lastname 5719] suffered a respiratory arrest from presumed mucous plugging. He was successfully resusitated. During the course of his hopsitalization Mr. [Known lastname 5719] developed an unstageable pressure ulcer on his coccyx maesuring 4x4 cm for which the wound care nurse [First Name (Titles) ] [Last Name (Titles) 4221]. A Mepilex sacral border dressing was applied. Neurologically he remains able to move upper extremities but has no lower extremity function. He continued to work with physical therapy and occupational therapy. He is currently tolerating trach mask for greater than 24hrs. Antibiotics were stopped on [2114-4-17] after subsequent negative culture data. Vancomycin was initiated [4-19] for a 7 day course prophylactically for his right lower extremity incision site which appears mildly erythematous. On [4-19] per Dr.[Last Name (STitle) ], Mr. [Known lastname 5719] was cleared for discharge to rehabilitation. All follow up appointments were advised. Medications on Admission: OUTPATIENT MEDICATIONS: NPH insulin 6 units [Hospital1 ] regular insulin 6 units [Hospital1 ] ( did not use sliding scale or do BG checks) Aspirin 325 mg PO/NG DAILY Atenolol 25 mg PO/NG DAILY Atorvastatin 40 mg PO/NG DAILY Aluminum-Magnesium Hydrox.-Simethicone prn Lactulose 30 mL PO/NG TID Omeprazole 40 mg PO DAILY Senna 1 TAB PO/NG [Hospital1 ] Tamsulosin 0.4 mg PO HS Docusate Sodium 100 mg PO BID . MEDICATIONS ON TRANSFER: Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Insulin SC (per Insulin Flowsheet) Lactulose 30 mL PO/NG TID Acetaminophen 650 mg PO/NG Q6H Lisinopril 20 mg PO/NG DAILY Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN Nitroglycerin SL 0.3 mg SL PRN CP Aspirin 325 mg PO/NG DAILY Omeprazole 40 mg PO DAILY Atorvastatin 80 mg PO/NG DAILY Atenolol 25 mg PO/NG DAILY Senna 1 TAB PO/NG [Hospital1 ] Bisacodyl 10 mg PO DAILY Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Docusate Sodium 100 mg PO BID Tamsulosin 0.4 mg PO HS . ALLERGIES: NKDA . Discharge Medications: 1. Acetaminophen 650 mg/20.3 mL Solution [Hospital1 ]: One (1) Solution PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Ten (10) mls PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension [Hospital1 ]: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. Atorvastatin 80 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Hospital1 ]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 11. Metoclopramide 5 mg/mL Solution [Last Name (STitle) ]: One (1) Injection Q6H (every 6 hours) as needed for nausea/vomiting. 12. Amiodarone 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily): 400mg x 7days then decrease to 200mg daily ongoing. 13. Warfarin 1 mg Tablet [Last Name (STitle) ]: as directed for afib Tablet PO once a day: based on INR for afib- INR goal 2-2.5. 14. picc line care Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 15. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO ONCE (Once) for 1 doses. Tablet(s) 16. Vancomycin 1000 mg IV Q 24H x 7 days->DC after dose on [2114-4-28] 17. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Year (4 digits) ]: One (1) Intravenous continuous as needed for AFib: 1800 units/hour to be adjusted for PTT goal 50-70, INR goal>2.0. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen [Year (4 digits) ]: One (1) Subcutaneous every six (6) hours: As per Sliding Scale. 19. Insulin Glargine 100 unit/mL Cartridge [Year (4 digits) ]: One (1) Subcutaneous twice a day: 30 units Q AM/ 15 units Q PM. Discharge Disposition: Extended Care Facility: [Hospital1 ] Hsopital Discharge Diagnosis: CAD s/p urgent CABG x2 NSTEMI BPH IDDM hypercholesterolemia Left MCA CVA [7-/2104] Acute postoperative stroke expressive aphasia prior TIA [2096] seizure disorder ? RHM Respiratory arrest/Respiratory failure Discharge Condition: stable alert, lethargic-grimaces to pain -unable to determine extent of orientation further due to impaired communication transfers via [Doctor Last Name ]. 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: Please call to schedule appointments Surgeon Dr. [First Name4 (NamePattern1) ] [5-7] @ 1:00 PM [Telephone/Fax (1) 170] Primary Care /cardiologist Dr. [Last Name (STitle) 5717] in [1-27] weeks or upon discharge [Hospital 5720] rehab. Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2114-4-19**]	[ "41071", "51881", "5070", "5849", "2760", "5990", "5180", "5119", "25000", "4019", "2720", "V5861", "42731" ]
Admission Date: [2158-4-6] Discharge Date: [2158-4-10] Date of Birth: [2090-9-12] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 922] Chief Complaint: Increasing fatigue Major Surgical or Invasive Procedure: [2158-4-6] Mitral valve replacement with a 33-mm St. [Male First Name (un) 923] Epic bioprosthesis. Resection of left atrial appendage. History of Present Illness: 67 year old female with known mitral valve prolapse and moderate to severe mitral regurgitation who presents today for surgical evaluation for possible mitral valve repair vs replacement. The patient is asymptomatic except for a brief single episode of chest discomfort accompanied by dyspnea. Cath showed clean coronaries. Referred for Mitral Valve Replacement. Past Medical History: Mitral Valve Regurgitation/Prolapse Osteopenia Depression Migraines Multiple syncopal events 12-13 years ago Dyslipidemia s/p D&C x several times for bleeding fibroids s/p breast implants Tubal ligation Social History: Race:Caucasian Last Dental Exam:last week Lives with:Widowed Occupation:Retired car sales Tobacco:Never ETOH:2 glasses of wine/day Family History: father died of cerebral hemorrhage at 62 Physical Exam: Pulse:68 reg Resp: O2 sat: B/P Right:126/77 Left: 128/80 Height:5'4" Weight:138# General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiates to apex and carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]- no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left:2+ Carotid Bruit : murmur radiates bilat. Pertinent Results: [2158-4-6] Echo: Pre-bypass: The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is moderate/severe mitral valve prolapse. An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. There was trace tricuspid regurgitation initially, but the patient developed atrial fibrillation and tricuspid regurgitation to 2+. Post-bypass: The patient is not receiving inotropic support post-CPB. There is a bioprosthetic valve well-seated in the mitral position with good leaflet excursion. Immediately post-bypass there was trace paravalvular and transvalvular regurgitation. The paravalvular regurgitation was no longer seen after protamine administration. The trace transvalvular regurgitation persisted and is eccentric with an anteriorly dirrected jet. The mean transvalvular gradient was 4 mm Hg with a cardiac output of 3.7 L/min. Left ventricular systolic function is moderately depressed (LVEF 30-39%). Right ventricular function similar to prebypass function. All other findings consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings discussed with Dr. [Last Name (STitle) 914] at the time of the exam. [2158-4-9] 09:45AM BLOOD WBC-11.0 RBC-2.91* Hgb-9.0* Hct-26.5* MCV-91 MCH-31.1 MCHC-34.1 RDW-12.9 Plt Ct-169 [2158-4-6] 11:00AM BLOOD WBC-9.0# RBC-2.31# Hgb-6.9# Hct-20.1# MCV-87 MCH-30.0 MCHC-34.5 RDW-12.0 Plt Ct-106# [2158-4-9] 09:45AM BLOOD PT-19.9* INR(PT)-1.8* [2158-4-6] 11:00AM BLOOD PT-16.4* PTT-42.3* INR(PT)-1.5* [2158-4-9] 09:45AM BLOOD Glucose-176* UreaN-15 Creat-0.7 Na-135 K-3.7 Cl-101 HCO3-27 AnGap-11 [2158-4-7] 03:12AM BLOOD Glucose-113* UreaN-12 Creat-0.5 Na-135 K-4.5 Cl-107 HCO3-23 AnGap-10 [2158-4-10] 06:55AM BLOOD PT-27.6* INR(PT)-2.7* Brief Hospital Course: Ms. [Known lastname 110096] was a same day admit and on [4-6] she was brought to the operating room where she underwent a mitral valve replacement. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable but critical condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated without difficulty. Post-operatively she had episodes of atrial fibrillation and received beta-blockers and Amiodarone. She was started on Coumadin and dosage titrated for therapeutic INR >2.0 for atrial fibrillation. On post-op day one she appeared to be doing well and was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Beta-Blocker/Statin/Aspirin/diuresis was intitiated. Physical therapy was consulted for strength and mobility evaluation. Ms.[Known lastname 110096] continued to progress and was cleared by Dr.[Last Name (STitle) 914] for discharge to home on POD# 4. Her INR/Coumadin dosing will be followed by her PCP, [Last Name (NamePattern4) ].[Last Name (STitle) ]. Follow up appointments were advised. Medications on Admission: ASA 81 mg daily MVI daily Fosamax 70 mg q SUNDAY Fluoxetine 20 mg daily Atenolol50 mg daily Calcium 1500 mg daily Vit. D daily simvastatin 20 mg daily ibuprofen prn ( none in past week) clindamycin prn dental proc Discharge Medications: 1. Aspirin 81 mg [Last Name (STitle) 8426], Delayed Release (E.C.) Sig: One (1) [Last Name (STitle) 8426], Delayed Release (E.C.) PO DAILY (Daily). Disp:60 [Last Name (STitle) 8426], Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Amiodarone 200 mg [Last Name (STitle) 8426] Sig: Two (2) [Last Name (STitle) 8426] PO BID (2 times a day). Disp:120 [Last Name (STitle) 8426](s) Refills:2 4. Warfarin 1 mg [Last Name (STitle) 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] Once Daily at 4 PM: INR goal >2.0. Disp:90 [Last Name (Titles) 8426](s) Refills:2 5. Furosemide 20 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO Q12H (every 12 hours) for 5 days. Disp:10 [Last Name (Titles) 8426](s) Refills:0 6. Potassium Chloride 10 mEq [Last Name (Titles) 8426] Sustained Release Sig: One (1) [Last Name (Titles) 8426] Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:10 [Last Name (Titles) 8426] Sustained Release(s) Refills:0 7. Ranitidine HCl 150 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO BID (2 times a day). Disp:60 [Last Name (Titles) 8426](s) Refills:2 8. Hydromorphone 2 mg [Last Name (Titles) 8426] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 [Last Name (Titles) 8426](s) Refills:0 9. Simvastatin 10 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO DAILY (Daily). Disp:60 [Last Name (Titles) 8426](s) Refills:2 10. Alendronate 70 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO QSUN (every Sunday). Disp:30 [Last Name (Titles) 8426](s) Refills:2 11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 12. Calcium Carbonate 500 mg [Last Name (Titles) 8426], Chewable Sig: Three (3) [Last Name (Titles) 8426], Chewable PO DAILY (Daily). Disp:90 [Last Name (Titles) 8426], Chewable(s) Refills:2 13. Cholecalciferol (Vitamin D3) 400 unit [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO DAILY (Daily). Disp:60 [Last Name (Titles) 8426](s) Refills:2 14. Ferrous Sulfate 300 mg (60 mg Iron) [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO DAILY (Daily). Disp:30 [Last Name (Titles) 8426](s) Refills:2 15. Metoprolol Tartrate 25 mg [Last Name (Titles) 8426] Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 [Last Name (Titles) 8426](s) Refills:2 16. Warfarin 1 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: [Location (un) 2203] VNA Discharge Diagnosis: Mitral Valve Regurgitation/Prolapse s/p Mitral Valve Replacement Past medical history: Osteopenia Depression Migraines Multiple syncopal events 12-13 years ago Dyslipidemia s/p D&C x several times for bleeding fibroids s/p breast implants Tubal ligation Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [Last Name (STitle) 914] in [5-9], at 1:45pm ([Telephone/Fax (1) 170]) Primary Care Dr. [First Name4 (NamePattern1) 17728] [Last Name (NamePattern1) ] in [2-11] weeks #[Telephone/Fax (1) 17465] *VNA to draw INR [2158-4-11] and call to Dr.[Last Name (STitle) ] for Coumadin dosing. INR goal >2.0 for Atrial fibrillation x 2months.#[Telephone/Fax (1) 17465] Cardiologist Dr. [First Name8 (NamePattern2) 19118] [Last Name (NamePattern1) 23705] in [2-11] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will Completed by:[2158-4-10**]	[ "4240", "311", "42731", "2875", "2859" ]
Admission Date: [2125-7-9] Discharge Date: [2125-7-18] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: failure to thrive Major Surgical or Invasive Procedure: [2125-7-11] percutaneous endoscopic gastrostomy tube [2125-7-17] [Month/Day/Year ], sphincterotomy, gallstone extraction, stent removal History of Present Illness: This 85M was recently admitted for cholangitis, and is now s/p percutaneous cholecystostomy tube, s/p [Month/Day/Year ]/stent, s/p trach. His hospital course was complicated by MRSA PNA and E.coli bacteremia, diarrhea (presumed to be C.diff, for which he was discharged on Flagyl), and acute gout flair. He was discharged to rehab on [2125-6-22]. He self d/c'd his Dobhoff and was transferred back to [Hospital1 18] for PEG placement as well as persistent fevers to 102. Past Medical History: 1. CAD, cath 5 years ago at NEBH (cardiologist [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) 2. CHF, TTE [3-5] w/depressed EF 3. Hypertension, per daughter pt's bp usually 90s-100s on meds 4. Severe lumbar spinal stenosis, mild cervical stenosis 5. Sleep apnea, on 2L home O2 at night 6. Afib, s/p failed DCCV, now rate controlled 7. Arthritis 8. Gout 9. COPD 10. NIDDM 11. E-coli sepsis (admission [2122-12-23] - [2123-1-1]) 12. BPH 13. Parkinson's disease 14. Cholangitis s/p percutaneous cholecystostomy tube & [Month/Day/Year ]/stent ([2125-5-16]) 15. s/p tracheostomy ([2125-5-28]) 16. diverticulosis, h/o diverticulitis & ulcers 17. s/p I&D R elbow 18. s/p excision of facial skin ca Social History: Transferred from [Hospital 100] Rehab. Formerly lived with daughter [Name (NI) 13118]. Widowed. No tobacco/EtOH. Formerly worked at Sears. Family History: Notable for CAD, HTN, and stroke. Physical Exam: On admission: 98.9 93 Afib 91/53 14 99% CMV Gen: ventilated, NAD HEENT: trach in position [Name (NI) ]: intubated, clear bilaterally CVS: irregularly irregular, -MRG Abd: soft/NT/ND, no masses, no rebound/guarding apparent Ext: mild edema diffusely . On discharge: 96.5 79 114/76 22 98%RA Gen: NAD CVS: RRR [Name (NI) ]: CTA b/l Abd: soft, NT, ND, +BS Ext: no c/c/e Pertinent Results: On admission: [2125-7-9] 06:00PM BLOOD WBC-14.1# RBC-2.68 Hgb-7.9* Hct-25.0* MCV-93 MCH-29.5 MCHC-31.6 RDW-17.9* Plt Ct-472* [2125-7-9] 06:00PM BLOOD PT-16.1* PTT-52.4* INR(PT)-1.4* [2125-7-9] 06:00PM BLOOD Glucose-348* UreaN-73* Creat-1.4* Na-143 K-3.3 Cl-107 HCO3-26 AnGap-13 [2125-7-9] 06:00PM BLOOD ALT-7 AST-6 AlkPhos-58 TotBili-0.3 [2125-7-9] 06:00PM BLOOD Lipase-12 [2125-7-9] 06:00PM BLOOD Albumin-2.3* Calcium-8.2* Phos-4.1 Mg-1.6 [2125-7-9] 8:33 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST: FINDINGS: There are small bibasilar effusions and associated atelectasis. No focal consolidation. Coronary artery calcifications are seen within an enlarged heart. There is no pericardial effusion. ABDOMEN: Again seen is pneumobilia, with an indwelling biliary stent in place, unchanged in position. A left hepatic lobe cyst measuring 3.1 x 3.9 cm is unchanged. There is a small gallstone within a decompressed gallbladder. There is no biliary dilatation. The spleen, pancreas, and adrenal glands are normal in appearance. The kidneys are somewhat atrophic; however, there is symmetric excretion of contrast. Multiple cysts, right side more so than left, some of which are slightly increased in density and likely reflect hemorrhagic/proteinaceous cysts. PELVIS: The bowel is decompressed, without dilated loop. There are air- fluid levels within the colon; however, there is no bowel wall thickening or surrounding stranding. Numerous diverticula are seen within the sigmoid colon, without inflammatory changes. A Foley catheter is present within a decompressed bladder. Atherosclerotic calcifications are again seen throughout. Extensive degenerative changes of the thoracolumbar spine without acute findings. IMPRESSION: 1. No abscess within the abdomen or pelvis, as clinically questioned. No bowel wall thickening or abnormality, aside from colonic fluid and diverticulosis. 2. Small bibasilar pleural effusions and adjacent atelectasis. [2125-7-10] 02:00AM BLOOD Phenyto-0.6* [2125-7-10] 02:00AM BLOOD Vanco-13.7 [2125-7-10] 02:00AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.030 [2125-7-10] 02:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2125-7-10] 02:00AM URINE RBC-0-2 WBC-[7-10]* Bacteri-RARE Yeast-MOD Epi-0-2 TransE-0-2 [2125-7-10] 2:00 AM URINE CULTURE (Final [2125-7-11]): YEAST. >100,000 ORGANISMS/ML.. [2125-7-14] 11:41 AM URINE CULTURE (Final [2125-7-15]): YEAST. >100,000 ORGANISMS/ML.. [2125-7-17] [Month/Day/Year ]: -A plastic stent previusly placed in the biliary duct was found in the major papilla and was removed using a snare. -Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. -Cholangiogram showed a CBD diamter of 11 mm with 2 mobile filling defects consistent with stones. -A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. -2 stones were extracted successfully using a 11 mm balloon. The duct was cleared with an occlusion cholangiogram. On discharge: [2125-7-16] 06:40AM BLOOD PT-14.0* PTT-46.5* INR(PT)-1.2* [2125-7-16] 06:40AM BLOOD Glucose-137* UreaN-44* Creat-0.7 Na-138 K-5.1 Cl-106 HCO3-26 AnGap-11 [2125-7-16] 06:40AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.4 [2125-7-18] 04:29AM BLOOD WBC-17.0* RBC-3.17* Hgb-9.4* Hct-30.4* MCV-96 MCH-29.5 MCHC-30.8* RDW-19.6* Plt Ct-390 [2125-7-18] 04:29AM BLOOD ALT-5 AST-13 AlkPhos-82 Amylase-120* TotBili-0.6 [2125-7-18] 04:29AM BLOOD Lipase-29 Brief Hospital Course: Patient was admitted to TSICU. WBC was 14. He was started on vancomycin for his h/o MRSA PNA. CT abdomen/pelvis failed to demonstrate abscess or bowel wall thickening/abnormalities. His biliary system was unchanged in appearance. Blood cultures were drawn and were negative. Urine culture grew yeast. He was hydrated and his WBC decreased to WNL. Vancomycin was d/c'd on HD 3. PEG was placed at bedside on HD 3. Tube feeds were started on HD 4. On HD 5, he was decannulated. Rheumatology was consulted for gout management and recommended Solumedrol followed by a prednisone taper, colchicine, allopurinol, and outpatient followup. His WBC increased; he was started on fluconazole for the yeast in his urine on HD 6. It was stable x 3 days at ~17 on discharge. On HD 7, he was transferred to the floor. On HD 8, Speech & Swallow cleared him for pureed solids and nectar thickened liquids. On HD 9, he underwent [Month/Day/Year ] for stent removal with extraction of 2 gallstones and sphincterotomy. The following morning, he was restarted on clears and tube feeds and advanced as tolerated. His LFTs were WNL. He was afebrile with stable vital signs, tolerating tube feeds and diet, and his pain was well controlled on PO medication. He is being discharged to [Hospital1 ] and will follow up with Dr. [First Name (STitle) ] (Rheumatology) and Dr. [Last Name (STitle) ]. Medications on Admission: Discharge Medications ([2125-6-22]): 1. Metronidazole 500 mg Tablet [Month/Day/Year ]: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:21 Tablet(s) Refills:0 2. Colchicine 0.6 mg Tablet [Month/Day/Year ]: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Coumadin 3 mg Tablet [Month/Day/Year ]: One (1) Tablet PO once a day: goal INR [3-4] Dose daily. Disp:30 Tablet(s) Refills:2 4. Carbidopa-Levodopa 25-100 mg Tablet [Month/Day (3) ]: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (3) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (3) ]: Ten (10) ml PO BID (2 times a day). Disp:600 ml Refills:2 7. Bacitracin Zinc 500 unit/g Ointment [Month/Day (3) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:2 8. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 9. Digoxin 125 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Trazodone 50 mg Tablet [Hospital1 ]: 1.5 Tablets PO HS (at bedtime) as needed. Disp:60 Tablet(s) Refills:0 11. Indomethacin 25 mg Capsule [Hospital1 ]: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:2 12. Fentanyl 75 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 13. Chlorhexidine Gluconate 0.12 % Mouthwash [Hospital1 ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day): Use only if patient is on mechanical ventilation. Disp:400 ML(s) Refills:0 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 15. Latanoprost 0.005 % Drops [Last Name (STitle) ]: One (1) Drop Ophthalmic HS (at bedtime). Disp:20 ml Refills:2 16. Ipratropium Bromide 17 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation QID (4 times a day). Disp:1 unit Refills:2 17. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours). Disp:500 ml Refills:2 18. Levothyroxine Sodium 50 mcg IV DAILY 19. Albuterol 90 mcg/Actuation Aerosol [Age over 90 ]: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:1 unit Refills:2 20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Age over 90 ]: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours) as needed for pain for 7 days. Disp:7 Adhesive Patch, Medicated(s) Refills:0 21. Lorazepam 0.5 mg Tablet [Age over 90 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 22. Bupropion 75 mg Tablet [Age over 90 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 23. Erythromycin 5 mg/g Ointment [Age over 90 ]: 0.5 in Ophthalmic QID (4 times a day). Disp:60 in Refills:2 24. Metoprolol Tartrate 5 mg IV Q6H:PRN AFIB / RVR 25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 26. Furosemide 40 mg Tablet [Age over 90 ]: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 27. Enoxaparin 100 mg/mL Syringe [Age over 90 ]: One Hundred (100) mg Subcutaneous Q 12H (Every 12 Hours): until therapeutic on coumadin (INR [3-4]) then may d/c lovenox. Disp:25 syringes Refills:2 Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr [Month/Day (3) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Enoxaparin 100 mg/mL Syringe [Month/Day (3) ]: One (1) ml Subcutaneous Q12H (every 12 hours). 3. Albuterol 90 mcg/Actuation Aerosol [Month/Day (3) ]: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Month/Day (3) ]: One (1) Adhesive Patch, Medicated Topical QDAILY (). 5. Carbidopa-Levodopa 25-100 mg Tablet [Month/Day (3) ]: One (1) Tablet PO TID (3 times a day). 6. Colchicine 0.6 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 7. Bupropion 75 mg Tablet [Month/Day (3) ]: One (1) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: Five (5) ML PO Q4H (every 4 hours) as needed for pain. 10. Digoxin 125 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Fluconazole 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 12. Colchicine 0.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Allopurinol 300 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Prednisone 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily) for 3 days: [Date range (1) 24818]. 15. Prednisone 10 mg Tablet [Date range (1) ]: Three (3) Tablet PO DAILY (Daily) for 3 days: [Date range (1) 40196]. 16. Prednisone 20 mg Tablet [Date range (1) ]: One (1) Tablet PO DAILY (Daily) for 3 days: [Date range (1) 20648]. 17. Prednisone 10 mg Tablet [Date range (1) ]: One (1) Tablet PO DAILY (Daily) for 3 days: [Date range (1) 40197]. 18. Prednisone 5 mg Tablet [Date range (1) ]: One (1) Tablet PO DAILY (Daily) for 3 days: [Date range (1) 17392]. 19. Prednisone Taper prednisone 40' x 3, 30' x 3, 20' x 3, 10' x 3, 5' x 3; colchicine 0.6 QOD until f/u at Rheum, allopurinol 300' titrated as outpt, f/u with Dr. [First Name (STitle) ] in 4 wks 20. Ipratropium Bromide 0.02 % Solution [First Name (STitle) ]: One (1) neg Inhalation Q6H (every 6 hours). 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 22. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN breakthorugh pain 23. Insulin NPH Human Recomb 100 unit/mL Suspension [First Name (STitle) ]: Twenty (20) units Subcutaneous twice a day. 24. insulin sliding scale check fingersticks q4h glucose regular insulin dose 0-70 mg/dL [1-31] amp D50 71-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 6 Units 161-180 mg/dL 9 Units 181-200 mg/dL 12 Units 201-220 mg/dL 15 Units 221-240 mg/dL 18 Units 241-260 mg/dL 21 Units 261-280 mg/dL 24 Units 281-300 mg/dL 27 Units 301-320 mg/dL 30 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: primary: failure to thrive . secondary: CAD s/p cath, CHF, HTN, severe lumbar spinal stenosis, mild cervical spinal stenosis, sleep apnea, atrial fibrillation, arthritis, gout, COPD, NIDDM, E.coli sepsis, MRSA PNA, E.coli bacteremia, BPH, Parkinson's disease, cholangitis s/p [Hospital1 ]/stent & percutaneous cholecystostomy tube, s/p tracheostomy, diverticulosis, h/o diverticulitis, s/p I&D R elbow, s/p excision of facial skin ca Discharge Condition: Afebrile, vital signs stable, tolerating tube feeds & pureed solids/nectar thickened liquids, pain well controlled on PO medication. Discharge Instructions: Please call your doctor or return to the emergency room if you have 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. * 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. Followup Instructions: Please call Dr.[Name (NI) ] office at ([Telephone/Fax (1) 2047] to schedule a follow up appointment in [3-4] weeks. . Provider: [First Name11 (Name Pattern1) 2890] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2125-8-15] 2:45 Completed by:[2125-7-18]	[ "41401", "4280", "4019", "32723", "42731", "496", "25000" ]
Admission Date: [2172-3-30] Discharge Date: [2172-4-2] Service: CCU HISTORY OF PRESENT ILLNESS: This is a 79-year-old female with a past medical history significant for coronary artery disease, status post myocardial infarction in [2172-4-4], osteoporosis, cataracts, asthma, osteoarthritis, who presented to the Emergency Department from rehabilitation after being found unresponsive. She was reportedly not using her left arm, and had left neglect, at which time the physician left the room for help, and when he returned, the patient was on the floor suffering from left-sided tonic-clonic seizure activity. The patient did not syncopize per report. According to the patient, she recalls having indigestion, vomited bile, she denied headache, dizziness, palpitations, shortness of breath. She did not recall falling, denied fainting in the past. She had no other complaints. PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Asthma. 3. Coronary artery disease status post myocardial infarction in [2169-4-5]. 4. Osteoporosis. 5. Cataracts. ALLERGIES: Penicillin. MEDICATIONS: 1. Albuterol metered dose inhaler. 2. Atrovent metered dose inhaler. 3. Fluticasone 2 puffs b.i.d. 3. Theophylline 300 mg b.i.d. 4. Aspirin 81 mg p.o. q.d. 5. Colace p.r.n. 6. Levaquin 500 p.o. q.d. [3-28] to [4-3]. 7. Indocin 25 mg p.o. q. 8 hours [3-28] to [4-3]. SOCIAL HISTORY: At nursing home rehabilitation, previously lived alone in [Location (un) 4628]. PHYSICAL EXAMINATION: Vital signs showed a fingerstick of 131, blood pressure 123-153/45-69, 100% on one liter nasal cannula, respiratory rate 15, heart rate in the 40s. In general she was lying in bed, pleasant in no apparent distress. HEENT: Pupils were equal, round, and reactive to light, extraocular movements intact, no nystagmus, oropharynx was clear with symmetric palate elevation. Neck: Jugular venous pressure was irregular due to AV dissociation, supple. Cardiovascular: There was a 2-3/6 systolic ejection murmur at the left and right sternal borders, no rubs or gallops. Lungs: Decreased breath sounds at the left base, occasional crackles in the bases bilaterally. Abdomen: Active bowel sounds, soft, nontender, nondistended, no organomegaly. Extremities: No edema. Mental status: Alert to month, year, not place, stated she was in [Location (un) ] at rehabilitation. Neurologic: Examination was nonfocal. Palate raised symmetrically. There was 3+/5 strength in the intrinsic hand muscles on the left; 4+/5 on the right intrinsic hand muscles. Upper and lower extremity strength was [6-8] bilaterally and symmetric. Nonfocal examination, no facial asymmetry, no word-finding difficulty, no pronator drift. LABORATORY DATA: On admission white count was 8.3, hematocrit 31.9, baseline 31.[2169-12-9], platelet count 559, MCV 81, neutrophils 69%, bands 0%, lymphocytes 14%, monocytes 6%. INR was 1.1. PTT 27.3, PT 12.8. Sodium 127, down from baseline 135, potassium 4.7, chloride 89, bicarbonate 23, BUN 11, creatinine 1, glucose 116, CK 135, CK MB 2, troponin less than 0.3. Head CT without contrast showed no intracranial hemorrhage, no mass effect, a large foci versus small infarction in the right occipital lobe, lacunar infarct in the left basal ganglia region. EKG showed complete heart block, ventricular rate of 61, atrial rate of 90, normal axis, QTC 454, QRS 86. Carotid ultrasound from [2169-8-5] showed mild 60-65% stenosis proximal left right coronary artery, no hemodynamically significant plaque in the right bulb or proximal internal carotid artery. HOSPITAL COURSE: The patient is a 79-year-old woman with a history of coronary artery disease status post myocardial infarction. She was admitted after an episode of emesis, left-sided neglect and seizure activity who was found to be in complete heart block. The patient was noted to be hemodynamically stable during the time in the Emergency Department with systolic blood pressures in the 120s to 150s and a ventricular rate ranging from the 40s to the 60s, without any evidence of distress. Since it couldn't be determined as to whether the patient had complete heart block as the cause of a possible global ischemia leading to the unmasking of a focal brain lesion leading to the one-sided deficit, the patient was transferred to the coronary care unit for a temporary transvenous wire pacer placement. This was done on the evening of admission. The patient had a right internal jugular placed for this purpose and the transvenous wire was placed into the right ventricle without difficulties. The patient was monitored overnight, and did not have any hemodynamic instability requiring the pacer to be utilized. In the meantime, AV nodal blocking agents including phenytoin were avoided. The patient had an EKG done the following morning and had a transthoracic echocardiogram. The transthoracic echocardiogram demonstrated a left ventricular ejection fraction of greater than 55%, a sclerotic aortic valve, and some trace mitral regurgitation. It was noted that this may be underestimated due to cardiac echo shadows during the examination. On the 25th the patient was taken for pacemaker implantation. The patient had a DDD pacer placed, model 5370, serial #[Serial Number 99285], serial lot #[Serial Number 99286]. The patient withstood the procedure without difficulty, and subsequent to pacer placement, had a chest x-ray which demonstrated the leads to be in the appropriate position. The pacer was interrogated and found to be in good working condition. Subsequent to pacer placement, the patient's heart rate elevated to the 80s and 90s, and her systolic blood pressure was consistently in the 140s to 160s. Thus it was determined in the setting of this new hypertension, the patient was initiated on a beta blocker on [4-2]. She was started on atenolol 25 q.d. As for the potential seizure, neurology was consulted in the Emergency Department. It was determined that the complete heart block would take precedence over the possible neurological event. As stated previously on admission, a CT of the head did not demonstrate any new evidence of infarct or bleed, and even in the Emergency Department there was no evidence of left-sided neglect, and only possible mild decreased strength in the intrinsic hand muscles on the left, otherwise her examination was nonfocal. She was scheduled for an EEG. Due to the evidence of possible lacunar infarcts in the past in addition to a possible transient ischemic attack which could have explained the brief period of left-sided neglect as well as seizure activity, it was determined to start the patient on pravastatin 20 mg q.d. since the patient was likely at risk for microvascular disease, especially in light of her previous myocardial infarction. A lipid panel was sent, and demonstrated levels within normal limits such as triglycerides 83, HDL 51 and LDL 96. Of course it may be slightly depressed in the setting of an acute event. The patient also had carotid Dopplers performed, at this time the final [Location (un) 1131] is not available, but suggested that there was still significant plaque in the left internal carotid artery with narrowing of approximately 60-69%, but no significant plaques in the right internal carotid artery. There was also normal antegrade flow in the vertebral arteries. Any further neurological work-up was deferred as an outpatient. Also in this setting there was concern that the hyponatremia, if it occurred rapidly, could have also played a role in her seizure activity. But her baseline sodium had previously been low, approximately 135. Urine and electrolytes were sent and a TSH was sent, though it was assumed that the patient had recently had a few days of Lasix in the past and may have just been volume depleted. She was thus given normal saline with appropriate correction of her sodium to the mid-130s. For her asthma the patient was continued on the Flovent metered dose inhalers b.i.d., albuterol and Atrovent p.r.n., and her theophylline was held briefly due to mildly elevated theophylline. It was reinitiated at discharge. The patient was then discharged back to rehabilitation after being deemed unsafe to return home by physical therapy and occupational therapy. DISCHARGE DIAGNOSES: 1. Third degree heart block status post DDD pacemaker placement. 2. Transient ischemic attack versus seizure. FOLLOW-UP APPOINTMENT: Device clinic on [4-13], 9:30 AM; and with primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1270]. DISCHARGE MEDICATIONS: 1. Atenolol 25 mg p.o. q.d. 2. Cepacol lozenges p.r.n. 3. Pravastatin 20 mg p.o. q.d. 4. Levofloxacin 250 mg p.o. x 1 day. 5. Dipyridamole aspirin one capsule b.i.d. 6. Tylenol p.r.n. 7. Fluticasone 2 puffs b.i.d. 8. Albuterol metered dose inhaler and Atrovent metered dose inhaler p.r.n. 9. Aspirin 81 mg p.o. q.d. 10. Theophylline 300 mg b.i.d. 11. Colace 100 mg b.i.d. p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12175], M.D. [MD Number(1) 37596] Dictated By:[Name8 (MD) 8876] MEDQUIST36 D: [2172-4-2] 12:26 T: [2172-4-2] 12:38 JOB#: [Job Number 99287]	[ "2761", "41401", "4019", "49390" ]
Admission Date: [2113-9-15] Discharge Date: [2113-9-27] Date of Birth: [2032-3-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2113-9-15] Strangulated right inguinal hernia repair,primary, with ileocolectomy and lysis of adhesions [2113-9-15] bedside exploratory laparotomy, Small bowel resection, discontinuous [2113-9-15] Left chest tube thoracostomy [2113-9-17] Exploratory laparotomy, enteroenterostomy and delayed primary closure. History of Present Illness: This patient is a 81 year old male with a h/o CAD, HTN, right sided inguinal hernia. 1 hour after eating lunch had midepig/perimb pain, with NBNB emesis. BM this AM - normal, none since Past Medical History: PMH Hypertension right inguinal hernia CAD depression vitaligo PSH THR Social History: Lives alone, supportive family ETOH none Tobacco remote Family History: non contributory Physical Exam: PE: 97.9 85 140/99 16 100% RA AAOx3 NAD, however did vomit infront of me - chunks of food and some bile RRR CTAB Mildly firm and distended R scrotum - large RIH - non-reducible - feels like it contains bowel, no erythema, moderately tender no edema, extrem warm no masses guaiac negative Pertinent Results: [2113-9-14] 08:50PM WBC-9.4# RBC-4.96 HGB-14.6 HCT-43.6 MCV-88 MCH-29.4 MCHC-33.5 RDW-16.4* [2113-9-14] 08:50PM NEUTS-89.3* LYMPHS-6.7* MONOS-2.3 EOS-1.3 BASOS-0.4 [2113-9-14] 08:50PM PLT COUNT-113* [2113-9-14] 08:50PM ALBUMIN-4.4 [2113-9-14] 08:50PM ALT(SGPT)-29 AST(SGOT)-33 ALK PHOS-60 [2113-9-14] 08:50PM GLUCOSE-173* UREA N-24* CREAT-1.3* SODIUM-139 POTASSIUM-2.9* CHLORIDE-99 TOTAL CO2-21* ANION GAP-22* [2113-9-15] 06:30AM WBC-7.3 RBC-2.01# HGB-6.0# HCT-18.2# MCV-91 MCH-30.0 MCHC-33.1 RDW-17.0 [2113-9-14] KUB : No radiographic evidence for obstruction. Please note, given the paucity of bowel gas, dilated loops of fluid-filled bowel are not excluded. No free air. [2113-9-16] TTE : Normal biventricular systolic function, small pericardial effusion with no evidence of tamponade physiology. Moderately dilated right ventricle [2113-9-16] Head CT : No acute intracranial process. Brief Hospital Course: Mr. [Known lastname 101787] was evaluated by the Acute Care service in the Emergency Room and based on exam and xray had an incarcerated right inguinal hernia and surgery was recommended emergently. The patient refused and due to the urgent circumstances a Psychiatric consult was obtained to clarify his competency. In the meantime his family talked with him and together they decided surgery was in his best interest. He was taken to the Operating Room on [2113-9-15] and underwent repair of a strangulated right inguinal hernia with ileocolectomy and lysis of adhesions. he tolerated the procedure well and returned to the ICU in stable condition. He remained intubated and sedated. Soon thereafter he developed elevated bladder pressures, a decreasing hematocrit and some hypotension requiring bedside exploratory laparotomy with resection of some necrotic small bowel with subsequent discontinuity. He was resuscitated with IV fluids and blood and his lowest hematocrit was 24. He also developed a left pneumothorax following central line placement requiring chest tube placement with complete re-expansion of the lung. Over the next 48 hours he maintained stable hemodynamics but did remain intubated and sedated. On [2113-9-17] he was taken back to the Operating Room for a washout, enteroenterostomy and delayed primary closure. He tolerated that procedure well and again returned to the ICU in stable condition. He remained intubated for 3 additional days and eventually was successfully extubated on [2113-9-20]. He underwent vigorous chest PT and incentive spirometry and remained free of any other pulmonary complications. For a short time he was enterally fed however as his bowel function returned he was able to gradually advance to a regular diet. He needs cueing and help at this point with feeding and will gladly take protein supplements. His hematocrit was stable in the 28 range for days but on [2113-9-24] it gradually decreased and eventually he developed melena without any other symptoms. On [2113-9-25] his hematocrit was 23.6 and he was transfused with 2 units of packed red blood cells. He felt better and his melena stopped. Subsequent hematocrits were >30. He was having normal formed bowel movements from that point on. He is still guiac positive but his stools are formed, brown and his hematocrit today is 33. He was evaluated by the Physical Therapy service and found to be very deconditioned and in need of a short term rehab prior to his return home. After a complicated course he was discharged on [2113-9-27]. Medications on Admission: Questran 1 packet [Hospital1 ] Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital - [Location (un) 86] Discharge Diagnosis: Strangulated right inguinal hernia with bowel obstruction. Postoperative bleeding and small bowel necrosis Acute blood loss anemia Left pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital for repair of your strangulated hernia. Your surgery was complicated by bleeding which required a second operation with removal of part of your small bowel. The bowel was not reconnected due to swelling. You ultimately required a 3rd operation to put the bowel back together and close the incision. * Despite a long difficult course , you have recovered well. * In order to get you back home we are sending you to a short term rehab so that you may work on Physical Therapy, eat a bit more and get stronger. * You need to follow up with the surgeon in [12-21] weeks or earlier if any new symptoms develop. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [12-21] weeks. Completed by:[2113-9-27]	[ "2851", "2762", "4019", "41401", "311", "2449" ]
Admission Date: [2116-12-7] Discharge Date: [2116-12-11] Date of Birth: Sex: F Service: PRINCIPAL DIAGNOSIS: Stroke. MAJOR PROCEDURES: Magnetic resonance imaging scan of brain, angiogram of head and neck. HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 46636] was an 82 year old woman with hypertension, diabetes, hypercholesterolemia and osteoarthritis who developed left-sided weakness and progressive nasal quality to her voice. She was evaluated initially at an outside hospital two days prior to admission with similar symptoms. She was then seen at [Hospital6 1760] Emergency Room on [2116-12-6], where she was presented with weakness, decreased palatal movements, and left hemiparesis. Magnetic resonance imaging scan revealed a right paramedian basis pontis and upper medulla stroke as well as basilar artery stenosis. Conventional angiogram showed multifocal stenosis of the left vertebral artery and a 5 mm aneurysm arising from the anterior communicating artery was incidentally found. In the course of her admission to the Intensive Care Unit, Mr. [Known lastname 46636] developed progressive weakness which involved the right as well as the left side. Follow up magnetic resonance imaging scan revealed extension with brain stem stroke attributed to basilar stenosis. Her quadriparesis was associated with profound palatal weakness and inability to clear secretions. In a family meeting Ms [Known lastname 46636] wishes about intubation were discussed and it was clear that she did not wish to be intubated or resuscitated. As per patient's and her relatives decision, she was made DNR/DNI. Because of her extensive brainstem damage, she gradually decreased her respiratory rate. She then passed away confortably on [2116-12-11], at 0132 hours. CONDITION ON DISCHARGE: Deceased. DR [First Name (STitle) 725] [Name (STitle) 726] 13.268 Dictated By:[Name8 (MD) 22618] MEDQUIST36 D: [2117-10-6] 18:13 T: [2117-10-6] 20:18 JOB#: [Job Number 46637]	[ "25000", "4019", "2720" ]
Admission Date: [2142-7-25] Discharge Date: [2142-8-1] Date of Birth: [2103-6-18] Sex: F Service: Primary care physician: [Name10 (NameIs) 7158] [Last Name (NamePattern4) 7159], M.D. CODE STATUS: Full code CHIEF COMPLAINT: Fever HISTORY OF PRESENT ILLNESS: A 39-year-old female with human immunodeficiency virus, last CD4 count of 400 two months ago in [2142-5-12] presents with four days of fever to 104??????, chills, nausea and diarrhea, also with multiple other complaints, intermittent abdominal pain, myalgias, arthralgias and headache, but these are classified as chronic according to the patient. The patient also says that her diarrhea is chronic. The patient presented on [2142-7-24] to [Hospital6 1708] where an abdominal CT was obtained which was negative and blood cultures were drawn in the Emergency Department. The patient was then discharged. Today, a report from [Hospital6 15291] is 1 of 4 blood cultures positive for gram positive cocci. In the Emergency Department here, two additional sets of blood cultures were sent and the patient was started on vancomycin and gentamicin. The patient also has end stage renal disease on hemodialysis Mondays, Wednesdays and Fridays. The patient had a fistulogram of the left upper extremity AV graft with angioplasty six days ago. The patient missed last hemodialysis prior to admission because she felt too sick to leave home. Patient's nephrologist is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. PAST MEDICAL HISTORY: 1. Human immunodeficiency virus positive, viral load less than 50, CD4 408 in [2142-5-12]. 2. End stage renal disease on hemodialysis Monday, Wednesday and Friday. Etiology human immunodeficiency virus or hypertensive nephropathy. 3. PPD positive, status post one year of INH, negative chest x-ray 4. B12 deficiency 5. Chronic diarrhea of unknown etiology 6. Clostridium difficile positivity in [2139], but subsequently Clostridium difficile negative 7. Depression 8. History pneumococcal sepsis in [2134] 9. Anemia secondary to hyperparathyroidism 10. Thrombocytopenia 11. Coronary catheter in [2140] which showed clean coronary arteries ALLERGIES: 1. AMPHOTERICIN LEADS TO SHAKING. 2. DILAUDID 3. PERCOCET 4. VIRACEPT SOCIAL HISTORY: No history of alcohol, tobacco or drug use. She is currently single, daughter entering college. No travel history, no sick contacts, born in [Country 2045]. Presumed contraction of human immunodeficiency virus through heterosexual contact. PHYSICAL EXAM: VITAL SIGNS: Initially temperature of 104.0??????, blood pressure 124/70, pulse of 100, respirations of 20, 98% on room air. Vital signs at time of examination after Tylenol and antibiotics - temperature 100.0??????, blood pressure 110/68, pulse 108, respiratory rate 16, saturating 98% on room air. GENERAL: Alert, pleasant, appears uncomfortable, rigors occasionally. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Mucous membranes dry. Extraocular movements intact. NECK: Supple, no meningismus. PULMONARY: Clear to auscultation bilaterally. CARDIOVASCULAR: Tachycardic, positive flow murmur, normal S1, S2. ABDOMEN: Soft, mildly tender right lower quadrant and left lower quadrant. No rebound or guarding. Positive bowel sounds. EXTREMITIES: 2+ peripheral pulses, no cyanosis, clubbing or edema. Left upper extremity fistula with a bruit and thrill. NEUROLOGIC: Alert and oriented x3. Strength .......... sensation not tested. INITIAL LABS: Sodium 134, potassium 5.1 moderately hemolyzed, chloride 96, bicarbonate 14, BUN 81, creatinine 17.2, glucose 181, calcium 9.7. White count 3.4, 81% neutrophils, 14% lymphocytes, 4% monocytes, hematocrit 31.0, platelets 133. PT of 13.9, INR of 1.3. IMAGING: Chest x-ray done in Emergency Department showed a small left effusion, no consolidation, mild vascular engorgement. HOSPITAL COURSE: Seen after admission to [Hospital3 ], the patient complained of her typical migraine headache, photophobia headache, nausea, developed [9-20] substernal chest pain and complained of throbbing pain on the left upper extremity AV graft. The patient also developed shaking chills and desaturation on room air to 87%. The patient was taken to emergent hemodialysis where a Quinton catheter was placed. Arterial blood gas was performed showing a mixed respiratory alkalosis and metabolic acidosis. The patient was then transferred to the Medical Intensive Care Unit for observation or further treatment. The patient's blood cultures in the Emergency Department came back [3-15] positive for coagulase positive Staphylococcus aureus and the patient was continued on vancomycin and gentamicin in the Medical Intensive Care Unit. The patient was evaluated by surgery and had AV graft removal in the Operating Room where a hematoma was seen and graft was sent for culture. The patient also had a PPE performed which showed severe mitral regurgitation, good left ventricular ejection fraction and a small density on the mitral valve that was suspicious for a vegetative lesion. The patient remained hemodynamically stable in the Medical Intensive Care Unit and was restarted on her HAART while continuing vancomycin and gentamicin until [2142-7-27] at which point she was transferred to the floor for further medical treatment. What follows is her hospital course from [7-27] onward. Cardiovascular: The patient's antihypertensive medications were stopped initially, as the patient was hypotensive during acute sepsis with blood pressures down to 120s/70s. After receiving vancomycin and gentamicin, the patient's blood pressures had been returning to normal hypertensive values. The patient was initially restarted on enalapril 5 mg po bid titrated up to 10 mg po bid. As blood pressures kept coming up, the patient was restarted on labetalol 400 mg po bid. The patient will be discharged on usual cardiac medications at home. The patient was taken off telemetry after coming back from the Medical Intensive Care Unit. She had been complaining of chest pain during her acute septic episode, but has not been complaining of chest pain ever since transfer from the Medical Intensive Care Unit. Serial ECGs had revealed no ST changes in the Medical Intensive Care Unit and pericardiac catheter showed clean coronary arteries, making ischemic cause of her chest pain highly unlikely. The patient received TEE on the [7-27] which showed severe mitral regurgitation from a prolapsed leaflet. No vegetation seen. No pericardial effusion seen. Trace aortic insufficiency. Ejection fraction normal. The patient had a [3-17] holosystolic murmur radiating to the axilla which did not change throughout hospital course. 2. Pulmonary: Soon after transfer to the Medical Intensive Care Unit, the patient developed new wheezing and dry crackles. The patient's O2 saturations were consistently above 90 initially on 2 liters per nasal cannula, but eventually weaned off of oxygen entirely with good O2 saturations. The patient's lung exam revealed crackles with prolonged expiratory phase, however no wheezing. The patient had a peak flow at bed side which showed peak flows between 300 and 400 which vary depending on patient effort. The patient had serial chest x-rays. On [7-24], chest x-ray showed no evidence of pneumonia, linear atelectasis of the left base. Chest x-ray on the 14th showed no acute cardiopulmonary disease. Chest x-ray on the 16th showed no evidence of congestive heart failure or pneumonia, unchanged from prior study. Chest x-ray on the 17th showed no acute cardiopulmonary disease, continued prominent vasculature consistent with mild congestive heart failure, but TCP could not be ruled. The patient's dry crackles, prolonged expiratory phase, gradually improved throughout hospital course. The patient was started on Robitussin DM for cough, has sputum collected for gram stain and culture and had gentle chest PT instituted with good response. 3. Renal: The patient has end stage renal disease requiring hemodialysis Monday, Wednesday, Friday. Hemodialysis regimen was continued in hospital. The patient's phosphate levels were found to be high and the patient was started on limited hydroxide suspension 30 ml po tid with meals and Renagel 2400 mg po tid. The patient's phosphate level dropped and limited hydroxide suspension was discontinued. The patient at no time developed symptoms of uremia throughout hospital course. It was believed that her crackles on lung exam and obstructive pattern may have been due to fluid overload and dialysis may have helped with improvement of her lung exam throughout hospital course. 4. Endocrine: The patient has secondary hyperparathyroidism and was in the work up process to have an neck exploration at surgery for parathyroid gland removal. The patient was scheduled to have thyroid ultrasound on day of discharge. Neck surgery should be postponed until antibiotic course of six weeks has finished. 5. Heme: The patient's anemia is presumably secondary to low erythropoietin level secondary to end stage renal disease. The patient was started on Epogen therapy in hospital 3500 units subcutaneous Monday, Wednesday and Friday. 6. Infectious disease: Patient with coagulase positive Staphylococcus aureus sepsis with infected AV graft as the presumed source. The patient ruled out for endocarditis by TEE. The patient was initially started on vancomycin and gentamicin therapy. Once sensitivities were received, the patient's gentamicin was discontinued. The vancomycin level was checked daily and was dosed to keep vancomycin level above 15 mcg per ml. Only set of positive blood cultures are from the day of admission. Surveillance blood cultures daily afterwards have been negative thus far. Tissue culture of the AV graft showed sparse coagulase positive Staphylococcus aureus growth. Stool cultures have thus far been, however on ova or parasites, few polymorphonuclear sites, no cyclosporin, no gastroesophageal reflux disease and no cryptosporidia, no Escherichia coli [Numeric Identifier 95089], nasogastric Clostridium difficile toxin, Campylobacter, Vibrio, Yersinia cultures are still negative thus far. 7. Gastrointestinal: The patient continued to have chronic diarrhea in the hospital. Clostridium difficile studies were negative. The patient complained of red blood on toilet paper x2, but patient was significantly guaiac negative. Hematocrit was stable throughout hospital course. Episode also complained of nausea which was controlled with Zofran and Ativan. 8. Prophylaxis: The patient was placed on proton pump inhibitor and was wearing Pneumo boots that hospital course. 9. Acces: AV graft was removed by surgery. The patient had Quinton catheters placed x2 for hemodialysis. Quinton catheter was eventually taken out once. PermCath was placed by interventional radiology without complication. DISCHARGE CONDITION: Good DISCHARGE STATUS: To home with outpatient primary care physician follow up, further hemodialysis, [Location (un) 4265] .......... with vancomycin dosing, hemodialysis for next six weeks. OUTPATIENT FOLLOW UP: Nephrology, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], attending DISCHARGE MEDICATIONS: 1. Aciclovir 200 mg po qd 2. Celexa 60 mg po qd 3. Clonidine patch 0.1 mg per hour q Saturday 4. Nephrocaps 1 qd 5. Ultram 50 to 100 mg po prn q 4 to 6 hours, no more than 400 mg in 24 hours 6. Omeprazole 20m g qd 17. Abacavir 300 mg po bid 18. Meperidine 25 mg tid to qid po prn 19. Efavirenz 600 mg po hs 20. Didanosine 125 mg po qd 21. Calcium acetate 1 tablet po tid 22. Vitamin B12 IM q month 23. Hytrin 5 mg po bid 24. Enalapril 10 mg po bid 25. Labetalol 800 mg po bid 26. Epoetin alpha 3500 units subcutaneous Monday, Wednesday, Friday 27. Vancomycin 500 mg to 1 gm intravenous with hemodialysis FUTURE TREATMENTS: Hemodialysis q Monday, Wednesday, Friday, vancomycin dosing at dialysis for next six weeks. DISCHARGE DIAGNOSES: 1. Gram positive sepsis 2. Human immunodeficiency virus 3. End stage renal disease 4. Anemia 5. Depression 6. Secondary hyperparathyroidism [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 568], M.D. [MD Number(1) 3808] Dictated By:[Doctor First Name 6677] MEDQUIST36 D: [2142-8-1] 10:26 T: [2142-8-1] 10:33 JOB#: [Job Number 95090]	[ "4280", "4240" ]
Admission Date: [2139-5-9] Discharge Date: [2139-5-21] Date of Birth: [2069-11-28] Sex: M Service: CCU CHIEF COMPLAINT: Respiratory failure. HISTORY OF PRESENT ILLNESS: Mr. [Known firstname ] [Known lastname ] is a 69-year-old previously healthy male who was transferred from an outside hospital for admission into the Medical Intensive Care Unit with the following primary problems; respiratory alkalosis, anion gap, metabolic acidosis, respiratory failure requiring intubation secondary to ventilatory fatigue, acute liver failure, and acute renal failure of unclear etiology. The history was obtained from two daughters; the patient was comatose at the time of presentation. One month ago, the patient was well walking roughly five miles per day. At that time he started complaining of exertional dyspnea and insomnia. His daughters described frequent weakness secondary to dyspnea and palpitations. He was seen at "urgent care" and diagnosed with anxiety. He was started on amitriptyline, lorazepam, and Tylenol PM. He also complained of coughing at that time and had a chest x-ray that was notable for a large heart and fluid. He was subsequently treated for pneumonia with a 10-day course of antibiotics and Combivent for one week. Three weeks prior to presentation, he returned to urgent care with a chief complaint of "thrush," but he was told he did not have pneumonia (per radiologist read of a chest x-ray), but he did have cardiomegaly; and, again "fluid in his lungs." At that time, Lasix was started. He saw Pulmonary on [4-28] where he had abnormal pulmonary function tests and an arterial blood gas as follows: 7.44/32/76 on room air. The patient was felt to have idiopathy pulmonary fibrosis. His daughters noted some slurred speech and tremors subsequent to that, and he was seen by his primary care physician four days prior to the current admission for an evaluation for profound exertional dyspnea. He was unable to go from chair to bed. His Lasix dose was increased, and over the past two to three days he has had continued worsening exertional dyspnea, increasing confusion, and disorientation. He coughed up some sputum. He was nauseated and had dry heaves for three, and he developed watery diarrhea and was started on p.r.n. Imodium. His daughters felt he was yellow three days ago and somewhat ashen-appearing today. The review of systems was also notable for an 18-pounds weight loss over the last four weeks. There is no history of intravenous drug use, recent travel, and the patient denies any sexual activity. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Esophageal stricture, status post multiple dilatations. MEDICATIONS ON ADMISSION: 1. Prilosec 20 mg p.o. q.d. 2. Paxil 20 mg p.o. q.d. 3. Combivent 2 puffs q.i.d. 4. Imodium AD p.r.n. 5. Amitriptyline 100 mg p.o. q.d. 6. Lorazepam 0.5 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone. He has 10 children. He is a widower since [2134]. One of his daughters died approximately one year after cocaine ingestion. She was the patient's primary care giver. The patient had a son who died in [2125] from human immunodeficiency virus/acquired immunodeficiency syndrome. The patient smokes one pack per day for the last 40 years. He is a former heavy alcohol drinker 30 years ago. He has been sober for the last 20 years. For the past 10 years he has had one drink per day. FAMILY HISTORY: The patient's family denies a family history of diabetes, hypertension, coronary artery disease, and cancer. Both of the patient's parents died in their 80s. HOSPITAL COURSE: (From [Hospital6 41256]) The patient presented intermittently apneic and tachypneic. An arterial blood gas there was as follows: 7.52/16/212 on 55% face mask. Subsequently, he went to 7.38/19/105. The patient was intubated for worsening ventilatory fatigue. His laboratories demonstrated acute renal failure with a creatinine of 2.2 (when it had been normal two weeks prior), and hepatitis transaminases in the 400s (climbing to greater than 1000 prior to transfer). A lactate level was 3.5, and TCA level was 550. An electrocardiogram demonstrated a wide QRS. On arrival here, he was hemodynamically stable, over-breathing the ventilatory, and unresponsive. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a blood pressure of 87/63, pulse of 77, oxygen saturation of 98%. Ventilator settings the patient was on were assist control, 14 X 700, with a positive end-expiratory pressure of 10, an FIO2 of 60, and arterial blood gas was 7.39/26/191. In general, intubated and comatose. Head, eyes, ears, nose, and throat revealed left pupil was 4 mm (down to 3 mm with light), the right was 3.5 mm (down to 3 mm). There was no blinking to threat, and there were absent corneal reflexes. The oropharynx was dry. Scleral icterus was noted. Chest had coarse breath sounds bilaterally. The cardiovascular examination was notable for distant heart sounds. The abdomen was soft, distended. There was flank dullness to percussion. The liver edge was 2 cm below the costal margin. The extremities showed 2+ pitting lower extremity edema and palmar erythema. The neurologic examination was as follows: the patient was comatose. The pupils were minimally reactive. There was no corneal reflex. There was withdraw to pain on the right but not on the left. The patellar reflexes were absent bilaterally. Babinski was upgoing bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data evaluated a white blood cell count of 11.6, hematocrit of 42, platelets of 185. The urinalysis showed large blood, negative nitrites, 30 protein, greater than 50 red blood cells, 6 to 10 white blood cells, many bacteria, and 6 to 10 hyaline casts. The PTT was 34.4. The PT was 19.1. INR was 2.5. SMA-7 revealed a sodium of 133, potassium of 5.4, chloride of 99, bicarbonate of 18, blood urea nitrogen of 89, creatinine of 2.9, and glucose of 141. The creatine kinase was 375 (it had been 158 and then 221). Alkaline phosphatase was 122, magnesium of 3.1, total bilirubin of 2.8, albumin of 3.8, calcium of 8.7, phosphorous of 9. Troponin was less than 0.4. The serum toxicology screen was negative except for TCA, and the urine toxicology screen was negative. The TCA level at [Hospital6 41256] was 550. The ALT was 1784, and the AST was 3065. RADIOLOGY/IMAGING: A CT of the head was suggestive of pontine stroke. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for management of multiple medical problems including comatose state of unclear etiology, worsening exertional dyspnea requiring intubation, evolving acute liver failure, and new acute renal failure of unclear etiology. In the Intensive Care Unit, the patient underwent a magnetic resonance imaging after the head CT suggested a pontine stroke. The magnetic resonance imaging was unremarkable. The patient was started on an acetylcysteine for possible Tylenol toxicity; although, a level was low/undetectable. He was extubated without difficulty on hospital day two. He was afebrile and hemodynamically stable throughout the rest of his acute course. His acute renal failure improved with gentle diuresis, and his liver function tests began trending down of their own [Location (un) ]. It was felt that the elevated transaminases may have been secondary to shocked liver versus TCA toxicity versus Tylenol toxicity. The patient's mental status was also noted to improve to the point where he was interactive. The patient was transferred to the floor on [2139-5-11], and the Congestive Heart Failure Service was consulted. It was felt that the patient's course of worsening dyspnea, cardiomegaly, and fluid overload on chest x-ray were all consistent with the development of new congestive heart failure. The patient was on captopril which was titrated up and switched to Zestril. Aldactone was added, and diuresis was attempted first with oral Lasix and then with increasing amounts of intravenous Lasix. From a pulmonary standpoint, the patient grew out Escherichia coli from his sputum and was started on Levaquin after his white blood cell count became to trend up and the patient started developing low-grade temperatures. In terms of gastrointestinal, the patient's transaminases continued to trend down for a peak AST of 3000 and a peak ALT of 1700, but the alkaline phosphatase and total bilirubin remained elevated. A right upper quadrant ultrasound was subsequently obtained that was consistent with congestive hepatopathy. From a renal standpoint, the patient's creatinine trended down to 1.4 to 1.5 with volume repletion. From a hematologic standpoint, the patient's platelets were noted to be decreasing on a daily basis, and heparin antibodies were eventually sent which came back positive for antiplatelet Factor IV antibody. The patient was on subcutaneous heparin at the time, which was discontinued. On the day of transfer to the Coronary Care Unit, the patient underwent a cardiac catheterization, and the right heart catheterization revealed the following pressures, right atrial mean of 15, right ventricular 60/18, pulmonary artery of 60/30, wedge 30, cardiac output of 3, with an index of 1.5 measured by sic, superior vena cava oxygen saturation of 48%, and a pulmonary artery saturation of 52%. These numbers improved with milrinone with his pulmonary artery diastolic pressure dropping from 30 to 18, and the wedge dropping from 30 to 15, cardiac output improving from 3 to 5.8, with an index improving from 1.5 to 2.9. Coronary angiography revealed 40% to 50% left main stenosis, a mild proximal circumflex lesion, and minimal luminal irregularities in the left anterior descending artery. The patient was brought to the Coronary Care Unit on [2139-5-15] for the management of Swan-[Location (un) ]/milrinone therapy to aid in diuresis. While in the Coronary Care Unit, the patient responded well to diuresis with milrinone. He was also maintained on Lasix, Zestril, and Aldactone to manage his heart failure. On [2139-5-18], the patient's milrinone was discontinued, but he became tachycardic and dyspneic and developed elevated right-sided pressures. The central venous pressure went up from 12 to 23, and the mean pulmonary artery pressure rose from 30 to 65. At that time, the patient also spiked a temperature to 103.4. It was felt that the patient failed to come off the milrinone in the setting of a new infection. Blood cultures obtained at the time of the temperature spike revealed 4/4 bottles positive for methicillin-resistant Staphylococcus aureus. The patient was empirically started on vancomycin, and then gentamicin was added 24 hours later. Over the next 48 hours, the patient's milrinone was slowly weaned off without difficulty. On the day prior to discharge from the Coronary Care Unit, the patient was noted to put out 3600 cc of urine with 500 cc of intake reported on 0.188 mcg/kg per minute of milrinone and a standing Lasix of 80 mg intravenously b.i.d. On [2139-5-18], the patient's PA catheter was removed and the line tip was cultured. It grew out greater than 15 CFU/mL of Staphylococcus aureus which has yet to be further speciated. Given the clinical setting, it was felt that the patient's bacteremia was secondary to line-related infection, tunnel site more so than endoluminal. At the time of discharge from the Coronary Care Unit, the patient was also noted to have two other mild laboratory abnormalities: (1) The patient's platelet count drifted down over a course of 48 hours from 104 to 83 in the setting of having all heparin held. A further workup is currently pending including DIC panel and repeat liver biochemistries. (2) The patient also had mild hyponatremia to 127 with a serum osmolality of 272, and a urine osmolality of 325. The hyponatremia was felt the be multifactorial including the patient's congestive heart failure, use of milrinone and Lasix, and possible excessive unsupervised free water intake. ACTIVE DISCHARGE PROBLEMS: At the time of discharge from the Coronary Care Unit, the patient's active problems remained as follows: 1. Congestive heart failure with a low ejection fraction (an ejection fraction of 10% by a prior echocardiogram) complicated by congestive hepatopathy. 2. Thrombocytopenia. 3. Mild hyponatremia. 4. Line-related methicillin-resistant high-grade Staphylococcus aureus bacteremia. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2653] MEDQUIST36 D: [2139-5-21] 12:28 T: [2139-5-21] 18:35 JOB#: [Job Number 41257]	[ "4280", "51881", "2762", "5849" ]
Admission Date: [2102-8-29] Discharge Date: [2102-8-31] Date of Birth: [2043-2-21] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline / Cipro Cystitis / Benadryl Decongestant / Motrin / Zofran / Prochlorperazine Maleate Attending:[First Name3 (LF) 2297] Chief Complaint: oxaliplatin desensitization Major Surgical or Invasive Procedure: none History of Present Illness: 59F with initial high risk pT3N2bMX KRAS/BRAF-WT colon cancer s/p resection [6-/2098] and adjuvant FOLFOX who developed metastatic recurrence [6-/2100] and is now s/p C15 FOLFIRI-Avastin followed by 7 cycles Cetuximab-Irinotecan who developed progressive disease and is now on third line oxaliplatin/capecitabine therapy. Was admitted a weeek ago for oxaliplatin reaction during her C2D1 oxaliplatin infusion. On first day of oxaliplatin, she vomited four times once home and felt nauseated, but improved overnight with sleep. On C2D1, within a few minutes of beginning her oxaliplatin, she developed nausea. The oxaliplatin was stopped and then restarted. With re-challenge, nausea returned and developed a diffuse maculopapular pruritic skin eruption with hives, flushing, intense itching. Also developed diarrhea and tachycardia. Was admitted for management of oxaliplatin reaction. She was treated with 20 mg IV dexamethasone, hydroxyzine for itching, 2 mg IV ativan, Emend, and received IVF 1L. Nausea was still not well controlled with Emend, and patient has hx of adverse rxns to zofran and compazine. Reaction was not considered to be anaphylactic in nature and patient had no respiratory symptoms or airway compromise. Symptoms resolved by hospital day 2. Since discharge she has resumed her Capecitabine 1gm [Hospital1 ] and on [8-22] completed 14d on therapy. She is using lorazepam for her nausea. On arrival to the MICU, patient's VS were: 983 123 101/67 23 98% RA Today feeling well. Notes that she has some nausea (always has nausea these days), diarrhea, pain in both knees and back, and numbness in her toes only. Also feels that her legs are more swollen than usual. Past Medical History: PAST ONCOLOGY HISTORY: -- [2098-7-7] when she was diagnosed with adenocarcinoma of the colon at the splenic flexure. Pathology showed low-grade adenocarcinoma of the colon with 10 of 17 pericolic lymph nodes being positive in the left colon. The lesion was classified as a pT3, pN2b, pMx lesion. Her pre-op CEA was 1.6. -- From [6-/2098]--[1-/2099] she received adjuvant chemotherapy with FOLFOX which was complicated by severe neuropathy, minor PORT problems and nausea. -- [2099-3-12] She had a takedown ileostomy resection of distal and proximal ileum w/ enterostomy. -- [2099-7-28] her CT torso showed no evidence of disease. At this time her CEA was 1.6 ([2099-8-6]). -- She was followed serially and on [2100-3-9] her CEA had risen to 9.3. -- [2100-3-16] CT abdomen that showed 4 solid appearing lesions w/in the liver consistent w/metastatic disease. -- [2100-3-24] a liver biopsy was planned. This procedure was aborted d/t difficult sedation and another biopsy was not attempted. -- [2100-4-28] her CEA had risen again to 10.5. -- [2100-7-9] Colonoscopy demonstrated submucosal prominence with overlying ulceration with some slight kinking of the edges, status post biopsy, very worrisome for malignancy at 20 cm. Pathology showed multiple foci of adenocarcinoma consistent with the patient's known adenocarcinoma of the colon. -- [2100-7-27] CT showed a 4cm hypodense lesion in the right lobe of the liver and a second hypodense lesion which measures 3.1cm in size. There is an exophytic 2.5cm hypodense lesion along the inferior liver margin anteriorly which is new from previous study. There is a probable new 1.8cm lesion in the right lobe of the liver. There is a probable nodular 1cm lesion anteriorly in the left lobe of the liver. -- [2100-8-11] she was seen in consultation with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and tentatively planned for colon resection, Right lobectomy, segmental liver resection, IOUS, and resection of prior ileosigmoid anastomosis on [2100-8-27]. A pre-operative CT torso was done [2100-8-11] and again showed unchanged liver lesions (when compared to [7-28] study), unchanged pelvic adenopathy and no new interval lesions. -- [2100-8-23] whole body PET-CT on which demonstrated PET-Avid intrabdominal disease. Additionally, the PET identified focal FDG uptake in the left humeral head has an SUV max of 5.47, without a definite anatomic correlate. There is no cortical disruption at this site. No other abnormal FDG avidity is present in the skeleton or soft tissues. -- [2100-8-29] MRI shoulder: An 8-mm lesion in the left proximal humerus, concerning for metastasis. Surgery was indefinitely postponed. -- [2100-9-13] PORT placed and C1D1 FOLFIRI, no avastin with cycle 1 due to recent PORT. -- [2100-10-13] C2D1 FOLFIRI-Avastin -- [2100-10-25] C2D15 FOLFIRI-Avastin -- [2100-11-8] C3D1 FOLFIRI-Avastin -- [2100-12-1] CT Torso: No evidence of disease progression. Stable liver metastases and mesenteric deposits. -- [2100-12-6] C4D1 FOLFIRI-Avastin -- [2101-1-10] C5D1 FOLFIRI-Avastin -- [2101-2-14] C6D1 FOLFIRI-Avastin -- [2101-3-9] CT Torso: Stable disease, no new sites -- [2101-3-15] C7D1 FOLFIRI-Avastin -- [2101-4-11] C8D1 FOLFIRI-Avastin -- [2101-5-6] C9D1 FOLFIRI-Avastin -- [2101-6-6] C10D1 FOLFIRI-Avastin -- [2101-6-14] CT Torso: Stable disease, no new sites -- [2101-7-26] C12D1 FOLFIRI-Avastin -- [2101-8-22] C13D1 FOLFIRI-Avastin -- [2101-9-1] admitted with buttock abscess, drained in ED -- [2101-9-28] C14D1 FOLFIRI (Avastin Held for buttock wound) -- [2101-10-17] C15D1 FOLFIRI (Avastin Held for buttock wound) -- [2101-10-21] CT TORSO with significant hepatic progression -- [2101-11-1] C1D1 Cetuximab-Irinotecan -- [2101-12-12] C2D1 Cetuximab-Irinotecan -- [1-3] C2D22 admitted with volume depletion, [Last Name (un) ], resolved with IVF and anti-motility agents. -- [2102-1-24] C3D1 Cetuximab-Irinotecan -- [2102-2-20] C4D1 Cetuximab-Irinotecan (D8, D15 Irinotecan held for diarrhea, D22 ([3-14]) Cetuximab held for worsening rash -- [2102-3-20] C5D1 Cetuximab-Irinotecan -- [2102-4-3] C5D15 HELD for diarrhea -- [2102-4-10] C5D22 Irinotecan held, Cetuximab given -- [2102-4-18] C5D28 Cetuximab -- [4-24] C5D36 Cetuximab -- [2102-5-1] C6D1 Cetuximab-Irinotecan -- [2102-5-23] C7D1 Cetuximab-Irinotecan -- [6-5], [6-12] -- Chemo held for GI toxicities -- [2102-6-14] CT with interval progression and >20% increase in hepatic disease burden, no new disease sites, CEA rising -- [2102-6-24] C1D1 Capecitabine 1500mg PO BID Other PMH: 1. Ovarian Cysts 2. Cervical Dysplasia 3. Osteoarthritis 4. Spinal Stenosis on chronic Darvocet 5. Torn Meniscus 6. Peripheral Edema 7. GERD 8. S/p CCK 9. Stage IV Colorectal cancer as above 10. MRSA R.buttock abscess, s/p I&D on [2101-9-1], tx with clinda Social History: Living/Support: Lives alone, no children. She has many local friends. [Name (NI) ]/Income: Works as an educational consultant and standard poodle breeder. Last won a show yesterday in NH. Her license plate says "Poodle." Tobacco: 1ppdx10yrs, quit 20yrs ago EtOH: 3 glasses/month Illicits: denies, no h/o IVDU Family History: - Mother: Died at 91 of natural causes, had thyroid cancer - Father: Died at 68 of CVA - Other: No known malignancies. She has a first cousin with hemachromatosis and an aunt with several gastric surgeries (not for malignancy) Physical Exam: EXAM ON ADMISSION 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. Port site c/d/i. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, mild tenderness to palpation, no rebound or guarding, +post-op scar GU: no foley Ext: Warm, well perfused, 2+ pulses, 1+ edema BL lower extremity Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, steady gait EXAM ON DISCHARGE 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. Port site c/d/i. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, mild tenderness to palpation, no rebound or guarding, +post-op scar GU: no foley Ext: Warm, well perfused, 2+ pulses, 1+ edema BL lower extremity Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, steady gait Pertinent Results: [2102-8-29] 11:20AM BLOOD WBC-16.0* RBC-3.61* Hgb-9.9* Hct-31.0* MCV-86 MCH-27.5 MCHC-31.9 RDW-22.4* Plt Ct-327 [2102-8-31] 05:23AM BLOOD Glucose-131* UreaN-15 Creat-0.4 Na-138 K-4.1 Cl-108 HCO3-23 AnGap-11 [2102-8-29] 11:20AM BLOOD ALT-28 AST-83* LD(LDH)-1818* CK(CPK)-193 AlkPhos-212* TotBili-2.5* DirBili-1.4* IndBili-1.1 [2102-8-29] 11:20AM BLOOD TotProt-6.5 Albumin-3.3* Globuln-3.2 Calcium-8.3* Phos-2.3* Mg-1.0* [2102-8-29] 11:20AM BLOOD CEA-2206* [2102-8-30] 09:18AM BLOOD Lactate-3.0* [2102-8-31] 05:38AM BLOOD Lactate-1.5 [8-30] RUQ US: FINDINGS: As known from prior CT of [2102-6-14], there are extensive metastatic lesions throughout the liver. The main portal vein is patent with hepatopetal flow. No intra- or extra-hepatic ductal dilatation is noted. Common bile duct measures 3 mm. The patient is status post cholecystectomy. Bilateral kidneys show no evidence of solid masses or hydronephrosis. Spleen measures 12.3 cm, slightly increased from prior examination. IMPRESSION: 1) Innumerable masses in the liver consistent with metastatic disease. No evidence of biliary obstruction; patent portal vein. 2) Spleen is increased slightly in size though remains upper limits of normal. [8-31] CXR FOR PORT EVAL: FINDINGS: PA, lateral, and oblique views of the chest were obtained with the patient in the upright position. The chemotherapy port catheter is seen with the tip in the mid SVC. There is no obvious break in the length of the catheter. The lungs are well expanded and clear. There are no pleural effusions or pneumothorax. There is moderate cardiomegaly. Osseous structures are unremarkable. There is some upper zone redistribution pattern. There is no edema, infiltrate or other acute process identified. IMPRESSION: There is no obvious break in the port catheter that can be visualized on plain film. We would recommend performing recanalization and further evaluation under fluoroscopic guidance if clinical concern remains. Brief Hospital Course: # Oxaliplatin desensitization: Followed protocol per hematology/oncology service with one to one monitoring, continuous vital signs monitoring, and premedication protocol including hydroxyzine, famotidine, montelukast, and methylprednisolone. In addition, prn lorazepam was given for anxiety as well as nausea. Electrolytes were aggressively repleted prior to initiation of the protocol. During initiation, patient was noted to have a fever to 101. Blood cultures and urine cultures were sent, which were ultimately negative, as was a CXR, which was negative for cardiopulmonary process. There was low suspicion for infection, and was thought to be drug related. The hem/onc fellow was notified. Overnight during escalation of dosing challenge, patient became acutely tachycardic to the 150s although remained normotensive. She received 50 mg IV diphenhydramine and 1 mg ativan in addition to a 1 liter fluid bolus, after which her heart rate improved. Thereafter, patient was found to have a 20 beat run of wide complex ventricular tachycardia while having a bowel movement, and was again tachycardic to the 130s, for which she received another liter of fluid bolus. Electrolytes were again aggressively repleted. # GERD: We continued her home omeprazole. # Chronic back pain: In order to better monitor vital signs, patient's home vicodin was held in favor of oxycodone for pain control. # Leukocytosis: Patient presented with a leukocytosis as noted on relevant laboratory studies. This was attributed to chronic steroid use, as the patient denied constitutional symptoms. Fever, discussed above, was thought to be due to drugs. However, blood culture, urine culture, and CXR were performed. # Mild transaminitis: Patient presented with mild transaminitis, likely secondary to chemotherapy. RUQ U/S was performed which suggested that transaminitis was most likely secondary to known extensive metastatic disease and no acutely reversible cause of obstruction, inflamation, or infection. # Chronic diarrhea: Patient complained of chronic diarrhea. C diff DNA was sent, which was negative. Medications on Admission: CAPECITABINE [XELODA] - 500 mg tablet - 2 tablet(s) by mouth twice a day Take [Hospital1 ] for 14days, then stop for 7days and repeat. ICD9 Code: 153.9 DEXAMETHASONE - 4 mg tablet - 2 Tablet(s) by mouth once a day On day 2 and 3 after chemotherapy. HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg tablet - 1 Tablet(s) by mouth Q4-6hrs as needed for pain LORAZEPAM - 0.5 mg tablet - [1-23] Tablet(s) by mouth q6hrs as needed for anxiety Do not drive while taking this medication OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth once a day -Patient also reports taking hydrochlorothiazide 50 mg prn for swelling. -Says she is currently not taking lumigan but may restart. Discharge Medications: 1. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q4-6HR:PRN pain 2. Omeprazole 20 mg PO DAILY 3. Capecitabine 500 2 PO BID per Dr. [Last Name (STitle) 3877] (2 tablet(s) by mouth twice a day Take [Hospital1 ] for 14days, then stop for 7days and repeat) 4. Dexamethasone 8 mg PO Q8H on day 2 and 3 after chemotherapy 5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety, nausea Discharge Disposition: Home Discharge Diagnosis: Primary: colon cancer Secondary: Desensitization for serious allergic reaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 805], It was a pleasure to take care of you at [Hospital1 18]. You were admitted for oxaliplatin treatment and desensitization. You were premedicated and continuously monitored for an adverse reaction. You are being discharged with an appointment to follow up with your Oncologist, Dr. [Last Name (STitle) 3877], most likely on [9-12]. Followup Instructions: Please follow-up with your Oncologist, Dr. [Last Name (STitle) 3877], who will be making an appointment for you for [9-12]. If you do not hear from them within 1 day of discharge, please call the office directly. Completed by:[2102-9-1]	[ "V1582", "2762", "53081" ]
Admission Date: [2117-1-1] Discharge Date: [2117-1-14] Date of Birth: [2052-12-12] Sex: F Service: NEUROSURGERY Allergies: Haldol Attending:[First Name3 (LF) 1835] Chief Complaint: Transfer from outside hospital for craniectomy Major Surgical or Invasive Procedure: Right Craniectomy History of Present Illness: 64yo woman with mild dementia, renal failure s/p renal stent, syncope and schizophrenia who originally presented to OSH with acute on chronic renal failure. At admission to OSH she was ambulatory and verbal, however at 7pm yesterday evening, she became aphasic and with left hemiplegia. CT scan at 2200 OSH showed a right temperal- parietal hemorrhage with mass effect. She was apparently unresponsive prior to transfer, but details are limited. Past Medical History: h/o syncope, aspiration pna, acute on chronic renal failure, schizophrenia, and dementia. Social History: Resident at [Hospital6 16009] home and receives full care with help in all her ADLs Family History: Noncontributory Physical Exam: O: T: 97.8 BP: 155/80 HR: 90 R: 22 O2Sats: 99% 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: Mental status: Lying in bed with eyes closed. Generally no spontatneous movement but on occasion some automatisms of the right hand, rubbing fingers together. No response to voice but flinch to clap and groans andlightly mumbles to heavy sternal rub. No folloing commands. no speech. Localizes pain with the right arm and moves left arm slightly antigravity. Cranial Nerves: Pupils equally round and reactive to light but both somewhat sluggish at 3 to 2 mm bilaterally. No blink to threat. Conjugate eye roving into both fields. Sensation intact V1-V3. Decreased left NLF. Motor: Slihgtly rigid throughout right arm ? left. No observed myoclonus or tremor Withdraws x 4 antigravity, but right much stronger than left. Sensation: withdraws Reflexes: +2 in BUE but more brisk left. Left leg has crossed adductor. left toe strongly up. Coordination: NA No gait or rhomberg. Exam on Discharge: Tc 98.6 BP 94/63 HR 87 RR 24 O2 Sats 97% on trach mask GEN: WDWN F in NAD, nonreactive, lying in bed HEENT: PERRL 2.5mm to 2mm bilaterally, eyes open spontaneously CV: RRR Resp: CTA bilaterally Abd: NDNT, soft, BS present Ext: no edema, cyanosis or clubbing Neuro: RUE - localizes and purposeful movement with painful stimulus; LUE - extensor posturing with painful stimulus; RLE withdraws with painful stimulus; LLE no movement with any stimulus or at rest Pertinent Results: [2117-1-8] 02:27AM BLOOD WBC-15.7* RBC-3.20* Hgb-9.8* Hct-29.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-15.1 Plt Ct-451* [2117-1-8] 02:27AM BLOOD Plt Ct-451* [2117-1-1] 04:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2117-1-8] 08:15AM BLOOD Na-150* Cl-119* [2117-1-8] 02:27AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.3 [2117-1-7] 03:23AM BLOOD Glucose-99 CT HEAD W/O CONTRAST [2117-1-1] 2:00 PM IMPRESSION: Interval decompression with craniectomy in the right frontoparietal bones. Large right-sided hematoma is again identified with surrounding edema and mass effect on the right lateral ventricle which has decreased. No new areas of hemorrhage. CT HEAD W/O CONTRAST [2117-1-5] 10:04 AM COMPARISON: [2117-1-1]. IMPRESSION: Essentially unchanged head CT with no new areas of hemorrhage; increase in dilatation of the right temporal [Doctor Last Name 534] is probably secondary to decreased compression (although trapping is still a possibility). CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST [2117-1-10] FINDINGS: There is continued evidence for the large hemorrhage within the right temporal lobe as well as prominent surrounding edema. The degree of ventricular compression and leftward subfalcine herniation is unaltered, compared to the prior study, as is the ventricular size, including the prominently dilated left lateral ventricle. The brain continues to herniate through the large right hemicraniectomy defect. There are no other areas of hemorrhage identified. There is continued prominent opacification of the sphenoid sinus, but lesser opacification of the ethmoid sinuses. There is persistent moderately prominent opacification of both mastoid sinus complexes. The sinus abnormalities could represent an allergic or some other type of inflammatory process. Sclerosis of the right sphenoid air cell is consistent with a prior inflammatory process. CONCLUSION: Essentially stable, grossly abnormal study as noted above. BILAT LOWER EXT VEINS P [2117-1-11] 11:07 AM TECHNIQUE AND FINDINGS: Grayscale, color flow, and Doppler images of both lower extremities were obtained. The both common femoral veins, superficial femoral veins, popliteal veins demonstrate normal compressibility, respiratory variation in venous flow, and venosus augmentation. IMPRESSION: No evidence of DVT in both lower extremities. Brief Hospital Course: Ms [Known lastname 77642] was admitted directly the ICU and underwent an emergent hemicraniectomy, post operatively her CT showed Large right-sided hematoma is again identified with surrounding edema and mass effect on the right lateral ventricle which has decreased. No new areas of hemorrhage. She was started on Keppra for seizure prophlyaxis. Post operatively she moved her right side particularly her arm spontaneously and withdrew her right leg. She extended her left arm and min movement of left leg. She had intermittent fevers on [1-5] and grew out yeast in her urine and was started on Diflucan. On [1-8] her exam was unchanged it was decided by her family to place a PEG and trach. A tracheostomy and a PEG were placed on [1-8]. She had increase white blood counts on [2122-1-11] LENIs were done which showed no evidence of a deep venous thrombosis. CDiff cultures were sent on [1-12] which were negative for toxin. She was fit with a helmet [2117-1-6] and was screened for rehab on [1-7]. On [1-14], the patient was deemed appropriate for transfer to her nursing facility having been weaned off of the ventilator, having been afebrile over the prior 24 hours and having a white blood cell count that has been steadily decreasing to normal levels. The patient will be discharged on oral Vancomycin to treat C. diff. Medications on Admission: Colace, risperdal 0.5mg', trazodone 50mgqhs, prilosec 20mg', norvasc 5mg', metoprolol 25mg", PRN senokot, tylenol, and MOM Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: [6-4] mL PO Q6H (every 6 hours) as needed. Disp:0 mL Refills:0 2. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). Disp:0 Refills:0 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). Disp:0 Units Refills:0 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:0 Tablet(s) Refills:0 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO QD () as needed for low Mg < 2.0. Disp:0 Tablet(s) Refills:0 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO HS (at bedtime) as needed for low Ca. Disp:0 Tablet, Chewable(s) Refills:0 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:0 ML(s) Refills:0 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Disp:0 ML(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:0 Tablet(s) Refills:0 11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 weeks: Please use oral liquid if available. Disp:0 Capsule(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 ] NE [Location (un) ] Discharge Diagnosis: Right temporal parietal IPH Discharge Condition: Neurologically in a vegetative state Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN 4 WEEKS with a head CT. YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST YOU WILL NOT NEED AN MRI OF THE BRAIN WITH OR WITHOUT GADOLIDIUM	[ "5849", "5990", "51881", "2760", "2859" ]
Admission Date: [2175-8-9] Discharge Date: [2175-8-14] Date of Birth: [2110-12-10] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8587] Chief Complaint: L arm pain Major Surgical or Invasive Procedure: L humerus ORIF History of Present Illness: 64F pedestrian struck. Was crossing the street and was hit by a car traveling an unknown MPH. Pt experienced loss of consciousness, doesn't remember being hit or falling to the ground. Evaluated by trauma team, c/o isolated left shoulder pain. Past Medical History: coronary artery disease, s/p coronary artery bypass [2173-9-8] PMH: Hypertension hyperlipidemia Peripheral Arterial Disease Carotid Artery Disease Bilateral subclavian stenosis s/p L stent [5-23] Chronic back pain/Head ache on narcotics Herpes Simplex coronary artery disease, s/p coronary artery bypass [2173-9-8] PMH: Hypertension hyperlipidemia Peripheral Arterial Disease Carotid Artery Disease Bilateral subclavian stenosis s/p L stent [5-23] Chronic back pain/Head ache on narcotics Herpes Simplex Social History: Lives with:alone Occupation:financial planner Tobacco:quit age 32 ETOH:6 glasses/week Family History: Father died of MI age 50, mother with MI age 65 Physical Exam: AOx3 NAD Breathing comfortably, speaking in full sentences RUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft LUE: incision on shoulder c/d/i; dressed No other skin changes. Axillary, R/M/U SITLT EPL FPL EIP EDC FDP FDI fire 2+ radial pulses LLE: ttp at lateral malleolus with mild swelling. Wrapped in ACE-bandage. Pertinent Results: [2175-8-9] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2175-8-9] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2175-8-9] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2175-8-9] 10:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-<1 [2175-8-9] 10:00PM URINE HYALINE-15* [2175-8-9] 10:00PM URINE MUCOUS-OCC [2175-8-9] 01:45PM PT-11.1 PTT-27.3 INR(PT)-1.0 Brief Hospital Course: The patient was admitted to the Orthopaedic Trauma Service for repair of a L Humerus fracture. The patient was taken to the OR and underwent an uncomplicated ORIF L Humerus. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. The patient became hypotensive on POD1 and was transferred to the TSICU for further care. Due to acute blood loss anemia, she was transfused 2UPRBC. The patient tolerated diet advancement without difficulty and made steady progress with PT. Weight bearing status: NWB LUE. Sling for comfort. The patient received peri-operative antibiotics as well as lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: 2. Acyclovir 400 mg PO Q12H PRN cold sores. Pt may refuse if not needed 3. Amlodipine 10 mg PO DAILY BP<100 4. Aspirin 325 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Clopidogrel 75 mg PO DAILY 9. Furosemide 20 mg PO DAILY BP<100 10. Isosorbide Mononitrate 30 mg PO DAILY BP<100, HR<60 11. Lisinopril 40 mg PO DAILY BP<100 12. Metoprolol Tartrate 12.5 mg PO BID Hold BP<100, HR<60 15. Sertraline 100 mg PO DAILY 16. Tizanidine 2 mg PO TID hold BP<100 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Acyclovir 400 mg PO Q12H PRN cold sores. Pt may refuse if not needed 3. Amlodipine 10 mg PO DAILY BP<100 4. Aspirin 325 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Clopidogrel 75 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Furosemide 20 mg PO DAILY BP<100 10. Isosorbide Mononitrate 30 mg PO DAILY BP<100, HR<60 11. Lisinopril 40 mg PO DAILY BP<100 12. Metoprolol Tartrate 12.5 mg PO BID Hold BP<100, HR<60 13. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain After PCA has been d/c RX oxycodone 5 mg [2-13] Tablet(s) by mouth q4hrs Disp #90 Tablet Refills:0 14. Senna 1 TAB PO BID:PRN constipation 15. Sertraline 100 mg PO DAILY 16. Tizanidine 2 mg PO TID hold BP<100 17. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: status post L humerus fracture ORIF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ***SIGNS OF INFECTION****** should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. **WEIGHT-BEARING*** Non weight bearing L arm **MEDICATIONS******* - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink 8-8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on Fridays. **FOLLOW-UP****** Please have your staples removed at your rehabilitation facility at post-operative day 14. Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [11-26] days post-operation for evaluation. Call [Telephone/Fax (1) 1228] to schedule appointment upon discharge. Please follow up with your PCP regarding this admission and any new medications/refills. Physical Therapy: NWB LUE Treatments Frequency: dry to dry; staples to be removed at 10-14 days Followup Instructions: **FOLLOW-UP****** Please have your staples removed at your rehabilitation facility at post-operative day 14. Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [11-26] days post-operation for evaluation. Call [Telephone/Fax (1) 1228] to schedule appointment upon discharge. Please follow up with your PCP regarding this admission and any new medications/refills. Please call Cognitive Neurology for further testing given your recent loss of consciousness: [Telephone/Fax (1) 6335]. Completed by:[2175-8-14**]	[ "2851", "4019", "2724", "311", "V4581", "V4582", "V1582" ]
Admission Date: [2197-12-4] Discharge Date: [2197-12-29] Date of Birth: [2133-4-22] Sex: F Service: MEDICINE Allergies: Aspirin / Codeine / Gadolinium-Containing Agents / Percocet / IV Dye, Iodine Containing / ondansetron Attending:[First Name3 (LF) 4057] Chief Complaint: fever, bacteremia Major Surgical or Invasive Procedure: ERCP Percutaneous biliary drain placement History of Present Illness: Ms. [Known firstname ] [Known lastname 87852] is a 64-year-old woman with Hx of metastatic breast cancer and active biliary cancer on chemotherapy who is transferred from [Hospital3 ] hospital with fever and bacteremia. She was originally admitted to [Hospital3 ] from [11-13] - [11-18] for fevers, chills, and abdominal pain, and was found to have one blood culture positive for Strep viridans. She was initially started on Zosyn and discharged on Augmentin. She re-presented to [Hospital2 ] [Hospital3 ] ER on [11-23] with chills, severe confusion, Temp 101.5 and HR 109. She was admittted for SIRS and given broad ABX with Vancomycin and Zosyn. Both of these ABX were discontinued on [11-26] secondary to negative blood cultures to date and the fact that they may have caused her to be nauseous. She was switched to Penicillin since the original organism had sensitivity to this. On [11-27] she had fever [Last Name (LF) ], [First Name3 (LF) ] Vancomycin was continued (no significant time had passed where it was actually stopped from before). She was thought to be fluid overloaded and was given lasix 40mg IV as well as 2 units of PRBCs for an Hct of 25. On [11-28] she received a TTE which showed normal systolic function and no vegitation; ESR that day was 65 and CRP was 174. On [11-29] she had temperature of 101 with rigors and had SVT with rate in the 170s. She also had altered mental status. A rapid response was called, and with IV lopressor and Ativan, her HR improved. This episode recurred the following day with T 104, rigors, and SVT. MRI was obtained in part for her mental status changes which showed extensive metastatic disease but no acute pathology. Per D/C summary, blood cultures from [11-30] had 2/4 bottles positive for Strep viridans and Zosyn was discontinued. However, on review of the daily notes and the orders, Zosyn was never restarted since it was stopped on [11-26]. On [12-1] she had a PICC placed in anticipation of having her port pulled. on [12-2] and [12-3] she continued to have temperatures to 102. ABX were not changed from Vancomycin and PCN from [11-26] until [12-4] when both were stopped. Her WBC count continued to increase. The patient received one dose of Imipenam before transfer on [12-4] since Blood culture on [12-1] had one out of four positive for Klebsiella which was sensitive to Imipenam. Of note patient had TEE which was negative for vegitation on [12-4]. On arrival to [Hospital1 18], she states that she generally feels well aside from her chronic mild abdominal pain. Review of Systems: (+) Per HPI She also states that she felt fast heart rate and shortness of breath at home 2 episodes but no chest pressure, chest pain, nausea, vomiting, or associated diaphoresis. (-) Denies night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: ONCOLOGIC HISTORY: Ms. [Known lastname 87852] is a 64-year-old woman who first presented with low back pain and left hip pain in 11/[2195]. Workup in [10/2196] revealed breast cancer metastatic to the lymph nodes and bone (invasive carcinoma with lobular and tubular features), grade 1 ER and PR positive, HER-2/neu negative on FISH. Concurrent with this workup, she was noted to have a 6 x 5.4 cm liver mass. Liver biopsy performed on [2197-1-3] was consistent with moderate to poorly differentiated adenocarcinoma consistent with pancreaticobiliary tumor and not her breast cancer. On [2197-2-3], she was taken to the OR by Dr. [Last Name (STitle) ] and was found to have unresectable gallbladder cancer with tumor encasing the porta hepatis and adherent to the duodenum. Bulky [Doctor Last Name ]-hard portal adenopathy posteriorly seen intraoperatively raised concern for lymph node involvement. She started chemotherapy with gemcitabine and cisplatin on [2197-2-27]. Imaging in [4-/2197] demonstrated excellent response of her breast cancer, particularly her bony metastasis; however, her liver mass was essentially stable. In the setting of pain, she was referred for CyberKnife therapy which was completed on [2197-7-4] after initial course was complicated by intercurrent biliary obstruction requiring hospitalization and stenting. She continued to have pain and was referred for a pain block which occurred on [2197-8-18]. Since that time, she has noted some improvement in her pain. [9-20] started Gemzar/Xeloda with [Hospital3 ] oncology group Other Past Medical History: -HTN -h/o minor MVA - rotator cuff injury s/p PT -hx nephrolithiasis -hx choledocolithiasis -C-section [2169] ALLERGIES: 1. Aspirin causes stomachache. 2. Codeine causes stomachache. 3. Gadolinium-containing agents cause rash. 4. IV and iodine-containing dye causes rash and itching. 5. Percocet results in general malaise. 6. Ondansetron causes severe anxiety. Social History: Married with one son. Retired administrator. Rare etoh. remote tobacco. Family History: Father died from suicide. Mother died at age 80 from CAD/DM. Physical Exam: Physical Exam on Admission: VS: Afebrile HR 87 bp 120/80 RR 20 SaO2 94 RA GEN: NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT, ND, no HSM, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c/e, 2+ DP/PT bilaterally SKIN: No rash, warm skin NEURO: oriented x 3, normal attention, no focal deficits PSYCH: appropriate Discharge PE GEN: NAD, awake, alert HEENT: sclera icteric NECK: Supple, no JVD CV: regular rate, [1-1] diastolic murmur CHEST: CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT, blanching erythematous rash in RLQ, perc drain in place MSK: normal muscle tone and bulk EXT: 2+DPs, 2+ pedal edema, trace edema in upper extremities NEURO: oriented to self and place, not date, follows most commands, but slow to respond at times Pertinent Results: Labs on Admission: [2197-12-5] 12:00AM PLT SMR-NORMAL PLT COUNT-184 [2197-12-4] 08:50PM GLUCOSE-122* UREA N-8 CREAT-0.4 SODIUM-138 POTASSIUM-3.1* CHLORIDE-100 TOTAL CO2-32 ANION GAP-9 [2197-12-4] 08:50PM ALT(SGPT)-9 AST(SGOT)-16 LD(LDH)-228 ALK PHOS-311* TOT BILI-0.8 [2197-12-4] 08:50PM CALCIUM-8.0* PHOSPHATE-2.9 MAGNESIUM-1.6 [2197-12-4] 08:50PM WBC-18.6# RBC-2.90 HGB-8.8# HCT-26.7# MCV-92 MCH-30.4 MCHC-33.0 RDW-20.6* [2197-12-4] 08:50PM NEUTS-89* BANDS-1 LYMPHS-2* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2197-12-4] 08:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-OCCASIONAL [2197-12-4] 08:50PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO [2197-12-4] 08:50PM PT-15.7* PTT-34.0 INR(PT)-1.5* . Relevant labs: [2197-12-6] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL negative [2197-12-29] 04:20AM BLOOD WBC-8.6 RBC-2.73* Hgb-8.2* Hct-26.1* MCV-96 MCH-30.1 MCHC-31.4 RDW-18.0* [2197-12-26] 03:34AM BLOOD Neuts-80.5* Lymphs-13.2* Monos-3.0 Eos-3.0 Baso-0.3 [2197-12-29] 04:20AM BLOOD Glucose-96 UreaN-10 Creat-0.3* Na-139 K-3.6 Cl-102 HCO3-33* AnGap-8 [2197-12-29] 04:20AM BLOOD ALT-9 AST-18 LD(LDH)-200 AlkPhos-377* TotBili-0.8 [2197-12-29] 04:20AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.7 . Microbiology [2197-12-20] 4:30 pm ABSCESS LIVER ABSCESS. FINAL REPORT [2197-12-24] GRAM STAIN (Final [2197-12-20]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). Reported to and read back by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] AT 7:35PM ON [2197-12-20]. FLUID CULTURE (Final [2197-12-24]): ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/tazobactam sensitivity testing available on request. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2197-12-19] 9:30 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BILE FLUID. FINAL REPORT [2197-12-25] BLOOD/FUNGAL CULTURE (Final [2197-12-23]): ENTEROBACTER CLOACAE COMPLEX. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 339-3196E [2197-12-19]. [Female First Name (un) ] ALBICANS. BLOOD/AFB CULTURE (Final [2197-12-20]): DUE TO OVERGROWTH OF BACTERIA AND YEAST, UNABLE TO CONTINUE MONITORING FOR AFB. Myco-F Bottle Gram Stain (Final [2197-12-20]): GRAM NEGATIVE ROD(S). BUDDING YEAST. Reported to and read back by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] AT 6:26PM ON [2197-12-20]. . Imaging . Chest x-ray [2197-12-5]: As compared to the previous radiograph, the patient has received a right Port-A-Cath. The patient also has received a left PICC line. The course of the line is unremarkable, the tip of the line projects over the cavoatrial junction. No evidence of complications, notably no pneumothorax. Low lung volumes. Bilateral basal areas of atelectasis. The presence of a minimal left pleural effusion cannot be excluded. . Abdomen w/o Contrast [2197-12-6] 1. Gallbladder carcinoma with invasion into the hepatic parenchyma with associated extensive biliary dilatation as previously seen on outside hospital CT from [2197-10-26]. 2. There are, however, four lesions which appear well delineated and are of fluid consistency seen within segments V and VI of the liver. Due to lack of IV gadolinium, these cannot be fully assessed, however, they are concerning in the appropriate clinical setting for hepatic abscesses vs. focal regions of tumor necrosis. Either repeat attempt imaging with MR [First Name (Titles) ] [Last Name (Titles) ] gadolinium or further evaluation with ultrasound plus or minus aspiration is recommended. 3. Heterogeneous bone marow signal intensity in keeping with known osseous metastatic disease. . KUB [2197-12-12] 1. Nonspecific bowel gas pattern without evidence of free air or obstruction. 2. Pneumobilia, expected within context of biliary stenting and recent ERCP. . Abdominal US [2197-12-15]: 1. No safe window available for aspiration of hepatic hypoechoic lesions, in particular there is risk of bile peritonitis due to dilated intrahepatic ducts. These findings were discussed with Dr. [Last Name (STitle) 9419], the resident of the primary team taking care of this patient, by radiology fellow over telephone on [2197-12-15] at 10:30 a.m. 2. Multiple liver lesion are most concerning for metastases . ERCP [2197-12-11]: There was severe erythema and edema at duodenal sweep. The lumen was narrowed. It was likely caused by the external compression of the cancer. It was traversed with a regular side-viewing scope. A metal stent was seen at ampulla. Cannulation of the biliary duct was successful and deep with a balloon catheter using a free-hand technique. Given the cholangitis, balloon sweeping was first performed. Large amount of sludge, debris and pus were extracted successfully using a 12 mm balloon. Small amount of tissue, likely from ingrowing cancer, was also extracted. After balloon sweeping, a final cholangiogram was obtained. There was diffuse and mild dilation of intrahepatic duct. The stent was widely patent. No additional filling defect was seen. The contrast and bile were drained well. . MRI abd [12-24] IMPRESSION: 1. Multiple small locules of fluid along the superior margin of the large infiltrative tumor in the right lobe. The size of these fluid collections has decreased compared to the prior study, however, there was an interval aspiration. The appearances are consistent with residual abscesses, the largest measuring 2.4 cm and 2 cm. 2. Extensive tumor surrounding the gallbladder, invading the liver and tracking along the common bile duct, the CBD stent remains patent with mild central intrahepatic duct dilatation. 3. Mild interval increase in the degree of pancreatic duct dilatation secondary to the tumor or mass extending along the common bile duct. 4. Very abnormal appearance of both kidneys suggestive of nephropathy/nephritis. 5. Bilateral pleural effusions. . LUE u/s IMPRESSION: Thrombosis extending from the distal left subclavian vein through the left axillary vein and into the basilic vein. . CXR [12-25] IMPRESSION: 1. Stable moderate right pleural effusion. 2. Improved left lower lung atelectasis and stable presumed small left pleural effusion. Brief Hospital Course: Ms. [Known firstname ] [Known lastname 87852] is a 64-year-old female with history of HTN, metastatic breast cancer and active biliary cancer on chemotherapy who is transferred from [Hospital3 ] hospital with fever and bacteremia. . #Bacteremia with Klebsiella and Strep Viridans: At [Hospital3 635] hosptial, blood cultures were positive for Klebsiella and Strep Viridans. The patient was initially treated with Vancomycin/Zosyn and then vanc/penicillin but continued to [Hospital3 ] temps. This was likely in part due to her intermediate sensitivity to antibiotics. Prior to transfer to [Hospital1 18], she was given Imipenem and was afebrile. 24 hours into the hospital course she spiked a temp to 102, was rigoring, was in AVNRT vs. NSVT to 170s alternating with sinus tach. She also became more lethargic than prior. Thus, patient was transferred to the ICU for sepsis. In the ICU, Pt's antibiotics were continued. She did not require pressors and received fluid resuscitation. Her chemo port was surgically removed on [12-6], which she tolerated well. Her leukocytosis reduced dramatically and she remained afebrile for the duration of her ICU stay. She also received a MRI abdomen / MCRP which demonstrated gallbladder carcinoma with invasion into the hepatic parenchyma with associated extensive biliary dilatation as previously seen, and four lesions which appear well delineated and are of fluid consistency seen within segments V and VI of the liver. The patient did not receive IV gadolinium because she became nauseated and did not tolerate the rest of the exam. These images were therefore unable to be fully characterized but suggested hepatic abscesses vs. focal regions of tumor necrosis. This was discussed with the infectious disease service, who felt at that time, aspirating the lesions would not change treatment given her proven bacteremia. All of the patient's cultures (port, PICC, blood, urine) remained negative throughout the hospital course. She was continued Vancomycin/Meropenem based on culture sensitivities from [Hospital3 ] hospital. Vanc trough therapeutic. Endocarditis ruled out with TEE at OSH. Since [12-9], LFTs were uptrending as was Tbili, suggesting an obstructive picture. Patient has biliary stent placed in 8/[2196]. On [12-11], she had an ERCP which showed debris and narrowing of the lumen of the ampulla. The debris was cleaned out, the lumen opened up, did not require new stent. Patient also has lesions in the liver which look like abscess vs. tumor necrosis as above. Given that she continued to [Month/Year (2) ] with no clear source, the decision was made to aspirate the liver lesions for further characterization. In radiology, abdomen US showed that bile ducts were very dilated and there was no safe pathway to access the liver lesions without high risk of puncturing a bile duct. Other options would be percutaneous biliary drain for decompression vs. ERCP to extend the stent. Spoke with IR and ERCP. Decision was made to have a percutaneous biliary drain placed for decompression. She went for the procedure on [2197-12-19]. During the procedure, patient required contrast to which she has a known allergy of hives. Despite premedication, after the procedure, when extubated, patient was experiencing respiratory distress and stridor. Thus, she was re-extubated and transfered to the ICU for monitoring overnight. . MICU COURSE: Patient re-intubated post-procedure after developed stridor/respiratory distress. Patient had episodes of severe hypertension and tachycardia felt secondary to pain/anxiety/and likely underlying hypertension. Due to these episodes, patient developed flash pulmonary edema and made her extubation difficulty initially. Pain and anxiety medications were uptitrated and started on labetalol and nitro. She was also aggressively diuresed with IV lasix. Her hemodynamics stabilized and she was extubated without difficulty after approximately 7 days of intubation. . Patient's micro data showed [Female First Name (un) ] in her bile, sputum, and urine cultures. Empirically started on micafungin, but then narrowed to fluconzole as the species was presumed [Female First Name (un) ] albicans. Also grew Enterobactor cloacae in her bile and patient was continued on meropenem. . Also upper extremity non-invasive showed a large occlusive DVT near her PICC. Given that patient has poor prognosis with her malignancy after discussion with her oncologist, a MRCP showing further infection in her liver with a marked white blood count despite antibiotics, and after discussion with her husband, it was felt to make the patient comfort measures. Since the DVT was not causing her pain and it was preventing her from being stuck for labs, the PICC was decided to stay in prior to transfer to the floor. . Patient transferred to floor from ICU on [2197-12-27]. While on floor, the patient has required up to 3.5LNC to maintain adequate oxygenation. Pain has been an ongoing issue, but the patient is now on morphine PCA and PO methadone which has been sufficient. She was taking IV morphine prn and IV methadone standing. Other issues have been with hypertension. The patient had SBP up to 190s requiring labetalol which she responded well to initially. An EKG showed questionable a fib vs a flutter and we started to use IV lopressor to bring down her blood pressure which she tolerated well. We also increased her carvedilol to 25mg [Hospital1 ]. She will be discharged with a foley in place, as her mental status comes and goes, and the foley is not currently bothering her. She was receiving IV meropenem for blood and abscess cultures growing enterobacter, but will leave on PO levaquin. She was also started on a nystatin cream for a rash on her RLQ and R upper thigh. She will also leave on PO fluconazole. Medications on Admission: Medications - Prescription AMLODIPINE - 5 mg Tablet - 1 tablet by mouth at bedtime ANASTROZOLE - 1 mg Tablet - 1 Tablet(s) by mouth once a day FENTANYL - 50 mcg/hour Patch 72 hr - 1 patch to skin change every 72 hours HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for pain HYDROMORPHONE [DILAUDID] - 4 mg Tablet - [11-27] Tablet(s) by mouth every 3 hours PRN pain LORAZEPAM - 0.5 mg Tablet - [11-27] Tablet(s) by mouth every eight (8) hours as needed for anxiety, insomnia, nausea ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth q 8 hr as needed for nausea/vomiting POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 1 packet by mouth once a day as needed for constipation PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth Take 40 mg 16hr, 8 hr, and 2 hr prior to scan PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 tablet by mouth three times a day as needed for nausea RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth Take 150 mg 1 hr prior to scan Medications - OTC DIPHENHYDRAMINE HCL - 25 mg Capsule - 2 Capsule(s) by mouth take 50 mg 1 hr before scan Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 4 weeks. 6. potassium chloride 20 mEq Packet Sig: One (1) Packet PO PRN (as needed). 7. nitroglycerin 2 % Ointment Sig: One (1) Transdermal DAILY (Daily): Please place nitropaste daily, ON for 14 hours, OFF for 10 hours . 8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation, delirium. 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 11. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): abdominal rash. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. morphine 4 mg/mL Syringe Sig: One (1) Injection once a day as needed for pain: 14. Morphine Sulfate 3 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 12 mg(s) please monitor sedation closely while on mPCA . 15. methadone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 16. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 17. lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for anxiety. 18. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 weeks. Discharge Disposition: Extended Care Facility: [Hospital ] Care Center Discharge Diagnosis: breast cancer/gallbladder cancer/bacteremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 87852], You were admitted to [Hospital1 18] on [2197-12-4] for bacteremia. You had a complicated hospital course spending time in the ICU and floor. You were found to have bacteria in your blood and pockets of infection in your abdomen. You received IV antibiotics in the hospital and will continue oral antibiotics for 4 more weeks. We had issues controlling your blood pressure during your stay. You will leave on a medication to control your blood pressure. You also experienced a fair amount of abdominal pain, in which you were given narcotics to control. You will be discharged to [Hospital ] Hospice for continued care. You should take the medications provided at time of discharge. You will need to schedule followup with an infectious disease specialist in two weeks for your ongoing infection and antibiotic regimen. Medication changes include: START levofloxacin 500mg for 4 more weeks (end date [2198-1-27]) START fluconazole 400mg for 4 more weeks (end date [2198-1-27]) START morphine PCA to help you control your pain START methadone to help you control your pain START carvedilol 25mg twice daily START nitroglycerin ointment to help with your blood pressure START colace, senna, and bisacodyl to help prevent constipation START protonix to help prevent reflux START seroquel for anxiety STOP amlodipine STOP anastrazole STOP vicodin STOP dilaudid You should continue your other medications as prescribed. Followup Instructions: Please schedule an infectious disease followup in two week in [Location (un) ] area. Your hospice facility will help to find you an Infectious Diseases specialist in the area.	[ "78552", "4019", "99592" ]
Admission Date: [2120-11-27] Discharge Date: [2120-12-2] Date of Birth: [2043-1-11] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Aspirin / Egg Attending:[First Name3 (LF) 1271] Chief Complaint: slurred speech, worsened gait instability Major Surgical or Invasive Procedure: Left craniotomy for subdural hematoma evacuation History of Present Illness: 77 year-old male with h/o shunt placement on [9-18] here at [Hospital1 18]. Patients presents today with slurred speech, gait instability noticed by his son. [Name (NI) ] admits headache, denies any visual changes, nausea, vomiting,chills, fever or lightheadedness. Qestionable fall last week per patient son will investigate regarding fall at home. Past Medical History: HTN GERD Urinary incontinence Cervical spondylosis s/p CCY s/p hernia repair Subdural Hematoma Right [9-18] Right VP shunt for NPH [9-18] Social History: Patient lives at home with his wife in [Name (NI) 932]. He is a retired mechanical engineer. no history of neurologic disease, has 24 hour a day aide to assist him and his wife at home.Patient drinks 1 Pack(24can) beer a week, Has a long history of smoking. Family History: no history of neurologic disease Physical Exam: On Admission Exam:Vital sigs:97.5 62 23 203/85 100%RA Gen:elderly gentelmen lying in strecther mild respiratoty distress. Neck: No carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect Orientation: oriented to person, place, and date Recall: [2-15] at 5 minutes Language: slurred speech, mild aphasia, with good comprehension some diffuculty of repetition; naming intact. No dysarthria. No apraxia, no neglect Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and face symmetric bilaterally. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor D T B Grip IP Gl Q H AT [Last Name (un) 938] Right 5 5 5 5 5 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 No pronator drift Sensation: Intact to light touch. Reflexes: B T Br Pa Pl Right 2 2 2 2 2 Left 2 2 2 2 2 Toes were downgoing bilaterally Coordination: normal on finger-nose-finger, heel to shin also normal Gait:shuffeling gait, appears to having difficulty walking with left leg. Pertinent Results: [2120-11-27] 06:00PM PT-11.9 PTT-26.1 INR(PT)-0.9 [2120-11-27] 06:00PM PLT COUNT-309 [2120-11-27] 06:00PM NEUTS-67.6 LYMPHS-24.0 MONOS-5.1 EOS-2.9 BASOS-0.3 [2120-11-27] 06:00PM WBC-10.5 RBC-4.36* HGB-13.7* HCT-38.1* MCV-87 MCH-31.4 MCHC-35.9* RDW-14.0 [2120-11-27] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-11-27] 06:00PM AMMONIA-15 [2120-11-27] 06:00PM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-109 AMYLASE-48 TOT BILI-0.3 Head CT [2120-11-27]: Brief Hospital Course: 77 year-old male presented to ED with new onset of slurred speech, and slight worsening of gait instability noticed by son. Initial head CT revealed left subacute on acute subdural hemorrhage with a left to right shift. Patient admitted to neuro ICU for overnight monitoring since his neurologic exam grossly nonfocal except slurred speech. Patient kept NPO, loaded with dilantin 1gm and 100mg tid as maintanence dose. Taken to OR first thing in the morning of [2120-11-28] for a left craniotomy for evacuation of subdural hematoma with left subdural [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drain. There is no intra-operative complications occurred. Postoperatively transferred back to neuro ICU for hemodynamic and neurologic monitoring. Immediate neurologic exam is remained as preoperative exam, slight improvement on the slurred speech. Petient blood pressure maintained around 120-160, able to transfer neuro step-down floor on postop day one. Left subdural [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drain removed on [2121-11-29] without any difficulty, patient tolareted procedure well, and the sture to be removed on [2120-12-4]. Serial Head CTs showed improvement on the left subdural hematoma postoperatively. Physical therapy consulted for evaluation and recommended the patient be discharged to a rehabilitation facility. Discharge Medications: 1. Doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 2. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). 3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO QD (). 4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Please hold for loose stools. 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Sliding scale as needed. 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): Check levels to dose to a therapeutic level between [9-28]. 12. Pantoprazole 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 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: s/p subdural hematoma evacuation via craniotomy on the left side Discharge Condition: Neurologically stable Discharge Instructions: No tub or swimming for 2 weeks. Keep incision dry. Staples are to be removed on postoperative day #10 ([12-8]) Please call the office or return to the emergency room for any change in mental status, lethargy, pain that is not controlled by pain medicine, new difficulties with speech or movement. Followup Instructions: Please see Dr. [Last Name (STitle) 739] in 2 weeks with a head CT scan (non-contrast). Please call [Telephone/Fax (1) ] to schedule the CT scan and appointment. Please keep your scheduled appointment with [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13790], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 44] on [2121-1-2] at 4:00. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2120-12-2]	[ "2720", "4019" ]
Admission Date: [2155-12-3] Discharge Date: [2155-12-11] Date of Birth: [2073-8-30] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1481] Chief Complaint: abdominal pain, small bowel obstruction Major Surgical or Invasive Procedure: Exploratory Laparotomy with Lysis of Adhesions History of Present Illness: 82F with abdominal pain and decreased PO intake since [2155-12-1]. Pt was transferred here from OSH after NGT decompression of one liter. CT scan at OSH showed small bowel obstruction. Pt's only surgery was an appendectomy at the age of 7. No recent colonoscopy reported. Pt denies any nausea or vomitting. Pt's last bowel movement was reported to be [12-1]. Pt denied fever, chills, chest pain, SOB, constipation, diarrhea, or urinary symptoms. Patietn was transferred and upon receiveing patient, it was decided that she would need an operation to relive the obstruction, and was therefore booked for urgent laparotomy. Past Medical History: PMH: Afib, HTN, NIDDM, dementia, hepatitis(20 years ago) PSH: Appendectomy at age 7 Social History: Lives with husband. [Name (NI) 1139]:none EtOH:occasional drugs:none Family History: Noncontributory Physical Exam: Physical Exam on Admission: VS: T:97.4 P:92 BP: 134/83 RR:20 O2sat: 97RA GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: irregular rythym PULM: CTA B/L w no W/R/R, normal excursion, no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: softly distended, NT, tympanitic, no mass, no hernia appreciated, no hernia, scar c/w prior open appendectomy PELVIS: no femoral/inguinal hernia EXT: WWP, no CCE, no tenderness, 2+ B/L radial/DP/PT NEURO: A&Ox1, no focal neurologic deficits, dementia DERM: rash over elbows PSYCH: normal mood/affect Pertinent Results: [2155-12-3] 02:25AM BLOOD WBC-12.2* RBC-4.05* Hgb-12.7 Hct-37.3 MCV-92 MCH-31.3 MCHC-33.9 RDW-12.9 Plt Ct-359 [2155-12-3] 10:45AM BLOOD WBC-9.5 RBC-3.91* Hgb-12.6 Hct-36.1 MCV-92 MCH-32.3* MCHC-35.0 RDW-13.0 Plt Ct-316 [2155-12-5] 07:30AM BLOOD WBC-2.7# RBC-3.15 Hgb-10.0* Hct-29.0* MCV-92 MCH-31.9 MCHC-34.6 RDW-12.7 Plt Ct-237 [2155-12-7] 11:30AM BLOOD WBC-5.3# RBC-3.23* Hgb-10.3* Hct-30.0* MCV-93 MCH-31.8 MCHC-34.3 RDW-12.6 Plt Ct-302 [2155-12-8] 06:20AM BLOOD WBC-5.3 RBC-3.39* Hgb-10.9* Hct-31.7* MCV-93 MCH-32.1* MCHC-34.4 RDW-13.0 Plt Ct-287 [2155-12-3] 02:25AM BLOOD Neuts-92.5* Lymphs-4.6* Monos-2.8 Eos-0.1 Baso-0.1 [2155-12-3] 02:25AM BLOOD PT-27.2* PTT-28.4 INR(PT)-2.6* [2155-12-3] 08:28PM BLOOD PT-18.9* PTT-29.4 INR(PT)-1.7* [2155-12-4] 02:13AM BLOOD PT-15.7* PTT-27.4 INR(PT)-1.4* [2155-12-10] 06:00AM BLOOD PT-19.6* PTT-34.5 INR(PT)-1.8* [2155-12-3] 02:25AM BLOOD Glucose-258* UreaN-40* Creat-1.1 Na-137 K-3.9 Cl-99 HCO3-22 AnGap-20 [2155-12-8] 06:20AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-141 K-3.7 Cl-111* HCO3-23 AnGap-11 [2155-12-3] 02:25AM BLOOD ALT-11 AST-22 AlkPhos-31* Amylase-63 TotBili-0.5 [2155-12-3] 02:25AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.7 Mg-1.6 [2155-12-8] 06:20AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.7 [2155-12-3] 02:28AM BLOOD Lactate-2.3* CT Abdomen and Pelvis ([2155-12-3]): Findings concerning for midgut volvulus with ischemic segments of small bowel in the left abdomen. The volvolus has led to complete small bowel obstruction with collapse of the colon. Differential diagnosis includes internal hernia although this is considered less likely. Brief Hospital Course: The patient was taken to the OR for exploratory laparotomy and lysis of adhesions on [2155-12-3]. She tolerated the procedure well. See operative note for details, but in brief, she had a band like adhesion causing obstruction, and proximal to this she ahd a small bowel volvulus around the mesentery. Postoperatively, in the PACU, she had an episode of rapid atrial fibrillation and was given 5 mg lopressor IV without effect, and 10 mg diltiazem IV with consequent improvement in heart rate. CK-MB cardiac markers were sent given potential ST changes on EKG, but these values were normal. The patient was transferred from the PACU to the surgical intensive care unit for monitoring overnight. She remained stable. Her pain was controlled with intravenous morphine. On post-op day two, she was transferred to the surgical floor. She was monitored with continuous telemetry. She was given lopressor IV 10 mg every four hours for rate control of her atrial fibrillation with rapid ventricular rate. She had episodes of mild agitation and delirium with pulling at some of her intravenous and monitoring lines. She was given haldol and risperdone by mouth for her agitation. She had an episode of atrial fibrillation with RVR on the morning of post-op day four that required metoprolol IV and subsequent hydralazine IV. She was seen by our inpatient geriatrics team. As her sleep-wake cycle normalized, she became lucid, alert, and oriented times three. On post-op day four she was advanced from sips to clears, which she tolerated well. She had a bowel movement, ambulated, and her foley was discontinued with subsequent incontinence (baseline) but no retention. She was seen by our inpatient physical therapy team who recommended PT at home and 24-hour supervision at home. On post-op day six she was restarted on her home regimen of coumadin and she received two 5 mg doses before she left. On [2155-12-10] she was felt to be medically stable enough for discharge to home with services. She was ambulating with contact guarding. She was pleasantly demented, as was her baseline, and she was cleared for home with supervision as attested to by her daughter. Medications on Admission: [Last Name (un) 1724]: Metformin 500 [Hospital1 ], Metoprolol 25 [Hospital1 ], Lasix 20, Diovan/HCTZ 12.5, Coumadin (alternates two days 5mg, one day 2.5mg) Discharge Medications: 1. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Diovan HCT 80-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Coumadin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: Alternates two pills for two days, then 1 pill for 1 day (and repeat). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Small Bowel Obstruction Atrial Fibrillation with Rapid Ventricular Response Hypertension Diabetes Mellitus Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 1511], You were admitted to the West 3 Surgery Service at [Hospital1 18] for a small bowel obstruction. You had surgery for this issue and you improved nicely during your stay here. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash 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. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Please call ([Telephone/Fax (1) 1483] upon discharge to schedule an appointment in the office of Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] in [1-26] weeks, or with any questions/concerns. Clinic is located in the [Hospital ] Medical Office Building, [Location (un) ], [Hospital1 18].	[ "42731", "4019", "25000" ]
Admission Date: [2108-3-14] Discharge Date: [2108-3-20] Service: ACOVE CHIEF COMPLAINT: Hypertensive urgency HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of hypertension, diabetes type II, chronic pain from peripheral neuropathy, deep venous thrombosis who presented to [Hospital6 2018] on [2108-3-13] in the evening with complaints of slurred speech, word finding difficulty, headache and nausea. The dysarthria had been going on for about two days. The nausea had been intermittent x2 weeks, but on admission was constant. The patient lives at [Hospital3 537], where her blood pressure was found to be 220 systolic while her baseline is 160 to 170. She was transferred to [Hospital6 1760] for further evaluation. On evaluation in the Emergency Department, the patient was found to be neurologically intact, without signs of dysarthria or aphasia. Nitropaste and intravenous labetalol were given without much effect. Neurology consult was obtained. The found that the patient was neurologically intact, recommended CT of the head. CT of the head showed no evidence of acute intracranial pathology. The patient was given 160 mg of Diovan and atenolol 25, with no significant change. Also, secondary to the patient's complaint of her pain in her legs, she was given multiple doses of morphine sulfate as well as Ativan. She at that time had some decrease in her blood pressure from the 240s to 200s. The patient was also given 5 of Norvasc, intravenous nitroglycerin drip was started and a systolic blood pressure of 160 to 170 was reached at a rate of 40 mcg an hour. The patient was then transferred to the Medical Intensive Care Unit due to a lack of beds on the cardiology floor. PAST MEDICAL HISTORY: 1. Type II diabetes 2. Hypertension 3. Peripheral neuropathy 4. Peripheral vascular disease 5. Deep venous thrombosis 6. Hypothyroid 7. Status post right hip replacement 5 years ago HOME MEDICATIONS: 1. Diovan 80 qd 2. Oxycodone 20 [Hospital1 ] 3. Synthroid 0.75 qd 4. Glyburide 2.5 qd 5. Coumadin 6.5 q hs DRUG ALLERGIES: PHENOBARBITAL SOCIAL HISTORY: The patient lives at [Hospital3 ] at [Hospital3 537]. No alcohol or tobacco. Her primary care physician is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The patient is a full code. PHYSICAL EXAM ON ADMISSION TO MEDICAL INTENSIVE CARE UNIT: VITAL SIGNS: Temperature 98.8??????, blood pressure 164/72, pulse 86, respiratory rate 16, O2 saturation 96%. GENERAL: The patient is an elderly female in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Pupils are reactive to light. Extraocular movements intact. Mucous membranes dry. NECK: Bilateral bruits. Neck supple, no jugular venous distention. CHEST: No wheezes or crackles, transmitted upper airway sounds. CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2, 3/6 systolic murmur at the left upper sternal border and radiating into the carotids, no S3 or S4. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: Petechiae on hands as well as feet, no cyanosis, clubbing or edema. NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves II through XII intact, decreased hearing. Motor was [1-24] in all major muscle groups. Sensation intact to light touch. Gait was not assessed on admission. LABORATORY STUDIES ON ADMISSION: White count 6.4, hematocrit 33.7, platelets 239. PT 19.6, PTT 46.3, INR 2.7. Sodium 129, potassium 4.2, chloride 88, bicarbonate 29, BUN 17, creatinine 0.9, glucose 94. 63% neutrophils, 25 lymphocytes, 8 monocytes. IMAGING: CT of the head showed no acute intracranial process, moderate mucosal thickening of left sphenoid sinus. Electrocardiogram was normal sinus rhythm with normal access and intervals, isolated Q wave in 3 and V1. HOSPITAL COURSE: 1. CARDIOVASCULAR: HYPERTENSION: The patient was initially administered multiple medications in the Emergency Department including nitropaste, labetalol, Diovan 160, atenolol 25, Norvasc 5 and a nitroglycerin drip was started. In the Medical Intensive Care Unit the patient was initially on a nitroglycerin drip, as well as some po labetalol and po Diovan. She had an episode of hypotension with a systolic blood pressure into the 70s, during which time she had mental status changes. The nitroglycerin drip was stopped. She was given a normal saline bolus and her blood pressure improved and the patient became responsive. She then, half an hour later, became unresponsive again but during this time her systolic blood pressure was in the 130s. Nitroglycerin drip was restarted for systolic blood pressure of 212. The patient again became decreased, responsive and neurologic work up commenced as described below. The patient was also noted to have positive cardiac enzymes during that time with a CK peak of 637, an MB of 16, troponin of 11.6 and an MB index of 2.5. She went for an echocardiogram the following day which showed an ejection fraction greater than 55%, mild AF, trace AR and trace MR. [Name13 (STitle) ] CKs and troponins trended down through her hospital stay, and it was thought that the positive enzymes were secondary to her transient hypotension. 2. NEUROLOGIC: The patient initially had a head CT that was negative. She was evaluated by neurology who found her to be neurologically intact. The patient then had some left sided neurologic findings and decline in mental status after the episode of hypotension. She had an MRI/MRA which showed no acute infarct, but decreased flow through the right MCA. Neurology then recommended keeping the patient's systolic blood pressure in the 160 to 180 range. They hypothesized that her symptoms were secondary to decreased flow during hypotension in the setting of a decreased flow through the right MCA. They also recommended an EEG and carotid Dopplers. At the time of this dictation, results of carotid Dopplers are pending. The EEG results are as follows: The EEG showed an abnormality due to presence of intermittent left temporal delta slowing suggestive of a subcortical dysfunction over that region. There was also changes consistent with a mild to moderate widespread encephalopathy. No epileptiform features were seen. This was done on the 27th. The patient, on the 28th, was noted to be having an improved mental status. She had been given significant amounts of Ativan in the Emergency Department and on arrival to the Medical Intensive Care Unit. This was discontinued on the day of the 26th and the patient became more alert and oriented and less agitated. On this day, she was transferred to the floor. She did not require any medications for agitation and her mental status slowly returned to baseline per her family. 3. HEME: The patient has a history of deep venous thrombosis. She was continued on Coumadin throughout her hospital course. She was transiently on aspirin in the setting of ruling in, however this was then discontinued. Whether the patient should be on aspirin long term should be discussed with the patient's primary care physician. 4. PULMONARY: The patient had a chest x-ray on the 26th that was suggestive of possible pneumonia versus atelectasis and a repeat two days later showed resolution of this. Her O2 saturations remained good and no evidence of pulmonary infection. 5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was initially hyponatremic and on a fluid restriction. Once she came out of the Medical Intensive Care Unit and was taking po's, her hyponatremia spontaneously resolved. Electrolyte imbalances that were also noted in the Medical Intensive Care Unit including hypophosphatemia, hypomagnesemia, hypokalemia also resolved with some minimal repletion of potassium and magnesium. The patient was taking good po's at the time of discharge. DISCHARGE DIAGNOSES: 1. Hypertensive urgency 2. Diabetes type II 3. Hypertension 4. Peripheral neuropathy 5. Peripheral vascular disease 6. Deep venous thrombosis 7. Hypothyroid DISCHARGE MEDICATIONS: 1. Metoprolol 25 tid with goal systolic blood pressure 140s to 160s 2. Coumadin 6.5 po q hs 3. Synthroid 0.75 po qd 4. Glyburide 2.5 po qd 5. Colace 100 po bid 6. Senna prn 7. Tylenol prn 8. OxyContin as previously taken FOLLOW UP: The patient should follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) ]. [First Name8 (NamePattern2) ] [Name8 (MD) 4174], M.D. [MD Number(1) 7901] Dictated By:[Name8 (MD) 2069] MEDQUIST36 D: [2108-3-20] 07:56 T: [2108-3-20] 08:34 JOB#: [Job Number 38929]	[ "2761", "4280", "2449" ]
Admission Date: [2124-3-21] Discharge Date: [2124-4-6] Service: VASCULAR CHIEF COMPLAINT: Endovascular graft leaking. HISTORY OF PRESENT ILLNESS: This patient was initially seen by Dr. [Last Name (STitle) 18835] in [2122-2-5]. He underwent an endovascular abdominal aortic aneurysm repair for an aneurysm secondary to intermittent pain for 2-3 weeks prior to repair. He has been followed continuously and was noted to have endovascular leak. He returned for further treatment of his endovascular leak. PAST MEDICAL HISTORY: 1. Hypertension. 2. Degenerative joint disease. 3. Kidney cyst. PAST SURGICAL HISTORY: 1. Renal surgery for renal cyst, which is remote. 2. T&A, which is remote. 3. Left cataract surgery, which is remote. 4. Bilateral femoral stent placement. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Univasc 25 mg q.d., Prozac 25 mg q.d., Hydrochlorothiazide 25 mg q.d., Lorazepam 1 mg at h.s., Prilosec 20 mg q.d., Beconase nasal spray p.r.n., ................. 20 mg q.d., Viagra 50 mg q.d. SOCIAL HISTORY: The patient lives with his spouse. [Name (NI) ] is retired. He ambulates independently. PHYSICAL EXAMINATION: Vital signs: Blood pressure 146/82, pulse 96. General: The patient was a white male in no acute distress. HEENT: Unremarkable. There were no carotid bruits. Chest: Lungs clear to auscultation. Heart: Regular, rate and rhythm without murmurs, rubs, or gallops. Abdomen: Unremarkable. Bowel sounds positive. Pulse exam: Dopplerable dorsalis pedis and posterior tibial bilaterally. No other pulses were documented. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [2124-3-21]. He underwent removal of endovascular stent graft with an aorto-iliac bypass graft with ligation of the left hypogastric artery. The patient had suprarenal clamping. There was a large amount of thrombus within the aorta. The patient required 3 U packed red blood cells intraoperatively and 700 cc of cell [Doctor Last Name 10105]. The patient was transferred to the PACU in guarded condition. The patient was admitted to the SICU for respiratory support. He was hemodynamically stable. His PAP was 42/29 with a wedge of 12, SVR 1111. He was sedated and intubated. Postoperative hematocrit was 37.2, white count 9.6, BUN 27, creatinine 1.3, potassium 4.1. Nitroglycerin IV was continued to maintain systolic blood pressure in the 100-150 range. He remained NPO. Perioperative Cephazolin was continued. About 7 p.m. of the operative night, the resident was called to see the patient secondary to loss of pulse in the right foot. The patient returned to the operating room at 11:50 for reexploration of thrombectomy of the right ABF limb and external iliac artery. Intraoperative findings included a right ABF limb. There was no twisting or kinking of the graft. There was no thrombus proximally, but there was distal thrombus. At the end of the procedure, the patient had a palpable right femoral and Dopplerable dorsalis pedis and posterior tibial. He returned to the SICU for continued care. Electrocardiogram was without ischemic changes. The patient remained in metabolic acidosis with a decreasing lactate. His cardiac index was diminished but responded to volume repletion. Total CK was 1700, MB 0, and troponin levels negative. On postoperative day #1, he remained afebrile and hemodynamically stable. Hematocrit remained stable at 37.9. Total CK was 1699, 98, MB was 30, MBI index was 1.8, and troponin level was 0.3. Chest x-ray was without failure. The patient remained sedated and intubated. He remained in the unit for continued monitoring. Epidural was placed intraoperative, but this was discontinued secondary to the patient's hypotension. The catheter was kept in place and capped. The catheter was removed when coags returned to [Location 213]. On postoperative day #2, the patient continued a trend of hypoxia. Lungs were clear to auscultation. Abdominal exam was soft, nontender, with no erythema. The patient's hematocrit drifted to 31.3. Chest x-ray showed bilateral pleural effusion with increased vascular congestion and no infiltrates. Total CKs continued to remain elevated, although MBs were 74 and 80 respectively, and indexes were 0.9 and 1.2. Troponin levels continued to remain less than 0.3. Hypoxia was initially attributed to potential volume overload, so fluids were titrated. TPN was begun. The patient's epidural catheter was removed on postoperative day #3. The patient underwent MRI of his spine because of the onset of neurological symptoms of right proximal muscle weakness and diminished deep tendon reflexes. The epidural was removed, and the tip was intact. The MR [First Name (Titles) ] [Last Name (Titles) 3780] that this did not show any definite epidural hematoma. By postoperative day #3, the patient developed some thrombocytopenia. Blood specimen for HIT was sent. Heparin was discontinued. The patient's CK continued to be elevated, and troponin level was 14.0 on postoperative day #3. There were no acute electrocardiogram changes. Troponin levels over the next 48-72 hours showed definite decline. The patient's platelet count improved after discontinuation of the Heparin. The patient's clinical status was also compounded with acute renal failure with an increase in creatinine, peaking to 2.2. The patient continued to diurese. Creatinine remained stable at 2.2. The PA line was discontinued on postoperative day #5. Postoperative chest x-ray was without pneumothorax. The patient had persistent low-grade temperatures. Sputum cultures were sent which grew ..............., moderate, and .................... which were pansensitive. The patient was begun on Levofloxacin. Others obtained the same time included urine culture, blood cultures, which were no growth, and CD tip culture which grew greater than 15 colonies of Enterococcus resistant to Levofloxacin, sensitive to Ampicillin, Penicillin, and Vancomycin. There were chest x-ray findings consistent with bilateral lower lobe atelectasis versus aspiration. The patient was weaned and extubated on postoperative #8. The patient passed flatus on postoperative day #9, and clear sips were begun. The patient developed some abdominal distention and nausea, and a KUB was obtained which showed an ileus. Ultrasound of the gallbladder and liver was unremarkable. A discussion was had with the patient regarding the risks and benefits of NG tube placement, but the patient continued to refuse to have NG placed. He was placed back on NPO, and TPN was continued. His renal insufficiency began to show resolution by postoperative day #12 with a creatinine of 1.9. On postoperative day #12, the patient started bowel movements. Abdomen still remained distended. He continued to be NPO. His diet was advanced to clears on postoperative day #13. Antibiotics of Levofloxacin and Vancomycin were discontinued on [4-3]. The patient was transferred to the regular nursing floor. The patient continued to show clinical improvement. His diet was advanced as tolerated. His Levofloxacin was not discontinued because of his pneumonia, and this will be continued for a total of 14 days from [2124-4-4]. Case Management and Physical Therapy evaluated the patient for discharge planning and rehabilitation. TPN will be slowly weaned as the patient tolerates his p.o. intake. This should be discontinued at the time of discharge. Wounds at discharge were clean, dry, and intact. He should follow-up with Dr. [Last Name (STitle) ] in two weeks. DISCHARGE MEDICATIONS: Albuterol 90 mcg aerosol 2-4 puffs q.6 hours, Ipratropium Bromide 18 mcg aerosol with adapter 4 puffs q.i.d., Morphine Sulfate 2 mg q.4 hours p.r.n. pain, Aspirin 325 mg q.d., Reglan 10 mg IV q.6 hours, when the patient tolerates, this can be converted to p.o. a.c. and h.s., Metoprolol 100 mg b.i.d., Levofloxacin 500 mg q.24 hours for a total of 14-days from [2124-4-4], and this will be continued until [4-17], Nifedipine 30 mg 1 q.d., Protonix 40 mg q.d., Fluroxatine 20 mg q.d. DISCHARGE DIAGNOSIS: 1. Endovascular stent leak status post endovascular stent removal with an aorto-iliac bypass graft. 2. Right leg ischemia status post reexploration with thrombectomy of the right aorto-bifemoral limb with a jump graft from the right ABF limb to the right external iliac artery. 3. Q-wave myocardial infarction. 4. Aspiration pneumonia with two organisms, ................... and Enterococcus .................., treated. 5. CVL hip line infection, treated. 6. Postoperative ileus, resolved. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2124-4-5] 11:28 T: [2124-4-5] 11:44 JOB#: [Job Number ], [Numeric Identifier 105286]	[ "5070", "41071", "51881", "5849" ]
Admission Date: [2173-8-9] Discharge Date: [2173-8-14] Date of Birth: [2145-8-19] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5167] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: None (Intubated at an outside hospital) History of Present Illness: Mr. [Known lastname 74621] is a 27 year old man with [Known lastname 60478], s/p VP shunt, seizure d/o, who presents 5 days after a shunt revision with status epilepticus. Per family, pt. had been in his USOH until 1 week PTA (last monday). On monday they felt that he was lethargic and not as interactive as he normally is. He had frequent seizures that day, which his parents describe as brief episodes (1-2 minutes) where his body would twist to the right and would become rigid, and his eyes would "bulge out." The seizures were happening 7-8 times an hour in the 4 hours that his parents observed him that afternoon. In between he was lethargic and never got back to his normal self. They felt that his pupils were assymetric and that the right was larger and less reactive than the left. They therefore brought him to [Location (un) ] ED. There he did not have any witnessed seizure activity per his parents. He had a Head CT, which the parents were told was unchanged from his last CT there several months prior. He was diagnosed with a UTI and sent home. His parents were called the next day by the infirmary at the group home and told that he had no further seizures and that he was "resting comfortably" and had eaten some food. The day after that they were called and told that although he still had no further seizures, he still was quite lethargic and was not waking up. They visited him and felt that he was diaphoretic, unresponsive to his name, and not at all himself (though they agree that they did not see any further seizures) They insisted that he be brought to [Hospital1 336], where he had last had his shunt revised a year earlier. There a Head CT was performed that showed hydrocephalus, and he was emergently taken to the OR for shunt revision. He was monitored for 2 days after that, and discharged home on Friday. His parents reports that on saturday his face was somewhat swollen on the left, and his eye was almost swollen shut. He was awake and more back to himself in terms of his mental status. They brought him back to [Hospital1 336], where they were told that it was normal post-op edema, and he was discharged back home. Today, they were called because he had a protracted GTC. His father describes the seizures he saw at the OSH (he was not present at the group home when the seizures started) He describes that his head was deviated R, and his eyes were deviated up and to the right. He became rigid, grunted loudly, and then started shaking his arms and legs violently. EMS and OSH ED records indicate that he was seizing for about 25 minutes. He received valium 15 mg PR x 2 in the field, and in the ED received Valium 5 mg IV, at which point the seizures stopped. He was intubated for airway protection at 14:00, and started on a Propofol drip at 14:45. He received Dilantin 1 g IV load. He received Ativan 2 mg IV at 17:10 prior to transport (no seizure activity noted at that point in the records) OSH labs at 12:30 were significant for a depakote level of 46, tegretol level of 0.7, normal LFTs, WBC Ct of 12.2, and noraml Chem 7. UA showed 30 protein, 250 glucose, negative ketones, LE, and nitrites, and 0-2 WBCs, lg blood, and mod bacteria. Past Medical History: [Last Name (LF) 60478], [First Name3 (LF) ] parents has a baseline L hemiparesis and can answer some simple Y/N questions, but is otherwise non-verbal Seizure disorder- baseline has a GTC Q3-4 months per parents VP shunt-revised 5 days PTH Social History: Lives in group home ([Location (un) 74622]); parents very involved in care Family History: NC Physical Exam: T- 104 BP- 142/64 HR- 116 RR- 18 O2Sat- 100% on RA Gen: Lying in bed, NAD, intubated HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender Ext: no edema <br> Neurologic examination: Mental status: opens eyes to voice, does not follow any commands. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Blinks to threat bilaterally. EOM intact with Doll's. L facial droop with grimace. + gag on ETT. + corneal bilaterally. Motor/Sensory: Normal bulk bilaterally. increased tone in L arm and leg. No observed myoclonus or tremor. Moves all 4 extremities spontaneously and withdraws them to pain purposefully, R more briskly than L. Reflexes: +2 in RUE and RLE, brisker in LUE and LLE. Toes upgoing on L, downgoing on R Pertinent Results: Labs: Lactate:2.4 136 102 10 -------------< 127 4.1 24 0.7 Ca: 9.2 Mg: 1.7 P: 1.6 WBC 9.3 Hgb 12.3 Plt 292 Hct 34.2 MCV 92 N:90.1 L:4.5 M:4.4 E:0.8 Bas:0.2 PT: 12.3 PTT: 22.3 INR: 1.1 CEREBROSPINAL FLUID (CSF) TUBE 1: WBC-8 RBC-11* POLYS-6 LYMPHS-85 MONOS-9 CEREBROSPINAL FLUID (CSF) TUBE 4: WBC-14 RBC-12* POLYS-5 LYMPHS-86 MONOS-9 CEREBROSPINAL FLUID (CSF) PROTEIN-334* GLUCOSE-80 CSF Cultures and Gram stain: negative Blood cultures: no growth after 5 days. <br> Imaging Non-Contrast Head CT: 1. No evidence of intracranial hemorrhage or hydrocephalus. 2. Chronic encephalomalacic changes most notable of the right cerebral hemisphere. 3. Small chronic subdural hematomas vs. cystic hygromas. 4. VP shunt catheter terminates in the frontal [Doctor Last Name 534] of the right lateral ventricle. No hydrocephalus identified, although prior studies are not available for comparison. <br> CXR: 1. ET tube tip terminates just above the level of thoracic inlet. 2. Pulmonary opacity at the right lung base which may represent aspiration and/or pneumonia. <br> EEG: This is an abnormal portable EEG due to the presence of multifocal sharp and slow wave discharges in a generalized, bifrontal, left hemispheric or right frontocentral distribution. Findings are suggestive of ongoing regions of cortical irritability with potential for epileptogenesis. No video accompanied this study, so it is unclear it a change in state is evident during times of discharges. In addition, multifocal slow transient discharges were noted; this abnormality may be seen in the context of a diffuse process involving the cortex but can also be seen in the context of a mild encephalopathy of toxic, metabolic, infectitious or anoxic etiology. Finally, persistent mixed frequency slowing was noted in the right parasagittal region, suggestive of cortical and subcortical dysfunction in that region. <br> Video Swallow: Mild oral dysphagia. No penetration or aspiration. Mild premature spillover with liquids. Brief Hospital Course: Mr. [Known lastname 74621] is a 27-year-old man with a history of mental retardation, cerebral palsy, a seizure disorder, and hydrocephalus s/p VP shunt placement with a VP shunt revision 5 days ago who presented to an outside hospital in status epilepticus (25 minutes of seizure activity documented); he was transferred to [Hospital1 18] for further care. His hospital course by problem is as follows: 1. Neuro: He was initially admitted to the Neuro ICU after receiving valium, being loaded with phenytoin, and being intubated at [Hospital6 8972]. CSF showed elevated protein and mildly elevated WBC (14), and he was febrile to 104F. He was started on vancomycin, ceftriaxone, and ampicillin for empiric meningitis coverage. However, it was later determined that the protein elevation reflected trapped CSF in the VP shunt and was not due to infection. Neurosurgery was consulted to evaluate the VP shunt function, which was fine. His CSF culture and gram stain were negative. Given his high fever, the trigger was presumed to be infectious. His Tegretol dose was increased from 400 [Hospital1 ] to 400 tid. He was continued on Depakote. Efforts were made to clarify his Lamictal dosing with his outpatient prescriber, but she could not be reached and so he was continued on his outpatient dose of 25 [Hospital1 ]. He did not have any seizures during his hospitalization at [Hospital1 18] and returned to his baseline level of function after 3 days. 2. ID: Pneumonia. As above, he was febrile to 104 and covered for meningitis. However, his CSF cultures were negative. His chest x-ray revealed a RLL opacity consistent with pneumonia; After receiving 4 days of the above antibiotics, he was given 3 days of cefpodoxime to complete a 7-day course for pneumonia. 3. FEN/GI: Swallowing. After sedation, he had trouble swallowing and had a nasogastric tube in place. He was cleared for full oral nutrition and medications by a video swallow study. He therefore resumed his prior diet. 4. Code: full 5. Dispo: He was discharged to his group home. Medications on Admission: Senna 3 tabs [Hospital1 ] Colace 100 [Hospital1 ] Tegretol XR 400 [Hospital1 ] Depakote 750 [Hospital1 ] Fluoxetine 30 mg QD Valium 15 mg PR PRN seizure Lamictal 25 mg [Hospital1 ] Trazodone 100 mg QHS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 3. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day): Total 100 mg. 6. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. Valproate Sodium 250 mg/5 mL Syrup Sig: Ten (10) mL PO Q8H (every 8 hours): Total 500 mg q8h. Disp:qs 1 month Refills:2 8. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 doses. Disp:10 Tablet(s) Refills:0 9. Medicaton Valium 15 mg PR prn seizure > 5 minutes or > 3 seizures in an hour. 10. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Discharge Disposition: Extended Care Facility: [Location (un) 74622] Discharge Diagnosis: Primary: 1. Seizure disorder 2. Community acquired pneumonia Discharge Condition: Stable condition. Neuro exam with significant cognitive impairment but non-focal and at baseline. He has occasional vocalization and intermittently tracks examiner. No seizures since admission. Discharge Instructions: You have been evaluated and treated for status epilepticus, a prolonged seizure. You had your Tegretol dose increased to 400 mg three times a day from twice a day. If you have any questions or concerns about your medications, please call your PCP or neurologist. Please take all medications as directed and keep all follow-up appointments. If you develop further seizures that last more than 5 minutes, or if you have more than 3 seizures in an hour, or if you develop any symptom that is concerning to you, please call your PCP or your neurologist or go to the nearest hospital emergency department. Followup Instructions: Please call your neurologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 74623], to schedule a follow-up appointment in [1-17] weeks to discuss the current regimen of seizure medications. Please also call your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 74624], at [Telephone/Fax (1) 74625] to schedule an appointment in [12-15] weeks. Completed by:[2173-8-14]	[ "486" ]
Admission Date: [2168-9-20] Discharge Date: [2168-9-21] Date of Birth: [2109-11-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 338] Chief Complaint: s/p intoxication Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 58M h/o NF1, SVT, CAD s/p stent, chronic EtOH abuse, depression and anxiety presenting with intoxication. The patient was found wandering the streets and brought in for intoxication. He had no signs of trauma. He was thought to be EtOH intoxicated, but his ETOH screen was negative. He then admitted to drinking [12-1] bottle of isopropyl alcohol. . In the ED his initial vitals were T 97.4, BP 122/78, HR 60, RR 22, O2sat 95% RA. He did vomit in the ED x1 per notes. He was given thiamine, folate, and MVI and lorazepam per CIWA scale. He was being admitted to the floor when he developed developed afib with RVR with rates in the 160s. He was given lopressor 5mg x3 with little effect and then dilt 5mg x1 which broke the rapid rate. His blood pressure never dropped with the tachycardia. He was placed on 4L oxygen NC for comfort given tachycardia. He is being transferred to the MICU for close monitoring for withdrawl. . Currently, he denies chest pain, SOB, palpitations, n/v, fevers, chills, dysuria, constipation, diarrhea, muscle pains or aches, headaches or change in vision. He endorses cough. Past Medical History: -- HTN -- CAD s/p RCA stent in [8-/2164] -- s/p closed fract tib/fib -- SVT (AVRT v. AVNRT) -- Chronic EtOH abuse (no h/o seizures; s/p detox 3 years ago, referred to [Hospital1 1680] house partial hospitalization program [5-5]) -- Depression/anxiety ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 66064] [Numeric Identifier 100681] @ [Hospital1 1680] JP; [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12528] [Telephone/Fax (1) 5260]) -- Neurofibromatosis - dx on last admission Social History: Unemployed, living alone in [Location (un) ] MA. Graduated from [University/College 72402]with a major in business, most recent work was as a security guard. Originally from [Hospital1 40198] MA. No siblings or other family. Denies illicit drugs. The patient has been drinking chronically since the mid [2150]'s. He was sober from [2157]-[2160]. In addition, he was sober from [Month (only) 116] to [2167-10-30], but relapsed after losing his job. He has had multiple blackouts, but denies history of w/d seizure or DT's. He denies any history of illicit drug use. He quit smoking 20 years ago, and smoked [4-3] cigs/day at that time. Family History: Mother with depression and CAD. Physical Exam: vitals: T 97.9, BP 121/71, HR 92, RR 14, O2sat 98% 4L NC General: lying in bed with eyes closed but answering questions appropriately HEENT: MMM, edematous lips, PERRL, EOMI Cardiac: RRR no murmur appreciated Pulmonary: CTAB no w/r/r Abdomen: +BS, soft, NTND Extremities: warm, dirt under fingernails. Strong pulses DP2+ symmetric, radial 2+ symmetric Skin: multiple small cutaneous neurofibromas. Several cafe-[Name Prefix (Prefixes) ]-[Last Name (Prefixes) 28584] spots noted. Pertinent Results: [2168-9-21] 04:21AM BLOOD WBC-4.0 RBC-4.54# Hgb-13.3# Hct-40.1 MCV-88 MCH-29.4 MCHC-33.2 RDW-16.0* Plt Ct-255 [2168-9-20] 03:36AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0 [2168-9-21] 04:21AM BLOOD Glucose-98 UreaN-11 Creat-1.2 Na-139 K-4.4 Cl-107 HCO3-23 AnGap-13 [2168-9-20] 03:36AM BLOOD ALT-19 AST-22 LD(LDH)-161 CK(CPK)-77 AlkPhos-91 TotBili-0.5 . CXR [9-20]: Comparison study of [9-5], there is again elevation of the right hemidiaphragmatic contour with atelectatic changes at the right base. The remainder of the right lung and the left lung are essentially clear. Brief Hospital Course: Assessment/Plan: 58 M h/o NF1, SVT, CAD s/p stent [2163], chronic EtOH abuse, depression and anxiety presenting with intoxication. . # Isopropyl alcohol ingestion: Patient admits to ingestion of isopropyl alcohol and had large amounts of acetone (metabolite) in the blood. He initially had a gap acidosis (AG 18) which resolved with fluid hydration. Initially put on a CIWA scale out of concern for etoh withdrawal, although this did not develop during this hospitalization. He was advised to not ingest further isopropyl EtOH in the future. SW was consulted and offered him placement in [Hospital1 ] House which he had been at in the past. . # Afib/Tachycardia: h/o SVT (AVRT vs. AVNRT). He had rate of 160s in the ED which broke with diltiazem. [Month (only) 116] have been mediated by med non-compliance vs etoh induced. Continued bblocker in-house without further recurrence of symptoms. . # Mild ARF: Had slight elev of Cr to 1.3 from baseline of 0.9. Partially resolved with IVF hydration to 1.2 at discharge. Initially held ACE which was restarted on discharge. Asked for patient to follow up with his PCP to have creatinine rechecked as an outpatient next month to ensure resolution to baseline. . # CAD: s/p stent [2163]. No acute issue. Continued ASA, statin, beta-blocker during his admission. . # Neurofibromatosis 1: diagnosed recently. Stable. . # Brain lesion: likely glioma per Dr. [Last Name (STitle) 724] (neuro-onc) note but slow growing. Seen by Dr [Last Name (STitle) 724] while here who stated that.... . # Anxiety/Depression: Has been on Celexa/Seroquel in past - continued during this hospitalization. To follow up with Dr. [Last Name (STitle) ] at [Hospital6 ] for further psychiatric issues. . # Hypertension: Initially held ACE, and continued BBlocker. ACE restarted on day of discharge. . # Communication (Per OMR): [Name (NI) ] [Name (NI) ] (HCP, neighbor) [Telephone/Fax (1) 100683] . DISPO - Patient discharged to f/u with his PCP as scheduled. Medications on Admission: Medications (from last d/c summary): -Thiamine HCl 100 mg Tablet PO DAILY -Folic Acid 1 mg Tablet PO DAILY -Hexavitamin TabletPO DAILY -Atorvastatin 10 mg Tablet PO DAILY -Lisinopril 5 mg Tablet PO DAILY -Atenolol 100 mg Tablet PO once a day Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Isopropyl alcohol intoxication Atrial Fibrillation now resolved Mild acute renal failure now resolved Discharge Condition: Stable to be discharged home Discharge Instructions: You were admitted with alcohol intoxication - please avoid drinking further as this will continue to damage your health. Please follow up with the [Hospital1 ] house to continue your detox program. Please follow up with your primary care doctor and Dr. [Last Name (STitle) 724] from neurology to continue to treat your medical problems. Please take medications as indicated below. No changes to your medications were made during this admission. If you develop any concerning symptoms, please contact your doctor or report to the nearest hospital. Followup Instructions: You are scheduled to see your primary care doctor Dr. [First Name (STitle) ] on [2168-10-27] at 2:30pm. Please go to [Hospital Ward Name 23] [Location (un) ] for this apointment. Call [Telephone/Fax (1) 250] if you need to reschedule this appointment. Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] at ([Telephone/Fax (1) 6574] to schedule a follow up appointment. Completed by:[2168-9-21]	[ "5849", "2762", "42731", "41401", "V4582", "4019" ]
Admission Date: [2193-12-15] Discharge Date: [2194-1-11] Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is an 84-year-old gentleman with a history of coronary artery disease, status post myocardial infarction was transferred to the [Hospital6 1760] on [2193-12-15] after awakening early in the morning with shortness of breath, chest congestion, shakiness, and nausea. The medics were called at that time by the patient's wife who brought him to [Name (NI) 1474] Hospital. He was treated there with IV Lasix and sublingual nitroglycerin as well as beta blockers and aspirin and placed on a heparin drip, a nitroglycerin drip, and he was transferred to [Hospital6 256] for further treatment. Upon admission, the patient was afebrile. He was in sinus rhythm of 70s, blood pressure 180/60, and his 5 liter nasal cannula oxygen saturation was 94-95%. On his physical examination, he did have jugular venous distention. He also had bibasilar crackles about half way up both lung fields. His physical examination was otherwise unremarkable. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2191]. 2. Hypercholesterolemia. 3. Peripheral vascular disease, status post bilateral carotid endarterectomies in [2188]. ADMISSION MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Lasix 20 mg p.o. q.d. 3. Atenolol 25 mg p.o. q.d. 4. Zyprexa 5 mg p.o. q.d. 5. Isosorbide 30 mg p.o. q.d. 6. Allopurinol 100 mg p.o. q.d. 7. Aricept 10 mg p.o. q.d. 8. Proscar 5 mg p.o. q.d. HOSPITAL COURSE: The patient was noted to have some memory and cognition difficulties upon admission to the hospital and unable to consent to procedures. He underwent cardiac catheterization on [2193-12-16] and this revealed a left ventricular ejection fraction of 30%, left main coronary artery stenosis of 70-80%, as well as three vessel coronary artery disease. A Neurology consultation was also obtained on [2193-12-16] due to the patient's mental status. It was the Neurology Service recommendation to get an MRI as well as to check some laboratory values. Cardiac Surgery consultation was obtained also on [2193-12-16] and it was felt that to sort out the patient's mental status and neurologic status prior to proceeding with coronary artery bypass surgery. On [2193-12-17], the patient underwent carotid ultrasound studies which showed no significant plaque in the right internal carotid artery, however, the left was not visualized and felt to be occluded. He was noted to have patent vertebral arteries, the right being with less blood flow than the left. Over the next couple of days, the patient did clear from a mental status standpoint, however, was noted to have some ST changes by EKG. This was treated medically. On [2193-12-18], the patient was seen by the Neurosurgery Service due to his neurovasculature. It was their recommendation to schedule the patient for angiography the following day to evaluate his carotid artery and cerebral blood flow. On [2193-12-19], the patient was also seen by the Rheumatology Service due to a new complaint of right knee pain. The patient did have an aspiration of the knee joint at that time and it was the rheumatologist's assessment that this could be gout in his knee. Cerebral angiography on [2193-12-19] revealed an occluded left internal carotid of 70% stenosis bilaterally of the vertebral arteries at that time. The patient continued to be followed on the Medical Service. He was placed on Plavix due to his cerebrovascular disease. On [2193-12-23], the patient was taken to the Neuroradiology Department to have stents placed in both the right and left vertebral arteries. This was done by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132]. The patient remained stable postprocedure and was transferred to the Intensive Care Unit for neurological checks and close monitoring. The patient remained hemodynamically stable in the Surgical Intensive Care Unit recovering from his vertebral artery stents awaiting coronary artery bypass grafting. On [2193-12-27], the patient was taken to the Operating Room with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] who performed an off-pump coronary artery bypass graft times three with a LIMA to the diagonal, saphenous vein graft to the OM and saphenous vein graft to the RPL. Postoperatively, the patient was on nitroglycerin, Neo-Synephrine, and Propofol drips. He was transported from the Operating Room to the Cardiac Surgery Recovery Unit in good condition. On postoperative day number one, the patient was weaned from mechanical ventilation and extubated and doing well. However, despite receiving blood transfusion had remained with low mixed venous oxygen saturations. He was ultimately started on milrinone IV drip for low cardiac output and low mixed venous oxygen saturations. He remained stable on milrinone and Neo-Synephrine drips over the next few days in the Intensive Care Unit. He was placed on levofloxacin due to copious pulmonary secretions. He continued to be transfused to maintain a hematocrit above 30% due to low C02s. On postoperative day number three, the patient underwent video swallow evaluation due to questionable aspiration risk and it was found that he was an aspiration risk with thin liquids but able to tolerate thick liquids and solid foods without a problem. The patient had multiple episodes of postoperative atrial fibrillation. On postoperative day number four, the Electrophysiology Service was consulted with the recommendation to continue the Amiodarone that he had been on and perhaps to add digoxin as well. The Heart Failure Service was also consulted at that time due to continued need for milrinone and low cardiac output. It was their recommendation to discontinue diuresis as the patient was intravascularly dry and to give low-dose daily digoxin. The patient continued to progress slowly in the Intensive Care Unit on milrinone, Amiodarone, and heparin drips. On postoperative day number six, the patient did receive some fluid, had some more continued atrial fibrillation, and ultimately converted out of that, being started on Lopressor and weaning his milrinone down. The patient continued to stay in the Intensive Care Unit. As oral Captopril was initiated, milrinone was discontinued on postoperative day number seven. The patient's Swan-Ganz catheter was also removed at that time and clinically the patient continued to progress appropriately. He remained hemodynamically stable over the next few days and was ultimately transferred out of the Intensive Care Unit to the telemetry floor on [2194-1-6], postoperative day number ten. He has progressed very slowly from a physical therapy standpoint and it is the recommendation that the patient be transferred from the acute care setting to a rehabilitation facility to work on increasing mobility and endurance. The patient has remained hemodynamically stable, had some troubles with hypertension and his Captopril has been increased over the past few days. The patient remained hemodynamically stable. He has had no further episodes of atrial fibrillation for the past few days and ready to be transferred to a rehabilitation facility. The patient's condition today, [2194-1-10], is as follows: Temperature 97.6, pulse 64, normal sinus rhythm, respiratory rate 20, blood pressure 134/45, although he had been as high as the 160s or 170s earlier this morning. His weight today is 67.6 kilograms. Neurologically, the patient is awake, alert, and oriented, moving all extremities well but does have a significantly flat affect. Pulmonary examination revealed that the lungs were clear to auscultation bilaterally. Coronary examination revealed a regular rate and rhythm with no murmur noted. His abdomen was benign. His extremities were warm and well perfuse without peripheral edema. His sternal incision was clean, dry, and intact. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Ranitidine 150 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Tylenol 325 mg p.o. q. four hours p.r.n. 5. Milk of magnesia q.d. p.r.n. 6. Plavix 75 mg p.o. q.d. times three months. 7. Digoxin 0.0625 mg p.o. q.d. 8. Amiodarone 400 mg p.o. q.d. 9. Lopressor 50 mg p.o. b.i.d. 10. Captopril 50 mg p.o. t.i.d. 11. Zyprexa 5 mg p.o. q.d. 12. Allopurinol 100 mg p.o. q.d. 13. Aricept 10 mg p.o. q.d. 14. Proscar 5 mg p.o. q.d. 15. Lipitor 10 mg p.o. q.d. FOLLOW-UP: The patient is to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] in approximately three weeks. His office number is [Telephone/Fax (1) 170]. The patient is to follow-up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 17025], upon discharge from the rehabilitation facility. He is also to follow-up with his primary cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] also upon discharge from rehabilitation. He should follow-up with the neurosurgeon, Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132], upon discharge from rehabilitation. Dr.[Name (NI) 9224] office number is [Telephone/Fax (1) 1669]. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Vertebral artery stenosis. 2. Coronary artery disease, status post coronary artery bypass graft. 3. Postoperative atrial fibrillation. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Doctor Last Name 28028] MEDQUIST36 D: [2194-1-10] 05:11 T: [2194-1-10] 17:22 JOB#: [Job Number 53601]	[ "41071", "4280", "42731", "40391", "41401" ]
Admission Date: [2158-2-7] Discharge Date: [2158-2-10] Date of Birth: [2106-11-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization and bare metal stent placement in right coronary artery History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: 51 yo M with cardiac risk factors including IDDMx18 years, smoker who recently quit 1 week ago, father with MI at age 49, who presents with 5/10 nonradiating SSCP associated with diaphoresis, lightheadeness, dizziness, nausea & emesis . The pain started suddenly while he was at rest about 2 hrs prior to ED visit. No prior MI. In route with EMS, he vomited x1 and was given SLNG x2 and ASA. . In the ED, he was 128/107, 76, 11, 100% on NRB. EKG showed inferior lateral STE. Code STEMI was called. He was given metoprolol, nitro gtt, plavix load 600mg, heparin gtt and brought to the cath lab. . In the cath lab, he had a BMS placed to the RCA. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for current absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: IDDM HTN Anxiety Depression ? Sleep apnea Social History: Social history is significant for tobacco use. Patient reports that he quit smoking 1 week prior to presentation. Does report drinking 2 glasses of vodka per night. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: 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: [2158-2-7] 09:45AM PT-11.0 PTT-22.7 INR(PT)-0.9 [2158-2-7] 09:45AM PLT COUNT-408 [2158-2-7] 09:45AM NEUTS-87.0* LYMPHS-8.7* MONOS-3.5 EOS-0.2 BASOS-0.6 [2158-2-7] 09:45AM WBC-13.6* RBC-4.98 HGB-16.4 HCT-47.4 MCV-95 MCH-33.0* MCHC-34.7 RDW-13.0 [2158-2-7] 09:45AM CALCIUM-10.0 PHOSPHATE-1.8* MAGNESIUM-1.8 [2158-2-7] 09:45AM estGFR-Using this [2158-2-7] 09:45AM GLUCOSE-144* UREA N-11 CREAT-0.8 SODIUM-137 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-20 [2158-2-7] 09:50AM cTropnT-0.02* [2158-2-7] 10:43AM HGB-13.1* calcHCT-39 O2 SAT-98 [2158-2-7] 10:43AM TYPE-ART O2 FLOW-15 PO2-180* PCO2-15* PH-7.67* TOTAL CO2-18* BASE XS-0 INTUBATED-NOT INTUBA [2158-2-7] 12:02PM PLT COUNT-347 [2158-2-7] 06:33PM PLT COUNT-290 [2158-2-7] 06:33PM CK-MB-342* MB INDX-11.0* . ECHO [2158-2-8]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior fat pad. IMPRESSION: Normal chamber sizes with mild regional left ventricular systolic dysfunction c/w CAD. Mild mitral regurgitation. . Cardiac catheterization: COMMENTS: 1. Coronary angiography in this right dominant system revealed one vessel coronary artery disease. The LMCA, LAD, LCx had no flow-limiting coronary artery disease. The RCA was totally occluded proximally. 2. Resting hemodynamics revealed elevated left and right sided filling pressures with mean PCW of 23 mmHg and RVEDP of 20 mmHg. There was mild-moderate pulmonary arterial hypertension with PASP of 35 mmHg. The cardiac index was 2.2 L/min/m2. There was normal systemic arterial pressure of 133/83 mmHg on Dopamine drip. 3. Left ventriculography was deferred. 4. Successful PTCA and stenting of the proximal RCA with a 4.0 x 24 mm DRIVER BMS. FInal angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI II flow in the distal RCA. (See PTCA comments) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Left ventricular diastolic dysfunction. 3. Elevated right sided filling pressure. 4. Acute Inferiot myocardial infarction. 5. Successful PCI of the proximal RCA. Brief Hospital Course: . ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: 51M smoker, IDDM, HTN, and +family history who presents with IMI-STEMI. Now s/p cath with BMS to RCA. . # CAD/Ischemia: No further chest pain - asa, plavix (for 1 year per cath report), statin, as tolerated - Started low dose bblocker and ace inhibitor and titrated as blood pressure tolerated. - Fasting lipids normal with LDL of 72 and HDL of 92. - HbA1c 13.1 - Patient to take home Chantix . # Pump: EF 45% with some hypokinesis of inferior walls noted on ECHO. Not in acute or chronic heart failure. On ACE inhibitor for comorbid coronary artery disease. . # Rhythm: Initially noted to have runs of NSVT, up to 11 beats post procedure, thought to be due to reperfusion injury. Monitored on telemetry for duration of admission and noted to have occasional PVCs with no further NSVT 24 hours after catheterization. . # Valves: 1+ MR noted on ECHO otherwise no valvular disease. . # HTN: Normotensive; on betablocker and ace inhibitor for coronary artery disease. . # DM: On lantus and novalog at home. Started on half home dose regimen for hypoglycemia post myocardial infarction. FS then elevated to 400s. Restarted on home regimen with improvement. HgA1C significantly elevated to 13.1. Given new glucometer. Will need close follow up of his diabetes mellitus. . # Depression - Continued Prozac . Medications on Admission: Lantus 50 Units SQ Q PM Novolin 15 Units SC before meals Prozac 40mg daily Chantix Medication for anxiety - unclear of name ativan viagra flexpan? Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Lantus 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous qPM. 7. Novolin N 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous before meals. 8. Medical supplies Glucometer 9. One Touch Ultra Test Strip Sig: One (1) strip In [Last Name (un) 5153] four times a day. Disp:120 strips Refills:2 10. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:120 lancets Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Inferior Myocardial infarction Secondary: Insulin dependent diabetes Discharge Condition: Good, chest pain free, vital signs stable Discharge Instructions: You were admitted to the hospital with a heart attack. You had a stent placed in your coronary artery to open up the blockage. . You were started on new medication which include: Aspirin Plavix Lisinopril Toprol XL . Please call [Hospital6 ] to update your registration information at ([Telephone/Fax (1) 1921]. You have been set up with a follow up appointment with a new primary care physician. [Name10 (NameIs) ] below. For registration purposes, [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ] will be listed as your primary care physician. . Please call Cardiology clinic to set up an appointment with a cardiologist ([Telephone/Fax (1) 2037] . Please call your doctor or return to the emergency room if you develop any worrisome symptoms such as shortness of breath, chest pain, palpitations, lightheadedness, bleeding, etc. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2671] [Last Name (NamePattern4) 11064], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2158-3-16] 3:30 located at [Hospital6 733], [Hospital Ward Name 23] Building [Location (un) ], [Location (un) 830] [Location (un) 86], MA	[ "41401", "3051", "25000", "V5867", "4019" ]
Admission Date: [2157-12-2] Discharge Date: [2158-1-18] Date of Birth: [2101-9-15] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Altered mental status, fatigue Major Surgical or Invasive Procedure: [2157-12-12] liver [Month/Day/Year ] [2157-12-14] roux en y hepaticojejunostomy [2157-12-18] ex lap colonoscopy History of Present Illness: 56yo man with hepatitis C/ETOH-induced liver cirrhosis with history of decompensation with recurrent ascites and recurrent encephalopathy s/p TIPS in [8-/2156], who is transferred from [Location (un) 21541] Hospital after presenting there with weakness. Per report, pt called EMS with weakness x 4days with fever and chills. He reports poor po intake/anorexia during this time. He denies any dietary indescretion, but he reports increasing abd girth and leg swelling. He did report a few missed doses of lactulose prior to weakness. . He was found by EMS in pool of stool, BS of 42, given an amp of D50 and brought to [Hospital3 ] hospital. He was found to be confused, but reorientable, incontinent of urine, 3+edema. On labs he had k of 6.2 and was given kaexalate, insulin/dextrose, calcium gluconate and repeat of 4.9 on transfer. He had abd CT and u/s of his abdomen which showed ascites, TIPS occlusion. A paracentesis was done. He had bld cxs that grew out GNRs. Pt received 8 vials of albumin for hepatorenal ppx, 1 dose of ceftriaxone and 1 dose of cefotaxime. He was transferred to [Hospital1 18]. . Initial ROS was (+)increasing protuberance of abd with abd pain, He reports that he has gained weight (ideal wt of 149-152), currently 70kgs. +SOB with increasing abd distension. + maroon stools. (-) denies significant confusion, n/v/d/dysuria/cp or any other symptoms. Past Medical History: - Cirrhosis, s/p TIPS placement [8-15] - HepC, dx [2129]: Nonresponder to interferon and ribavirin after six months of therapy in [2149]. From [Month (only) 116] to [2151-12-10], the patient was treated with pegylated interferon and ribavirin for a period of six months. For unclear reasons, this treatment was discontinued. The patient was subsequently enrolled in the colchicine arm of the COPILOT trial in the past. [10-15] viral load is 441,000 IU/mL. - Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last year) - Depression. - Osteoarthritis - Hip osteopenia - Right knee surgery - Bilateral hip repair - s/p Umbilical hernia repair . Social History: Lives on [Hospital3 ] in a garage apartment which he rents from a family with whom he has a good relationship. Also has supportive ex-wife and daughter. [Name (NI) ] works in a recording studio and plays the guitar in a band. He has a history of alcohol abuse (last drink [2136-10-9], drank heavily for 12 years). Also h/o IV drug use many years ago. Pt smoked occasionally for 30 years, quit a year ago. Denies any recent ETOH ingestion. Family History: non-contributory Physical Exam: On arrival to the MICU VS 100.6, 126, 185/90, 27 and 100% on NRB, then 3L NC GENERAL - chronically ill appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, slightly icteric sclera, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - breath sounds in upper lobes, decreased breathsounds at bases, no r/r/w, no accessory muscle use HEART - slightly tachy, RR, with systolic murmur, nl S1-S2 ABDOMEN - tense, tender to palpation, shifting dullness, +splenomegaly, no rebound/guarding, +umbilical hernia - easily compressed EXTREMITIES - WWP, 1+ edema on left, 3+ edema on right 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox2, CNs II-XII grossly Pertinent Results: On Admission: [2157-12-2] WBC-12.9* RBC-2.93* Hgb-10.7* Hct-31.8* MCV-109* MCH-36.5* MCHC-33.6 RDW-16.1* Plt Ct-21# PT-31.8 PTT-56.1* INR(PT)-3.3* Glucose-112* UreaN-63* Creat-2.1# Na-132 K-4.2 Cl-99 HCO3-26 AnGap-11 ALT-36 AST-76* LD(LDH)-488* AlkPhos-143* TotBili-5.6* DirBili-3.3* IndBili-2.3 Albumin-3.0* Calcium-10.7* Phos-3.2 Mg-2.4 At Discharge: [2158-1-17] WBC-10.3 RBC-2.92* Hgb-9.6* Hct-28.4* MCV-97 MCH-32.8* MCHC-33.8 RDW-19.2* Plt Ct-220 Glucose-145* UreaN-52* Creat-1.3* Na-134 K-4.8 Cl-101 HCO3-25 AnGap-13 ALT-157* AST-90* AlkPhos-215* TotBili-0.2 Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-1.6 tacroFK-9.3 [2158-1-2] TSH-15* T4-3.0* T3-53* Brief Hospital Course: Upon arrival at [Hospital1 18], patient was admitted to the [Doctor Last Name 3271]-[First Name4 (NamePattern1) 679] [Last Name (NamePattern1) 4869]. He was treated with Ceftrixone and albumin for presumed SBP and hepatorenal syndrome. Diuretics were held. Lactulose, rifaxamin, and ursodiol were continued. Abdominal ultrasound confirmed no flow through portal vein and likely TIPS occlusion. OSH cultures revealed GNR, speciation revealed Serratia. Ceftriaxone was continued. . On [12-3] a diagnostic paracentesis was performed. Post procedure, he became rigorous with brief hypoxia to 80% on 2L. He was then placed on NRB and transfered to the MICU given concern for impending sepsis, need for high volume resuscitation and poor respiratory status. . Upon arrival the MICU, patient was rigorous, VS 100.6, 126, 185/90, 27 and 100% on NRB, then 3L NC. He denied any pain or recent fever but did report increase in diarrhea. He quickly was weaned from the oxygen. He remained hemodynamically stable with no evidence of sepsis, although he did have recurrent episode of rigors. Blood cultures were negative. . Given known occluded TIPS, elevated bilirubin, and severe ascites, there was consideration of TIPS revision. This was decided against out of concern for worsening liver failure. Therapeutic tap was not performed initially because of infected peritoneum and later out of concern for worsening renal failure (see below). The patient was noted to be on the top of the liver [Month/Year (2) ] list. An NG tube was placed under direct visualization in order to optimize nutrition. . Urinary tract infection: Urine grew enterococcus sensitive to vanco which was started. Vancomycin was held for 4 days for a high level. Creatinine was elevated to 2.1 from 1.0 from three weeks prior. Diuretics were held. Creatinine trended down to 1.4. However, it then rose again. Albumin was given for two days for likely hepatorenal syndrome. . Abdominal pain and elevated WBC: On hospital day 7, a day after beginning tube feeds, the patient complained of abdominal pain with upward WBC trend. KUB did not show evidence of obstruction. The tube feeds were stopped, and stool studies sent for c diff. Repeat diagnositic paracentesis demonstrated 190 leukocytes, 78% PMN. . Osteoporosis/hypercalcemia: Patient had known vertebral compression fractures and low bone mineral density. The etiology of osteoporosis was thought to be a combination of poor nutrition, alcoholism, and hypogonadism (see below). Spine films to rule out new fracture showed evidence of pelvic fracture. Follow-up dedicated pelvic films confirmed fractures involving bilateral superior and inferior pubic rami and bilateral sacral ala fractures. The orthopedics consult service saw the patient and recommended weight bearing as tolerated and brace to be worn when oob. The patient was initially given calcitriol and calcium supplementation for treatment of osteoporosis. These were stopped in consultation with the endocrinology consulting service given borderline elevated calcium and replete 1,25 hydoxy vitamin D levels. His hypercalcemia was thought to be due to prolonged immobilization, and PTH levels were appropriately low. . Hypogonadism: As part of the work-up of his osteoporosis, testosterone, FSH, and LH were checked and found to be low. He was given a testosterone patch for supplementation. Further work-up with pitutitary MRI was deferred to the outpatient setting. Hypothyroidism: The patient was found to be hypothyroid, and levothyroxine supplementation was begun. The dose was raised early in [Month (only) ]. Repeat Thyroid studies should be done mid-Decemeber On [12-12], a liver donor was available and the patient accepted the donation. He underwent cadaveric liver [Month/Day (4) ]. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please see operative report for complete details. He received standard induction immunosuppression consisting of solumedrol and cellcept. He received multiple blood products and was transferred to the SICU intubated immediately postop where he continued to recieve blood products for hemostasis. LFTs trended down, but he experienced a large volume of bilious drainage via the JP drains. Therefore, on [12-14], he returned to the OR and underwent roux en y hepaticojejunostomy for cystic duct leak and necrotic recipient bile duct. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Postop, he returned to the SICU intubated. On [12-18], he had melena and NG aspirate that was blood tinged. A colonoscopy was performed noting blood in the entire colon from introduction of the scope in the rectum througout the colon to the cecum. there was blood in the terminal ileum. No discrete bleeding source could be localized in the colon. He received PRBC,plt and FFP. He was taken to the OR by Dr. [Last Name (STitle) 816] for exploratory laparotomy for GI bleeding. There was no obvious blood in the stomach and duodenum, the jejunojejunal anastomosis as well as hepaticojejunostomy were without bleeding. A small incision was made in the Roux limb and irrigated. The anastomosis was fine. There was no obvious blood. Hct stabilized. A PPI drip was given.TPN was given then discontinued when a post pyloric feeding tube was placed. Tube feedings were advanced to goal. Zosyn was stopped on [12-23]. He continued to be hypertensive and tachycardic receiving beta blockers. Free water was given for hypernatremia to 155. This trended down to 148 11/13 am. He became disoriented and a bit paranoid with diffuse tremor. He received zyprexa briefly for this. Protonix drip changed to [Hospital1 ]. A cholangiogram was done on [12-21] which showed the Roux tube migrated out of the biliary tree and out of the Roux limb, terminating within the peritoneal cavity. The patient did not have any more episodes of hematemesis or hematochezia, Hct remained stable at 35, and so his flexseal was placed back again and his NGT removed. His dobhoff tube feeds continued. His sodium rose again to 150 and his free water replacements began. He continued having loose stool. [Date range (1) 46801] Cellcept was decreased to 500 [Hospital1 ] from 1000 [Hospital1 ], and his stool became less loose. Flexaseal was removed. Multiple stool samples were sent for c.diff and culture which were all negative. Banana flakes were added to the feedings. Serum sodium responded to free water replacements and was down to 136. Water boluses were stopped. He remained hemodynamically stable, and so was transferred to the [Hospital Ward Name 121] 10 (Med-[Doctor First Name ] Unit) on [12-28]. Tube feedings were changed from 1/2 strength Nutren Renal to full strength. Diet was slowly advanced. A speech and swallow eval cleared him for solid food. He did not have dysphagia, but lacked lower dentures. Kcal counts were insufficient (143-545/day).The feeding tube was self removed on [1-1] and attempts were made on [1-2] and [1-3] in fluoro to place this post pyloric. This was unsuccessful. The JP drainage decreased significantly allowing for removal of the JPs. The foley was removed and he was initially incontinent requiring a condom catheter. On [12-28], Orthopedics was consulted for the patient's compression fractures; kyphoplasty was not recommended upon review of the CT. Though he got a brace for walking, he remained with back pain. He ambulated a few steps with PT with moderate to max assist with TLSI brace used. [Last Name (un) ] was consulted for hyperglycemia. Low dose NPH insulin was used with sliding scale. NPH was then stopped and just sliding scale utilized for glucoses in the 100-170 range. Immunosuppression was adjusted per protocol with solumedrol weaned down to prednisone taper which is due to be tapered to off within the next ten days. cellcept continued at 500mg [Hospital1 ] and prograf which was adjusted based on daily trough levels with goal level of 10. LFTs were normal and stable. Creatinine fluctuated some likely from prograf. TSH was noted to be 13 on [12-8]. Levoxyl was started. On [1-2], TSH was 15 with T4 of 3.0 and T3 of 53. Levoxyl was increased to 75mcg once daily. He was started on a 14 day course of H Pylori therapy for positive antibody and notation of gastritis and esophagitis when Dobhoff had to be replaced. He received oxycodone for abdominal and back pain. Social work followed for support. He continues with tube feeds at goal with the bridled Dobhoff tube. Diet remains thin liquids which he is tolerating. He is ambulating with 2 person assist and brace whenever he is upright or ambulating. He has intermittent stooling which have all been C diff negative. Medications on Admission: 1. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY 2. Furosemide 40 mg Tablet Sig: (3) Tablet PO DAILY (Daily). 3. Vicodin/Oxycodone 5 mg PRN pain. 4. Pantoprazole 40 mg Tablet, Delayed Release Daily 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID 6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID, titrate to 3 bowel movements per day, do not exceed > 5 BM. 9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 10. Rifaxamin 200mg TID Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): Hold for SBP < 110 or HR < 60. 9. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (MO). 13. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days: H pylori prophylaxis. Through [1-26]. 16. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours): H pylori prophylaxis. Through [1-26]. 17. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: [1-18] - [1-22] then decrease to 5 mg daily on [1-23]. 22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): starting [1-23]. 23. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 24. Tacrolimus Please provide 0.25 mg PO BID in suspension form Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: HCV cirrhosis s/p liver [Hospital1 ] [2157-12-12] bile leak GI bleeding: resolved malnutrition serratia bacteremia UTI< Enterococcus vertebral compression fractures Discharge Condition: stable, fair Discharge Instructions: Please call the [Month/Day/Year 1326] Office [Telephone/Fax (1) 673] if fever > 101, chills, nausea, vomiting, inability to take any of your medications, abdominal pain, worsening diarrhea, abdominal distension, continued weight loss or any concerns Labs every Monday and Thursday [Telephone/Fax (1) 1326] office to adjust all medications Continue tube feeds as ordered Followup Instructions: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2158-1-26] 10:00 [Last Name (LF) ],[First Name3 (LF) 156] [First Name3 (LF) ] SOCIAL WORK Date/Time:[2158-1-26] 11:00 Completed by:[2158-1-18]	[ "5849", "486", "5990", "2760", "2767", "2875", "2449", "311" ]
Admission Date: [2178-12-10] Discharge Date: [2178-12-16] Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female admitted to the Medical Intensive Care Unit with a 3-day history of gross hemoptysis. She was admitted to [Hospital 26200] Hospital from [11-28] through [12-4] for congestive heart failure with large bilateral pleural effusions, responded well to diuresis. A transthoracic echocardiogram was done at that time revealing moderate aortic stenosis, tricuspid regurgitation, mild mitral regurgitation, and severe pulmonary hypertension. After discharge, she felt well at home but then developed blood-tinged sputum on [2178-12-6], that progressed to coughing up large clots of blood. She presented to the [Hospital 26200] Hospital Emergency Department where a chest x-ray showed left lower lobe infiltrate. The patient was afebrile at that time. Of note, the patient was not anticoagulated, and she had stopped taking aspirin on [2178-12-7] in anticipation of an outpatient colonoscopy on the week of admission (scheduled to investigate iron deficiency anemia). She was started on levofloxacin and Flagyl on [12-9] for a questionable pneumonia. On [2178-12-10], she underwent bronchoscopy which revealed a brisk bleed in the left lower lobe with overflow of blood into the right lower lobe. No definite lesions were seen at that time. She remained hemodynamically stable despite a hematocrit drop from 36 to 30, and thus was transferred to [Hospital1 69] for further management. REVIEW OF SYSTEMS: The family reports that at most she vomited a cup full of blood followed by teaspoon amounts. The patient admits to a 30-pound weight loss this summer without intention. PAST MEDICAL HISTORY: 1. Congestive heart failure, diastolic dysfunction. 2. Status post left carotid endarterectomy. 3. Status post cerebrovascular accident in [2178-6-26]. 4. Coronary artery disease, status post myocardial infarction, status post percutaneous transluminal coronary angioplasty in [2171] of right coronary artery in [State 33174]. 5. Hypertension. 6. Non-insulin-dependent diabetes mellitus for 14 years. 7. Status post pelvic fracture in [2178-4-26] secondary to fall. 8. Hyperlipidemia. 9. Hypomagnesemia. 10. Rheumatic fever. 11. Iron deficiency anemia, recent diagnosis. 12. Status post tonsillectomy and adenoidectomy. 13. Status post bladder suspension and rectocele repair in [2177-2-25]. 14. Bilateral inguinal hernia repair in [2137]. 15. History of self-limited hemoptysis four years ago. 16. Chronic obstructive pulmonary disease. MEDICATIONS ON TRANSFER: (From [Hospital 26200] Hospital) 1. Magnesium oxide 400 mg p.o. b.i.d. 2. Ditropan-XL 10 mg p.o. q.d. 3. Lisinopril 20 mg p.o. b.i.d. 4. Glucophage 500 mg p.o. q.d. 5. Lasix 80 mg p.o. q.d. 6. Lopressor 100 mg p.o. b.i.d. 7. Wellbutrin-SR 150 mg p.o. b.i.d. 8. Flagyl 500 mg intravenously q.6h. (day two). 9. Levaquin 500 mg intravenously q.d. (day two). 10. Amaryl 4 mg p.o. q.d. 11. Sublingual nitroglycerin p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a widow. Smoked half a pack per day for 50 years; quit two weeks ago. Rare alcohol use. Lives alone. Daughter lives across the street. Daughter is a physical therapist. FAMILY HISTORY: Father died of cancer with metastases to lungs, primary unknown. Mother died from postpartum pulmonary embolus. Brother with diabetes mellitus; died at age 41 from coronary artery disease. Brother status post carotid endarterectomy at age 60. Sister status post myocardial infarction and cerebrovascular accident. Son died at age 42 secondary to diabetes and renal failure. PHYSICAL EXAMINATION ON PRESENTATION: On admission to Medical Intensive Care Unit blood pressure was 163/45, heart rate 68, respirations 18, oxygen saturation 97% on 40% face mask. In general, nontoxic, alert and oriented times three, in no acute distress with a raspy voice. Head and neck examination revealed no jugular venous distention. Bilateral carotid bruits versus transmitted murmur. Mucous membranes were dry. Tongue was red with dry blood. Lungs had decreased anterior motion and faint crackles in right lower lobe, dullness at left lower lobe. Otherwise clear to auscultation bilaterally. Cardiovascular revealed a 2/6 systolic ejection murmur at the right upper sternal border with harsh crescendo-decrescendo, a 2/6 systolic ejection murmur at the left sternal border, a regular rate and rhythm. Normal first heart sound and second heart sound auscultated. No audible third heart sound. Soft fourth heart sound (equivocal). Abdomen was soft, nontender, and nondistended, good bowel sounds in all four quadrants. Extremities revealed 2+ distal pulses. No edema. Neurologic examination was nonfocal. LABORATORY DATA ON PRESENTATION: Laboratories on admission to Medical Intensive Care Unit revealed a white blood cell count of 10.9, hemoglobin 9.6, hematocrit 28.9, platelets 422. PT 13.8, PTT 29.4, INR 1.3. Sodium 141, potassium 3.8, chloride 102, bicarbonate 33, BUN 16, creatinine of 0.7, glucose of 129. ALT 27, AST 23. Creatine kinase 24. Alkaline phosphatase 76, total bilirubin 0.9, albumin 3.3. Calcium 8.8, phosphorous 3.4, magnesium 1.5. RADIOLOGY/IMAGING: Electrocardiogram dated [12-9] from outside hospital revealed normal sinus rhythm at 77 beats per minute, axis -40 degrees, borderline first-degree AV block, Q wave in III and aVF, 1-mm ST segment elevation in lead III and aVF (old), 1-mm ST segment depression in I and aVL, V2 through V5 (old). A chest x-ray from outside hospital revealed left-sided consolidation, enlarged cardiac silhouette, no obvious mass. No congestive heart failure. Chest CT from outside hospital revealed left lingular consolidation, areas of emphysema. No mass. HOSPITAL COURSE: The patient was a 77-year-old female presenting with a 3-day history of hemoptysis with a hematocrit drop from 36 to 29, status post bronchoscopy on the a.m. of transfer to Medical Intensive Care Unit. The bronchoscopy showed a "brisk bleed" in the left lower lobe with spillage into the right lower lobe. On transfer, the patient was hemodynamically stable without active hemoptysis. The differential diagnosis of the hemoptysis in the patient included, but was not limited to: (1) Bronchogenic carcinoma given her history of smoking and weight loss, although no mass was identified by bronchoscopy or CT. (2) Infection, although the patient was afebrile with normal white blood cell count. The patient could have had a loculated abscess or fungus ball. (3) Pulmonary embolus given her recent hospitalization and immobilization. (4) Pulmonary hypertension of unclear etiology. (5) Mitral regurgitation or mitral stenosis given her history of rheumatic fever. (6) Arteriovenous malformation. Given the patient's relatively instability and risk of embolus from her diseased and calcified aorta, the Medical Intensive Care Unit team held off on getting a bronchial arteriogram, and the patient was managed as follows: 1. PULMONARY: The patient was given supplemental oxygen to keep her oxygen saturation above 92%. In case respiratory decompensation, the plan was to consider intubation with a double lumen endotracheal tube with selective intubation of the right main stem bronchus with positioning of the patient in the left lateral decubitus position. The patient was given albuterol and Atrovent nebulizer therapy p.r.n. The plan was for Interventional Radiology to perform an angiogram if the patient had an acute hematocrit drop. A chest x-ray was done showing no change from the prior study with left-sided consolidation. While in the Medical Intensive Care Unit the patient had an episode of submassive hemoptysis. A bronchoscopy was done showing 100 cc of blood from the area of the left lingula spilling into the right main stem bronchus. Cardiothoracic Surgery and Interventional Radiology were aware of the case and were on board in case of a massive bleed. The patient was observed, and there was no further hemoptysis after bronchoscopy. The patient was hemodynamically stable on transfer to the floor. While on the floor, the patient had no further episodes of hemoptysis and hematocrit remained stable. Chest CT from the outside hospital was reviewed, showing cystic spaces in the left lingula with dense infiltration with mediastinal adenopathy. The differential diagnosis of the findings included tuberculosis, fungal etiology, cancer, bronchiectasis, arteriovenous malformation, septic emboli, and vasculitis. However, the cystic lesions were presumed to likely be old secondary to pre-existing left lower lobe bullous disease, and the rest of the left lingular disease was presumed to be secondary to pneumonia. Thus, cancer, vasculitis, and arteriovenous malformation were presumed to be much less likely. The patient was continued on Levaquin and Flagyl for a presumed pneumonia. The patient's hemoptysis was presumed to be secondary to a pneumonic process as well as pulmonary hypertension of unknown etiology. 2. DYSPNEA: The patient was noted to have baseline chronic obstructive pulmonary disease and was presenting with hemoptysis. The patient was continued on oxygen with a goal oxygen saturation of greater than 92%. The patient was continued on p.r.n. albuterol and Atrovent nebulizer therapy. 3. HYPERTENSION: The patient was continued on Lopressor, Lasix, and lisinopril. In the Intensive Care Unit, nitroglycerin paste was added as needed to keep the patient's blood pressure below 140 with adequate blood pressure control. The patient's blood pressure was stable on transfer to the floor and was stable for the remainder of her admission. 4. HEMATOLOGY: On admission to the Intensive Care Unit the patient's hematocrit was 28.9. The patient was transfused 2 units of packed red blood cells. Aspirin was put on hold. Hematocrit was checked every six hours. Transfusion parameters were set at 30, given the patient's history of coronary artery disease. Hematocrit on transfer to the floor was stable and continued to remain stable throughout the remainder of the hospital course. 5. GASTROINTESTINAL: A gastrointestinal bleed was not presumed to be contributing to the patient's hematocrit drop. The patient was continued on Protonix 40 mg p.o. q.d. The patient was arranged to have an outpatient colonoscopy and endoscopy and was to follow up with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 33175], regarding this matter. 6. ENDOCRINE: On transfer to the Intensive Care Unit the patient was not eating. The patient was continued on regular insulin sliding-scale and oral hypoglycemics (Glucophage and Amaryl) were put on hold. On transfer to the floor, the patient resumed on a regular diet, and Glucophage and Amaryl were restarted. The patient had adequate glucose control while on the floor. 7. RENAL: The patient was continued on her Lasix 80 mg p.o. q.d. on transfer to the floor. The patient's creatinine was noted to mildly increase from 0.7 to 1 after transfer to the floor. The p.o. food and fluid intake was encouraged with the patient's cooperation. Creatinine was then noted to decrease to 0.9. The patient was encouraged to continue good p.o. intake on discharge home. 8. PROPHYLAXIS: The patient was continued on Protonix, Pneumo boots, and Colace. 9. CODE STATUS: The patient was a full code. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient was to go home with home physical therapy and [Hospital6 407] services. DISCHARGE DIAGNOSES: Hemoptysis presumably secondary to pneumonia and pulmonary hypertension of unknown etiology. MEDICATIONS ON DISCHARGE: 1. Metoprolol 100 mg p.o. b.i.d. 2. Wellbutrin 150 mg p.o. b.i.d. 3. Lisinopril 20 mg p.o. b.i.d. 4. Magnesium oxide 400 mg p.o. q.d. 5. Glucophage 500 mg p.o. q.p.m. 6. Amaryl 4 mg p.o. q.a.m. 7. Vitamin C and vitamin E. 8. Ditropan 10 mg p.o. q.p.m. 9. Aspirin 325 mg p.o. q.d. 10. Lipitor 20 mg p.o. q.d. 11. Multivitamin 1 tablet p.o. b.i.d. 12. Lasix 80 mg p.o. q.d. 13. Peri-Colace p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 33176], M.D. [MD Number(1) 33177] Dictated By:[Name8 (MD) 2692] MEDQUIST36 D: [2178-12-18] 21:53 T: [2178-12-22] 17:45 JOB#: [Job Number 33178] (cclist)	[ "486", "496", "4019", "25000", "4280", "41401" ]
Admission Date: [2112-12-20] Discharge Date: [2112-12-23] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81 year old woman with a history of meningioma removal in [2091], stroke in [2105], pulmonary embolism in [2102]. She is on Coumadin. She had a fall five days ago, hitting her head. Yesterday, she was standing by the bed when she again fell. This time, she hit the back of her head around 8:30 p.m. She was lying on the floor for ten hours before being found by her son in the morning. She could not stand up. She was taken to an outside hospital, which showed a subdural hematoma. She was transferred to [Hospital1 69]. She had no loss of consciousness the morning of the fall. PHYSICAL EXAMINATION: On physical examination, her temperature was 97.9; blood pressure was 221/74, heart rate 63; respiratory rate 14; saturation 98% on room air. In general, she was in no acute distress. Cardiac: Regular rate and rhythm, no murmur. Chest was clear to auscultation. Neurologically, she was alert and attentive, oriented times three, fluent speech. Extraocular movements full. Face: Sensation was intact. She had no facial droop; question of a left old one from her old stroke. Tongue was midline. Palate was gross symmetrically. Strength was [5-16] in all muscle groups. Sensation was intact to light touch. Finger to nose and coordination were intact. Her gait was deferred secondary to her critical condition on admission. She also had a left ptosis and history of right leg weakness and left ptosis from previous stroke and surgery. HOSPITAL COURSE: She was admitted to the Intensive Care Unit. She was monitored in the Intensive Care Unit. She had a repeat CAT scan which showed stable appearance of a left subdural hematoma. She also has a right subdural hematoma which was found to be stable as well. The patient was monitored in the Intensive Care Unit. Her blood pressure was kept under 150. She was restarted on her p.o. medications although she still continued to have some episodes of hypertension, requiring some intravenous medication. She did remain stable and was transferred to the floor on [2112-12-21]. She remains neurologically stable. Repeat head CT today is stable. She was offered surgery (craniotomy) to decompress the Left Subdural hematoma, but the patient refused. She was seen by physical therapy and occupational therapy and found to be safe for discharge to home with a walker and home safety evaluation. Her condition was stable at the time of discharge. MEDICATIONS: Metoprolol XL 250 mg p.o. q h.s.; hold for systolic less than 100 and heart rate less than 50. Heparin 5000 subcutaneous which will be discontinued before discharge. Manoxapril 15 mg p.o. q. day. Diltiazem extended release 80 mg p.o. q. day. Atorvastatin 10 mg p.o. q. day. CONDITION: Stable at the time of discharge. She will follow-up with DR. [First Name (STitle) 742] [Name (STitle) ], M.D. in two weeks with a repeat head CT at that time. [Name6 (MD) 742] [Name8 (MD) ], M.D. [MD Number(1) 743] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2112-12-23] 10:52 T: [2112-12-23] 10:56 JOB#: [Job Number 53954]	[ "V5861", "4019" ]
Admission Date: [2151-11-29] Discharge Date: [2151-12-2] Date of Birth: [2086-5-12] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female hospitalized in [2151-5-25] for a left lower lobe pneumonia with a history of hypoxemia, chronic hypercarbia on home O2, who was brought to the Emergency Room following a fall at home. In the ER, she was anxious, disoriented with O2 sats 70s-80s. An ABG was performed and revealed a PCO2 of 120. Subsequently, the patient was placed on biPAP with some improvement of her mental status. Of note, she was brought to the Emergency Room the day before by her husband after she had become shaky and tremulous at home and had suffered a fall at home. She was confused by the report of her family members. She was given ativan and discharged and she continued to do poorly at home. They called her PCP who found her bicarb level to be 54 which had been drawn in the Emergency Room. The patient denies cough, occasionally has chest pain. She cannot really describe it well in nature. She is a poor historian. Shortness of breath at baseline. No nausea. No vomiting. No diaphoresis. She does not snore according to her husband. She has been more somnolent over the past week with frequent daytime napping. PAST MEDICAL HISTORY: Diabetes, hypercarbia, paroxysmal atrial fibrillation on amiodarone, anxiety disorder, DVT at age 37, GERD, hypoxemia on home O2 followed by Dr. [Last Name (STitle) 575] and pulmonology, and left lower lobe pneumonia in [5-25]. SOCIAL HISTORY: She lives with her husband. A 30 year smoking history and currently a nonsmoker. FAMILY HISTORY: Daughter with congenital heart defect. Mother with cancer of "spine." PHYSICAL EXAM: Heart rate in the 70s, blood pressure 140/33, O2 sat 81% on 3 liters. General - alert, sitting up in bed, O2 by nasal cannula. HEENT - oropharynx clear. Pupils equal, round and reactive to light. Thorax - diminished breath sounds at bases, otherwise clear, no wheezes present, buffalo hump. Cardiovascular - regular rate and rhythm, no murmurs. Abdomen - bowel sounds present, soft, obese, nontender. Extremities - no edema, no cyanosis. Neuro - alert, oriented to date, place, situation. Cranial nerves II through XII intact. Resting tremor. Skin - erythematous papules on back. Hyperkeratotic plaques on left elbow. MEDS: Amiodarone, albuterol, Atrovent, Flovent, lasix, glyburide, metformin, Monopril, Ovcon drips, K-Dur. LABS: Sodium 142, potassium 5.1, bicarb 44, chloride 93, BUN 25, creatinine 1.1, glucose 184, calcium 8.4, mag 1.8, phosphate 2.5, white cells 8.5, hematocrit 32.4, platelets 313, CK 53, troponin less than 3. ABGs - 7.22, 120, 49, 52, then went to 7.44, 22, 43, 50. Chest x-ray showed opacity left lung base obscuring left heart border, patchy right basilar opacities. Chest CT on [11-25] showed left lower lobe consolidate improving, small bilateral pleural effusions. On [7-22] MIBI - EF of 63%, normal wall motion and no perfusion defects. PFTs recently - FEV1 83% predicted, FVC 55 predicted, FEV1/FVC 96% predicted, DLCO 46% predicted. EKG - normal sinus rhythm, rate of 70s, left anterior descending, new left bundle branch block. ALLERGIES: Penicillin. HOSPITAL COURSE: She was admitted to the MICU and she did well on BIPAP with improvement of her mental status and improvement of her oxygenation. She was transferred to the floor on [2151-12-1] and at that time her ABG showed a bicarb of 80 on 2 liters nasal cannula. The MICU team did find that whenever her CO2 sat went above 88% she would retain CO2, going as high as 90 in the MICU, and she also had some crackles on exam and was diuresed in the MICU with good affect. She was also found to have vitamin B12 deficient anemia. She was started on B12 shots and she had a swallow evaluation which she failed and she was put on a thick liquid diet in the MICU. On the floor she did well overnight. She was given BIPAP at night and her O2 sat stayed under 90%. Her mental status continued to improve and by [2151-12-2] she was feeling well enough to be discharged. We have consulted pulmonary rehab to see if she could be accepted. We think that if she was followed by pulmonary rehab for a few days she could optimize management of her home O2, because we think that the reason she is here in the first place is because she was titrating up her home O2. They can also initiate BIPAP at night which she will need to continue at home and they can also assess her ability to swallow which may be improved now that her mental status is improving. She will be discharged in stable condition. DIAGNOSES: Hypercarbia, congestive heart failure, vitamin B12 deficiency anemia. DISCHARGE MEDICATIONS: Will be included in an addendum. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Name8 (MD) 6340] MEDQUIST36 D: [2151-12-2] 12:24 T: [2151-12-2] 12:40 JOB#: [Job Number 17506]	[ "51881", "4280", "5849", "42731", "496", "25000", "4019", "53081" ]
Admission Date: [2199-5-7] Discharge Date: [2199-5-18] Date of Birth: [2131-6-3] Sex: F Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 613] Chief Complaint: Pericardial effusion Major Surgical or Invasive Procedure: Pericardial window History of Present Illness: 67 yF with h/o metastatic cervical cancer c/b bulky LAD w/R hydronephrosis necessitating nephrostomy tube placement, hypercoagulability resulting in mult CVAs and more recently, PE/[Hospital 19601] transferred to [Hospital1 ] for management of pericardial effusion and UGIB. 1 week prior to this admission, she was treated for PE/DVT and CAP at [Hospital3 7569], d/c'ed on lovenox / coumadin; she was treated with levaquin in-house, which was not continued on an out-patient basis. During that admission, she had an echo showing a pericardial effusion. She was d/c'ed prior to final read of a f/u echo, which showed increased size of the effusion. Thus, she was called to return to [Location (un) ] the day after d/c ([5-7]). Incidentally, pt had hematemesis x3 on that day as well. Pt was transferred from [Location (un) ] ED to [Hospital1 ] and was admitted to the CCU where she was also followed by CT [Doctor First Name ] and GI. While in the CCU she received 2U PRBCs for her UGIB which had remitted. NGL cleared, so upper endo was not pursued. She underwent pericardial window for drainage of effusion. Finally, she underwent R ureteral stent and IVC filter placment by IR. Her acute cardiac issues had resolved and she was called out to the medicine service. . On the day of transfer to medicine, pt's creat (b/l 1.1) had risen to 2.0, despite stent placement, prompting a Renal consult. In addition, her coags were elevated and trending up with an INR of 3.6 (DIC labs neg; LFTs WNL), despite being off coumadin since admission. Past Medical History: 1) CVA 2) Metastatic cervical cancer 3) PE/ DVT diagnosed one week ago 4) right hydronephrosis secondary to lymphadenopathy, s/p right nephrostomy tube 5) HTN 6) hyperlipidemia 7) appendectomy 8) NSTEMI LVEF > 55% 3/15 9) Gout Social History: retired pharmacy technician who lives with her daughter. no etoh, tobacco, or ivdu Family History: NC Physical Exam: In the CCU: G: Elderly female, NAD HEENT: Clear OP, MMM Neck: Difficult to assess JVD Lungs: Decr BS BL at bases, crackles BL CV: S1S2, No murmurs Abd: Soft, NT, ND, BS+ Ext: [1-6]+ pitting edema ... On transfer to the floor: PE: 98 109/66 117 16 96%RA Gen: Middle-aged F, appearing older than stated age and markedly pale, lying in bed, NAD HEENT: MM dry, PERRL, OP clear CVS: RRR, no M/R/G Chest: CTA B Abd: soft, NT/ND NABS Ext: [1-6]+ edema; pneumoboots in place Pertinent Results: Admission Labs: [2199-5-7] 02:52PM BLOOD WBC-11.3* RBC-3.30* Hgb-9.5* Hct-29.1* MCV-88 MCH-28.9 MCHC-32.7 RDW-16.6* Plt Ct-566# [2199-5-7] 08:05PM BLOOD Hct-24.6 [2199-5-7] 02:52PM BLOOD Neuts-88* Bands-2 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2199-5-7] 02:52PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-OCCASIONAL Polychr-1+ Ovalocy-1+ Tear Dr[Last Name (STitle) 833] [2199-5-7] 02:52PM BLOOD PT-20.0* PTT-40.5* INR(PT)-2.6 [2199-5-7] 02:52PM BLOOD Plt Ct-566# [2199-5-7] 02:52PM BLOOD Glucose-97 UreaN-38 Creat-1.2* Na-140 K-4.4 Cl-110* HCO3-19* AnGap-15 [2199-5-8] 05:33AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.1* [2199-5-7] 02:52PM BLOOD Cholest-163 [2199-5-7] 02:52PM BLOOD Triglyc-176* HDL-23 CHOL/HD-7.1 LDLcalc-105 Echo [2199-5-7]: MEASUREMENTS: Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Ascending: 3.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) INTERPRETATION: Findings: This study was compared to the prior study of [2199-2-28]. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. PERICARDIUM: Moderate pericardial effusion. No significant respiratory variation in mitral/tricuspid valve flows. Brief RA diastolic collapse. [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7216] collapse. GENERAL COMMENTS: Results were reviewed with the Cardiology Fellow involved with the patient's care. Bilateral pleural effusions. Ascites. Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is a moderate sized circumferential pericardial effusion extending 2.4cm inferior and 2cm lateral to the left ventricle, but <1cm around the apex and anterior to the right ventricle. There is brief right atrial and left atrial diastolic collapse without eccentuation of transmitral E wave velocities. Compared with the prior study (tape reviewed) of [2199-2-28], the pericardial effusion is new. Serial evaluation is suggested. . CTA Chest [2199-5-8]: 1. Chronic pulmonary embolism in the right lung. 2. Large bilateral pleural effusions, right greater than left. Large pericardial effusion. 3. Ascites. . Pleural fluid cytology: Rare atypical epithelioid cells present. Scattered mesothelial cells and numerous lymphocytes. . Pericardial fluid cytology: NEGATIVE FOR MALIGNANT CELLS. . Renal U/S [2199-5-14]: Small kidneys bilaterally with normal arterial and venous waveforms. The right hydronephrosis has resolved status post stenting. Large volume ascites is noted. Renal scan: 1. Renal parenchymal disease of the right kidney with no evidence of obstruction. 2. Partial obstruction of the left kidney. Superimposed renal parenchymal disease of the left kidney cannot be excluded. . CXR [2199-5-15]: Resolution of previously seen apical pneumothorax on the left. Unchanged appearance of bibasilar patchy atelectasis/consolidation. Brief Hospital Course: 1. Pericardial effusion: Pt was found to have a new pericardial effusion on Echo, was seen by thoracic surgery, and underwent thorascopic pericardial window with chest tube insertion. She was noted to have 100cc of serosanguinous fluid drained from the pericardium itself, along with 500cc of pleural fluid. Both fluids were sent for cytology, with the pleural fluid noted to contain atypical cells concerning for malignancy and the pericardial fluid devoid of atypical cells. She had a repeat echo, which showed a small pocket of apical fluid collection and resolution of the larger pericardial effusion. Oncology noted that the patient could be followed as an outpatient for further management of the pleural malignancy. The chest tube was pulled without complications. 2. GI Bleed: The patient was initially started on heparin drip due to concerns about the presence of PE; however, this medication was discontinued as her hematocrit decreased while on the drip. She was transfused and her Hct remained stable following. Further workup of the GI bleed can be done as an outpatient. 3. Chronic PE: As above, the patient was placed on the heparin drip for 1 day for concern of PE/DVT, but as she had an IVC filter placed this drip was discontinued. She was asymptomatic throughout. Given her hypercoagulability, she will likely need long-term AC, which may be re-initiated on an outpatient basis after the IVC filter has been removed. 4. R nephrostomy/acute renal failure: On admission, pt's creat was 1.1, began climbing on HD#4, and peaked at 2.1 on HD#9. She had had a nephrostomy tube placed in [3-6] obstruction of her R kidney and resultant ARF at that time. On the weekend of [4-4], her urine output decreased and her nephrostomy output also decreased. She was given large amounts of fluid as her CVPs were low (0-6), but her urine output failed to respond. Her creatinine levels started to rise, and the etiology of her renal failure remained elusive. She was taken to IR on [5-13], where the R ureter was stented with good flow into the bladder, and the nephrostomy tube was kept in place with plans for capping. However, her urine output remained low post-procedure. Urine lytes were sent, with FeNa of 1.5% indicating intrinsic renal or post-renal disease. The urine contained a large number of RBCs post-stenting, and we were unable to appreciate casts or eosinophils when it was spun. Despite this, levofloxicin was changed to azithro/CTX due to concerns for AIN. Abdominal u/s showed resolution of prior R hydronephrosis, but was unable to visualize the renal arteries. Renal artery u/s was done to evaluate for concerns of IVC obstruction of the renal arteries as an etiology of the ARF--pre-renal that eventually became ATN; however, this showed normal arterial and venous flow. Both kidneys were noted be small, measuring 9.0cm R and 9.1cm L, suggesting bilateral intrinsic disease. The renal service was consulted for help in sorting out the etiology of her ARF. They felt that, as her creat was rising despite the recent R ureteral stent, pt likely had bilateral disease. As she was never HD unstable to suggest possible renal ischemia, and there were no muddy brown casts on urine sedment exam, ATN was unlikely. Renal felt that findings were therefore most c/w post-obstructive physiology, [2-6] metastatic dz. Urology was consulted and recommended a nuclear scan of the kidneys, which showed a possible L-sided obstruction. Pt was taken to the OR for cystoscopy, left retrograde pyelogram and insertion of left double-J stent. After stent placement, her creat began to trend down and was 1.2 on the day of discharge. Urology instructed the pt that the stent would have to be changed in 3 months and that it would increase irritability of the bladder and that she may have chronic hematuria, requiring transfusion. . 5. PNA: The patient was febrile on arrival to the CCU, and remained febrile overnight. The etiology was initially attributed to atelectasis/post-OP fever, but repeat CXR showed RLL haziness concerning for PNA (pt also had an elevated WBC). Given the clinical concerns, she was started on levo for community-acquired PNA on [5-9], which was changed to azithro/CTX on [5-13] (see above). She will complete a 10 day course of ABX, to end [5-18]. . 6. Coagulopathy: INR increased to 3.6. DIC panel was negative and liver function normal. Likely [2-6] nutritional deficiency as pt w/low albumin and poor PO intake. Also with possible contribution of ABX displacement of coumadin, although she is 7 days s/p stopping coumadin and INR is still rising, making this unlikely. Vitamin K was held, given no evidence of bleeding; however, she receievd FFP prior to stent placement. . 7. Malnutrition: The patient was noted to have a large amount of third spacing, as above, with a low albumin. The persistently elevated INR despite being off coumadin for days raised the concern for malnutrition (protein deficiency). Nutrition was consulted, and transferritin/prealbumin were also sent. Megace and Boost supplements were started. [Male First Name (un) ] hose were placed to help mobilize the fluid. . 8. Metastatic cervical cancer: Underlying cause for all of her current acute issues. Dr.[Last Name (STitle) 27538], who has followed pt in-house on prior admits, but who is NOT pt's primary oncologist (Dr.[Location (un) 27539]) discussed her poor prognosis with pt and family. She also attempted to contact Dr.[Last Name (STitle) ] to let her know of the admission, but was unsuccessful. Dr.[Last Name (STitle) 27538] recommended CT torso to restage pt; however, given her rising creat, this was postponed and may be done on an out-pt basis. In addition, Dr.[Last Name (STitle) 724] in Neuro-oncology requested a brain MRI w/gad to evaluate the changes seen on prior imaging (?mets vs. CVAs). However, given the IVC filter placement, this too will need to be deferred until removal. . 9) Dispo: Pt was discharged home with services once her creatinine was decreasing and she was afebrile and HD stable. She has numerous follow-up appointments anbd studies, detailed at the end of this report. Medications on Admission: Lovenox Iron Coumadin Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. 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 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 9. 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 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Megestrol Acetate 40 mg/mL Suspension Sig: Five (5) ML PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Metastatic cervical CA pericardial effusion/tamponade s/p pericardial window Acute renal failure Upper GI bleed Pulmonary embolism DVT s/p R and L ureteral stent placement ... CVA vs. brain mets Gout right hydronephrosis secondary to lymphadenopathy, s/p right nephrostomy tube placed [3-9] HTN hyperlipidemia appendectomy NSTEMI LVEF > 55% [2199-3-19] Discharge Condition: Fair Discharge Instructions: Please call your doctor and return to the hospital for, chest pain, light headedness/confusion, if you are not making urine, if you are vomiting blood, or for any other concerning symptoms. . Followup Instructions: Please follow-up with Dr.[Last Name (STitle) 27540] in 1 week after discharge. Please call for appointment: [Telephone/Fax (1) 27541]. Please discuss re-initiation of your anticoagulation medication. . Please have bloodwork drawn by VNA prior to your appointment with Dr.[Last Name (STitle) 27542]. Please have results faxed to his office. . Please follow-up with Dr.[Last Name (STitle) ], Nephrology, in [7-14] days after discharge. Please call for appointment: (^17) [Telephone/Fax (1) ]. . Please folow-up with Dr.[Last Name (STitle) ] after discharge. Please call for appointment. Please discuss obtaining a re-staging CT scan of the torso after your kidney function has improved . Please follow-up with Dr.[Last Name (STitle) 724] in [Hospital 746] clinic. Please call for appointment: ([Telephone/Fax (1) 27543]. Please discuss scheduling of brain MRI with gadolinium after your IVC filter is removed. . Please follow-up with Dr.[Last Name (STitle) 952] in [3-8] weeks after discharge. Please call for apointment ([Telephone/Fax (1) 11763] . Please follow-up with Interventional Radiology in 1 week after discharge for removal of your IVC filter ([Telephone/Fax (1) 27544]. . Please follow-up with GI for upper endoscopy with Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 437]. Please call for appointment ([Telephone/Fax (1) 22467]. . Please follow-up with Urology for stent replacement in 3 months. Please call for appointment ([Telephone/Fax (1) 27545]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "5849", "5119", "486", "4019" ]
Admission Date: [2154-1-17] Discharge Date: [2154-1-18] Date of Birth: [2154-1-17] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] delivered precipitously in the car at term gestation, weighing 3790 gm and was admitted to the Newborn Intensive Care Unit for management of respiratory distress. Mother is a 39 year old gravida 3, para 2, now 3 mother with prenatal screens which included blood type B positive, antibody screen negative, hepatitis B surface antigen negative, Rubella immune and Group B Streptococcus positive. Mother's medical history is significant for a bipolar disorder for which she takes Lithium and Inderal. She also has hypothyroidism and is treated with Levoxyl. Her pregnancy was reportedly uncomplicated. On the day of delivery, mother had onset of spontaneous labor and rupture of membranes and while traveling in the car on the way to [Hospital6 256] the father delivered the infant. The newborn intensive care team arrived at the car and found the mom holding the baby against her chest and the baby was grunting and slightly dusky. She was placed in a transport isolette and given blow-by oxygen and brought to the Intensive Care Unit. Apgar scores were not assigned. PHYSICAL EXAMINATION: Physical examination on admission showed weight 3790 gm, length and head circumference were not recorded. Anterior fontanelle was open, flat and soft, palate intact, symmetric chest excursions with audible grunting and retracting, breathsounds with limited aeration. Normal S1 and S2 without murmur, ruddy pink with normal pulses. Abdomen, soft, nondistended, nontender, no hepatosplenomegaly, three vessel cords. Normal external female genitalia, hips stable, spine straight intact. Infant active and alert with examination. HOSPITAL COURSE: Respiratory - The infant was placed on continuous positive airway pressure of 6 cm of water, 30% oxygen on admission for grunting and retracting. Weaned off of CPAP to room air by four hours of age and has remained in room air with oxygen saturations in the high 90s and comfortable work of breathing since four hours of age. Noted on physical examination today, the infant has a hoarse inspiratory noise that occurs intermittently with vigorous crying, no distress, no noise of stridor noted at rest. Cardiovascular - Blood pressure on admission 65/41 with a mean of 54, no murmur. Fluids, electrolytes and nutrition - She was placed on D10/W by peripheral intravenous line on admission for respiratory distress. Initial blood glucose 33 and she was given 2 cc/kg bolus of D10/W with D6, increasing to the 60s. The intravenous was discontinued around 12 hours of life as the patient is ad lib feeding, Enfamil 20 with Iron well. She is voiding and stooling appropriately. Gastrointestinal - No issues. Hematology - Hematocrit on admission was 69. Polycythemia thought secondary to cord not being clamped until arrival of team after the delivery. A partial exchange transfusion was performed with the follow up hematocrit 64%. Neurology - Examination age appropriate. Infectious disease - Complete blood count and blood culture was drawn on admission and the patient was placed on Ampicillin and gentamicin due to respiratory distress. Complete blood count showed a white count of 11,900 with 60 polys, no bands. Length of therapy is planned for 48 hours pending blood culture. Sensory - Hearing screen has not been performed yet and she will need one prior to discharge. CONDITION ON TRANSFER: Stable, infant feeding well. DISCHARGE DISPOSITION: Transfer to the [Location (un) ] nursery. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Hospital ] [Hospital6 6613], [Street Address(2) 37885], [Location (un) ] [Numeric Identifier 37886]. Telephone [Telephone/Fax (1) 37887]. CARE RECOMMENDATIONS: 1. Feeds - Ad lib demand feeds, Enfamil 20 with Iron. 2. Medications - Ampicillin and gentamicin. 3. State screen - Has not been drawn and will need to be done around 72 hours of life. 4. Immunizations - Has not received hepatitis B immunization, recommend prior to discharge. DISCHARGE DIAGNOSIS: 1. Appropriate for gestational age term female 2. Transient tachypnea of the newborn resolved 3. Rule out sepsis 4. Polycythemia [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 36096] MEDQUIST36 D: [2154-1-18] 17:07 T: [2154-1-18] 17:18 JOB#: [Job Number 37888]	[ "V290", "V053" ]
Admission Date: [2153-4-4] Discharge Date: [2153-4-5] Date of Birth: [2073-1-13] Sex: M Service: MEDICINE Allergies: Fentanyl / Heparin Agents Attending:[First Name3 (LF) 398] Chief Complaint: altered mental status/LFTs Major Surgical or Invasive Procedure: none History of Present Illness: 80 y.o male with h/o CVA in [12-4], L4-L5 osteomyelitis,CHF, atrial fibrillation, presents from [Hospital 100] Rehab with altered mental status, elevated LFTs and jaundice. He has had increasing delerium and a worsening gait disorder and word finding difficulty since mid- [Month (only) 956]. His son recalls that it got worse in the past two weeks. An EEG was scheduled for late [Month (only) 958]. He had an MRI of the head on [4-2] which demonstrated an old right cerebellar CVA which is unchanged. Wrt his osteomyelitis he had an MRI done on [4-2] which demonstrated and improvement and his ESR was 4 down from a high of 57 in [2-4] on [2153-3-30]. His other labs at this time demonstrated elevated total bili to 2.9, AST = 146, ALT = 209 with an elevated LDH = 348. His protein C and protien S free and total were found t be low at 48 (65-130_ and 56 (60-130) respectively. His PT was elevated to 3.2. He was admitted for ? tylenol toxicity since he had been on standing tylenol at his NH for back pain. Of note he also recently developed a petechial rash which was biopsied last week and the biopsy result is pending. In the ED he was found to have a UTI and ?bibasilar PNA. His INR was elevated but he was too agitated to have a head CT. He had a temp of 99.6 and was tachy to 125. He was given levofloxacin, lactulose, vancomycin after two sets of blood cultures drawn, ativan 0.5 mg IV, ceftriaxone 2 mg IV, 5 mg haldol, 0.5 mg ativan and 500 mg flagyl. <BR> <I> ROS Pt unable to give ROS. <br> Past Medical History: HTN urinary retention legally blind (optic atrophy of childhood) lumbar stenosis s/p L4-5 laminoforaminectomy [2149] R foot drop, using brace x 10 mo chronic gait problems, balance problems Social History: Lives at [Hospital1 5595] MACU. Retired computer analyst. Divorced, has 2 kids. Lifetime nonsmoker, no etoh, no drugs. Writing economic papers in [Month (only) 1096]. Used to walk with a cane and lived alone until his stroke in [12-4] and was able to return home in [1-10] against doctor's orders secondary to balance but then re-presented in [Month (only) 404] with bacteremia and since then went to [Hospital1 ]->[Hospital1 5595]. He used foot brace for foot drop. Balancing his own check books in [2152-11-29]. Family History: No strokes, CAD, seizures, DM or other neurologic disorders. Physical Exam: VS T 96.1, P 115 BP 143/88 RR 16-20 O2Sat 99% on 4L NC GENERAL: Deeply jaundiced cachectic male moving round in bed. HEENT: NC/AT, PERRLA, +scleral icterus noted, ? dried blood in mouth. dry MMM, no lesions noted in OP Neck: supple, elevated JVP Pulmonary: Lungs CTA bilaterally without R/R/W but pt id not cooperating with lung exam Cardiac: irregularly irregular nl. S1S2, [4-3] murmur at LLSB with radiation to the axilla. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, trace PT pulses b/l and non-doppable pulses. Skin: multiple petechiae on bilateral lower extremites and L upper extremity Neurologic: -mental status: Alert, oriented x 1. Unable to obey commands. -cranial nerves: II-XII intact- no facila droop -motor: decreased normal bulk, and normal tone throughout. Moving all extremities. -sensory: No deficits to light touch throughout. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [2153-4-4] 11:45PM TYPE-ART PO2-147* PCO2-31* PH-7.48* TOTAL CO2-24 BASE XS-1 [2153-4-4] 11:45PM LACTATE-3.5* [2153-4-4] 11:45PM O2 SAT-98 [2153-4-4] 02:42PM COMMENTS-GREEN TOP [2153-4-4] 02:42PM LACTATE-4.3* [2153-4-4] 02:30PM estGFR-Using this [2153-4-4] 02:30PM ALT(SGPT)-260* AST(SGOT)-177* CK(CPK)-89 ALK PHOS-483* AMYLASE-70 TOT BILI-2.8* DIR BILI-1.8* INDIR BIL-1.0 [2153-4-4] 02:30PM LIPASE-49 [2153-4-4] 02:30PM CK-MB-NotDone cTropnT-<0.01 [2153-4-4] 02:30PM CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-2.9* [2153-4-4] 02:30PM AMMONIA-26 [2153-4-4] 02:30PM AMMONIA-26 [2153-4-4] 02:30PM CARBAMZPN-<1.0* [2153-4-4] 02:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2153-4-4] 02:30PM WBC-8.6 RBC-4.54# HGB-12.5# HCT-39.8# MCV-88 MCH-27.5 MCHC-31.3 RDW-16.9 [2153-4-4] 02:30PM NEUTS-77.3* LYMPHS-12.6* MONOS-9.0 EOS-0.7 BASOS-0.4 [2153-4-4] 02:30PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ [2153-4-4] 02:30PM PLT COUNT-125* [2153-4-4] 02:30PM PT-41.2* PTT-41.2* INR(PT)-4.7* [2153-4-4] 02:30PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.024 [2153-4-4] 02:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD [2153-4-4] 02:30PM URINE RBC-[7-8]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[4-2] [2153-4-4] 02:30PM URINE GRANULAR-[4-2]* [2153-4-4] 02:30PM URINE CA OXAL-FEW ECG: Atrial fibrillation at 114 no acute changes. Chest PA/L: Equivocal bibasilar PNA [2-4]: Echo: EF 60%, 2+ MR/2+ TR MRI brain: [2153-4-2] Old R cerebellar infarct L spine MRI: Improving osteomyelitis. [2153-3-30] DIAGNOSIS Skin, right lower leg, punch biopsy (A): Epidermis with dyskeratotic keratinocytes, and subjacent dermis with perivascular and interstitial lymphocytic infiltrate and extravasated red blood cells (see note). Note: No vasculitis is seen. The differential diagnosis of the histologic pattern seen in this specimen includes 'senile/itching' purpura, a purpuric drug or hypersensitivity reaction, and a pigmented purpuric eruption. Clinical correlation is requested Brief Hospital Course: Hospital Course: 80 y.o. M with htn, atrial fibrillation, CHF, history of enterococcus bactermia presenting with acute on chronic worsening of mental status. . Altered mental status: On admission the differential in this gentleman was quite broad including infection, seizure, cardiac ischemia, CVA, ICH given elevated INR, malignancy, liver failure. Possible etiologies of his infection include UTI, mennigitis, encephalitis, pneumonia, The first U/A performed in the ED was a poor sample. However, levofloxacin was initially administered. Other usual cultures were sent. CT head showed chronic right cerebellar hemisphere infarct. Further diagnostic work up was deferred as the patient's code status changed. A discussion was held with the patient's son and health care proxy, [Name (NI) ]. His father recently made a living will which clearly stated that he did not want aggressive care in the event of being in his present non-functional state. The patient's son felt that a code status change to comfort measures only/do not hospitalize would be consistent with his father's wishes in his present medical condition. The patient is to be discharged to [Hospital1 10151] today. . Elevated coags: The differential includes dic, coumadin toxicity, vitamin k deficiency, factor VII deficiency, liver disease. No overt signs of bleeding. Will check dic panel. No overt signs of bleeding. Guaiac negative in ED. As above, further work-up was not pursued given change in code status. . Elevated LFTs; with elevated direct bili thus c/w cholystatic picuture. Serum tox negative for tylenol. This was concerning for cholecystitis/cholangitis, though abdomen non-tender on exam and patient afebrile. Work-up was not pursued given change in code status. . TCP: This was concerning for DIC from possible malignancy or infection vs HIT. Work-up was not pursued given change in code status. . Prophylaxis: Initially patient given PPI, [Last Name (un) 12376] regimen, not on SQ heparin given elevated INR. Medications were discontinued with the change in code status to comfort care. . FEN: The patient NPO given mental status. . Contact: [Name (NI) ] [Name (NI) ] [Name (NI) 98884] home [2153], w [Telephone/Fax (1) 98885], C [Telephone/Fax (1) 98886] Medications on Admission: APAP 975 tid Celexa 10 mg po qd Colace 100 mg [Hospital1 ] Haldol 1 mg [Hospital1 ] IM lactulose 20 gm [Hospital1 ] lopressor 100 mg tid MVT 1 T qd pantoprazole 40 mg po qd Senna 1T simvastatin 40 mg po qd Discharge Medications: 1. Morphine (PF) in D5W 100 mg/100 mL Parenteral Solution Sig: [2-17] Intravenous TITRATE TO (titrate to desired clinical effect (please specify)): titrate to comfort. 2. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal ONCE (Once) as needed for secretions. 3. Haloperidol 2.5 mg IV BID:PRN Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: primary: altered mental status, transaminitis secondary: s/p right cerebellar CVA hypertension urinary retention legally blind Discharge Condition: The patient's code status has been made comfort measures only. He remains comfortable on examination. Discharge Instructions: The patient has been made CMO on this admission. He has furthermore been made DNH-do not hospitalize. This was discussed with the patient's son and HCP, [Name (NI) ]. The patient's wishes were expressed in his living will. He is to return to [Hospital1 100] Rehabilitaiton for further management of his comfort. Followup Instructions: The patient will be following up with his physicians at [Hospital1 10151].	[ "42731", "486", "4280", "5119", "4019" ]
Admission Date: [2135-11-19] Discharge Date: [2135-11-27] Date of Birth: [2070-12-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: n/v, hypoxia, malaise Major Surgical or Invasive Procedure: none History of Present Illness: This is a 64 year-old man with a history of probable ALS (diagnosed [4-/2135]) and depression, hypothyroidism, who presented to the ED two days ago complaining of nausea and vomiting. He was found to have slight elevation of transaminases. This was felt to be due to his ALS medication (Rilutek) so this was stopped. He was given zofran and IVF and observed. His nausea resolved, however, he described some SOB and had hypoxemia on room air (88% sat). A chest x ray was done which revealed possible early RLL pneumonia, so he is admitted for further management. He was given levofloxacin in the ED. Past Medical History: 1. ALS, recently diagnosed, video swallow normal last month, still high functioning, employed nearly full time, cycles daily, pfts near normal 2. Depression and insomnia 3. Hypothyroidism Social History: no etoh or drug use Family History: no hx. als Physical Exam: VS: AF and VSS, O2 sat 94% on room air. . General Appearance: pleasant, comfortable, NAD, non-toxic appearing Eyes: : PERLL, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, oropharynx without exudate or lesions, no supraclavicular or cervical lymphadenopathy, no JVD, no carotid bruits, no thyromegaly or palpable thyroid nodules Respiratory: BL LL rales and rhonchi Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated Gastrointestinal: nd, +b/s, soft, nt, no palpable masses or hepatosplenomegaly Musculoskeletal/extremities: no cyanosis, clubbing or edema Skin/nails: warm, no rashes/no jaundice/no splinter hemmorhages Neurological: AAOx3. upper ext fasciculations with movement Heme/Lymph: no cervical or supraclavicular lymphadenopathy GU: no catheter in place Pertinent Results: Labs on admission: [2135-11-18] 02:30PM URINE MUCOUS-MOD [2135-11-18] 02:30PM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-RARE EPI-3 [2135-11-18] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG [2135-11-18] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.028 [2135-11-18] 02:30PM PLT COUNT-213 [2135-11-18] 02:30PM NEUTS-85.2* LYMPHS-7.0* MONOS-7.0 EOS-0.7 BASOS-0.2 [2135-11-18] 02:30PM WBC-10.7# RBC-4.32* HGB-13.2* HCT-39.8* MCV-92 MCH-30.6 MCHC-33.2 RDW-13.2 [2135-11-18] 02:30PM ALT(SGPT)-103* AST(SGOT)-83* ALK PHOS-65 TOT BILI-0.9 [2135-11-18] 02:30PM estGFR-Using this [2135-11-18] 02:30PM UREA N-25* CREAT-0.7 SODIUM-134 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-30 ANION GAP-13 [2135-11-18] 02:30PM GLUCOSE-106* [2135-11-19] 12:35PM PT-13.1 PTT-28.2 INR(PT)-1.1 [2135-11-19] 12:35PM PLT COUNT-209 [2135-11-19] 12:35PM NEUTS-89.5* LYMPHS-5.2* MONOS-4.9 EOS-0.2 BASOS-0.2 [2135-11-19] 12:35PM WBC-9.0 RBC-4.30* HGB-12.9* HCT-38.0* MCV-88 MCH-29.9 MCHC-33.9 RDW-13.3 [2135-11-19] 12:35PM CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-2.0 [2135-11-19] 12:35PM ALT(SGPT)-94* AST(SGOT)-60* ALK PHOS-72 TOT BILI-1.0 [2135-11-19] 12:35PM GLUCOSE-111* UREA N-28* CREAT-0.7 SODIUM-132* POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-27 ANION GAP-15 . Imaging: [2135-11-21] CTA Chest: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Progressive interstitial pulmonary edema with enlarging bilateral pleural effusions and associated compressive atelectasis. 3. Calcified thyroid nodule. . [2135-11-22] CXR: FINDINGS: In comparison with the study of [11-21], there is continued enlargement of the cardiac silhouette with evidence of pulmonary vascular congestion. This is somewhat asymmetric, most prominently involving the right hemithorax. The possibility of supervening pneumonia in this region or in the retrocardiac area cannot be excluded, and a lateral view would be most helpful if clinically possible. . [2135-11-22] ECHO: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30-40 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Labs on discharge: [2135-11-26] 07:00AM BLOOD WBC-9.1 RBC-3.83* Hgb-11.3* Hct-34.4* MCV-90 MCH-29.6 MCHC-33.0 RDW-12.9 Plt Ct-370 [2135-11-26] 07:00AM BLOOD Glucose-108* UreaN-22* Creat-0.7 Na-137 K-4.5 Cl-100 HCO3-32 AnGap-10 [2135-11-26] 07:00AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.0 [2135-11-22] 04:49AM BLOOD PEP-THICKENED IgG-689* IgA-105 IgM-65 IFE-NO MONOCLO [2135-11-25] 06:15AM BLOOD CRP-175.0* [2135-11-22] 04:49AM BLOOD Free T4-1.2 [2135-11-22] 04:49AM BLOOD TSH-2.6 [2135-11-24] 09:50PM BLOOD proBNP-3938* [2135-11-18] 02:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.028 [2135-11-18] 02:30PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG [2135-11-18] 02:30PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-RARE Epi-3 Pulmonary Report SPIROMETRY over time Results as of [2135-11-25] Pre Drug Post Drug FVC FEV1 MMF FEV1/FVC FVC FEV1 MMF FEV1/FVC [2135-11-25] 10:51 AM 2.09 1.50 0.49 72 %Predicted 55% 56% 18% 102% [2135-11-22] 2:11 PM 1.58 1.33 1.55 84 1.70 1.44 1.76 84 %Predicted 42% 50% 58% 119% 45% 54% 65% 119% [2135-10-19] 11:19 AM 3.08 2.53 2.66 82 2.87 2.31 2.45 80 %Predicted 81% 95% 99% 117% 76% 86% 91% 114% [2135-5-27] 10:01 AM 3.34 2.57 2.17 77 2.76 2.13 1.82 77 %Predicted 88% 96% 81% 109% 73% 80% 68% 109% [2134-8-23] 11:19 AM 3.38 2.64 2.33 78 3.21 2.51 2.26 78 %Predicted 89% 98% 85% 110% 84% 93% 83% 110% [2134-3-29] 7:58 AM 3.62 2.81 2.46 78 3.29 2.56 2.33 78 %Predicted 95% 104% 90% 109% 86% 95% 85% 110% [2133-10-2] 8:27 AM 3.52 2.73 2.35 77 %Predicted 92% 100% 84% 109% Brief Hospital Course: Patient is a 64 year old man with history of recently diagnosed ALS, high functioning, presents with malaise, anorexia, shortness of breath. . 1.) Hypoxemia/Acute systolic heart failure: On initial presentation, CXR demonstrated possible right lower lobe pneumonia, so patient was started on levofloxacin. However, symptoms did not improve x 2 days, and crackles were heard on exam, so repeat CXR was performed and demonstrated volume overload. Due to this, an echocardiogram was obtained that demonstrated systolic dysfunction, with an EF of 30-40%, global hypokinesis. The patient was treated with IV lasix for diuresis, was started on an ACE I for afterload reduction, with improvement in symptoms and oxygen requirement. For work up, EKG demonstrated non-specific changes, cardiac enzymes demonstrated a normal CK, but slightly elevated troponin (peak 0.3), and elevated BNP at >3000. Cardiology was consulted and the etiology of his acute heart failure was thought to be viral myocarditis. He will be medically managed with Lasix 40 mg po qday, metoprolol XL 25 mg po qday (goal of 50 mg limited by hypotension), lisinopril 2.5 mg po qday. He was educated on fluid restriction and a low salt diet. He did require a small amount of potassium repletion while on Lasix, and was discharged with instructions to take 10 meq potassium daily. A chemistry should be obtained in the next to weeks to assure appropriate potassium levels. He will follow up with Dr. [Last Name (STitle) 7965] in two weeks in cardiology clinic. 2. decreased forced vital capacity/hypoxia: Of note, neurology was also consulted early in this [Hospital 228] hospital course to assess if his ALS was contributing to his hypoxia. Initial evaluation by respiratory demonstrated very low vital capacity (at 750cc) with normal NIF test, and the patient was therefore temporarily transferred to the intensive care unit for monitering. However, formal PFTs were performed and demonstrated low vital capacity. Repeat spirometry prior to discharge remained diminished from prior baseline, so he was arranged to have home BiPAP. His outpatient sleep/pulmonary physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] was notified and will follow up. He may benefit from a formal sleep study. 3.) Mild transaminitis: LFTs were checked on admission given the patient's complaint of malaise, anorexia. They were noted to be very mildly elevated, and therefore his outpatient Rilutek was held as the possible etiology of his mild transaminitis. His rilutek was held during his hospital course and will be restarted as an outpatient. . 4.) ALS: Recently diagnosed, very functional at this stage. Neurology was involved throughout his hospital course. His PFTs were monitered as above. . 5. calcified thyroid nodule: incidental finding on CTA. should be followed as an outpatient. Thyroid function was normal. Medications on Admission: Citalopram [Celexa] 10 mg Tablet three Tablet(s) by mouth once daily . Levothyroxine [Levoxyl] 88 mcg Tablet 1 Tablet(s) by mouth each day . Mirtazapine [Remeron] 15 mg Tablet 1 Tablet(s) by mouth once daily (Prescribed by Other Provider) . Riluzole [Rilutek] 50 mg Tablet 1 Tablet(s) by mouth twice a day . Temazepam 15 mg Capsule [1-12] Capsule(s) by mouth at bedtime Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Temazepam 15 mg Capsule Sig: [1-12] Capsules PO HS (at bedtime) as needed. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:1 11. BiPAP QHS, Settings [10-16], titrate to comfort. 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Acute systolic congestive heart failure Transaminitis nocturnal hypoxia Secondary: ALS Hypothyroid Depression Discharge Condition: Good. Patient feeling better, appetite improved, breathing stable. Discharge Instructions: You were admitted to the hospital with complaints of malaise, decreased appetite, and shortness of breath and found to have congestive heart failure. Your pulmonary function tests showed decreased vital capacity and you will need to use BiPap at night. Please take medications as directed. Please follow up with appointments as directed. Please contact your primary physician if develop worsening shortness of breath, chest pain/pressure, nausea/vomiting, abdominal pain, any other questions or concerns. Followup Instructions: Please follow up with cardiology, Dr. [Last Name (STitle) 73] ([Telephone/Fax (1) 2037] on [12-22] at 1:20pm. The cardiology offices are located in the [Hospital Ward Name 23] building at [Hospital3 ] Hospital on the [Location (un) ]. Please follow up with these previously scheduled appointments: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1045], [Name12 (NameIs) 1046] Phone:[Telephone/Fax (1) 1047] Date/Time:[2135-11-29] 2:00 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2135-12-13] 8:20 Provider: [Name10 (NameIs) ] [Name8 (MD) ], M.D. Date/Time:[2135-12-14] 4:40	[ "4280", "311", "4019", "2724" ]
Admission Date: [2180-2-25] [Year/Month/Day ] Date: [2180-3-11] Date of Birth: [2096-11-20] Sex: F Service: SURGERY Allergies: Iodine / Tramadol Attending:[First Name3 (LF) 371] Chief Complaint: Leukocytosis and mental status changes Major Surgical or Invasive Procedure: IR drainage of abscess History of Present Illness: Asked to see this 83 F who is well known to ACS surgery after undergoing multiple laparotomies over the past 4 months. She initially underwent sigmoid colectomy and Hartmann's for a giant sigmoid diverticulum. Subsequently she underwent a small bowel resection as a result of an SBO. A week later she dehisced and underwent a 3rd operation. Today she returns from [Hospital 100] Rehab with worsening mental status and leukocytosis to 30,000. Per the patient's daughter, her mental status has not been clear for months, however she has worsened over the past 2 days. She does not report fevers or chills, however does report one bout of coffee ground emesis yesterday as well as black tarry stool from her ostomy. Past Medical History: CHF, CAD, ESRD on HD since '[76], HTN, DMII, OA, multinodular goiter, Hyperlipidemia, Depression, hemorrhoids, Diverticulosis PSH: Ex-lap with drainage of pelvic abscess, small bowel resection and anastomosis, and closure of abdominal fascial dehiscence [2180-1-20]; SBR for ischemic bowel due to SBO [2180-1-13]; Washout of R. hip [11-2]; Resection of massive sigmoid diverticulum, Sigmoid colectomy with end colostomy [2179-7-6]; cataracts; LUE AV graft and subsequent thrombectomy in [2172]; L. hip replacement [2172]; Cholecystectomy Social History: Lived at home alone until admission in [2179-10-25], since then been at [Hospital 671] Rehab, then moved to Windgate. Has 2 daughters in the [Name (NI) 86] area. One daughter [Name (NI) ] is the HCP, works here at [Hospital1 18] in the send out lab department. Denies tobacco, EtOH, drugs. Family History: CAD and death from MI (son in his 40's, her sister and her mother in their 60s) Physical Exam: ON ADMISSION: PE: 98.3 96 142/58 18 96% RA --> SBP then in 70's during my exam, improved to 80's with 1L IVF A&O x 1, appears uncomfortable, confused EOMI, anicteric sclera L. SC PICC in place. Site c/d/i without erythema; R. IJ tunnelled dialysis catheter in place. Site c/d/i RRR Decreased breath sounds at left base Abdomen soft, nondistended, mild midline tenderness along incision/wound. Wound with healthy granulation tissue with small amount of yellow exudate at inferior aspect. Ostomy with gas and dark black, soft stool. Guiac +. LE warm, trace edema; Bilateral UE with 1+ edema Stage 4, 5 cm x 5 cm foul smelling sacral decubitus ulcer\ Foley catheter with thick [Doctor Last Name 352]/brown urine ON [Doctor Last Name 894]: PE: 98.2 82 118/62 20 100%RA exam grossly unchanged from admission. A&O to self. pt resting comfortably and attends to voice but does not follow commands. confused. R IJ HD catheter in place with entry site clean, dry, and intact. L subclavian line in place with entry site and overlying skin clean, dry and intact. Cardiac: RRR Abd: soft, no apparent tenderness (no grimmace), nondistended. Mild erythema (stable) along midline incision/draining wound. Wound continues to have healthy granulation tissue w/ fibrinous exudate and no frank purulence. Ostomy w/ soft tool. Ext: warm, 1+ bilateral edema. Other: Large (~6x8cm) decubitus ulcer with healthy granulation tissue at the base, no frank purulence is appreciated. Minimal erythema appreciated at the edges of the wound. Pertinent Results: [2180-3-9] 05:21AM BLOOD Hct-22.9* [2180-3-8] 08:39PM BLOOD Hct-19.8* [2180-3-8] 04:46AM BLOOD WBC-15.2* RBC-2.34* Hgb-6.9* Hct-21.5* MCV-92 MCH-29.5 MCHC-32.0 RDW-15.3 Plt Ct-280 [2180-3-6] 09:25AM BLOOD WBC-16.6* RBC-2.69* Hgb-8.0* Hct-24.5* MCV-91 MCH-29.7 MCHC-32.6 RDW-15.0 Plt Ct-328 [2180-3-4] 09:15AM BLOOD WBC-13.4* RBC-2.37* Hgb-6.9* Hct-21.5* MCV-91 MCH-28.9 MCHC-31.8 RDW-16.1* Plt Ct-273 [2180-2-29] 01:26AM BLOOD WBC-19.9* RBC-3.34* Hgb-9.9* Hct-30.3* MCV-91 MCH-29.5 MCHC-32.6 RDW-15.7* Plt Ct-275 [2180-2-25] 02:20PM BLOOD WBC-30.8# RBC-3.03 Hgb-8.9* Hct-27.7* MCV-91 MCH-29.3 MCHC-32.1 RDW-16.2* Plt Ct-259 [2180-2-25] 02:20PM BLOOD Neuts-81.9* Lymphs-11.7* Monos-4.6 Eos-0.8 Baso-1.1 [2180-3-8] 04:46AM BLOOD Plt Ct-280 [2180-3-6] 09:25AM BLOOD Plt Ct-328 [2180-2-26] 03:08AM BLOOD PT-15.4* PTT-30.3 INR(PT)-1.4* [2180-3-10] 04:53AM BLOOD Glucose-62* UreaN-12 Creat-2.6* Na-134 K-3.3 Cl-99 HCO3-30 AnGap-8 [2180-3-8] 04:46AM BLOOD Glucose-75 UreaN-13 Creat-2.7* Na-138 K-3.5 Cl-103 HCO3-30 AnGap-9 [2180-3-6] 09:25AM BLOOD Glucose-56* UreaN-22* Creat-3.4# Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 [2180-3-4] 09:15AM BLOOD Glucose-72 UreaN-13 Creat-2.3 Na-138 K-3.6 Cl-104 HCO3-29 AnGap-9 [2180-3-3] 05:03AM BLOOD Glucose-77 UreaN-23* Creat-2.9* Na-138 K-3.6 Cl-103 HCO3-30 AnGap-9 [2180-3-2] 05:53AM BLOOD Glucose-68* UreaN-20 Creat-2.2* Na-136 K-3.6 Cl-100 HCO3-30 AnGap-10 [2180-2-29] 01:26AM BLOOD Glucose-64* UreaN-59* Creat-3.9* Na-138 K-4.8 Cl-100 HCO3-27 AnGap-16 [2180-2-25] 02:20PM BLOOD Glucose-95 UreaN-40* Creat-1.8# Na-140 K-4.1 Cl-101 HCO3-30 AnGap-13 [2180-2-26] 03:08AM BLOOD ALT-6 AST-10 LD(LDH)-323 AlkPhos-107* Amylase-86 TotBili-0.3 [2180-2-25] 02:20PM BLOOD ALT-8 AST-10 LD(LDH)-418* AlkPhos-120* TotBili-0.4 [2180-2-26] 03:08AM BLOOD Lipase-47 [2180-2-25] 02:20PM BLOOD cTropnT-0.15* [2180-3-10] 04:53AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.5* [2180-3-8] 04:46AM BLOOD Calcium-7.0* Phos-2.8 Mg-1.6 [2180-3-6] 09:25AM BLOOD Calcium-7.5* Phos-3.7 Mg-1.8 [2180-3-10] 04:53AM BLOOD Vanco-17.5 [2180-3-8] 04:46AM BLOOD Vanco-18.5 [2180-3-6] 09:25AM BLOOD Vanco-17.4 [2180-3-3] 05:03AM BLOOD Vanco-21.0* [2180-2-25] 02:33PM BLOOD Lactate-2.4* [2180-2-25]: EKG: Artifact is present. Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave changes. Compared to the previous tracing of [2180-1-13] atrial fibrillation has replaced sinus rhythm and the Q-T interval is shorter [2180-2-25]: cat scan of abdomen and pelvis: IMPRESSION: 1. Limited study without IV contrast. New thin 6 x 2 x 6 cm walled hypodense collection in the right lower pelvis, with interspersed pockets of air, concerning for interval development of organizing abscess. Possible communication with the cutaneous defect at the right anterior pelvic wall. Recommend direct inspection. 2. No bowel obstruction. Oral contrast has reached the colostomy bag. 3. Moderate bilateral pleural effusions with adjacent atelectasis. 4. Moderate-to-severe anasarca. 5. Moderate-to-severe degenerative and post-infectious and post-surgical changes of the right hip. [2180-2-25]: Ultrasound: IMPRESSION: No evidence of DVT in the right upper extremity. Edema is noted within the right upper extremity [2180-2-28]: IR drainage: IMPRESSION: CT-guided attempted aspiration and drainage of a lower anterior abdomen phlegmon in a patient with extensive surgical history and wound infection. No spontaneous aspirate was retrieved and no drainage catheter was placed. A small sample obtained after injection/aspiration of small amount of sterile saline was sent to microbiology for further analysis. [2180-2-26]: chest x-ray: Poor definition of the left diaphragmatic pleural surface can be explained by small left pleural effusion and perhaps basal atelectasis. Lung volumes remain low, but there is no pulmonary edema or definite consolidation. Elevation of the right lung base could be due to a small volume of right pleural fluid as well. Left subclavian line ends in the mid SVC and dialysis catheter in the right atrium. Heart is not enlarged. No pneumothorax. [2180-2-26]: Wound culture: WOUND CULTURE (Final [2180-2-28]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +. RARE GROWTH. [2180-2-26]: urine culture: URINE CULTURE (Final [2180-2-29]): YEAST. 10,000-100,000 ORGANISMS/ML.. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [2180-2-27]: Wound: WOUND CULTURE (Final [2180-2-29]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Brief Hospital Course: The patient was admitted directly to the SICU under the ACS service. Her hospital course by systems is as follows: NEURO: The patient's mental status on admission was confused and disoriented. The patient continued to be confused throughout her stay and seemd to be oriented to her family member only. CVS: The patient was started on levophed while in the ED. Later, after transfer to the SICU, she was still requiring small doses of pressors to maintain MAP >60. Pressors were discontinued on [2-27]. PULM: Pt doing well on RA. CXR early on demonstrated a Left pleural effusion vs atelectasis. No clinical signs of PNA. FEN/GI: The patient was made NPO and maintained on IVF. GU: The patient's urine was sent for U/A and UCx. The nephrology team was notified upon admission and she underwent HD under their direction. ENDO: The patient was put on a regular ISS. ID: On admission, the patient was started on vanc/zosyn. Pt had a positive UA and it was thought that she became septic from this infection. In addition pt underwent attempted drainage of her abdominal abscess. During the procedure the drain was inserted above the assumed fistula, however the drain came out of the skin at the site of the fistula and any further attempts of draining were discontinued. No drain was left in place. HEME: The patient's hct dropped to 22.7 on HD2 from an admission hct of 27.7. She was therefore transfused 2 units of PRBC with a post-transfusion hct of 27.6. The pts HCT remained stable after that. Hospital course since admitted to floor: updated by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 20841], NP Transferred to the surgical floor on [2-29]. Vancomycin and zosyn were continued for empiric coverage.During this time, patient exhibited signs of confusion. Family concerned about long term progress. Goals of care were initiated. She continued on dialysis as per schedule. Discussion of PICC placement addressed with family as well as concerns for mother's comfort and long-term outlook. Palliative care was contact[Name (NI) ] and met with family to address their concerns. Attempts were made to introduce food, but reported to have aspirated. Speech and swallow consulted and reported that she was noted to aspirate on thin liquids and continued NPO. She continued to be followed by Renal to assess her kidney status and hemodialysis continued. On HOD # 15, she did require a unit PRBC for a hematocrit of 19 which increased it to 22.9. She does have a large decubitus on her coccyx which has been monitored by the wound nurse and has had dressing changes. She has continued to have ostomy care. Palliative care continued to keep in contact with the family and because of their mother's poor prognosis, the decision was made to provide comfort once pt was transfered to a hospice center. However, this transition was held until the HCP daughter returned from a trip, approximately 1 week. During this time the pt continued to recieve regular hemodialysis and wound care including monitoring and care for her decubitus ulcer and abdominal fistula. In further discussion with palliative care it was recommended that the central dwelling lines should remain as their removal wound result in increased pain/discomfort and unecessary risk to the pt. The plan was discussed with both daughters who agreed to leaving them in with the caveat of having them covered to that they were not inadvertantly removed by their mother when not being supervised. Of note: as per Speech and swallow: she has continued to aspirate liquids and has been NPO Medications on Admission: epogen, diovan 160', aricept 10', zemplar, vanco per HD protocol, senna 8.6', sensipar 30', VitD3 2000U, pravastatin 20', ASA 81', tylenol 1000''', dilaudid 6-10mg q4hrs, imdur 30' on non-dialysis days, nitroglycerin 0.4mg SL prn, metoprolol tartrate 25', docusate 100', lotrimin AF 2% powder''', Bcomplex vitamin, lidoderm 5% patch to knee, miralax [Name (NI) ] Medications: 1. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 2. Outpatient Lab Work Heparin Flush (1000 units/mL) 4000-[Numeric Identifier 2249] UNIT DWELL PRN line flush Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). [Numeric Identifier ] Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] [Location (un) ] Diagnosis: abdominal collection [Location (un) ] Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. [Location (un) ] Instructions: You were recently discharged from the hospital to a rehabilitation facility. You were re-admitted to the hospital with an elevated white blood cell count and worsening mental status. You were in the intensive care unit where you received additional fluid and required medication to support your blood pressure. You had your abscess drained by IR. Hemodialysis was resumed. You have been maintained on antibiotics for a UTI. You had difficulty swallowing and failed multiple swallow studies. Attempts were made to provide you with the necessary nutritional support. Family meetings with palliative care have ensured over the past week and goals of care were addressed. You are now being discharged to an extended-care facility with hospice care. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. Phone:[Telephone/Fax (1) 1228] Date/Time:[2180-3-29] 2:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8708], M.D. Phone:[Telephone/Fax (1) 719] Date/Time:[2180-5-4] 1:30	[ "0389", "78552", "40391", "5990", "99592", "2724", "41401", "25000" ]
Admission Date: [2200-9-26] Discharge Date: [2200-11-5] Date of Birth: [2160-7-16] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 6169] Chief Complaint: AML, admitted for sibling (sister) matched allo-BMT. Major Surgical or Invasive Procedure: Chemotherapy Intubation Initiation of Hemodialysis Blood transfusions Platelet transfusions Subclavian line placement Tunneled Hickman line placement x 2 History of Present Illness: Mrs. [Known lastname 50789] is a 40 yo F with AML, admitted for a sibling-matched [Known lastname 51240]. Onc history: She was first diagnosed with AML approximately 20 years ago when she presented with pancytopenia. She underwent 7+3+3 induction chemotherapy and two cycles of high dose cytarabine consolidation and attained a complete remission. She was lost to follow-up until she presented in [8-17] with pancytopenia and AML. She was re-induced with 7+3, received three cycles of high dose cytarabine consolidation, and went into complete remission. She remained in remission until [6-19] when she noted increasing lower extremity bone pain and fatigue and a CBC revealed a decreased white blood count with circulating blasts. She was admitted to [Hospital1 18], had a Hickman line placed, and was induced with 7+3, again attaining complete remission. Her post-induction course was complicated by E. coli bacteremia for which she was treated with a 14 day course of levofloxacin. Recent history: She had a tooth extraction on [9-4]. Following that, she developed some left facial numbness and was treated with Valtrex and clindamycin for possible shingles and tooth infection. She was admitted to [Hospital1 18] on [9-11] with a fever of unknown source. She was found to have suspected Nocardia bacteremia of an unclear etiology. Her Hickman line was removed, she was treated with Bactrim, became afebrile, and was discharged on [9-17] on Bactrim DS 2 tabs tid. Since her discharge she has felt well. She denies fevers, chills, or sweats. She does endorse a congestion sensation in her left sinus but denies any pain or pressure. She denies headaches, sore throat, cough, dyspnea, abd pain, dysuria, diarrhea, or new rashes. Past Medical History: 1. AML - dx 17 yrs ago. in remission after induction chemo. no consolidation therapy. relapsed in [2198]. 2. Panic attacks/anxiety 3. Peripheral neuropathy secondary to chemo, responsive to oxycodone. 4. Chronic left sided sinusitis, thought to be due to a structural problem. 5. Ovarian cyst. 6. H/O line infections with E. coli, Nocardia Surgical history: 1. s/p C4-6 fusion due to herniated disk in [2193] 2. s/p Tubal ligation. 3. s/p Tonsillectomy. Social History: She lives in [Location 8117], NH with her husband and two children, ages 12 and 15. She has previously lived in [Location ], MA. She is not currently working. They have an adult dog with no medical issues, shots up to date. She has travelled to [Location (un) 11177], [Country 149] ([2187]), NY, ME, PA. No other foreign travel. She does not drink alcohol for a "long time" and smokes marijuana occasionally but quit 3 months ago. She quit smoking cigarettes 3 months ago. Family History: Her mother had a myocardial infarction and died of CVA at a young age. Her father had lung cancer. Physical Exam: T 97 P 70 BP 130/80 RR 18 O2 100% RA Genl: Lying in bed, pleasant, cooperative HEENT: Anicteric, MMM, OP clear Neck: Supple, no appreciable lymphadenopathy or thyromegaly Heart: RRR, nl S1, S2, no extra sounds Lungs: CTA bilaterally, no rales or ronchi Abd: Soft, non-tender, non-distended, normal BS, no hepatosplenomegaly Ext: No edema, cyanosis, or clubbing. 2+ dorsalis pedis pulses bilaterally Neuro: A&O x 3 Skin: Left triple lumen and right Hickman catheter sites with minimal dried blood, otherwise clean. No bruises or rashes. Pertinent Results: Labs on admission: wbc 3.6 N:54.8 L:37.3 M:4.5 E:2.2 Bas:1.2 h/h 11.0/32.2 plt 93 Na 141 Cl 104 BUN 16 glc 110 K 4.4 CO2 27 Cr 0.8 Ca: 9.9 Mg: 2.2 P: 4.2 ALT: 32 AP: 98 Tbili: 0.5 Alb: 4.7 AST: 22 LDH: 209 PT: 12.2 INR: 1.0 Serologies: HIV neg Toxo pos HBcAb neg, HBsAb neg HCV neg RPR neg HSV I IgG pos HIV II IgG neg VZV IgG pos CMV IgG pos EBV consistent with past infection . Imaging: [2200-9-26] Chest CT: 1. Partial resolution of multiple bilateral pulmonary nodules. Unchanged nodule in superior segment of left lower lobe. . Lower Ext dopplers [10-24]: Technically limited study. No evidence of left lower extremity DVT. . Abdominal Sono [10-30]: 1. [Name2 (NI) ] portal veins are patent with hepatopetal flow. 2. Left and main hepatic veins are patent, with limited evaluation of phasicity secondary to patient respiration. The right hepatic vein is incompletely evaluated. 3. Slight interval decrease in right-sided pleural effusion. 4. Moderate intraabdominal ascites. 5. 2.2 x 1.6 x 1.9 cm hypoechoic lesion adjacent to IVC within right liver lobe. This was not seen on prior ultrasound, but is not significantly changed since prior CT dated [2200-10-12], and likely represents a hemangioma. 6. Interval significant decrease in gallbladder wall edema. 7. Stable size of spleen compared with prior CT dated [2200-10-12]. . X-ray foot [10-30]: Soft tissue changes as described. No fracture or cortical fragmentation . CT head [11-3]: No evidence of acute intracranial hemorrhage . CT Torso 9/19:1. Interval development and worsening of diffuse bilateral ground glass opacity within the lungs with multiple areas of more dense nodular opacity and collapse/consolidation of the right lower lobe with bilateral pleural effusions. Differential diagnosis is broad and includes infectious/inflammatory processes, CHF, and ARDS. 2. Splenic infarcts. 3. Large perfusion defect in the right lobe of the liver worrisome for hepatic infarct. The portal vein and hepatic arteries appear patent, although contrast enhancement is less brisk/robust compared to the prior study. The right hepatic vein stump is opacified with lack of opacification of the majority of the right hepatic vein, 4. Anasarca with increased ascites. 5. Bilateral expanded appearance of the flanks with loss of the normal fat plane between the flank musculature that may represent edema or swelling. A hematoma cannot be excluded. . CXR [11-4] (last CXR): Right and left central venous lines and ET tube are in stable position. Allowing for marked right-sided rotation, findings are not significantly changed. There are large bilateral pleural effusions and persistent pulmonary vascular congestion and pulmonary edema. No pneumothorax. IMPRESSION: No significant change from the previous exam. . Last Labs: [2200-11-5] 02:30PM BLOOD WBC-13.0# RBC-3.04 Hgb-9.2* Hct-26.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-23.7* Plt Ct-52* [2200-11-5] 04:00AM BLOOD Neuts-82* Bands-11* Lymphs-1* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-0 NRBC-124* [2200-11-5] 06:58PM BLOOD Plt Ct-24# [2200-11-4] 09:09PM BLOOD FDP-160-320 [2200-10-14] 01:00AM BLOOD Gran Ct-4182 [2200-11-5] 04:00AM BLOOD Glucose-218* UreaN-78* Creat-1.6* Na-131* K-4.9 Cl-97 HCO3-12* AnGap-27* [2200-11-5] 04:00AM BLOOD ALT-1155* AST-2846* LD(LDH)-8580* AlkPhos-722* Amylase-72 TotBili-37.5* [2200-11-5] 04:00AM BLOOD Lipase-25 [2200-10-15] 12:30AM BLOOD CK-MB-5 [2200-10-6] 03:27PM BLOOD proBNP->[Numeric Identifier ] [2200-10-6] 12:00AM BLOOD CK-MB-2 cTropnT-0.02* [2200-11-5] 04:00AM BLOOD Albumin-2.8* Calcium-8.2* Phos-5.5* Mg-2.0 [2200-11-4] 04:00AM BLOOD Hapto-<20* [2200-11-5] 04:00AM BLOOD Vanco-24.0* [2200-11-5] 04:00AM BLOOD Cyclspr-512* [2200-11-5] 07:50PM BLOOD Type-ART pO2-85 pCO2-39 pH-7.20* calHCO3-16* Base XS--11 [2200-11-5] 07:50PM BLOOD Lactate-6.5* [2200-11-5] 07:50PM BLOOD freeCa-0.90* Brief Hospital Course: 40 yo with AML admitted for thymoglobulin, cytoxan, and total body irradiation for sibling (sister) matched [Month/Day/Year 51240]. . Acute Myelogenous Leukemia: Patient was admitted for sister matched [Name2 (NI) 51240]. She received thymoglobulin [33mg on day -3 (0.5mg/kg), 132 mg on days -2, -1 (2mg/kg)], cytoxan 3720 mg (60mg/kg) [Hospital1 ] on days -5 and-4, and TBI on days -3, -2,-1, and day 0. She received her cells on [10-2] (day 0). She experienced a fair amount of back pain with the ATG that was improved with pre-medication with methylprednisolone, up to 100 mg. Several hours following her stem cell transfusion she developed a syndrome of severe body aches (especially in her head, back, and legs), rigors, and tachycardia. This was thought to be a delayed reaction to the ATG and she felt better after being treated with Solu-Medrol, Benadryl, and Demerol. The Solu-Medrol was changed to methylprednisolone and weaned to [11-19] daily. After being transferred to the MICU on [2200-10-22] for treatment of progressive VOD ( SOS) the patient was continued on daily cyclosporine, initially at 48 mg daily then increased to 54 mg daily to maintain levels of 450-550. The patient was also continued on steroids of methylprednisolone decreased to 5 mg [Hospital1 ]. Weekly CMV viral load assays were performed which were initially negative. CMV viral load on [10-31] was positive at 56,800, then 78,500. The patient was then started on Ganciclovir. The Bone Marrow Transplant team continued to follow the patient during the ICU stay. . Respiratory Failure: On day +2 following her stem cell transfusion she began to complain of a dry cough and required 1-2 L O2 by NC to maintain her sats in the mid 90s. A portable chest X-ray was suggestive of fluid overload but was also worrisome for a diffuse infectious process or an ATG effect. A chest CT scan showed moderate-sized bilateral pleural effusions, scattered nodules, ground-glass opacities in a predominantly perihilar distribution, increased septal lines and periportal edema. These findings were thought to be consistent with interstitial/pulmonary edema, potentially secondary to a diffuse infection. Since the differential included fluid overload, infectious process, and ATG effect, she was treated for all three possibilities with Lasix for diuresis, broad spectrum antibiotics, and Solu-Medrol for ATG effect. A pulmonary consult was also obtained and they agreed with the plan outlined above. Over the course of several days her cough resolved, she became less short of breath, and she did not require any supplementary oxygen. She was diuresed with Lasix with little improvement. Over the next 2 weeks, patient gained >30 pounds from excess volume. Aggressive diuresis was unable to keep the patients ins and outs completely even. The patient had a stable oxygen saturation on 2L, but her breathing became more labored. Eventually, the patient was transferred to the MICU for increasing respiratory distress on [2200-10-22]. The patient was electively intubated for airway protection due to worsening encephalopathy and shortness of breath. Patient was ventilated with assist control ventilation with low tidal volumes ranging from 400-500 and low FIO2 40-50%. Attempts to transfer to pressure support were unsuccessful due to patient agitation and discomfort therefore AC was maintained throughout her ICU admission. The differential for respiratory failure remained unchanged and still included fluid overload vs. diffuse infectious process vs. ATG effect. Patient also with low EF with MR [First Name (Titles) ] [Last Name (Titles) ] likely contributing to pulmonary edema. In terms of an infectious process there is concern for fungal infection as the patient was severely immunosuppressed. Serial CXR suggestive of pulmonary edema with bilateral infiltrates and round opacities suggestive of aspergillus. Galactomanin was negative, although drawn after initiation of antifungal therapy. Initially, the patient was placed on a Lasix drip increasing to 20 mg per hour with little improvement in diuresis. Patient was started on hemodialysis on day 2 of ICU admission for fluid removal and acute renal failure. Daily HD was performed with removal of up to 5 L of fluid daily with no hemodynamic compromise. Her vital signs remained stable. Patient was also maintained on high levels of pain control and sedation with Fentanyl and Midazolam since attempts to wean her sedation lead to agitation, tachycardia, and episodes of crying (likely secondary to severe pain). In terms of coverage for an underlying infectious process, the patient was treated with Meropenem, Caspofungin, and Acyclovir all dosed with HD. The decision was made not to switch to Voriconazole for coverage of Aspergillus since this medication is hepatotoxic and has numerous drug-drug interactions. The decision was also made to hold off on bronchoscopy for tissue diagnosis given the patient's coagulopathy and critical condition. Vancomycin was added on [2200-10-28] after blood cultures grew gram positive cocci in pairs and chains. Surveillance cultures were drawn from all central lines. Patient was also placed on contract precautions for MRSA. On [10-27] blood cultures came back positive for Enterococcus, from an unlabelled line. This was sensitive to Vancomycin however. the decision was made to treat through the lines since the risk of removing all lines and placing new lines was significantly higher given her risk of bleeding and coagulopathy. Patient also had a bronchoscopy with BAL performed on [10-30] which showed friable mucosa, no lesions or active bleeding. Cultures and cytology pending. The patient remained on mechanical ventilation until she passed away on [2200-11-5]. . Renal Failure: Following her transplant her creatinine rose, thought to be due to cyclosporin toxicity. Renal was consulted and with adjustment of cyclosporin, her Creatinine went as low as 1.5 (still above her baseline). The next week, it began to slowly rise, peaking at 3.7 upon admission to the ICU. The renal failure was thoought to be secondary to her progressive VOD. The renal team was reconsulted to assess need for hemodialysis and recommendations for diuresis. Her medications were all renally dosed and eventually dosed with HD. Her BUN and Cr improved with HD coming down to a Cr of 3.0. Renal continued to follow the patient in the ICU and was able to remove large amounts of fluid, up to 5 kg per day with HD. The decision was made to continue intermittent HD vs. CVVH due to the patient's participation in the Defibrotide study since the pharmacokinetics of the drug were unclear and the patient was not to have any procedures performed while receiving Defibrotide. She was continued on daily HD with removal of increasing amounts of fluid every day, up to 6.5 kg daily. Unfortunately, the patient had an obligate intake of over 4 L daily and therefore net fluid removal was approximately 1-2 L daily. Her creatinine remained elevated but decreased from peak to 1.2. Subsequently, the patient missed one day of HD on [11-3] due to problems with medication dosing, since the patient required Defibrotide which was restarted. On [11-4], HD was attempted by the patient became hypotensive and therefore it was discontinued. On [11-5], the decision was made to convert to CVVH due to her low blood pressures and in the hope to remove more fluid over an extended period of time. Unfortunately, CVVH was never started due to the patient's declining hemodynamic status. The patient passed away that same evening. . Venoocclusive disease (VOD) of Liver (Sinusoidal Obstructive Syndrome): During the week of [10-12], patient had an isolated slowly rising LDH. Liver ultrasounds were done which showed ascites and patent portal and hepatic vein flow. By [10-17] the patient's transaminases were also elevated, and her bilirubin exceeded 2.0. At this point the patient met clinic criteria for VOD (weight gain, bilirubin>2.0, RUQ pain and hepatomegaly). The patient was enrolled in a [Hospital3 328] clinical trial of defibrotide, randomized to high-dose treatment. The patient was followed by a study nurse with extensive study guidelines maintained in the patient's chart and a daily log was filled out in the chart. The patient was monitored for side effects including bleeding. In compliance with the study, daily labs were sent including CBC, Coags, LFTs with direct Bili, and Fibrinogen. Initially the patient received q 6 hourly labs including platelets, hematocrit and INR due to high transfusion requirements. The patient required ongoing platelet transfusions to maintain platelets greater than 50,000. The patient consumed platelets at a fast rate and therefore the parameter was reduced to 30,000 since she was not bleeding. The mechanism for her rapidly declining platelets was secondary to the VOD. Platelets were maintained due to the high risk of bleeding with Defibrotide. HIT antibody was sent which was negative. The patient was also transfused for Hct <35 in order to maintain liver perfusion and to optimize platelet function. She completed 14 days of the Defibrotide study on [10-30] but was maintained on the drug for continued treatment. Her transfusion requirements eventually decreased given the fact that she was rapidly consuming platelets. From [10-29] onwards the patient was transfused for platelets <30 and then <20. On [10-31], however, she began to having bleeding from an OG tube that was placed on [10-30] and from her ET tube and was transfused to maintained platelets >50. In terms of FFP, she was transfused approximately 1 unit daily to maintain and INR of 1.5 or less. She was transfused for Hct <30 and required one unit on [10-31] due to blood loss from her ET/NG tubes. Defibrotide was therefore held for several doses on [10-31] due to bleeding. After completing the study she had a RUQ ultrasound which showed no change in her liver and patent vasculature. After the patient stopped bleeding, Defibrotide was restarted at a lower dose. Then, CT scan performed on [11-3] showed infarction of a large portion of her liver on the right side with question of right hepatic vein thrombosis. Her liver function tests began to rapidly elevate again to the thousands. Defibrotide was continued in the last days of her life in an attempt to treat her preogressive VOD. Left foot dry gangrene/cellulitis: Initially, her left foot became dusky involving only the heal which became violacious and dark in color. It continued to progressto involve her entire sole and dorsal surface of her foot. Her toes seemed to be primarily involved and eventually became frankly necrotic with dry gangrene. Her right foot did not show similar changes but did have some superficial skin breakdown on the dorsal aspect. Pulses continued to be present with Doppler. Vascular surgery was consulted and continued to follow the patient, with no recommendations for surgery at that time. Most likely cause was the underlying microvascular obstruction from underlying VOD but an embolic source could not be ruled out. Lower extremity dopplers were done to r/out DVT which were negative. Little treatment could be offered due to her coagulopathy and low platelets. Meticulous wound care was performed in order to prevent infection. On [10-30], her shin and ankle appeared more erythematous and it appeared as though she was developing cellulitis of her LE which did not progress past her ankle and lower calf. Her plantar and dorsal surfaces of her left foot remained stable although her toes werer frankly gangrenous (dry). ID consult was placed regarding her multiple infections and they did not recommend any further changes to her antibiotic regimen. Meticulous wound care was continued. . Upper GI Bleed: On [10-30], NG tube was placed for initiation of a bowel regimen. The tube was placed without trauma, however, given the patient's low platelets and coagulopathy she started to have some bleeding from the OG tube. OG lavage was positive for moderate blood. She was started on IV PPI [Hospital1 ]. She also developed some blood tinged secretions from her ET tube on [10-31]. These persisted throughout the day. She was transfused one unit of RBCs and several units of platelets to keep them greater than 50. DIC labs were sent, for which the interpretation was obscured given her underlying liver disease but were not frankly indicative of DIC (see pertinent labs), although fibrinogen remained elevated. She had intermittent bloody secretions from both her ET and OG tubes over the last few days of her life, on the last day she had dark brown material from her OG tube likely coffee grounds/blood vs. feculent matter. Her Hct remained relatively stable despite this and required minimal blood transfusions for this problem. . CHF/Cardiomyopathy: On day 3 of admission she complained of chest tightness and was noted to have a pericardial friction rub on exam. A TTE showed no pericardial effusion but did reveal moderate tricuspid and mitral regurgitation and global mild to moderate hypokinesis, new from previous echocardiogram. An EKG was unchanged from previous and cardiac enzymes were flat. A cardiology consult was obtained and they felt her chest pain was unlikely to be ischemic in origin or due to pericarditis. They felt that her decreased EF and valvular regurgitation was most likely due to toxicity from her chemotherapy and did not warrant any acute treatment. She continued to complain of mild chest tightness for several days but this gradually dissipated. The patient was chest pain free for the next 3 weeks, although she was tachycardic and hypertensive. Patient's pain was treated and a beta blocker was started on [10-21]. She required increased doses of beta blockers with Lopressor 5 mg IV q 6 hrs. Her blood pressure remained borderline high throughout around 140s/80s. Repeat ECHO was performed on [11-4] once the patient became hypotensive and CT showed infarction of her liver and spleen. This was essentially unchanged with an EF of 40-50%. It did not show any masses or thrombi. . Coagulopathy: Stable INR <2, also with thrombocytopenia [3-19] to hepatic failure and study drug Defibrotide. Patient was transfused with FFP approximately 1 unit daily and for plts <30, or <50 with active bleeding. Towards the last few days of her life, her INR steadily increased to >2.0 despite repeated transfusions of FFP. . Hypothermia: Patient with history of low temps in the past down to 92 F. She was treated with warming blankets when she was hypothermic. She had a long period of time when her temperature was stable, although she became hypothermic again, down to 94F during the last few days. . Gordonia/CMV/Enterococcus infections: Patient initially diagnosed with Nocardia line infection on past admission, incorrectly diagnosed, now thought to be Gordonia. Treated with imipenem, then switched to meropenem as her renal function declined. Likely complicating resp status. She was continued on Meropenum throughout her ICU stay for boad coverage given her immunocompromise. CMV viral loads were drawn weakly and eventually came back positive with 56,800 --> 78,500 copies/ml, which was previously undetectable. This was thought to be due to reactivation since the patient was IgG positive on past admission. In addition, Enterococcus grew from one of her central lines which was Vancomycin sensitive. She was therefore treated with Vancomycin without line removal since the line source was unknown. Surveillance cultures were drawn from each line and labelled but remained negative. It was decided that removal and replacement of her central lines would be far too great a risk given her coagulopathy, low platelets and immunocompromise. Both infectious disease and oncology teams agreed to treat her through the line. . . Rash: Patient noted to have erythematous area over her upper chest and shoulders, thought to be cellulitis, line infection or possibly the onset of GVHD. This rash remained stable, possibly less severe and was followed clinically with continued broad spectrum antibiotic treatment. . Encephalopathy/Altered Mental Status: Essentially unchanged throughout her ICU admission. Patient began to have auditory and visual hallucinations on [10-8]. She became agitated at night, showing evidence of delirium exacerbated by her baseline anxiety. Psychiatry was consulted and recommended Haldol. Other psychotropic medications were weaned and Haldol was started. During the next two weeks, the patient became increasingly agitated and confused. The patient's symptoms were felt to be related to uremia, hepatic encephalopathy, Haldol, benzodiazepines, and decreased clearance of morphine. The patient was changed to a fentanyl PCA on [10-21] to better control pain/agitation. On transfer to the MICU, patient was much less responsive, moving all extremities and withdrawing to pain, but not following commands. In the ICU, patient remained intubated and sedated. Attempts to wean sedation were unsuccessful since she became agitated, tachycardic, with episodes of crying, likely in a lot of pain. She was continued on heavy sedation for comfort with Fentanyl 50 mcg/hr and Midazolam 1 mg/hr. CT of the head was performed on [11-3] which was negative for any bleed or other intracranial changes. Patient remained heavily sedated for pain throughout her ICU admission. . Septic Shock: Patient with dropping blood pressures x 3 days which began on [11-3], requiring pressors with Levophed initially and then vasopressin. Her WBC rose to 19 with rising lactate to 7.8 thought to be due to underlying sepsis from her multiple known infections or possibly due to a new infection. On [11-5], the patient was on maximum pressors with still dropping blood pressures. On the evening of [11-5] her SBP dropped to 40s then not detectable by doppler prior to passing away. The differential remained broad but included pneumonia, line infection, intraabdominal infection given positive for enterococcus, CMV, and gordonia. Surveillance cultures were negative and she was treated with broad spectrum antibiotics, antivirals and antifungals. Her intravascular volume was also maintained with blood products including FFP, pRBCs and platelet transfusion. Eventually the patient also required IVF boluses although this was a last measure given her severe fluid overload. . Liver Infarction/Splenic infarcts: Initially, patient had dramatically elevated LFTs thought to be due to VOD, this improved with treatment with Defibrotide with essentially normalization of her liver function tests but with persistent hyperbilirubinemia. On [11-1] her LFTs started to rise slowly, and then very dramatically back into the thousands on [11-5]. CT of the abdomen was performed which showed a large area of infarction in the right portion of her liver with multiple splenic infarcts. An embolic source was considered and Echocardiography was performed which was negative for an embolic source. Most likely this was due to thrombosis of hepatic vein which was poorly visualized on sono and CT scan but suggestive of thrombosis. The mechanism for thrombosis was unclear given her severe coagulopathy and low platelets. Defibrotide was continued during her lasts days of life in an attempt to treat her liver disease. Official liver consultation was placed with recommendations for further imaging of the abdomen, however at that stage, the patient was so severely ill that further diagnostic measures were considered futile. . Abdominal distension: CT of the abdomen was negative for obstruction and showed old contrast from prior studies (almost one month prior) still in the colon. On [11-5] the patient was noted to have a firm, markedly distended abdomen. Prior exams were positive for edema and distension but her abdomen had always been soft. The patient had a dramatically rising lactate from 4.0 to 7.8 over the span of a few hours and therefore the diagnosis of bowel perforation or ischemia was considered. The decision was made with the ICU team and family to continue current treatment but not to provide any further interventions given her worsening status. Imaging by CT done the day prior did not reveal any obstruction or free air. Surgery was not an option at that stage given her severe hemodynamic compromise, coagulopathy, multiorgan failure as well as underlying infections and immunosuppression, therefore continue supportive measures were continued while treating underlying infections, maintaining blood pressure support and giving blood products as necessary. . Pain: Patient has a history of neuropathic pain in bilateral legs from prior chemotherapy. This was well-controlled during her last admission with oxycontin/oxycodone. She was continued on Oxycontin 10 mg [Hospital1 ] with oxycodone 5-10 mg prn. After development of VOD/SOS, the patient was presumed to have significant pain from underlying hepatic capsule distension and morphine PCA was started. As her mental status declined, this was changed to a basal fentanyl PCA. Upon transfer to the MICU, she was placed under heavy sedation with Fentanyl and Midazolam. In addition, it was presumed that she had pain from necrosis of her left foot. Attempts at weaning sedation produced agitation and tachycardia with one episode of crying. As such she was maintained on these medications for comfort. She was monitored throughout for signs of pain including agitation and tachycardia. . FEN: Patient was seen by nutrition and started on TPN for nutrition. Careful monitoring of electrolytes which were subsequently managed with HD. Fluid balance was maintained with HD with volume only given as necessary for transfusion/medications. . Prophylaxis: Initially she was not receiving a bowel regimen since she was maintained on TPN. Protonix was given coagulopathy and later increased to [Hospital1 ] with active GI bleeding. On [10-30] and OG tube was placed in order to initiate a bowel regimen. She had not had a BM since being admitted to the ICU but had only been receiving TPN for nutrition. OG tube placement was not difficult however patient did develop positive lavage with frank blood and clots the following morning. As such her bowel regimen was held. Insulin drip for strict glucose control. . Code status: Full. On [11-5] discussions with the family during a family meeting concluded that all treatments would be continued but that further treatment would be medically not indicated including cardiopulmonary resuscitation. . Access: R Hickman, L subclavian central line, R femoral HD catheter, A-line . Communication: With husband- ([Telephone/Fax (1) 51241] (home), ([Telephone/Fax (1) 51242] (cell). Medications on Admission: Bactrim DS 2 tabs po tid Celexa 20 mg po daily Klonopin 1 mg po tid Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: AML anxiety disorder Gordonia bacteremia Acute Renal Failure [Last Name (un) ] Occlusive Disorder Discharge Condition: Patient passed away on [11-5] from cardiac arrest secondary to sepsis Discharge Instructions: none Followup Instructions: none	[ "4280", "5990", "99592", "51881", "5845", "78552" ]
Admission Date: [2181-10-21] Discharge Date: [2181-10-26] Date of Birth: [2138-10-18] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old gentleman who originally presented from an outside hospital for presumed drug overdose. Patient states he drank two large bottles of wine and passed out. He denies any heroin, cocaine, or crack use that night. He denies any past suicide attempts. That night the patient got into an argument with his 17-year-old daughter because she got paint on his face while painting the house. As part of the medical record, after the argument the patient left, drank, and was found in his car, unresponsive. He was then brought to the outside hospital's emergency department. He had pinpoint pupils, a urine that positive for opiates, and he responded to Narcan. He was given charcoal, aspirated, and then was intubated. He received Ceftriaxone and Clindamycin at the outside hospital. Labs found him to have a glucose of 309 and a creatinine of 2.5. He had an anion gap metabolic acidosis with a respiratory acidosis superimposed. He was transferred to our Emergency Room and then subsequently sent up to our Medical Intensive Care Unit. In the MICU he was weaned off the ventilator, given aggressive fluid hydration for his increased creatinine. He was extubated on hospital day two without problems. [Name (NI) ] did spike in the MICU to 101.5. An Infectious Disease workup was begun. He was not started on any antibiotics. HIS PHYSICAL EXAMINATION UPON ADMISSION TO THE FLOOR: Temperature 98.8, heart rate is 99, his pressure is 161/93, respirations 28. He is satting 94% on room air. The patient is lying in bed, happy. Pupils are equal, round, and reactive to light. Neck is supple. He has no jugular venous distention. Chest is clear. He has no wheezing. He is tachycardiac. He has regular rhythm but with no murmurs. Abdomen: Soft and nontender. Bowel sounds are present. Extremities are warm. He is alert and oriented times three. LABORATORY DATA: His laboratory values showed a white count of 15.2, hematocrit of 35.8, platelets of 147. Chem-7 was unremarkable with a creatinine of 0.9 after aggressive hydration in the MICU. Calcium, magnesium, and phosphatase were normal. INR was normal. He had some elevated CKs that peaked at 600, initially started out at 415. His troponins were all negative. He had a urinalysis that showed a couple white blood cells but no bacteria. He had a sputum culture that showed 2+ gram positive cocci in pairs, 1+ gram negative rods, 1+ gram positive rods. He had a chest x-ray upon admission out to the floor that showed some improvement in his pulmonary edema. No episodes of pneumonia. HOSPITAL COURSE: Impression was for a 43-year-old male with significant ETOH and substance abuse, question of psychiatric history, now presenting with an aspiration event requiring intubation following a binge alcohol intoxication +/- opioid use. For his substance abuse the patient was given the option of meeting with Social Work and a Psych. Addictions nurse, for which he declined. Patient was placed on a CIWI Scale for his history of alcohol use. For the questionable failure/pneumonia chest x-ray, plan to diurese him p.r.n., check an echocardiogram to evaluate his ejection fraction and/or for possible cocaine or alcohol cardiomyopathy. Pulmonary status: Patient's respiratory status was stable. On hospital day four the patient was still having some low-grade temperatures up to 100.3. His white count remained stable at 12.9. He had a blood culture that grew out coag-negative Staphylococcus. On hospital day five the patient had a blood cul [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1207], M.D. [MD Number(1) 1208] Dictated By:[Last Name (NamePattern1) 3809] MEDQUIST36 D: [2181-12-27] 11:51 T: [2181-12-27] 14:54 JOB#: [Job Number 54122] eo	[ "5070", "51881", "5849", "2762" ]
Admission Date: [2166-4-3] Discharge Date: [2166-4-10] Date of Birth: [2082-12-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Fever, mental status changes; hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: 83 year old woman c history of COPD on home O2 (baseline 91% on 3L), mental retardation, presents from [Doctor First Name 391] [Hospital ] nursing home with fever, altered mental status, lab abnormalities. One week ago diagnosed with Bells palsy (for new L facial droop) and started on steroids. Today, the patient was noted to be less alert (at baseline AO2) and febrile in her nursing home to 101.3 and was sent to the ED. As per the nursing home there has been no known vomiting, abdominal pain. She did have a cough on friday, on transfer her O2 was 77-80, 91% on 3L, BP 196/74, P 87. In the ED, the patient had VS:HR 90, T 98.4, BP 140/78, RR 18, 94%. She was lethargic, on a NRB. She was noted to have a UTI, an elevated lactate (>4.0), hypernatremia, and hyperglycemia (>700). She received 10 u IV insulin followed by an insulin gtt. She was also noted to have a troponin of 0.[Street Address(2) 101316] depressions laterally; as a result, she was given ASA and a bolus of heparin. CT head was done that was negative and a chest X ray was negative for for consolidation. Her UA was positive and she received ceftriaxone then one dose of vanco, zosyn, she received 3L of NS. She also received an asa 325 and a heparin bolus of 5000u IV In the MICU she received 1/2NS with potassium, insulin gtt, serial labs. Also heparin gtt. Past Medical History: PAST MEDICAL HISTORY: 1. Breast cancer. 2. COPD. 3. Diabetes. 4. Psoriasis. 5. Mental retardation. 6. Dementia 7. Hypertension. 8. h/o polia Social History: No tobacco, alcohol, or drug use. Lives at Marine Bay Nursing Home, has been there since the place opened. Pt states she is visited by her niece/nephew : [Name (NI) 2048]/[First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. DNR/DNI (in [2162]) Family History: Noncontributory. No cancer or CAD. Physical Exam: vitals-97.6, HR 79, BP 184/96, HR 79, 95%2L gen-elderly woman, pleasant cv-RRR, S1, S2 pulm-slight crackles and left lower base HEENT-left facial droop, left eye lateral deviation neck-no jvd elevation Abd-soft, NT, scar down right , reducible hernia extrem-trace edema bilaterally skin-LLE-evidence of old cellulitis neuro-oriented times one (baseline times two) rectal stool guaiac negative as per ED Pertinent Results: ADMISSION LABS: [2166-4-3] 05:58PM GLUCOSE-706* LACTATE-4.6* [2166-4-3] 06:00PM PT-13.1 PTT-21.8* INR(PT)-1.1 [2166-4-3] 06:00PM PLT COUNT-359 [2166-4-3] 06:00PM NEUTS-90.9* LYMPHS-7.0* MONOS-1.9* EOS-0.2 BASOS-0.1 [2166-4-3] 06:00PM WBC-13.7* RBC-3.57* HGB-10.8* HCT-34.4* MCV-96 MCH-30.3 MCHC-31.4 RDW-13.7 [2166-4-3] 06:00PM CK-MB-NotDone [2166-4-3] 06:00PM cTropnT-0.08* [2166-4-3] 06:00PM CK(CPK)-63 [2166-4-3] 06:00PM estGFR-Using this [2166-4-3] 06:00PM GLUCOSE-765* UREA N-45* CREAT-1.1 SODIUM-159* POTASSIUM-3.7 CHLORIDE-113* TOTAL CO2-27 ANION GAP-23* [2166-4-3] 06:15PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [2166-4-3] 06:15PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2166-4-3] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.026 [2166-4-3] 09:25PM LACTATE-6.8* [2166-4-3] 11:13PM PT-ERROR INR(PT)-ERROR [2166-4-3] 11:13PM PLT COUNT-358 [2166-4-3] 11:13PM NEUTS-90.6* BANDS-0 LYMPHS-7.6* MONOS-1.7* EOS-0.1 BASOS-0.1 [2166-4-3] 11:13PM WBC-21.2# RBC-3.42 HGB-10.3* HCT-32.8* MCV-96 MCH-30.1 MCHC-31.4 RDW-13.7 [2166-4-3] 11:13PM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-3.1* [2166-4-3] 11:13PM GLUCOSE-449* UREA N-40* CREAT-1.1 SODIUM-167* POTASSIUM-2.9* CHLORIDE-125* TOTAL CO2-25 ANION GAP-20 [2166-4-3] 11:29PM freeCa-1.11* [2166-4-3] 11:29PM GLUCOSE-378* LACTATE-7.8* [2166-4-3] 11:29PM TYPE-[Last Name (un) ] TEMP-36.4 PH-7.28* ------------- [2166-4-3] CT Head: No evidence of intracranial hemorrhage or acute major vascular territorial infarction. If there is further clinical concern MRI is suggested. . [2166-4-3] CXR: Markedly limited study. No definite consolidation or other acute process. . [2166-4-4] CXR: No acute cardiopulmonary process. Brief Hospital Course: . 80F with a history of resected breast cancer, COPD, diabetes, and hypertension with mental retardation who presented with MS changes, UTI, electrolyte derangements including hypernatremia, hyperglycemia. Initially admitted to the MICU. . #. Hyperglycemia: Diabetic, likely the result of steroids and infection. Initial glucose >700 with anion gap 19 and trace ketones. Treated with insulin gtt in ICU initially; now much improved and back on SC insulin (glargine and sliding scale). [Last Name (un) ] consult obtained for recommendations. . #. Hypernatremia: Likely the result of poor access to free water due to mental status with component of osmotic diuresis from hyperglycemia. Initially given normal saline, then half normal. Improved steadily and now within normal range. Lasix held. . #. UTI: Initially treated broadly with vanc/zosyn; now on Cipro (start abx [2166-4-4]) She will continue on cipro for 2 more doses following discharge. . # Leukocytosis. Known UTI would likely explain. Negative for C.diff x 2. Improved to 11K by discharge. Intermittently with low fevers (<101) during admission without evidence of additional infection. . #. Atrial fibrillation: Not documented any on past history and ECG tracings are poor quality. In ICU was as fast as 130s though there are no tracings avaiable. Now back in sinus. Aspirin had been started given initial concern for ACS (see below); she can continue this for now and risks/benefits of anticoagulation can be discussed in the future with her primary care team. Diltiazem continued. . #. Hypoxia: Inially hypoxic on room air at nursing home to 80's, briefly requring NRB in ED. CXR in ED without evidence of infiltrate. No ABG. Now stable on home O2 regimen. Episode likely due to profound lethargy with electrolyte abnormalities. Also with persistently high respiratory rate since admission though does not appear particularly distressed. Her home COPD meds were continued, as well as oxygen at 2L, which she should continue once back at her nursing home. . # ECG changes. On presentation had lateral ST depressions and troponin elevation (though <0.1) which was flat (also in setting of renal failure). Aspirin started. On heparin gtt in the unit until MI ruled out enzymatically. No chest pain. . #. Bells Palsy: In the setting of DKA/HHS heldsteroids. Did not restart given lack of strong evidence for use of prednsione alone in Bells Palsy. . #. COPD: Continued fluticasone, albuterol and iptratropium. . #. CHF: Echo with normal EF; not overloaded one exam. Held lasix. Edema particularly involving upper extremities. Had discussion with family and guardian re: further workup, after talking with them held off on further testing (?upper extremity venous drainage problem). . #. Dementia/?bipolar: Stable; on depakote and abilify #. Hypertension: Continued diltiazem. Well controlled. #. H/O breast cancer: on Femara. #. Hypothyroidism: continued levothyroxine. . # FEN: Speech and swallow recommending nectar thickened liquids and puree; encouraged PO. # CODE DNR/DNI as per DC summary [2162], documented in this admission # Contact: Brother [First Name5 (NamePattern1) ] [Name (NI) ]) - [Telephone/Fax (1) 101317], Guardian ([Name (NI) 553] [Name (NI) 78199]; lawyer) Medications on Admission: 1. Diltiazem 120mg [Hospital1 ] 2. Depakote 1000mg po daily 3. Flovent q12 hours 4. Albuterol tid 5. Ipratropium neb qid 6. Gabapentin 100mg tid 7. Vit c 500mg 8. Acetaminophen 325mg tab two tabs daily 9. Metaclopramide 5mg qachs 10. Teargen drops 11. Lacrilube 12. Milk of magnesia 13. Lactaid 14. Trazodone 50mg tid prn agiation 15. Prochlorperazine 25mg supp q 8 hours 16. Prednisone 60mg po for 7 days starting [3-28], 50mg daily for three days, 40mg daily for three days, 30mg, 20, 10 daily for three days levothyroxine 25mcg qam 17. Levothyroxine 25mcg daily 18. Abilify 5mg daily 19. Pantoprazole 40mg daily 20. Lasix 20mg daily 21. MVI 22. Femara 2.5mg daily 23. Vitamin D 400mg daily 24. Colace 100mg daily 25. Ativan 0.5mg PRN agitation Discharge Medications: 1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day): pls hold sbp <100, HR <55. 2. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QACHS. 10. Teargen 1.4 % Drops Sig: One (1) drops Ophthalmic three times a day as needed for dry eye. 11. Lacri-Lube S.O.P. Ointment Sig: One (1) application Ophthalmic once a day as needed. 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) ml PO once a day as needed for constipation. 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for agitation. 14. Compazine 25 mg Suppository Sig: One (1) Rectal every eight (8) hours as needed for nausea. 15. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 19. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily (). 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 doses. 22. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 23. insulin please see attached schedule (including glargine 30 units and sliding scale) 24. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. 25. Depakote ER 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 26. lactaid 3000 units with meals 27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay - [Hospital1 392] Discharge Diagnosis: Severe hypernatremia Diabetic ketoacidosis Urinary tract infection . Altered mental status COPD Diabetes type II Mental retardation Dementia Hypertension Hypothyroidism Bells palsy Discharge Condition: Stable Discharge Instructions: You were admitted with an infection in your urine and high sodium and glucose levels. We treated you with antibiotics and corrected your abnormal labs with fluids and insulin. . Please return to the hospital or call your doctor if you have fever >101, difficulty breathing, diarrhea, change in behavior or confusion, or any new symptoms that you are concerned about. . Since you were admitted we have made the following important changes to your medications: * You will need to take cipro (an antibiotic) twice daily for 2 more doses. * Stop taking prednisone. * Stop taking lasix. * We have started aspirin. Followup Instructions: Please see your doctors at your nursing facility within [11-27] weeks. . You made need further adjustments of required insulin; your doctors at your nursing home can do this as needed. You can also discuss with your doctors [First Name (Titles) 25151] [Last Name (Titles) ] [Name5 (PTitle) ] would be appropriate for you given a single episode of atrial fibrillation while in the hospital. For now we have started you on daily aspirin. . You have the following upcoming appointment at [Hospital1 18] for mammography: Phone:[Telephone/Fax (1) 327] Date/Time:[2166-4-22] 1:55 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "5849", "2760", "5990", "V5867", "42731", "496" ]
Admission Date: [2163-1-13] Discharge Date: [2163-1-19] Date of Birth: [2108-8-9] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old gentleman with a history of exertional chest pain for over five years. He had a positive exercise tolerance test and catheterization one year ago and was advised to have a coronary artery bypass graft but refused. A new physician who he saw this month recommended an exercise tolerance test again. The patient exercised for three minutes and stopped due to electrocardiogram changes. He had a catheterization on [2162-12-31] which showed an ejection fraction of 60%, left anterior descending artery with 60% stenosis proximally, 80% stenosis with mild diffuse disease, and a high-grade diagonal. The left circumflex with 90% stenosis and an 80% stenosis at the obtuse marginal. The right coronary artery with a 90% ostial stenosis and 60% mid vessel stenosis, and 70% distal stenosis. The patient was then revealed to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Obesity. 4. Cataract in the left eye; for which he has had surgery. PAST SURGICAL HISTORY: 1. Appendectomy. 2. Craniotomy for a benign brain tumor as a child. 3. A gunshot wound to his back in [2154]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: (Medications included) 1. Atenolol 50 mg by mouth once per day. 2. Lipitor 10 mg by mouth once per day. 3. Lotrel [6-22] one tablet by mouth every day. 4. Sublingual nitroglycerin as needed. SOCIAL HISTORY: The patient is single and lives alone. He works with retarded adults. He is not a smoker and rarely drinks alcohol. He has no street drug use. REVIEW OF SYSTEMS: His review of systems was negative for shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea. No transient ischemic attacks. No cerebrovascular accidents. No gastrointestinal bleed. No hematochezia. No peptic ulcer disease. No diabetes. No cancer. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was an obese gentleman in no apparent distress. His vital signs revealed a heart rate of 72, his blood pressure was 148/74, his respiratory rate was 18, and his oxygen saturation was 100%. In general, the patient was alert and oriented times three. He moved all extremities with a nonfocal examination. His head, eyes, ears, nose, and throat examination revealed pupils with the left greater than right. There was no erythema or exudate. The neck was supple. No jugular venous distention. No bruits. Chest examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops. The abdomen was soft, nontender, and nondistended. No hepatosplenomegaly. He had a well-healed mid abdominal incision. The extremities were warm and well perfused. There was no clubbing, cyanosis, or edema. Pulses revealed carotid pulses to be 2+ bilaterally with no bruits. His radial arteries were 2+ bilaterally. His femoral arteries were 1+ bilaterally. Dorsalis pedis pulses were 0 bilaterally. Posterior tibialis pulses were 1+ bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: On [2163-1-13] the patient underwent coronary artery bypass grafting times four with a left internal mammary artery to left anterior descending artery, saphenous vein graft to diagonal, saphenous vein graft to the obtuse marginal, and a saphenous vein graft to the right coronary artery. The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 130 minutes and a cross-clamp time of 111 minutes. The surgery was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537], with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 16398] and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] nurse practitioner as assistant. The patient tolerated the procedure well and was transferred to the Surgical Recovery Unit on propofol and Neo-Synephrine drips. The patient was in a normal sinus rhythm with two atrial and two ventricular pacing wires, two mediastinal and one left chest tube. The patient was noted to be a difficult intubation and was kept intubated throughout the operative night. By the first postoperative morning, the patient was awake and alert. He was doing well on continuous positive airway pressure. He was extubated successfully with anesthesia present. His chest tubes were discontinued without incident, and his Neo-Synephrine drip was weaned off. As part of his surgical procedure, he was involved in one of distal anastomoses being done using the converge device. Consequently, he was started on Plavix postoperatively and loaded on the first postoperative day with 300 mg and with 75 mg by mouth every day subsequently. By postoperative two, he began to be diuresed with Lasix and was started on Lopressor. By postoperative three, his hematocrit was noted to be 20.8% and the patient was transfused 2 units of packed red blood cells. Following transfusion, the patient was transferred to the surgical floor and began his cardiac rehabilitation. The patient was allowed to ambulate and encouraged to ambulate three times during the day and more if he felt up to it. By postoperative four, the patient had his pacing wires discontinued without incident. Plans were begun for his discharge to home. He continued to progress well. He passed a level V on his Physical Therapy evaluation. On postoperative day six, the patient was ready for discharge to home. PHYSICAL EXAMINATION ON DISCHARGE: The patient's physical examination on discharge revealed his lungs were clear to auscultation bilaterally. His heart was regular in rate and rhythm. His abdomen was obese, soft, nontender, and nondistended. His extremities revealed mild edema. His incisions were clean, dry, and intact. PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's discharge laboratories revealed a white blood cell count of 11.9, his hematocrit was 25.2%, and his platelet count was 271,000. The patient's sodium was 142, potassium was 4.3, chloride was 104, bicarbonate was 32, blood urea nitrogen was 21, creatinine was 1.1, and blood glucose was 96. The patient's discharge chest x-ray showed no effusion and no signs of infiltrate. CONDITION AT DISCHARGE: The patient's condition on discharge was good. DISCHARGE STATUS: The patient was to be discharged to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician (Dr. [Last Name (STitle) ] in one to two weeks. 2. The patient was instructed to follow up with his cardiologist (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) in two to three weeks. 3. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] in four weeks. 4. The patient was instructed to follow a cardiac diet. 5. The patient was instructed to continue with his physical rehabilitation. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Lopressor 100 mg by mouth twice per day. 2. Captopril 12.5 mg by mouth three times per day. 3. Plavix 75 mg by mouth once per day (times one month); for anticoagulation with regard to a study for a converge device for distal anastomosis. 4. Lasix 20 mg by mouth twice per day (for 10 days). 5. Potassium chloride 20 mEq by mouth twice per day (for 10 days). 6. Multivitamin one tablet by mouth once per day. 7. Percocet one to two tablets by mouth q.4h. as needed (for pain). [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 53984] MEDQUIST36 D: [2163-1-18] 15:59 T: [2163-1-18] 16:04 JOB#: [Job Number 53985]	[ "41401", "4019", "2720" ]
Admission Date: [2176-10-9] Discharge Date: [2176-10-17] Service: MEDICINE Allergies: Ambien / Valium Attending:[First Name3 (LF) 56857] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: central line placement, arterial line placement History of Present Illness: [Age over 90 ]-year-old female with advanced Alzheimer's dementia who presented to the ED with altered mental status. Pt's family notes that she was less interactive than baseline this morning. At the ED, initial vitals were 99.7 70 88/61 16 95% ra. U/A was grossly positive with >182WBC and many bacteria. She was covered empirically with vancomycin and cefepime. Other significant labs included Na of 171, Cr of 2.0 (baseline normal), WBC 14.7, Hct of 48.7, lactate of 3.0, trop of 0.05. She was given a total of 3L NS upon arrival to the MICU. Of note, she was last hospitalized with UTI on [2175-11-5]. Urine culture grew <[2164] enterococcus and she was discharged on total 14 day course of amoxicillin On arrival to the MICU, HR 68 BP 118/55 RR 16 98% on RA. Pt. responding only to noxious stimuli with incoherent vocalizations. Review of systems: Unable to obtain Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. Shingles - [2169] 4. Depression 5. Anxiety 6. Advanced Dementia - Behavioral issues in the past with paranoia. No recent behavioral issues. 7. Status post GI bleed - The patient has a history of bleeding ulcers with significant bleeds in [2151] and [2167]. She no longer takes aspirin for this reason. 8. Falls 9. Insomnia 10. Constipation 11. Urinary retention Social History: Lives with daughter and her 3 grandchildren. Has 24 hour supervision and family is extremely supportive. Dependent for ADL's. Quit tobacco 60 years ago. Denies alcohol or IVDA. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: HR 68 BP 118/55 RR 16 98% on RA General: Somnolent, arouses minimally to sternal rub HEENT: Sclera anicteric, dry mucus membranes, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: significant skin tenting present. 1cm ulcer over right hip w/ minimal surrounding erythema. Neuro: moans and opens eyes to sternal rub. withdraws from painful stimuli. Unintelligible vocalizations. Moving all 4 extremities. Uncooperative with neuro exam. DISCHARGE PHYSICAL EXAM: VS 98.5/99.4 HR 78-94 BP 106/60 (100s-130s/50s-60s) RR 16-18 O2 98-99%RA GEN: somnolent, non-verbal, not following commands, NAD HEENT: NCAT. EOMI. PERRL. dry MM. no LAD. no JVD. neck supple. CV: RRR, normal S1/S2, no murmurs, rubs or gallops. LUNG: exam very limited [2-29] poor inspiratory effort [2-29] cognitive impairment from advanced dementia, no rales, wheezes or rhonchi appreciated ABD: soft, ND, does not grimace to palpation, +BS. no rebound or guarding. neg HSM. EXT: W/WP, trace edema, no C/C. 1+ DP/PT pulses bilaterally. SKIN: W/D/I NEURO: Unable to perform exam [2-29] severe dementia & pt unable to cooperate Pertinent Results: Admission labs: [2176-10-9] 01:45PM BLOOD WBC-14.7# RBC-4.96 Hgb-14.6 Hct-48.3# MCV-97# MCH-29.5 MCHC-30.3# RDW-15.7 Plt Ct-114* [2176-10-9] 01:45PM BLOOD Neuts-71.1* Lymphs-24.5 Monos-4.1 Eos-0.1 Baso-0.3 [2176-10-9] 07:59PM BLOOD Neuts-69.9 Lymphs-26.6 Monos-3.3 Eos-0.1 Baso-0.2 [2176-10-9] 07:59PM BLOOD WBC-13.5* RBC-3.66# Hgb-10.9# Hct-36.1# MCV-99* MCH-29.9 MCHC-30.3* RDW-15.7* Plt Ct-95* [2176-10-9] 01:45PM BLOOD PT-12.6* PTT-25.8 INR(PT)-1.2* [2176-10-9] 07:59PM BLOOD PT-14.0* PTT-23.0* INR(PT)-1.3* [2176-10-9] 01:45PM BLOOD Glucose-92 UreaN-54* Creat-2.0# Na-171 K-4.8 Cl-133* HCO3-26 AnGap-17 [2176-10-9] 07:59PM BLOOD Glucose-113* UreaN-47* Creat-1.5* Na-169* K-3.8 Cl-140* HCO3-26 AnGap-7* [2176-10-9] 10:12PM BLOOD Glucose-185* UreaN-43* Creat-1.4* Na-168* K-3.2* Cl-140* HCO3-23 AnGap-8 [2176-10-9] 01:45PM BLOOD cTropnT-0.05* [2176-10-9] 01:45PM BLOOD Calcium-9.7 Phos-4.2 Mg-3.0* [2176-10-9] 07:59PM BLOOD Calcium-7.8* Phos-2.8 Mg-2.4 [2176-10-9] 10:12PM BLOOD Calcium-7.2* Phos-2.1* Mg-2.2 [2176-10-10] 02:15AM BLOOD Type-ART Temp-36.7 pO2-83* pCO2-33* pH-7.33* calTCO2-18* Base XS--7 Intubat-NOT INTUBA [2176-10-10] 10:49AM BLOOD Type-[Last Name (un) ] pO2-90 pCO2-29* pH-7.37 calTCO2-17* Base XS--6 [2176-10-9] 02:41PM BLOOD Glucose-90 Lactate-3.0* [2176-10-9] 08:11PM BLOOD Lactate-2.1* [2176-10-10] 02:15AM BLOOD Lactate-1.0 Na-160* K-2.8* Cl-138* [2176-10-10] 04:07AM BLOOD Glucose-98 Lactate-1.1 Na-159* K-3.2* Cl-141* [2176-10-10] 07:40AM BLOOD Glucose-84 Lactate-1.8 Na-157* K-3.8 Cl-141* [2176-10-10] 10:49AM BLOOD Glucose-74 Lactate-1.5 Na-156* K-3.7 Cl-141* [2176-10-10] 04:07AM BLOOD freeCa-1.10* [2176-10-10] 10:49AM BLOOD freeCa-1.05* Discharge labs: Imaging: [2176-10-9] CXR: No acute intrathoracic process. [2176-10-10] IR Guided PICC Placement: Successful PICC exchange, with placement of a new 36 cm double-lumen PowerPICC. The tip is within the distal SVC. The line is ready to use. [2176-10-14] CXR: In comparison to prior radiograph, a new right-sided PICC terminates in the mid SVC. Left lower lobe opacities could represent aspiration versus pneumonia. The right lung is grossly clear. Extensive vascular clips are noted. Cardiac size is normal without any signs of heart failure. Brief Hospital Course: [Age over 90 ]-year-old female with advanced Alzheimer's dementia who presented to the ED with altered mental status and hypotension, found to have a leukocytosis, positive UA, hypernatremia to 171, and ARF. # Sepsis: Pt. met [3-2] SIRS criteria (WBC 14.7 and HR 100) and has evidence of infection, likely urinary source, based on UA with positive LE, >182 WBCs, and many bacteria. Initially presented with hypotension 88/61, which improved with 2L NS. Lactate on presentation was 3.0. At the MICU, she was started on vancomycin and cefepime while awaiting urine culture results. She was also on levophed to maintain MAP > 65. With treatment of her infection and with IVFs (see below), she was able to be weaned off the pressor and was transferred to the medical floor. # Hypernatremia: Pt presented with Na of 171. Her family endorsed that she had been refusing food and drink for several days. This degree of hypernatremia most likely represents a significant free water deficit caused either by decreased PO intake of free water, or increased urinary losses, i.e. diabetes insipidis. Calculated free water deficit was 6.2L on admission. We must assume this hypernatremia has been present for at least 24 hours, and therefore we corrected her serum Na at a rate no greater than 10mEq per day in order to avoid iatrogenic cerebral edema. Renal consult was obtained and with their guidance, patient was placed on IVFs that were adjusted based on her rate of correction. She was initially on 1/2NS, then D5W and NS and briefly on hypertonic saline to prevent overcorrection. Electrolytes were monitored every 2 hours initially and spaced out as electrolytes normalized. Sodium level eventually normalized to the low 140 range and she was maintained on D5 [1-29] normal saline as she was taking PO. # Altered mental status: Caretaker reported that she was less responsive than baseline. Likely multifactorial. Primary contributor is likely her profound hypernatremia. This may be exacerbated by underlying UTI/sepsis as well as baseline severe dementia. She was continued on memantine and mirtazapine. # [Last Name (un) ]: Pt.'s severe hypernatremia and evidence of volume depletion on exam argue strongly for a pre-renal etiology. Cr returned to baseline with IVFs. # UTI: Patient with evidence of UTI on urinalysis, but culture was without growth. She was initially started on vanco/cefepime given likely sepsis (above) and later transitioned to ampicillin. She continued to spike low grade fevers, so was transitioned back to cefepime and ultimately transitioned to PO ciprofloxacin to complete a 7 day total course on [2176-10-17]. # LLL consolidation: Patient with evidence of pneumonia vs. aspiration pneumonitis on CXR from [10-14]. She was without cough and leukocytosis had resolved and patient remained afebrile. She is on ciprofloxacin for UTI (above) and will complete course on [10-17]. She was seen by speech and swallow given aspiration risk and they felt she could eat with precautions and recommended pureed solids and nectar thick liquids. # HTN: Patient was initially hypotensive from sepsis (above) and home atenolol was held on admission. This can be restarted as patient can tolerate PO medications. # HLD: Stable, continued home simvastatin. # Advanced Dementia, Goals of care: Pt was initially full code when admitted to the MICU. Discussion was held regarding goals of care in light of her advanced dementia. Her caretaker (daughter [Name (NI) ], HCP) made the decision to make her DNI/DNR. She requested that procedures that would cause pain not be performed. The hospice team was consulted and helped arrange hospice care for the patient including pain medication prescriptions and a hospital bed will be delivered to the patients home address. # Transitional issues: - Patient is now home hospice, she was provided with prescriptions for pain medications and a hospital bed will be delivered to her home - Several medications were discontinued on discharge, including memantine and simvastatin in order to simplify medicine regimen - Patient to complete a course of ciprofloxacin on [2176-10-22] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Simvastatin 10 mg PO DAILY 2. Senna 1 TAB PO BID:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Mirtazapine 7.5 mg PO HS 5. Memantine 10 mg PO BID 6. Calcitriol 0.25 mcg PO DAILY 7. Atenolol 50 mg PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Mirtazapine 7.5 mg PO HS 3. Senna 1 TAB PO BID:PRN constipation 4. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #9 Tablet Refills:0 5. Atenolol 50 mg PO DAILY 6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. RX heparin lock flush (porcine) [heparin lock flush] 10 unit/mL Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen Daily Disp #30 Each Refills:0 7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. RX sodium chloride 0.9 % [Normal Saline Flush] 0.9 % Flush 3 mL IV every eight (8) hours Disp #60 Syringe Refills:0 8. PICC line care Please provide PICC line care and dressing changes 3 times per week. 9. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN moderate to sever pain or shortness of breath RX morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25 mL by mouth every four (4) hours Disp #4 Each Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 3005] Hospice Discharge Diagnosis: Primary diagnoses: - Sepsis from a urinary source - Hypernatremia to 171 - Metabolic encephalopathy - Pneumonia Secondary diagnoses: - Dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and somnolent, not interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [Known lastname 66673], You were admitted to the hospital because your sodium level was very high and you were less interactive than your baseline. You were treated with IV fluids and your sodium level came back to normal. You were also found to have an infection in your blood, urine and possibly in your lungs as well. You were treated with IV antibiotics and you were changed to oral antibiotics (ciprofloxacin) which you should continue taking as prescribed through [10-22]. You were also seen by the hospice team and your family including your daughter [Name (NI) ] who is your health care proxy decided to move forward with hospice care. You will be provided with prescriptions for pain as needed and a hospital bed will be delivered to your home. Followup Instructions: Hospice team will be visiting you at home. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1239] DO 12-ASV Completed by:[2176-10-17]	[ "486", "5990", "2760", "5849", "2762", "4019", "2724", "V1582" ]
Admission Date: [2108-12-14] Discharge Date: [2108-12-18] Date of Birth: [2076-1-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization Pericardiocentesis History of Present Illness: 32 M with pericarditis (dx 2 days pta) presents with worsening CP with radiation to the back, diaphoresis, N/V nad abd pain. BP intially 70s/50s. Bedside U/S by ED showed pericardial effusion with some RV invagination. He received 4L NS with resolution of BP. He had CTA of Torso which showed effusion and evidence of RHF. . The patient reports having similar symptoms last year when he was diagnosed with pericarditis as well. He has had 3 prior episodes of similar symptoms, all with diagnosis of pericarditis, but each time the duration of symptoms has increased. He reports being admitted to St. [Hospital 11042] Hospital in [Location (un) 1468], MA last year, and was apparently diagnosed with autoimmune mediated pericarditis. At the time of this note, these records were unavailable. He reports having negative TB skin tests in the past, as well as negative HIV test in the last 8 months. . On review of symptoms, he reports having diarrhea the last 2 days with some nausea. He had multiple episodes of vomiting today. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is significant for chest pain, but absent for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: history of Pericarditis x3 Cardiac Risk Factors: none Social History: Social history is significant for occasional tobacco and occasional marijuana use. He admits to cocaine use in the past, but not in the past 5 years. He denies IVDU. He occasionally drinks ETOH. Family History: There is no family history of pericarditis. He has a first cousin with a diagnosis of lupus, otherwise no other rheumatological diseases. Physical Exam: VS: T 97.5, BP 118/75 , HR 86, RR 25 , O2 95% on 4L Pulsus=8 Gen: WDWN athletic appearing black male, in mild to moderate respiratory distress with difficulty speaking in complete sentences. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry mucous membranes Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. no friction rub ausculated Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly labored and tachypneic. Decreased BS in the bases, but no crackles, wheeze, or rhonchi. Abd: mild to moderate tenderness in RUQ/RLQ with voluntary guarding. difficult to determine liver size given guarding. tenderness to percussion with some dullness in RUQ. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP/PT [Name (NI) 2325]: Carotid 2+ without bruit; 2+ DP/PT Pertinent Results: [2108-12-18] 06:30AM BLOOD WBC-7.4 RBC-4.09* Hgb-11.6* Hct-35.7* MCV-87 MCH-28.3 MCHC-32.4 RDW-13.1 Plt Ct-575* [2108-12-13] 08:40PM BLOOD Neuts-82.4* Lymphs-10.3* Monos-6.1 Eos-0.9 Baso-0.3 [2108-12-13] 09:07PM BLOOD PT-12.3 PTT-29.4 INR(PT)-1.1 [2108-12-15] 03:49AM BLOOD ESR-55* [2108-12-17] 06:07AM BLOOD Lupus-NEG [2108-12-18] 06:30AM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-136 K-3.8 Cl-100 HCO3-25 AnGap-15 [2108-12-13] 08:40PM BLOOD ALT-34 AST-40 LD(LDH)-136 CK(CPK)-69 AlkPhos-98 TotBili-1.4 [2108-12-15] 03:49AM BLOOD ALT-74* AST-72* AlkPhos-100 Amylase-32 TotBili-1.2 [2108-12-15] 03:49AM BLOOD Lipase-16 [2108-12-13] 08:40PM BLOOD cTropnT-0.04* [2108-12-17] 06:07AM BLOOD TotProt-5.7* Calcium-8.7 Phos-4.7* Mg-2.0 [2108-12-15] 03:49AM BLOOD TotProt-6.2* Albumin-3.0* Globuln-3.2 [2108-12-13] 08:40PM BLOOD TSH-1.2 [2108-12-17] 06:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [2108-12-15] 03:55PM BLOOD dsDNA-NEGATIVE [2108-12-15] 03:49AM BLOOD CRP-271.1* [2108-12-14] 06:45PM BLOOD [Doctor First Name ]-NEGATIVE [2108-12-14] 06:45PM BLOOD RheuFac-25* [2108-12-15] 03:55PM BLOOD C3-156 C4-27 [2108-12-14] 06:45PM BLOOD HIV Ab-NEGATIVE [2108-12-17] 06:07AM BLOOD HCV Ab-NEGATIVE [2108-12-13] 08:55PM BLOOD Lactate-1.8 [2108-12-16] 09:48PM URINE Color-AMBER Appear-Clear Sp [Last Name (un) ]-1.010 [2108-12-16] 09:48PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 [2108-12-16] 09:48PM URINE U-PEP-NO PROTEIN [2108-12-17] 11:15AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG marijua-PRESUMPTIV [2108-12-15] 01:50PM OTHER BODY FLUID WBC-2300* RBC-[Numeric Identifier 75954]* Polys-82* Lymphs-2* Monos-15* Eos-1* [2108-12-15] 01:50PM OTHER BODY FLUID TotProt-5.0 Glucose-95 LD(LDH)-840 Amylase-21 Albumin-2.6 . Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . . [2108-12-13] ECHO The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal/small cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No mitral regurgitation is seen. There is a small to moderate sized (1.0-1.5cm) circumferential pericardial effusion without right atrial or right ventricular diastolic collapse. . IMPRESSION: Small-moderate sized circumferential pericardial effusion without evidence for hemodynamic compromise. Clinical correlation and serial evaluation are suggested. . [2108-12-13] CTA IMPRESSION: 1. Large pericardial effusion, heterogeneous perfusion of the liver with periportal edema, gallbladder wall edema, enlarged IVC and interval development of ascites (between initial and 20-minute delayed imaging) all suggest impaired venous return to the heart (early tampanade physiology?) and hepatic congestion. . 2. No evidence of aortic dissection or pulmonary embolism. . [2108-12-15] C. Cath COMMENTS: 1. Succesful pericardiocentesis. Pericardial drain placed with initial CI 2.46 up to 3.01 l/min/m2 and RA pressure 18 down to 10 mmHg. The uncomplete normalization of RA pressure may suggest constrictive physiology. . FINAL DIAGNOSIS: 1. Succesful pericardiocentesis. 2. Possible effusive constrictive physiology. . [2108-12-17] ECHO Overall left ventricular systolic function is normal (LVEF>55%). There is abnormal septal motion suggestive of pericardial constriction. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is a trivial/physiologic pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. . [2108-12-17] Cardiac MRI Impression: 1. Areas of focal pericardial thickening with circumferential pericardial late-gadolinium enhancement suggestive of pericardial inflammation. Pericardial tethering on tagged images is consistent with, but not diagnostic of pericardial constriction. 2. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 56%. The effective forward LVEF was borderline-normal at 54%. No MR evidence of prior myocardial scarring/infarction. 3. Normal right ventricular cavity size and systolic function. The RVEF was normal at 55%. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 5. Mild right and moderate left atrial enlargement. 6. Moderate bilateral pleural effusions. . Findings are consistent with acute on chronic pericarditis with possible pericardial constriction. . Brief Hospital Course: 32 M without significant PMHx with acute pericarditis and tamponade and also has RUQ pain with nausea and vomiting . # Pericarditis/Tamponade: The patient was found to have his 4th episode of pericarditis over the last few years. His previous episodes were managed at an outside hospital. He has never had a diagnosis of tamponade before this hospitalization. On admission, the patient had an Echocardiogram that was suggestive of tamponade but he was hemodynamically stable with IV fluids. Repeat Echo also showed probable tamponade physiology, and the patient was then taken to the cath lab for further evaluation. He had equalization of pressures, consistent with tamponade, and a pericardial drain was placed with removal of pericardial fluid. During this hospitalization, a complete workup was done for the cause of the recurrent pericarditis, and now tamponade. A rheumatology consult was called, and the patient will follow with them in clinic as well. The patient had a slight elevation in his LFTs, but hepatitis serologies were negative. HIV test was negative. Rheumatoid factor was slightly elevated, but [Doctor First Name ], dsDNA were both negative with normal C3/C4 levels. The patient also had CH50, anti-LAC, anti-ro, anti-[Doctor Last Name ], anti-CL sent which were all pending at discharge. The patient's TB test was also negative during this admission. The pericardial fluid was negative by cultures, AFB, and negative for malignant cells on cytology. Viral cultures were also pending at discharge. The patient has made a PCP appointment at [Name9 (PRE) 191], and will also followup in cardiology and rheumatology clinics as well. He will continue indomethacin, colchicine, and percocet prn for pain. At discharge, his symptoms of dyspnea and chest pain had improved and the patient was able to tolerate activity without difficulty. A cardiac MRI was done prior to discharge as well. It showed evidence of pericardial thickening, and likely pericardial constriction which is consistent with his recurrent pericarditis. . # RUQ pain/nausea/vomiting: The patient presented with RUQ pain, slightly elevated LFTs, but negative hepatitis serologies. The patient had a RUQ ultrasound which showed gall bladder wall edema, but no evidence of cholecystitis. This was likely due to backflow of venous pressures from the tamponade physiology. Prior to discharge, the patient's symptoms had improved and he was eating without difficulty. Medications on Admission: Ibuprofen PRN Discharge Medications: 1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 2 weeks. Disp:42 Capsule(s) Refills:1 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:1 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pericardial Effusion with Tamponade Secondary Diagnosis: Pleural Effusion Discharge Condition: Good, afebrile. Symptoms improved Discharge Instructions: You were admitted for chest pain. You were found to have inflammation around your heart, and you were found to have fluid around your heart as well. The fluid caused decreased function of your heart and therefore you had a procedure performed to remove the fluid. Your symptoms markedly improved prior to discharge. You were seen by the rheumatology consult as well. You will need to followup with them in clinic to followup on your lab results that are pending at the time of discharge. Please take all medications as prescribed. Please make all appointments scheduled. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: worsening chest pain, shortness of breath, fevers, chills, cough, or weakness. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Phone:[Telephone/Fax (1) 920] Date/Time:[2109-1-11] 9:00 Provider: [Name10 (NameIs) 39063] [Last Name (NamePattern4) 39064], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2109-2-13] 1:30 You will receive a phone call from the [Hospital 2225] Clinic at [Hospital6 ] to schedule an appointment with Dr. [Last Name (STitle) 75955]. Please call them at [Telephone/Fax (1) 75956] with any questions. Your Rheumatologist will followup the pending lab results during your appointment. Your Cardiologist, Dr [First Name (STitle) ], [First Name3 (LF) ] discuss the Cardiac MRI results with you at your appointment.	[ "5119" ]
Admission Date: [2146-11-9] Discharge Date: [2146-11-15] Date of Birth: [2081-7-21] Sex: F Service: CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: This is a 65 year old Caucasian female with past medical history significant for three times myocardial infarction in [2141], [2144] and [2146] and coronary artery bypass graft in [2139] who presented with 8 out of 10 chest pain and nausea, while being transferred to [Hospital3 1761], shortly after being transferred from [Hospital ] Hospital. She had been admitted to [Location (un) ] for an eight day admission after a fall. Per patient's husband, the patient initially had brief syncope, two days prior to first admission with loss of consciousness. Shortly after blood pressure was still 70s/40s. She presented to [Location (un) ] two days later with severe lower back pain. Per discharge summary, a bone scan showed no evidence for acute fracture in the right hand or the pelvis with some arthritis in the hips. A right hip x-ray was normal. Lumbar spine magnetic resonance imaging scan was normal and vertebral spine was within normal limits. She had some arthritis of both hips with normal sacrum. The patient's typical angina usually is pressure like but she has had no typical angina for approximately two weeks. At that time she had been admitted to [Hospital1 20954] Hospital and ruled in for myocardial infarction at that time. Cardiac catheterization was done with grafts open at that time. At the day of admission, the patient's chest pain was sharp and well localized. Per Emergency Medical Services, she received three sublingual nitroglycerin and aspirin with resolution of her pain. Heartrate was between 30s to 40s with systolic blood pressure between 110 to 130. Electrocardiogram showed possible Wenckebach per Emergency Medical Services but on review it showed mostly sinus bradycardia with occasional premature atrial contractions. In the Emergency Department she continued to have 5 out of 10 chest pain and was made painfree with nitroglycerin drip. Electrocardiogram there showed sinus bradycardia with frequent premature atrial contractions. At this time she was transferred to the Coronary Care Unit for further management. PAST MEDICAL HISTORY: As stated above - 1. Coronary artery disease with coronary artery bypass graft in [2139] involving the grafts, left internal mammary artery to V1, saphenous vein graft to posterior descending artery, saphenous vein graft to left anterior descending and saphenous vein graft to obtuse marginal. 2. Myocardial infarction in [2141] with pericarditis, non-Q wave in [2144]. Catheterization at that time showing three vessel disease with patent graft. Myocardial infarction in [2146-6-3] at [Hospital1 29305]. 3. Hypertension. 4. Chronic renal insufficiency. Apparently she has 60 to 70% left renal artery stenosis. Her [Hospital1 20955] discharge summary study was done to show that this lesion was not hemodynamically significant. 5. Peripheral vascular disease, Mrs. [Known lastname 29306] has had two carotid endarterectomies. The right side was done in [2141] and the left was done in [2145-4-3]. This carotid endarterectomy was complicated by left anterior cerebellar infarct with minimal residua. She also had a left femoral-popliteal bypass in [2133] and right iliac angioplasty in [2133]. 6. Insulin dependent diabetes mellitus diagnosed in [2133] as triopathy. 7. Congestive heart failure with ejection fraction of 45 to 50% per echocardiogram in [2144]. Echocardiogram at that time in the office showed inferior akinesis, posterior hypokinesis, 2+ mitral regurgitation and 1+ aortic regurgitation. 8. Pilonidal cyst. 9. Cholecystectomy in [2099]. 10. Cesarean section times two. 11. Left retinal hemorrhage. 12. History of seizures. ALLERGIES: Hydralazine. FAMILY HISTORY: Various family members with myocardial infarctions and strokes. Two brothers had coronary artery bypass graft. Hypertension. SOCIAL HISTORY: His family has a 100 pack year history but quit in [2133]. She denies alcohol use. MEDICATIONS ON ADMISSION: 1. Aspirin 325 q.d. 2. Captopril 50 mg p.o. t.i.d. 3. Zoloft 50 mg p.o. q.d. 4. Cardura 1 mg p.o. q.d. 5. NPH subcutaneous insulin 6 mg subcutaneously b.i.d. 6. Labetalol 300 mg t.i.d. 7. Nitroglycerin 8. Dilantin 300 mg p.o. b.i.d. 9. Colace 10. Isordil extended release 60 mg p.o. b.i.d. 11. Procardia XL 60 mg p.o. q.d. 12. Xanax 0.25 mg b.i.d. 13. Prevacid 30 mg p.o. q.d. 14. Lipitor 20 mg p.o. q.d. 15. Tylenol 3 16. Dulcolax 17. Pepcid 20 mg b.i.d. 18. Reglan 5 mg p.o. q.i.d. LABORATORY DATA: On admission complete blood count revealed white blood cell count of 6.3, hematocrit 26, platelets 167, PT 11.6, PTT 27, INR 0.9, first CK was 66 with a troponin of 1. Phenytoin of 22.7. Chem-7 showed the following, sodium 132, potassium 6, chloride 98, bicarbonate 26, BUN 96, creatinine 2.9, blood sugar 181, albumin 3.1, calcium 9.7, phosphate 3.8, neb 2.2. Electrocardiogram on admission showed possible junctional rhythm, first wondering atrial pacemaker versus sinus bradycardia with premature atrial contractions. There is also left ventricular hypertrophy with strain and ST depression in leads 1, 2, V5 and V6, as compared to prior electrocardiogram from [2145-4-3]. Chest x-ray showed mild emphysematous changes. HOSPITAL COURSE: Coronary artery disease - Mrs. [Known lastname 29306] was admitted to the CCU for further evaluation and observation. She was placed on Telemetry and ruled out for myocardial infarction. Serial CKs and troponins were significant for second troponin of 17.3, however, third troponin was .7, indicating that there was laboratory error in the second troponin. CPKs were flat throughout with no MB fraction. She was placed on Aspirin, Zocor, Nitroglycerin, GT drip and Heparin. Beta blocker was held secondary to her bradycardia. When she ruled out for myocardial infarction, heparin was discontinued. Echocardiogram was checked the following morning showing the following left atrium markedly dilated, left ventricular cavity size normal, overall left ventricular systolic function mildly depressed. Resting regional wall motion abnormalities included severe inferior and inferolateral hypokinesis along with basolateral hypokinesis. Mild to moderate aortic regurgitation was seen as well as moderate to severe mitral regurgitation. Moderate 2+ tricuspid regurgitation was seen with moderate pulmonary artery systolic hypertension. There was no pericardial effusion. Rhythm - Mrs.[Known lastname 29307] presentation to [Hospital ] Hospital indicated possible syncopal episode which may have been secondary to brady or tachyarrhythmia. Electrophysiology consult was requested. She also had a brief history of nonsustained ventricular tachycardia, 2 to 3 beats in the setting of inferior myocardial infarction. As ejection fraction was suboptimal, electrophysiology study was seriously considered with possible implantable cardioverter defibrillator placement to help prevent further tachyarrhythmia. However electrophysiology was unconvinced that this was a tachyarrhythmia as opposed to possible bradyarrhythmia versus autonomic failure. Tilt test was considered at this time. Physical therapy was made to walk Mrs. [Known lastname 29306] with careful documentation of pulses and blood pressures. Pulse had expected increase while walking. Of note, blood pressure was decreased by ten points from lying to standing with no rise in blood pressure from standing to walking. Orthostatics were also completed showing increase in heartrate from lying to standing. It was the opinion of the electrophysiology service at that time not to further pursue electrophysiology study. Vascular - In the Emergency Department the physician on call was able to get a history of atypical sharp chest pain which radiated to the back. Blood pressure was normal on both arms with normal pulses. She had widened pulse pressure likely due to aortic regurgitation. Chest x-ray was done to help rule out air dissection. Chest x-ray had no widening of the mediastinum. No further evaluation was done. She was continued on Cardura, Isordil and Procardia XL. Procardia was changed to Norvasc 10 mg q.d. in light of her significant coronary artery disease. Fluids, electrolytes and nutrition - Blood sugars were carefully documented q.i.d. with gentle regular insulin sliding scale. Potassium was rechecked on several occasions during the first day. Potassium came back at 6 down to 5.4 down to 5.2. No further treatment was done. Heme - Mrs. [Known lastname 29306] had hematocrit drop from 31 to 26. She was transfused 1 unit of packed red blood cells with post transfusion hematocrit of 27. She was transfused an additional unit with good response. DISPOSITION: Mrs. [Known lastname 29306] was full code. As she was on the way to rehabilitation on the day of admission she will be transferred back to rehabilitation. Physical therapy and occupational therapy consults were made with recommendation to go to rehabilitation. DISCHARGE MEDICATIONS: All home medications with the exception of Procardia. In its place will be Norvasc 10 mg p.o. q.d. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 8073] MEDQUIST36 D: [2146-11-13] 04:22 T: [2146-11-12] 18:10 JOB#: [Job Number 29308]	[ "42789", "4168" ]
Admission Date: [2163-7-10] Discharge Date: [2163-7-15] Date of Birth: [2095-7-19] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: s/p trip down stairs Major Surgical or Invasive Procedure: [2163-7-11]: ORIF Right ankle fracture History of Present Illness: Ms. [Known lastname 107672] is a 67 year old female who had a mechanical trip and fall while going down stairs. She was taken to the [Hospital1 18] for further evaluation. Past Medical History: Untreated hypercholesterolemia GERD Depression, anxiety Obesity Chronic EtOH use- pt reports 2 glasses daily PSH: Rhinoplasty at 33 yo. Social History: Lives with her daughter-in-law, son and a male friend [Name (NI) 11229]. Daughter is also local. Denies ever using drugs. Quit smoking 17 yrs ago after 35 pack yr history. Drinks 2 glasses of wine daily. Family History: n/a Physical Exam: Upon admission: RLE: skin intact, mild ankle swelling/ecchymosis, [Last Name (un) 938]/FHL firing, TA/GS limited by pain, 2+ DP pulse, toes warm Pertinent Results: [2163-7-10] 10:37PM GLUCOSE-119* UREA N-19 CREAT-1.1 SODIUM-139 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 [2163-7-10] 10:37PM estGFR-Using this [2163-7-10] 10:37PM WBC-12.0# RBC-4.32 HGB-14.8 HCT-44.0 MCV-102 MCH-34.2* MCHC-33.6 RDW-13.4 [2163-7-10] 10:37PM NEUTS-84.8* LYMPHS-10.9* MONOS-3.1 EOS-0.8 BASOS-0.5 [2163-7-10] 10:37PM PLT COUNT-308 [2163-7-10] 10:37PM PT-12.3 PTT-21.4* INR(PT)-1.0 Brief Hospital Course: Ms. [Known lastname 107672] presented to the [Hospital1 18] on [2163-7-10] after a fall. She was evauated by the orthopaedic surgery service and found to have a right ankle fracture. She was admitted, consented, and prepped for surgery. Patient triggered on [2163-7-11] pre-operatively for tachycardia and low urine output and was given lopressor overnight and 250cc/500cc/500cc bolus with improvement in sx and was cleared by medicine to proceed to the OR. On [2163-7-11] she was taken to the operating room and underwent an ORIF of her right ankle fracture. She tolerated the procedure well, was transferred to the recovery room still intubated. She was extubated in the recovery room but had difficulty becoming aggitated, tremulous, and tachycardic. She required re-intubated. Her vital signs normalized with intubation and propofol. She was then transferred to the T/SICU for further care. Patient was intubated until [2163-7-13] and returned to the floor. Patient reported shortness of breath on [2163-7-14], CXR showed mild pulmonary edema and medicine consult was called with recommendation for lasix 20mg IV x1. Patient was discharged to rehabilitation facility in stable condition. Medications on Admission: Omeprazole Celexa Discharge Medications: 1. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Albuterol Sulfate Inhalation 10. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for EtOH withdrawal. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Discharge Disposition: Extended Care Facility: [Location (un) ] healthcare Discharge Diagnosis: Right ankle fracture Discharge Condition: Stable Discharge Instructions: Continue to be non-weight bearing on your right leg Continue your lovenox injections as instructed for a total of 4 weeks after surgery Please take all medications as prescribed Take off your cast daily to inspect your skin, monitor for signs/symptoms of infection If you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Physical Therapy: Activity: As tolerated Right lower extremity: Non-weight bearing in bivalve cast Treatments Frequency: Staples/sutures out 14 days after surgery Take off cast daily look for signs/symptoms of wound breakdown or pressure areas Dry dressing daily Followup Instructions: Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in orthopaedic clinic on [2163-7-26], please call [Telephone/Fax (1) 1228] to schedule that appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2163-7-15]	[ "51881", "53081", "2720", "4280", "32723" ]
Admission Date: [2139-11-5] Discharge Date: [2139-11-11] Date of Birth: [2056-7-9] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Dizzy spells Major Surgical or Invasive Procedure: [2139-11-6] - AVR(23mm St. [Male First Name (un) 923] Tissue Valve), CABGx1(Left internal mammary->Left anterior descending artery). [2139-11-5] - Cardiac Catheterization History of Present Illness: I recently had the pleasure of seeing your patient, [Known firstname 56584] [Known lastname ] in consultation. As you recall, he is a 83- year-old gentleman with a history of aortic stenosis and now dizzy spells for the past three months. Recent EKG was performed which showed some inferior Q waves and a follow up echocardiogram was also performed which showed that his aortic stenosis has had now become severe. His aortic valve area previously was 0.8 cm2 and now is 0.5 cm2. Given these findings, he has now been referred for surgical evaluation. Independent review of his cardiac echocardiogram from [2139-9-30] again showed severe aortic stenosis with an aortic valve area of 0.5 cm2. His mean gradient is 52 mmHg and he has mild mitral regurgitation, trace tricuspid regurgitation, left atrial enlargement, an ejection fraction of 65%, concentric left ventricular hypertrophy, and a trileaflet aortic valve. He also had a Holter monitor placed and review of the data shows sinus rhythm with occasional PACs and PVCs. There are two episodes of supraventricular tachycardia but no significant ventricular tachycardia or ventricular fibrillation. Past Medical History: Past medical history is notable for hyperlipidemia, benign prostatic hypertrophy, prior inferior wall MI based on Q waves on his EKG, hepatitis A, memory loss, and sleep apnea. Social History: Currently, he is retired. He quit smoking 20 years ago after a 45-pack-year history. He drinks one to two glasses of wine per day. He lives with his wife and his last dental examination was a year ago. Family History: His family history is relatively unremarkable, however, there is a sister who had congestive heart failure in her 70s. Physical Exam: On physical examination, his pulse is 74 and regular. Respirations are 12. His blood pressure on his right is 136/78 and on his left is 130/76. He is 6'1" tall and weighs 190 lbs. In general, he is a well-developed and well-nourished elderly gentleman in no acute distress. Skin is warm and dry without clubbing, cyanosis, or edema. HEENT examination shows him to be normocephalic and atraumatic. His pupils are equal, round, reactive to light. Sclerae is anicteric. His oropharynx is benign and he does have upper and lower dentures, however, has few upper and lower gold capped teeth that remain. His neck is supple with full range of motion and no JVD. His lungs are clear are clear to auscultation. Heart shows a regular rate and rhythm with normal S1 and S2. There is a III/VI systolic ejection murmur without rub or gallop. His abdomen is soft, nondistended, and nontender with normoactive bowel sounds and there is no hepatosplenomegaly. Extremities are warm and well perfused without edema. He does have a small right thigh superficial varicosity but overall his bilateral greater saphenous vein appears suitable if needed. Pulse are 2+ throughout. Neurologically, he is alert and oriented x3. There are no focal deficits. He moves all of his extremities. Gait is steady and there is some notable short-term memory loss on physical examination. There is a transmitted murmur versus bruit over his bilateral carotid arteries. Pertinent Results: [2139-11-5] Cardiac Cath 1. Coronary angiography in this left dominant system revealed no angiographically apparent coronary artery disease of the LMCA, LAD, LCx or RCA. 2. Limited resting hemodynamics revealed normal systemic arterial pressure with SBP of 120 mmHg and DBP of 71 mmHg. 3. Left ventriculography was deferred. [2139-11-6] ECHO PRE-CPB:1. The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. The NCC is immobile. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. Trivial AI and trivial paravalvular leak prior to protamine administration. Peak gradient now 28 mmHg. Preserved biventricular systolic function. MR remains mild. Aortic contour is normal post decannulation. [2139-11-6] Carotid Ultradsound No significant stenosis bilaterally [2139-11-11] 05:15AM BLOOD WBC-9.3 RBC-3.40* Hgb-11.3* Hct-32.1* MCV-94 MCH-33.2* MCHC-35.2* RDW-13.7 Plt Ct-264# [2139-11-10] 05:50AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-140 K-4.3 Cl-105 HCO3-27 AnGap-12 [2139-11-10] 05:50AM BLOOD Mg-2.2 Brief Hospital Course: 83 year old white male underwent aortic valve replacement (23mm St. [Male First Name (un) 923] tissue), and coronary artery bypass grafting x 1 (LIMA->LAD) on [2139-11-6]. Cardiopulmonary bypass time waws 79 minutes, cross-clamp time was 62 minutes For further details, please see operative report. Overall the patient tolerated the procedure well and post-operatively was transfered to the CVICU for further observation and recovery. Within twenty-four hours, the patient was extubated and all drips had been weaned. On POD 1 the patient was alert and oriented (with baseline short-term memory loss), breathing comfortably and off all inotropic and vasopressor support. He was found suitable for transfer to the telemetry floor at this time. Chest tubes and pacing wires were discontinued without complication. The patient was diuresed toward his preoperative weight. The physical therapy service was consulted for assistance with strength and balance. The patient went into atrial fibrillation post-operatively. Amiodarone was started, and beta blocker was titrated up accordingly. He was still in atrial fibrillation on discharge, however, rate was well controlled. The patient developed a fever on POD 3 and cultures were sent. Urinalysis was positive, and patient was started on bactrim empirically. Hospital course was essentially uneventful and the patient was discharged to rehab on POD 5. Medications on Admission: namenda 20 [Hospital1 ] zocor 20 daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 6. Namenda 10 mg Tablet Sig: Two (2) Tablet PO bid (). Disp:120 Tablet(s) Refills:0 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 5 days, then 200mg [Hospital1 ] x 1week, then 200mg daily. Disp:120 Tablet(s) Refills:2 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay - [Hospital1 392] Discharge Diagnosis: AS/CAD s/p CABG/AVR Hyperlipidemia BPH Prior MI Hepatitis A Short term memory loss sleep apnea Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in 2 weeks. Please follow-up with Dr. [Last Name (STitle) 15942] in [2-1] weeks. [Telephone/Fax (1) 60570] Please call all providers for appointments. Completed by:[2139-11-11]	[ "4241", "9971", "5990", "2762", "41401", "42731", "4280", "32723", "412", "2724" ]
Admission Date: [2122-10-22] Discharge Date: [2122-11-6] Date of Birth: [2067-8-22] Sex: M Service: [Hospital1 ] CHIEF COMPLAINT: Fever, sputum production HISTORY OF PRESENT ILLNESS: This is a 55-year-old man with a history of metastatic left tonsillar cancer status post resection, chemotherapy, radiation and tracheostomy placement, who presents with chest pain, productive sputum and fever. The patient states that, two to three days prior to admission, he felt weak and fatigued. He has a chronic cough at baseline, but notices that it has been increasingly productive over the past several days. He states that sputum is pinkish in color. He has not had any documented fevers. He denies any chills or sweats. In the Emergency Department, he was found to be febrile at 100.8. Chest x-ray demonstrated bibasilar nodular opacities and new right middle lobe collapse. CTA demonstrated no pulmonary embolism, but did demonstrate right middle lobe nodular opacity with surrounding ground-glass and impaction of airways with partial collapse of the right middle lobe. Several other nodular opacities were noted. A small left effusion and subcarinal and hilar adenopathy was also noted. The patient was admitted for pneumonia. PAST MEDICAL HISTORY: 1. Metastatic left tonsillar squamous cell carcinoma, originally diagnosed back in [2119]. The patient had left tonsillar fullness and left neck mass and underwent tonsillectomy in [2120-9-22] by Dr. [First Name (STitle) ] of ENT. He started on chemotherapy with Taxotere, cisplatin and 5-FU in [2120-9-22]. His diagnosis included Stage IV and III squamous cell carcinoma. He underwent left modified radical neck dissection in [2121-6-22] following several round of chemotherapy. On [2121-12-12], the patient underwent neurosurgery for a C6 metastatic vertebral tumor. He had a C6 vertebrectomy, C5 to C7 anterior cervical arthrodesis and fusion, and C5 to C7 anterior cervical instrumentation performed by Dr. [Last Name (STitle) 1327]. On [2122-7-2], the patient demonstrated bilateral vocal cord paralysis and airway obstruction. He received a #6 Shiley cuffless fenestrated tracheotomy tube by Dr. [First Name (STitle) ] of ENT. 2. Orthopaedic problem in right knee with metal plate ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lactulose 30 cc once daily 2. Morphine elixir 15 mg every six hours 3. Diazepam 30 mg every six hours SOCIAL HISTORY: The patient is approximately a 120 pack year smoker, but quit approximately ten years ago. He has a history of heavy alcohol abuse in the past, but no longer drinks. He has a history of nasal cocaine use, but has no history of intravenous drug use. The patient is a homosexual man, but has never engaged in anal intercourse. He has had one partner who passed away from HIV. He has had many occupations, including art student, bartender, and landlord. FAMILY HISTORY: Father died in his 80s of a cerebrovascular accident. His father also had prostate cancer, but had not received treatment. He had a brother who died at age 12 of leukemia. PHYSICAL EXAMINATION: Vitals: Temperature 100.8, blood pressure 112/74, pulse 110, respiratory rate 20, oxygen saturation 100% on room air. General: Cachectic male in no acute distress, who is alert and oriented x 3, and speaks through a trach. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation, extraocular movements intact, trach in place, mucous membranes moist. Lungs: Positive rhonchi, upper airway noise, otherwise clear. Cardiovascular: Tachycardic, but no murmurs, gallops or rubs. Abdomen: Soft, nontender, nondistended. Lower extremities: No cyanosis, clubbing or edema. LABORATORY DATA: White blood cells 7.9, hematocrit 27.5, hemoglobin 8.8. Neutrophils 82, bands 8, platelets 358. HOSPITAL COURSE: 1. Pneumonia: During the [Hospital 228] hospital course, the patient was initially noted to have increased secretions and increasing oxygen requirements. He also had worsening chest x-ray and increasing size of left pleural effusion. Ultrasound revealed this pleural effusion was loculated, and the patient went for ultrasound-guided drainage by Radiology. The patient had been on Levaquin and clindamycin intravenously prior to the tap. The tap revealed 11,450 white blood cells, LDH of 3695, glucose of 4. Gram stain was negative. Cytology was suggestive of metastatic disease, although this could not be confirmed. Given the low glucose and LDH, concern was raised over possible empyema. Interventional Pulmonology was consulted, and they placed a chest tube. Fluid was drained, but this was felt to be a parapneumonic effusion. The chest tube had good output and drained over 300 cc of yellow fluid. The patient's chest x-ray improved gradually with this. The patient's oxygen requirement remained fairly stable, but did slightly decrease. The patient appears to have copious secretions. On hospital day nine, the patient required transfer to the Medical Intensive Care Unit for more frequent suctioning. The patient returned to the floor on hospital day ten. On hospital day 12, the patient underwent bronchoscopy for question of tracheal stenosis. This revealed no signs of tracheal stenosis, but did reveal edema of the false vocal cords, copious secretions, and mild granulation tissue around the trach. On hospital day 14, the patient had his chest tube discontinued by Cardiothoracic Surgery. Follow-up chest x-ray revealed mild left-sided effusion. Of note, the patient also had his tracheotomy changed twice during this admission. First he had it changed to a cuffed Shiley due to concern over the patient's large secretions. Due to patient preference and wish to speak, this was changed back to his non-cuffed fenestrated trach prior to his discharge. The patient started to have slightly decreased secretions and decreased oxygen requirements. The patient did undergo a substantial improvement. Given his need for frequent suctioning and respiratory needs, he was felt to need rehabilitation. 2. Hematology: The patient came in anemic at 27.5. Due to the patient's shortness of breath, it was felt he may benefit from transfusion. His hematocrit slowly trended down to 23, and the patient was transfused two units of packed red blood cells on hospital day eight. The patient's hematocrit increased to about 31, where it remained stable. This was felt to be likely due to an anemia of chronic disease. The patient was on Epogen and iron. 3. Oncology: The patient is seen by Dr. [Last Name (STitle) 100194] and Dr. [Last Name (STitle) ] of Oncology. The patient had been receiving outpatient chemotherapy with Taxol and carboplatin for palliative chemotherapy. These were held during his admission. The patient may need to renew these as an outpatient. 4. Gastrointestinal: The patient has had a gastrostomy tube placed in [2119]. He had this fixed prior to his most recent admission. During his admission, he had some leaking from the tube, and the patient went down to Interventional Radiology, who changed the external tubing with good relief of his leaking gastrostomy tube. 5. Pain: The patient initially came in on morphine elixir. The patient had this dose slowly titrated up. When the patient received his chest tube, he required increasing pain medications and received a dilaudid patient-controlled analgesia with good relief. Once the chest tube was discontinued, the patient was able to transition back to morphine elixir, although at a higher dose. DISCHARGE STATUS: The patient is to be discharged to rehabilitation, where he will be able to maintain his functional status and receiving suctioning. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSIS: 1. Pneumonia, likely post-obstructive 2. Metastatic left tonsillar squamous cell carcinoma 3. Status post left thoracentesis 4. Status post left chest tube placement 5. Status post bronchoscopy 6. Left chest wall pain 7. Gastrostomy tube repair 8. Anemia of chronic disease status post two units of packed red blood cells transfusion DISCHARGE MEDICATIONS: 1. Lactulose 30 ml by mouth once daily 2. Tylenol 325 to 650 mg by mouth every four to six hours as needed 3. Diazepam 5 to 10 mg by mouth every six hours 4. Epoetin alfa 14,000 units subcutaneously weekly 5. Guaifenesin 10 ml by mouth every four hours 6. Ranitidine 150 mg by mouth twice a day 7. Levofloxacin 500 mg by mouth once daily 8. Clindamycin 450 mg by mouth every six hours 9. Morphine sulfate oral solution 30 mg by mouth every four hours for pain [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 17420] MEDQUIST36 D: [2122-11-6] 02:10 T: [2122-11-6] 03:11 JOB#: [Job Number ]	[ "5070", "5119", "2859" ]
Admission Date: [2189-2-2] Discharge Date: [2189-2-12] Date of Birth: [2128-3-22] Sex: F Service: MEDICINE Allergies: Metformin / Lipitor / Codeine / Tylenol / Percocet Attending:[First Name3 (LF) 2745] Chief Complaint: Altered mental status, Elevated lactate Major Surgical or Invasive Procedure: Intubation History of Present Illness: 60F, tx from [Hospital 1474] hospital after EMS called to home for delta MS. Pt noted initially to be hypoglycemic with unequal pupils and a negative head CT. At OSH, seized, found to be hypothermic to 92.5 with a lactate 6.9. Pt was xfr here because no icu beds. INR 2.0. Trop neg. HCO3 < 10. WBC ct 15.9. UA neg. ABG 6.47/11/518. LP done at OSH which was not concerning for infection. Gram stain negative. Intubated at OSH for airway protection after seizure. Received vanc/Zosyn. . Arrived here 36.6. Intubated, sedated. On propofol. No obvious signs of external trauma. Pupils sluggish and unequal. Came w/ R fem. line. Placed a-line and never needed pressors. Placed on insulin and D10 drip out of concern for AKA. Also received K/Calcium/Mag. Also treated with acyclovir for possible encephalitis. Tox screens neg. Pt given thiamine 100 and NS bolus x2L after transient hypotension in setting of propofol administration. Admitted to the MICU for further managamement. Past Medical History: Diabetes hypertension Seizure disorder Anxiety Hyperlipid Glaucoma COPD Renal insufficiency Blind in right eye Social History: Lives w/ either boyfriend or husband. Vehemently denies etoh use/abuse Family History: noncontributory Physical Exam: VITALS: 97.7, 113/60, 84, 22, 97%RA GEN: Somnelent but arousable and keeps eyes open for part of conversation. Oriented x 2. Answers some questions but then drifts off. HEENT: Pupils reactive, left more than right. EOMI. OP clear, no teeth. MMM. NECK: JVP about 7. CV: RRR, no M/G/R. PULM: CTAB, no W/R/R. ABD: Soft, NT, ND, +BS EXT: No pedal edema. Left arm swollen, possibly from an infiltrated IV. NEURO: CN II-XII intact except poor vision and right pupil slow to react. UE strength normal. Plantar flexion normal. Knee flexion weak bilaterally but probably from poor effort. Pertinent Results: ADMISSION LABS: [2189-2-2] 03:30PM BLOOD WBC-17.8* RBC-3.27* Hgb-10.9* Hct-35.4* MCV-108* MCH-33.4* MCHC-30.9* RDW-16.3* Plt Ct-226 [2189-2-2] 07:15PM BLOOD Neuts-83* Bands-1 Lymphs-9* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2189-2-2] 07:15PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [2189-2-2] 03:30PM BLOOD PT-22.5* PTT-38.0* INR(PT)-2.2* [2189-2-2] 07:15PM BLOOD Glucose-114* UreaN-24* Creat-1.3* Na-142 K-2.9* Cl-109* HCO3-LESS THAN [2189-2-2] 03:30PM BLOOD ALT-18 AST-67* LD(LDH)-269* CK(CPK)-98 AlkPhos-38* Amylase-67 TotBili-1.6* [2189-2-2] 03:30PM BLOOD Lipase-142* [2189-2-2] 03:30PM BLOOD CK-MB-13* MB Indx-13.3* cTropnT-0.18* [2189-2-2] 03:30PM BLOOD Calcium-7.6* Phos-6.0* Mg-2.0 [2189-2-3] 02:43AM BLOOD VitB12-700 Folate-4.6 Hapto-23* [2189-2-7] 04:50PM BLOOD calTIBC-142* Ferritn-435* TRF-109* [2189-2-2] 03:30PM BLOOD Osmolal-320* [2189-2-3] 04:56AM BLOOD %HbA1c-5.3 [2189-2-5] 06:14AM BLOOD TSH-5.9* URINE STUDIES: [2189-2-2] 03:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.010 [2189-2-2] 03:30PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-100 Ketone-50 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [2189-2-2] 03:30PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 MICROBIOLOGY: [2-3], [2-4], [2189-2-6] C. Diff: [2189-2-2] and [2189-2-6] Blood cultures: negative [2189-2-6] Urine cultures: negative IMAGING: [2189-2-2] ADMISSION CXR: 1. NG tube projects below the stomach, although the sideport is at GE junction; recommend advancement if tube to be used for feeding. 2. ETT in standard position. 3. No pneumothorax or pleural effusion. [2189-2-2] CT ABD/PELVIS: 1. Mild pancolitis without extramural abnormality. 2. Findings suggestive of mild acute pancreatitis. [2189-2-2] NCHCT: Although there are no definte findings to suggest infarction, there is generalized loss of grey white contrast, and small sulci. This is particularly prominent in the temporal lobes, and raises a concern of possible global ischemia or hypoxia. Comparison with the prior head CT, a follow up CT, and an MR examination would be helpful if this fits with the clinical presentation. [2189-2-5] NCHCT: Hypoattenuating region within the right frontal lobe (2:12) which appears to have been present on previous study however less conspicuous. This may represent a artifact or small vessel disease, however, an underlying lesion cannot be entirely excluded and non-urgent MRI may be obtained for further evaluation. [2189-2-10] MRI HEAD: Saccular formation is identified on the bifurcation of the middle cerebral artery on the left measuring less than 3 mm in size consistent with a saccular aneurysmatic formation as described in detail above. There is no evidence of stenosis or vasospasm. Anatomical variant consistent with hypoplasia of the A1 segment on the right, both anterior cerebral arteries are filling through the left side. [2189-2-8] EEG: This is an abnormal EEG in the waking and sleeping states due to intermittent very brief bursts of mixed frequency slowing in the left temporal region, raising the possibiltiy of subcortical dysfunction there. The tracing cannot specify the etiology. There were no associated epileptiform features. The slow background indicates a widespread encphalopathic process, with the most common causes being metbolic disturbances, infection or medication. Brief Hospital Course: ALTERED MENTAL STATUS: Unclear cause. She was hypoglycemic in the field, and there was some concern for metformin overmedication with metabolic acidosis. Tox screens were negative. She has an LP at the OSH prior to transfer and was kept on acyclovir empirically while viral studies were pending (they were returned negative on [2-7], and acyclovir was discontinued). Empiric vancomycin and zosyn were discontinued once cultures returned negative. The nuerology and toxicology services were following the patient. Depakote levels were in therapeutic range. EEG was performed on [2-8] to see if AMS was from seizure activity; toxic-metabolic abnormalities, but no sz activity. Brain MRI on [2189-2-10] showed small LMCA aneurysm and mild meningeal enhancement c/w post-LP changes. She was kept on thiamine, folate, and a multivitamin while in house. All cultures/microbiology data were negative. RESPIRATORY FAILURE: Patient had a brief MICU stay and was intubated for respiratory failure in the setting of a profound metabolic acidosis. THROMBOCYTOPENIA, ANEMIA: Blood counts were slowly decreasing over the admission. There was no evidence of gross blood loss, and DIC labs on admission were negative. Depakote may cause BM suppression but given long duration of treatment and higher CBC earlier in hospital course, it was less likely to be causing the current thrombocytopenia/anemia. HIT antibody was negative. Her low counts were ultimately thought to be from bone marrow suppression in the setting of metabolic acidosis and acute illness. Platelet counts evetually recovered; Hct was low but stable ~21 prior to discharge. DIARRHEA: Patient was complaining of diarrhea. C. diff was negative x 3. Stool cultures were negative. Medications on Admission: Albuterol 90mcg 2Puff QID Depakote 1000Qam,500Qnoon, 500Qpm Gemfibrozil 600mg Qdaily Singulair 10mg QPM Evista 60mg Qdaily Metformin 100mg [Hospital1 ] Beconase 1Puff [Hospital1 ] Betimol hemihydrate once a day Tricor 145 Qdaily Ethosuximide 250 Q6h Atenolol 25mg Qdaily Aspirin 81mg Azopt 1% gtt TID Paroxetine 20mg Qdaily Zarontin 250 QID Discharge Medications: 1. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day): Please take at noon and in the evening. You should take 1000 mg in the morning. 2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)): You should take 1000 mg in the morning. Please take 500 mg at noon and in the evening. . 3. Ethosuximide 250 mg Capsule Sig: One (1) Capsule PO Q6h (). 4. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). Disp:30 Tab,Sust Rel Osmotic Push 24hr(s) Refills:2 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic TID (3 times a day). 7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 15. Beconase AQ 42 mcg (0.042 %) Aerosol, Spray Sig: One (1) puff Nasal twice a day. 16. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. 17. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary Diagnoses: Hypoglycemia Metabolic acidosis, likely secondary to Metformin use Diabetes Seizure disorder Discharge Condition: Stable-- afebrile, satting in upper 90's on room air; signficantly improved from admission. Discharge Instructions: You were admitted to the hospital with low blood sugar and abnormal blood levels of acid. This was thought to be due to your medication called metformin, and you should not take the metformin any more. Please follow the list of medicines very closely. Several changes were made and you need to be careful when you take your medicines when you go home. The following changes have been made: (1) Do not take metformin anymore. We think this caused your acid levels in your blood to be very high. (2) You have been started on a new medicine for your diabetes called glipizide. You should take this once a day. Your primary care doctor will decide if this is a good dose for you. (3) Your blood pressure medicine atenolol was held in the hospital because you did not need it and your blood pressure was low enough on its own. you should ask your primary care doctor when you should restart atenolol. (4) You were also started on a multivitamin, folic acid and thiamine vitamins. You can buys these over the counter. Please note that you were noted to have a small aneurysm on MRI of your brain. The neurologists have recommended a repeat MRI of the brain be taken on six months to see if this has changed in size. Followup Instructions: Please call your primary care doctor, Dr. [Last Name (STitle) 37742] [Name (STitle) ], at ([Telephone/Fax (1) 77554] to make an appointment for a follow-up visit. You should be seen in the next 1 - 2 weeks.	[ "51881", "2762", "5849", "2875", "496" ]
Admission Date: [2169-2-6] Discharge Date: [2169-2-22] Date of Birth: [2118-2-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9598] Chief Complaint: scrotal edema Major Surgical or Invasive Procedure: IVC venogram, thrombectomy, tPA X 2 History of Present Illness: Mr. [Known lastname ] is a 50-year-old African-American male with hormone refractory metastatic prostate cancer status post multiple previous treatments, OSA, hypercholesterolemia, and h/o bilateral LE DVTs c/b bilateral PE with placement of IVC filter who presents with complaints of increased scrotal swelling. Of note, the pt has been hospitalized twice this month for c/o increased LE edema. On his most recent hospital course, he had a CT scan that showed clot cranially and caudally from the IVC filter extending down the iliac veins b/l. The pt was initially treated with thrombectomy and local tPA which produced minimal result and then was given systemic tPA with resolution of the pt's LE edema. He was placed on a heparin gtt and transitioned to enoxaparin 120 mg [Hospital1 ] by time of discharge. He reports feeling better at the time of discharge and was able to walk without difficulty. Since then, the pt has noted increasing scrotal edema and increasing R leg pain X 3 days. Denies prior h/o scrotal edema. Swelling is associated with b/l achy pain. He also reports R upper thigh pain that is intermittent. His wife reports a slight increase in his RLE edema. Denies fevers, chills, SOB, chest pain. . ROS is remarkable for new L sided temporal headaches over the past week. Denies neck stiffness, photophobia, visual changes, new weakness or numbness. Takes Tylenol at home with relief. Otherwise extensive ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY: Metastatic prostate cancer to bone refractory to hormone therapy s/p cycle 1 of Carboplatin and Taxotere [2168-12-15]. Dx in [2163] as [Doctor Last Name ] 8 s/p surgical prostatectomy with XRT to t9 spinal metastasis in [11-11] followed by hormonal therapy, Taxotere (2 cycles), ketoconazole, hydrocortisone, mitoxantrone, and DES. He was recently noted to have a rise in his PSA to the 400 range, and a L-spine MRI on [11-14] showed multiple spine metastatic foci (no prior MRI L-spine for comparison, bone scan in [6-/2168] without clear spine metastases). He received his first cycle of Carboplatin and Taxotere on [2168-12-15]. . PAST MEDICAL HISTORY: 1. Metastatic prostate cancer to bone refractory to hormone therapy (see above) 2. Bilateral LE DVTs complicated by bilateral PE [4-/2168], treated with enoxoparin then warfarin, and status post IVC filter placement 04/[2168]. Last with DVT on [2169-1-7], now on enoxoparin 120 mg daily. 3. Psoriasis 4. Hypercholesterolemia 5. Seasonal allergies 6. Obstructive sleep apnea on CPAP at home Social History: He lives at home with his wife and his 12 year-old son. [Name (NI) ] does not smoke. Family History: Father had prostate cancer. He has noother relatives with psoriasis and denies thyroid disease,rheumatoid arthritis and lupus in his family. Physical Exam: VITALS: T 99.7 BP 110/70 HR 112 RR 20 O2 sat 91-92% on RA GEN: Pleasant, NAD, AAO X 3 HEENT: EOMI. sclera anicteric. PERRL. MMM. OP clear. NECK: No cervical lymphadenopathy. Unable to appreciate JVD secondary to body habitus. RESP: CTA b/l CVS: RRR, +s1/s2, no m/r/g GI: Obese, soft, non-tender. normoactive bowel sounds. Genitalia: +3 scrotal swelling EXT: [2-11]+ symmetric pitting edema in lower extremities to knees. +1 DP pulses b/l. Negative [Last Name (un) 5813] sign on RLE. SKIN: No rashes. Venous stases changes in b/l LE NEURO: CN II-XII intact. Strength 5/5 in upper and lower extremities. Reflexes 2+ and symmetric at bicep, patella, brachioradialis, Achilles. No sensory deficits. Pertinent Results: [2169-2-6] 06:35PM WBC-7.1# RBC-3.06* HGB-8.2* HCT-25.9* MCV-85 MCH-26.7* MCHC-31.5 RDW-18.6* [2169-2-6] 06:35PM PLT COUNT-265 [2169-2-6] 06:35PM PT-13.6* PTT-30.0 INR(PT)-1.2* [2169-2-6] 06:35PM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.9 [2169-2-6] 06:35PM GLUCOSE-102 UREA N-6 CREAT-1.1 SODIUM-141 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [2169-2-6] 09:56PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2169-2-6] 09:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2169-2-6] 09:56PM URINE RBC-6* WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . Scrotal US [2-6]: The right testicle measures 3.1 x 2.0 x 2.6 cm. The left testicle measures 3.0 x 2.4 x 1.9 cm. Both testicles are normal and homogeneous in echotexture. Arterial and venous color flow and Doppler waveforms are demonstrated. There are small bilateral hydroceles. Bilateral epididymi are normal. There is massive subcutaneous and interstitial edema within the surrounding soft tissues. IMPRESSION: 1. Normal appearing testicles. 2. Large subcutaneous edema. . CXR (PA and lat) [2-7]: The cardiac silhouette, mediastinal and hilar contours are normal and stable. The pulmonary vasculature is normal and there is no pneumothorax. The lungs are clear without consolidations or effusions. The surrounding soft tissue and osseous structures are unchanged. IMPRESSION: No acute cardiopulmonary process. . RELEVANT IMAGING DATA: [2168-12-30] MRI L-spine: Bony metastases are visualized in the lumbar vertebral bodies, sacrum and both iliac bones. No significant change is seen. No epidural abscess identified or new epidural mass seen. . [2168-12-6] MRI L-spine: Numerous metastatic tumor deposits, with possible small epidural lesions seen anterior to the thecal sac at the L4 and L5 levels, versus distended epidural veins secondary to a moderate posterior disc protrusion at L4-5. . [6-/2168] Bone scan: Widespread metastatic disease in multiple ribs, right iliac crest, and vertebra L4. . [2169-1-6] BLE U/S: 1. Noncompressible deep venous thrombosis in left common femoral vein almost occluding the lumen. No clot demonstrated distal to superficial femoral vein. 2. Clot in the left greater saphenous vein. 3. No evidence of DVT on the right. Brief Hospital Course: The patient was admitted to the OMED service for complaints of scrotal edema and increasing R leg pain. Given his past history, it was thought that his scrotal edema was secondary to known IVC clot extending down to the bilateral iliac veins. A scrotal ultrasound was significant for no signs of torsion, normal doppler studies, and massive amounts of subcutaneous edema. Vascular surgery was consulted and it was felt that the patient would not be a candidate for surgical management of his clot. The patient underwent IR guided repeat IVC venogram with repeat thrombectomy and systemic administration of tPA on hospital day 2. He was admitted to the the MICU for observation. IR had placed vascular sheath which were removed on [2169-2-8]. He was restarted on IV heparin after sheath removal and discharged from the ICU back to the floor. He was kept on a heparin drip for several days as he had previously clotted off his IVC after his prior thrombectomy. Although it was noted that his lower extremity and scrotal edema improved slightly after the repeat thrombectomy and tPA, it was agreed upon by the medical, oncologic, and radiology teams that a repeat IVC venogram with repeat thrombectomy and tPA would be performed to help evaluate IVC flow and to improve the pt's chances of post-procedure success. The repeat venogram revealed good flow through the IVC from the prior thrombectomy and a repeat thrombectomy with tPA administration was performed. This was complicated by an episode of epistaxis that resolved spontaneously and an episode of hematuria, which also subsequently resovled. During these episodes, his heparin was held and then restarted once all signs of bleeding had stopped. . The [Hospital 228] hospital course was complicated by intermittent fevers. No clear sources of infection were found initially and antibiotics were not started for a week and a half. However, a UA that was sent for culture studies did come back positive, and the patient was started on cipro. The following day, it was noted that the patient's Cr climbed from 1.1 to 1.7. The patient was given IVF as it was thought his renal failure may have been secondary to dye load from the IVC venogram the day prior or from pre-renal causes. The subsequent day the pt's Cr continued to increase up to 2.3 and renal was consulted. A urine sediment showed many WBC and WBC casts and was thought to be consistent with AIN. Cipro was discontinued and switched to ceftriaxone and the pt was placed on steroids. A renal US was negative for renal vein thrombosis as well as a MRI/MRA of the kidneys. . Due to the patient's fevers without a clear source of infection, ID was consulted for FUO. After further work-up, it was thought that the pt's fevers were secondary to the patient's clot burden rather than an infectious process or an allergic reaction to his other medications. . The patient also complained of tremors and twitching. His electrolytes were within normal limits and a PCO2 was wnl as well. Neurology was consulted who felt that the pt's tremors were more consistent with asterixis. LFTs and an ammonia level were wnl. His neurontin was tapered down from 900 mg to 300 mg tid with a significant improvement in his symptoms. . His hospital course was also complicated by several episodes of chest pain. Cardiac enzymes remained negative and multiple EKGs were without ischemic changes. Given his large clot burden, intermittent fevers and intermittent episodes of hypoxia with O2 sats down to the 80s on RA, the possibility was considered. Initially, the pt was not imaged given his ARF and the fact that he was already on a heparin drip. A V/Q scan was performed that showed a low likelihood of PE. . The patient also complained of neck pain during the hospital course without other meningeal signs, including headaches, photophobia, elevated WBC, altered mental status. It was thought to be musculoskeletal in nature as the neck pain resolved with acetaminophen and toradol. . He was transitioned to lovenox 120 mg SQ [Hospital1 ] from heparin gtt once renal vein thrombosis was ruled out definitively with the MRI and was discharged home in good condition with follow-up with his oncologist and renal. Medications on Admission: 1. Gabapentin 900 mg TID 2. Amitriptyline 50 mg qhs 3. Docusate Sodium 100 mg [Hospital1 ] 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch qd 5. Morphine SR 75 mg q8h 6. Hexavitamin qd 7. Senna 1 tab [Hospital1 ] prn 8. Ferrous Sulfate 325 qd 9. Folic Acid 1 mg qd 10. Lovenox 160 mg q12h 11. Hydromorphone 4 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain. Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QDAILY (). Disp:30 Adhesive Patch, Medicated(s) Refills:0 7. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:180 Tablet Sustained Release(s) Refills:0 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:2 9. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [Age over 90 ]y (120) mg Subcutaneous Q12H (every 12 hours). Disp:7200 mg Refills:2 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for for pain. Disp:30 Tablet(s) Refills:0 11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:40 Tablet(s) Refills:0 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 13. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: IVC filter clot Acute Interstitial Nephritis [2-10] ciprofloxacin Tremor Secondary Diagnosis: Metastatic Prostate Cancer Bilateral DVTs OSA Discharge Condition: Good, breathing well on room air, eating regular diet, ambulating. Discharge Instructions: You were admitted for increasing lower extremity edema and scrotal edema. Two seperate thrombectomies with tPA administration were performed to restore flow through the inferior vena cava and leg veins. Please take all medication as prescribed. You will need to continue to take lovenox 120 mg subcutaneously twice a day. Due to your resolving renal failure, we started you on a steroid called prednisone. You will need to take this daily and have your kidney function tests checked within 1 week of discharge. If your kidney function continues to improve, the steroids will be tapered slowly as an outpatient. You have an appointment to follow-up with a kidney doctor, Dr. [Last Name (STitle) 4883]. We also decreased your neurontin dose to 300 mg three times a day, which we believe were the primary cause of your tremors. Call your doctor or return to the emergency room if you experience any of the following: fever > 100.5, chills, night sweats, increased burning on urination, decreased urine frequency or output, shortness of breath, chest pain, increasing lower extremity and scrotal edema. Followup Instructions: You have the following appointments: Kidney Doctor: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 435] Date/Time:[2169-3-7] 9:00 Provider [Last Name (NamePattern4) ]. [First Name (STitle) ]/DR. [First Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2169-3-9] 9:00 Please call ([Telephone/Fax (1) 31457] to make an appointment to follow-up with Dr. [Last Name (STitle) ] within 1 week. [Name6 (MD) ] [Last Name (NamePattern4) 9601] MD, [MD Number(3) 9602] Completed by:[2169-2-22]	[ "5990", "5849", "2720", "32723" ]
Admission Date: [2143-3-27] Discharge Date: [2143-4-2] Date of Birth: [2143-3-27] Sex: M Service: NB HISTORY: Infant arrived at the NICU at 4 hours of age from the newborn nursery for respiratory distress. Patient was born at term to a 34 year-old, Gravida III, Para I mother whose pregnancy was unremarkable. Prenatal screens were also unremarkable. Blood type A positive. HBSAG negative. Rubella immune. RPR nonreactive. GBS negative. No sepsis risk factors. Born by spontaneous vaginal delivery. Had precipitous delivery with thin meconium, required a brief period of positive pressure ventilation with Apgars of 6 and 8 at 1 and 5 minutes respectively. Infant went to the normal newborn nursery where the NICU team was called for respiratory distress and the infant had some tachypnea. Infant was taken to the NICU for respiratory distress. HOSPITAL COURSE: 1. Respiratory: In the NICU, the infant required a nasal cannula at 500 cc flow and 100% FI02 for nasal stuffiness and respiratory distress. The initial chest x-ray was essentially clear. The infant was started on Dexamethasone and phenylephrine nasal drops to decrease nasal inflammation. On day of life 1, the infant had persistent nasal congestion and stuffiness. ORL was consulted at that time and did a flexible bronchoscopy. Their results showed some vocal cord edema and no lower airway edema below the vocal cords and essentially upper airway and nasal edema. The nasal drops were discontinued at that time and the infant remained on nasal cannula until weaned off on [3-29], day of life 2. Infant has been on room air since that time but still has some mild persistent nasal edema. The nasal drops were restarted on [2143-4-1] and that was the dexamethasone drops and the phenylephrine drops. Those drops were subsequently discontinued 48 hours later on [2143-4-2], despite continued mild nasal edema. The infant has been stable on room air since [2143-3-29] otherwise, with no apnea or bradycardiac events. 1. Cardiovascular: The infant has been hemodynamically stable since birth. One episode of an audible transient murmur on the newborn day and then no subsequent murmurs were audible after that. Heart rate and blood pressure are within normal limits. There has been no bradycardia. 1. Fluids, electrolytes and nutrition: The infant was attempting breast feeding on the newborn day unsuccessfully due to the breathing difficulties, was made n.p.o. and intravenous fluids were initiated on the newborn day. Enteral feedings were initiated on [2143-3-29], day of life 2 of breast feeding. At that time, on [2143-3-29], the infant had one tiny episode of faint green emesis at that time but subsequently continued to eat and do well. IV fluids were weaned off on [2143-3-29]. The infant breast fed fair, although he did have persistent small spits throughout the feeding and was breast feeding up until the day of discharge, [2143-4-2]. On the morning of discharge was noted to have a bilious spits prompting transfer to [Hospital3 1810] for UGI. 1. Gastrointestinal: Due to the bilious emesis within 24 hours from the discharge date, an upper GI was performed at [Hospital3 1810]. The upper GI showed absent passage of contrast distally at level of duodenum. General surgery was contact[Name (NI) ] at that time for surgical intervention. The infant is presently at the [Hospital3 1810] for surgical intervention. 1. Bilirubin: The infant has not required phototherapy and has had a peak bilirubin level of 12.3 over 0.3 on [2143-3-30]. 1. Hematology: CBC was done at birth. The hematocrit was 58.9. No blood typing was done on the infant. The infant has required no blood product transfusions. 1. Infectious disease: A CBC and blood culture were screened on admission. The infant received 48 hours of Ampicillin and Gentamicin pending the negative blood culture at that time. The antibiotics were thus discontinued. The CBC was benign, had 18.3 whites, 77 polys with 1 band. There have been no subsequent issues with sepsis. 1. Neurology: The infant has maintained a normal neurologic exam for gestational age. 1. Sensory: Audiology hearing screen was performed with automated auditory brain stem responses on [2143-3-30] and the infant passed bilaterally. 1. Psychosocial: There are no active ongoing psychosocial issues at this time. The [Hospital1 ] social worker has been involved with the family. If there are any psychosocial issues, she can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Unstable and guarded. DISCHARGE DISPOSITION: Transferred to [Hospital3 1810] for surgical intervention for intestinal obstruction. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 66565] from [Hospital1 1474]. CARE RECOMMENDATIONS: Surgical evaluation of mid gut volvulus. Infant has had state screens sent on [2143-3-30]. Those results are pending. Hepatitis B vaccine was given on [2143-3-30]. 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: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. DISCHARGE DIAGNOSES: 1. Mild hyperbilirubinemia. 2. Respiratory distress. 3. Nasal edema. 4. Upper airway edema. 5. Rule out sepsis. 6. Mid gut volvulus. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Name8 (MD) 62299] MEDQUIST36 D: [2143-4-2] 17:15:50 T: [2143-4-2] 17:37:32 Job#: [Job Number 66566]	[ "V290" ]
Admission Date: [2198-3-23] Discharge Date: [2198-4-1] Date of Birth: [2119-7-10] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Mild dyspnea Major Surgical or Invasive Procedure: [2198-3-23] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with vein grafts to the ramus intermedius and PLV. Replacement of Ascending Aorta utilizing a 26mm Gelweave Dacron Graft. History of Present Illness: Mr. [Known lastname 45068] is a 78 year old male found to have abnormal ECG on routine exam. Subsequent ETT in [2198-2-8] was notable for 1.0-1.5mm ST depression in V4-V6 at peak exercise. Imaging revealed inferoapical and septal ischemia. Cardiac catheterization in [2198-3-8] showed severe three vessel disease and normal LV function. Based upon the above results, he was referred for cardiac surgical intervention. Past Medical History: Coronary Artery Disease, Hypertension, Hypercholesterolemia, Osteoarthritis, Depression Social History: 40 pack year history of tobacco, quit approximately 38 years ago. Admits to drinking several glasses of wine per day. Retired. Married with one child. Family History: Brother and sister with CABG in their 80's. Denies premature CAD. Physical Exam: Vitals: BP 176/94, HR 81, RR 12 General: elderly male in no acute distress HEENT: oropharynx benign, sclera red without discharge Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub, distant heart sounds Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [2198-3-23] Intraoperative TEE: MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Ascending: 4.5 cm (nl <= 3.4 cm) Aorta - Arch: 2.6 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.7 cm (nl <= 2.5 cm) INTERPRETATION: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. Low normal LVEF. 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 RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated ascending aorta. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Focal calcifications in aortic arch. Mildly dilated descending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. Brief Hospital Course: Mr. [Known lastname 45068] was admitted and underwent coronary artery bypass grafting surgery. Given intraoperative findings of an ascending aortic aneurysm, he required replacement of his ascending aorta as well. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and weaned from Neosynephrine without difficulty. His CSRU course was uneventful, and he transferred to the SDU on postopertive day two. He initially required a 1:1 sitter for some postoperative delirium/confusion. Haldol was intermittently utilized for agitation. Bursts of paroxsymal atrial fibrillation were noted which resolved with an increase in beta blockade. Beta blockade was advanced as tolerated while K and Mg levels were monitored and repleted per protocol. He also required several units of packed red blood cells for a postoperative anemia. Over several days, his mental status improved. Sternal drainage was also noted but there was no clinical evidence of infection. stop [3-27] Medications on Admission: HCTZ 50 qd, Simvastatin 80 qd, Atenolol 50 qd, Aspirin 325 qd, Ativan prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:28 Capsule(s)* Refills:0 7. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day for 7 days. Disp:7 packets Refills:0 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease and Ascending Aortic Aneursym - s/p Coronary Artery Bypass Grafting and Replacement of Ascending Aorta, Postoperative Atrial Fibrillation, Postoperative Anemia, Postoperative Altered Mental Status, Hypertension, Hypercholesterolemia, Osteoarthritis, Depression Discharge Condition: 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. Followup Instructions: Cardiac surgeon, Dr. [First Name (STitle) ] in [4-12] weeks. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [2-10] weeks. Local cardiologist, Dr. [First Name (STitle) ] in [2-10] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173]	[ "41401", "2851", "42731", "4019", "2720", "311" ]
Admission Date: [2193-7-23] Discharge Date: [2193-7-29] Date of Birth: [2125-3-14] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p Aortic valve replacement (21 mm [Company 1543] Porcine) [2193-7-23] History of Present Illness: 68 year old female with history of aortic stenosis with dyspnea on exertion, exercise intolerance, and fatigue. She underwent cardiac catherization on [6-10] for preoperative evaluation which revealed 40% LAD stenosis, with otherwise clean coronaries. Past Medical History: 1. HTN, diagnosed in her 40s, usual BP in 180s 2. DM, diagnosed in 30s, does not take insulin 3. Hyperlipidemia, diagnosed in 50s 4. DVT as a young adult when on OCPs 5. Aortic stenosis 6. 4 SVD pregnancies 7. CVA [3-17] 8. Anemia 9. PVD 10. Diverticulosis Social History: Works as electronic assembler Tobacco denies Stopped drinking 7 years ago Lives with daughter Family History: Mother died of stroke in her 70s Physical Exam: General NAD HR 70, b/p 138/68, wt 150 ht 62" Skin warm dry HEENT NCAT, PERRLA, EOMI, op benign, edentulous Neck supple, full ROM + rt bruit no JVD Chest CTA bilat Heart RRR 4/6 blowing systolic murmur Abdomen soft ND, NT +BS Ext warm well perfused trace LE edema Varicosities none Neuro a/o x3 nonfocal, gait steady, 5/5 strength Pertinent Results: [2193-7-29] 12:50PM BLOOD WBC-9.1 RBC-3.20* Hgb-9.4* Hct-27.5* MCV-86 MCH-29.5 MCHC-34.3 RDW-14.1 Plt Ct-451# [2193-7-23] 10:05AM BLOOD WBC-7.6 RBC-2.07# Hgb-6.0# Hct-18.0# MCV-87 MCH-28.7 MCHC-33.1 RDW-14.1 Plt Ct-171# [2193-7-29] 12:50PM BLOOD Plt Ct-451# [2193-7-23] 10:05AM BLOOD PT-15.8 PTT-43.7* INR(PT)-1.4* [2193-7-23] 10:05AM BLOOD Fibrino-166 [2193-7-29] 12:50PM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-143 K-4.2 Cl-103 HCO3-27 AnGap-17 [2193-7-23] 12:27PM BLOOD UreaN-15 Creat-0.5 Cl-119* HCO3-23 [2193-7-29] 12:50PM BLOOD Mg-1.6 [2193-7-24] 03:10AM BLOOD Mg-1.7 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 104526] (Complete) Done [2193-7-23] at 9:00:11 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division of Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2125-3-14] Age (years): 68 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Hypertension. Shortness of breath. ICD-9 Codes: 402.90, 786.05, 440.0, 424.1 Test Information Date/Time: [2193-7-23] at 09:00 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.5 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 1.5 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 3.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 62 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 42 mm Hg Aortic Valve - Valve Area: 0.9 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the RAA. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. No LV mass/thrombus. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. Focal calcifications in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. No masses or vegetations on aortic valve. Moderate-severe AS (area 0.8-1.0cm2). Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. There is no ASD by color or 2-D. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. No masses or vegetations are seen on the aortic valve. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Well-seated bioprosthetic valve in the aortic position. No paravalvular leak. Trivial AI. Flow seen in LMCA and RCA. Preserved biventricular systolic gfunction. Mild MR [First Name (Titles) ] [Last Name (Titles) 1506] from preop. The aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2193-7-23] 10:17 [Known lastname ],[Known firstname ] M [Medical Record Number 104527] F 68 [2125-3-14] Cardiology Report ECG Study Date of [2193-7-23] 12:47:02 PM Baseline artifact. Sinus rhythm. Possible ST-T wave abnormalities with mild Q-T interval prolongation. Since the previous tracing of [2193-7-17] the QRS voltage has decreased. The axis is more leftward. Clinical correlation is suggested. Read by: [Last Name (LF) ],[First Name3 (LF) 900] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 112 90 418/454 45 -24 36 Brief Hospital Course: Admitted same day surgery and underwent aortic valve replacement, see operative report for further details. Was transferred to the intensive care unit for hemodynamic monitoring. In the first twenty four hours she was weaned from sedation, awoke neurologically intact and was extubated without complications. She was started on beta blockers for rate control and lasix for gentle diuresis. Physical therapy worked with her on strength and mobility. Chest tubes were discontinued on POD #2 without complication. Her wires were removed on the following day. With ambulation, incentive sprirometry, lasix, and pulmonary toilet her breathing improved. she continued to progress and was ready for discharge to rehab on POD 6. Medications on Admission: Plavix 75mg daily Actos 15mg daily Norvasc 10mg daily Lipitor 80mg daily Lasix 40mg alternating with 20mg daily Metformin 1000 mg [Hospital1 ] NPH 20 units qhs Glyburide 10 mg [Hospital1 ] Toprol XL 200 mg daily Zetia 10 mg daily Mavik 8 mg daily Verapamil 240 mg daily ASA 81 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: please evaluate weight and edema. 9. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Insulin SS humalog Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 61-109 mg/dL 0 Units 0 Units 0 Units 0 Units 110-130 mg/dL 2 Units 2 Units 2 Units 0 Units 131-150 mg/dL 4 Units 4 Units 4 Units 0 Units 151-180 mg/dL 6 Units 6 Units 6 Units 0 Units 181-210 mg/dL 8 Units 8 Units 8 Units 2 Units 211-240 mg/dL 10 Units 10 Units 10 Units 4 Units 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous at bedtime. 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): total - 75mg twice a day. Discharge Disposition: Extended Care Facility: [Hospital ] health care Discharge Diagnosis: Aortic Stenosis s/p AVR Hyperlipidemia Hypertension Peripheral vascular disease Anemia Diverticulosis Diabetes Mellitus CVA [2190] h/o deep vein thrombosis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 1 week ([Telephone/Fax (1) 250]) Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [1-13] weeks Wound check appointment [Hospital Ward Name 121] 6 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2193-7-29*]	[ "4241", "4019", "25000", "2859" ]
Admission Date: [2186-7-13] Discharge Date: [2186-7-26] Date of Birth: [2124-11-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: 61 y/o male adm. to OSH 12 days PTA w/C/O abd. bloating, LE edema & fatigue, found to be in CHF, natrecor started. Cath revealed LM & 3vCAD, transferred to [Hospital1 18] for CABG Major Surgical or Invasive Procedure: CABG X 4 ([2186-7-17]) History of Present Illness: The patient is a 61-year-old man who presented with congestive heart failure, left lower extremity edema and ascites. He has a history of cirrhosis and liver dysfunction. It was elected to proceed with bypass surgery. The patient was transferred to the [Hospital1 69] from [Hospital ] Medical Center and was treated for heart failure and liver dysfunction prior to surgery. A Cardiac catheterization revealed three vessel coronary artery disease with an ejection fraction of 25%, He was thus referred for CABG Past Medical History: Hepatitis B Cirrhosis venous stasis disease CAD Social History: Occas. ETOH Smokes [2-5] PPD Family History: non-contributory Physical Exam: Neuro: alert, oroented in NAD Pulm: crackles bilat Cor: gr [4-9] syst. murmur Abd: soft, mod. distended Ext.: min. edema Pertinent Results: [2186-7-25] 04:25PM BLOOD WBC-7.5 RBC-3.40* Hgb-11.0* Hct-34.1* MCV-100* MCH-32.2* MCHC-32.1 RDW-16.8* Plt Ct-264 [2186-7-25] 04:25PM BLOOD Plt Ct-264 [2186-7-25] 04:25PM BLOOD PT-12.3 INR(PT)-1.0 [2186-7-25] 04:25PM BLOOD Glucose-106* UreaN-32* Creat-1.2 Na-150* K-4.0 Cl-108 HCO3-33* AnGap-13 [2186-7-25] 04:25PM BLOOD ALT-19 AST-22 LD(LDH)-207 AlkPhos-122* TotBili-0.8 Brief Hospital Course: Admitted to hospital, on cardiac surgery service. Heart failure service consulted, recommended diuresis pre-operatively. He was subsequently started on a Lasix drip. Hepatology also consulted, recommending preoperative ultrasound and abdominal CT scan. The RUQ ultrasound showed normal portal venous flow and two small gallbladder polyps. The abdominal scan was essentially unremarkable - there was no focal liver lesions, with only a small amount of perihepatic ascites. He otherwise remained stable on medical therapy and was eventually cleared for surgery. On [7-17], Dr. [Last Name (STitle) ] performed four vessel coronary artery bypass grafting utilizing the left internal mammary artery to the diagonal branch of left anterior descending artery, saphenous vein graft to the distal left anterior descending artery, saphenous vein graft to the obtuse marginal branch of the circumflex, saphenous vein graft to the posterior descending coronary artery. Postoperative echo was notable for a LVEF of 20% with no mitral regurgitation or aortic insufficiency. After the operation, he was brought to the CSRU. Within 24 hours, chest tubes were removed and he was extubated. He was slow to wean from inotropic support and initially required AV pacing for junctional rhythm. Beta blockade was initially withheld. The EP service was consulted to evaluate for permanent pacemaker plus/minus AICD(given his severely depressed LV function). He concomitantly experienced aphonia. Bedside swallow examination showed bilateral vocal cord paralysis, diffuse pharyngeal weakness and silent aspiration. He was subsequently made NPO and started on tube feedings. Over several days, his native heart rate improved to the 80's. Epicardial wires were eventually removed without complication. He otherwise remained stable on medical therapy. It was decided that a pacemaker was not indicated at this time but the need for an AICD will need to be assessed three months postoperatively. On postoperative day five, he transferred to the Step Down Unit. He continued to require diuresis and remained stable from a cardiac and liver standpoint. Beta blockade was not resumed. Over several days, he made clinical improvements as he worked daily with physical therapy. At discharge, his oxygen saturations were 99% on room air. His aphonia gradually improved. Repeat bedside swallow examination showed no signs of aspiration with pureed diet. Aspiration was however noted with thin liquids. Videofluroscopic evaluation on [7-24] confirmed aspiration but functional swallow was achieved with pureed/ground solids and honey thick liquids. Medications were subsequently crushed in puree and repeat videoswallow was recommended in one week to evaluate for diet advancement. By discharge, he was tolerating solids without difficulty. He was eventually cleared for discharge on postoperative day five. He will follow up in [Location (un) 37361], RI on [7-27] and again in two weeks. Medications on Admission: Aldactone Accupril Digoxin Aspirin Lamivridine Insulin Coreg Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 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. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [2-5] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:1 5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: CAD post-op dysphagia Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions Followup Instructions: with Dr. [Last Name (STitle) ] tomorrow in [Location (un) 37361], and again in 2 weeks with Dr. [Last Name (STitle) 64132] in [3-9] weeks Completed by:[2186-7-26]	[ "41401", "4280", "42789", "3051", "25000", "V5867", "4019", "2724" ]
Admission Date: [2140-8-30] Discharge Date: [2140-8-30] Date of Birth: [2140-8-30] Sex: F HISTORY: This 36 and 4/7th week gestational age female was admitted to the Neonatal Intensive Care Unit with gastroschisis. She was delivered to a 19-year-old gravida 2, para 0 to 1 woman whose past obstetric history was notable for medical history were non-contributory. PRENATAL SCREENS: Blood group A+, direct antibody test negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B streptococcus unknown. The last menstrual period was uncertain. Estimated date of estimated gestational age of 36 and 4/7th weeks. An abnormal alpha-fetoprotein resulted in an ultrasound showing gastroschisis at 18 weeks. She subsequently had an unremarkable pregnancy, until the development of spontaneous onset preterm labor early today. Membranes were ruptured 2.5 priors to delivery, yielding yellow stained amniotic fluid. This was initially thought to be secondary to meconium, but subsequently appeared to be bile. No maternal fever or fetal tachycardia were noted. Intrapartum antibiotic prophylaxis was administered 3.5 hours prior to delivery. She proceeded to a spontaneous vaginal delivery under epidural anesthesia. The infant emerged with good tone and cried on transfer to the warmer. Oral and nasal bulb suctioning were performed. The infant's lower torso was placed in a bowel bag containing warmed normal saline and the bag was secured at the upper abdomen. The upper torso and head were dried. Free flow oxygen was administered for central cyanosis, and the infant was noted to be mildly tachypneic. Apgars were 8 at 1 minute and 8 at 5 minutes. She was transferred uneventfully to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION ON ADMISSION: Weight was 2230 gm (25th percentile). Heart rate was 170, respiratory rate 54, admission temperature 98.8??????, blood pressure 58/37 (mean 45), oxygen saturation 100% in room air. The anterior fontanel was soft and flat. Facies were non-dysmorphic. Palate was intact. There was initial mild nasal flaring, but this had resolved by 45 minutes of age. The neck and mouth were normal. There were initial mild intercostal retractions, but these had also resolved by 30 minutes of age. Breath sounds were good bilaterally with no crackles. The infant was initially well perfused, although perfusion did decrease by one hour of age. The heart rate was regular and femoral pulses were of normal volume. First and second heart sounds were normal, and no murmur was present. Examination of the abdomen showed a periumbilical abdominal wall defect, with the umbilical cord positioned at the 2 o'clock position to a mass of pink, apparently well perfused bowel. A three vessel umbilical cord was normal. She had normal female genitalia. She was active, alert and had tone appropriate for her gestational age. She was moving all extremities, and the suck/root/gag/grasp reflexes were normal. The examination of the integument, spine, limbs and extremities were all within normal limits. HOSPITAL COURSE: While in the neonatal unit, the following issues have been of concern: 1. RESPIRATORY: As noted above, the infant initially had mild respiratory distress. However, this had resolved by approximately 45 minutes of age and was presumably secondary to transitional respiration, rather than to pulmonary pathology. An arterial blood gas drawn at 30 minutes of age in blow-by oxygen showed a pH of 7.31, PACO2 38, PAO2 203 and bicarbonate 20. At the time of transfer, the infant is breathing comfortably in room air with excellent oxygen saturations. 2. CARDIOVASCULAR: The infant developed poor perfusion and had a drift in the mean blood pressure from a mean of 45 mmHg down to 35 mmHg by one hour of age. An initial bolus of normal saline, 10 cc per kg, was administered just prior to transport. Examination of the cardiovascular system was otherwise within normal limits. 3. FLUIDS, ELECTROLYTES AND NUTRITION: The infant has been NPO since birth. A nasogastric tube was placed to low suction, and several milliliters of bile secretions were obtained on placement. Position of this tube has not been confirmed radiographically yet, given the need for transfer to [Hospital3 1810]. A peripheral intravenous line was placed, and D10W was started at a total fluid intake of 120 cc per kg per day, which represents approximately 150% of baseline maintenance due to presumed bowel losses. Initial capillary glucose was 106. There was apparent initial small volume of urine output in the delivery room. 4. GASTROINTESTINAL: The abdominal wall defect has been irrigated with warm normal saline and protected in a "bowel bag". The [Hospital3 1810] surgical service has consulted regarding the gastroschisis and will bring the infant to the operating room for definitive surgical management immediately on transfer to [Hospital3 1810]. 5. HEMATOLOGIC: The infant did not receive any blood products during the admission. The initial hematocrit was 43.2 and platelet count 507. 6. INFECTIOUS DISEASE: In light of the history of preterm labor with unknown GBS status, a CBC and blood culture have been drawn and the infant had been started on broad spectrum antibiotic therapy for an anticipated course of at least 48 hours pending decisions about mode of surgical management, resolution of hypotension, white blood cell count and blood culture results. The initial white blood cell count was 15.2, but a differential is not yet available. 7. NEUROLOGIC: The infant has been neurologically normal during the brief admission. She will require a hearing screening prior to hospital discharge. 8. SOCIAL: The infant's mother had an antenatal consultation with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 37080] of the [Hospital3 1810] surgical service and seemed well prepared for tonight's events. The father of the baby, as well as the mother's extended family, appear involved. DISCHARGE CONDITION: Guarded DISCHARGE DISPOSITION: The infant has been transferred to [Hospital3 1810]. NAME OF PRIMARY PEDIATRICIAN: Not yet available. MEDICATIONS: 1. Ampicillin 150 mg per kg per day q 12 h 2. Gentamicin 4 mg per kg per dose q 24 h DISCHARGE DIAGNOSES: 1. Prematurity (36 and 4/7th weeks gestation) 2. Gastroschisis 3. Sepsis risk, on antibiotics [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern5) 43805] MEDQUIST36 D: [2140-8-30] 04:57 T: [2140-8-30] 07:16 JOB#: [Job Number 43806]	[ "V290" ]
Admission Date: [2153-10-21] Discharge Date: [2153-10-31] Date of Birth: [2076-2-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7651] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring IABP x 3 days and pneumonia treated with flagyl and levaquin. She was sent to rehab on [10-19] and presents from rehab with increasing SOB. . Pt reports that at rehab, every night she had chest tightness, rating [7-30], associated with heavy breathing and nausea. No diaphoresis. The discomfort would last all night, preventing her from sleeping. She states it's a different pain than her MI. She denied any f/c. She reports that she has a chronic cough, but is blood-tinged. Notablely, she has a cough with lisinopril, which she is currently on. At 3PM, she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98. She was taken to the ED. . In the ED, initial VS: 85/47, On exam, pt was using accessory muscles. A bedside ultrasound showed minimal pericardial effusion, no evidence of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn and 1 L NS. RIJ placed. Initially she was on dopamine without much response and was switched to levophed, currently at 0.18. 70, 97/78, 18, 99% on 2 L. CVP 11-16. Cardiology to perform formal ECHO when patient hits the floor. Past Medical History: Asthma Hyperlipidemia Hypertension Coronary artery disease Diabetes mellitus type 2 GERD Social History: Pt is divorced, has 2 children. Worked as a housewife. She smoked from [2120]-[2132]. No etoh or recreational drug use. Family History: Father died with DM. Mother died with kidney disease Physical Exam: Vitals - T: 97.5 BP: 119/71 HR: 83 RR: 17 02 sat: 98% on 2L NC GENERAL: Anxious. No apparent distress. HEENT: No LAD. JVP is slightly elevated. Supple CARDIAC: Regular rate and rhythm, no m/r/g LUNG: Bilateral inspiratory crackles and expiratory wheezes. Good respiratory effort- no signs of accessory muscle use. ABDOMEN: +bs, soft, non-tender, non-distended EXT: trace edema in b/l LE. No c/c. NEURO: AAO x 3. Grossly intact DERM: No rashes or lesions noted. Pertinent Results: [2153-10-21] 05:16PM BLOOD WBC-20.1* RBC-3.38* Hgb-9.6* Hct-29.4* MCV-87 MCH-28.4 MCHC-32.7 RDW-15.0 Plt Ct-383 [2153-10-22] 03:53AM BLOOD WBC-30.8# RBC-3.35 Hgb-9.7* Hct-29.0* MCV-87 MCH-28.9 MCHC-33.3 RDW-15.0 Plt Ct-510* [2153-10-23] 04:54AM BLOOD WBC-26.2* RBC-3.33* Hgb-9.4* Hct-29.1* MCV-88 MCH-28.3 MCHC-32.4 RDW-14.9 Plt Ct-522* [2153-10-24] 04:16AM BLOOD WBC-20.5* RBC-3.19* Hgb-9.2* Hct-28.1* MCV-88 MCH-28.8 MCHC-32.7 RDW-15.0 Plt Ct-556* [2153-10-25] 04:13AM BLOOD WBC-16.5* RBC-3.24* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.7 MCHC-32.8 RDW-15.1 Plt Ct-457* [2153-10-25] 09:37PM BLOOD WBC-11.7* RBC-2.94* Hgb-8.4* Hct-25.5* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.2 Plt Ct-320 [2153-10-26] 03:06AM BLOOD WBC-13.1* RBC-3.02* Hgb-8.7* Hct-26.2* MCV-87 MCH-28.8 MCHC-33.2 RDW-15.3 Plt Ct-355 [2153-10-27] 03:40AM BLOOD WBC-16.5* RBC-3.19* Hgb-9.1* Hct-27.6* MCV-87 MCH-28.7 MCHC-33.1 RDW-15.4 Plt Ct-410 [2153-10-28] 04:10AM BLOOD WBC-21.3* RBC-3.25* Hgb-9.4* Hct-28.0* MCV-86 MCH-29.0 MCHC-33.7 RDW-15.2 Plt Ct-421 [2153-10-29] 05:21AM BLOOD WBC-23.9* RBC-3.35* Hgb-9.5* Hct-28.7* MCV-86 MCH-28.2 MCHC-32.9 RDW-15.2 Plt Ct-368 [2153-10-30] 05:10AM BLOOD WBC-21.3* RBC-3.29* Hgb-9.6* Hct-28.1* MCV-86 MCH-29.2 MCHC-34.1 RDW-15.2 Plt Ct-334 [2153-10-21] 05:16PM BLOOD Neuts-88* Bands-2 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [2153-10-21] 05:16PM BLOOD PT-53.0* PTT-45.4* INR(PT)-5.9* [2153-10-21] 11:00PM BLOOD PT-57.8* PTT-46.4* INR(PT)-6.5* [2153-10-22] 03:53AM BLOOD PT-45.1* PTT-44.5* INR(PT)-4.8* [2153-10-22] 02:20PM BLOOD PT-27.6* PTT-36.4* INR(PT)-2.7* [2153-10-23] 04:54AM BLOOD PT-23.8* PTT-34.5 INR(PT)-2.3* [2153-10-24] 04:16AM BLOOD PT-24.2* PTT-31.4 INR(PT)-2.3* [2153-10-25] 04:13AM BLOOD PT-25.7* PTT-31.5 INR(PT)-2.5* [2153-10-26] 03:06AM BLOOD PT-36.0* PTT-32.9 INR(PT)-3.7* [2153-10-27] 03:40AM BLOOD PT-44.1* PTT-34.5 INR(PT)-4.7* [2153-10-28] 04:10AM BLOOD PT-42.0* PTT-34.8 INR(PT)-4.4* [2153-10-29] 05:21AM BLOOD PT-33.7* PTT-34.2 INR(PT)-3.4* [2153-10-30] 05:10AM BLOOD PT-29.5* PTT-31.9 INR(PT)-2.9* [2153-10-31] 05:10AM BLOOD PT-28.2* PTT-30.0 INR(PT)-2.8* [2153-10-31] 05:10AM BLOOD Plt Ct-317 [2153-10-22] 03:53AM BLOOD Fibrino-799* [2153-10-22] 02:20PM BLOOD Fibrino-817* [2153-10-22] 02:20PM BLOOD FDP-10-40* [2153-10-21] 05:16PM BLOOD Glucose-153* UreaN-35* Creat-1.6* Na-133 K-5.7* Cl-96 HCO3-26 AnGap-17 [2153-10-21] 11:00PM BLOOD Glucose-230* UreaN-37* Creat-1.6* Na-133 K-4.6 Cl-99 HCO3-22 AnGap-17 [2153-10-22] 03:53AM BLOOD Glucose-206* UreaN-35* Creat-1.4* Na-134 K-4.5 Cl-101 HCO3-24 AnGap-14 [2153-10-23] 04:54AM BLOOD Glucose-251* UreaN-36* Creat-1.3* Na-138 K-4.8 Cl-106 HCO3-23 AnGap-14 [2153-10-24] 04:16AM BLOOD Glucose-191* UreaN-42* Creat-1.3* Na-141 K-5.0 Cl-110* HCO3-25 AnGap-11 [2153-10-25] 04:13AM BLOOD Glucose-182* UreaN-46* Creat-1.2* Na-141 K-5.0 Cl-109* HCO3-26 AnGap-11 [2153-10-25] 09:37PM BLOOD Glucose-243* UreaN-48* Creat-1.2* Na-139 K-4.6 Cl-107 HCO3-25 AnGap-12 [2153-10-26] 03:06AM BLOOD Glucose-180* UreaN-50* Creat-1.2* Na-141 K-4.8 Cl-107 HCO3-25 AnGap-14 [2153-10-26] 05:57PM BLOOD Glucose-281* UreaN-47* Creat-1.1 Na-139 K-4.6 Cl-104 HCO3-26 AnGap-14 [2153-10-27] 03:40AM BLOOD Glucose-199* UreaN-45* Creat-1.1 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 [2153-10-27] 03:54PM BLOOD Glucose-308* UreaN-42* Creat-1.2* Na-135 K-4.3 Cl-97 HCO3-31 AnGap-11 [2153-10-28] 04:10AM BLOOD Glucose-176* UreaN-41* Creat-1.2* Na-139 K-4.0 Cl-97 HCO3-34* AnGap-12 [2153-10-29] 05:21AM BLOOD Glucose-161* UreaN-39* Creat-1.0 Na-138 K-3.4 Cl-96 HCO3-35* AnGap-10 [2153-10-30] 05:10AM BLOOD Glucose-121* UreaN-37* Creat-1.1 Na-139 K-3.9 Cl-97 HCO3-32 AnGap-14 [2153-10-31] 05:10AM BLOOD Glucose-183* UreaN-32* Creat-0.8 Na-139 K-4.0 Cl-101 HCO3-29 AnGap-13 [2153-10-21] 05:16PM BLOOD CK(CPK)-110 [2153-10-21] 11:00PM BLOOD CK(CPK)-94 [2153-10-22] 03:53AM BLOOD LD(LDH)-446* CK(CPK)-79 TotBili-0.6 [2153-10-22] 02:20PM BLOOD CK(CPK)-80 [2153-10-23] 04:54AM BLOOD CK(CPK)-77 [2153-10-25] 08:12PM BLOOD CK(CPK)-84 [2153-10-26] 03:06AM BLOOD CK(CPK)-73 [2153-10-21] 05:16PM BLOOD CK-MB-3 [2153-10-21] 05:16PM BLOOD cTropnT-2.08* [2153-10-21] 11:00PM BLOOD CK-MB-NotDone cTropnT-1.93* [2153-10-22] 03:53AM BLOOD CK-MB-NotDone cTropnT-1.48* [2153-10-22] 02:20PM BLOOD CK-MB-NotDone cTropnT-1.30* [2153-10-23] 04:54AM BLOOD CK-MB-NotDone cTropnT-1.06* [2153-10-26] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.60* [2153-10-26] 05:57PM BLOOD proBNP-[Numeric Identifier 1343]* [2153-10-27] 03:40AM BLOOD proBNP-[Numeric Identifier 83958]* [2153-10-21] 11:00PM BLOOD Calcium-7.7* Phos-4.5 Mg-1.9 [2153-10-30] 05:10AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.1 [2153-10-22] 03:53AM BLOOD Hapto-285* [2153-10-27] 06:09AM BLOOD Vanco-12.6 [2153-10-28] 05:43AM BLOOD Vanco-13.0 [2153-10-22] 09:54AM BLOOD Type-ART Temp-35.4 pO2-74* pCO2-41 pH-7.34* calTCO2-23 Base XS--3 Intubat-NOT INTUBA Comment-LEFT RADIA [2153-10-22] 01:58PM BLOOD Type-ART pO2-99 pCO2-44 pH-7.32* calTCO2-24 Base XS--3 [2153-10-23] 05:07AM BLOOD Type-CENTRAL VE Temp-36.7 Rates-/12 PEEP-5 FiO2-50 pO2-79* pCO2-53* pH-7.27* calTCO2-25 Base XS--2 Intubat-INTUBATED Vent-SPONTANEOU [2153-10-25] 06:19PM BLOOD Type-ART pO2-40* pCO2-47* pH-7.33* calTCO2-26 Base XS--1 [2153-10-25] 10:35PM BLOOD Type-ART Temp-36.5 Rates-18/ Tidal V-500 PEEP-5 FiO2-40 pO2-137* pCO2-28* pH-7.54* calTCO2-25 Base XS-3 -ASSIST/CON Intubat-INTUBATED [2153-10-25] 11:48PM BLOOD Type-ART Temp-36.1 Rates-12/ Tidal V-500 PEEP-5 FiO2-40 pO2-128* pCO2-36 pH-7.45 calTCO2-26 Base XS-2 -ASSIST/CON Intubat-INTUBATED [2153-10-26] 01:12AM BLOOD Type-ART Temp-36.1 Rates-[9-21] Tidal V-450 PEEP-5 FiO2-40 pO2-123* pCO2-48* pH-7.36 calTCO2-28 Base XS-1 -ASSIST/CON Intubat-INTUBATED [2153-10-26] 02:12AM BLOOD Type-ART Temp-36.1 PEEP-5 FiO2-35 pO2-120* pCO2-43 pH-7.40 calTCO2-28 Base XS-1 Intubat-INTUBATED [2153-10-27] 06:21AM BLOOD Type-ART Temp-35.8 FiO2-35 pO2-125* pCO2-46* pH-7.45 calTCO2-33* Base XS-7 Intubat-INTUBATED [2153-10-21] 06:00PM BLOOD Lactate-3.1* [2153-10-21] 11:13PM BLOOD Lactate-2.1* [2153-10-22] 09:54AM BLOOD Lactate-2.5* [2153-10-22] 01:58PM BLOOD Lactate-1.5 [2153-10-23] 05:07AM BLOOD Lactate-1.7 [2153-10-25] 10:35PM BLOOD Lactate-1.7 [2153-10-25] 10:35PM BLOOD freeCa-1.13 ECHO ([2153-10-21])- The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the septum and anterior walls, apex, and distal lateral wall. The apex is mildly aneurysmal. The remaining segments contract normally (LVEF = 25-30 %). No intraventricular thrombus is seen. 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. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. No right ventricular diastolic collapse is seen. IMPRESSION: Extensive regional left ventricular systolic dysfunction c/w CAD. Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. CXR ([2153-10-21])- IMPRESSION: Right middle lobe opacity concerning for pneumonia. CXR ([2153-10-23])- Comparison is made with a prior study performed a day earlier. Mild pulmonary edema has improved. Cardiac size is top normal. There is mild bilateral pleural effusions, greater on the right side. Left lower lobe atelectasis has increased. Opacity in the right lower lobe is most likely atelectasis. Right IJ catheter, ET tube and NG tube remain in place. CXR ([2153-10-29])- COMPARISON: [2153-10-28]; [2153-10-27]. PORTABLE UPRIGHT CHEST RADIOGRAPH: Again seen is a right internal jugular catheter with tip projecting over the mid SVC. Heart size and mediastinal contours are unchanged. The aorta is mildly calcified and unfolded. There is persisting bu t improved retrocardiac and right basilar opacity. There are no large pleural effusion. No pneumothorax. LENIs ([2153-10-26])- CONCLUSION: 1. There is no ultrasound evidence of deep venous thrombosis of the lower extremities. 2. There is evidence of edema of the soft tissues of both lower limbs. Brief Hospital Course: # Sepsis: Patient presented from rehab for increasing SOB. Patient was recently discharged from and OSH for STEMI and was being treated for a Pneumonia with Levaquin and Flagyl. On arrival here, she was noted to have hypotension with CXR consistent with RML Pneumonia. She was started on pressors for blood pressure control. She was intubated [1-22] to respiratory distress. She was started on Vanco/Zosyn initially for her Pneumonia and was switched to Vanco/Cefepime/Ciprofloxacin on the morning of [10-22] for treatmed of health care associated pneumonia. She was weaned off of pressors. On [10-24], she was extubated and then reintubated the following day [1-22] respiratory distress. Cardiology was consulted given recent history of STEMI with EF of 20% as CHF was thought to be contributing to her respiratory distress and difficulty with extubation. She was diuresed with Lasix gtt and re-extubated successfully on [10-27] which was successful. She was transferred to the medical floor on [10-28]. Upon transfer, she was continued on PO vanc. Patient remained afebrile but continued to have an elevated WBC. She was ruled out for C.diff x 3 and CXR improved daily. Shortness of breath also improved. Her BP's returned to [Location 213] limits and she remained hemodynamically stable. Upon discharge, patient was doing well. She was started on amiodarone at OSH but it was held while here given her hemodynamic status- we continued to hold it on discharge and will ask that her outpatient cardiologist re-evaluate giving her amiodarone. She was restarted on her home dose of lisinopril 5mg daily. Her beta-blocker was also restarted but, instead of Toprol XL 50mg daily, she was given metoprolol tartrate 12.5mg PO BID. Her aldactone was also held on discharge. Patient will have her cardiac medications re-evaluated once she see her outpatient cardiologist in [12-22] weeks. # Health Care Associated Pneumonia: Patient presented with a right middle lobe pneumonia s/p recent discharge from hospital for her STEMI. She was treated with Vanco/Zosyn/Cipr as above. She was transitioned to PO vancomycin and did well. CXR improved daily. She also remained afebrile. She is to continue PO vanc for a 14 day course (day 1 was [10-28]). # Acute Systolic Heart Failure: Mr. [Known lastname ] had a recent STEMI complicated by new EF of 20%. She was treated with Lasix as above with improvement in her respiratory status. She diuresed well She was discharged on lasix 40mg by mouth daily. # Diarrhea: Patient initially complained of diarrhea and was started on Flagyl empirically for c.difficile infection. During her hospitalization, WBC became elevated on treatment for her HAP and diarrhea became more significant so she was staretd on Vanco PO for presumed for c.diff. C.diff was then sent and was negative x 3. Patient's diarrhea had resolved by discharge. # CAD, s/p recent STEMI, now with EF 20%: Cardiology was consulted as above. Beta blocker was held intitially [1-22] hypotension. She was continued on her ASA, Plavix, Statin. Beta-blocker (metoprolol tartrate 12.5mg PO BID), ACE-I (lisinopril 5mg daily) were restarted. Her home dose of aldactone was held on discharge. She was chest-pain free on discharge. She will continue aspirin 325mg daily and plavis # Afib: Patient was in sinus rhythm. amiodarone and beta-blocker were held intially as patient was hypotensiv. Her blood pressures returned to [Location 213] levels so she was restarted on lisinopril and metoprolol. Amiodarone was discontinued (per above). Her INR was supratherapeutic on admission so her coumadin was initially held. It returned to a therapeutic level (2.9) on [10-30] so her coumadin was resumed at 1mg PO daily. # HTN: Per above. Lisinopril 5mg daily and beta-blocker (metoprolol 12.5mg PO BID) resumted. Aldactone and amiodarone were held on discharge. Patient hemodynamically stable on discharge. # Hyperlipidemia: continued atorvastatin 80mg po daily # Asthma: started on Methylprednisolone on [10-22] and was treated for a 5 day course, she was also treated with albuterol inhalers and placed on her home advair. She was also given Ipratropium Bromide. Patient counseled not to over-use her asthma medications # Diabetes mellitus type 2: Metformin held as an inpatient, treated with insulin sliding scale while in-house, with good control of her sugars. She was restarted on home dose of metformin 500mg daily upon discharge. # GERD: Continued patient on home dose of ranitidine 150mg daily Medications on Admission: Atenolol 25 mg daily ASA 325 mg daily Plavix 75 mg daily Atorvastatin 80 mg daily Lasix 40 mg QOD Flagyl 500 mg po tid Levofloxacin 750 mg QOD Lisinopril 5 mg po daily Amiodarone 200 mg [Hospital1 ] x 3 weeks then d/c Aldactone 2.5 mg daily Advair 250/50 i puff [Hospital1 ] Glucophage 500 mg daily Zantac 150 mg daily Atrovent nebulizers Xanax 0.5 mg TID Toprol XL 50 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for anxiety. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Glucophage 500 mg Tablet Sig: One (1) Tablet PO once a day. 14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 9 days: 14 total days (day 1- [10-28]). Last day is [11-10]. Discharge Disposition: Extended Care Facility: [Hospital1 ] of [Hospital1 ] Discharge Diagnosis: Primary: Anterior ST-elevation myocardial infarction Secondary: Asthma, GERD, Hypertension, hyperlipidemia Discharge Condition: Good. Vital signs stable. Ambulated with physical therapy- cleared for rehab. Discharge Instructions: You were admitted to the hospital after suffering a heart attack. Afterward, you developed some difficulty breathing that required a intubation. You were kept in the ICU and did well. We diuresed you using lasix with good results. Your chest x-rays improved daily and your shortness of breath continued to resolve. You denied any chest pain. Upon discharge, you were stable and asymptomatic. The following changes were made to your medications: 1. Please stop taking amiodarone 200mg by mouth twice daily 2. Please stop taking Toprol XL 50mg by mouth daily 3. Please start taking metoprolol tartrate 12.5mg by mouth twice daily 4. Please stop taking your aldactone 5. Please start taking vancomycin 125mg by mouth every 6 hours for a total of 14 days (day 1- [10-28], last day is [11-10]) 6. Please start taking ipratropium bromide inhaler- 2 puffs four times/day Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please set-up an appointment with a primary care physician of your choice (you mentioned someone in [Location (un) 620]) in [12-22] weeks. [Name6 (MD) ] [Last Name (NamePattern4) 6559], MD (Cardiology) Phone:[Telephone/Fax (1) 62] Date/Time:[2153-11-16] at 9:40am Completed by:[2153-10-31]	[ "0389", "51881", "78552", "486", "99592", "4280", "41401", "42731", "4019", "49390", "2724", "25000", "53081", "V4582" ]
Admission Date: [2102-3-13] Discharge Date: [2102-3-16] Date of Birth: [2057-6-6] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base / Floxin / Iodine; Iodine Containing / Gadolinium-Containing Agents / Amoxicillin / Latex Attending:[First Name3 (LF) 1283] Chief Complaint: IVC tumor Major Surgical or Invasive Procedure: Resection of IVC tumor, IVC graft repair of suprahepatic segment, T external illiac vein to IVC bypass History of Present Illness: 44 F who underwent a partial hysterectomy in 199 with completion in [2095] c/b PE, undergoing embolectomy. Since that time she had been followed for suspected chronic clot in IVC. MRI in [Month (only) 1096] suggested leimyomatosisThis tumor ran throughout the R internal illic vein, the IVC, up into the right atrium. Past Medical History: Invasive Leiomyotosis IVC tumor Saddle PE- s/p embolectomy asthma PUD hiatal hernia s/p repair '[96] colitis partial hysterectomy [2094](benign leiomyotosis) completion hysterectomy [2095] C-section '[76]&'[78] CCY '[78] Tubal ligation Appy '[96] sternal wire removal '[01] Social History: lives with mother and sister. [Name (NI) 1403] for [Location (un) 5700] ambulance Denies ETOH and tobacco Family History: noncontributory Physical Exam: On Admission: Afebrle, vitals witin nml range NAD CTAB RRR well healed sternal wound abdomen was non-tender no distended no edema Pertinent Results: [2102-3-15] 11:59PM BLOOD WBC-5.0 RBC-3.42* Hgb-10.1* Hct-29.3* MCV-86 MCH-29.5 MCHC-34.5 RDW-15.8* Plt Ct-157 [2102-3-15] 10:30PM BLOOD Hct-33.7* Plt Ct-185 [2102-3-15] 08:20PM BLOOD WBC-5.2 RBC-3.78* Hgb-11.2* Hct-31.4* MCV-83 MCH-29.7 MCHC-35.8* RDW-15.4 Plt Ct-187# [2102-3-15] 06:37PM BLOOD WBC-5.4 RBC-4.03# Hgb-11.7 Hct-34.0# MCV-85 MCH-29.1 MCHC-34.4 RDW-15.3 Plt Ct-71 [2102-3-15] 04:49PM BLOOD WBC-4.0 RBC-3.12# Hgb-9.6# Hct-27.1# MCV-87 MCH-30.7 MCHC-35.4 RDW-14.8 Plt Ct-85* [2102-3-15] 11:19AM BLOOD WBC-3.7* RBC-4.46 Hgb-12.7 Hct-37.4 MCV-84 MCH-28.5 MCHC-33.9 RDW-13.9 Plt Ct-149* [2102-3-13] 01:00PM BLOOD WBC-4.8 RBC-4.72 Hgb-13.8 Hct-38.5 MCV-82 MCH-29.2 MCHC-35.8* RDW-13.8 Plt Ct-197 [2102-3-15] 11:59PM BLOOD Plt Ct-157 [2102-3-15] 11:59PM BLOOD PT-19.6* PTT-109.3* INR(PT)-1.9* [2102-3-15] 08:20PM BLOOD PT-19.8* PTT-83.2* INR(PT)-1.9* [2102-3-15] 06:37PM BLOOD PT-20.8* PTT-104.3* INR(PT)-2.0* [2102-3-15] 11:19AM BLOOD PT-15.6* PTT-119.0* INR(PT)-1.4* [2102-3-14] 04:24PM BLOOD PT-15.5* PTT-69.8* INR(PT)-1.4* [2102-3-13] 01:00PM BLOOD PT-14.9* PTT-26.2 INR(PT)-1.3* [2102-3-15] 08:20PM BLOOD Fibrino-245 [2102-3-15] 06:37PM BLOOD Fibrino-241 [2102-3-15] 11:19AM BLOOD Fibrino-317 [2102-3-15] 11:59PM BLOOD UreaN-11 Creat-1.1 Na-151* Cl-118* HCO3-19* [2102-3-15] 08:20PM BLOOD Glucose-126* UreaN-11 Creat-0.9 Na-148* K-3.4 Cl-114* HCO3-19* AnGap-18 [2102-3-13] 01:00PM BLOOD Glucose-86 UreaN-15 Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 [2102-3-15] 08:20PM BLOOD ALT-56* AST-98* LD(LDH)-464* AlkPhos-50 Amylase-28 TotBili-4.2* [2102-3-13] 01:00PM BLOOD ALT-28 AST-25 AlkPhos-63 Amylase-47 TotBili-2.1* [2102-3-15] 08:20PM BLOOD Lipase-31 [2102-3-13] 01:00PM BLOOD Lipase-39 [2102-3-16] 01:38AM BLOOD Type-ART PEEP-12 FiO2-100 pO2-37* pCO2-49* pH-7.25* calTCO2-23 Base XS--6 AADO2-636 REQ O2-100 Intubat-INTUBATED [2102-3-16] 01:04AM BLOOD Type-ART pO2-48* pCO2-48* pH-7.24* calTCO2-22 Base XS--6 [2102-3-16] 12:35AM BLOOD pO2-18* pCO2-68* pH-7.10* calTCO2-22 Base XS--11 [2102-3-16] 12:28AM BLOOD Type-ART pO2-41* pCO2-46* pH-7.18* calTCO2-18* Base XS--11 [2102-3-16] 12:04AM BLOOD Type-ART pO2-35* pCO2-52* pH-7.20* calTCO2-21 Base XS--8 [2102-3-15] 11:07PM BLOOD Type-ART pO2-251* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 [2102-3-15] 11:07PM BLOOD Type-ART pO2-251* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 [2102-3-15] 10:42PM BLOOD Type-ART pO2-47* pCO2-43 pH-7.19* calTCO2-17* Base XS--11 [2102-3-15] 09:18PM BLOOD Type-ART PEEP-12 pO2-61* pCO2-46* pH-7.24* calTCO2-21 Base XS--7 Intubat-INTUBATED [2102-3-15] 08:25PM BLOOD Type-ART pO2-82* pCO2-44 pH-7.29* calTCO2-22 Base XS--4 [2102-3-15] 07:52PM BLOOD Type-ART pO2-83* pCO2-46* pH-7.26* calTCO2-22 Base XS--6 [2102-3-15] 06:19PM BLOOD Type-ART pO2-153* pCO2-43 pH-7.31* calTCO2-23 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [2102-3-15] 04:49PM BLOOD Type-ART pO2-121* pCO2-40 pH-7.32* calTCO2-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2102-3-15] 04:07PM BLOOD Type-ART pO2-397* pCO2-39 pH-7.22* calTCO2-17* Base XS--11 [2102-3-15] 03:28PM BLOOD Type-ART pO2-420* pCO2-38 pH-7.37 calTCO2-23 Base XS--2 [2102-3-15] 03:05PM BLOOD Type-ART pO2-483* pCO2-33* pH-7.34* calTCO2-19* Base XS--6 [2102-3-15] 01:11PM BLOOD Type-ART pO2-742* pCO2-40 pH-7.32* calTCO2-22 Base XS--5 [2102-3-16] 01:38AM BLOOD Glucose-68* Lactate-13.1* [2102-3-16] 01:04AM BLOOD Lactate-11.5* [2102-3-16] 12:04AM BLOOD Glucose-97 Lactate-10.4* K-3.4* [2102-3-15] 10:42PM BLOOD Glucose-144* Lactate-10.1* K-4.3 [2102-3-15] 09:18PM BLOOD Glucose-118* Lactate-7.8* [2102-3-15] 08:25PM BLOOD Lactate-7.0* POST OP CXR: 1. Status post median sternotomy, placement of two right-sided chest tubes, two left-sided chest tubes, endotracheal tube and nasogastric tube. 2. Interval development of diffuse bilateral airspace opacities could represent pulmonary edema or massive aspiration. 3. Probable small residual left pneumothorax. Brief Hospital Course: She came in on [2102-3-13] preoperatively and was placed on a heparin drip and discussed her case with all of her physicians. She was seen preop by the cardiac, vascular, cardiology, and transplant team. She had all her questions answered and understood the risks and benefits of the procedure. On [2102-3-15] she underwent a resection of the IVC tumor, an IVC graft of the supraheptic segment of the IVC, and a right external illiac vein to IVC bypass. Intraop she received a total of 24,531 of IVF (5250 PRBC, 3686 FFP, 1032 plts, 2300 cell save, 263 cryo, [Numeric Identifier 890] crystalloid) and put out [2035] of urine. Her chest was closed and her abdomen was left open. Please refer to the respective operative notes for more details. She came out of the OR on epinephrine, milrinone, Neo-Synephrine, and vasopressin. She was paralyzed with cis-atracuronium since her abdomen was open. Her chest X-ray was suggestive of severe pulmonary edema. Her PaO2 was 80 on 100% O2. PEEP was increased and her tidal volumes were kept between 6-8 cc/kg. Her urine output was very low and she required higher doses of pressors. She was started on Nitric oxide without much benefit. She became increasingly harder to oxygenate and the decision was made to open her chest at the bed sites with the hope that her oygenation would improve. She was also increasingly acidotic and bicarb also was given. She also had her elevated INR corrected with 2 units of slowly infusing FFP. There was no sign of active bleeding. Her lungs looked very poorly compliant and were prominent. She was ventilated with an ambu-bag throughout the procedure. Post redo-sternotomy in the CSRU her PaO2 rose from 47 to 251. The retractor was kept in place since every time we attempted to remove it her pressures dropped. Her pressures remained around 110 with the retractor in. Two chest tubes were placed in the mediastium and lap pads and sterile towels followed by Ioban were used to cover the open wound. However, her pressure continued to drop and her oxygenation worsened as her next PaO2 came back at 35. Levophed was also started since her pressures dropped further. Her oxygenation remained poor and her blood pressure was becoming increasingly harder to keep up. Her family was at the bedside and decided on no further measures and she passed. Throughout the entire post op course the CSRU resident and the Cardiothoracic fellow were both at the bedside. The fellow was in discussion with the cardiac and ICU attendings and the vascular and transplant teams were also consulted with. Medications on Admission: Coumadin 5', Protonix 40', Vicodan prn, albuterol, ativan 2", Advair 500/50, lomotil prn, compazine prn, lasix 40-80/prn Discharge Disposition: Expired Discharge Diagnosis: IVC tumor Discharge Condition: expired Followup Instructions: none	[ "4168", "V5861", "49390" ]
Admission Date: [2146-6-5] Discharge Date: [2146-6-16] Date of Birth: [2066-9-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6169] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Ureteral stent revision History of Present Illness: Ms. [Known lastname ] is a 79-year-old woman with hx of CVA, HTN, hypothyroidism newly diagnosed Diffuse large B-Cell Non-Hodgkins Lymphoma who presents with fever, malaise, poor appetite. She recently underwent exploratory laparotomy with tumor biopsy [2146-5-25] for evaluation of a pelvic mass with placement of bilaterel ureteral stents. The surgery was complicated by acute renal failure with creat up to 2.6 from baseline 1.5 suspectedly due to ATN from ureteral obstruction although renal US revealed no clear obstruction and she was discharged [5-29] with creat improved to 1.9. She initially was feeling well but over the next 2 days developed worsening fevers, nausea w/o vomiting and decreased urine output. She continued to take all of her medications as prescribed. On the day of admission she developed a fever to 102 with night sweats on the night prior with worsening confusion and was brought to the ED. She denied cough, has mild abdominal discomfort and had no BM. She denies dysuria but did report some mild bilateral flank pain. . In the ED she was found to be in acute on chronic RF with elevated lactate to 7.6 and positive UA. Abd CT revealed left sided mild hydronephrosis with no asymmetric stranding and diffuse lymphomatous involvment of the retroperitoneum extending up the ureters and involving the renal pelvises as well. Sepsis line placed and she was started on vancomycin, levofloxacin and flagyl and given 3l NS for hydration with vital signs stable. She was also evaluated by Ob/gyn who agreed that admission to ICU for sepsis was appropriate. Past Medical History: B-cell NHL- presented with three to four months of appetite loss, nausea, and back pain. CT scan performed on [2146-5-6] revealed extensive ascites and peritoneal masses concerning for ovarian cancer. Also, noted were bilateral ureteral irregularities close to obstruction, both on the left and the right. CVA- no residual deficit R carotid artery occlusion Melanoma- (~[2140]) Left eye localized involvement, s/p proton beam tx without evidence of recurrence hypertension hypercholesterolemia hypothyroidism gout . Psurg: Appendectomy Social History: married, lived with her husband in [Name (NI) 1268] until her most recent hospitalization. No current tobacco, or illicits. Drinks 2 glasses of wine per week. smoking 20+ years ago. Not currently working. She has 6 children who live in the area and daughter in law who is a nurse. Family History: She has one cousin with history of breast cancer and daughter had renal cell cancer. Physical Exam: ED:T 102 HR 90 BP 170/85 RR 16 Vitals on Admit to ICU: T 99.0 HR 90 BP 98/65 RR 16 O2sat 98% [Female First Name (un) ] Gen:NAD, A and Ox3 HEENT:PERRL, MMdry, upper full dentures lower bridge, no elev JVP NEck:supple CV:RRR, nS1S2 no MRG PULM:fine crackles at bases bilat Abd:bilat mild CVA tenderness, severe tenderness around incision, fullness to left side of incision with no fluctuance, mild erythema along staple line Extrem:2+ rad and dp pulses, 2+ LE edema worse on left Neuro:CNII-XII intact, [6-11] UE and LE strength except for [5-12] in hip flexers bilat, distal sensation intact Pertinent Results: [2146-6-4] 08:20PM WBC-21.7# RBC-3.79 HGB-11.6* HCT-34.2* MCV-90 MCH-30.6 MCHC-33.9 RDW-15.3 [2146-6-4] 08:20PM GLUCOSE-94 UREA N-24* CREAT-2.0* SODIUM-138 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-18* ANION GAP-26* [2146-6-4] 08:20PM CALCIUM-10.9* PHOSPHATE-2.6* MAGNESIUM-1.5* [2146-6-4] 08:20PM ALT(SGPT)-12 AST(SGOT)-28 ALK PHOS-84 AMYLASE-25 TOT BILI-0.7 [2146-6-4] 11:13PM LACTATE-7.5* . CXR ([2146-6-5]): There has been interval withdrawal of the right IJ line, with the tip now in the distal SVC. The remainder of the study has not significantly changed in comparison to the prior exam. Again seen are NU stents overlying the abdomen. . CT abd/pelvis ([2146-6-5]): 1. Bilateral NU stents. Left proximal NU stent is in the proximal left ureter, and there is associated hydronephrosis. There is extensive soft tissue around both ureters, which may reflect extension of the patient's known lymphoma. Additionally, there is soft tissue stranding around the left ureter, and associated forniceal rupture cannot be excluded. 2. Extensive soft tissue in the pelvis, which likely reflects a combination of the uterus, the known lymphoma, and unopacified loops of bowel, though subacute hemorrhage cannot be excluded. The stent position is not well evaluated without IV contrast. There is extension into the retroperitoneum (including around the ureters), and extensive mesenteric lymphadenopathy. Tiny foci of air within this, and also likely small extraluminal air, likely reflect changes related to prior biopsy and recent surgery. These findings are consistent with patient's known lymphoma. 3. Diverticulosis without definite diverticulitis. 4. Small amount of fluid along the anterior abdominal wall incision. 5. Foley catheter positioned within the vagina. 6. Two pulmonary nodules, largest measuring 16 mm in the right middle lobe. . . SPINAL FLUIDS: [2146-6-13] 06:21PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-44 Monos-56 [2146-6-13] 06:21PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-84 LD(LDH)-23 . RENAL ULTRASOUND: IMPRESSION: 1. No evidence of hydronephrosis. Two tiny right renal cysts. 2. Small volume ascites. . DISCHARGE LABS: . [2146-6-16] 12:00AM BLOOD WBC-0.4* RBC-2.96* Hgb-9.2* Hct-26.5* MCV-90 MCH-31.2 MCHC-34.9 RDW-13.7 Plt Ct-97* [2146-6-16] 12:00AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-135 K-4.0 Cl-101 HCO3-30 AnGap-8 [2146-6-16] 12:00AM BLOOD ALT-13 AST-21 LD(LDH)-398* AlkPhos-51 TotBili-0.3 [2146-6-16] 12:00AM BLOOD Albumin-2.5* Calcium-7.8* Phos-2.1* Mg-1.8 Brief Hospital Course: The patient was admitted with fevers, leukocytosis, acute renal failure and hypotension. She was felt to have signs of urosepsis. She was started on broad antibiotic coverage for gram negative rods in the blood. The etiology of the patient's urosepsis is likely ureteral obstruction. CT confirmed hydronephrosis. The patient underwent a failed trial at IR placement of a percutaneous nephrostomy tube. She successfully underwent a urologic procedure with re-stenting of the ureters. The GNR's in the blood speciated to pan-sensitive E. Coli. The patient's antibiotic regimen was narrowed to ceftriaxone. Subsequent blood and urine cultures were without growth. The patient was initiated on solumedrol daily in hopes of shrinking her abdominal mass. The patient was transferred to the oncology service for likely chemotherapy. . BMT COURSE: The patient began chemotherapy on [2146-6-7]. She received cytoxan, prednisone, vincristine, and intrathecal methotrexate. She tolerated the chemo well. She developed tumor lysis syndrome which was treated with high rates of IVF and diuresis to keep her urine output up. She did not develop complications, and tumor lysis resolved. . She continued to have hematuria, the etiology of which was felt to be ureteral irritation by both the tumor mass and the several urologic procedures for stenting of her occluded ureters. Her foley catheter was pulled and she diruesed well and urinated well. Her hematocrit and coagulation studies were normal. She will be discharged with follow up with Dr. [First Name (STitle) ] to evaluate for the need for continued uretheral stenting. Any concerns of ongoing hematuria can also be addressed to him. A renal ultrasound was performed on the day prior to discharge to eval for resolution of hydronephrosis. It showed no evidence for hydronephrosis. . On discharge, her WBC was beginning to drop as expected and she began GCSF treatment. She was not febrile. She is to see Dr. [First Name (STitle) 1557] on Monday in follow up. Medications on Admission: Percocoet 5/325 mg 1-2T q4-6h Alprazolam 0.5 mg qd allopurinol 10 mg qd Lipitor 10 mg qd Nexium 40 mg qd aspirin 81 mg qd Levothyroxine 125 mcg qd clopidogrel 75 mg qd triamterene 37.5/25 qd atenolol 50 mg qd motrin prn colace 100mg [Hospital1 ] 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. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 11. Saliva Substitution Combo No.2 Solution Sig: [2-8] Mucous membrane qid () as needed for mouth sores. 12. Filgrastim 480 mcg/1.6 mL Solution Sig: Four [Age over 90 11578]y (480) mcg Injection Q24H (every 24 hours): adminitration should continue until instructed by Dr. [First Name (STitle) 1557] to d/c. 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Morphine Sulfate 2 mg IV Q4H:PRN 16. Ceftriaxone 1 g Recon Soln Sig: One (1) gram Intravenous once a day: To be discontiued when WBC counts are increased adn instructed to discontinue by Dr. [First Name (STitle) 1557]. 17. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN 10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units heparin) each lumen Daily and PRN. Inspect site every shift. 18. Ondansetron 4-8 mg IV Q8H:PRN 19. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Extended Care Facility: [Doctor First Name 533] Centre for Extended Care Discharge Diagnosis: Burkitt's Lymphoma Ureteral Obstruction Hematuria Hypertension Discharge Condition: ambulating with assist, good oxygen saturations, tolerating POs Discharge Instructions: Please take all medications as prescribed. Please attend all follow up appointments. If you develop fever, chills please contact your health care providers right away. . You had stents placed in your ureturs as they were obstructed by the tumor. This is the cause of the blood in your urine. You have a follow up appointment with the Urologist Dr. [First Name (STitle) ] in 3 months time to address the need for the continuation or removal of these stents. If have continued hematuria, problems making urine, or pain associated with decreased urine output, please contact the office of Dr. [First Name (STitle) ]: [Telephone/Fax (1) 6317] Followup Instructions: Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2146-6-20] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2503], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2146-6-20] 3:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 7614] Date/Time:[2146-6-27] 11:15	[ "4019", "2449" ]
Admission Date: [2100-12-24] Discharge Date: [2100-12-29] Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 2836] Chief Complaint: Rigors, fever, change in mental status, tachypnia and abdominal pain. Major Surgical or Invasive Procedure: ERCP [2100-12-24]. History of Present Illness: This is an 86-year-old female with dementia (non-verbal at baseline), h/o afib and PE on coumadin, hypertension, diabetes, who was admitted from [Hospital3 3583] with cholangitis. Had originally presented to [Hospital3 3583] with fever to 102 and rigors. On imaging at [Hospital3 3583], there was question of dilated CBD and possible CBD stone. Tbili at admission was 3.3 and has since climbed to 4.3. Per report from [Hospital3 3583], patient has blood culture positive for GNR. . This morning, she went for ERCP to attempt to remove the stone. She was sedated with propofol and after the ERCP scope was passed, she became hypoxic and bradycardic. The scope was promptly pulled, propofol was stopped, NRB was applied for supplemental oxygen. Patient's sats quickly recovered, though she became tachycardic to the 130s with BP climbing up to 200s/100s. She was given furosemide 20 mg IV and metoprolol 5 mg IV x 3 with HR falling to the 100s. She was noted to be diffusely rhonchorous with frothy brown secretions requiring suctioning. . The patient was admitted for further management. Past Medical History: PAST MEDICAL HISTORY: 1) Dementia, non-verbal at baseline 2) Cerebrovascular Accident 3) Diabetes 4) Atrial fibrillation 5) Pulmonary embolism 6) Hypertension 7) Osteoarthritis 8) h/o GI bleed 9) Chronic UTI 10) Chronic constipation 11) Diverticulosis Social History: Lives in nursing home. Tobacco: None ETOH: None Family History: Non-contributory Physical Exam: On Admission: VS: T 96.4, HR 109, BP 137/86, RR 21, O2Sat 92% 2L NC GEN: Awake, alert, appears comfortable HEENT: Right pupil reactive to direct and consensual light, left pupil does not react directly or indirectly, eyes track movement, patient does not participate in EOM testing, oral mucosa very dry NECK: Supple, no [Doctor First Name ] PULM: Minimal basilar crackles, no rhonchi anteriorly CARD: Irregular, nl S1, nl S2, no M/R/G ABD: BS+, soft, patient does not grimace to deep palpation, no guarding or rebound EXT: no C/C/E SKIN: No rashes NEURO: Patient non-verbal, moving all extremities with grossly normal strength and tone, though patient does not comply with full neuro exam Pertinent Results: On Admission: [2100-12-24] 12:55PM GLUCOSE-128* UREA N-32* CREAT-1.2* SODIUM-144 POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-19* ANION GAP-19 [2100-12-24] 12:55PM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.2 [2100-12-24] 12:55PM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.2 [2100-12-24] 12:55PM WBC-15.2* RBC-4.13* HGB-11.0* HCT-34.3* MCV-83 MCH-26.6* MCHC-32.0 RDW-15.0 [2100-12-24] 12:18PM TYPE-ART PO2-210* PCO2-45 PH-7.32* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED [2100-12-24] 12:18PM LACTATE-2.2* [2100-12-24] 06:35AM ALT(SGPT)-177* AST(SGOT)-228* ALK PHOS-110 TOT BILI-3.5* [2100-12-24] 12:55AM GLUCOSE-251* UREA N-35* CREAT-1.2* SODIUM-142 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 [2100-12-24] 12:55AM WBC-15.5* RBC-3.89* HGB-10.0* HCT-32.5* MCV-83 MCH-25.6* MCHC-30.7* RDW-15.0 [2100-12-24] 12:55AM NEUTS-91.6* LYMPHS-5.4* MONOS-3.0 EOS-0 BASOS-0.1 [2100-12-24] 12:55AM PT-26.9* PTT-35.0 INR(PT)-2.6* . IMAGING: [2100-12-26] CXR: Cardiac silhouette is enlarged, and interstitial edema has slightly progressed since the recent radiograph. No focal areas of consolidation. Small pleural effusions are present bilaterally. . MICROBIOLOGY: [2100-12-24] MRSA SCREEN Site: NARIS (NARE) FINAL REPORT [2100-12-26] MRSA SCREEN (Final [2100-12-26]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . [2100-12-24] Urine Cx: No Growth - FINAL. . [2100-12-24] Blood CX: No Growth to date - PRELIM. . [2100-12-25] Blood Cx x2: No Growth to date - PRELIM. . [2100-12-26] 11:28 am SWAB Source: perineal. FINAL REPORT [2100-12-28] WOUND CULTURE (Final [2100-12-28]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. RARE GROWTH. Brief Hospital Course: This is an 86-year-old female with dementia (non-verbal at baseline), history of atrial fibrillation and PE on coumadin, hypertension, diabetes, who was admitted overnight from [Hospital1 3325] with cholangitis. . [Hospital Unit Name 13533] [12-24] - [2100-12-25]: #. Hypoxia: Most likely explanation was that patient had an episode of flash pulmonary edema in setting of hypertension and tachycardia caused by autonomic surge with ERCP. The severity of hypertension and tachycardia is not surprising in setting of patient initially being bradycardic during procedure. Patient was assessed as being acutely rhonchorous with frothy brown pulmonary secretions. STAT CXR performed upon arrival to the ICU showed cardiomegaly and additionally confirms suspicion of volume overload. Patient's hypoxia quickly improved after administration of 20 mg IV furosemide and metoprolol 5 mg IV x 3. Her heart rate was controlled with metoprolol and her BP was controlled with captopril. . #. Acute cholangitis: This is reason for patient's original presentation to the hospital; ERCP was perfomed however, stone was never removed. Patient was afebrile upon admission to ICU, however, tbili was rose from 4.3 from 3.3 upon admission. Blood cultures from [Hospital3 3583] were positive for gram negative rods. Due to severity of patient's illness and the fact that stone was never actually removed (possibility for worsening infection increased), patient was continued on Zosyn throughout [Hospital Unit Name 153] course. She continued to do well, and improved both by labs and clinically. She was transferred to the floor in stable condition. . #. Atrial fibrillation: Patient was initially controlled with IV metoprolol, but transitioned to PO when clinical condition improved. On the floor, she was continued on metoprolol 25mg [Hospital1 ]. . #. Diabetes: Patient was kept on an insulin sliding scale . # Hypertension: Patient was switched from lisinopril to captorpil, as the latter is shorter acting, and more appropriate if clinical picture were to worsen. Patient tolerated captopril well, and BPs were well-controlled. . Ms. [Known lastname ] was given heparin sub-Q for DVT prophylaxis and a bowel regimen. Access was with peripheral IVs. She is DNR/DNI except for intubation for procedures. Her emergency contact person is [Name (NI) ] [Name (NI) ]: [Telephone/Fax (1) 84308] (cell- preferred); [Telephone/Fax (1) 84309] (home). Patient was transferred to the inpatient floor for further care on [2100-12-25]. . [Hospital Ward Name ] 9 COURSE: [12-25] - [2100-12-28]: The patient arrived on the floor NPO except medications, on IV fluids, with a foley catheter in place, and continued on IV Zosyn. The patient was hemodynamically stable. . Neuro: At baseline, the patient has severe dementia and is non-verbal. Mental status remained at her baseline during her [Hospital Ward Name 121] 9 course. Safet precautions remained in place. The nursing and medical staff routinely evaluated for pain; she did not require any pain medications while on the floor. . CV: Atrial fibrillation remained well controlled on Metoprolol 25mg PO BID. Also, hypertension was stable on the Metoprolol and new started Captopril. Upon admission, prophylactic Coumadin was held. Coumadin 3mg PO daily restarted on [2100-12-28]. Will need an PT/INR checked daily until again therapeutic. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: On the floor, the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . GI/GU/FEN: Post partial ERCP, the patient was NPO on IV fluids. On [2100-12-28], she was returned to her pre-hospital diet consisting of Pureed (dysphagia) regular with nectar prethickened liquids. She tolerated her diet well with good intake and no evidence of aspiration. Foley catheter was discontinued on [2100-12-28]; she subsequently voided without problem. Electrolytes were routinely followed, and repleted when necessary. As outlined above, the ERCP was aborted midway through the procedure due to the acute onset of cardio-pulmonary distress. Given that her symptoms resolved and her condition improved, another ERCP was not re-attempted due to the procedural risks. Should her symptoms return, she would most likely need to undergo another ERCP attempt. In this case, her care team should refer her back to Gastroenterology for re-evaluation. Dr. [First Name (STitle) ] (General Surgery) would welcome the patient back should she have need for a surgical consult. . ID: Upon transfer from the Outside Hospital, the patient was continued on IV Zosyn given pre-admission cholangitis and report of GNR on OSH blood culture. Blood and urine cultures performed at [Hospital1 18] have been no growth to date. On [2100-12-27], the Zosyn was discontinued, and the patient placed on a ten day course of Augmentin. While hospitalized, the patient placed on contact precautions for a positive MRSA screen. . Endocrine: The patient's blood sugar was monitored throughout his stay; NPH and sliding scale insulin was administered accordingly with stable glycemic control. . Hematology: The patient's complete blood count was examined routinely; no transfusions were required. . Prophylaxis: Upon admission, prophylactic Coumadin was held. The patient received subcutaneous heparin and venodyne boots were used during this stay. Coumadin restarted at discharge. She ambulated frequently with nursing. She was continued on a bowel regimen. . Psychosocial: Case Management and Social Work followed the patient throught the admission. Code Status at Discharge: DNI/DNR. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a her modified regular diet, ambulating with assistance, voiding with assistance, and was not experiencing any pain. She was discharged back to the Nursing Home facility, where she permanently resides. The patient's daughter received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1) Atenolol 50 mg daily 2) Glyburide 2.5 mg daily 3) Lisinopril 5mg daily 4) Novolin NPH 8 units [Hospital1 ] 5) RISS 6) Warfarin 3 mg daily 7) Colace 8) Senna 9) Remeron 15 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP <100. 5. Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Novolin N 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous twice a day. 7. Insulin Regular Human 100 unit/mL Solution Sig: 2-12 units Injection As directed per Regular Insulin Sliding Scale. 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Amoxicillin-Pot Clavulanate 250-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 days: Completion Date: [2101-1-6]. 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Baypath-[Location (un) 22287] Discharge Diagnosis: Primary: 1. Cholangitis 2. Cholodolcolithiasis 3. Dementia 4. Episode hypoxia - resolved 5. Episode Bradycardia - resolved 6. DNI/DNR Secondary: 1. Type II IDDM 2. HTN 3. Atrial fibrillation with h/o PE Discharge Condition: Mental Status:Confused - always Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-9] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [Name Initial (PRE) ]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [Name5 (PTitle) ] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [Location (un) 2831] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Please call ([Telephone/Fax (1) 84310] to arrange a follow-up appointment with Dr. [Last Name (STitle) 42310] (PCP) in [2-2] weeks. . Should your symptoms return, your physician can arrange [Name Initial (PRE) ] follow-up consult with a Gastroenterologist at [Hospital1 18]. Phone: ([Telephone/Fax (1) 451]. . Should you need a General Surgeon in the future, you may call ([Telephone/Fax (1) 8105] to arrange a consult appointment with Dr. [First Name (STitle) ]. Completed by:[2100-12-28**]	[ "9971", "5990", "2760", "42789", "42731", "4019", "25000", "V5861" ]
Admission Date: [2106-7-28] Discharge Date: [2106-8-1] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: S/P carotid catheterization with left internal carotid stent Major Surgical or Invasive Procedure: Carotid catheterization with left internal carotid stent History of Present Illness: Pt is a 80 yo male with h/o HTN, hyperlipidemia, PVD, renal failure, vertigo, and COPD who underwent carotid evaluation after having a few episodes of some transient right leg tingling as well as some dizziness.([2106-4-6] Carotid ultrasound: 71-90% stenosis of the Left ICA, <50% right ICA.) The patient presented to the [Hospital3 ] ER on [2106-5-16] with loss of conciousness. He was watching TV one evening and felt dizzy/room spinning. He lowered himself down to the floor and did not wake up again until the next morning. The patient ruled out for an MI. An echo was done which revelaed mild left ventricular hypertrophy with normal wall motion and EF of 65%. An EEG was also done and was negative. He could not give a good history regarding exactly what happened but says he has a history of dizziness. On [2106-5-31] pt underwent carotid endarterectomy and found to have high bifurcation it was felt that it would not be possible to safely clamp the distal internal carotid arteries for endarterectomy. It was decided to abort the carotid endarterectomy and refer the patient for carotid stenting. Today had catheterization of carotids with stenting to [Doctor First Name 3098]. In the cath lab he had alternating hypertension on nipride and hypotention and started on He denies CP, SOB, palpitations, visual changes, headache, dizziness. He says that he has some pain when he walks from a [Hospital Ward Name ] cyst in LLE. Denies PND, orthopnea. Past Medical History: Appendectomy COPD hypertension hyperlipidemia vertigo lumbar radiculopathy renal failure [Hospital Ward Name ] cyst on left leg PVD Meniere's disease cataract surgery BPH Social History: Lives with wife. [Name (NI) ] 4 children. Denies ETOH use. Quit smoking 30-35 years ago after smoking for about 20 years 2 PPD. Family History: Denies any CAD but he does not know his parents history and says that his brother has diabetes. Physical Exam: ROS: No dysuria, hematuria, melena, hematemesis. Physical Examination: Vitals: T 97.3 BP 128/76 HR 67 R 15 O2 sats 100% on 2 L NC General: Pleasant elderly male lying flat in bed in NAD. HEENT: no JVD, no carotid bruits CV: nl S1S2, 3/6 systolic ejection heard best at the apex Pulm: CTA b/l anteriorly Abd: normal BS, obese, soft, NT/ND Ext: 2+ dp pulses b/l, trace edema, LLE larger than R LLE Neuro: oriented to person, month and that he is in the hospital, he was unsure of which one. Knew day of week but unclear on date. Could say "no ifs ands or buts" CN II-XII grossly intact with exception of hearing loss b/l left worse than right, 5/5 strength in upper and lower extremities, sensation to light touch grossly intact throughout Pertinent Results: [2106-7-28] 10:10PM BLOOD WBC-7.2 RBC-4.49* Hgb-13.7* Hct-38.8* MCV-86 MCH-30.5 MCHC-35.4* RDW-12.4 Plt Ct-134* [2106-7-31] 07:05AM BLOOD WBC-7.2 RBC-4.33* Hgb-13.2* Hct-38.4* MCV-89 MCH-30.6 MCHC-34.5 RDW-12.9 Plt Ct-126* [2106-7-28] 10:10PM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2 [2106-7-31] 07:05AM BLOOD Plt Ct-126* [2106-7-28] 10:10PM BLOOD Glucose-119* UreaN-11 Creat-0.9 Na-141 K-4.0 Cl-103 HCO3-28 AnGap-14 [2106-7-31] 07:05AM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-27 AnGap-13 [2106-7-28] 10:10PM BLOOD Calcium-9.3 Phos-3.3 Mg-1.7 [2106-7-31] 07:05AM BLOOD Mg-1.8 [2106-7-28] CT HEAD W/O CONTRAST Reason: APHASIA.?BLEED Attending evaluation of the images identifies a small area of decreased attenuation in the left frontal lobe cortex and white matter, consistent with recent infarction. This was not reported on the initial resident interpretation, but was indicated as possible infarction by the neurologist who evaluated the patient. Additionally, there is increased density within the intracranial vasculature. Conversation with Dr. [First Name (STitle) ] on [2106-7-29] at 10:15 a.m. reveals that the patient had a procedure prior to the CT, a left carotid stent was placed and contrast was administered. Time of the procedure relative to the scan and onset of symptoms is not clear. Dr. [First Name (STitle) ] was informed of the change in the report. The patient subsequently had an MRI on [2106-7-29], at 8 a.m. and this verifies a subacute left frontal lobe infarction. The MRA does not show a vascular abnormality of the carotid, vertebral, anterior, middle, or posterior cerebral arteries. IMPRESSION: Left frontal lobe infarction, with acute appearance. Correlate with clinical signs. No acute intracranial hemorrhage. Generalized osteopenic appearance to the calvarium and base of the skull. This may be due to Paget Disease. Hyperparathyroidism would also be a consideration. Correlate with clinical history and labs. [2106-7-28] Carotid catheterization 1. Access: 6F shuttle sheath in the right common femoral artery. 2. Thoracic Aorta: Type I arch without significan lesions. 3. Carotid/Vertebral arteries: The RCCA was normal. The [Country ] had midl disease. The [Doctor First Name 3098] fills the ipsilateral ACA/MCA with contralateral filling of the ACA/MCA. The [Doctor First Name 3098] had a tubular 99% lesion with slow flow. The [Doctor First Name 3098] fills the ipsilateral MCA. 4. Successful PTCA/stenting of the [Doctor First Name 3098] with a 6-8x40mm AccuLink stent postdilated with a 4.5mm balloon with excellent results (see PTCA comments). 5. Right femoral arteriotomy site was successfully closed with a 6F angioseal closure device. FINAL DIAGNOSIS: 1. [Doctor First Name 3098] stenting. [2106-7-29] MRA BRAIN W/O CONTRAST IMPRESSION: 1. There is an area of cortical and subcortical white matter signal abnormality in the anterior left frontal lobe, which represents an infarction. Given the pattern of T2 and diffusion signal in this location, this infarction may be several hours to several days (up to 10-14 days) in age. Correlation with onset of symptoms is recommended to better establish the duration of the infarction. There are also findings to suggest a small amount of hemorrhage within the left frontal lobe infarction. Additional areas of chronic ischemia and infarction are noted in the brain. MRA of the circle of [Location (un) 431] demonstrates patency of the major branches of this circulation. Findings were discussed with Dr. [First Name (STitle) ] at 10:15 a.m. and Dr. [Name (NI) ] of neurology at 10:35 a.m. on [2106-7-29]. Brief Hospital Course: 80 yo male with h/o HTN, hyperlipidemia, PVD, renal failure, vertigo, and COPD with several TIAs found to have carotid disease now s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3098] stent complicated by anterior frontal lobe infarction with a small amount of hemorrhage with resulting expressive aphasia . 1. Carotid stenting: Patient underwent catheterization of his carotid arteries and received a Acculink stent to his left internal carotid artery. During the procedure his blood pressure was labile and had to be controlled with nipride and phenylephrine. Upon arrival to the floor the patient was alert, awake and oriented to person, place, an date. He was a bit slow with saying "no ifs ands or buts" and with calculations. His blood pressure were stable in the 130s upon arriving to the floor. The evening of the cath he began to have some word finding difficulties. Neurology was consulted and a CT head without contrast was ordered. It was read as no acute bleed. However, the neurologist read it as possible stroke in left frontal lobe and request at MRI. The patient was put on the list but could not get the study until the next morning. Early on hospital day number 2 he woke up with aphasia. He had garbled speech and seemed frustrated that he could not express himself. MRI was read as infarct in left frontal lobe with a small amount of hemorrhage. His blood pressures were maintained in the 140s and the head of his bed was kept flat. We discontinued all of his blood pressure medication in orer to maintain his SBPs in the 140s. His neurological symptoms improved within 2 days and he was scheduled to go to rehab for PT and speech therapy at [Location (un) 38]. He will need to have his antihypertensives added back slowly as to keep his SBPs >140. 2. COPD: Patient had no shortness of breath or cough. His regular inhalers were continued PRN. 3. BPH: Continue Tamsulosin HCl 0.4 mg PO DAILY 4. Meniere's disease: With significant hearing loss. No dizziness on this admission. Continued Meclizine HCl 25 mg PO BID Medications on Admission: metformin 500mg daily KCL 20meq [Hospital1 ] Prilosec 20mg daily Norvasc 10mg daily Atenolol 100mg [Hospital1 ] Clonidine 0.2mg qhs Meclizine 25mg [Hospital1 ] Flomax 0.4mg daily Lovastatin 80mg daily Centrum Silver daily Advair 250mg 1puff [Hospital1 ] prn Ecotrin 325mg daily Plavix 75mg daily Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Left internal carotid stenosis Left frontal lobe stroke Discharge Condition: Improving neurologic function, BP stable Discharge Instructions: If you have any increasing dizziness, visual changes, chest pain, shortness of breath or ant other concerning symptoms call your doctor or go to the emergency room We have held your blood pressure medications at we want to keep your blood pressure >140. When you get to rehab they may be able to start your medicines as your blood pressure allows. First they can add back atenolol 100 mg twice per day, then norvasc 10 mg once daily, then clonidine 0.2 mg qhs. Followup Instructions: You have a follow up appointment with Dr. [First Name (STitle) ] in 1 month. Call for an appointment [Telephone/Fax (1) 4023]. You will also need to schedule a carotid ultrasound prior to the appointment. Yous should make a follow up appointment with your primary care doctor Dr. [Last Name (STitle) 34561] [Telephone/Fax (1) 33330] within 1 month. Completed by:[2106-8-1]	[ "496", "4019" ]
Admission Date: [2171-2-21] Discharge Date: [2171-2-26] Date of Birth: [2110-7-25] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 60-year-old white male had an abnormal EKG and a positive stress test prior to a hernia repair. He denies having any chest pain or dyspnea. He exercises on a treadmill on a daily basis with no symptoms. He underwent cardiac catheterization at [Hospital1 190] on [2171-2-8] which revealed an ejection fraction of 58 percent, normal right coronary artery, a 60 percent left main stenosis, an 80 percent mid left anterior descending stenosis, and a 70 percent intermedius stenosis. He is now admitted for elective coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for a history of non- insulin-dependent diabetes, hypercholesterolemia, and hypertension. ALLERGIES: He has no known allergies. MEDICATIONS ON ADMISSION: Lopressor 100 mg p.o. twice daily, Univasc 15 mg p.o. twice daily, glyburide 2.5 mg p.o. once daily, metformin 500 mg p.o. once daily, Lipitor 20 mg p.o. once daily, folate 400 mg p.o. once daily, and aspirin 81 mg p.o. once daily. FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: He is married. He does not smoke cigarettes and drinks alcohol occasionally. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION ON PRESENTATION: He was a well- developed and well-nourished white male in no apparent distress. Vital signs were stable. He was afebrile. HEENT examination revealed normocephalic and atraumatic. The extraocular movements were intact. The oropharynx was benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. The carotids were 2 plus and equal bilaterally without bruits. The lungs were clear to auscultation and percussion. The abdomen was soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly with a positive hiatal hernia which was reducible. The extremities were clubbing, cyanosis, or edema. Neurologic examination was nonfocal. SUMMARY OF HOSPITAL COURSE: He was admitted, and on [2-21] he underwent a coronary artery bypass graft times three with a LIMA to the LAD, a reversed saphenous vein graft to OM2 and the ramus. He tolerated the procedure well and was transferred to the CSICU in stable condition on Neo- Synephrine, propofol, and insulin. He was extubated on postoperative night. On postoperative day one, he was transferred to the floor. On postoperative day two, his epicardial pacing wires and chest tubes were discontinued. He continued to progress. On postoperative day five, he was discharged to home in stable condition. His laboratories on discharge were a hematocrit of 28, a white count of 7300, and platelets of 248,000. Sodium was 140, potassium was 4.6, chloride was 103, bicarbonate was 30, BUN was 17, creatinine was 1.1, and blood sugar was 112. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. once daily. 2. Plavix 75 mg p.o. once daily. 3. Lipitor 20 mg p.o. once daily. 4. Colace 100 mg p.o. twice daily. 5. Lasix 20 mg p.o. twice daily (for seven days). 6. Metformin 500 mg p.o. twice daily. 7. Glyburide 2.5 mg p.o. once daily. 8. Potassium 20 mEq p.o. twice daily (for seven days). 9. Lopressor 50 mg p.o. twice daily. 10. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). DISCHARGE DIAGNOSES: 1. Hypertension. 2. Non-insulin-dependent diabetes. 3. Hyperlipidemia. 4. Coronary artery disease. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2171-2-26] 18:48:48 T: [2171-2-26] 19:16:05 Job#: [Job Number 58745]	[ "41401", "25000", "2720", "4019" ]
Admission Date: [2154-6-28] Discharge Date: [2154-7-1] Date of Birth: [2107-4-14] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: Intoxication/Hypotension Major Surgical or Invasive Procedure: none. History of Present Illness: 47F history of depression, HCV, polysubstance abuse, and longstanding prior rubbing alcohol ingestions with residual ataxia, presenting with lethargy and questionable overdose. Per report, pt was found minimally responsive at home by her sister. She was minimally responsive to sternal rub, and it is unclear how long she was like this. On arrival to the ED, systolic blood pressures were measuring in the 80's to 100's mmHg. She received 2 L NS with improvement in her mental status and was able to communicate that she ingested rubbing alcohol earlier on. In the ED, EKG showed no QT/QRS prolongation. CT head and CXR were both negative. Labs showed a normal WBC count with 40 percent PMN's, macrocytosis with HCT of 37.6, UA was negative for signs of infection with trace ketones, serum tox negative for ASA, EtOH, APAP, benzos, barbituates, or TCAs. Urine tox was positive for cocaine. Cardiac enzymes were negative. CK of 300. CMP showed creatinine of 1.2 (baseline around 0.9), no evidence of a gap. Serum OSMS were 364 with a calculated OSMS of about 288 (gap of 76). Toxicology was consulted and suggested fomepizole administration if AG present. Patient's CMP was rechecked to affirm no evidence of an anion gap, thus making ethanol or methylene glycol ingestion unlikely. Blood pressures continued to be in the high 70's to low 80's systolic. Prior to transfer to MICU, vitals were HR 80 BP 88/51 RR19 100% 2L. Blood pressure still in the 80's systolic after rec'd total 2L NS IV. Access 2 peripheral 18g. Per report pt was alert, communicating, but unclear of date. She received another 1 L NS on transit to MICU. On the floor, patient is non verbal. She opens eyes to command but otherwise is not answering questions. She can squeeze fingers. BP on arrival is 110/67. Past Medical History: Depression HCV Poor dentition Alcohol Abuse/Rubbing alcohol ingestions Cocaine/Crack abuse History of burn to back, arms, chest s/p skin graft History of stable carotid aneurysm seen on CTA [8-17] Social History: The patient is originally from [State 5170] currently lives in [Location 686]. She lives alone in an apartment, Section 8 housing, with her father nearby. She is currently unemployed and receives food stamps and financial support from her father. She has 4 children ages 16-30 who currently all live in [State 5170]. - Tobacco: 1 cigarette a day - Alcohol: Yes. Also drinks rubbing EtOH - Illicits: Crack cocaine abuse. Active. Family History: Sister and mother with DM Physical Exam: Admission Physical Exam: Vitals: T:97.1 BP:110/67 P:80 R:10 O2:100% 3L General: in fetal position on left side. Opens eyes to name. HEENT: Osciliating lateral 2 beat nystagmus with slow pendulous movement across midline. Sclera anicteric, MMM, poor dentition. Pupils reactive 4mm to 2mm BL. Neck: supple, JVP not elevated, no LAD Lungs: Non compliant with commands for inspiration. CTABL in upper lung fields b/l. Faint lung sounds throughout otherwise. 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. Large areas of burn scars on lateral thigh with skin graft scars. S/p skin graft on back and arms as well. Soles of feet with small macular hyperpigmented areas possibly c/w plantar warts. ========================================== Discharge Physical Exam: VS: 98.3/97.9 141/90 80 18 100%RA Gen: NAD, A+Ox2, gives short phrase answers or nods/shakes head. HEENT: NC/AT with areas of clearing of scalp, PERRLA, MMM, clear OP Neck: no LAD, bruits, JVD. supple Pulm: CTAB CV: tachycardic, reg rhythm, +S1/S2, no m/r/g Ab: +BS, NT/ND. Ext: no c/c/e. +1dp Neuro: non-focal. Pertinent Results: [2154-6-28] 12:30PM GLUCOSE-102* UREA N-8 CREAT-1.2* SODIUM-140 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15 [2154-6-28] 12:30PM CK(CPK)-300* [2154-6-28] 12:30PM cTropnT-<0.01 [2154-6-28] 12:30PM OSMOLAL-372* [2154-6-28] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2154-6-28] 12:30PM WBC-8.1 RBC-3.76* HGB-13.0 HCT-37.6 MCV-100* MCH-34.5* MCHC-34.6 RDW-14.4 [2154-6-28] 12:30PM NEUTS-43.2* LYMPHS-52.7* MONOS-2.4 EOS-0.6 BASOS-1.1 [2154-6-28] 12:30PM PLT COUNT-343 [2154-6-28] 12:30PM PT-13.1 PTT-30.7 INR(PT)-1.1 [2154-6-28] 01:25PM URINE UCG-NEGATIVE [2154-6-28] 01:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2154-6-28] 01:25PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2154-6-28] 01:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG CT Head: IMPRESSION: No acute intracranial process. . CXR: IMPRESSION: No acute cardiopulmonary process. . Echo ([2154-6-29]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Brief Hospital Course: 47 F history of HCV, polysubstance abuse (crack cocaine, EtOH, prior rubbing alcohol ingestions with residual ataxia & ?cognitive decline), p/w lethargy and hypotension, likely [12-26] to OD, clinically improved & stable, back to baseline. . #Hypotension: Patient's BP improved to 100's systolic after receiving 3 L NS in the ED. Differential includes hypovolemia in setting of toxin ingestion and poor po intake or secondary effect of toxin as a CNS depressant. Other concerns are cardiomyopathy and depressed CO in the presence of frequent crack cocaine abuse. There was no evidence of infection or decompensated liver disease based on laboratory data. Patient had no signs of decompensated heart failure and TTE was WNL, EF>55%, no structural disease. . #Isopropanol Alcohol Ingestion: Isopropanol ingestion was most likely cause of elevated osmolal gap in absence of anion gap acidosis. Osmolal gap continued to diminish with subsequent measurements (83->69->47). Absence of anion gap makes ethylene glycol/methylene glycol ingestion unlikely, and patient was ethanol negative on tox screen. Isopropyl alcohol ingestion may also cause non-cardiogenic pulmonary edema and gastritis, but repeat CXR did showed no effusion/pulmonary edema. GI prophylaxis with pepcid per toxicology recommendations were given during her hospital stay. . #HCV: LFTs and albumin were checked and were unremarkable. . # PNA vs aspiration pneumonitis: Repeat CXR ([2154-6-29]) shows "possible developing left basilar infiltrate," but throughout entire admission, patient did not develop any s/s of SOB, cough, CP, fever, or any other concerning s/s of infection. . # Depression/Substance abuse: pt stated that she wasn't interested in quitting or treating substance abuse but after family visit yesterday, became more interested in seeking help. When psychiatry and social work saw her, she regressed a bit and was precontemplative. She was given a list of local NA and strongly encouraged to call her PCP should she change her mind and want to enter into a detoxification center. Will continue her Citalopram as outpatient. . #Code status: full. . . . Pending tests: none. . Transitional issues: -Patient denied any immediate care/support for substance abuse treatment. PCP should revisit this issue to see if patient has moved past precontemplative stage. Medications on Admission: Citalopram Folate MV Thiamine Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital ] Health Systems Discharge Diagnosis: Isopropanol Alcohol Ingestion/Overdose Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at the [Hospital1 771]. You were admitted to the hospital after suffering an overdose from drinking rubbing alcohol. You were found to be unsteady and lethargic, and we had to treat you with aggressive intravenous fluids. You recovered well and was transferred from the Intensive Care Unit to the Internal Medicine service. Psychiatry and Social workers saw you as well, and we all believe that you would benefit from going to a rehabilitation center or detoxification center when you feel ready to do so. In the mean time, we would strongly encourage you to stop drinking rubbing alcohol, smoking crack cocaine, or using other illicit drugs as they endanger your life. Should you change your mind at any time, please call your PCP ([Last Name (LF) ],[First Name3 (LF) ] A. [Telephone/Fax (1) 7976]) and arrange to go to a detoxification program and address your substance abuse. Followup Instructions: You have the following appointments: Department: NEUROSURGERY When: THURSDAY [2154-7-18] at 1 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 7746], MD [Telephone/Fax (1) 3666] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital1 7975] INTERNAL MEDICINE When: THURSDAY [2154-8-1] at 3:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "486" ]
Admission Date: [2184-9-22] Discharge Date: [2184-9-28] Date of Birth: [2184-9-22] Sex: M Service: Neonatology HISTORY: This is an Interim Summary covering [9-22] to [2184-9-28]. This patient is an 1160 gram twin B product of a 26 [7-5] gestation born to a 22 year old gravida IV, para III woman whose pregnancy was uncomplicated until four days prior to delivery when she developed preterm labor and vaginal bleeding. She was transferred to the [Hospital1 190] for further management. She was treated with magnesium sulfate, ampicillin and Flagyl. She was given one dose of betamethasone and had rupture of membrane just prior to delivery. Fluid was clear. There were no risk factors for infection. He was delivered by cesarean section for breach positioning of both twins. Prenatal screens were A positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune and unknown GBS. At delivery the infant emerged with poor respiratory effort. He responded to bag mask ventilation and the heart rate remained above 100. He was given CPAP in the Delivery Room. Apgars were 6 and 8. He was brought to the Newborn Intensive Care Unit from the Delivery room. At that time he was intubated and given surfactant. PHYSICAL EXAMINATION: The infant was 1160 grams, was pink and nondysmorphic. He did not have any bruising. He had moderate retractions but with little air entry. His heart was regular rate and rhythm without murmurs. His abdomen was benign. His genitalia was normal. His neurologic examination was age appropriate. HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant was initially intubated and given surfactant times two. He was quickly weaned to CPAP where he continued to require oxygen. On day of life day number two because of increasing oxygen need a chest x-ray was obtained which showed a normal thorax on the right with tension. At this time the pneumothorax was needled and evacuated of a large amount of air but air continued to be evacuated and at that time a chest tube was placed on the right. A follow up chest x-ray showed that the pneumothorax was evacuated and he quickly was down on oxygen. He had been intubated for this procedure. In addition on day of life 3 he was quickly weaned off the ventilator to room air by day five. The chest tube was pulled after three days and the air leak had resolved. Follow up chest tube has been removed does not show any recurrence of the pneumothorax. He remains of caffeine for apneic and bradycardic spells of which he has had none and he remains on room air quite comfortable. The chest tube site is covered with a dressing. Cardiovascular: The infant initially had a murmur on day of life three and has had two echocardiograms in the first six days of life which both of which have shown very small PVA. Even though he has a loud murmur today his murmur has decreased significantly and his pulses are normal. He has had no problems with [Name2 (NI) ] pressure. Fluid, electrolytes and nutrition: The infant was initially NPO and started on intravenous fluids. He was started on peripheral nutrition his first hospital day. He started on feeds by day of life two but when he developed the pneumothorax these were held. Consequently he was restarted on feeds on day of life five and has been advancing slowly. His electrolytes have remained stable without concerns and will be followed. Gastrointestinal: The infant has had hyperbilirubinemia off and on. Phototherapy was restarted today for a bilirubin of 6.4 and this will be followed in the morning. Hematology: He has had a hematocrit of 40 on his first hospital day and this will be followed subsequently. Infectious Disease: The infant was started on Ampicillin and gentamicin for the first two days of life. After [Name2 (NI) ] cultures were negative he was taken off these antibiotics. Neurology: The infant will have a head ultrasound on day of life eight, which is this Thursday. INTERIM DIAGNOSES: 1. Prematurity. 2. Respiratory disease syndrome. 3. Pneumothorax. 4. Hyperbilirubinemia. 5. Rule out sepsis. DR [Last Name (STitle) 37692] [Name (STitle) 37693] 50.454 Dictated By:[Last Name (NamePattern1) 57691] MEDQUIST36 D: [2184-9-28] 16:26:30 T: [2184-9-28] 18:08:26 Job#: [Job Number 49403]	[ "7742" ]
Admission Date: [2145-10-29] Discharge Date: [2145-11-9] Date of Birth: [2066-12-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Colon polyp with high grade dysplasia. Major Surgical or Invasive Procedure: s/p Right laparascopic colectomy s/p Electrical cardioversion History of Present Illness: Mrs. [Known lastname 31738] is a 78yo female with a h/o AFIB c/b embolus to L arm, s/p cardiac ablation, s/p pacemaker, HTN, CRI. She underwent routine colonoscopy and extensive flat polyp at hepatic flexure seen. Biopsy showed adenoma with some dysplastic features. This is not amenable to resection via the endoscope. The patient was given her options and wished to have surgical treatment at this point in time, via laparoscopic approach. Past Medical History: PMH: Paroxysmal A. fib h/o embolus to L arm s/p cardiac ablation s/p pacemaker placement [1-15] sick sinus syndrome HTN CRI PSH: s/p hysterectomy Social History: Lives alone. Supportive daughter. Denies use of ETOH, tobacco, and illicit drugs. Family History: Non contributory No history of cardiac disease No diabetes Physical Exam: VS - 98.0 130/82 hr 98 (100-130s) 98% ra I/O @ MN - + 1200; I/O @ noon today + 1100 Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no JVD CV: irreg irreg. normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, mildly tender over sugical scars; purple band of eccyhomoses on lower abdomen; OBSESE. + bowel sounds. surgical incisions covered w/ steri strips, healing well, c/d/i. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: IMAGING: CHEST (PA & LAT) [2145-10-31] 5:45 PM [Hospital 93] MEDICAL CONDITION: 78 year old woman with s/p R lap colon HISTORY: Elevated white count. IMPRESSION: PA and lateral chest compared to [2140-11-9]: Mild cardiac enlargement, with substantial left atrial enlargement, accompanied by mild vascular engorgement but no edema, new since [2139]. Pleural effusion, if any, is minimal. Transvenous right atrial and right ventricular pacer leads are continuous from the right pectoral pacemaker. No pneumothorax. Supine intact. . ABDOMEN (SUPINE & ERECT) [2145-11-1] 8:42 AM [Hospital 93] MEDICAL CONDITION: 78 year old woman with polyps s/p Right Lap colon REASON FOR THIS EXAMINATION: Complaints of nausea. Rule out obstruction. HISTORY: Nausea, evaluate for obstruction. IMPRESSION: Findings highly suspicious for mid-distal small bowel obstruction. LABS: [2145-11-5] 01:30PM BLOOD WBC-8.0 RBC-3.32* Hgb-10.1* Hct-29.6* MCV-89 MCH-30.3 MCHC-33.9 RDW-15.7* Plt Ct-271 [2145-11-4] 05:47PM BLOOD Neuts-65.7 Lymphs-25.8 Monos-6.5 Eos-1.8 Baso-0.1 [2145-11-5] 01:30PM BLOOD Plt Ct-271 [2145-11-5] 01:30PM BLOOD PT-24.0* PTT-30.6 INR(PT)-2.3* [2145-11-5] 02:41AM BLOOD Glucose-106* UreaN-29* Creat-1.6* Na-137 K-3.6 Cl-100 HCO3-30 AnGap-11 [2145-11-5] 02:41AM BLOOD CK(CPK)-57 [2145-11-4] 05:47PM BLOOD CK(CPK)-66 [2145-11-4] 09:40AM BLOOD CK(CPK)-65 [2145-11-4] 03:15AM BLOOD CK(CPK)-69 [2145-11-3] 08:35PM BLOOD CK(CPK)-87 [2145-10-30] 06:05PM BLOOD CK(CPK)-338* [2145-11-5] 02:41AM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-4] 05:47PM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-4] 09:40AM BLOOD CK-MB-NotDone cTropnT-0.17* [2145-11-4] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.17* [2145-11-3] 08:35PM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-5] 02:41AM BLOOD Calcium-7.3* Phos-4.7# Mg-2.0 Brief Hospital Course: Mrs. [Known lastname 31738] underwent a right laparoscopic colectomy [2145-10-29] without complications. Subsequently she developed atrial flutter with rapid ventricular response and was transferred to [Hospital Unit Name 196] service. . # Adenoma w/ atypia Patient underwent right laproscopic ileocolectomy for adenoma that was not amenable to resection via colonoscopy. She tolerated the procedure well. Post-operatively she developed an ileus however soon thereafter she tolerated clear and then full diet. Her bowel function also normalized as well. . # Atrial fibrillation / Flutter Patient has known hx of aflutter / fibrillation. She underwent right sided aflutter ablation in [2138]. On post-op day 5 she entered what was considered left sided atrial flutter with RVR to 120-140s. EP was consulted and her HR was controlled initially w/ IV nodal agents. She was subseqeuntly transferred to the [Hospital Unit Name 196] service for afib/flutter management. She was treated with amiodarone, digoxin and metoprolol, and finaly underwent successfull electrical cardioversion . . # Troponin Elevation In the setting of aflutter w/ RVR her CE's were checked. Troponin reached peak 0.17 despite flat CKs. In the setting of somewhat decreased GFR, the trop elevation was considered secondary to demand ischemia. She was chest pain free during the episodes and EKG showed aflutter w/o ekg changes. . # Hypothyroidism Home dose levothyroxine was continued. . # COPD Patient experienced baseline SOB, worse w/ ambulation. She has known hx of COPD, w/ worsened PFT's most recently in [Month (only) 216] [2144]. Inhalers were initially deferred, especially given lack of bronchodilation on PFTs. She was counseled to follow up w/ her pulmonologist. . # Anemia: most likely anemia of chronic disease, no source of bleed, and HCT stable with normal B12/folate and iron. Medications on Admission: Fosamax 70mg q/week Spironolactone 25mg qday Synthroid 75mg qday Cozaar 50mg qday Amiodarone 100mg qday Lasix 80mg qday Coumadin 3.5 2xweek, 5mg 5x week Lipitor 20qday Toprol 50mg qday Biotin Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): this is ongoing Amiodarone after she tapered 400 to 200 too 100 mg daily. Disp:30 Tablet(s)* Refills:2 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 5. Levothyroxine 50 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 8. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: please start with this dose after discharge and continue for seven days, then 200 mg for seven days, then 100 mg. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: continue after 400mg course finished for seven days then 100 mg. 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): decrease dose for SBP <90. 16. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: 1. colon adenoma 2. Colectomy 3. Post-op ileus 4. Atrial fibrilation 5. Hypertension 6. Obstructive sleep apnea 7. Sick sinus syndrome 8. Chronic diastolic dysfunction 9. Cervical spondylosis 10. left meralgia paresthetica Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) ] in [1-16] weeks. 2. Please follow-up with PCP, [Last Name (NamePattern4) ].[First Name (STitle) 971] [Last Name (NamePattern4) 92972],[Telephone/Fax (1) 3393] in 1 week or as needed. 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2145-12-29] 2:30 4. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2145-12-29] 3:00	[ "496", "4280", "4019", "42731", "2449" ]
Admission Date: [2112-7-2] Discharge Date: [2112-7-11] Service: GREEN GENERAL SURGERY HISTORY OF PRESENT ILLNESS: This 81-year-old elderly lady underwent an open cholecystectomy and common bile duct exploration for type I Mirizzi syndrome three weeks prior to admission. On [2112-7-1], one day prior to admission, she had a normal T-tube cholangiogram without antibiotic coverage. She was seen by Dr. [Last Name (STitle) 519] in his office and approximately two hours later removed the T-tube without incident. After the removal of the tube, the patient developed progressive nausea and chills and right sided abdominal pain as reported by her daughter. She presented to the [Hospital6 256] Emergency Department hypotensive to 80s systolic and acidotic leading to intubation and institution of pressor support. Her white count at the time of admission was 12 with a total bilirubin of 3.6. AST and ALT were both above 500 with an alkaline phosphatase of 334. Her amylase and lipase were both in the normal range. On examination at the time of admission, Mrs. [Known firstname 524] [Name (STitle) 525] abdomen was soft with mild right upper quadrant guarding. CT examination showed no collection and a mildly dilated common bile duct. Ascending cholangitis secondary to seeding at the time of cholangiogram with stricture at the T-tube site with or without a retained stone was the diagnosis. PAST MEDICAL HISTORY: 1. Hypertension 2. Breast cancer 3. High cholesterol 4. Diabetes mellitus 5. Hypothyroidism 6. Multinodular goiter PAST SURGICAL HISTORY: Breast lumpectomy in [2103] and a thyroidectomy in [2106]. HOME MEDICATIONS: 1. Atenolol 2. Glyburide 3. Synthroid 4. Lipitor 5. ASA HOSPITAL COURSE: On [2112-7-3], Mrs. [Known lastname 526] was admitted to the Surgical Intensive Care Unit for close management of her respiratory, cardiovascular and infectious status. She was seen by the ERCP service/fellow and she received an emergency MRCP for ascending cholangitis. This study showed altered papilla anatomy, dilated common bile duct and question of common hepatic duct stricture. There was no small leak at the site of the cystic duct/T-tube track. The ERCP resulted in 10 cc of purulent aspirate and a 10 French x 8 cm stent was placed. After this procedure, Mrs. [Known lastname 526] continued to be monitored closely in the Intensive Care Unit where her cardiovascular status was monitored using a Swan-Ganz catheter. By hospital day #3, Mrs. [Known lastname 526] was showing clinical improvement from her ascending cholangitis. On this day, she started to wean off the ventilator and her white count declined to 5.7. The rest of Mrs.[Known lastname 527] Surgical Intensive Care Unit course was characterized by progressive weaning from the ventilators and from dobutamine and other medications used to support her cardiovascular status. Intravenous antibiotics consisting of Flagyl, ceftriaxone and ampicillin were continued. The patient was extubated on [7-7] and on [2112-7-9] she was transferred to the patient floor out of the Intensive Care Unit and placed on Levaquin. Her status continued to stabilize and improve on the floor and her condition at the time of discharge was very good. DISCHARGE STATUS: Very good DISCHARGE DIAGNOSIS: Ascending cholangitis Per consultation with the physical therapy service, discharge of the patient to a rehabilitation center was suggested, as the patient lived alone and would not be able to, at the time of discharge, successfully complete all of her necessary activities of daily life. FOLLOW UP PLANS: Dr. [Last Name (STitle) 519] and this should be done in two weeks after discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern1) 528] MEDQUIST36 D: [2112-7-11] 10:36 T: [2112-7-11] 10:55 JOB#: [Job Number 529]	[ "2762", "51881", "25000", "2449", "4019" ]
Admission Date: [2135-7-1] Discharge Date: [2135-7-21] Date of Birth: [2135-7-1] Sex: M Service: NB HISTORY: This is a premature male infant born at 32-6/7 weeks gestation delivered by C- section due to breech presentation and oligohydramnios to a 42-year-old G3, para 0, 1 mom. PREGNANCY HISTORY: Prenatal labs were as follows: 1) O+/antibody negative, 2) Hep-B surface antigen negative, 3) RPR nonreactive, 4) rubella immune, 5) HIV negative, 6) GBS unknown. The EDC was [2135-8-20]. Pregnancy complicated by oligohydramnios noted during third trimester, with worsening amniotic fluid index of 2.9 on [2135-6-30]. Prenatal ultrasound noted hydronephrosis bilaterally, mild. Poor placental function was suspected by the Ob/Gyn team, and estimated fetal weight on [6-21] was [2056] grams, reassuring fetal status, and mom received betamethasone x2 at that time. No history of contractions or vaginal bleeding. Decision for elective C-section was based on worsening oligohydramnios and breech presentation. Patient was delivered via C-section with nuchal cord x1, and had initial Apgar scores of 9 and 9. Was transferred to the NICU with respiratory distress, grunting and mild retractions. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Temperature 98.6, pulse 140-160, respiratory rate 30-40 requiring 80% oxygen to maintain saturations greater than 95%, blood pressure 60/39, mean of 46, and dextrose was 21 on admission. Birthweight was 2,500 grams, length 46 cm, and head circumference 32.5 cm. GENERAL: Baby was [Name2 (NI) ] in color, alert and active, in mild respiratory distress. HEENT: Nondysmorphic, AF soft and flat, no caput, a red reflex bilaterally, and intact palate. SKIN: Nevus flammeus on forehead and nape of neck and bruise over left shoulder, multiple small bruises over the back, with nuchal hair over temples and arms. Warm skin. HEART: Regular rate and rhythm, no murmur. Good pulses. RESPIRATORY: Coarse rhonchi, grunting, subcostal retractions and tachypnea. ABDOMEN: Soft. No masses. Good bowel sounds. Three-vessel cord. No hepatosplenomegaly. GENITALIS: Patent anus and normal male genitalia with testes descended bilaterally. EXTREMITIES: Intact clavicles. Stable hips. Spine straight. No defects. Moving all extremities bilaterally with good tone. HOSPITAL COURSE: On admission, the patient was placed on antibiotics, amp and gent, for rule out sepsis, and labs were obtained. 1. RESPIRATORY SYSTEM: The patient started on nasal cannula, and on [7-3] required intubation for poor ventilation and hypercarbia. Patient was treated with 2 doses of surfactant and remained intubated until [7-4], when he was extubated to CPAP with follow-up gas which showed pH 7.39/39/57. The patient was on room air from [7-5] to the present time, breathing 40s-60s, with no retractions and no apneic episodes, and is currently stable. 2. CARDIOVASCULAR: Patient has remained cardiovascularly stable throughout the entire hospital course. There has been no murmur documented. Blood pressures have been stable. There was no hypertension. Currently, heart rates range from 130s-150s, and the latest blood pressure was from [2112-7-19]/45, mean of 56. 3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was started on D10 water requiring a bolus due for hypoglycemia, which improved rapidly with blood sugars of 80, 109, 78, 60, and has been stable ever since. Patient remained n.p.o. until day of life 4, on [7-5], when was started on breast milk. The latest electrolytes have been normal. On [7-4], sodium 140, potassium 3.1, chloride 106, bicarbonate 26, BUN 5, creatinine 0.4. A follow-up BUN and creatinine were 17 and 0.2 on [7-15]. Discharge weight - 2835 grams 4. GI: The patient began feeding on [7-5], partially fed by tube and partially p.o., which continued until [7-18], when the baby began to take all feeds by mouth p.o. to make a total of 167 cc/kg/D p.o. ad. lib feeding. The diet is breast milk 24 cal/oz, supplemented with Enfamil powder 4 kcal/oz. The patient seems to be tolerating feedings very well and has progressed successfully. 5. HEMATOLOGY: The patient initially had a CBC which was as follows: 13.6 white count, hematocrit 43%, platelets 273, neutrophils 32, bands 2, lymphocytes 56. Patient has not required any transfusions during this hospital stay. 6. HYPERBILIRUBINEMIA: On [7-7], bilirubin was 13.9 and direct was 0.3. Patient was started on single-phototherapy which was continued until [7-9], when it was discontinued. Follow-up bilirubin was 5.4 with a direct of 0.2 and stable. 7. SKIN: The patient has had a diaper dermatitis since [7-12], being treated with Criticaid and zinc oxide, and Criticaid has been discontinued, and currently the baby is having barrier protection with Desitin. 8. INFECTIOUS DISEASE: On admission, the patient was started on amp and gent which was discontinued after 72 hours. Blood cultures were negative. Mother was being treated empirically for presumed yeast infection of her breasts with po antifungals. The baby was started on 2-day course of prphylactic Nystatin. No thrush was visualized in the child's mouth. Otherwise, the baby has been infection-free during the newborn stay. Temperature was stable since [7-12] when the baby was transferred from an isolette to a crib and has maintained stable temperatures since that time. 9. RENAL: The patient had a renal ultrasound on [7-18] which was a follow-up showing mild left hydronephrosis, otherwise normal right kidney and bladder. No prophylaxis was deemed necessary at this time. Patient can follow-up as per pediatrician. 10. NEUROLOGY: The patient is neurologically stable and has had no problems since birth. Patient has not required any head ultrasounds during this admission. Hearing screen with auditory brainstem responses was passed in both ears. Hepatitis B vaccine was given on [7-9]. State screen was sent. Car seat test passed. CPR class was taken by parents. DISCHARGE CONDITION: Good. Weight on the day of discharge 2835 grams. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 60051], MD, [Hospital 620] Pediatrics, phone# [Telephone/Fax (1) 37814], and the patient has a follow- up appointment on [Last Name (LF) 2974], [7-22], and [Hospital6 1587] will be going to the house probably Saturday. DISCHARGE MEDICATIONS: 1. Tri-Vi-[Male First Name (un) ] 1 ml p.o. once daily. 2. Status post nystatin for 2 days. 3. Desitin. Recommendations: 1. Baby should have a follow-up renal ultrasound at 1 month of age. 2. Because of prematurity and initial respiratory disease would recommend consideration of treatment with RSV prophylaxis with Synagis in the RSV season - [Month (only) ] through [Month (only) 547]. It is also recommended that careproviders receive the Influenza vaccine this fall. DISCHARGE DIAGNOSES: 1. Prenatal hydronephrosis - follow up mild residual unilateral hydronephrosis. 2. Prematurity. 3. Respiratory distress syndrome, resolved. 4. Sepsis ruled out. 5. Hyperbilirubinemia, status post. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(1) 37238] Dictated By:[Last Name (NamePattern1) 61253] MEDQUIST36 D: [2135-7-21] 08:15:30 T: [2135-7-21] 11:51:58 Job#: [Job Number 63752]	[ "7742", "V290" ]
Admission Date: [2113-7-2] Discharge Date: [2113-7-11] Date of Birth: [2113-7-2] Sex: F Service: NB HISTORY: Baby Girl [Known lastname ] [Known lastname 9035] delivered at 29 2/7 weeks gestation weighing 1210 grams and was admitted to the newborn Intensive Care Unit for management of prematurity. Mother is a 33 year-old gravida II, para I, now II woman with estimated date of delivery [2113-9-15]. Her prenatal screens included blood type A positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative, and group B strep unknown. The pregnancy was complicated by uterine septum. Maternal history notable for a left cystic renal mass. Obstetrical history notable for a previous cesarean section. The mother presented to [Hospital3 38285] three days prior to delivery with spontaneous rupture of membranes. She was transferred to [Hospital1 346] for further management. She was treated with a complete course of Methasone and received antibiotics consisting of Keflex and erythromycin. Due to progressive labor [Known lastname ] was delivered by repeat cesarean section. [Known lastname ] was vigorous at delivery with Apgars of 8 and 9. She was transferred to the newborn intensive care nursery with free flow O2. PHYSICAL EXAMINATION: On admission weight 1212 grams (50th percentile), length 37 cm (30th percentile), head circumference 26 cm (25th percentile). On examination a vigorous preterm female, pink with some free flow oxygen, minimal distress. Anterior fontanelle soft, flat. Nondysmorphic, intact palate, fair to good aeration. Mild retractions. Clear breath sounds. No murmur, normal pulses. Soft abdomen, three vessel cord. No hepatosplenomegaly. Normal preterm female genitalia with a small vaginal tag. Patent anus. No hip click. No sacral dimple. Normal tone for age. Vigorous. Moves all extremities equally. Good perfusion. Ruddy pink color. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: She was placed on continuous positive airway pressure without supplemental oxygen on admission for respiratory distress. She weaned off continuous positive airway pressure to nasal cannula for flow, no supplemental oxygen around 18 hours of life. She weaned off the nasal cannula at 48 hours of life. She has remained in room air since with comfortable work of breathing. Her respiratory rate ranged in the 40s to 60s. [Known lastname ] was started on caffeine citrate on day of life 3 for apnea of prematurity and she remains on caffeine citrate at the time of transfer receiving about 7 1/2 mg/kg per day. She continues to have several brief apnea and bradycardia episodes per day. CARDIOVASCULAR: [Known lastname ] has been hemodynamically stable throughout her hospital stay with her heart rate ranges in the 140s to 160s. No murmur. Recent blood pressure 69/45 with a mean of 51. FLUIDS, ELECTROLYTES AND NUTRITION: She was initially NPO. She was initially maintained on D10 amino acid solution on first day of life and then placed on parenteral nutrition. Enteral feeds were started on day of life 2 and she advanced to full volume feeds on day of life 7 without problems and her IV fluids were discontinued. Metabolic acidosis was noted on day of life 3 on her electrolytes and blood gas which was treated with increasing her acetate and her parenteral nutrition. Her lowest carbon dioxide on her electrolytes was 11 on day of life 4. On day of life 6 her electrolytes showed a sodium of 134, potassium 6.3 hemolyzed, chloride 105 and CO2 of 18. She has repeat electrolytes pending on [2113-7-11]. At time of discharge her feeds are expressed breast milk with human milk fortifier to equal 24 calories per ounce at 150 ml per kilo per day with the plan to go up to 24 calories per ounce. DC weight is 1150 grams down 10 grams from the day previously. Lytes from [7-11] show a Sodium 133, K 6.1 HCO3 19. GASTROINTESTINAL: [Known lastname ] was started on phototherapy on day life 2 for a bilirubin total of 6.3, direct .3. Phototherapy was discontinued on [2113-7-9] for a bilirubin of total of 3.5, direct .3. A rebound bilirubin was done on [2113-7-10] and was total 4.3, on direct .2. A bilirubin from [2113-7-11] is 5.9 up from4 range the day previously. HEMATOLOGY: Her hematocrit on admission was 43%. She has not received any blood products during this hospital stay. INFECTIOUS DISEASE: Due to respiratory distress and prolonged preterm rupture of membranes a CBC and blood culture was drawn on admission and [Known lastname ] was started on ampicillin and Gentamicin. She received 48 hours of ampicillin and gentamicin and antibiotics were discontinued. Her CBC on admission showed a white count of 7.7 with 15 polys, 1 band, platelets 411,000. NEUROLOGY: Head ultrasound was done on day of life 5 and was normal. SENSORY: Hearing screening has not been performed and will need an examination to evaluate her retinal vessels when she is about 32 weeks corrected age. CONDITION AT DISCHARGE: A 9 day old former 29 [3-27] week preterm infant, stable on room air, advancing on calories. DISCHARGE DISPOSITION: Transfer to [Hospital3 ]. Name of pediatrician is not known but plans to have care at [Hospital 246] Pediatrics. CARE AND RECOMMENDATIONS: 1. Feeds: Breast milk with human milk fortifier 2 calories per ounces with plans to increase the human milk fortifier to 4 calories per ounce. 2. Medications: Caffeine citrate 9 mg by gavage once a day. Recommend iron and vitamin E. 3. State Newborn screen was sent on [2113-7-5] and is pending. 4. Has not received any immunizations. DISCHARGE DIAGNOSES: 1. AGA 29 [3-27] week preterm female. 2. Transitional respiratory distress, resolved. 3. Indirect hyperbilirubinemia. 4. Perinatal sepsis ruled out. 5. Metabolic acidosis, resolved. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2113-7-10] 14:55:30 T: [2113-7-10] 16:38:06 Job#: [Job Number 61534]	[ "7742", "V290" ]
Unit No: [Numeric Identifier 75868] Admission Date: [2113-1-4] Discharge Date: Date of Birth: [2113-1-4] Sex: F Service: NB HISTORY: Girl [Known lastname 75869] was born at 28 5/7 weeks' gestation to a 29-year-old G2, P0-now 2, blood type B+, antibody negative, HBsAg negative, rubella immune, RPR nonreactive, GBS unknown, beta complete and was conceived via IUI-assisted di-di twins. The pregnancy was complicated by cervical shortening (a cerclage was put in at 18 weeks.), gestational diabetes (on insulin), polycystic ovary syndrome, and rupture of membranes on [2113-1-3]. The patient was born by c- section and was the first twin. The second twin was breech. Apgars were 4 and 8. The reason for delivery was progression of labor. There was no maternal fever. The infant emerged with a weak cry, but then became apneic and required positive pressure ventilation with a heart rate of less than 100 initially, which improved. The patient was intubated with a 2.5 ET tube at approximately 4 minutes of life. The infant was admitted to the NICU. DISCHARGE PHYSICAL EXAMINATION: Vital Signs: Weight was 3310 g (55th percentile); length 50.5 cm (75th percentile); head circumference 36 cm (75th percentile). General: Comfortable in open crib; alert; no apparent distress. HEENT: Palate intact; good suck; anterior fontanelle open, soft, and flat; normocephalic; red reflex present bilaterally; no obvious strabismus. Respiratory: Clear to auscultation bilaterally; no wheeze or rhonchi. Cardiac: Regular rate and rhythm; S1; S2; no murmur. Abdomen: Soft; nontender; nondistended; no mass; no organomegaly; positive bowel sounds. GU: Normal female. Extremities: Warm; well-perfused; moved all 4 extremities spontaneously; good pulses; negative Barlow, Ortolani, and Galeazzi signs. Spine: Straight; no lesions; very small, pigmented, lumbar nevi; sacral dimple - bottom easily visible. Neurologic: Alert; active; good tendon reflexes; no focal deficits. SUMMARY OF HOSPITAL COURSE: 1. Respiratory: The patient initially became apneic and required intubation. The patient was intubated with a 2.5 ET tube and remained intubated until day of life 2 when she was extubated to CPAP and remained in CPAP until day of life 5 at which time the patient was continued on room air till discharge. She was on caffeine until the end of [Month (only) 1096] when it was discontinued secondary to tachycardia. The patient did have occasional apnea and bradycardic spells which required several spell countdowns. She was without apnea or bradycardia for 5 days prior to her diacharge. 2. Cardiovascular: No pressors were necessary to maintain blood pressure. A UVC was placed on day of life 0, but was removed on day of life 3. 3. Fluids, Electrolytes, and Nutrition: The patient was started on parenteral nutrition on day of life 1, was started on PG feeds on day of life 3, and was on all PG feeds by day of life 10, after which the parenteral nutrition was discontinued. She began p.o. feeds on day of life 38 and was on all p.o. feeds by day of life 54.She was discharged home on Enfacare 24 kcal/oz formula and she demonstrated good weight gain on that formula. 4. GI: The patient required phototherapy for 3 days for a max bilirubin of 6.4. 5. Hematology: The patient suffered some anemia during her course in the NICU. On [2113-1-30], the patient had a hematocrit of 28.7, but the retic count was 18.8. No transfusion was given. On [2113-2-6], CBC was rechecked, with a hematocrit of 33.6%. There was no further anemia throughout the hospital course. The patient was on iron and vitamin E. Vitamin E was discontinued at discharge. 6. Infectious Diseases: Shortly after delivery, the patient had cultures, which were negative, and she required rule- out sepsis with 48 hours of ampicillin and gentamicin. 7. Neurology. The patient had 2 normal head ultrasounds - one on [2113-1-12] and one on [2113-3-4]. 8. Sensory/Audiology: Hearing screen was performed with automated auditory brain stem responses. Results were normal in both ears. 9. Ophthalmology - mature: The eyes were examined most recently on [2113-2-27], and a follow-up exam is recommended in 9 months. 10.Psychosocial. [Hospital1 18] social work was involved with the family. The contact social worker can be reached at [Telephone/Fax (1) ]. Follow-up will be provided if desired. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY CARE PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 72876], MD (phone number [Telephone/Fax (1) 42721]; fax number [Telephone/Fax (1) 75870]). CARE & RECOMMENDATIONS: 1. Feeds: The plan was to continue EnfaCare 24-calorie feeds until 6 to 9 months of age (corrected). 2. Medications: No medications other than iron. 3. Iron and Vitamin D Supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months of age. Continue her 2 mg/kg supplementation until 12 months of age. She will be receiving adequate vitamin D supplementation of 200 international units daily on her current Enfamil. 4. Car Seat Positioning Screening: Passed. 5. State Newborn Screening: Initial newborn screen was sent on [2113-1-7] and showed increased amino acids. Repeat screen was sent on [2113-2-20] and was normal. 6. Immunizations: The patient received Pediarix on [3-7], [2113], hepatitis B vaccine on [2113-2-3], DTaP on [2113-3-7], and pneumococcal vaccine on [3-7], [2113]. The patient also received Synagis on [3-13], [2113]. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, school-age sibling; 3) chronic lung disease; 4) hemodynamically significant CHD. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out- of-home caregivers. This infant has not received a rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. 7. Follow-up Appointments: The patient will follow up on [2113-3-24] at 11 a.m. with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 72876] and will also have a VNA visit on [2113-3-22]. DISCHARGE DIAGNOSES: 1. Prematurity at 28 5/7 weeks 2. Respiratory distress syndrome. 3. Twin gestation 4. Rule out sepsis. 5. Apnea of prematurity 6. Hyperbilirubinemia [Doctor First Name 11709] [Initials (NamePattern4) ] [Last Name (NamePattern4) 41519], M.D. [MD Number(2) 75306] Dictated By:[Last Name (NamePattern1) 75871] MEDQUIST36 D: [2113-3-21] 14:37:22 T: [2113-3-21] 15:37:58 Job#: [Job Number 75872]	[ "7742", "V053" ]
Admission Date: [2201-2-3] Discharge Date: [2201-2-4] Date of Birth: [2121-1-12] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 594] Chief Complaint: Pneumothorax Major Surgical or Invasive Procedure: none (thoracentesis had been done [2201-2-3] prior to admission) History of Present Illness: Mr. [Known lastname 10940] is a 80 yoM with history of HTN, afib, and new diagnosis of MDS in [2200-9-11] who presented to clinic on the afternoon of admission for a therapeutic and diagnostic thoracentesis of a new pleural effusion. 2.5L of straw colored transudative fluid was removed. A post-thoracentesis CXR revealed a small apical pneumothorax. The patient was called and told to return to the ED for possible chest tube, but thoracics deemed that the PTX was not large enough to need a chest tube. Instead, the plan was to keep the patient on non-rebreather overnight to aid in PTX reabsorption and to check serial CXRs. . His Onc hx: -- In [2200-7-11] his CBC revealed a new anemia (hgb 10.9) and thrombocytopenia (35). He was referred by his PMD to heme at [Hospital1 18] for BMBx, but cancelled appt since he was anxious about the pain. He notes in the past 2 months he has had increased fatigue and has needed to walk slower and rest. He continued his daily 30 minutes walks until 2 weeks PTA, when he was too fatigued and SOB. Over the prior month he also reported decreased appetite. -- [2200-10-4] consulted for new anemia and thrombocytopenia by the ER. He was sent in to ER by PMD for critical platelets 11 and Hgb 7.0. Initial peripheral Smear (pre transfusion): anisocytosis, normocytic to microcytic (as oppose to mcv 115), + tear cells, + reticulocytes, nl pmn, lymphocytes, eosinophils, with few atypical cells. No blasts. with no evidence of blasts. no evidence of schistocytes. no hypersegmented neutrophils. significantly decreasedplatelets with rare gaint platelets. Admitted for transfusion with 3 pRBC and 1unit of platelets. -- [2200-10-5] BMBx: HYPERCELLULAR BONE MARROW WITH DYSPLASTIC TRILINEAGE HEMATOPOIESIS, CONSISTENT WITH A MYELODYSPLASTIC SYNDROME, BEST CLASSIFIED AS REFRACTORY CYTOPENIA WITH MULTI-LINEAGE DYSPLASIA (RCMD) (WHO CLASSIFICATION). -- [2200-10-6] Discharged; Hospitalization included BMBx, treatment for CAP for leukocytocysis, cough and CXR with atelectasis vs PNA and tamsulosin started for urinary retention. . In the ED, initial VS were: 100.2, 121/67, 115, 20, 95%. The patient was placed on a nonrebreather. A CXR was done that showed a slightly smaller apical PTX. The patient had slight increase in his HR, c/w his afib. He was given a dose of 10mg Diltiazem and transfered to the floor. . On arrival to the MICU, the patient is in NAD. He said that he had a slight cough after the [Female First Name (un) 576], but no recent fevers, chills, or respiratory symptoms. He is comfortable on NRB. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. 10lb weight loss last year. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: - HTN - afib on atenolol, personally decided to stop warfarin 2 years ago - urinary retention during hospitalization, recently started flomax - Varicose vein and venous stasis changes of left leg no surgeries or hospitalizations never colonoscopy Social History: former smoker retired, used to work in laundry since coming to the US(denies working with chemicals); born in [Country 651]; raised in [Location (un) 35723] and emigrated [2155]; lives with wife [Name (NI) 32579] speaking; son lives nearby [Location (un) 6409], other children out of state; DNR - discussion with patient and Cantonese translator (in hospital) Family History: no blood dyscrasias Brother with lung cancer (heavy smoking history). Physical Exam: ADMISSION EXAM Vitals: T: 97.4 BP: 135/70 P: 97 R: 18 O2: 100% General: Alert, oriented, no acute distress, on NRB, cachectic looking 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: Slightly more tympanitic to palpation of LUL, slightly bronchial breath sounds of LLL, good breath sounds BL, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM T96.9, HR 110, BP 116/90, RR 20, SpO2: 100% RA Heart rhythm: AF (Atrial Fibrillation) General: Alert, oriented, no acute distress, on NRB, cachectic looking HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Slightly more resonant to palpation of LUL, slightly bronchial breath sounds of LLL, good breath sounds BL slightly decreased at base, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS [2201-2-2] 09:35AM BLOOD WBC-3.1* RBC-2.94* Hgb-9.6* Hct-27.5* MCV-94 MCH-32.8* MCHC-35.0 RDW-16.5* Plt Ct-36# [2201-2-2] 09:35AM BLOOD Neuts-45 Bands-2 Lymphs-29 Monos-13* Eos-2 Baso-1 Atyps-8* Metas-0 Myelos-0 [2201-2-2] 09:35AM BLOOD PT-14.5* PTT-32.9 INR(PT)-1.4* [2201-2-2] 09:35AM BLOOD UreaN-14 Creat-0.7 Na-133 K-4.3 Cl-96 HCO3-32 AnGap-9 [2201-2-2] 09:35AM BLOOD ALT-18 AST-16 AlkPhos-89 TotBili-1.5 [2201-2-4] 03:36AM BLOOD TotProt-5.8* Albumin-3.1* Globuln-2.7 Calcium-8.6 Phos-3.9 Mg-2.1 [2201-2-4] 03:36AM BLOOD TSH-3.1 DISCHARGE LABS [2201-2-4] 03:36AM BLOOD WBC-4.0 RBC-2.77* Hgb-8.8* Hct-25.8* MCV-93 MCH-31.8 MCHC-34.1 RDW-17.8* Plt Ct-59* [2201-2-4] 03:36AM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-137 K-4.0 Cl-101 HCO3-34* AnGap-6* CXR [2201-2-3] Left-sided pneumothorax 3.8 cm in maximal dimension. CXR [2201-2-4] As compared to the previous radiograph, the extent of the pre-existing left pneumothorax is unchanged. Also unchanged is the left basal fluid collection as well as the relatively extensive left parenchymal opacity. No evidence of tension. Unchanged appearance of the right heart border and the right hemithorax. CT CHEST W/O CONTRAST [2201-2-4] 1. Moderate left hydropneumothorax and small right pleural effusion. 2. Extensive left lung consolidation and airway plugging, worst in the left lower lobe. 3. Anasarca. Brief Hospital Course: Mr. [Known lastname 10940] is an 80y/o gentleman with Afib, HTN, MDS and new left pleural effusion who underwent an outpatient thoracentesis complicated by apical PTX requiring MICU admission for 100% NRB to help reabsorption. He was discharged home the next day. . #. PTX: Complication from thoracentesis, resolving. Interventional Pulmonology felt no chest tube was needed. He was admitted to the MICU for non-rebreather treatment overnight. On imaging, the PTX was still present but not growing. He had no O2 requirement; will follow up in I.P. clinic after discharge. . #. Left lung consolidation and airway plugging: no clinical manifestations. He had no change in his repiratory status; imaging revealed these findings and he was advised to undergo bronchoscopy, but he declined. He will follow up in I.P. clinic after discharge. . #. Afib: Not rate controlled. Patient is not on Warfarin or beta blocker at home. Heart rate was 100-120. It was felt that his tachycardia could be contributing to an element of diastolic HF so he was started on Metoprolol with resulting rate ~100. He will follow up in I.P. clinic. . #. MDS: with cytopenias. Not an active issue this admission. He will follow up with his Oncologist. . #. Transitional Issues -pending at discharge: [2201-2-3] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2201-2-3] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY --DVT: Pneumoboots # Access: peripherals # Communication: Patient # Code: DNR/DNI Medications on Admission: None Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day for 30 doses. Disp:30 Tablet Extended Release 24 hr(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you were told that you had a pneumothorax (air that escaped from the lung into the chest cavity) after a thoracentesis. You were admitted to the Medical ICU because you needed a special oxygen delivery device (non-rebreather), which helped to resorb some of the air. You still have a pneumothorax, and it is STRONGLY ADVISED for you to stay in the hospital for a procedure known as a bronchoscopy. You stated that you understood this but still wished to leave. At this time, although we recommend that you have this procedure, you are stable to be discharged home with Interventional Pulmonary clinic follow-up. It is strongly recommended that you attend the pulmonary clinic. . In addition to your pneumothorax, you have a fast heart rate which could be contributing to some fluid in the lungs. You were started on a medication (Metoprolol) to slow the heart rate. . We made the following changes to your medications: -START Metoprolol Please do not hesitate to return to the hospital if you have any worrisome symptoms. Followup Instructions: BMT/ONCOLOGY When: FRIDAY [2201-2-6] at 12:00 PM [Telephone/Fax (1) 447] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: Main Garage INTERVENTIONAL PULMONOLOGY Department: Chest Disease Center When: THURSDAY [2201-2-12] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6543], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You will need a chest x-ray prior to this appointment. Please go to [Hospital1 7768], [Hospital Ward Name 517] Clinical Center, [Location (un) *] Radiology 30 minutes prior to your appointment.	[ "4019", "42731" ]
Admission Date: [2178-5-21] Discharge Date: [2178-6-1] Date of Birth: [2100-12-3] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1406] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2178-5-22] Cardiac catheterization [2178-5-27] Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) History of Present Illness: 77 year old man with a history of HTN, HLP, asymptomatic AAA followed by vascular (last infrarenal, 4.2cm [12-30]), who presents with 3 weeks of intermittent exertional substernal chest discomfort. The patient first noted chest discomfort 3 weeks ago when he began increasing his work out regimen of weight lifting. The pain was dull, substernal, mild, nonradiating and he would usually try to work through the pain until it went away. 1 week prior to admission he noticed his pain increase in frequency and intensity, occuring with even walking or delivering fruit at his job, and this would be relieved with rest. On Wednesday [2178-5-20], he was picking up a heavy carton of watermelons when he noticed the chest pain at its most severe, with associated presyncope, diaphoresis. He went to see his PCP [Last Name (NamePattern4) ] [2178-5-21] who sent him to the ED. Of note, he had been complaining of intermittent upper back discomfort for months, that is associated with weight lifting, but nonexertional and not related to his chest pain. Past Medical History: 1) BPH - s/p transurethral resection of the prostate [12-30] 2) Dyslipidemia 3) HTN 4) Arthritis 5) GERD 6) AAA - infrarenal aneurysms, asymptomatic, slow growing, followed by vascular surgery. Last measurements of largest, 4.2cm [12-30]. Social History: Lives with:alone Occupation:Semi-retired owner of a fruit delivery company Tobacco:denies ETOH:denies Family History: Father died of MI at age 58 Brother died of AAA at 68. Physical Exam: ADMISSION: VS: 96.7 117/77 76 20 100%RA 142lbs GENERAL: Well-appearing elderly man in NAD, comfortable, appropriate, mildly anxious. HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat except faint post-tussive rales at left base, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact Pertinent Results: [2178-5-21] 07:25PM GLUCOSE-83 UREA N-18 CREAT-0.9 SODIUM-143 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14 [2178-5-21] 07:25PM CK(CPK)-273 [2178-5-21] 07:25PM cTropnT-0.11* [2178-5-21] 07:25PM WBC-5.1 RBC-4.92 HGB-14.8 HCT-43.8 MCV-89 MCH-30.1 MCHC-33.8 RDW-13.8 TTE [5-23]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to severe hypokinesis/akinesis of the inferior septum, inferior free wall, and posterior wall. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior mitral leaflet prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [2171-8-15], left and right ventricular contractile function is reduced. Carotid US [5-25]: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is mild heterogeneous plaque in the ICA. On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 49/17, 62/19, 74/30 cm/sec. CCA peak systolic velocity is 65 cm/sec. ECA peak systolic velocity is 129 cm/sec. The ICA/CCA ratio is 1.1. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 78/21, 58/20, 59/22 cm/sec. CCA peak systolic velocity is 73 cm/sec. ECA peak systolic velocity is 71 cm/sec. The ICA/CCA ratio is 1.1. These findings are consistent with <40% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA <40% stenosis. Left ICA <40% stenosis. [2178-6-1] 03:43AM BLOOD WBC-5.8 RBC-3.42* Hgb-10.5* Hct-30.1* MCV-88 MCH-30.8 MCHC-34.9 RDW-14.6 Plt Ct-218 [2178-6-1] 03:43AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-13 Brief Hospital Course: Mr.[Known lastname 94727] presented to the emergency room with substernal chest pain and was ruled in for non ST elevation myocardial infarction based on elevated troponin with peak 0.15. He then underwent cardiac catheterization that revealed significant coronary artery disease and was referred for surgical evaluation. He underwent preoperative workup and plavix washout. On [5-27] he was brought to the operating room for coronary artery bypass graft surgery x 3(Left internal mammary artery to left anterior descending, and reverse saphenous vein grafts, one to the obtuse marginal and the other went to right posterior descending)with Dr.[Last Name (STitle) ]. Cardiopulmonary bypass time 90 minutes. Cross-clamp time 75 minutes. See operative report for further surgical details. He received cefazolin and vancomycin for perioperative antibiotics and transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. Post operative day one he remained in the intensive care unit on phenylephrine for blood pressure management and bradycardia requiring epicardial pacing. All lines and drains were discontinued in a timely fashion per potocol criteria. POD#2 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of his postoperative course was essentially uneventful. Plan to reinstate Lisinopril as an outpatient per his cardiologist when blood pressure tolerates. On POD#5 he was cleared for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: Lisinopril 2.5mg PO daily Simvastatin 20mg PO daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days. Disp:20 Packet(s) Refills:0 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. metoprolol tartrate 25 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:50 Tablet(s) Refills:0 7. ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). Disp:60 Refills:2 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary artery disease s/p CABG Non ST elevation myocardial infarction (troponin 0.15) Benign prostatic hypertrophy Dyslipidemia Hypertension Gastric esophageal reflux disease Abdominal aortic aneurysm Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 2+ (L)LE/1+(R)LE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr.[Last Name (STitle) ] on [6-24] at 1:15pm Cardiologist: Dr.[Last Name (STitle) ] on [7-7] on 9:30am in [Hospital1 18] office on [Hospital Ward Name 23] 7 VASCULAR LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2178-7-8] 10:30 VASCULAR LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2178-7-8] 11:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2178-7-8] 11:45 Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) 2204] in [3-24] weeks [Telephone/Fax (1) 2205] 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:[2178-6-1]	[ "41071", "41401", "2720", "4019", "53081" ]
Admission Date: [2193-4-23] Discharge Date: [2193-5-6] Date of Birth: [2155-8-3] Sex: F PRINCIPAL DIAGNOSIS: Flat back deformity. OPERATION: 1. L2 anterior corpectomy, anterior release and fusion instrumented fusion T4 to L4 with 40 degree lumbar lordosis correction. HISTORY: The patient is a 37-year-old female with a history of scoliosis who has had multiple back surgeries for her scoliosis. She has had significant loss of lumbar lordosis secondary to a previous [Location (un) 931] rod fusion for scoliosis. kyphosis at that level, decompensated by over 15 cm. She was admitted for L2 vertebrectomy and osteotomy with correction of lumbar lordosis. HOSPITAL COURSE: The patient underwent the anterior portion of her operation on [2193-4-23]. She was admitted postoperatively. She did well. There were no complications to her initial procedure. Postoperatively her bilateral lower extremity exam revealed intact tibialis anterior, gastroc soleus, [Last Name (un) 938] and peroneal muscle groups. The patient remained hemodynamically stable. The patient was kept on TEDD stockings and pneumoboots for DVT prophylaxis postoperatively. She was seen by the pain service who put her on her usual preoperative medication including MS Contin 45 mg po bid, Morphine PCA, Valium and Neurontin. On postoperative day #3 the patient was taken back to the operating room for the posterior portion of her procedure. She underwent L2 osteotomy and vertebrectomy and lumbar lordosis correction with effusion from T4 to L4. The patient tolerated the procedure well. There were no complications to her procedure. Postoperatively she was neurovascularly intact with a 5/5 strength in her tibialis anterior, gastroc soleus, [Last Name (un) 938] and peroneal muscle groups bilaterally. Sensation was intact to light touch. She was admitted to the surgical Intensive Care Unit postoperatively for management of her hemodynamic status given the length and amount of bleeding of her surgery. In total she had a 5 liter blood loss and was given 8 units of packed red blood cells in the operating room including four units of FFP and 450 cc of cell [Doctor Last Name 10105]. Postoperatively the patient had a hematocrit of 30.8. She was put on a Dexamethasone taper, 8 mg q 8 hours times two, then 6 mg q 8 hours times two, then 4 mg q 8 hours times two, then 2 mg q 8 hours time two, then off. The patient was transferred out of the Intensive Care Unit to the regular floor on postoperative day #1 from her posterior procedure. She had a hematocrit of 31.4, she was neurovascularly intact. The patient did have a headache which was suggestive of spinal headache after the second procedure. The operation was a revision operation which included a lot of scarring and there were two intraoperative dural tears which were repaired with 6-0 Prolene. The patient was therefore kept flat and given Tylenol for her headache. She also has a history of migraine headaches which she suggested her postoperative headache felt like. She was given Imitrex for this reason. Her headache did not resolve and the patient was kept flat for the next several days. She was hemodynamically stable with good urine output and stable hematocrit. Her Hemovac drain was putting out serosanguineous fluid. Her incision was clean, dry and intact with no evidence of drainage. On [2193-4-29] the patient had her head of the bed elevated to 30 degrees. She complained of intense headache and therefore was again laid flat. The patient was kept flat for one more day. A CT scan was done to evaluate for any collections of CSF in the extradural space. There was no evidence of any collection. On [2193-4-30] the patient said her headache was improved, her head of bed was kept flat until the following morning on [2193-5-1] when the head of the bed was raised 30 degrees. She tolerated this well without complaint of further headache. She therefore was allowed to sit up and advanced to a full diet. Her Foley catheter was removed. Pain service continued to follow and discontinued her PCA on [2193-5-1]. On [2193-5-2] the patient was able to mobilize with physical therapist. She had no complaints of headache. She increased her po intake and had no difficulty with ambulating to the bathroom with her walker. On [2193-5-3] the patient was cleared for discharge to home medically, however, the physical therapist's recommendations were that she have [4-8] more visits before clearance home. It was decided that should the patient be offered a spot in the rehabilitation center, prior to her physical therapy clearance to home, that she would be transferred to rehabilitation. There were no other complications throughout [Hospital 228] hospital stay. She will be discharged on [2193-5-6] to either home or rehabilitation. DISCHARGE INSTRUCTIONS: 1. Medications: Zantac 150 mg po bid, Colace 100 mg po bid, Morphine Sulfate 60 mg po q 8 hours, extended release, Morphine Sulfate 15-30 mg po q 2-3 hours breakthrough pain, Tylenol 650 mg po pr q 4 hours prn pain, fever, Benadryl 25 mg po q h.s. prn sleep, Oxaprozin 600 mg po q d, Neurontin 600 mg po qid, Hydroxychloroquine Sulfate 200 mg po bid, Fosamax 70 mg q week, Clonidine 0.1 mg po tid, Simethicone 80 mg po qid prn gas, Valium 5 mg po bid prn spasm pain, Meclizine 25 mg po tid prn vertigo, Trazodone 50 mg po q h.s. prn pain. Dressings: The patient can leave her dressings off. Her incisions are clean, dry and intact. Should there be any oozing, the patient should dress the wound until the oozing stops. The patient can shower as tolerated. 2. Weight bearing instructions: The patient can weight bear as tolerated in her brace. 3. Diet: Regular. DISPOSITION: Home vs rehabilitation facility. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 3863] Dictated By:[Name8 (MD) 38902] MEDQUIST36 D: [2193-5-3] 15:57 T: [2193-5-3] 19:19 JOB#: [Job Number 38903]	[ "4240", "2851", "53081" ]
Admission Date: [2101-1-16] Discharge Date: [2101-1-21] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5188] Chief Complaint: Upper GI BLEED Major Surgical or Invasive Procedure: [1-16]: exlap, pylorotomy, oversewing of duodenal ulcer History of Present Illness: Pt is a 85 yo gentleman with dementia, on therapeutic lovenox for a DVT, and a resident of [Hospital 100] Rehab who was admitted yesterday after having black tarry stools and a hct drop from 34 in [Month (only) 1096] to 21 here in the ED. Yesterday he was in his usual state of health, was noted to be briefly unresponsive in the morning (not an unusual occurence for him with a negative workup), and then had black tarry stools. He was monitored there for a little while and then brought to the ED when his hct was found to be 25.8 from a baseline of 34. He was also found to have a LLL infiltrate, and empiric antibiotics were started. He continues to remain asymptomatic. He is only able to answer yes and no to some questions, but denies any pain currently. Patient has received a total of 3 units of prbcs and is getting a 4th now. GI did an EGD this am showing a large duodenal bulb ulcer, not currently bleeding but with a large pusating artery. Past Medical History: moderate dementia gait d/o, h/o falls dual chamber pacemaker for sinus node dysfunction HTN orthostatic hypotension on midodrine HOH Urinary incontinence Chronic lower extremity edema Hx of recurrent PNA DVT in R femoral vein (1 yr ago) on lovenox at prophylactic dose Social History: Needs assistance w/ all ADLs exc feeds self. Ambulates w/ assistance. No tob/etoh. [Hospital 100] rehab resident. Supportive son who is [Name8 (MD) ] MD. Family History: Noncontribitory Physical Exam: At Admission: PE: BP 119/68, HR 71, irreg. Responsive, but oriented to person only and very hard of hearing but in no apparent distress CTAB, slight crackles base Irregularly irregular soft, non-tender, nondistended, no hernias, +bs guiac + with maroon stools in vault no c/c/e . At discharge: V.S: 97.5, 111, 138/79, 20, 96 RA Gen: Alert. Confused. CV: RRR, no m/r/g Resp: lscta bl Abd: soft, sl tender, nd, hypoactive BS Incision: ota with staples Ext: no c/c/e Pertinent Results: -[2101-1-20] 06:07AM BLOOD WBC-8.2 RBC-3.07* Hgb-9.8* Hct-27.5* MCV-90 MCH-32.0 MCHC-35.6* RDW-15.9* Plt Ct-127* [2101-1-15] 11:02PM BLOOD WBC-18.7* RBC-2.45* Hgb-7.9* Hct-21.5* MCV-88 MCH-32.4* MCHC-36.8* RDW-15.3 Plt Ct-240 [2101-1-15] 11:02PM BLOOD Neuts-86.2* Lymphs-11.8* Monos-1.9* Eos-0.1 Baso-0.1 [2101-1-20] 06:07AM BLOOD Plt Ct-127* [2101-1-20] 06:07AM BLOOD Glucose-123* UreaN-24* Creat-0.8 Na-142 K-3.4 Cl-115* HCO3-22 AnGap-8 [2101-1-15] 11:02PM BLOOD Glucose-154* UreaN-72* Creat-1.4* Na-140 K-4.5 Cl-105 HCO3-22 AnGap-18 [2101-1-19] 07:15AM BLOOD ALT-13 AST-24 AlkPhos-36* TotBili-1.1 [2101-1-15] 11:02PM BLOOD ALT-13 AST-22 CK(CPK)-35* AlkPhos-38* TotBili-0.3 [2101-1-20] 06:07AM BLOOD Calcium-7.2* Phos-2.7 Mg-2. . STUDIES: Iron: 19 calTIBC: 150 Ferritn: 336 TRF: 115 Triglyc: 91 . MICRO: H. pylori Ab: EQUIVOCAL MRSA SCREEN (Final [2101-1-19]): No MRSA isolated. . EGD Impression: Duodenal ulcer Ulcer in the cardia Small hiatal hernia Otherwise normal EGD to second part of the duodenum . CXR A right-sided PICC was installed, likely ending in the upper to mid SVC, not clearly seen, but not extending in the right atrium. Bilateral pleural effusion increased, now small to moderate. Left basilar opacity also increased, could be atelectasis. Left dual chamber pacemaker ends in expected position. Brief Hospital Course: In the ED, initial vs were: T 97.5 P 84 BP 122/56 R 16 O2 sat 100% on RA. Lg melana here that is guiac +. NG lavage w/ brown-tinged mucus that cleared immediately. Repeat vitals: 83, 128/52, 20, 100% on 2L. General Surgery and GI were consulted. Patient was given zosyn for possible pneumonia- LLL infiltrate noted on Chest XRAY. Initial plan or care included: Protonix IV. 2 U PRBC. 2.5 L IVF. 2 18 G placed. Foley placed. . Patient went to the MICU where for closer monitoring - given 6u PRBCs, 2u FFP, and six pack of platelets. Pt's hct did not respond appropriately-> up to 23% only. EGD by GI showing duodenal bulb ulcer w/artery in middle -> not amenable to clipping/sclerosis. Pt. intubated in the MICU and taken to the OR for definitive management. Ulcer oversewn. Given an additional 5u PRBC, 4u FFP, and calcium in the OR. Neo on until the end of the case to maintain blood pressure intra-op. Then transferred to TICU from OR for post-op care. . Pt was admitted to [Hospital Ward Name 1950] 5 from the TICU with a foley, IV hydration, IV medications. A PICC line was place [1-19] and TPN was started on [1-19]. [1-20] TPN with lipids/fats was started (triglycerides-81). Pt tolerating small amounts of clear liquids. Evaluated by speech and swallow at bedside---recommended continuation of clear liquids and small pills, large pills to be crushed and given in apple sauce as needed. Pt should be followed by [Hospital 100] rehab Speech and swallow team as his diet is advanced to solid foods. TPN should be weaned once patient is able to meet daily caloric needs by mouth. Pertinent labwork should be monitored at least [Hospital1 ]-weekly to asses progress. Foley catheter can be removed on [2101-1-20] upon arrival at rehab as long as urine output >30cc/hour. Physical therapy should be continued and all home meds except Metamucil should be restarted. Resume metamucil once bowel function basck to baseline. Currently, patient is unable to comment if passing flatus. [Month (only) 116] require actual bowel movement, assessment of bowel sounds, and abdominal distention to determine return of bowel function. Abdominal incision intact, OTA with staples. Staples will be removed per REHAB facility on POD7 which is Sunday [1-23]. . [Name (NI) 1094] son's was called and informed about the d/c and transfer to [Hospital 100] rehab. Patient should follow-up with Dr. [Last Name (STitle) 5182] in office in 1 week. Medications on Admission: Vit D, aricept 10, Lovenox 40, Finasteride 5, Lasix 20/40, Midodrine 5, Potassium, Metamucil, Tamsulosin . Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection Q8H (every 8 hours) as needed for line flush: PICC Line care. 3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: PICC Line care. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 2 weeks. 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Once tolerating PO's. 6. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Dilaudid 1 mg/mL Solution Sig: 0.5 mL Injection every four (4) hours as needed for pain for 3 days: Switch to PO Dilaudid once tolerating diet. 8. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 10. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day. 13. Midodrine 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 15. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 16. Insulin sliding scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [12-24] amp D50 61-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units 281-320 mg/dL 10 Units > 320 mg/dL Notify M.D. 17. Metamucil Powder Sig: One (1) PO once a day as needed for constipation: Resume once bowel function back to baseline. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: upper gastrointestinal bleed from large duodenal bulb ulcer acute blood loss anemia managed with blood transfusion hypovolemia managed with Intravenous hydration Malnutrition managed with transparental nutrition . Secondary: moderate dementia, gait d/o, h/o falls, dual chamber pacemaker for sinus node dysfunction, HTN, orthostatic hypotension on midodrine, HOH, Urinary incontinence, DVT in R femoral vein (1 yr ago) on lovenox at prophylactic dose, HLD, Diastolic heart failure, LVH, EF > 55% on last ECHO by report w/ Mild MR, Mild TR, mod/severe pulm HTN, LAE, Anemia of chronic disease, Basal cell carcinoma, Prosthetic R eye, Hypoalbuminemia w/ recent wt loss of 18 Discharge Condition: Stable. Tolerating clear liquids, and TPN with fat(day 2) via PICC. Pain well controlled with oral medication Discharge Instructions: FOR REHAB: Please call doctor or return patient to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples should be removed on Post/op day 7 which is [1-23], [2100]. -Please apply Steri-strips. They will fall off on their own. Please remove any remaining strips 7-10 days after application. -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. . PICC: -A PICC line was placed for TPN . TPN: -TPN was started to provide adequate nutrition due to patient's malnourished state, while you are on a clear liquid diet. -Please advance diet from clears to regular once bowel function returns, including passing of flatus and bowel movements. -Please have Speech & Swallow specialist continue to evaluate patient's ability to take oral medications and solid foods. Followup Instructions: 1. Please call Dr [Last Name (STitle) 80716] [Telephone/Fax (1) 5189] office to make a follow up appointment in 1 week. Arrange for transporation to [Hospital1 18]. 2. Follow-up with primary doctor as needed. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2101-1-20]	[ "5849", "4280" ]
Admission Date: [2167-1-27] Discharge Date: [2167-2-12] Service: MEDICINE Allergies: Norvasc Attending:[First Name3 (LF) 317] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization and stent placement History of Present Illness: 86 year old male w/ pacer, svt, avnrt, mvr, htn, high chol, panhypopit with chief complaint of chest pain. No prior CAD, now intubated with ST depressions anteroseptally and elevations inferiorly in setting of AV paced rhythm. In field BP 60/P but mentating. Went directly to Cath lab where he had 40 % LMCA ulcerated lesion, 99% prox. Lcx occlusion with thrombus and 80% mid LAD. He was left dominant. Patient had Kissing DES to LCX, LAD into LMCA ostium. His PCWP on 2 pressors and IABP was 22 mmHg. CO 5.18 l/min and CI 2.80 l/min. He had episode of VT on Dopamine in lab requiring shock. Sent up to CCU on small dose of Levophed and IABP, intubated. Past Medical History: 1. HTN 2. Hyperlipid. 3. Pan-Hypopit s/p pituitary adenoma resection [2158] on only Synthroid 4. H/O Tachy-Brady syndrome s/p PPM in [2154] 5. H/O SVT 5. h/o SIADH Pertinent Results: [2167-2-8] 07:45AM BLOOD WBC-14.1* RBC-3.93* Hgb-12.2* Hct-35.5* MCV-90 MCH-31.0 MCHC-34.4 RDW-13.2 Plt Ct-362 [2167-2-7] 06:45AM BLOOD WBC-11.3* RBC-4.06* Hgb-12.3* Hct-36.5* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.5 Plt Ct-371 [2167-2-1] 06:00AM BLOOD WBC-7.4 RBC-3.27* Hgb-10.3* Hct-28.9* MCV-89 MCH-31.4 MCHC-35.6* RDW-14.4 Plt Ct-132* [2167-1-30] 04:34PM BLOOD Hct-25.9* [2167-2-8] 07:45AM BLOOD Glucose-86 UreaN-31* Creat-0.9 Na-141 K-3.7 Cl-105 HCO3-31* AnGap-9 [2167-1-29] 04:53AM BLOOD CK(CPK)-1850* [2167-1-28] 05:14PM BLOOD CK(CPK)-2785* [2167-1-28] 03:59AM BLOOD CK(CPK)-3764* [2167-1-27] 10:55PM BLOOD CK(CPK)-4056* [2167-1-29] 04:53AM BLOOD CK-MB-57* MB Indx-3.1 cTropnT-6.17* [2167-1-28] 05:14PM BLOOD CK-MB-99* MB Indx-3.6 cTropnT-7.96* [2167-1-28] 03:59AM BLOOD CK-MB-253* MB Indx-6.7* cTropnT-12.68* [2167-1-27] 11:45AM BLOOD cTropnT-0.02* [2167-1-28] 08:25AM BLOOD Hapto-20* [2167-2-7] 06:45AM BLOOD TSH-1.9 [2167-2-7] 06:45AM BLOOD Free T4-1.3 [2167-1-28] 05:14PM BLOOD Cortsol-216.4* CT scan: There is a small amount of retroperitoneal hemorrhage present, as well as bleeding into the left psoas and right iliacus muscle. There is no dominant retroperitoneal hemorrhage collection. TTE [2167-1-28]: Conclusions: The left ventricular cavity is unusually small. There is mild regional left ventricular systolic dysfunction. LV systolic function appears depressed. Right ventricular chamber size is normal. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (tape reviewed) of [2167-1-27], left ventricular systolic function appears similar to slightly improved except that the heart rate is now higher. TTE [2167-1-27]: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Marked lateral hypokinesis and inferior/posteror akinesis are present. 3. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. 4. The ascending aorta is mildly dilated. 5. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Cardiac Cath: HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.85 m2 HEMOGLOBIN: 13.4 gms % FICK *PRESSURES RIGHT ATRIUM {a/v/m} 26/27/23 16/17/14 RIGHT VENTRICLE {s/ed} 47/26 36/16 PULMONARY ARTERY {s/d/m} 47/27/33 36/22/28 PULMONARY WEDGE {a/v/m} 31/42/29 24/27/22 AORTA {s/d/m} 80/104/ CARDIAC OUTPUT HEART RATE {beats/min} 80 RHYTHM PACED O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 45 CARD. OP/IND FICK {l/mn/m2} 5.1/2.8 RESISTANCES SYSTEMIC VASC. RESISTANCE 926 PULMONARY VASC. RESISTANCE 63 % SATURATION DATA (NL) PA MAIN 74 COMMENTS: 1. Selective coronary angiography revealed a left dominant system. The LCX had a 99% proximal stenosis with thrombus. The LMCA had an ulcerated plaque with a 40% stenosis. The LAD had an 80% mid-vessel lesion. The RCA was small and nondominant. 2. Hemodynamics on entry showed elevated filling pressures (RVEDP 26 mm Hg, PCWP mean 29 mm Hg), moderate pulmonary hypertension (PASP 47 mm Hg), and a normal cardiac index (2.8 l/mn/m2) while on dopamine, levophed, and with the IABP in place on 1:1. Additionally, there were large V waves to 42 mm Hg in the PCWP tracing, suggestive of ischemic mitral regurgitation. 3. Hemodynamics after intervention showed decreased filling pressures (RVEDP 16 mm Hg, PCWP mean 22 mm Hg) without the large V waves on the PCWP tracing. Post intervention the pulmonary hypertension was less severe (PASP 36 mm Hg). 4. Diagnostic procedure was complicated by one episode of ventricular tachycardia, which resolved with 200 J defibrillation and lidocaine 100 mg IV bolus. 5. Successful primary PCI of the LCX with a 3.0 x 18 mm Cypher DES, complicated by likely stent thrombosis, treated with a 3.5 mm balloon and export cathter. 6. Successful PCI of the proximal-mid LAD with a 3.0 x 18 mm Cypher DES. 7. Successful kissing stent deployment in the LMCA into the LAD (3.0 x 23 mm) and LCX (3.5 x 23 mm) with two Cypher DES. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Ischemic MR. 3. Moderate pulmonary hypertension. Elevated filling pressures. 4. Acute lateral myocardial infarction, managed by acute PCI of the LCX, LAD, and LMCA. 5. Cardiogenic shock, managed with IABP insertion. Brief Hospital Course: 1. CAD: Mr. [Known lastname 5448] was taken emergently to the cath lab, and had stents to his LCx, LAD, and kissing stents placed in his LMCA. An IABP was placed in the lab, and he was transferred to the CCU on levophed. One day after admission, his BP acutely dropped and a stat echo was obtained. This was essentially unchanged from one day prior. His balloon pump and levophed were eventually weaned off. He was kept on aspirin, plavix, and a statin. He was placed on an ACE inhibitor and a beta blocker, which were titrated up for pulse and blood pressure control. He will need to have a relook cath in 3 months given his L main stents. 2. Pump: His EF was 30%, and he received a great deal of IVF resuscitation. Once his bp stabilized, he was aggressively diuresed with Lasix. He had a repeat echo the day after admission which demonstrated an improved EF, of 40-45%. He was placed on [First Name8 (NamePattern2) ] [Last Name (un) ] for afterload reduction, and a beta blocker was added later. 3. Rhythm: He had a pacemaker already in place, and initially he was intermittently A-sensing and V-pacing, as well as AV pacing. This was changed by the attending so that he was a-sensing and a-pacing. He also had a very short (minutes) run of afib, which self-terminated. He was bolused with amio and placed on an amio drip, and then changed to po loading doses. This was tapered down to 400 mg po daily. Per the attending, because he had peri-MI afib, he may only need 1 month of amiodarone and then this can stop altogether. He had no further arrhythmias. He was not anticoagulated [1-14] GI bleed. 4. Pulm: He was initially intubated because he was hypotensive and unstable. He remained intubated in the setting of his volume overload, and he wasn't extubated until his pulmonary status was maximized with diuresis. He also had thick secretions from his ET tube, which twice grew out serratia. He had an infiltrate on CXR. He was treated initially with Zosyn, which was changed to levofloxacin per sensitivities, for a total 10 day course. 5. Endocrine: Because of his history of pan-hypo pit and his hypotension, he was placed on stress-dose steroids. These were tapered down once his bp was stable, and need to be tapered to his home dose of prednisone 5 mg po qd. Please see discharge instructions. He was placed on an insulin sliding scale while on the high dose steroids, as well as synthroid. He no longer required the insulin once his steriods were tapered. 6. Altered mental status: He remained slightly confused with a labile mood, even after transfer out to the floor. He was seen by psychiatry, who recommended Haldol 0.5 mg po qhs. However, after this he developed bilateral intention tremor of his hands, and the haldol was discontinued. 7. Anemia: His hematocrit initially dropped, but this was felt dilutional [1-14] his large volume resuscitation. However, his crit dropped sharply on [1-30*], and he had a CT scan which showed a small retroperitoneal bleed with psoas and iliacus muscle bleeds. His heparin (for the afib) was stopped, and he was transfused to a crit over 30. He remained hemodynamically stable, and his hematocrit was stable after this. He did have guaiac positive stool, but no gross melena or bright red blood per rectum. Medications on Admission: Prednisone 5 mg po qd Lipitor HCTZ Avapro Prevacid Synthroid Toprol Testosterone patch Discharge Medications: 1. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s)* Refills:0 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Milk of Magnesia 311 mg Tablet, Chewable Sig: One (1) ML PO Q6H (every 6 hours) as needed for heartburn. 9. Atacand 4 mg Tablet Sig: One (1) Tablet PO QD (). 10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 12. Amiodarone HCl 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 9 days: then start 200 mg per day for 3 more weeks, then off. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: [12-14] Tablet Sustained Release 24HR PO DAILY (Daily): hold for sbp < 100, hr < 60. 14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: Then 10 mg for 7 days then 5 mg ongoing. 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO DAILY (Daily). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for systolic blood pressure < 100. 17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough for 7 days. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: 1. s/p acute MI, cardiogenic shock 2. Hyperlipidemia 3. Pan-Hypopituitary s/p pituitary adenoma resection [2158] on only Synthroid 4. History of Tachy-Brady syndrome s/p PPM in [2154] 5. H/O SVT 5. h/o SIADH 6. Hypertension 7. CHF Discharge Condition: good Discharge Instructions: Continue amiodarone, aspirin, lipitor, captopril, plavix, lisinopril, toprol, lasix, prednisone, aldactone, synthroid and also complete a course of levaquin. Call your doctor [First Name (Titles) ] [Last Name (Titles) 5162], chest pain, shortness of breath, dizzyness, or swollen legs. You will also need to complete a steroid taper. Please see attached prescription. Followup Instructions: You should have another cardiac catheterization in 3 months. Please see your PCP [Last Name (NamePattern4) ] 2 weeks: [Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 1713] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6719], M.D. Where: [Hospital6 29] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2167-2-24] 2:15 Please draw a chemistry and complete blood count in 5 days. Have your blood pressure checked and adjust lasix, atacand, and metoprolol accordingly.	[ "4280", "486", "42731", "41401", "2859", "4019", "2720" ]
Admission Date: [2101-9-5] Discharge Date: [2101-9-13] Date of Birth: [2019-12-15] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dypsnea on exertion Major Surgical or Invasive Procedure: [2101-9-5] Aortic Valve Replacement([Street Address(2) 17167]. [Male First Name (un) 923] Regent mechanical valve) History of Present Illness: This is a 81 yo female with severe aortic stenosis followed by serial echos. She complains of dyspnea on exertion and displays Class III heart failure. Most recent echo showed [Location (un) 109] 0.5 cm2. Cardiac cath showed 70% diagonal lesion. Based upon the above, she was referred to Dr. [Last Name (STitle) 1290] for cardiac surgical intervention. Past Medical History: Aortic Stenosis Hypercholesterolemia Type II Diabetes Mellitus Hypertension Obesity Osteoarthritis Pulmonary Nodules Social History: Quit tobacco 25 years ago. Occasional ETOH. Lives with husband. Family History: Non-contributory Physical Exam: 62" 240# obese, NAD scattered spider veins throughout PERRLA,EOMI,anicteric,left tear duct abnormal neck supple, no JVD, murmur radiates to bil. carotids CTAB RRR with 4/6 SEM throughout precordium to carotids soft, NT, ND, no HSM warm, well-perfused, no peripheral edema no obvious varicosities neuro grossly nonfocal exam; MAE [4-14] strengths 2+ bil. radials 1+ bil. DPs 1+ right fem/2+ left fem NP PTs Pertinent Results: [2101-9-13] 06:00AM BLOOD WBC-8.8 RBC-3.18* Hgb-9.3* Hct-28.4* MCV-89 MCH-29.2 MCHC-32.7 RDW-14.6 Plt Ct-283 [2101-9-13] 06:00AM BLOOD PT-21.5* PTT-28.3 INR(PT)-2.1* [2101-9-12] 10:51AM BLOOD PT-19.4* PTT-26.1 INR(PT)-1.9* [2101-9-11] 06:14AM BLOOD PT-19.7* PTT-31.8 INR(PT)-1.9* [2101-9-10] 05:27AM BLOOD PT-21.2* PTT-36.6* INR(PT)-2.1* [2101-9-9] 08:00AM BLOOD PT-24.3* PTT-33.3 INR(PT)-2.4* [2101-9-8] 12:06PM BLOOD PT-18.8* INR(PT)-1.8* [2101-9-13] 06:00AM BLOOD UreaN-33* Creat-1.3* K-4.3 [2101-9-12] 10:51AM BLOOD UreaN-35* Creat-1.3* K-4.3 [2101-9-11] 06:14AM BLOOD UreaN-36* Creat-1.4* K-3.9 [2101-9-10] 05:27AM BLOOD UreaN-40* Creat-1.4* K-3.9 [2101-9-12] 10:51AM BLOOD Mg-2.5 [2101-9-13] Chest x-ray: When compared to prior studies dated [2101-9-7] and [9-6], bilateral small pleural effusions, greater on the left side, have slightly increased in amount. Left perihilar and left lower lobe retrocardiac atelectases are unchanged. Left cardiac border is obscured by the pleural and parenchymal abnormalities. Right internal jugular vein catheter tip is in unchanged position in the SVC. There is no pneumothorax. [2101-9-5] Intraop TEE: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 3. Right ventricular chamber size is normal. 4. There are complex (>4mm) atheroma in the ascending aorta. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild to moderate ([1-11]+) mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. 8. The pulmonic valve leaflets are thickened. 9. There is a small pericardial effusion. POST-BYPASS: 1. Biventricular systolic function is unchanged. 2. Mechanical valve seen in the aortic postion. Leaflets move well and the valve appears well seated. Washing jets seen. 3. Mild mitral regurgitation present. 4. Aorta intact post decannulation. Brief Hospital Course: Admitted [9-5] and underwent AVR with Dr. [Last Name (STitle) 1290]. Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Extubated the next day and transferred to the floor on POD #2 to begin increasing her activity level. Went into A fib on POD #2 and treated with Amiodarone. Coumadin also started for her mechanical valve and dosed for a goal around 2.5 to 3.0. Chest tubes and pacing wires were eventually removed without complication. By POD#3, she converted back to a normal sinus rhythm. She maintained a normal sinus rhythm for the remainder of her hospital stay. No further episodes of atrial fibrillation were noted. Over several days, she continued to make clinical improvements with diuresis and was medically cleared for discharge to home on [9-13]. Following discharge, she is to get a follow-up CT scan of the chest in 6 months for bilateral pulmonary nodules. Dr. [Last Name (STitle) ] office has been notified of this finding. Dr. [Last Name (STitle) 17887] will also monitor Coumadin as an outpatient. Medications on Admission: lisinopril 20 mg/HCTZ 12.5 mg daily ecotrin 325 mg daily glipizide 2.5 mg daily zocor 20 mg daily amoxicillin prn dental Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 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:2 4. 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 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:42 Capsule, Sustained Release(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:20 Tablet(s) Refills:0 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: then decrease to 200 mg daily until discontinued by cardiologist. Disp:45 Tablet(s) Refills:0 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for 1 days: then INR check to be calld to Dr. [Last Name (STitle) ] office for continued dosing. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: s/p Aortic Valve Replacement(mechanical) Postop Pleural Effusions Postop Atrial Fibrillation AS NIDDM HTN obesity osteoarthritis elev. chol. Discharge Condition: good Discharge Instructions: shower daily, pat incisions dry, no baths no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call surgeon for fever greater than 100.5, redness or drainage CHEST CT scan IN 6 MONTHS for bilateral lung nodules Followup Instructions: see Dr. [Last Name (STitle) 17887] in [1-11] weeks see Dr. [Last Name (STitle) 7047] in [2-12] weeks see Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] CHEST CT SCAN IN 6 months Completed by:[2101-10-25]	[ "4241", "42731", "25000", "4019", "2720" ]
Admission Date: [2166-12-6] Discharge Date: [2166-12-7] Date of Birth: [2093-3-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3561] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Right IJ CVL Left Arterial line History of Present Illness: This is a 73 F with advanced ovarian cancer with peritoneal carcinomatosis, h/o atrial fibrillation, recurrent episodes of SBO (nonsurgical candidate), who presented to the ED earlier yesterday s/p fall at home. Per family, patient began vomiting 1 day PTA and sustained a fall at home due to dizziness, hitting her head. She had no other symptoms at the time, including fevers/chills, chest pain, SOB, diarrhea or dysuria. +abdominal pain that also began 1 day PTA, diffuse in nature and consistent with her prior presentations of SBOs. She was brought into the ED for further evaluation. . In the ED, patient was hypotensive to the 70's systolic, requiring titration up to three pressors after IVF, although SBP still remained in the 70's. Right IJ and A-line were also placed. She was tachypneic and became increasingly acidemic throughout her ED course: 7.44->7.34->7.29. She received 4.5 L NS with CVP responding at 9, and then started on pressors (levo, dopa, vasopression). She also received Cefepime, flagyl, and repletion of her low K and low Mg. Cardiology performed a bedside TTE to rule out pericardial effusion/tamponade as an etiology of her hypotension. OB/gyn, heme-onc, and surgery were made aware of her admission. She was deemed to be a nonsurgical candidate. Past Medical History: Stage I breast cancer (right), s/p mastectomy Ovarian cancer, stage IIIb-IV with peritoneal carcinamatosis atrial fibrillation h/o atrial septal defect s/p CABG and repair HTN h/o bradycardia s/p pacemaker Social History: Lives at home with her husband, no tobacco/EtOH/illicits. Family History: The patient's father had multiple myeloma. Physical Exam: VS: Tc 95.9, BP 74/49, HR 70, RR 32, SaO2 87%/NRB General: critically-ill appearing female in respiratory distress, moaning from abdmoninal discomfort HEENT: PERRL, EOMI. +NRB in place Neck: supple, +right IJ with oozing Chest: diffuse expiratory wheezes with crackles at the bases b/l CV: RRR no m/g/r Abd: firm, distended with TTP diffusely. +voluntary guarding. Decreased BS. Ext: no c/c/e, +left radial A-line Pertinent Results: [2166-12-6] CT abd/pelvis - 1. Limited examination. 2. Findings concerning for small-bowel obstruction secondary to mass in the terminal ileum. 3. Ventral wall hernia involving segment III of the liver. 4. Right adnexal mass. 5. Hyperdense subcapsular metastasis has increased in size. . [2166-12-6] CXR - Single bedside AP examination labeled" "upright" with extreme right CP angle excluded from the film, and tubing overlying the thorax. The study is compared with similar examination dated [2166-9-17]; the overall appearance is essentially unchanged. The patient is status post median sternotomy [2164] apparently intact sternal cerclage wires. Left-sided unipolar pacemaker appears to terminate in the RV apex, unchanged (single view) evidence of denuding of a short, 6 mm segment of wire installation, representing "sheath separation" at the costoclavicular intersection, a finding unchanged on serial studies dating to [10-9]. The heart size is unchanged, with no specific evidence of CHF. No focal consolidation is seen. . [2166-12-6] CT head - No ICH or mass effect. . Brief Hospital Course: This is a 73 y/o female with advanced ovarian CA with peritoneal carcinomatosis, recurrent SBO, who presented with abdominal pain and refractory hypotension, hypothermia, leukopenia with bandemia, and tachypnea. She fit criteria for septic shock and was admitted to the MICU for further management. Upon admission, she was on 4 vasopressors with SBP's in the 70's. Presumed source was her abdomen (likely ischemic bowel with superinfection) and surgery was consulted while she was in the ED for her SBO. She was deemed not to be an operative candidate given her extensive abdominal involvement from the ovarian cancer. Her urine and CXR were unremarkable. She was continued on broad-spectrum antibiotics to cover all potential sources and was also started on IV steroids due to profound refractory hypotension on 4 pressors. She had a severe metabolic acidosis on admission due to lactic acidosis and respiratory support measures (i.e. NIV and intubation) were discussed with the patient and her family. Given her profund septic shock, we explained to the family and the patient that once she were intubated, the chance of being extubated was low. The patient and family understood and expressed wishes for the patient to be a DNI/DNR. An extensive discussion was held with the family regarding the patient's grim prognosis, given her septic shock, non-operable status, and need for maximal medical support. A decision with the MICU attending present was made to make the patient comfort measures only, as she was rapidly declining on maximal medical support. She was kept comfortable with morphine IV prn and fentanyl IV prn for her abdominal pain and respiratory status. She expired approximately 4 hours after arrival to the MICU with her family present. The case was discussed with medical examiner, who declined the case. The family declined autopsy as well. Medications on Admission: 1. Coumadin 3 mg daily 2. Ranitidine 150 mg [Hospital1 ] 3. Dyazide 1 tab daily 4. Compazine prn 5. Femara 2.5 mg daily 6. Neurontin 900 mg tid 7. Megace 400 mg daily 8. Digoxin - dose unclear Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2166-12-9]	[ "0389", "78552", "5849", "99592", "42731", "V4581" ]
Admission Date: [2184-7-1] Discharge Date: [2184-7-2] Date of Birth: [2114-11-23] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Hematochezia 200cc clots x 2 Major Surgical or Invasive Procedure: [7-1] ex-lap and attempted SMA revascularization [7-2] second look History of Present Illness: This 69M was discharged to [Hospital ] rehab on [6-29] s/p AVR/CABG with Dr. [Last Name (STitle) 914] on [2184-5-31]. His post-operative course then was complicated by encephalopathy, ileus, sternal dehiscense, and pericardial effusion requiring takeback and sternal plating. This evening he had 2 episodes of BRBPR of ~200cc each and was transferred to the ED for work up. He has had diffuse abdominal pain today. His SPB is stable in the 130's and his Hct is 39. A paracentesis was performed and acitic fluid was sent for studies. A rectal revealed BRB in the vault. Past Medical History: - Aortic Stenosis/Coronary Artery Disease - Type II Diabetes Mellitus - Hypertension - Cirrhosis, Portal Hypertension, with Splenomegaly, Varices and Ascites - Psoriasis - Cataract Surgery - AVR and CABG x 2 on [2184-5-31] Social History: Mr. [Known lastname 1007] is a custodian at a retail store. He reports smoking cigars in the past. He denies drinking alcohol. He lives with his wife. Family History: Noncontributory Physical Exam: Admission PE: VSS Lungs: Clear CV: RRR without R/G/M Abd: soft, diffusely tender to palpation, +BS Incisions: healing well, sternum stable. JP drain in place. Neuro: alert, sl. confused Pertinent Results: [2184-7-1] 09:01AM BLOOD Type-[Last Name (un) ] pH-7.36 Comment-GREEN TOP [2184-7-1] 01:14PM BLOOD Type-ART pO2-244* pCO2-42 pH-7.17* calTCO2-16* Base XS--12 Intubat-INTUBATED [2184-7-1] 02:04PM BLOOD Type-ART FiO2-21 pO2-246* pCO2-44 pH-7.26* calTCO2-21 Base XS--6 Intubat-INTUBATED [2184-7-1] 03:01PM BLOOD Type-ART pO2-155* pCO2-46* pH-7.15* calTCO2-17* Base XS--12 Intubat-INTUBATED [2184-7-1] 05:17PM BLOOD Type-ART pO2-86 pCO2-41 pH-7.24* calTCO2-18* Base XS--9 [2184-7-2] 03:32AM BLOOD Type-ART pO2-79* pCO2-34* pH-7.41 calTCO2-22 Base XS--1 [2184-7-2] 08:41AM BLOOD Type-ART pO2-104 pCO2-26* pH-7.43 calTCO2-18* Base XS--4 [2184-7-2] 10:09AM BLOOD Type-ART pO2-112* pCO2-25* pH-7.41 calTCO2-16* Base XS--6 [2184-7-2] 12:34PM BLOOD Type-ART pO2-158* pCO2-28* pH-7.37 calTCO2-17* Base XS--7 [2184-7-1] 03:00AM BLOOD Albumin-2.0* Calcium-8.1* Phos-5.1* Mg-2.3 [2184-7-1] 08:48AM BLOOD Albumin-2.1* Calcium-7.7* Phos-5.1* Mg-2.1 [2184-7-1] 05:03PM BLOOD Albumin-2.1* Calcium-7.8* Phos-5.4* Mg-1.8 [2184-7-2] 03:08AM BLOOD Albumin-2.1* Calcium-7.7* Phos-4.2# Mg-1.6 [2184-7-1] 03:00AM BLOOD ALT-19 AST-38 CK(CPK)-43 AlkPhos-147* TotBili-5.9* [2184-7-1] 08:48AM BLOOD ALT-16 AST-30 CK(CPK)-41 AlkPhos-128* TotBili-5.5* [2184-7-1] 05:03PM BLOOD ALT-16 AST-33 AlkPhos-112 TotBili-5.4* [2184-7-2] 03:08AM BLOOD ALT-18 AST-53* AlkPhos-123* TotBili-9.1* [2184-7-1] 03:00AM BLOOD Glucose-129* UreaN-40* Creat-2.1* Na-150* K-4.0 Cl-115* HCO3-20* AnGap-19 [2184-7-1] 05:03PM BLOOD Glucose-88 UreaN-38* Creat-2.0* Na-150* K-3.7 Cl-117* HCO3-18* AnGap-19 [2184-7-2] 03:08AM BLOOD Glucose-113* UreaN-34* Creat-2.1* Na-146* K-3.8 Cl-111* HCO3-19* AnGap-20 [2184-7-1] 03:01AM BLOOD PT-22.4* PTT-38.0* INR(PT)-2.1* [2184-7-1] 05:03PM BLOOD PT-23.8* PTT-150* INR(PT)-2.3* [2184-7-1] 10:15PM BLOOD PT-21.1* PTT-40.6* INR(PT)-2.0* [2184-7-2] 03:08AM BLOOD PT-22.0* PTT-40.3* INR(PT)-2.1* [2184-7-1] 03:00AM BLOOD WBC-17.1# RBC-3.67 Hgb-11.8* Hct-36.6* MCV-100* MCH-32.1* MCHC-32.2 RDW-18.2* Plt Ct-244 [2184-7-2] 03:08AM BLOOD WBC-13.5* RBC-3.79* Hgb-11.8* Hct-36.7* MCV-97 MCH-31.1 MCHC-32.1 RDW-18.4* Plt Ct-168 [2184-7-1] 1. No findings to account for bright red blood per rectum. Multiple air- fluid levels throughout non-dilated loops of small bowel and colon, which is nonspecific. The stomach is mildly distended and fluid is noted within the esophagus; the patient may benefit from an NG tube. No large abdominal mass and no secondary signs of ischemic bowel. 2. Anasarca with increased ascites and slightly increased right greater than left pleural effusions. [2184-7-1] EGD Food in the lower third of the esophagus Erythema and congestion in the whole stomach compatible with mild portal hypertensive gastropathy Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Admitted to West I surgical service. He received aggressive IV hydration. Anticoagulants were held due to coagulopathy and GI bleeding. CT scan was performed which didn't show any source for the GI bleed. EGD was negative. Due to worsening clinical status he was brought to the operating room for exploration. Laparoscopy showed dusky bowel from ligament of treitz to ileum. The abd was opened and there was no pulse in the SMA. Patient was brought to the angiography suite and an occlusion of the sma was visualized via angiogram of the celiac trunk. Multiple attempts were made to access the SMA but were not successful. He was brought back to the icu. He was taken back to the OR the next day for a 2nd look. His bowel looked more dusky and irrecoverable. Discussions were had with family members and he was made [Name (NI) 3225]. He was disconnected from the ventilator at 6pm and died at 8:10. Medications on Admission: Medications - Prescription ADALIMUMAB [HUMIRA PEN] - (Prescribed by Other Provider) - Dosage uncertain CLOBETASOL - (Prescribed by Other Provider) - Dosage uncertain GLIPIZIDE - (Prescribed by Other Provider) - 2.5 mg Tablet Extended Rel 24 hr (2) - 1 (One) Tab(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1 (One) Tablet(s) by mouth once a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day 25mg OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider; OTC) - 325 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day CALCIUM - (Prescribed by Other Provider) - Dosage uncertain CYANOCOBALAMIN - (Prescribed by Other Provider) - 1,000 mcg Tablet Sustained Release - 1 (One) Tablet(s) by mouth once a day FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg Iron) Tablet - 1 (One) Tablet(s) by mouth once a day MULTIVITAMIN [DAILY VITAMIN] - (Prescribed by Other Provider; OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: mesenteric ischemia Discharge Condition: deceased Completed by:[2184-7-2]	[ "4019", "25000", "5845", "V4581" ]
Admission Date: [2150-12-29] Discharge Date: [2150-12-30] Date of Birth: [2131-9-1] Sex: F Service: MEDICINE Allergies: Haldol / Morphine / Percocet / Dilaudid / Demerol Attending:[Last Name (NamePattern4) 290] Chief Complaint: dyspnea and stridor Major Surgical or Invasive Procedure: none History of Present Illness: pt is a 19 yo female with PMH of multiple admissions with intubation for presumed asthma exacerbations, paradoxical vocal cord dysfunction, depression, and conversion disorder presents with dyspnea and stridor. She states that today after walking on the treadmill and then walking to Starbucks she began feeling dyspnea, stridor, and chest tightness typical of her usual symptoms. She reports a dry cough and congestion during the last few days but no fevers/chills, HA, photophobia, CP, N/V. She reports two sick contacts who live in her dorm. Of note, she has three recent [Hospital1 18] admissions (most recent [12-23], [11-22], [10-23]) for paradoxical vocal cord movement vs asthma flare requiring intubation during two of them. During her last admission, she was not intubated and she was noted to respond well to prn ativan. . In the ED, she had a RR in the 30's, and she received albuterol nebs, heliox, and 3mg ativan. Her O2 sats remained 98-100%. She was transferred to the [Hospital Unit Name 153] for continued monitoring. . In the [Name (NI) 153], pt is satting well on 35% O2 and reports that she feels better with no more chest tightness. She continues to have audible inspiratory stridorous sounds that increase during examination and were no longer present when she fell asleep. Past Medical History: # Question asthma: Patient had been treated for asthma since [2148], with home medications including prednisone, albuterol, ipratropium, montelukast, and fluticasone. Additionally, pt had been hospitalized for supposed asthma flares requiring intubation. Supposed to have methacoline challange PFT as an outpatient but hasn't been performed yet. Followed by Dr. [Last Name (STitle) 2171]. # Paradoxical vocal fold dysfunction: Diagnosed per ENT fiberoptic exam 9/[2150]. # Depression # Conversion disorder: Per OMR notes recounting conversation with [Hospital1 2025] psychiatry ([First Name8 (NamePattern2) ] [Doctor Last Name ]), pt demonstrated fictitious symptoms including asthma, hyperventilation, LOC [3-20] hyperventilation, pseudo-seizures, and self-induced cellulitis. Social History: She is a sophomore nursing student at [University/College ]. She lives in a dorm. She denies tobacco, alcohol, and other illicit drugs. Family History: # Brother: Seasonal allergies # Father died of MI in his 40s Physical Exam: vitals: T 96.1 BP 127/79 HR 98 RR 21 SpO2 99 gen: overall well appearing, in NAD heent: NCAT, EOMI grossly pulm: inspiratory stridorous sounds, no crackles or wheezes cv: tachycardic, no m/r/g abd: s/nt/nd/nabs/no hsm extr: no c/c/e neuro: aox4, ch [3-30] intact grossly Pertinent Results: [2150-12-29] 10:45PM GLUCOSE-102 UREA N-9 CREAT-1.0 SODIUM-141 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 [2150-12-29] 10:45PM WBC-7.3 RBC-4.65 HGB-13.2 HCT-38.1 MCV-82 MCH-28.3 MCHC-34.6 RDW-16.0* [2150-12-29] 10:45PM NEUTS-71.8* LYMPHS-22.6 MONOS-4.6 EOS-0.6 BASOS-0.4 [2150-12-29] 10:45PM PLT COUNT-234 . CHEST (PORTABLE AP) [2150-12-29] 11:16 PM FINDINGS: AP view of the chest in upright position. The cardiomediastinal silhouette is normal. The lungs are clear. There is no pneumothorax or pleural effusion. The pulmonary vasculature is normal. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 19 yo female with hx of question of asthma with many exacerbations, vocal cord dysfunction, depression, and conversion disorder presents with stridor and tachypnea. . # dyspnea and stridor: this is typical of her previous ? asthma exacerbations, for which she does not appear to have a definitive diagnosis. She received ativan, heliox, and nebs in the ED with some resolution of symptoms. Although she has a question of airway disease and a diagnosis of vocal cord dysfuction, this is most likely a manifestation of her conversion disorder. CXR appears normal and unchanged. Most recent admission reported good response to ativan. She continues to sat well in the upper 90s. She will likely benefit most from consistent social and outpatient medical support to help her more effectively deal with anxieties and avoid the ED/ICU where iatrogenic harm may come to her. She has seen ENT before. She was given ativan prn, reassurance, and her inhalers were continued. A coordinated attempt improve her support structure was already in development, but further impetus was placed by emails and phone calls to her major sources of health care support - her PCP, [Name10 (NameIs) 19039] and [University/College 3036]. Will discuss with PCP, [Name10 (NameIs) 19039], and [University/College 68304]: coordination of care. Follow up appointments are set up [University/College 68305]health services on [12-31] at 9 am. They agreed to set up support services necessary to her after the visit tomorrow. Will encourage her to follow up with speech/swallow/behavioral therapy as outpatient . # conversion disorder: previously diagnosed at [Hospital1 2025]. As above, this is likely the root cause of her exacerbations and would benefit from greater outpatient and social support. . # depression: previously treated with lamotrigine, though not currently treated. Possible [Hospital1 18] or [University/College ]psychiatric referal after appointments at [University/College ]and/or PCP. . # FEN: regular diet, replete lytes prn . # PPx: ambulation, cont outpatient PPI . # Code: full Medications on Admission: # Pantoprazole 40 mg Q12H # Ferrous Sulfate 325 mg DAILY # Fluticasone-Salmeterol 250-50 [Hospital1 ] # singulair 10 # [Doctor First Name ]-D 24 Hour 180-240 mg PO once a day. # Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H prn shortness of breath or wheezing for 1 weeks. # Flonase 50 mcg/Actuation Aerosol 2 sprays once a day. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. [Doctor First Name ]-D 24 Hour Oral 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: PRIMARY 1. Paroxysmal vocal cord dysfunction SECONDARY 1. Depression 2. ? Reactive airways disease Discharge Condition: Good. Afebrile and hemodynamically stable. Discharge Instructions: You were admitted to the intensive care unit with difficulty breathing and URI-like symptoms. Your symptoms are likely due to vocal cord dysfunction, please follow the management plan discussed. Please continue your breathing and relaxing exercises as these helped improve your symptoms. . Please take all of your medications as prescribed. . Please keep your follow-up appointments. Followup Instructions: Please call [Telephone/Fax (1) 250] to schedule an appointment with your primary care provider, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. . You also have an appointment scheduled with [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 68306] at [University/College ]Health Services on [12-31] at 9 am. They will arrange for any further services needed. Please keep your previously scheduled appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 30764], MD Phone:[Telephone/Fax (1) 1723] Date/Time:[2151-1-6] 3:45 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 3731] Date/Time:[2150-12-30] 4:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 3731] Date/Time:[2151-1-13] 4:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 3731] Date/Time:[2151-1-19] 4:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "49390", "311" ]
Admission Date: [2200-6-13] Discharge Date: [2200-6-22] Date of Birth: [2144-11-5] Sex: F Service: MEDICINE Allergies: Latex / lisinopril Attending:[First Name3 (LF) 87302] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Lumbar puncture Thoracentesis left breast wound drainage History of Present Illness: 55 yo F with breast cancer, HTN, DM2, presents with dyspnea on exertion, orthpnea, and lower extremity edema. She says her symptoms started 2 weeks ago, even before her breast surgery, which was on [2200-6-4]. At that time, she underwent left needle-localized lumpectomy, sentinel node biopsy, and low axillary dissection. During the last couple of weeks, her dyspnea has worsened. It is worse with exertion and with lying flat. She has also noticed lightheadedness and has needed to steady herself when walking. She has had a cough, productive of yellow sputum. No hemoptysis. +bilateral ankle swelling. Due to wheezing, she was treated with albuterol as an outpatient, but that did not seem to help. The symptoms became worse over the past couple of days, leading the patient to present to the ED. In the ED, initial VS were: T 98.0 BP 103/73 HR 112 RR 16 Sat 97%/RA. Bedside ultrasound showed significant bilateral pleural effusion without pericardial effusion. The patient was given levofloxacin and vancomycin due to concern for infection. Subsequently CTA showed PE. She was guaiac negative, but head CT showed an abnormality for which the differential included subarachnoid hemorrhage, so heparin was not started. The patient was given 500 cc of normal saline. On transfer to the [Hospital Unit Name 153], vital signs were 97.5 120 24 128/75 100%/2L. On arrival to the MICU, the patient stated that her breathing was improved. Past Medical History: diabetes mellitus, type 2 breast cancer (see below) vitamin D deficiency HTN hyperlipidemia obesity low vision congenital syphilis Oncologic history: -Breast cancer, stage IIB -[12-16] Mammogram/ultrasound: Mass in left upper outer quadrant. Hypoechoic solid, irreg., spiculated 2.5x2.1x2.4cm. Left axilla with multiple hypoechoic nodules consistent with lymph nodes, largest 1.7cm and 3.4cm. -Pathology: Poorly differentiated invasive ductal carcinoma without definite in situ or lymphatic vascular invasion. Immunohistochemistry showed a negative estrogen and progesterone receptor HER2/neu was 2+. -[2200-1-15]: CT chest/abd/pelvis neg for malignancy -[2200-1-31] - [2200-3-14]: 4 cycles of Adriamycin and Cytoxan -[2200-3-28], [2200-4-4] and [2200-4-11] Taxol 80mg/m2 and Herceptin -[5-2] Taxol 175/m2, herceptin (cycle #3) -[2200-5-16] taxol/175/m2, herceptin C4 Social History: Has 8 children. Tobacco: Quit [2186] EtOH: Quit 22 year ago. Drugs: Quit 22 years ago. Family History: Daughter with breast cancer. No family history of venous thromboembolism. Physical Exam: ADMISSION EXAM: Vitals: HR 115 BP 117/66 Sat 96% General: Alert, oriented, no acute distress HEENT: Left eye cloudy, with chronic visual loss, MMM, oropharynx clear, EOMI Neck: supple CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds at bilateral bases Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, trace bilateral LE edema Neuro: Right pupil round and reactive. Left eye opacified (chronic). EOMI, with end-gaze nystagmus in all directions of gaze. Facial movement full, 5/5 strength upper extremities, lower extremity movement symmetric but did not stress calves due to possibility of DVT. DISCHARGE EXAM: Vitals: 97.4, 98/68 (90-100/60-80s), 100, 20, 97% on RA General: Alert, oriented, no acute distress HEENT: Left eye with congenital lid lag, MMM, EOMI Neck: Supple Axilla: Left axilla with area of swelling at surgical site, surrounding erythema and induration CV: Tachycardic, no m/r/g Lungs: Decreased breath sounds at bases b/l, otherwise clear without wheezes Abdomen: +BS, soft, non-distended, no tenderness Ext: Warm, well perfused, no pedal edema Neuro: Right pupil round and reactive. Left eye opacified (chronic). Pertinent Results: ADMISSION LABS: [2200-6-13] 03:30PM WBC-5.1 RBC-3.88* HGB-11.3* HCT-35.8* MCV-92 MCH-29.0 MCHC-31.5 RDW-16.3* [2200-6-13] 03:30PM NEUTS-68.6 LYMPHS-22.1 MONOS-5.5 EOS-3.1 BASOS-0.6 [2200-6-13] 03:30PM PLT COUNT-305 [2200-6-13] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2200-6-13] 03:53PM LACTATE-1.5 [2200-6-13] 03:30PM GLUCOSE-97 UREA N-10 CREAT-0.9 SODIUM-139 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15 CARDIAC LABS: [2200-6-13] 03:30PM CK(CPK)-72 [2200-6-13] 03:30PM cTropnT-0.04* [2200-6-13] 03:30PM CK-MB-2 [2200-6-14] 12:06AM BLOOD CK-MB-2 cTropnT-0.04* [2200-6-14] 05:22AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-684* [2200-6-14] 04:16PM BLOOD CK-MB-2 cTropnT-0.02* BODILY FLUIDS: [2200-6-14] 01:14PM PLEURAL WBC-450* RBC-3550* Polys-5* Lymphs-68* Monos-15* Eos-1* Atyps-2* Meso-2* Other-7* [2200-6-14] 01:14PM PLEURAL TotProt-1.8 Glucose-94 LD(LDH)-74 Cholest-17 Triglyc-8 [2200-6-14] 05:28PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-1 Lymphs-77 Monos-22 [2200-6-14] 05:28PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-65 LD(LDH)-16 Herpes simplex PCR: negative DISCHARGE LABS: [2200-6-22] 04:48AM BLOOD WBC-4.1 RBC-3.68* Hgb-10.3* Hct-33.3* MCV-91 MCH-28.1 MCHC-31.1 RDW-15.7* Plt Ct-287 [2200-6-22] 04:48AM BLOOD Glucose-88 UreaN-8 Creat-0.8 Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 [2200-6-22] 04:48AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0 MICROBIOLOGY: [2200-6-15] BLOOD CULTURE -NO GROWTH [2200-6-14] CSF GRAM STAIN (Final [2200-6-14]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2200-6-17]): NO GROWTH. FUNGAL CULTURE (Final [2200-7-4]): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. NO MYCOBACTERIA ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [2200-6-14] PLEURAL FLUID GRAM STAIN (Final [2200-6-14]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2200-6-18]): NO GROWTH. ANAEROBIC CULTURE (Final [2200-6-20]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2200-6-15]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [2200-6-13] BLOOD CULTURE - NO GROWTH. IMAGING: # [2200-6-13] CXRay: IMPRESSION: Bilateral moderate pleural effusions with adjacent bibasilar atelectasis and mild pulmonary congestion. Pneumonia cannot be entirely excluded in the right clinical setting. # [2200-6-13] CTA chest: IMPRESSION: 1. Left lower lobe segmental pulmonary embolism without evidence of right heart strain or pulmonary infarction. 2. Interlobular septal thickening is concerning for fluid overload. Given the lack of nodularity, carcinomatosis seems much less likely, but is hard to completely excluded. 3. Moderate bilateral pleural effusions, larger on the right than the left. In conjunction with the septal thickening, these are most likely secondary to fluid overload from CHF, although malignant effusions cannot be completely excluded. 4. Bibasilar consolidations are likely atelectasis, although in the proper clinical setting, infection cannot be excluded. 5. Subcutaneous air in the left breast, possibly extending to the skin. These are likely postoperative changes. Recommend clinical correlation, however, with direct inspection of the operative site. 6. Left axillary seroma. 7. Trace pericardial effusion. # [6-13] CT head: Abnormal gyriform hyperdensity in the left frontal lobe of uncertain etiology in the setting of prior intravenous contrast administration, but the differential diagnosis includes abnormal enhancement associated with leptomeningeal carcinomatosis, possibly with a parenchymal mass or edema; although unlikely, it is not possible to exclude hemorrhage. Recommend an MRI for further evaluation. # [6-14] Echo: Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-6]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Cardiomyopathy. Pericardial effusion. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. # [6-14] MRI w and w/o contrast: CONCLUSION: Left frontal and right parietal enhancing lesions appear most likely to be subacute infarction, with the right parietal lesion more recentthan the left frontal. # [6-14] CTA head: No vascular abnormalities detected on the head CTA. Left frontal enhancement and left mastoid opacification appear unchanged. # [6-16] CXR IMPRESSION: Moderate left and trace right pleural effusion with likely mild pulmonary edema. # [6-20] Left axillary U/S: FINDINGS: A focused left axilla ultrasound was performed in the in the region of concern. Two heterogeneous complex collections, which appear to communicate, are identified in the anterior left axilla. The 1st more superior and superficial collection in subdermal location, measures 5 cm in transverse and 2 cm deep. This collection demonstrates several persistent foci of low-level back and forth flow. A 2nd more inferior collection measures 7 x 6.5 cm. No Doppler flow is seen in this 2nd collection. The collections are far removed from the left axillary artery. IMPRESSION: Two, apparently communicating, 5 and 7 cm complex fluid collections in the left axilla may represent hematomas although infection cannot be excluded. Flow into the more superior collection may be due to mobile fluid or slow continued bleeding (felt less likely). A contrast CT may be useful to evaluate for continued bleeding, if clinically warranted, but venous bleeding can be difficult to assess. Brief Hospital Course: 55 yo female with hx breast cancer, HTN, DM2, who presented with dyspnea on exertion, orthopnea, and lower extremity edema found to have a PE, bilateral pleural effusions, and pericardial effusion with new systolic CHF. ACTIVE ISSUES: # PE: Pt presented with DOE, orthopnea and cough, likely due in part to new diagnosis of pulmonary embolism. In the [Name (NI) ], pt was guaiac negative, but head CT showed an abnormality for which the differential included subarachnoid hemorrhage, so initiation of heparin was deferred and pt was transferred to the [Hospital Unit Name 153]. Neurology was consulted and an LP was performed, which was unrevealing for any infectious etiologies. Neurology felt it was safe to start anticoagulation so she was started on Lovenox. Pt was not interested in Coumadin monitoring so she was continued on Lovenox. She had a TTE which was negative for any evidence of right heart strain. She was quickly weaned off oxygen and was satting in mid to high 90s on room air at time of discharge. # systolic CHF: Because of new pleural effusions noted on chest CT, TTE was performed which showed severe global left ventricular hypokinesis with EF of 25% along with small pericardial effusion (no tamponade), which was new from prior echo at start of chemo therapy. The concern is that her new diagnosis of CHF may have been secondary to chemotherapy she received for recent diagnosis of breast cancer. Pt had a therapeutic/diagnosis paracentesis performed, which was transudative in nature. She was initially diuresed, but this was complicated by hypotensive episodes. At time of discharge, pt appeared euvolemic. She was started on Valsartan and low dose aspirin and will follow up with cardiology as an outpatient. Consider spironolactone and beta blocker once stable to medically optimize, although anticipate cardiomyopathy may reverse when Adriamycin is complete and these medications may not be necessary. Her pleural fluid cytology was negative for malignant cells. # Axillary fluid collection: Pt was noted to have increasing erythema, warmth and induration in left axilla at site of recent breast drainage. Surgery was consulted and drained a small collection of serosanguinous fluid. She was initially started on Keflex for presumed cellulitis, however the patient was afebrile and without leukocytosis so Keflex was discontinued. Her factor X level was checked given that patient was on Lovenox and there was concern that if she was supratherapeutic, it may be contributing to bleeding within her recent surgical site. However, her Lovenox dosing appeared adequate and her hct remained stable. She had a left axillary ultrasound that did show a communicating fluid collection so surgery drained more fluid. At time of discharge, pain and induration had improved, and pt will follow up with surgery as an outpatient. # Brain MRI c/w infarcts: Because of abnormal head CT obtained in the [Last Name (LF) ], [First Name3 (LF) ] MRI was obtained which showed several enhancing lesions consistent with subacute infarcts. Neurology felt that these were most likely embolic in nature. She had a TTE with negative bubble study. She was continued on her pravastatin and aspirin and will need a repeat MRI as an outpatient in [1-6] months. # neuropathy: Pt complained of recent onset lower extremity tingling, concerning for chemotherapy induced neuropathy. She was started on low dose gabapentin during this admission and this can be increased as necessary as an outpatient. CHRONIC ISSUES" # Breast cancer: Staged as 2B s/p treatment with Adriamycin and cyclophosphamide, Taxol, and weekly Herceptin, needle-localized lumpectomy, sentinel node biopsy, and low axillary dissection with pleural effusion negative for malignancy. Her further chemotherapy options may be limited as pt appeared to develop CHF in setting of active chemotherapy. She will follow up with oncology as an outpatient. # T2DM: Pt was on metformin at home, though this was held while in house. Her blood sugar was controlled with insulin 75/25 as well as sliding scale insulin. Her insulin dose was decreased during this hospitalization given low blood sugars. Her metformin was resumed on discharge. # Depression: Continued bupropion TRANSITIONAL ISSUES: # Pt's hypercoagulable work up was pending at time of discharge and should be followed as an outpatient. # Pt will need a repeat outpt brain MRI in [1-6] months. # She will need to establish care with cardiology as an outpatient for continued adjustment of medications given her new diagnosis of heart failure. # Pt will need to follow with surgery regarding her left axillary seroma. Medications on Admission: Losaratan 50mg Oral daily Pravastatin 40mg Daily Metformin 1000mg daily Clobetasol 0.05% Topical PRN (eczema) Insulin Lispro 75-25 KwikPen 18 units before breakfast and dinner (does not check her BG usually otherwise) Buproprion 300mg XL daily Herceptin - every 4 weeks infusion Discharge Medications: 1. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous every twelve (12) hours. Disp:60 syringes Refills:0 2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. valsartan 40 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:0 4. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. 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:0 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:0 9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Six (6) units Subcutaneous twice a day. 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY: Pulmonary embolism Congestive heart failure SECONDARY: breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 4427], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for shortness of breath. You were found to have a pulmonary embolism (a blood clot in your lungs) as well as congestive heart failure. This means that your heart does not pump as effectively as it should. You were noticed to have some bleeding into your left breast where you had surgery. Because of the blood clot, you will need to be on blood thinners. We also changed some of your other medications for your heart. Please make the following changes to your medications: # START lovenox 80 mg injections twice a day # START valsartan 20 mg daily # START omeprazole 40 mg daily # START aspirin 81 mg daily # START gabapentin 100 mg three times a day # USE albuterol inhaler every 4 hours as needed for shortness of breath # STOP losartan # DECREASE insulin 75-25 to 6 units in the morning and before dinner. Please check your blood sugars 4 times a day, as your insulin dose may need to be adjusted further. Please continue all other medications as prescribed. Followup Instructions: Cardiology Appointment: Thursday, [6-26] at 1:30pm With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location:[Hospital1 ] [Location (un) 4363], [Location (un) 86], [Numeric Identifier ] Phone: [Telephone/Fax (1) 2258] PCP [Name Initial (PRE) 648]:[Last Name (LF) 2974], [6-27] at 10:40am With:[First Name11 (Name Pattern1) 2114] [Initials (NamePattern4) ] [Last Name (NamePattern4) 2113],MD Location: [Hospital1 641] Address: [University/College 2899], [Location (un) ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 2115] Hematology/Oncology: [Last Name (LF) 2974], [7-4] at 11am With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 349] Location:[Hospital1 ] [Location (un) 4363], 4th fl [Location (un) 86], [Numeric Identifier ] Phone: [Telephone/Fax (1) 3468] Surgery Appointment:PENDING With: Dr. [First Name4 (NamePattern1) 69494] [Last Name (NamePattern1) 4048] Phone: [Telephone/Fax (1) 100016] We are working on a follow up appointment with Dr.[Last Name (STitle) 4048] in the next week. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number above. You should be seen this week. You will also need to have a repeat MRI brain done as an outpatient. Please discuss this with your primary care doctor. Completed by:[2200-7-4**]	[ "5119", "25000", "4019", "2720", "V5867", "4280" ]
Admission Date: [2129-10-10] Discharge Date: [2129-10-15] Service: MEDICINE Allergies: Codeine / Aspirin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 7333] Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] y/o DNR/DNI female with HTN, HLD, mild dementia, who presented to [Hospital1 18] ED today in setting of fall. Per discussion with patient, she has not been in her usual state of health for the past 1 week. She denies CP or SOB, but reports diaphoresis and feeling generally unwell for the past week. Today, she came in for evaluation of her fall. . Per [Hospital3 ] and daughter, the fall occured 2 days ago and was unwitnessed and she was found awake on the floor. Per patient, she felt dizzy, had +LOC, and fell without any pulmonary or cardiac symptoms prior. She refused to go to hospital. Over the course of the next day, her breathing became labored and her mental status had changed and she was confused. She refused to go to the hospital until today. . In the ED, there was concern for head trauma. She also reported pain in R arm and L hip. CT head and spine without acute pathology. Also had CT spine showing grade II anterolisthesis of C3 on C4, likely chronic. Imaging of spine, pelvis, hip, elbow, and shoulder were all normal, without acute pathology, per prelim read. CXR without acute pathology. . EKG was notable for non-specific ST-T wave changes, no prior for comparison. Her troponin was 0.66. Cardiology was consulted for NSTEMI. Aspirin and heparin gtt was initiated, with plan for admission to [Hospital1 1516]. . However, per ED, patient became "poorly responsive" at 6 pm. Repeat Head CT performed due to concern for ICH, as patient was started on heparin. Head CT was negative. A 2nd set of CE's was drawn and troponin was 1.10. EKG was checked and patient had new ST elevations in V3-V5, with concern for STEMI. Patient's mental status was now reported as back to baseline. She denied CP or SOB and did not have any symptoms. ED spoke with the family and daughter, and initial plan was for cardiac cath. Dr [Last Name (STitle) ] was called in. Cardiology was re-consulted. Bedside echo showed that her anterior inferior wall was down, but time course was unclear. . Patient was placed on heparin gtt again, and given eptifibatide (plavix was ordered but pt unable to swallow). Upon discussion with cardiology, and given overall clinical picture along with patient's desire to not proceed with cardiac cath, this was deferred. Plan to admit to CCU due to evolving STEMI with consideration for cath if patient develops any symptoms. . On transfer, vs: afebrile, 68, 151/90, 24, 100 2L (94% RA), no CP. She is AOx2 and has 1 PIV. . In CCU, pts vitals: afebrile, BP 142/84,HR 74, 95% on 3L. Pt reports some diapharesis in the ED but currently denies any chest pain, no diapharesis, no nausea, no jaw pain, no SOB. . Pt currently denies any chest pain, no shortness of breath, does report constipation, no headaches, no neurological changes, remainder of ROS is negtive. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: has had cardiac catheterization in [State 108] in the past, unclear when, without reported intervention -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: N/A -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY (per daughter): -Hx of supraventricular tachycardia -mitral valve prolapse -anemia on iron -gout -osteoarthritis vs RA of her bilateral hands and upper extremities, as well as her neck -venous stasis ulcers -Hemmorhoids -Colon polyps -"swollen legs" and wears compression stalkings . Past Surgical History (per PCP [Name Initial (PRE) 626]): -[2035] Tonsils -[2052] Appendix -[2066] Hysterectomy -[2068] and [2088] Surgery for "Ulcerated Rectum" -[2094] vaginal hernia -[2097] hernia repair with mesh Social History: -Tobacco history: never -ETOH: denies -Illicit drugs: denies Lives in [Hospital3 ] at Admiral's [Doctor Last Name ] in [Location (un) ]. Ambulating with walker last week. HHA 6:30-8:30am, 6:30-8:30pm (needs assist getting in/out of bed). . Family History: Mother (died age 60) and father (died age 40) both died of MIs . No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission VS: afebrile, BP 142/84,HR 74, 95% on 3L GENERAL:NAD Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm. CARDIAC: RRR, no mrg. LUNGS: no crackes, rhonchi, rhales ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ Pertinent Results: CBC: [2129-10-10] 11:55AM BLOOD WBC-11.9* RBC-3.90* Hgb-10.8* Hct-32.7* MCV-84 MCH-27.8 MCHC-33.1 RDW-14.3 Plt Ct-302 [2129-10-12] 06:05AM BLOOD WBC-16.1* RBC-3.79* Hgb-10.6* Hct-33.6* MCV-89 MCH-27.9 MCHC-31.5 RDW-14.8 Plt Ct-245 [2129-10-15] 08:00AM BLOOD WBC-11.9* RBC-3.56* Hgb-10.1* Hct-30.4* MCV-85 MCH-28.4 MCHC-33.3 RDW-15.9* Plt Ct-77* . Chem: [2129-10-10] 11:55AM BLOOD Glucose-140* UreaN-39* Creat-1.3* Na-142 K-4.5 Cl-102 HCO3-29 AnGap-16 [2129-10-11] 02:19PM BLOOD Glucose-137* UreaN-52* Creat-2.1* Na-143 K-4.8 Cl-108 HCO3-24 AnGap-16 [2129-10-13] 04:21AM BLOOD Glucose-102* UreaN-85* Creat-3.9* Na-143 K-5.1 Cl-107 HCO3-21* AnGap-20 [2129-10-14] 11:00AM BLOOD Glucose-117* UreaN-105* Creat-4.6* Na-140 K-5.2* Cl-114* HCO3-10* AnGap-21* [2129-10-15] 08:00AM BLOOD Glucose-117* UreaN-120* Creat-5.4* Na-144 K-5.4* Cl-110* HCO3-15* AnGap-24* . CEs: [2129-10-10] 11:55AM BLOOD cTropnT-0.66* [2129-10-10] 06:45PM BLOOD cTropnT-1.10* [2129-10-11] 02:40AM BLOOD CK-MB-20* MB Indx-8.4* cTropnT-1.37* [2129-10-11] 02:19PM BLOOD CK-MB-14* MB Indx-6.4* cTropnT-1.54* [2129-10-12] 06:05AM BLOOD CK-MB-14* MB Indx-4.8 cTropnT-1.59* Brief Hospital Course: [Age over 90 ] F with h/o HLD and HTN admitted for fall found to have STEMI (suspected to be in LAD territory given ST changes in V1-3). Pt and family declined cardiac cath and wished to proceed with solely medical management. CK-MB peaked at 20, Trop rose to 1.59. Pt was treated with aggressive medical management for STEMI with aspirin, bb, integrillin gtt, lisinopril. However, renal failure persisted, and pt began experiencing respiratory distress from fluid overload. No intervention was pursued, and patient was made CMO. Shortly thereafter, pt passed away. Medications on Admission: MEDICATIONS, per [Hospital3 ]: Paroxetine 15mg daily Miralax 17g PO QOD Prednisone 3mg daily Tramadol ER 200mg QHS Bisacodyl 10mg PO prn constipation >3d Lactulose 30mL [Hospital1 ] prn constipation Loperamide 2mg QID prn diarrhea Vit D 1,000 U daily Tylenol 650mg PO BID CaCO3 600mg (1500mg) daily furosemide 20mg PO daily Lisinopril 2.5mg daily lutein 6mg PO daily Toprol XL 75mg daily Omeprazole 20mg daily Oxycodone 2.5mg [Hospital1 ] Oxycodone 2.5mg Q6h prn pain Vit B12 1,000 mcg monthly sub q Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased	[ "5845", "4280", "42731", "2875", "2724", "40390", "4240" ]
Admission Date: [2173-8-12] Discharge Date: [2173-8-15] Service: MEDICINE Allergies: Bactrim / Procardia Attending:[First Name3 (LF) 458] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 87yo M with hx of DM, HTN, diverticulosis,s/p partial colectomy, depression, CKD, parkinson's vascular dementia, s/p pacemaker, who has been experiencing night desaturation for the past few days, worse this evening. At [Hospital 100] Rehab, he had awoken with SOB, satting 89% on 3L NC, improved to 95% on mask at 5L. Pt was given Lasix 40 mg po and 81 mg ASA. Pt had a second episode of SOB overnight, satting 70-80% on mask at 8L and was transferred to [Hospital1 18]. RR was 28, BP 150/80, HR 64, T 98 ax. Patient was non-communicative at time of exam and history was obtained from medical record and from family report. . On arrival to [Hospital1 18] ED, SpO2 76% on NRB, ABG of 7.34/66/53. He was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement of O2 sat to 90-100%. He received a nitro gtt, Lasix 60 mg IV, levofloxacin 750 mg IV, and albuterol nebulizer. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He has a chronic raspy cough per the daughter. [Name (NI) ] of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations. Daughter is not aware of any dyspnea on exertion, orthopnea. She has noted that he had ankle edema ("elephant legs") in the late winter and early spring and had asked [Hospital1 100] Senior Life to start the patient on Lasix. Daughter denies any syncope or presyncope. He has poor functional capacity at baseline. Past Medical History: PAST MEDICAL HISTORY: 1. Type 2 DM 2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter 3. HTN 4. Diverticulosis, s/p partial colectomy 5. Depression 6. CRI (baseline Cr 1.3-1.7) 7. Parkinson's disease 8. Vascular dementia 9. Pacemaker c/b lead thrombus. Previously followed by Dr [Last Name (STitle) ] for "episodic unreponsiveness." This resolved with pacemaker adjustment. Recently seen by Dr. [Last Name (STitle) ]/[Doctor Last Name ] for the thrombus, anticoagulation deferred for h/o falls, unsteady gait, and confusion. 11. s/p hip fracture requiring ORIF in [3-/2172] with a complicated medical course including hypoxic respiratory failure. 12. Chronic diastolic dysfunction. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Patient resides at [Hospital 100] Rehab. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 95.7 ax, BP 130/85, HR 79, RR 16, O2 95% on BiPap Gen: Fatigued older male in NAD. Oriented to self only, "[2138]", "[Hospital1 100]." Per daughter, mental status at baseline. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. ?S3. No murmurs noted. Chest: No accessory muscle use. Decreased breath sounds throughout, diffuse rhonchi. No crackles, wheezes. Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits. Ext: No femoral bruits. Trace pedal edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: PERRL, EOMI. Resting tremor. . Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP/PT [Name (NI) 2325]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP/PT Pertinent Results: ADMISSION LABS: [2173-8-12] 04:05AM BLOOD WBC-10.8 RBC-4.64# Hgb-13.5# Hct-41.4# MCV-89 MCH-29.1 MCHC-32.6 RDW-14.3 Plt Ct-146 Neuts-84.1* Lymphs-10.8* Monos-2.3 Eos-2.6 Baso-0.2 PT-14.0* PTT-27.7 INR(PT)-1.2* Glucose-208* UreaN-22* Creat-1.5* Na-145 K-3.5 Cl-101 HCO3-37* AnGap-11 [2173-8-12] 04:05AM BLOOD ALT-16 AST-19 LD(LDH)-200 CK(CPK)-85 AlkPhos-70 TotBili-0.4 CK-MB-NotDone proBNP-1203* Albumin-4.2 Mg-2.0 . [2173-8-12] 04:20AM BLOOD Type-ART pO2-53* pCO2-66* pH-7.34* calTCO2-37* Base XS-6 Intubat-NOT INTUBA . [2173-8-12] 05:37AM TYPE-ART PO2-70* PCO2-68* PH-7.32* TOTAL CO2-37* BASE XS-5 INTUBATED-NOT INTUBA . [2173-8-12] 10:51AM TYPE-ART PEEP-5 O2-60 PO2-130* PCO2-66* PH-7.35 TOTAL CO2-38* BASE XS-8 INTUBATED-NOT INTUBA . [2173-8-12] 01:44PM CK-MB-NotDone cTropnT-0.02* [2173-8-12] 01:44PM CK(CPK)-67 . [2173-8-13] 04:28AM Triglyc-163* HDL-34 CHOL/HD-4.1 LDLcalc-72 . [Hospital1 18] [Numeric Identifier 96306]Portable TTE (Complete) Done [2173-8-12] at 2:12:50 PM FINAL The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. . Compared with the prior study (images reviewed) of [2173-5-25], the previously suspected thrombus on the pacing wire is not apparent on the current study. However, the suboptimal image quality precludes close examination of the pacing wrie. The other findings are similar. . Radiology Report CHEST (PORTABLE AP) Study Date of [2173-8-12] 4:03 AM UPRIGHT PORABLE CHEST Streaky linear atelectasis is noted extending from the region of the right hila and at the left base in this patient with persistent low lung volumes. No evidence of interstitial pulmonary edema, pneumothorax, or consolidation to suggest pneumonia. The cardiomediastinal silhouette is unchanged with stable appearance to abnormal contour projecting above the aortic knob consistent with the patient's known pseudoaneurysm. Positioning of pacemaker leads is unchanged. . Radiology Report CHEST (PA & LAT) Study Date of [2173-8-14] 1:55 PM Lateral views are not well penetrated. The right hemidiaphragm is elevated, as before. The lungs appear clear except for streaky density in the retrocardiac area, which is suboptimally evaluated. The cardiac silhouette appears large but may be exaggerated by AP technique. A 4.5 cm round density projected adjacent to the aortic knob, consistent with a known aortic pseudoaneurysm is unchanged. Mediastinal structures are unchanged in appearance, and the bony thorax is grossly intact. A bipolar transvenous pacemaker remains in place. IMPRESSION: Streaky density in the retrocardiac area that may represent partial atelectasis or consolidation. Elevation of the right hemidiaphragm. No definite interval change. Brief Hospital Course: The patient is an 87yo man with a history of Diabetes, Hypertension, diastolic CHF, s/p pacemaker, CKD, Parkinson's, and vascular dementia who presented for SOB/hypoxia and found to be in hypercarbic/hypoxic respiratory failure requiring BiPap. . # Hypercarbic/hypoxic respiratory failure: The patient was hypoxic on admission with SpO2 76% on NRB and an arterial blood gas of 7.34/66/53. He was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement of O2 sat to 90-100% which was weaned over several hours. The patient had no history of COPD or asthma. His acute hypoxia was felt to be due to diastolic heart failure, although CXR appeared to have mild pulmonary edema without significant change from [4-22]. The patient was afebrile, without cough, fever or leukocytosis. PE was considered given a previously noted thrombus in the RA and the patient's poor functional capacity at baseline. However, repeat ECHO was without evidence of thrombus and there was no evidence of DVT on physical exam. The patient received Lasix boluses for diuresis and was slowly switched back to his home dose of PO Lasix. Over the course of hospitalization the patient had marked improvement in his supplemental oxygen requirements and at the time of discharge he was sating well on 4L of oxygen. . # Diastolic CHF: The patient had an Echocardiogram in [Month (only) ] with evidence of mild pulmonary artery systolic hypertension and diastolic dysfunction. On presentation this admission, the patient lacked overt volume overload on arrival and chest xray was not remarkably changed from previous exams. However, BNP was elevated at 1203. Blood pressure was noted to be 150/80 and the patient was given IV Lasix boluses and started on a Nitro gtt for blood pressure control. Repeat ECHO showed little change since previous exam. We would encourage daily weights and a low sodium diet in this patient. Should his weight increase greater than 3 pounds, he should be given an extra PM dose of Lasix. . # HTN: The patient was noted to be hypertensive during admission, with systolic blood pressures to the 160's/170's. He was initially started on a Nitro drip for immediate blood pressure control. He was then transitioned to oral medications. His home dose of metoprolol was increased from 12.5mg daily to 100mg and he was started on Imdur 30mg daily with a good response in BP. At the time of discharge, his blood pressure was in an acceptable range of 110's systolic. . # CAD/Ischemia: The patient had an episode of chest pain. Cardiac enzymes were unremarkable with troponin was slightly elevated in setting of chronic renal failure, possible demand ischemia from diastolic CHF. The patient had no known history of CAD and no evidence of acute ischemic changes on EKG. . # DM: The patient was maintained in glipizide and an insulin sliding scale for extra coverage. . # CRI (baseline Cr 1.3-1.7): The patient had a history of chronic renal insufficiency and on arrival, his creatinine was at baseline. Following Lasix diuresis, the patient's creatinine increased to a peak of 1.9 but was trending down at the time of discharge. The patient was discharged on his home dose of Lasix (60mg). His renal function should be carefully monitored and his Lasix dosing adjusted accordingly. . # Parkinson's disease/Vascular Dementia/Depression: The patient was maintained on his normal regiment of donepezil, Mirapex, bupropion HCl, and Celexa 20 mg. His nightly trazodone dose was increased to 25mg QHS. . # Code status: Full code, confirmed with daughter. . Medications on Admission: CURRENT MEDICATIONS: Furosemide 60 mg daily, started in [4-22] Metoprolol XL 12.5 mg daily KCl 10 meq MWF Glipizide 5 mg daily Acetaminophen 975 mg q 6 hrs Bupropion Hcl 75 mg [Hospital1 ] Celexa 20 mg daily Donepezil 10 mg daily Mirapex 0.25 mg TID Trazodone 12.5 mg qhs Keflex 500 mg daily for chronic suppressive therapy Ferrous sulfate 325 mg daily Vitamin D 1000 units daily Calcium carbonated 650 mg [Hospital1 ] Vitamin C Vitamin B12 1000 mcg IM monthly Melatonin 4 mg qhs Discharge Medications: 1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO MWF. 17. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 18. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 19. Vitamin C 100 mg Tablet Sig: One (1) Tablet PO once a day. 20. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 21. Melatonin 1 mg Tablet Sig: Four (4) Tablet PO qHS. 22. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary: diastolic Heart Failure HTN Type 2 DM CRI (1.3-1.7) Secondary: Diverticulosis, s/p partial colectomy Depression Parkinson's disease Dementia-vascular on MRI [2162] Pacemaker Discharge Condition: The patient was hemodynamically stable, afebrile and without pain. He was sating 96% on 3L NC oxygen. Discharge Instructions: You were admitted for evaluation of shortness of breath. It was felt that your symptoms were realated to poor heart function. You were treated with diuretics and oxygen with a significant improvement in your symptoms. During your hospitalization, it was noted that your blood pressure was elevated. We have increased your dose of metoprolol to 100mg daily and we have also added an additional medication (Imdur). You should take both medications as prescribed. We have also increased your dose of trazadone from 12.5 to 25mg every evening. Please take all medications as prescribed. You should follow-up with your primary care doctor with regards to your kidney function. You should be weighed daily. If you have a weight gain > 3lbs, you should take an EXTRA dose of Lasix (40 mg) in the evening. Please call your doctor or return to the hospital if you develop chest pain, increased shortness of breath, numbness or tingling in your arm, nausea, vomiting, fevers, chills or any other symptoms of concern. Followup Instructions: Appointments scheduled prior to admission: . Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2173-12-2] 1:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2173-12-2] 1:45 Completed by:[2173-8-15]	[ "51881", "311", "25000", "5859", "4280" ]
Admission Date: [2108-3-29] Discharge Date: [2108-4-8] Date of Birth: [2032-5-22] Sex: M Service: MEDICINE Allergies: Penicillins / Azithromycin / furosemide Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Acute kidney injury Major Surgical or Invasive Procedure: balloon valvuloplasty History of Present Illness: 75 YOM with h/o severe AS ([Location (un) 109] 0.8), sCHF (EF of 20-25% on [2108-2-14]) and regular patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] presenting to [Hospital1 18] ED after routine labs showed [Last Name (un) ]. He was last hospitalized here at [Hospital1 18] in [1-/2107] for NSTEMI, found to have 3VD and underwent CABG. Intraoperative assesment of his aorta revealed extensive calcification and he was felt to be extremely hig risk for open AVR. His AS has been managed medically since. 2 weeks ago he was admitted to OSH with SOB and found to be in CHF exacerbation. He was diuresed and on discharge his torsemide was increased to 40mg QD 2 weeks ago. He was seen yesterday in Dr.[Name (NI) 12389] office, where they agreed to pursue TAVI and a follow up appointment with Dr. [Last Name (STitle) ] was planned. He underwent routine Lab check at that time which showed [Last Name (un) ]. (Cr 7 base line 1.9) with hyperkalemia. He was telephoned this afternoon and sent to the ED. He is reportedly asyptomatic but had tenuous BP's (SBP in the 80's). Prior to [2107-10-27] it looks like his sBP's have been running in the 100's but since the new year he has been living in the 90's. Given his low EF, critical AS and dehydration he is being admitted to the CCU for fluid resuscitation and close monitoring. . Of note he had shingles during last hospitalization and was put on valcyclovir; he still c/o some residual intermittent pain on his L flank and back. Currently denies CP, SOB, abdom pain, F/C, D/C, N/V. Does report [Month (only) ]'d PO intake recently; has been taking all his Rx as directed. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: [2107-2-4] and underwent an off-pump coronary bypass grafting x1 with the left internal mammary artery to left anterior descending artery. - PERCUTANEOUS CORONARY INTERVENTIONS: NONE - PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: AS- [Location (un) 109] 0.8cm2 and EF 10% in [1-/2107] CAD- NSTEMI in [1-/2107] with 3VD chronic systolic heart failure CRI (baseline Cr 1.9) right foot w diabetic ulcer PVD Depression Past Surgical History Left CEA Right fem-[Doctor Last Name ] bypass [2-/2106] Prostatectomy Partial colectomy for adenoma [2104] Social History: Race: Caucasian Lives with: wife Occupation: retired, sales Tobacco: 60 pack yrs, quit 1 year ago ETOH: denies Family History: Family History: Father, CHF, d. age 54 pneumonia Mother DM, d. age [Age over 90 ] myocardial infarction Brother CA unknown Brother Bladder ca No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.1 BP=93/36 HR= 58 RR=17 O2 sat=100%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP flat/not visualized. CARDIAC: RR, normal S1, S2. 4/6 systolic murmur loudest at RUS border heard throughout precordium. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: middle of L stomach, flank, and back in dermatomal distribution, are several scattered papules c/w healing vesicles/scabs NEURO: AAOx3, CNII-XII intact PULSES: DP and PT pulses b/l difficult to assess DISCHARGE EXAM: 98.1, 103/59, 90, 18, 99% RA, Weight 72.8kg GENERAL: NAD. Comfortable, appropriate and in NAD CARDIAC: RRR, S1, S2 but heart sounds faint. 1/6 systolic murmur loudest at RUS border. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: middle of L stomach, flank, and back in dermatomal distribution, are several scattered erythematous patches with healing scabs. rash is TTP. No other rashes noted. NEURO: AAOx3, PULSES: 1+ DP/PT, no pedal edema Pertinent Results: ADMISSION LABS: [2108-3-29] 12:00PM BLOOD WBC-8.2 RBC-3.59* Hgb-11.1* Hct-35.3* MCV-98 MCH-31.0 MCHC-31.5 RDW-14.3 Plt Ct-310 [2108-3-29] 12:00PM BLOOD PT-10.9 PTT-27.8 INR(PT)-1.0 [2108-3-29] 12:00PM BLOOD Glucose-113* UreaN-113* Creat-7.3# Na-134 K-6.6 Cl-100 HCO3-15* AnGap-26* [2108-3-29] 12:00PM BLOOD Calcium-8.9 Phos-5.7# Mg-2.6 [2108-3-29] 07:23PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 [2108-3-29] 07:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [2108-3-29] 07:23PM URINE RBC-1 WBC-7 Bacteri-NONE Yeast-NONE Epi-<1 [2108-3-29] 07:23PM URINE CastHy-25* [2108-3-29] 07:23PM URINE Hours-RANDOM UreaN-468 Creat-119 Na-65 K-23 Cl-57 . DISCHARGE LABS: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2108-4-8] 06:00 7.8 2.83* 9.0* 28.4* 100* 31.8 31.7 14.5 268 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2108-4-5] 00:14 83.1* 10.5* 5.9 0.3 0.2 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2108-4-8] 06:00 1231 27 1.4* 139 4.6 107 21* 16 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2108-4-7] 06:00 33 67* 386* 2501 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2108-4-8] 06:00 7.9* 1.7* 2.5 . MICROBIOLOGY: -[2108-3-29] 7:59 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. C. difficile DNA amplification assay (Final [2108-3-30]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). -[2108-4-5] 7:42 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. C. difficile DNA amplification assay (Final [2108-4-6]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [2108-4-6]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2108-4-7]): NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. . IMAGING: -[3-30] Renal US: FINDINGS: The right kidney measures 10.7 cm and the left kidney measures 9.9 cm. No hydronephrosis or mass is seen in either kidney. No obstructing stone is present. Several echogenic foci in the renal sinus fat bilaterally may represent vascular calcifications. The bladder is moderately well distended and appears normal. IMPRESSION: Unremarkable renal ultrasound. No hydronephrosis. -[2108-4-2] Cardiac Catheterization: COMMENTS: 1. Selective coronary angiography of this right dominant system showed three vessel coronary artery disease. The LMCA had 30% stenosis. The LAD was patent with evidence of competative flow indicating a patent LIMA. The Lcx had a 90% origin stenosis. The RCA was occluded. 2. Resting hemodynamics showed normal RVEDP of 5 mmHg and mild LVEDP of 17 mmHg. There was mild PAHTN with PASP of 34/12 mmHG. There was severe AS with calculated [Location (un) 109] of 0.59 cm2. There was normal cardiac index of 2.5 L/min/m2. 3. Successful closure of left femoral arteritomy (has right fem-[Doctor Last Name ] bypass) with 8F angioseal. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease including unrevascularized ostial Lcx disease. 2. Patent LIMA 3. Severe AS 4. Successful aortic valvuloplasty with two inflations of 22mm Tyshak II balloon. 5. Successful LFA angioseal. 6. If recurrent symptoms, CoreValve 7. Consider Lcx PCI [2108-4-2]: ECHO: Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis with more pronounced hypokinesis of the inferolateral wall (LVEF = 25 %). No masses or thrombi are seen in the left ventricle. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional and global systolic dysfunction. Critical aortic valve stenosis. Mild mitral regurgitation. [2108-4-3] ECHO: There is severe regional left ventricular systolic dysfunction with akinesis of the basal inferior and inferolateral segments. There is moderate hypokinesis of the remaining segments (LVEF = 25-30%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: Severe calcific aortic stenosis. Mild aortic regurgitation. Severe regional and global left ventricular systolic dysfunction, most c/w with multivessel CAD. Compared with the prior study (images reviewed) of [2108-4-2], measured transvalvular gradient is slightly lower, but overall - the findings are quite similar. Brief Hospital Course: BRIEF CLINICAL SUMMARY: 75 YOM with h/o severe AS ([Location (un) 109] 0.8), sCHF (EF of 20-25% on [2108-2-14]) and regular patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] admitted for [Last Name (un) ] likely from over-diuresis and pre-renal azotemia. The patient underwent an aortic valvuloplasty. [Last Name (un) ] improved throughout hospital course. . ACTIVE ISSUES: . # [Last Name (un) ]: Cr on presentation 7.3 w/ a BUN of 113. Pre-renal etiology likely from recently increased Torsemide dose. FeUrea showed pre-renal etiology. Creatinine improved after IVF re-hydration. Pt remained euvolemic on exam. We held eplerenone, lisinopril and carvedilol to promote renal perfusion. His home torsemide was changed to 20mg qod dosing. Cr on discharge was 1.4, which was near the patient's baseline. He will get lytes checked on [4-11] and follow up with PCP [Last Name (NamePattern4) ] [4-12]. . # Aortic Stenosis: [Location (un) 109] 0.8. Critical aortic stenosis, not amenable to aortic valve replacement. Patient evaluated by Dr. [Last Name (STitle) ] who feels he is high risk for Cor Valve. He was planned to receive a balloon valvuloplasty, and received a valvuloplasty without complication on [2108-4-2]. He will be reevaluated in 6 months; if valvuloplasty fails then may proceed to Cor Valve . # CAD: Known 3VD S/P CABG. Chronic, stable without e/o ischemia at present. We cont [Date Range ], atorvastatin 80mg qd, metoprolol succinate 12.5mg qd. His ACE was held in the setting of [Last Name (un) ], as it was thought to be a contributor to his [Last Name (un) ]. . # CHF: now euvolemic. Chronic, systolic CHF without acute exacerbation during this admission, LVEF 20-25%. Hypovolumic on admission with ARF improving after IVF hydration. The patient was continued on beta [Last Name (LF) 7005], [First Name3 (LF) ], atorvastatin and torsemide 20mg qod. The patient also has an intermittent LBBB which does not seem to be rate related. This will likely transform to a permanent LBBB over the course of time. . # Shingles: had recent outbreak several wks prior to admission; he had healing skin lesions upon admission, but some residual pain (pt said he did not currently need pain Rx). We d/c'd his valcyclovir given that the treatment course if for 7 days. We continued Tramadol and Morphine PRN for pain. . #. Hyperkalemia: likely from holding diuretics. Off Torsemide in the course of the hospitalization, his potassium rose, but no concerning EKG changes. On the day of discharge the patient's K was 4.6. He will be restarting torsemide 20mg QOD on discharge so this will likely come down. He will be getting lytes checked on [4-11] and follow up with PCP [Last Name (NamePattern4) ] [4-12]. . # HTN: some relative, asymptomatic hypotension, systolic mid-80s throughout hospitalization course. We gave periodic IVF infusions and held beta blockade intermittently. ACE-inhibitor held and beta [Month/Year (2) 7005] changed to metoprolol succinate on discharge. CHRONIC ISSUES: . # HLD: stable. continued statin. . # DM: stable; ISS in house. discharged on home metformin. . TRANSITIONS OF CARE 1. He will be reevaluated in 6 months; if valvuloplasty fails then may proceed to Cor Valve 2. Patient has intermittent LBBB, will likely become permanent; does not appear to be rate related 3. restarted torsemide at 20mg QOD on discharge to prevent volume overload when pt goes home - please follow up lytes on [4-11] and volume status and adjust torsemide as needed. 4. Discharge weight: 72.8kg; pt was euvolemic to slightly volume depleted on discharge. Medications on Admission: HOME MEDICATIONS: ATORVASTATIN [LIPITOR] - 80 mg [Month/Year (2) 8426] - 1 [Month/Year (2) 8426](s) by mouth once a day CARVEDILOL - 3.125 mg [Month/Year (2) 8426] - 1 [Month/Year (2) 8426](s) by mouth twice a day EPLERENONE - 25 mg [Month/Year (2) 8426] - 1 [Month/Year (2) 8426](s) by mouth daily LISINOPRIL - 5 mg [Month/Year (2) 8426] - 1 (One) [Month/Year (2) 8426](s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - Dosage uncertain TORSEMIDE - (Prescribed by Other Provider) - 20 mg [Month/Year (2) 8426] - 1 (One) [Month/Year (2) 8426](s) by mouth twice daily TRAMADOL - (Prescribed by Other Provider) - Dosage uncertain VALACYCLOVIR - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - (OTC) - 81 mg [Month/Year (2) 8426], Delayed Release (E.C.) - one [Month/Year (2) 8426](s) by mouth once a day Discharge Medications: 1. Outpatient Lab Work Please check Chem-7 on Wednesday [2108-4-11] with results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 62] phone or [Telephone/Fax (1) 89795].9 ICD-9 2. atorvastatin 80 mg [Telephone/Fax (1) 8426] Sig: One (1) [Telephone/Fax (1) 8426] PO DAILY (Daily). 3. aspirin 81 mg [Telephone/Fax (1) 8426], Chewable Sig: One (1) [Telephone/Fax (1) 8426], Chewable PO DAILY (Daily). 4. metoprolol succinate 25 mg [Telephone/Fax (1) 8426] Extended Release 24 hr Sig: 0.5 [Telephone/Fax (1) 8426] Extended Release 24 hr PO DAILY (Daily). Disp:30 [Telephone/Fax (1) 8426] Extended Release 24 hr(s) Refills:2 5. metformin 1,000 mg [Telephone/Fax (1) 8426] Sig: One (1) [Telephone/Fax (1) 8426] PO once a day. 6. torsemide 20 mg [Telephone/Fax (1) 8426] Sig: One (1) [Telephone/Fax (1) 8426] PO every other day. 7. Zofran 4 mg [Telephone/Fax (1) 8426] Sig: One (1) [Telephone/Fax (1) 8426] PO every 4-6 hours as needed for nausea for 1 weeks. Disp:8 [Telephone/Fax (1) 8426](s) Refills:0 Discharge Disposition: Home With Service Facility: Steward Home care and Hospice Discharge Diagnosis: Primary Diagnosis: Acute Kidney Injury Ischemic colitis Secondary Diagnoses: Severe aortic stenosis Coronary artery disease Systolic congestive heart failure Shingles (resolving) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 28660], It was a privilege to provide care for you here at the [Hospital1 ] Hospital. You were admitted because you had blood tests which showed that you had some kidney damage. This was likely due to dehydration, due to decreased appetite and the torsemide water pills. You were treated with intravenous fluids and were monitored closely, and your kidney function has improved. You were also evaluated by Dr. [Last Name (STitle) ], and you received a balloon valvuloplasty. Dr. [Last Name (STitle) ] would like to re-evaluate you in 6 months and if you need another procedure he can discuss your options with you at that time. Your condition has improved and you can be discharged to home. During your stay, you had some loose stools with blood and were evaluated by Gastroenterology. This was felt to be related to "ischemic colitis," or bowel irritation in the setting of low blood pressures, which is resolving now. Your heart medications were changed during this admission but please note that management of your heart failure is an ongoing process, and doses will change based on food and fluid intake. Please weigh yourself every morning and call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. (Your weight on discharge is 72.5kg, or 159.5lbs). Please keep your follow-up appointments as scheduled below. The following changes were made to your medications: -STOP Carvedilol -STOP Lisinopril -STOP Eplerenone -STOP VALACYCLOVIR (treatment of your zoster is complete) -START Toprol XL (for heart protection and heart rate control, instead of Carvedilol) -ADJUSTED torsemide: new dose is 20mg every other day Followup Instructions: PRIMARY CARE Name:[Doctor Last Name ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ],MD Specialty: Primary Care Location: ALL CARE MEDICAL Address: [Location (un) 89384], [Hospital1 ],[Numeric Identifier 40170] Phone: [Telephone/Fax (1) 55136] When: Thursday, [4-12] at 2:15pm GASTROENTEROLOGY With: Dr. [Last Name (STitle) 41033] Time/Date: [4-18] (Wednesday) at 1:45pm Phone: [Telephone/Fax (1) 89796] CARDIOLOGY Department: CARDIAC SERVICES When: MONDAY [2108-5-7] at 8:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "4241", "2767", "4280", "412", "V4581", "25000", "2724", "4019", "41401" ]
Admission Date: [2180-8-23] Discharge Date: [2180-8-26] Date of Birth: [2101-5-1] Sex: F Service: NEUROLOGY Allergies: Sulfamethoxazole / Quinolones Attending:[First Name3 (LF) 8747] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 79 year old woman with a history of cerebral amyloid angiopathy s/p multiple bleeds who now presents with another intraparenchymal hemorrhage. Thursday afternoon (six days prior to admission), the [Name (NI) 1094] husband noted that she was "less focused" and more lethargic. She also had frequent non-specific head turning either side. She was still able to eat breakfast without significant difficulty. At baseline, she is aphasic and needs assistance with all ADLs. When watching TV, she occassionally moans or laughs. The husband [Name (NI) 653] her outpatient doctor who recommended increasing her neurontin. She then presented to an OSH ED within 1-2 days after the onset of symptoms, where she had a CXR and urine studies (results unknown at this time) and was then discharged to home. She returned to the ED today for repeat evaluation due to persistence of symptoms. She had a head CT which showed a new right temporal bleed. She was transferred to [Hospital1 18] for further evaluation/management. Past Medical History: - Multiple intraparenchymal hemorrhages due to amyloid angiopathy. The first hemorrhage was in [2160] (presented with R hemiparesis). Later had a large L fronto-parietal bleed (became aphasic). - Focal motor facial seizures. Previously treated with Dilantin, now on Neurontin. - Myoclonic jerks - High cholesterol - Hypertension Social History: Lives at home with her husband. Also has a home health aide. They take 24 hour care of her. She is unable to do any of her ADLs. She is fairly nonresponsive at baseline, but occ says [11-21] words or laughs at the TV according to her family. No tobacco, EtOH, or illicit drug use. Family History: h/o cad and stroke in the family Physical Exam: Physical Exam on admission: T 98.6 BP 172/107 HR 68 RR 14 General - Eyes open, NAD. Lungs - CTAB, good air movement CV - RRR, no m/r/g Abdomen - non-tender, non-distended, bowel sounds present Ext - warm, no edema Neurologic Examination: Awake, alert, looking around with eyes open, not talking, does not follow simple commands, leftward gaze preference; blinks to threat b/l; PERRL 2 to 1 mm, face symmetric; decreased bulk throughout, markedly increased spastic tone in all extremities, unable to formally test power all limbs in a flexed posture; reflexes 1+ in legs and 2 in arms (slightly brisker on right); toes upgoing b/l Pertinent Results: Admit Labs: [2180-8-23] 06:00PM BLOOD WBC-5.9 RBC-4.62 Hgb-14.4 Hct-41.7 MCV-90 MCH-31.1 MCHC-34.5 RDW-13.7 Plt Ct-204 [2180-8-23] 06:00PM BLOOD PT-16.4* PTT-35.8* INR(PT)-1.9 [2180-8-23] 06:00PM BLOOD Glucose-91 UreaN-9 Creat-0.5 Na-134 K-4.1 Cl-97 HCO3-27 AnGap-14 [2180-8-24] 12:45AM BLOOD TSH-1.8 [2180-8-24] 03:30AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 [2180-8-24] 03:30AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD [2180-8-24] 03:30AM URINE RBC-[4-28]* WBC-21-50* Bacteri-MANY Yeast-NONE Epi-[1-22] ---- Discharge Labs: [2180-8-26] 06:50AM BLOOD Glucose-87 UreaN-8 Creat-0.5 Na-139 K-4.0 Cl-103 HCO3-25 AnGap-15 [2180-8-24] 12:45AM BLOOD ALT-56* AST-36 CK(CPK)-97 AlkPhos-139* Amylase-73 TotBili-0.8 ---- CXR:Very large hiatal hernia. Right lower lobe opacity, which may reflect atelectasis, aspiration, or early pneumonia. Dedicated PA and lateral chest radiograph is suggested for more complete assessment. ---- Head CT:Right temporal hematoma. This currently measures 29 x 42 mm in cross-sectional dimension. ---- EEG:Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing as well as a background asymmetry with higher voltage slowing on the left and a lower voltage background on the right. The first two abnormalities signify a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. The focal slowing on the left indicates a subcortical dysfunction there while a lower voltage background on the right suggests more widespread cortical dysfunction or material interposed between the cortex and recording electrodes. No epileptiform features were seen. Brief Hospital Course: 79 year old woman with amyloid angiopathy, prior cerebral hemorrhages, and now new ~12 cc intraparenchymal hemorrhage presented with mental status change. The new bleed is most likely related to her amyloid disorder. She was initially admitted to the ICU for blood pressure mangagement. This proved to not be an issue, and her BP was well controlled without medication throughout(was high briefly initially). She was initially more lethargic than her baseline, but quickly returned to her home level of functioning after transfer from the ICU. We were concerned she may have other pathologies contributing to her symptoms given the fact that the bleed was fairly small and that it had occured 7 days prior to presentaion. An EEG was performed to rule out seizure, and although very abnormal given her longstanding pathology, it did not show evidence of seizure activity. She then had a CXR which showed questionable opacity, but this could not be well discerned given portable study and her large hiatal hernia. This may have been atelectasis. She did have a low grade temperature while here, so a UA was sent which was grossly positive. She has an indwelling foley, so the results will be clouded. She had the foley changed and given her temperature and lack of obvious other infection(PNA was felt unlikely due to lack od symptoms), she was treated for 3 days with cefpodoxime. She was initially NPO and had a video swallow evaluation which cleared her for a limited diet. She will obtain a formal outpatient swallow study after discharge and recovery which will hopefully clear her for a full diet. Her INR was initially elevated to 1.9 on admission. She was given FFP to normalize this. However, she developed a reaction(rash) to this and it was stopped. She received Vitamin K as well as this was felt to be due to a nutritional problem. [Name (NI) ] INR did normalize, but stayed sligtly elevated at 1.2-1.3. DIC labs were not significant(high D-dimer is non-specific). Finally, her neurontin was initially held and she had an increase in the amount of myocvlonic jerking she experienced. With the reintroduction of her Neurontin, this returned to baseline. She recovered well here and was back to her home baseline by discharge. She will have home services after discharge. There is no further intervention for her amyloid angiopathy. At discharge, she was alert, but non-verbal and only very occasionally addressing her environment. She is spastic in all of her limbs at her baseline. She has a significant left gaze preference and head deviation. She will follow up with Dr [Last Name (STitle) 10442] at her scheduled appointment. Medications on Admission: Neurontin 600mg TID Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses. Disp:3 Tablet(s) Refills:0 3. Formal swallow study Please obtain formal outpatient swallow evaluation after discharge. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Intracranial hemorrhage UTI -- myoclonic jerking Discharge Condition: Improved to baseline functioning. Afebrile. Discharge Instructions: PLease call your PCP or return to the ED if you have any change in behavior, grogginess, chest pain, shortness of breath, or if you pass out. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16747], M.D. Phone:[Telephone/Fax (1) 16748] Date/Time:[2180-9-8] 4:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16747], M.D. Phone:[Telephone/Fax (1) 16748] Date/Time:[2181-5-4] 1:00	[ "5990", "2720", "4019" ]
Admission Date: [2116-9-14] Discharge Date: [2116-9-18] Date of Birth: [2082-3-28] Sex: F Service: MICU-A HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old female with a past medical history significant for asthma, obstructive sleep apnea, morbid obesity, and migraine headaches who presented with a 2-day history of headaches similar in nature to her previous migraines and a subjective fever times one day. The patient states that her current headaches are frontal, increasing in intensity, and associated with neck and back pain; similar to past migraine headaches. REVIEW OF SYSTEMS: Pertinent positives on review of systems included diarrhea times two days three days prior to admission (no blood, no mucous) which resolved spontaneously. No increased secretions along her tracheostomy. No tenderness at the tracheostomy site. No change in ventilator settings. She denies dysuria or sick contacts. Of note, the patient was discharged in [2116-3-28] with similar symptoms of [11-6] frontal headaches as well as fevers. No lumbar puncture was successfully completed secondary to her morbid obesity, and the patient defervesced and was discharged following a 2-day hospitalization. The patient went home with a peripherally inserted central catheter to complete a course of intravenous vancomycin and ceftriaxone for possible meningitis. She also completed a course of Keflex for a left lower extremity cellulitis. She was most recently hospitalized from [4-28] to [4-30] for a left lower extremity cellulitis presumably secondary to incomplete treatment. She was discharged to home with dicloxacillin to complete a 14-day course of treatment. PAST MEDICAL HISTORY: 1. Asthma; status post intubation with tracheostomy placement on [2114]. 2. Obstructive sleep apnea (on home [Hospital1 ]-level positive airway pressure). 3. Morbid obesity (plan for gastric bypass surgery in the next several months). 4. History of migraine headaches. 5. Anemia (with a baseline hematocrit of 25 to 27). 6. Anxiety. 7. Depression. MEDICATIONS ON ADMISSION: 1. Paxil. 2. Lasix 80 mg by mouth once per day. 3. Albuterol. 4. Flovent. 5. Ibuprofen as needed. 6. Potassium chloride. ALLERGIES: PERCOCET (causes swelling). FAMILY HISTORY: Father suffered a myocardial infarction in his 50s and had a history of abdominal aortic aneurysm. SOCIAL HISTORY: Rare alcohol use. No smoking or intravenous drug use. She lives at home alone and is currently on disability. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 104.2 degrees Fahrenheit, her blood pressure was 109/68, her heart rate was 96 to 116, her respiratory rate was in the 20s, and her oxygen saturation was 96% to 98% on assist-control 700/15/40% with a positive end-expiratory pressure of 5. In general, the patient was alert and oriented times three. She spoke in full sentences and appeared in no apparent distress. Head, eyes, ears, nose, and throat examination revealed the patient was normocephalic and atraumatic. The pupils were equally round and reactive to light and accommodation. The oropharynx was clear. Neck examination revealed no lymphadenopathy noted. The neck was supple. Negative Kernig. Tracheostomy site with mild erythema. No discharge or induration. Cardiovascular examination revealed a regular rate and rhythm. A 2/6 systolic murmur. Normal first heart sounds and second heart sounds. Pulmonary examination revealed coarse breath sounds. No rales or rhonchi. The abdominal examination revealed normal active bowel sounds. The abdomen was soft and nontender. Extremity examination revealed 1+ pitting edema in the calves. No erythema or asymmetry noted. Dorsalis pedis pulses were equal bilaterally. Neurologic examination was nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's white blood cell count was 14.6, her hematocrit was 33.6, and her platelets were 252. Differential revealed 93% neutrophils, 0% bands, 4.6% lymphocytes, and 1.5% monocytes. Chemistry-7 was within normal limits. Urinalysis revealed negative nitrites, negative leukocyte esterase, 0 to 2 white blood cells, and no bacteria. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 16191] MEDQUIST36 D: [2117-1-3] 17:32 T: [2117-1-5] 09:38 JOB#: [Job Number 34659]	[ "49390" ]
Admission Date: [2177-8-21] Discharge Date: [2177-8-22] Date of Birth: [2112-7-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Fatigue, shortness of breath, edema Major Surgical or Invasive Procedure: None. History of Present Illness: This patient is a 65 year old male with history of type 1 diabetes melltius for 35 years (A1c 6.7), kidney transplant in [2165], who was transferred from [Hospital3 24012] ED where he presented with fatigue x5 days, worsening edema and mild dyspnea on exertion. He was was in the ER to have acute on chronic renal failure with a creatinine of 5.6, hyponatremia to 113 and question of PNA on chest Xray. Patient reports feeling extremely week for the past 5 days. He complaints of extreme fatigue preventing him from getting up on his own. he denies fevers, chills. he complains of some difficulty breathing and orthopnea for the past week. He has been nauseated with dry heave for the past 5 days. He has also noticed increased scrotal edema x1 month and periorbital edema occassionally for the past month. He has had worsening LE edema since [Month (only) ] and was started on lasix in the beginning of [Month (only) 462]. He reports no change in his urination, denies frequency or burning. No changed in the color. His stool has changed, as he goes about 3 times a day now, and previously he was constipated. He also reports decreased PO intake His issues started around last [Month (only) 547] when he had an epsidode of vomitting in the setting of 4 days of constipation. This resolved, but he remained weak since then. He went to [State ] for a week at the end of [Month (only) 116] and that is when he first noticed swelling in his feet. He recalls that the swelling has been getting worse slowly since then. He finally called his nephrologist Dr. [First Name (STitle) ] in the middle of [Month (only) ] who scheduled an ECHO and requested him to have his labs drawn. He also adjusted the dosages of his Tacro. The patient went to [Hospital3 24012] [7-22] or low blood sugar and again [2177-7-28] because he was feeling very weak. At that time he was found to have low sodium and chloride and low blood count and was given 2 units of blood and 2 bags of NS (according to wife). He felt much better after this admission, was able to take long walks with his wife, and his appetite returned. This last until 5 days ago when he started with the above symptoms. In the ED his blood pressure ranged from 151-208/77-106, T 97, HR 65-79, RR 16 sat 100% RA. He was fiven LEvaquin 750mg IV, Lasix 80mg IV, labetolol 10mg IV, Compazine 10mg IV. He put out 1300 cc lasix after a foley was placed. Past Medical History: - Diabetes type 1 x34 years Last Hb A1c 6.7 [8-4] - s/p living related kidney transplant [1-/2166] - gastroparesis - neuropathy - retinopathy with microaneurysms, s/p surgery [2155] - GERD - Hypercholesterolemia - Gastroparesis - Osteopenia Social History: Patient denies smoking, drinking, or ilicit drug use. He is a retired teacher. lives in [Location 24013] with his wife. [Name (NI) ] has 2 grown children, one in [State ] one in [Location (un) ]. Family History: His mother's sister has type two diabetes, and a paternal aunt also has type two diabetes mellitus. There is no family history of heart disease. Physical Exam: On admission: Vitals: T: 97.5 BP: 142/79 P: 80 RR: 16 O2Sat 92% RA Gen: no acute distress HEENT: Clear OP, MMM, periorbital edema NECK: Supple, No LAD, JVD about 7 cm CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: 3+ pitting edema. Upper extremity edema. Anasarcic Scrotum: edematous NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [11-27]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2177-8-21] 11:13PM GLUCOSE-313* UREA N-50* CREAT-5.6* SODIUM-112* POTASSIUM-3.9 CHLORIDE-82* TOTAL CO2-16* ANION GAP-18 [2177-8-21] 06:30PM URINE HOURS-RANDOM UREA N-169 CREAT-33 SODIUM-30 [2177-8-21] 06:30PM URINE OSMOLAL-196 [2177-8-21] 06:30PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2177-8-21] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2177-8-21] 06:30PM URINE RBC-0-2 WBC-[1-29] BACTERIA-FEW YEAST-NONE EPI-[1-29] [2177-8-21] 06:30PM URINE AMORPH-FEW [2177-8-21] 04:54PM CYCLSPRN-43* tacroFK-LESS THAN [2177-8-21] 03:50PM GLUCOSE-273* UREA N-45* CREAT-5.6# SODIUM-113 POTASSIUM-3.8 CHLORIDE-79* TOTAL CO2-18* ANION GAP-20 [2177-8-21] 03:50PM estGFR-Using this [2177-8-21] 03:50PM proBNP-[Numeric Identifier 24014]* [2177-8-21] 03:50PM CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.3 [2177-8-21] 03:50PM WBC-8.6 RBC-3.27* HGB-10.3* HCT-28.7* MCV-88# MCH-31.5 MCHC-35.8* RDW-14.6 [2177-8-21] 03:50PM PLT COUNT-351# [2177-8-21] 03:50PM PT-12.8 PTT-30.2 INR(PT)-1.1 Chest x-ray [2177-8-21]: CONCLUSION: Pulmonary edema, likely cardiogenic. Bibasal effusions. Increased density at right lung base, confluent edema versus pneumonia. Followup post diuresis is recomended. The study and the report were reviewed by the staff radiologist. Renal Ultrasound [2177-8-21]: IMPRESSION: 1. Interval development of mild-to-moderate hydronephrosis within the transplanted kidney. 2. Slight broadening of the waveform of the mid pole renal artery, hoever resistive indices within normal range Transthoracic Echo [2177-8-22]: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior report (images unavailable for review) of [2170-10-1], concentric left ventricular hypertrophy and moderate diastolic dysfunction now evident. IMPRESSION: moderate diastolic dysfunction of the left ventricle with normal ejection fraction Brief Hospital Course: Patient is a 65 year old male with type one diabetes mellitus, renal transplant in [2165], gastroparesis, who presented with fatigue, hyponatremia, worsening edema, dyspnea on exertion, and worsening renal insufficiency who was transferred from an outside hospital for further management. Patient was admitted to the medical intensive care unit. The nephrology team was consulted and discussed dialysis with the patient. He refused dialysis, and was able to state the risks associated with doing so. He understood what dialysis entailed, and was also not interested in temporary dialysis. It was recommended that he be treated with trial hypertonic saline to see if there was improvement in his hyponatremia and energy level. He refused to stay as an inpatient and declined a PICC line for administration of hypertonic saline. He was evaluated by the psychiatry team to help assess whether there was a component of depression, and to ensure that his mental status was not clouded by his low sodium. The psychiatry team felt that the patient was competent and had the capacity to make medical decisions and fully understood the implications of refusing dialysis and other treatments. His primary nephrologist confirmed that this was in accordance with prior discussions regarding the goals of his care. The patient stated that his goals were to return home and spend time with his wife. Social work, palliative care, and case management were then involved to assist with arranging home Hospice services to meet the patient's wishes. A Hospice bed was available for the next day and would be arranged for him in his home. Per his and his wife's wishes, he was discharged home. A regimen of salt tabs and lasix was initiated for his hyponatremia after discussion with the renal team. His code status is DNR/DNI, and paperwork was completed for his ambulance ride home for this order. Medications on Admission: Fosamax 70mg qweek Azathioprine 50mg once a day Calcium 600mg daily Cyclosporine 50mg twice a day Fludrocortisone Acetate 0.1mg once a day Glyburide 5mg once a day Lipitor 10mg Lantus 5-6 units before breakfast. Novolog [11-27] units before each meal Midodrine 5mg three times a day Protonix 40mg daily Prednisone 1mg 3 3 tablets once a day lasix 20mg twice daily Discharge Medications: 1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Lasix 80 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 6. Insulin Glargine 100 unit/mL Solution Sig: 5-6 units Subcutaneous QAM: Resume your home dosing. 7. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours: As needed for seizure, discomfort. Disp:30 Tablet(s) Refills:0 8. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q1 hour PRN: PRN shortness of breath, discomfort. 9. Insulin Aspart 100 unit/mL Solution Sig: [11-27] units Subcutaneous before meals: Please resume your home dosing. Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Primary diagnoses: - Acute on chronic renal failure - Hyponatremia Secondary diagnoses: - Diabetes Mellitus - Renal transplant - Gastroparesis - Neuropathy - Retinopathy - GERD Discharge Condition: Fair, alert, oriented. Discharge Instructions: You were admitted from an outside hospital for management of your renal failure, low sodium, mild shortness of breath, fatigue, and swelling of your extremities. It was recommended that you undergo dialysis or have other treatments for your low sodium, however you declined these treatments. The psychiatry team helped evaluate you, and they were in agreement that you understood the risks and benefits of this decision. The palliative care team and case management helped to arrange for a discharge home with Hospice services. . Please call your primary care physician if you have any pain, worsening shortness of breath, or other concerns that need attention. . You should take 80 mg of lasix three times a day in addition to [11-27] salt tabs 3 times a day. Please continue all of your other medications as directed or appropriate. A foley catheter has been placed for comfort and should be left in unless otherwise directed. Followup Instructions: You decided that you wanted to go home with Hospice. Please contact your primary care physician or other providers for any needs you may have outside of Hospice services.	[ "5849", "2761", "486", "53081", "2720" ]
Admission Date: [2150-2-22] Discharge Date: [2150-3-11] Date of Birth: [2150-2-22] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby girl [First Name4 (NamePattern1) ] [Known lastname ] delivered at 33-6/7 weeks gestation weighing 2545 grams and was admitted to the Intensive Care Nursery from Labor and Delivery for management of respiratory distress and prematurity. Mother is a 31-year-old gravida 2, para 0, now 1, mother with estimated date of delivery [2150-4-7]. Prenatal screens included blood type A+, antibody screen negative, RPR nonreactive, hepatitis B surface antigen negative, Rubella immune and group B Strep unknown. The pregnancy was uncomplicated until the day prior to delivery when the mother presented with preterm labor and premature rupture of delivery. The membranes were ruptured about 18-1/2 hours prior to delivery. No maternal fever. The mother received intrapartum antibiotics about 14-1/2 hours prior to delivery. The infant emerged with a good cry. Received free flow oxygen in the Delivery Room and then was transported to the Intensive Care Nursery. Apgars scores were 8 and 8 at one and five minutes respectively. PHYSICAL EXAMINATION ON ADMISSION: Weight 2545 grams (75-90th percentile). Length 46 cm (50-75th percentile). Head circumference 29.75 cm (25th percentile). In general, a nondysmorphic, pink infant. Skin without rashes or petechiae. Head: Anterior fontanelle, soft, flat. Eyes: Red reflex present bilaterally. No cleft. Lungs: Inspiratory crackles with grunting, flaring and retracting. Heart: Normal sinus rhythm, no murmur. Pulses 2+ all extremities. Abdomen soft without hepatosplenomegaly. No masses. Genitalia: Normal preterm female. Patent anus. Spine intact. Hips stable. Reflexes appropriate for gestational age. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Was intubated and received one dose of surfactant for respiratory distress syndrome. Maximum ventilator support pressures 25/5, rate of 24, 35% oxygen. Responded well to the surfactant and was extubated on day of life one. Required supplemental oxygen by nasal cannula until day of life seven. Has remained on room air since with comfortable work of breathing with respiratory rate in the 30's to 50's. Had mild apnea of prematurity but did not require methylxanthine therapy. The last episode was on [2150-3-6]. 2. Cardiovascular: Has remained hemodynamically stable throughout hospitalization. No heart murmur. Recent blood pressure 68/33 with a mean of 46. 3. Fluids, electrolytes and nutrition: Initially maintained on peripheral intravenous fluid of D10W. Enteral feeds were started on day of life one and reached full volume feeds on day of life four. At discharge is taking expressed breast milk or breast feeding well with weight gain. Discharge weight 2760 grams. 4. Gastroenterology: Was treated with phototherapy for indirect hyperbilirubinemia. Peak bilirubin total 14.5, direct 0.5. 5. Hematology: Hematocrit on admission 53%. Did not require any blood products during this admission. 6. Infectious Disease: A CBC and blood culture was drawn on admission. Was treated with 48 hours with ampicillin and gentamicin. Blood culture was negative. CBC was benign. 7. Neurology: Examination is age appropriate. 8. Sensory: Hearing screening was performed with automated auditory brain stem responses. Infant passed both ears. 9. Orthopedic: Noted to have an eversion of the right foot due to positioning in utero. Was seen by Occupational Therapy who noted the right foot was everted was minimal plantar flexion. The parents were taught exercises to promote active plantar flexion and some inversion plus some gentle stretching exercises. The infant has improved during this hospitalization and follow up is not needed at this time. CONDITION AT DISCHARGE: A 17-day-old now 36-2/7 weeks corrected age preterm infant who is feeding and gaining weight. DISCHARGE DISPOSITION: Discharge home with parents. PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D., [Telephone/Fax (1) 45985]. CARE AND RECOMMENDATIONS: 1. Ad lib demand feeds. Monitor growth. 2. Medications: Fer-in-[Male First Name (un) ] 0.25 cc p.o. once a day. 3. Car seat position screening pending. 4. State newborn screen sent on [2-27] and [3-10]. Results are pending. 5. Immunizations received: Received hepatitis B immunization on [2150-3-5]. Received Synagis on [2150-3-5]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants meeting the following three criteria: (a) Born at less than 32 weeks; (b) Born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with pre-school sibslings; or (c) with chronic lung disease. 7. 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 RECOMMENDED: Appointment with pediatrician recommended week of discharge. DISCHARGE DIAGNOSES: 1. AGA 33-6/7 week preterm female. 2. Respiratory distress syndrome resolved. 3. Sepsis ruled out. 4. Indirect hyperbilirubinemia resolved. 5. Apnea of prematurity resolved. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern1) 36138] MEDQUIST36 D: [2150-3-10] 13:48 T: [2150-3-10] 13:09 JOB#: [Job Number 45986]	[ "7742", "V290", "V053" ]
Admission Date: [2183-3-26] Discharge Date: [2183-5-27] Date of Birth: [2183-3-26] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname 40545] was born at 31 3/7 weeks gestation to a 39-year-old gravida I, para 0 now I woman. Her prenatal screens are blood type O negative, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B strep unknown. The patient's previous medical history is remarkable for epilepsy, treated before and during her pregnancy with Tegretol and Lamictal. The mother has had a seizure disorder since she was 17 years old. The pregnancy was also complicated by pregnancy-induced hypertension and the mother completed a course of betamethasone on [2183-3-17]. Cesarean birth was done due to worsening hypertension. The infant emerged with spontaneous respirations. Apgars were 7 at one minute and 8 at five minutes. PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic, pre-term infant. Anterior fontanel open and flat, positive bilateral red reflexes, positive grunting, flaring and retracting, with inspiratory crackles. Positive subcostal and intercostal retractions. Normal S1, S2 heart sound, no murmur. No hepatosplenomegaly, abdomen soft, three vessel umbilical cord. Testes descended bilaterally, patent anus, intact spine, negative hip click, and age-appropriate tone and reflexes. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant was intubated soon after admission to the [Date Range ] Intensive Care Unit, and received two doses of surfactant. He weaned to nasopharyngeal continuous positive airway pressure on day of life number two, and then weaned to nasal cannula oxygen on day of life number four. He then successfully weaned to room air after several attempts on day of life 38, and has remained in room air since that time. He was treated with caffeine for apnea of prematurity from day of life number four until day of life number 46. His last episode of apnea was with feeding and occurred on [2183-5-22]. His respirations are comfortable. His lung sounds are clear and equal. 2. Cardiovascular: He has remained normotensive throughout his [Date Range ] Intensive Care Unit stay. He did develop a Grade II/VI systolic ejection murmur on day of life 22 that has continued to be present. He had a cardiac evaluation on day of life number 60, which showed normal four extremity blood pressures. He had an electrocardiogram with normal axis and normal sinus rhythm, showing no atrial or ventricular hypertrophy, and he had a chest x-ray which showed a generous cardiac silhouette with normal lung markings. He is planned to have an echocardiogram at [Hospital3 1810] after his discharge from [Hospital1 69] on [2183-5-27]. 3. Fluids, electrolytes and nutrition: Enteral feeds were begun on day of life three, and advanced without difficulty to full volume feedings by day of life number nine. He then advanced to calorie-enhanced breast milk of 30 calories/ounce with added ProMod. Consistent weight gain allowed weaning and, at the time of discharge, he is eating breast milk or 20 calorie Enfamil. The infant's birth weight was 1365 grams. His birth length was 41 cm, and his birth head circumference was 28 cm. Those are all within the 25th to the 50th percentile for gestational age. His measurements at the time of discharge are a weight of 3090 grams, length 49 cm, and head circumference 35.5 cm. 4. Gastrointestinal: His peak bilirubin level occurred on day of life number four and was total of 6.4, direct 0.4. He never required any phototherapy. There are no gastrointestinal issues. 5. Hematology: His last hematocrit on [2183-5-1] was 33.3 with a reticulocyte count of 5.5. He is receiving supplemental iron to provide 2 mg/kg/day. 6. Infectious Disease: He was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the infant was clinically well and his blood cultures remained negative. He has remained off antibiotics since that time. 7. Neurology: His first head ultrasound on [2183-4-3] showed bilateral subependymal hemorrhages. Follow-up ultrasound on [2183-4-18] showed resolved germinal matrix hemorrhage, normal-sized ventricles, and no evidence of periventricular leukomalacia. 8. Sensory: Hearing screening was performed with automated auditory brain stem responses. The infant passed in both ears on [2183-4-20]. The eyes were examined most recently on [2183-4-16] and found to have mature retinal vessels in both eyes, and no retinopathy of prematurity. 9. Psychosocial: The mother has been very involved in the infant's care throughout his [Date Range ] Intensive Care Unit stay. The mother, throughout this [Name (NI) ] Intensive Care Unit stay, has continued to be treated with the drug Lamictal for her seizure disorder. She has been counseled by the [Name (NI) ] Intensive Care Unit staff that there is not enough data to support safely taking this drug during breast feeding, however, she feels that she wants to continue breast feeding, and has done so throughout her stay. She also states that she takes some herbs given to her by her chiropractor, although she does not know the name of the herb. She also has been counseled that we do not recommend taking those herbs while breast feeding. The father and mother are not married. The father also has visited frequently during the infant's [Name (NI) ] Intensive Care Unit stay, and has been involved in the infant's care. After discharge, the infant's last name will be [Name (NI) 40546]. The infant's first name is [Name (NI) 40547]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: The infant is being discharged home with his mother. PRIMARY PEDIATRIC CARE: Will be provided by Dr. [First Name4 (NamePattern1) 16951] [Last Name (NamePattern1) 40548], telephone number [Telephone/Fax (1) 40549]. CARE RECOMMENDATIONS: 1. Feedings: The infant is being discharge home on 20 calorie Enfamil or breast feeding on an ad lib schedule. 2. Medications: Poly-vi-[Male First Name (un) ] 1 cc by mouth once daily, Fer-in-[Male First Name (un) ] 0.3 cc by mouth once daily to provide approximately 7.5 mg of iron by mouth once daily. 3. State [Male First Name (un) 19402] screening status: The last [Male First Name (un) 19402] screen was sent on [2183-4-14] and no abnormalities were reported. 4. Immunizations received: Hepatitis B vaccine on [2183-5-20], DtaP on [2183-5-27], HIB on [2183-5-27], IPV on [2183-5-27], and pneumococcal vaccine on [2183-5-27]. 5. Follow-up appointments and recommendations: a. The infant will be followed by Early Intervention of [Doctor Last Name ]-[Location (un) 16843], telephone number [Telephone/Fax (1) 40550]. b. The infant will have a cardiac echocardiogram on [2183-5-27] at [Hospital3 1810] after discharge from [Hospital1 346]. DISCHARGE DIAGNOSIS: 1. Status post prematurity at 31 3/7 weeks gestation 2. Status post respiratory distress syndrome 3. Sepsis ruled out 4. Status post apnea of prematurity 5. Status post germinal matrix hemorrhage 6. Heart murmur 7. Status post circumcision on [2183-5-19] [First Name8 (NamePattern2) 36400] [Name8 (MD) ] M.D.50-595 Dictated By:[Last Name (NamePattern1) 37333] MEDQUIST36 D: [2183-5-27] 04:21 T: [2183-5-27] 04:30 JOB#: [Job Number 40551]	[ "V290" ]
Admission Date: [2115-3-28] Discharge Date: [2115-4-2] Date of Birth: [2050-6-16] Sex: F Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 46915] Chief Complaint: dizziness with right cerebellar hemorrhage Major Surgical or Invasive Procedure: none. History of Present Illness: 64 year old right handed woman with history of hypertension (sbp 140-150s at home on meds) presents with lightheadedness, right arm incoordination, and slurred speech. Last night she was at dinner with her husband when she felt weird, lightheaded and tried to reach for glass of water with right hand but could not coordinate her hand enough to get the water. She then spoke to her husband and noticed that her speech was slurred. She attempted stand but could not walk because she felt too imbalance. Her husband helped her to a bench outside the restaurant and noticed that she kept veering to the right. He got the car and brought her home where she went to bed. She woke up at 4 am and went to the bathroom clinging to the walls. She awoke this and had breakfast but vomited it because she was so nauseous. She denies any headache or diplopia. She was brought to OSH where right cerebellar hemorrhage was found with bp 167/89. She was then transferred to [Hospital1 18] for further manangement. Her bp her has been 160-180s despite labetolol x 2. Therefore, labetolol drip was started. ROS: Patient denies any fever, chills, headache, neck pain, weakness, numbness, tingling, visual changes, hearing changes, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, diarrhea, brbpr, or bowel/bladder problems. Past Medical History: hypertension x 2 years Social History: She works in appliance sales and drinks 2-3 etoh/weeks. no tobacco or ivdu Family History: mother died at age 86 of stroke father died at age [Age over 90 ] of prostate cancer Physical Exam: Gen: nad Neck: Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect Orientation: oriented to person, place, and date Attention: able to due serial substractions Recall: [1-24] at 5 minutes Language: fluent with good comprehension and repetition; naming intact. no paraphasic errors. scanning cerebellar hemorrhage No apraxia, no neglect [Location (un) ] intact Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. unable to see fundi 2nd to patient's movement III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor full power [3-28] No pronator drift Sensation: Intact to light touch, pinprick, temperature (cold), vibration, and propioception Reflexes: brisk throughout Grasp reflex absent Toes were downgoing on left and upgoing on right Coordination: dysmetria on right finger-nose-finger, dysmetria on right heel to shin Gait: veers to right with help Pertinent Results: MRI/MRA head and neck [2115-3-29]: There is a 2 x 2.6 cm area within the right cerebellar hemisphere which appears T1 isointense to the adjacent normal cerebellar tissue and dark on T2-weighted images with slight surrounding edema. Following administration of gadolinium there is no enhancement in this region. No feeding vessels or draining veins from this area are identified. There is some mass effect on the fourth ventricle. On gradient echo images there is an area of susceptibility within the right cerebellar hemisphere and tiny foci within bilateral basal ganglia and small linear area within the left corona radiata. On diffusion-weighted images no areas of restricted diffusion is seen. IMPRESSION: No acute infarct. 2.1 x 2.2 cm area of intraparenchymal hemorrhage within the right cerebellar hemisphere. There is no area of enhancement within this region to indicate vascular malformation or underlying mass. MR ANGIOGRAM OF THE BRAIN. TECHNIQUE: 3D time-of-flight imaging of the anterior and posterior cerebral circulations were obtained. There are no prior studies for comparison. FINDINGS: There is no hemodynamically significant stenosis or aneurysmal dilatation of the visualized vasculature. IMPRESSION: Unremarkable circle of [Location (un) 431] MR angiogram. EKG: Baseline artifact. Sinus rhythm. Left axis deviation with left anterior fascicular block. Non-specific T wave changes in the inferior leads. No previous tracing available for comparison. Brief Hospital Course: Pt was admitted to the Neurology ICU where she remained stable and without clinical change. Likely etiology of the hemorrhage hypertension, though MRI with gad performed to rule-out other etiology such as neoplastic or mass. MRI without evidence of tumor or mass. No evidence of other microbleeds on susceptibility sequences. MRA without evidence of aneurysmal dilatation or other vascular pathology. Pt tranferred out of ICU and to step-down unit where she tolerated PO lopressor with titration up to 75mg [Hospital1 ] for good BP control. In addition, she was evaluated by PT/OT and arrangements were made for her to continue home PT on discharge. Medications on Admission: benacar 20 vitamin E soy Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: right cerebellar intraparenchymal hemorrhage Discharge Condition: stable. Discharge Instructions: Take all medications as prescribed. Follow-up with all appointments as directed. If you have any worsening of your symptoms or if new neurological symptoms arise then call your PCP or our office as soon as possible. Followup Instructions: Please call [Telephone/Fax (1) 1694] for an appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in the [Hospital 18] [Hospital 4038] Clinic in [5-1] weeks time. Please call you primary care provider for [Initials (NamePattern4) ] [Last Name (NamePattern4) 702] appointment in [11-25] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 46916] Completed by:[2115-4-2]	[ "4019" ]
Admission Date: [2192-4-11] Discharge Date: [2192-4-13] Date of Birth: [2121-3-6] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2181] Chief Complaint: Back pain, Chills Major Surgical or Invasive Procedure: Lumbar Puncture, Intubation/Extubation History of Present Illness: 71F with hx of diet controlled insulin insensitivity (HBa1c 6.0), HTN, GERD, and LE neuropathy being transferred from OSH ED for concern of epidural abscess. Patient presented to [Hospital1 2519] ED with 2 weeks of headache, malaise, mid-low back pain, and chills having been recently tested for and started on bactrim x 1 day for a UTI by his PCP (positive UA and UCx from [4-6] with 100k colonies of pan-sensitive E. coli). Her ROS was negative for visual changes, neck stiffness, or altered thinking. Per ED attending note, her initial VS were 98F, 97, 130/66, 20, 96%RA. She had CBC with a white count of 2, a UA with leukesterase but per report no wbc's or bacteria, lactate WNL's, and had a CT abd/pelv non-con which was unremarkable and read as c/w gastroenteritis, and a CT head that was unremarkable. She 2 weeks prior had a brain MRI with findings of old left basal ganglia lacunar infarct. She later developed a fever of 100.7 and downtrending blood pressures (initial [Location (un) 1131] in records from OSH shows 68/45, all others wnl's), rec'd single doses of vanc/ceftriaxone 1gm/levofloxacin as well as 4LNS. Patient had central line placed but no pressors started at OSH. She was transferred to [Hospital1 18] for further evaluation and management with concern for possible spinal epidural abscess. . In the ED, initial VS were: 6 100.0 103 90/45 24 93% 3LNC -She was given another 2LNS and started on levophed given low BP's -Administered another gram of ceftriaxone for meningitic dosing -Intubated for airway protection per report -LP performed, studies pending -MRI total spine with wetread negative for infection of spine -Transferred to the unit for further management . On arrival to the MICU, patient is fully sedated and intubated with initial VS of 98.8, 67, 139/68, 16, 100% on the ventilator. Spoke with patients daughter and son who confirm the above history and state that yesterday evening she went bowling (one of her favorite activities) and went home after starting the bactrim. That evening she described feeling unwell and was brought to the ED by her daughter. Of note, she was admitted 2 years ago to [Hospital1 112] apparently for sepsis and underwent a temporal artery biopsy for suspected temporal arteritis which was per family report negative. . Review of systems: Unable to obtain ROS Past Medical History: -Prior lacunar CVA (age unknown) -Diabetes/diet controlled -hypertension -lower extremity neuropathy -GERD Social History: Lives alone, socially active, ~25 pack year smoking history, quit 20 years ago, no drinking or drugs. Family History: No significant family hx Physical Exam: ADMISSION PHYSICAL EXAM: Tmax: 38.1 ??????C (100.5 ??????F) Tcurrent: 38.1 ??????C (100.5 ??????F) HR: 75 (66 - 81) bpm BP: 109/54(66) {109/54(66) - 140/74(88)} mmHg RR: 14 (14 - 18) insp/min SpO2: 96% (ventilated) General: Sedated, intubated HEENT: Sclera anicteric, MMM, ET tube in place 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, obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place draining normal appearing urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Unable to formally assess given sedation . DISCHARGE PHYSICAL EXAM: VS: Tm 98.8 BP98-100/55 HR 80-85 RR 18 Satting 99% on 2L FS 109 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, 2/6 systolic murmur Lungs: faint crackles in LLL Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: . [2192-4-11] 06:45AM BLOOD WBC-8.1 RBC-3.97* Hgb-12.6 Hct-39.3 MCV-99* MCH-31.7 MCHC-32.0 RDW-13.2 Plt Ct-180 [2192-4-11] 06:45AM BLOOD Neuts-97.6* Lymphs-1.2* Monos-0.7* Eos-0.3 Baso-0.2 [2192-4-11] 06:45AM BLOOD PT-12.5 PTT-28.2 INR(PT)-1.2* [2192-4-11] 06:45AM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-141 K-3.3 Cl-111* HCO3-19* AnGap-14 [2192-4-11] 06:45AM BLOOD ALT-22 AST-30 AlkPhos-61 TotBili-0.2 [2192-4-11] 06:45AM BLOOD Albumin-3.2* [2192-4-11] 04:01PM BLOOD Calcium-7.6* Phos-4.0 Mg-2.6 [2192-4-11] 07:36AM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5 FiO2-100 pO2-296* pCO2-41 pH-7.36 calTCO2-24 Base XS--1 AADO2-368 REQ O2-66 -ASSIST/CON Intubat-INTUBATED [2192-4-11] 06:52AM BLOOD Lactate-1.1 [2192-4-11] 04:26PM BLOOD freeCa-1.13 [2192-4-11] 07:49AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]->1.050* [2192-4-11] 07:49AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2192-4-11] 07:49AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 [2192-4-11] 01:30PM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-2950* Polys-18 Lymphs-78 Monos-4 [2192-4-11] 01:30PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-23* Polys-7 Lymphs-73 Monos-20 [2192-4-11] 01:30PM CEREBROSPINAL FLUID (CSF) TotProt-89* Glucose-62 . DISCHARGE LABS: [2192-4-13] 06:29AM BLOOD WBC-3.9* RBC-4.15* Hgb-12.9 Hct-39.9 MCV-96 MCH-31.0 MCHC-32.3 RDW-13.1 Plt Ct-134* [2192-4-13] 06:29AM BLOOD Glucose-68* UreaN-13 Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-26 AnGap-13 [2192-4-13] 06:29AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9 . MICRO/PATH: . Blood Cx x 3 [2192-4-11]: ngtd CSF Cx [2192-4-11]: ngtd UCx [2192-4-11]: No growth MRSA Screen [2192-4-11]: Pending IMAGING/STUDIES: [2192-4-12] Radiology CT CHEST W/O CONTRAST: 1. Small left lower lobe consolidation, concerning for pneumonia. 2. Left ventricle enlargement. 3. Enlarged pulmonary artery, suggestive of pulmonary arterial hypertension. 4. Calcified right thyroid nodule. Further evaluation is recommended with non-urgent ultrasound. [2192-4-12] Radiology CHEST (PORTABLE AP): FINDINGS: Tip of the endotracheal tube ends approximately 4.4 cm above the carina, right internal jugular line terminates at mid SVC, and orogastric tube is seen to course into the stomach; however, the distal end is looped with the tip in the fundus. Since yesterday's radiograph, increased opacity in the left lower lung, reflecting atelectasis, has improved. Small left pleural effusion is unchanged. There are no new lung opacities on the right side. Minimal opacity in the right lung base from the prior radiograph has resolved suggesting it was atelectasis. Heart size, mediastinal and hilar contours are normal. There is no pneumothorax. [2192-4-11] Radiology MR C/T/L-SPINE W& W/O CONTR: IMPRESSION: 1. No evidence of spondylodiscitis, epidural or paraspinal abscess/phlegmon throughout the entire spine. 2. No pathologic focus of enhancement. 3. Severe multifactorial degenerative disease of the mid-cervical spine with secondary kyphosis, ventral canal narrowing, and cord "confinement" and remodeling; however, there is no abnormality of spinal cord signal. 4. Degenerative disc disease in the lower lumbosacral spine with subarticular zone and neural foraminal stenosis and resultant neural impingement, as detailed above. 5. Bilateral pleural effusions with apparent associated subsegmental atelectasis, incompletely imaged; correlate with dedicated chest radiography. [2192-4-11] Radiology CHEST (PORTABLE AP): IMPRESSION: Appropriate position of lines and tubes. No pneumothorax. Left retrocardiacopacity likely representing atelectasis. Brief Hospital Course: 71F with hx of diet controlled DM2, HTN, and LE neuropathy transferred from OSH ED and admitted to the MICU intubated with presumed sepsis. ACTIVE DIAGNOSES: #Sepsis with hypotension from UTI and Pneumonia: Patient was transferred from [Hospital3 ] ED with fevers, tachycardia, hypotension, and altered mental status along with back pain concerning for possible epidural abscess. She was administered a total of 6L NS (4L at OSH, 2L in our ED), started on pressors (IJ placed at [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) and intubated for concern of airway protection and respiratory distress. Her WBC count was wnl's, UA was clean, UCx here was negative (although on [4-6] she had a positive UA with UCx growing 100K pan-sensitive E. coli for which she rec'd 1 dose of bactrim with clearance of her UA at [Hospital3 4107]). She had a CT abd/pelvis with contrast at OSH which was negative for perinephric abscess, CT head non con which was negative at OSH, MRI total spine here which was negative for abscess/infection but showed degenerative disease, and had an LP in the ED which had negative chemistries. CXR at OSH was read as having retrocardiac opacity and CXR here was read as retrocardiac opacity versus atelectasis although it appeared suspicious for LLL pneumonia. Patient rec'd vanc/ceftriaxone/levofloxacin at OSH and was switched to ceftriaxone and levofloxacin on arrival to the unit. She did well overnight and was extubated early on HD#1. She was weaned off pressors and called out to the floor for further management. CT scan of her chest was obtained which showed mild consolidation, LVH, enlarged PA and a calcified thyroid nodule. She was dc-ed home in a stable condition on levofloxacin for 5 more days. We held her BP meds and will have them restarted by PCP if pressures stable. CHRONIC DIAGNOSES: # Diet-Controlled Pre-Diabetes: Patient was euglycemic but placed on a conservative humalog sliding scale as a backup. #Bilateral Lower Extremity Neuropathy: Chronic issue. -Will start gabapentin when taking PO??????s TRANSITIONAL ISSUES: - We held her anti-htn meds. PCP should restart if pressures stable - Pt was incidentally found to have a calcified thyroid nodule. Will require f/up ultrasound to assess for malignancy Medications on Admission: -Meclizine 12.5mg PO BID PRN -Omeprazole 20mg PO BID -Simvastatin 40mg tab daily -Atenolol 50mg tab PO daily -HCTZ 25mg PO daily -Gabapentin 200mg PO tid -Vitamin D 100units PO daily -Bactrim 1 tab PO BID x 1 dose Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for pain/fevers. Disp:30 Tablet(s) Refills:0 6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: please taking until [2192-4-18]. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Urinary Tract Infection - Community Acquired Pneumonia Secondary Diagnosis: - Diabetes Mellitus 2 - Hypertension - Gastroesophageal reflux Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [First Name8 (NamePattern2) ] [Known lastname ], It was a pleasure taking care of you here at the [Hospital1 18]. You presented to us in a very sick state which was thought to be likely secondary to an infection. We discovered that you had a urinary tract infection and treated you with antibiotics. You responded very well to the treatment and you were discharged home in a safe condition. Physical therapy advised that you will require 24 hour supervision from your family for the first day. You will also require an ultrasound of your thyroid to evaluate a nodule that was incidentally noted in a CT scan of your chest. Changes to your medications are as follows. - STARTED Levofloxacin (antibiotic): Please continue to take this once a day until [2192-4-18] - STARTED TYLENOL: please take one to two tablets thrice a day for pain or fever - HOLDING ATENOLOL and HYDROCHLOROTHIAZIDE: please do not restart these medications until you see your PCP as your blood pressures were on the low side while you were in the hospital. Followup Instructions: Name: [Last Name (LF) ], [Name8 (MD) 110742] NP Location: [Hospital ] HEALTH CENTER Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 1265] Phone: [Telephone/Fax (1) 25350] Appointment: WEDNESDAY [4-18] AT 11:30AM	[ "78552", "51881", "5990", "99592", "4019", "2720", "53081", "V1582" ]
Admission Date: [2144-7-23] Discharge Date: [2144-7-27] Date of Birth: [2095-4-26] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy. History of Present Illness: This is a 49 y.o. female w/ history of two liver transplants for hemochromatosis and EtOH (first in [2136], second following hepatic artery thrombosus in [2137]) and ESRD on TuThSa dialysis, who was transferred from [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [7-23] with abdominal pain and hematemesis. The morning of admission, the patient had been feeling weak with DOE. She then went to her dialysis appointment where she had worsening of the Sx and decided to go to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. In triage at [Hospital1 ], the patient unexpectedly vomited a large volume of blood. At that time, she was transfused 2 units, Pantoprazole drip was started and she was transferred to [Hospital1 18]. Past Medical History: - h/o hypoxic respiratory failure and hypotension in [3-/2144] for altered mental status and ? PE, s/p intubation complicated by VAP - possible PE, now on coumadin - ESRD [3-4] hypotension in [3-/2144] - ETOH cirrhosis s/p OTL [2137-12-7], s/p OTL [2136-6-4] - renal insufficiency (due to cyclosporine: baseline cr 1.4) - hemochromatosis - HTN - CAD s/p MI - asthma - h/o cyclosporine toxicity - history of antiphospholipid syndrome with myopathy and neuropathy . Social History: Lives with husband. - Tobacco: smokes [4-3] pack per day - Alcohol: drinks EtOH rarely, [2-2] glass of wine a week - Illicits: Denies Family History: Father with [Name2 (NI) ] ca and DVT Physical Exam: On admission: General: Cachectic, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at L>R bases, clearing above, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender but greatest in the lower quadrants. No organomegaly. No rebound or guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, trace symmetric edema Neuro: CNII-XII intact, moving all extremities, gait not assessed. On discharge: VS: 98.0 1121/67 60 16 97% General: Walking around room, in no acute distress HEENT: Laceration over left eyebrow with 3 sutures in place, sclera anicteric, MMM, oropharynx clear Neck: supple, JVD not elevated, no LAD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender but greatest in the lower quadrants. No organomegaly. No rebound or guarding. Ext: warm, well perfused, 2+ pulses Neuro: A&Ox3 Pertinent Results: Labs at admission: [2144-7-23] 12:00PM BLOOD WBC-7.6# RBC-2.71* Hgb-8.1* Hct-23.8* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.0* Plt Ct-268 [2144-7-23] 12:00PM BLOOD PT-16.2* PTT-25.9 [Month/Day/Year 263](PT)-1.4* [2144-7-23] 12:00PM BLOOD UreaN-91* Creat-4.6* Na-136 K-5.5* Cl-104 HCO3-18* AnGap-20 [2144-7-23] 12:00PM BLOOD ALT-7 AST-15 AlkPhos-117* TotBili-0.4 [2144-7-24] 02:59AM BLOOD Cortsol-4.9 [2144-7-23] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2144-7-23] 08:12PM BLOOD Lactate-1.2 Studies: EGD [7-24]: Varices at the fundus. Erythema, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy. Otherwise normal EGD to second part of the duodenum RUQ U/S: IMPRESSION: Normal hepatic echotexture with patent vessels. Trace free fluid. Splenomegaly to at least 13 cm. CXR: FINDINGS: Right-sided internal jugular dialysis catheter terminates with tip in the right atrium. The lungs demonstrate bibasilar atelectasis and scarring in the left upper lobe. There is no pleural effusion or pneumothorax. The heart is normal in size. Normal cardiomediastinal silhouette. EKG: Regular. P wave axis is abnormal. Normal QRS. Echo: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 55-60%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate ([2-2]+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([2-2]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 49 year old woman with EtOH cirrhosis s/p two liver transplants ([2136] and [2137]), ESRD on TuThSa HD here with hemodynamically significant upper GI bleed and abdominal pain. Now with improved abdominal pain and no further episodes of UGI bleed/melena. #Upper GI bleed: Patient with history of liver disease and is s/p two liver txpts. She reports having an EGD performed approximately 2 years ago for reasons unrelated to her liver disease that did not show varices. She presented [7-23] following an episode of hematemis at OSH. She received 1 unit of blood at OSH and then an addional 2 units here. She was also started on a PPI drip in the ED and a 7 day course of ciprofloxacin. She was initially transferred to the MICU, where her HCT remained stable following transfusion. An EGD on [7-24] revealed non-bleeding varices at the fundus and portal hypertensive gastropathy. Transferred to [Hospital Ward Name 121] 10 in stable condition on [7-25]. On the floor she remained stable without further bleeding. #Hypotenstion: The patient has chronically low blood pressures in the 70-90s systolic. She describes even lower BPs during dialysis. The patient denies any symptoms related to her low BP. In the MICU, the patient was started on midodrine and an AM cortisol was checked that revealed a level of 4.9, indicating likely adrenal insufficiency. She was started on high-dose hydrocortisone. The following day, a repeat AM cortisol was perfomed >12 hours after the prior steroid dose, and the level was 21.3. The steroids were stopped and the patient's BP remained >90 systolic for the remainder of her inpatient stay. She will be discharged on midodrine. #Abdominal pain: The patient developed abdominal pain following her episodes of hematemesis. Likely related to spasming during vomiting but also considered ischemia related to low BP. Lactate was measured to be 1.2 on admission and climbed to 5.5 during her hospital stay. Unclear etiology, but may be related to hypotension/ischemia vs. inability to clear lactate due to ESRD and skipped dialysis sessions while inpatient. The patient's abdominal pain resolved largely by the end of the first hospital day. She was continued on her home doses of oxycontin. #ESRD: The patient developed ESRD during her prior admission in early [2144]. On 3x weekly dialysis. She was dialysed as an inpatient on [2144-7-27]. #Fall: The patient frequently left the floor for extended periods of time during her inpatient stay. Often left to smoke despite counseling. During one trip on the night of [7-25], the patient tripped and fell causing a laceration above her left eye that required 3 sutures by surgery and a Head CT. The head CT did not reveal any ICH. She will require suture removal by her PCP on [Name9 (PRE) 2974], [7-31]. #Liver transplant: Continued cellcept and sirolimus. No active issues. #Possible PE: The patient was started on warfarin x3 months during her last admission due to a possible PE. She reported being on warfarin at home at admission although was subtherepeuticwith [Name9 (PRE) 263] 1.3. As an inpatient, coumadin was held in the setting of recent UGI bleed. She will be discharged off coumadin. Also stopped ASA given recent bleed. #Chronic pain/fibromyalgia: has chronic, neuropathic pain throughout her body. We continued her home dose of oxycontin (60mg QAM, 40mg QPM) and her lyrica. Medications on Admission: - diazepam 5mg PO TID PRN - mycophenolate mofetil 500mg [Hospital1 ] - oxycontin 40mg [Hospital1 ] - oxycontin 20mg [Hospital1 ] - Lyrica 50mg daily - simvastatin 20mg daily - sirolimus 2mg daily - warfarin 3mg daily - zaleplon 5mg QHS - ascorbic acid 500mg [Hospital1 ] - Aspirin 81mg daily - ferrous sulfate 325mg daily - folic acid 0.4mg daily Discharge Medications: 1. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). 2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. ciprofloxacin 500 mg Tablet Sig: 0.5 Tablet PO Q24H (every 24 hours) for 2 days. Disp:3 Tablet(s) Refills:0 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. zaleplon 5 mg Capsule Sig: One (1) Capsule PO at bedtime. 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper gastrointestinal bleed End-stage renal disease on hemodialysis 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 after a bleed from the stomach. You underwent an upper endoscopy that showed varices in the stomach, although no evidence of active bleeding. You received several transfusions of red blood cells and one cycle of dialysis, and you remained stable afterwards with no further bleeding. The following changes were made to your medicines. - ADDED midodrine 5 mg three times daily. - ADDED pantoprazole 40 mg once daily for stomach acid suppression. - ADDED ciprofloxacin 250 mg once daily to take for three more days. - STOPPED warfarin. - STOPPED aspirin. Please discuss with your liver doctor at your clinic appointment on Wednesday before restarting. - STOPPED diazepam due to low blood pressure. Please discuss with your primary care physician before restarting. There were no other changes to your medicines. Please note your follow-up appointments below. Your sutures should be removed at your primary care visit appointment this coming Friday. Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [2144-7-29] at 9:40 AM With: TRANSPLANT [Hospital 1389] CLINIC [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital ] MEDICAL GROUP Where: [Street Address(2) 3375], [Location (un) ], MA With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8682] [Telephone/Fax (1) 133] When: FRIDAY [2144-7-31] at 8:15 AM Completed by:[2144-7-27]	[ "40391", "3051", "49390", "41401", "412", "V5861" ]
Admission Date: [2120-1-28] Discharge Date: [2120-2-9] Date of Birth: [2068-6-11] Sex: M Service: CHIEF COMPLAINT: Nausea and vomiting. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with a history of multiple myeloma and chest plasmacytoma (status post radiation therapy approximately two weeks ago) who now presents with nausea, vomiting, decided oral intake, and chest pressure. The chest pressure is not exertional, it is not new, and is presumably secondary to the large retrosternal plasmacytoma. The patient has had nausea and vomiting for the two weeks prior to admission, and he describes his vomitus as black with chunks, and his stool as dark. The patient vomited once after presenting to the Emergency Room and had clear yellow emesis. He also complained of early satiety, orthopnea, and a persistent cough. The patient described some shortness of breath related to this full feeling in his chest. Of note, he had a repeat chest computed tomography prior to admission which revealed a decreased size of the retrosternal mass, a thickened pericardium, and thickened wall of the stomach to 6.1 cm. In the Emergency Department, his systolic blood pressure was in the high 80s/low 90s. He had no pulsus paradoxus, and he was mentating well. He received intravenous fluids while in the Emergency Department and was sent to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: (His past medical history is significant for) 1. Multiple myeloma and chest wall plasmacytoma diagnosed in [Country 5881] in [2117-11-5] where it was initially treated in [2119-8-6] with .................... and prednisone. The patient has received CVAD through [2119-11-5], and he received radiation therapy treatment to the anterior chest wall (which was completed approximately two weeks ago). The patient did have a large 18-cm X 17-cm plasmacytoma extending from the inferior portion of the sternum to the inferior peritoneum. This mass was concerning for advancement to the pericardium, left hepatic lobe, and anterior stomach wall. 2. The patient has a history of chronic obstructive pulmonary disease/asthma (which has never required intubations in the past). 3. He has a question of diabetes; given that he had elevated blood sugars while on dexamethasone. MEDICATIONS ON ADMISSION: (His medications included) 1. OxyContin 20 mg p.o. b.i.d. 2. Oxycodone 5 mg to 10 mg p.o. q.4-6h. p.o. as needed. ALLERGIES: No known drug allergies. FAMILY HISTORY: Family history was noncontributory. SOCIAL HISTORY: The patient smokes at home. He lives with his wife. [Name (NI) ] is from [Country 5881]. He does not drink alcohol. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed vital signs with a temperature of 100.3; other vital signs were stable. General appearance revealed a well-appearing and well-nourished male in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equally round and reactive to light and accommodation. Sclerae were anicteric. Extraocular movements were intact. The neck was supple. Jugular venous distention of 9 cm. Heart was regular in rate and rhythm, distant. No murmurs, rubs, or gallops. Pulmonary examination revealed no crackles. Clear to auscultation bilaterally. The abdomen revealed positive bowel sounds, soft, nontender, and nondistended. Rectal examination was guaiac-negative. Extremity examination revealed no edema. PERTINENT LABORATORY VALUES ON PRESENTATION: His complete blood count on admission showed white blood cell count was 4, hematocrit was 30.6, and an elevated neutrophil and band count. His urinalysis was sent and remained essentially normal. His electrolytes were within normal. HOSPITAL COURSE: Given the above, the patient was sent to the Medical Intensive Care Unit for further without. 1. PLASMACYTOMA ISSUES: The patient initially was monitored in the Intensive Care Unit to prevent any further drop in his hematocrit or any further episodes of hematemesis or bright red blood per rectum. However, after remaining stable he was transferred to the Bone Marrow Transplant Service for the possible recurrence of plasmacytoma. He had an endoscopy with biopsies performed by the Gastroenterology Service. These initially showed a cardiac ulcer with granulation tissue, but no tumor. Therefore, the patient had a repeat esophagogastroduodenoscopy performed. The second esophagogastroduodenoscopy showed hyperplasia and mild regeneration of the gastric pit. No neoplasm was seen in this sample. Considering the gross appearance, the lesion was thought to represent either an inflammatory or hypoplastic polyp. There was also possibly an underlying lesion of the gastric wall. The third biopsy was performed with ultrasound guidance which was not available at the time of discharge; however, it suggested fungal elements with possible lymphocytes consistent with plasmacytoma. The patient was instructed to follow up as an outpatient for this recurrence of his plasmacytoma. 2. GASTROINTESTINAL ISSUES: Otherwise, in terms of gastrointestinal issues, the patient continued to have guaiac-positive stools for the first few days of his hospitalization; however, these normalized. He experienced constipation and was treated with an aggressive bowel regimen. 3. MUSCULOSKELETAL ISSUES: His left arm had severe pain on admission; requiring an increase in his OxyContin dose to approximately 60 mg p.o. b.i.d. over the next few days. The patient was seen by the Orthopaedic Surgery Service, and plain films were obtained which suggested a left humeral fracture and a thrombolytic lesion. This thrombolytic lesion appeared to impinge on the ulnar nerve (according to a computed tomography scan which was performed). Therefore, Radiology/Oncology was also consulted. Orthopaedic Surgery felt that the fracture was not significant enough to be repaired surgically. Therefore, they signed off. Radiology/Oncology treated the thrombolytic lesion in the humerus for a few days prior to discharge. They set up outpatient appointments as well for the patient. Otherwise, the patient also experienced some left hip pain; for which plain films were obtained, suggesting a thrombolytic lesion in the proximal femur. This will also be followed up as an outpatient. As well, the patient had some radial and medial nerve damage; according to an electromyogram which was performed while he was in house. This possibly suggested a brachial plexus nerve route injury, and a magnetic resonance imaging was attempted. However, the patient had significant anxiety despite Haldol, Xanax, morphine, and Ativan. Anesthesia was consulted, and the patient was to return on [2120-2-15] for a magnetic resonance imaging of the neck and left arm under anesthesia. DISCHARGE STATUS: The patient was discharged to home on [2120-2-9]. MEDICATIONS ON DISCHARGE: 1. OxyContin 20 mg p.o. b.i.d. 2. Oxycodone 5 mg to 10 mg p.o. q.4-6h. as needed. 3. Zofran 8 mg p.o. q.4-6h. as needed. 4. Colace 100 mg p.o. b.i.d. 5. Dulcolax 10 mg p.o. q.d. 6. Lactulose 5 cc to 10 cc p.o. q.i.d. as needed. 7. Protonix 40 mg p.o. b.i.d. The patient was not continued on his Glucophage. He was not continued on his allopurinol. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [Last Name (STitle) ]. 2. The patient was to follow in the Radiology/[Hospital ] Clinic. 3. The patient was also to follow up for his magnetic resonance imaging on [2120-2-15]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], M.D. [MD Number(1) 7782] Dictated By:[Name8 (MD) 10249] MEDQUIST36 D: [2120-2-11] 16:11 T: [2120-2-11] 16:17 JOB#: [Job Number 35422]	[ "496", "3051", "53081" ]
Admission Date: [2118-10-3] Discharge Date: [2118-10-8] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: [10-5] CT Guided stereotactic aspiration of Right Cerebellar hemorrhage History of Present Illness: This is an 89 year old male with a history significant for metastaic melanoma, on coumadin (INR 4.9), 81 mg aspirin, with recent lumbar laminectomy doing rehab at home. The night prior to presentation, he was feeling dizzy. In the middle of the night he was grasping at the door frame, and kept waking every half hour to vomit. He woke and felt nauseous and vomited. That morning, he had a fall at home and hit the right side of the head, no LOC. He was taken to [Hospital1 18] by ambulance. Past Medical History: Primary melanoma in [2105] with right axillary dissection and radiation - discontinued due to R arm swelling. L-sided axillary mass w/ excision of chest wall tumor and L-axillary dissection and s/p 10 treatments XRT recently. S/p a lumbar spinal laminectomy in [2118-7-31], has been unsteady and using walker at home. prostate cancer diabetes Social History: He lives in [Hospital1 ]. He used to work as an attorney. He is currently in rehabilitation. He lives with his wife. [Name (NI) ] has four children and five grandchildren. Family History: NC Physical Exam: On Admission: T 97.2 BP 126/66 P 80s R 16 SpO2 97% GEN: elderly male lying on bed in c-collar, NAD HEENT: non-icteric, atraumatic CV: RRR, no murmurs Pulm: CTABL Abd: soft, NT, ND Ext: RUE swelling significantly larger then L MS: alert, oriented to [Hospital1 ], date, and name. Speech was slurred, slight dysarthria, but was fluent, no paraphasic errors, no anomia, no evidence of neglect, apraxia. CN: pupils [3-1] b/l to light, VFF to confrontation, EOMI w/ significant R-beating nystagmus on lateral gaze, facial sensation intact, smile symmetric, hearing intact b/l, palate symmetric, tongue midline. Motor: increased tone b/l at LE, significant swelling of the R arm, strength full throughout Reflexes: normal throughout, toes flexion b/l Coordination: significant dysmetria w/ b/l arms and legs on FNF testing and on HTS testing Sensation: intact to light touch and pinprick throughout Gait: not tested On Discharge: Expired Pertinent Results: [2118-10-3] 08:33AM PT-46.0* PTT-33.0 INR(PT)-4.9* [2118-10-3] 08:33AM PLT COUNT-156 [2118-10-3] 08:33AM NEUTS-89.7* LYMPHS-6.3* MONOS-3.7 EOS-0.1 BASOS-0.1 [2118-10-3] 08:33AM WBC-5.8 RBC-3.99* HGB-11.0* HCT-33.4* MCV-84 MCH-27.7 MCHC-33.1 RDW-15.0 [2118-10-3] 08:33AM cTropnT-0.02* [2118-10-3] 08:33AM estGFR-Using this [2118-10-3] 08:33AM GLUCOSE-321* UREA N-32* CREAT-1.3* SODIUM-131* POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16 CTA Head and Neck [2118-10-3] 1. Right cerebellar hemisphere hemorrhagic lesion, better seen on the recent non-contrast head CT. No evidence of underlying AVM or aneurysm. This could represent a parenchymal hematoma in the setting of the patient's anticoagulated status or a metastasis from his melanoma. 2. No cervical spine fracture. Extensive degenerative changes. 3. Post-radiation/post-surgical changes in the right lung apex and right axilla partially visualized. CT head [2118-10-3]: Large (~ 6.0 x 4.8 cm) Ill-defined hyperdense collection in the right cerebellar hemisphere with hematocrit levels, consistent with hemorrhage, likely subacute. Local mass effect as described, with leftward shift of the right cerebellar hemisphere and concern for early tonsillar herniation. Differential diagnosis includes traumatic injury, hemorrhagic metastatic disease given history of melanoma or vascular abnormality. MRI/MRA or CTA should be considered for further evaluation. CXR [2118-10-3]: AP supine portable view of the chest is obtained. Low lung volumes somewhat limit evaluation as well as slight patient rotation to the right. Clips in the right axilla are noted. The lungs appear clear bilaterally, aside from area of known scarring in the right lung apex. The cardiomediastinal silhouette appears unremarkable. Old healed right lower rib fractures are again noted. No acute fractures are seen. IMPRESSION: No acute traumatic injuries evident. MRI Brain [2118-10-4]: 1. Nodular area of enhancement along the lateral margin of the large infratentorial hemorrhage is suggestive of an underlying mass, compatible with metastatic disease. 2. New small focus of hemorrhage in the left anterior inferior cerebellar hemisphere. New supratentorial subarachnoid hemorrhage in the sylvian fissures and the occipital sulci. 3. Intraventricular hemorrhage. Stable partial effacement of the fourth ventricle with stable enlargement of the lateral and third ventricles. 4. The cerebellar tonsils efface the CSF space in the foramen magnum but do not herniate below the foramen magnum. CT head [2118-10-4] Compared to [10-3] head CT, increased size and distribution of right cerebellar hemorrhage with increased surrounding edema and mass effect; however, lesion is stable compared to more recent MRI. Increased hydrocephalus, particularly evident in the left lateral occipital [Doctor Last Name 534]. Doppler US [2118-10-4]: No new acute deep vein thrombosis identified. Chronic, occlusive subclavian clot is seen, the appearance of which is stable since the torso CT of [2118-5-9]. A single tiny venous structure identified in the region of the subclavian represents either collateral flow or is extremely diminutive vessel lumen. [10-5] Head CT: IMPRESSION: Decreased size of right cerebellar hemorrhage with decreased associated mass effect and reestablished patency of the fourth ventricle. Stable hydrocephalus. New post-operative extra-axial pneumocephalus and air within pre-existent clot cavity. [10-6] Head CT: IMPRESSION: No significant interval change. 1. Similar size of right cerebellar hemorrhage. 2. Stable hydrocephalus. 3. Bilateral frontoparietal and occipital subarachnoid hemorrhage which appears similar. 4. Interval decrease in size of extra-axial pneumocephalus, and stable air within preexisting clot cavity. [10-7] Head CT: 1. Interval worsening in the obstructive hydrocephalus. 2. Stable bilateral frontal, parietal, and occipital subarachnoid hemorrhage. 3. Stable right cerebellar hemorrhage with slight redistribution of blood due to positioning. Brief Hospital Course: Mr. [Known lastname 953] was admitted to SICU under the care of Dr. [Last Name (STitle) 739] on [2118-10-3] for evaluation of Right cerebellar hemorrhage. He had an MRI on the evening on [10-4] which revealed tumor, presumed to be metastatic melanoma. He required Zyprexa for this study bu was still lethargic and disoriented many hours later. CT revealed extension of the hemorrhage. He was slowly becoming for alert. A family meeting was held with Dr. [Last Name (STitle) 739] and his wife and four children. Surgical nd conservative treatments were discusses. Dr. [Last Name (STitle) 724] of the Neuro oncology group reviewed the images and was in favor of surgery. Dr. [Last Name (STitle) ] also met with the family to discuss the potential for a CT guided stereotactic biopsy and spiration. They agreed to procede. On [10-5], he was more lethargic and confused and he was taken to the OR. Surgical frame was placed on pre-op and he had a CT scan. Biopsy and aspiration was performed without complication. Approximately 40ml was aspirated. The patient remained intubated and in the PACU overnight. Post op head CT revealed residual hematoma but significant evacuation and decompression of 4th ventricle. On POD#1 a repeat Head CT was performed and stable. He was weaned from the neosynephrine and extubated. Pt's exam was stable but he remained lethargic. He was transferred to ICU for close neurological observation. The family was updated and plan was to place EVD if hydrocephalus were to worsen vs. no intervention if hemorrhage were to worsen. The patient's code status was changed back to DNR/DNI. On POD#2 the patient became less verbal. A Head CT was performed revealing extension of the hemorrhage. The family was updated and decided that no further intervention would be performed. Upon their arrival to the ICU, the patient was made CMO. On [10-8], patient passed away with family at bedside. Medications on Admission: Uroxatral 10 mg daily Glyburide 5 mg daily Lisinopril 5 daily Metoprolol Tartrate 25 mg daily Omeprazole 20 mg daily Simvistatin 40 mg daily Warfarin 2.5 daily Aspirin 81 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cerebellar tumor Cerebellar hemorrhage Hydrocephalus Intraventricular Hemorrhage Brain Compression Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2118-10-8]	[ "4019", "25000", "V4582", "V5861" ]
Admission Date: [2183-6-24] Discharge Date: [2183-6-28] Date of Birth: [2107-9-30] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Fosamax / Tylenol Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion, fatigue Major Surgical or Invasive Procedure: [2183-6-24] Aortic valve replacement with a 21-mm St. [Hospital 923] Medical Biocor tissue valve. Coronary artery bypass grafting x2, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal branch. History of Present Illness: 75 year old woman with history of aortic stenosis which has been followed by serial echocardiograms. Over the past 6 months, she has noticed an increase in her exertional dyspnea and fatigue. She denies chest pain, but does report occasional pain on her left side after gardening. She has been referred for surgical evaluation for AVR, ?MVR, +/-CABG. Past Medical History: Aortic Stenosis Coronary Artery Disease PMH: Bilat. carotid artery stenoses Breast cancer Hypertension Psoriasis Rhinitis Anemia Peripheral vascular disease Thalassemia trait Tympanic membrane perforation Urinary incontinence H/O myositis Depression Lichen sclerosus Osteopenia Polymyalgia rheumatica Hypothyroidism GERD Past Surgical History: Left lumpectomy (no radiation) bilateral cataracts tonsillectomy right tympanic membrane repair Social History: Lives: alone, husband is in palliative care at VA Occupation: retired from [First Name4 (NamePattern1) 46] [Last Name (NamePattern1) ] Tobacco: Quit in [2156]. 2ppd for 35 years ETOH: Denies Family History: mother died at 82 following complications from AVR/CABG father died at 42yo following complications of a brain tumor brother died at 39 MI sister died at 43 MI Physical Exam: Pulse: 59 Resp: 16 O2 sat: 99 B/P Right: 149/74 Left: 138/68 Height: Weight:152 General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [] not reactive, s/p lens implants, EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [2-9] syst. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [] mild spiders Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: NP Left: NP Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: radiation of cardiac murmur Pertinent Results: [2183-6-24]- intra-op TEE Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results before surgical start. POST-BYPASS: Normal RV and LV systolic function. LVEF 55%. Intact thoracic aorta. The aortic bioprosthesis is stable, functioning well with a residula mean gradient of 12 mm of Hg. There is no regurgitation seen across or around the aortic prosthesis. MR stays the same. 2+ MR Admission Labs: [2183-6-24] 12:40PM BLOOD WBC-9.4 RBC-2.87# Hgb-7.5# Hct-22.4* MCV-78# MCH-26.1# MCHC-33.4 RDW-18.1* Plt Ct-131* [2183-6-24] 12:40PM BLOOD PT-16.6* PTT-36.7* INR(PT)-1.5* [2183-6-24] 12:40PM BLOOD Fibrino-202 [2183-6-24] 02:33PM BLOOD UreaN-14 Creat-0.9 Na-136 K-5.2* Cl-112* HCO3-22 AnGap-7* [2183-6-24] 12:40PM PT-16.6* PTT-36.7* INR(PT)-1.5* [2183-6-24] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Discharge labs: [2183-6-27] 06:30AM BLOOD WBC-9.9 RBC-3.77* Hgb-10.4* Hct-29.6* MCV-79* MCH-27.7 MCHC-35.2* RDW-19.4* Plt Ct-100* [2183-6-27] 06:30AM BLOOD Plt Ct-100* [2183-6-27] 06:30AM BLOOD Glucose-100 UreaN-25* Creat-1.0 Na-130* K-4.3 Cl-97 HCO3-26 AnGap-11 [2183-6-27] 06:30AM BLOOD Mg-2.0 Radiology Report CHEST (PORTABLE AP) Study Date of [2183-6-26] 2:56 PM Final Report: Bilateral lung volumes are low with bibasilar atelectasis. Pulmonary vascularity is mildly plethoric, but there is no evidence of pulmonary edema. There are bilateral minimal pleural effusions which are unchanged since [2183-6-24]. Atelectasis of the bilateral lung bases is seen. The cardiac silhouette is enlarged due to cardiomegaly and is relatively stable. There is no evidence of pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 16988] [Name (STitle) 16989] DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] Brief Hospital Course: The patient was a same day admission for AVR/CABg on [2183-6-24]. On that day the patient underwent aortic valve replacement and coronary bypass grafting with Dr. [Last Name (STitle) ]. Please see the operative report for details, in summary she had: Aortic valve replacement with a 21-mm St. [Hospital 923] Medical Biocor tissue valve, and coronary artery bypass grafting x2, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal branch. Her bypass time was 114 minutes with a crossclamp of 85 minutes. The patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition on Neosynephrine and Propofol infusions. In the immediate post-op period she was hemodynamically stable, she woke from anesthesia neurologically intact and was extubated. POD 1 found the patient extubated, alert and oriented and breathing comfortably. She weaned from vasopressor support, Beta blocker was initiated and the patient was begun on diuretics. She also transferred from the ICU to the stepdown floor. All chest tubes, lines and epicardial pacing wires were removed per cardiac surgery protocol without complication. The remainder of the patients hospitalization was uneventful. She worked with the physical therapy service for assistance with strength and mobility. At the time of discharge on POD 4 the patient was ambulating, the wound was healing and pain was controlled with Ultram. The patient was discharged [Hospital 108453] Rehab in [Hospital1 392] in good condition. She is to follow up with Dr [Last Name (STitle) ] on [2183-7-17] @1:15PM. Medications on Admission: ATENOLOL 25 mg Tablet - 0.5 Tablet(s) by mouth once a day COLESTIPOL - 1 gram by mouth twice a day LEVOTHYROXINE -50 mcg once a day LISINOPRIL - 40 mg once a day OMEPRAZOLE - 20 mg daily SIMVASTATIN - 80 mg once a day VENLAFAXINE - 37.5 mg twice a day ASPIRIN - 325 mg Tablet once a day CHOLECALCIFEROL Dosage uncertain Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Tablet(s) 7. colestipol 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital 66] Rehab & Nursing Center - [Hospital1 392] Discharge Diagnosis: Aortic Stenosis s/p AVR Coronary Artery Disease s/p CABG PMH: Bilateral carotid artery stenoses Breast cancer Hypertension Psoriasis Rhinitis Anemia Peripheral vascular disease Thalassemia trait Tympanic membrane perforation Urinary incontinence Myositis Depression Lichen sclerosus Osteopenia Polymyalgia rheumatica Hypothyroidism GERD Past Surgical History: Left lumpectomy (no radiation) bilateral cataracts tonsillectomy right tympanic membrane repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Ultram Sternal Incision - 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, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check-Cardiac Surgery Office [Hospital Ward Name ] 2A on [2183-7-2] @10:30 [Telephone/Fax (1) 170] Surgeon Dr. [Last Name (STitle) ] in [Hospital Ward Name ] 2A on [2183-7-17] @1:15 phone:[Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) 33746] in 1 month. Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 68409],[First Name3 (LF) 20] B. [Telephone/Fax (1) 68410] in 1 week after rehab. 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:[2183-6-28]	[ "4241", "41401", "4019", "311", "2449", "53081", "2875" ]
Admission Date: [2119-11-9] Discharge Date: [2119-11-10] Date of Birth: [2089-1-7] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3326] Chief Complaint: diabetic ketoacidosis Major Surgical or Invasive Procedure: none History of Present Illness: 30F w/ IDDM, needle phobia, poor [First Name3 (LF) 31217] compliance, recurrent DKA, p/w nausea, vomiting, abdominal pain concerning for DKA. . Pt went home last night, and started to notice nausea, abdominal pain with several bouts of NB/NB vomiting. Pt could not tolerate po, other than water. Her urine dip stick was notable for moderate ketone. Pt also complained of headache, lightheadedness. But she denied recent sickness, no diarrhea, cough. Her menstrual period has been normal. Per pt, she measures her FSG 3-4 times a day, she does lantus, but inconsistent with Humalog. She typically tries to make her blood sugar between 200-300. She has recently started to see [Last Name (un) 387] psychiatrist. . In the ED inital vitals were 98.4, 136, 131/67, 18, 100%. Her blood sugar on arrival to the ER was over 400, her labs were notable for an anion gap of 28, bicarb of 5 and glucose of 478. Her blood sugar after 2LNS was 440 so she was given 6 units of IV [Last Name (un) 31217] and started on an [Last Name (un) 31217] gtt at 6 units per hour. Prior to transfer she was transitioned to D5 with 40meq of K+, but her repeat fingerstick remained over 400. VS on transfer: 123, 118/66, 15, 100% on RA. Past Medical History: Type 1 Diabetes Mellitus, diagnosed at age 25 Needle Phobia, recently started seeing psychiatrist at [Last Name (un) ] Inguinal hernia Social History: - Tobacco: None - Alcohol: Rare, has not had any drinks over past week - Illicits: None Lives with parents, works as hostess at a restaurant. Family History: not assessed Physical Exam: Admission Vitals: 98.4, 107, 115/70, 18, 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no w/r/rh CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: soft, diffusely tender to palpation, no guarding/rebound Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, two round erythematous macule measuring 3 cm in diameter, per pt was old. Discharge General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no w/r/rh CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: soft, diffusely tender to palpation, no guarding/rebound Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, two round erythematous macule measuring 3 cm in diameter, per pt was old. Pertinent Results: Admission [2119-11-9] 03:40AM BLOOD WBC-8.9# RBC-5.06 Hgb-15.6 Hct-46.6# MCV-92 MCH-30.9 MCHC-33.6 RDW-14.5 Plt Ct-459# [2119-11-9] 08:46AM BLOOD Glucose-203 UreaN-10 Creat-0.7 Na-144 K-3.5 Cl-120* HCO3-8* AnGap-20 [2119-11-9] 08:46AM BLOOD ALT-13 AST-13 LD(LDH)-129 AlkPhos-70 Amylase-34 TotBili-0.1 [2119-11-9] 08:46AM BLOOD Albumin-3.6 Calcium-7.3* Phos-1.1* Mg-1.5* [2119-11-9] 03:49AM BLOOD Glucose-478* Lactate-1.6 Na-140 K-5.5* Cl-107 calHCO3-5* Discharge [2119-11-10] 06:26AM BLOOD WBC-2.9# RBC-3.94 Hgb-12.0 Hct-34.8* MCV-88 MCH-30.5 MCHC-34.6 RDW-13.8 Plt Ct-222 [2119-11-10] 06:26AM BLOOD Glucose-218* UreaN-3* Creat-0.5 Na-143 K-3.7 Cl-112* HCO3-24 AnGap-11 [2119-11-10] 06:26AM BLOOD Calcium-7.0* Phos-1.0* Mg-1.8 CXR [11-9] The cardiac, mediastinal and hilar contours are unremarkable. Both lungs are clear with no focal consolidation, pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 30yoF w/ t1DM, needle phobia, poor [Month/Year (2) 31217] compliance, recurrent DKA, p/w nausea, vomiting, abdominal pain concerning for DKA. . Upon admission to the hospital was found to have hyperglycemia, a bicarb of 8, anion gap 16, and a UA showing ketones and >1000 glucose. She has a needle phobia and so had only been taking her long-acting [Month/Year (2) 31217], not her short acting. She is going through CBT with a psychiatrist at the [Hospital ] clinic, and is making progress. She was started on an [Hospital 31217] drip and IVF. By 630pm on the day of admission, her anion gap had closed. She was then transitioned to long acting [Hospital 31217] with a humalog sliding scale. Her N/V and abdominal pain improved with correction of her DKA. [Last Name (un) ] was consulted and felt that she was safe to go home from the ICU. The patient was anxious to leave the hospital as she is supposed to travel tomorrow. She will follow up in [Hospital ] clinic on Monday. The [Last Name (un) ] consult team had a number of helpful ideas as to how to help her become more compliant. They were interested in an [Last Name (un) 31217] pump, and possibly a pancreas transplant. TRANSITIONAL ISSUES # Will follow up with [Last Name (un) ] on Monday # Needs continued teaching about taking the necessary amount of [Last Name (un) 31217] to prevent DKA # Glargine was increased to 44 units at night, from 40 units Medications on Admission: 1. ethyl chloride Topical 2. fluoxetine 20 mg qd 3. lorazepam 0.5 mg prn tid 4. Ambien 5 mg prn qd 5. [Last Name (un) 31217] glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 6. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: please see attached sheet. Discharge Medications: 1. ethyl chloride 100 % Aerosol, Spray Sig: One (1) spray Topical PRN as needed for pain from injections. 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety . 4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. [Last Name (un) 31217] glargine 100 unit/mL Solution Sig: Forty Four (44) units Subcutaneous qHS. 6. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day. Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the [Hospital1 18] Intensive Care Unit because of diabetic ketoacidosis (DKA). This is a condition where you get dangerous levels of acid in your blood, caused by very high blood sugars. You got this because you were not taking all of your home [Hospital1 31217]. DKA is a life-threatening illness; to prevent further attacks, it is vitally important that you take all of your [Hospital1 31217] as prescribed, including the short and long acting form. The following changes were made to your medications: CHANGE [Hospital1 31217] glargine to 44 units at night subcutaneous (from 40 units) Followup Instructions: [Hospital ] clinic on Monday (per your [Last Name (un) ] doctor)	[ "V5867" ]
Admission Date: [2188-2-8] Discharge Date: [2188-2-12] Date of Birth: [2105-3-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4760] Chief Complaint: [First Name3 (LF) ] Urgency Major Surgical or Invasive Procedure: None History of Present Illness: 82 y/o man with HTN, Hyperlipidemia, PVD s/p femoral bypass, ruptured AAA and Afib who is admitted to the [Hospital Ward Name ] ICU with altered mental status. . He was initially admitted two weeks ago to [Hospital1 18] neurosurgical service when he presented with a headache, nasuea, and vomitting and was found to have a posterior fossa intracranial hemorrhage. He was transfered from OSH where the inital thought was that there was a mass + hemorrhage. He went to the OR for evacuation and exploration and no mass found, only bleed. He was discharged to rehab. . While at rehab, he had ongoing weakness, confusion, and poor appetite. He was sent to [Hospital1 18] for evaluation. . At [Hospital1 18], he had a head CT that was seen by neurosurgery. Neursurgery did nto feel there were any changes and recommended disposition back to rehab. He became [Hospital1 ] in the ED however to the 200s systolic requiring labetalol 10mg IV x 3 for control and pressures dropped to 130's systolic and remained there. He further complianed of headache, also developed a fever to 101 and had some neck stiffness. An LP was discussed but not performed as it was felt his headache was due to [Hospital1 ] urgency. He had blood and urine cultures sent, no antibiotics were administered. His wound was evalulated by neurosurgery who felt it was well healing, without evidnece for superficial infection. . On admission to the ICU, vitals stable, patient reports significantly improved headache. No other complaints, no CP, no SOB, no changes in vision. Family states patient has been more confused over the last week with word finding difficulties and increased disorientation. Today patient appeared increasingly lethargic and weak. . Past Medical History: Intracranial Hemorrhage Atrial fibrillation, on coumadin until recent hemorrhage Hypertension AAA s/p emergent endovascular repair in [7-/2187] after presenting with back pain and hypertension Peripheral Vascualr Disease s/p LLE bypass Symptomatic Bradycardia s/p PPM Social History: Social History: Married, lives with wife (admitted from rehab however). Has 5 children one of whom lives with him. Non smoker, no EtOH. Used to own a dry cleaning business. Family History: n/c Physical Exam: On Presentation: VS: Af 125/81 78 15 100% on RA GEN: NAD, pleasant, elderly male laying in bed HEENT: PERRLA, dry mmm, no OP lesions, no scleral icterus CV: Regular rate, no mrg PULM: CTAB ABD: + BS, soft, NTND EXT: No edema 2+ DP pulses, skin with hyperpigmented patches NEURO: Oriented to person, year and type of place (hospital though unable to name which one). Able to state former President but not current. Unable to state birthday. Able to name [3-11] obeject at 0 minutes and [1-12] objects at 3 minutes. Strength: [5-13] UE/LE bilaterally Sensation: intact and qual bilaterally UE/LE Reflexes: 2+ U/L Crainial Nerves: [2-21] intact Pertinent Results: [2188-2-8] 10:15PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2188-2-8] 10:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2188-2-8] 10:15PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2188-2-8] 06:36PM LACTATE-1.1 [2188-2-8] 06:30PM GLUCOSE-115* UREA N-20 CREAT-1.1 SODIUM-133 POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-29 ANION GAP-14 [2188-2-8] 06:30PM estGFR-Using this [2188-2-8] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2188-2-8] 06:30PM WBC-3.9* RBC-3.87* HGB-12.0* HCT-35.6* MCV-92 MCH-31.1 MCHC-33.8 RDW-16.7* [2188-2-8] 06:30PM NEUTS-82.6* LYMPHS-11.0* MONOS-5.5 EOS-0.2 BASOS-0.8 [2188-2-8] 06:30PM PLT COUNT-112* [2188-2-8] 06:30PM PT-14.9* PTT-36.9* INR(PT)-1.3* . CT Head [2188-2-8]:Final Report HISTORY: 82-year-old male with headache. Evaluate for intracranial hemorrhage or mass. COMPARISON: Series of prior non-contrast head CTs, most recently [2188-1-26], dating back to [2188-1-24]. TECHNIQUE: Non-contrast head CT was obtained. Residual foci of high density within the right cerebellar surgical bed are decreased in comparison to [2188-1-26]. No new intracranial hemorrhage is identified. Coarse calcifications of the basal ganglia are unchanged. [Doctor Last Name ]-white matter differentiation is preserved. The ventricles, basal cisterns and sulci are stable in size and configuration. Changes of suboccipital subtotal right craniectomy are stable. The paranasal sinuses and mastoid air cells appear well aerated. The orbits are unremarkable. IMPRESSION: Residual hyperdense foci in the region of the surgical bed of the right cerebellum. No new intracranial hemorrhage. The study and the report were reviewed by the staff radiologist. . CXR [2188-2-8]: PA AND LATERAL CHEST [2188-2-8] AT 19:48 HOURS. HISTORY: Mental status changes. COMPARISON: Multiple priors, most recent dated [2188-1-26]. FINDINGS: The lungs are well expanded and clear. There is a tortuous atherosclerotic aorta. The cardiac silhouette remains enlarged. No effusion or pneumothorax is evident. A single-lead pacemaker is stable in course and position. The regional osseous structures are unremarkable. The proximal stent of an aortic stent is again included and unchanged. IMPRESSION: [Month/Day/Year ] cardiomediastinal configuration with indwelling stable pacemaker and no acute pulmonary process. Brief Hospital Course: 82M with ICH, afib, PPM, PVD, ruptured AAA, who presented with altered MS [First Name (Titles) ] [Last Name (Titles) ] urgency. . # Delirium/Moderate Cognitive Impairment/Likely Traumatic Brain Injury: Pt delirium rapidly cleared with no intervention, but pt does have a new moderate cognitive impairment. Per family, patient was not mentating at baseline, has long term and short term memory deficits and some word finding difficulties. Neuro exam otherwise intact. Patient has posterior fossa intracranial hemorrhage several weeks ago and is s/p posterior crainitomy for evacuation of bleed. He had a head CT in the ED, unchanged from prior. Neurosurgery saw in ED and felt that scan was unchanged and there was no evidence of new bleed. From their perspective they recommended discharge back to rehab (admitted then for [Last Name (Titles) ] urgency). Patient was also febrile in ED to 101.1 though was afebrile on arrival to ICU. Initial concern was for meningitis, but LP was not performed as pts mental status quickly improved, he had no further fevers other than isolated fever in the ED, no leukocytosis, and bacterial meningitis unlikely in the setting of 1 week of mental status changes. Medications can be a cause of AMS in the elderly - per rehab records, percocet was prescribed starting on [1-30], however patient's wife, patient last received that on [2-4]. Ua/urine culture was negative for UTI, CXR negative for PNA. He had no abdominal symptoms or diarrhea to suggest colitis.TSH/B12folate levels were normal. It is possibly pts delirium was due to labile hypertension/[Month/Year (2) ] urgency, but his BP here on his home regimen was in the 110s-140s. Pt was seen by OT here, noted to have [1-14] short term recall, could not appropriately draw a clock, and could not say months of year backwards. OT felt these findings were more consistent with TBI rather than dementia or delirium. Biggest deficits were in memory and executive functioning. Recommended outpatient formal neurocognitive evaluation in 1 month which has been arranged. . # Headache: Likely [2-11] to surgery +/- TBI, pain has improved to [2-19]. CT unchanged from prior, no new bleed. Neurosurgery saw no intervention necessary. Controlled pain with tylenol. . # S/P Posterior Crainiotomy/ICH: Patient underwent craniectomy for evacuation of cerebellar hemorrhage by Dr. [Last Name (STitle) 739] on [1-25]. Was evaluated by neurosurg and found to be stable from neurologic perspective. Plan was to follow up with Dr. [Last Name (STitle) 739] in 4 weeks after his last discharge. Follow up has now been arranged for 3 weeks from now with a head CT prior. . # Thrombocytopenia: Plt at baseline in 90s-low 100s. Could be [2-11] to drug effect such as famotidine. B12/folate WNL. Famotidine was stopped (pts medication list evaluated, and this is the one offending medication that he is on) and protonix was started. . # Atrial Fibrillation: Rate controlled on beta-blocker. No anti-coagulation or ASA given ICH - was stopped at last admission. Rediscussed with neurosurgery, and it was deemed safe to restart ASA (which we did). They would like to hold off still on starting coumadin until pt follows up with Dr. [Last Name (STitle) 14074] in 3 weeks. . # Malignant Hypertension: Was [Last Name (STitle) ] to 200's in ED ,requiring labetalol 10mg IV x 3 for control and pressures dropped to 130's systolic. SBP remained in 100s-140s on pts home blood pressure regimen. . # Hyponatremia: Admission Na was down to 130 from baseline of 140. Felt to be volume depletion vs. SIADH. On trial of IVF, pts Na did improve up to 136, c/w dehydration. Do not think this is cerebral salt wasting given pt is not hypotensive or dry in appearance. Lasix was stopped and can be resumed in the future if he has any evidence of volume overload. . # Communication: With patient, wife [Name (NI) 22362] [Telephone/Fax (1) 79160], [Name2 (NI) ]ter [Name (NI) 3692] [Telephone/Fax (1) 79161] Medications on Admission: Acetaminophen 325-650mg q6 prn Docusate Sodium 100 mg [Hospital1 ] Allopurinol 200 qd Atorvastatin 10 mg qd Doxazosin 4 mg qhs Furosemide 20 mg qd Isosorbide Mononitrate 30 mg SR qd Sertraline 50 mg qd Senna 8.6 mg [Hospital1 ] Bisacodyl 10 mg Tablet qd Atenolol 25 mg Tablet qd Hydralazine 10 mg q6h Famotidine 20 mg [Hospital1 ] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, headache, fever. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Rehab Hospital Of [Doctor Last Name ] Discharge Diagnosis: Delirium [Doctor Last Name ] urgency Hyponatremia Thrombocytopenia Moderate cognitive impairment Discharge Condition: stable Discharge Instructions: You were admitted with confusion and hypertension. Your blood pressure was treated with medications, and has remained normal since you have been on your home blood pressure regimen. Your confusion resolved on its own. You had an isolated fever on admission, but you had no evidence of urinary tract infection, pneumonia, or other infection. . Take all medications as prescribed. Your famotidine was changed to protonix in the case that famotidine has been causing your platelet level to be low. . You were seen by occupational therapy an diagnosed with moderate cognitive deficit. This is likely due to traumatic brain injury after your fall. You have been scheduled for a formal behavioral neurology evaluation as per below. Please also follow up with neurosurgery at your scheduled appointment time. Your aspirin has been restarted, but not your coumadin yet. . Call your doctor or go to the ER for any worsening confusion, dehydration, fever, new weakness/numbess of any arms/legs, slurred speech, worsening headache, visual changes, or any other concerning symptoms. Followup Instructions: 1. Neurosurgery: Please follow up with Dr. [Last Name (STitle) 739] on [2-27]. You need to first have a CAT scan of the head again at 2:00 PM on the same day located in the main [Hospital Ward Name 517] [Hospital 18] hospital ([Location (un) 591] Building) [Location (un) 470] radiology. Your appointment with Dr. [Last Name (STitle) 739] is located in another building and is at 3:00 PM. He is located in the [Hospital Unit Name 3269], [Apartment Address(1) 79162] B. You can call [Telephone/Fax (1) 1272] if you have any questions or need to change this appointment. . 2. Behavioral Neurology: Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [3-20] at 10:30 AM. He is located in the [Hospital Ward Name 5074], [Hospital1 18], [Hospital Ward Name 860] [Doctor Last Name ], [Location (un) ], [Apartment Address(1) ]. This is for a formal cognitive evaluation to test your memory and thinking. ([Telephone/Fax (1) 1703] . 3. Please call Dr. [First Name (STitle) 2405] at [Telephone/Fax (1) 74550] to follow up with him after your discharge from rehab.	[ "2761", "2875", "42731", "2724" ]
Admission Date: [2160-9-14] Discharge Date: [2160-9-14] Date of Birth: [2129-8-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Reason for MICU Admission: Foreign body ingestion Major Surgical or Invasive Procedure: Laryngoscopy History of Present Illness: This is a 31 y.o. female with history of depression, alcohol use, past history of who presents for evaluation after swallowing a piece of steak post drinking. She apparently had sensation of fullness and coughing after this, and her friends were concerned that she was choking and sent her in by ambulance to the ED for evaluation. Laryngoscopy was performed in ED and did not reveal a foreign body in upper airway. GI was consulted in ED and will scope patient in AM. Review of systems: Patient denies any current sensation of food stuck in throat. She complains of throat pain after laryngoscopy. Denies any nausea, vomitting, abdominal pain, changes in bowel habits, fevers, chills, urinary symptoms, rashes, shortness of breath, chest pain, or any other concerning symptoms. Past Medical History: Depression--followed by [First Name8 (NamePattern2) 25812] [Last Name (NamePattern1) ] at [Hospital3 33953] Clinic ovarian cyst Social History: From Brasil, in U.S. for 4 years. Lives with roommates in [Location (un) 577]. + Alcohol. No tobacco or illicit drug use. Family History: Denies Physical Exam: Admission exam: Vitals:98.4, 100/50, 64, 15, 97% on RA GEN: NAD, Portugese speaking female, apperas disheveled HEENT: EOMI, anicteric, dry MM, OP clear COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS EXT: No C/C/E NEURO: A&O x 3, CN II-XII intact SKIN: No rashes, jaundice or ecchymoses Pertinent Results: [2160-9-14] 01:40AM WBC-6.8 RBC-3.89* HGB-12.6 HCT-35.8* MCV-92 MCH-32.4* MCHC-35.2* RDW-13.8 [2160-9-14] 01:40AM PLT COUNT-221 [2160-9-14] 01:40AM GLUCOSE-92 UREA N-13 CREAT-0.8 SODIUM-144 POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16 [2160-9-14] 01:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2160-9-14] 01:40AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Chest X-ray: PORTABLE AP CHEST RADIOGRAPH: Comparison was made with the prior chest radiograph dated [2160-2-15]. Cardiac and mediastinal contours are within normal limits, and lungs are clear. There is no consolidation or effusion or CHF. There is no evidence of radiopaque foreign body. Brief Hospital Course: This is a 31 y.o. female with history of depression, alcohol use past history of cleaning solution ingestion, who presents with foreign body ingestion (steak). The patient had a laryngoscopy in the emergency room to evaluate the upper airway; no foreign body was seen. Her symptoms resolved by the time she was transfered to the intensive care unit. No foreign body was seen on chest xray. GI was consulted and recommended that she have an EGD as an outpatient. The patient was discharged and given the phone number to follow up with GI. Medications on Admission: Per most recent discharge summary: Escitalopram 10mg qdaily Thiamine Folate Hexavitamin Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Foreign body impaction of esophagus Secondary Diagnoses: Depression Discharge Condition: Stable, tolerating normal diet. Discharge Instructions: You were admitted for evaluation of possible choking on food. You received a laryngoscopy in the emergency room to evaluate if food went into your breathing passages. That was normal. You should follow-up with a gastroenterologist for an EGD (endoscopy) as an outpatient. Please call your physician or return to the emergency room if you notice trouble breathing, nausea, vomitting, fevers, chills, or any other concerning symptoms. Followup Instructions: Please call ([Telephone/Fax (1) 2233], to schedule an EGD as an outpatient in the next 2-4 weeks. Please follow-up with your primary care physician [Last Name (NamePattern4) ] [1-15] weeks if appointment is available. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2160-9-14]	[ "2859", "311" ]
Admission Date: [2105-3-22] Discharge Date: [2105-3-31] Date of Birth: [2045-5-11] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2387] Chief Complaint: syncope Major Surgical or Invasive Procedure: RIJ placement and removal Implantation of Internal Cardiac Defibrillator and biventricular pacemaker History of Present Illness: 59 F with CAD s/p LAD BMS x 2 on [2105-3-16], CHF (EF 20%), pulm htn and asthma recently discharged three days ago now presented with lightheadness and syncope. During her last hospitalization, she ruled in for an NSTEMI and had cath at NEBH which showed RCA clot. She was transferred to [Hospital1 18] for asa desensitization and cath here showed resolution of the RCA clot. There were 70% stenosis of the LAD and 2 BMS were placed. She also had SOB from her asthma and CHF and her diuretic regimen was increased from lasix to torsemide. Her discharge weight was 137 pounds. . At home, she had been feeling weak and lightheaded for the past 3 days. She also had some mild small volume diarrhea. She took all her medication as prescribed including asa, plavix, torsemide and her antihypertensives. This morning, she felt dramatically lightheaded that she had to close her eyes and lay herself on the kitchen floor. She remembers trying to get up repeated but eventually lost consciousness. When she woke up, she discovered a bruise on her face and had pain in her R shoulder. She was still able to get up and finish her breakfast. She called her neighbors who came over and encouraged her to call her doctor. She took her BP and it was in the 70's. The covering physician encouraged her to come to the ED so she called an ambulance. . In the ED, her initial vitals at triage was listed as 96, 114/90, 88, 100% NC. The blood pressure was thought to be an error since her BP was in the 60s and 70's when she was evaluated. She was given about 2L NS. She was started on dopamine and then neo was added. She got 100 mg IV hydrocortisone. Her SBP's were in the 90's. EKG had some deeper STD laterally but cardiac markers were not significantly elevated. Card's consult saw her in the ED and thought she may be overdiuresed. She had a central line placed and was admitted to the CCU. . She had chest burning consistent with her heart burn but no new chest pain. Her right shoulder still has pain. She has SOB but could not tell if it is her asthma. She reports that her weight was about 135 pounds at home. She denies palpitations. . ROS: Denies orthopnea, PND, peripheral edema. Denies abd pain, n/v. + dysuria since discharge. Denies hematachezia or BRBPR. . Past Medical History: Non ischemic Cardiomyopathy EF 20-25% diagnosed 14 years ago Asthma HTN Mitral valve regurgitation Sleep apnea Pulmonary HTN Hypothyroidism Depression/Anxiety . Cardiac Risk Factors: -Diabetes, Dyslipidemia, Hypertension . Percutaneous coronary intervention, [2105-3-13] anatomy as follows: Left main normal LAD gives rise to mod diag, 50% prox and 50% mid LAD stenosis Left circ 30% ostial stenosis RCA dominant. 70-80% stenosis distal RCA. run off very good . Pacemaker/ICD: pt has refused in past Social History: Patient is single. Works part time at library. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. . Family History: FHX: She has history of premature CAD with father having MI in 50s. Physical Exam: GEN: A+Ox3, pleasant, NAD HEENT: PERRL, EOMI, OP clear, MMM/. R facial edema and ecchymoses NECK: JVP about 10 cm on the left, R IJ in neck CV: RRR, II/VI holosystolic M at apex, no gallops, rubs PULM: CTAB, no W/R/R ABD: Soft, mildly distended, NT, +BS EXT: No peripheral edema. NEURO: mentating normally, talkative. CN II-XII intact. Mobilizes all extremities. No focal weakness Pertinent Results: Admission Labs - [2105-3-22] [2105-3-22] 04:30PM BLOOD WBC-15.4* RBC-3.94* Hgb-11.1* Hct-32.4* MCV-82 MCH-28.3 MCHC-34.3 RDW-15.2 Plt Ct-487* [2105-3-22] 04:30PM BLOOD Neuts-83.9* Lymphs-7.5* Monos-4.4 Eos-3.8 Baso-0.4 [2105-3-22] 04:30PM BLOOD PT-14.9* PTT-29.4 INR(PT)-1.3* [2105-3-22] 04:30PM BLOOD Glucose-135* UreaN-40* Creat-1.7* Na-125* K-7.1* Cl-90* HCO3-24 AnGap-18 [2105-3-23] 12:14AM BLOOD ALT-28 AST-19 LD(LDH)-245 CK(CPK)-62 AlkPhos-60 TotBili-0.6 [2105-3-22] 04:30PM BLOOD cTropnT-0.13* [2105-3-22] 04:30PM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.4* Mg-2.8* [2105-3-22] 04:30PM BLOOD Digoxin-0.8* [2105-3-22] 04:44PM BLOOD Glucose-118* Lactate-1.5 Na-129* K-4.5 Cl-91* calHCO3-25 . DISCHARGE LABS: [2105-3-31] 05:00AM BLOOD WBC-8.2 RBC-3.77* Hgb-10.3* Hct-31.7* MCV-84 MCH-27.2 MCHC-32.4 RDW-15.5 Plt Ct-338 [2105-3-31] 05:00AM BLOOD Neuts-51.9 Lymphs-32.3 Monos-5.4 Eos-9.9* Baso-0.6 [2105-3-22] 04:30PM BLOOD Neuts-83.9* Lymphs-7.5* Monos-4.4 Eos-3.8 Baso-0.4 [2105-3-31] 05:00AM BLOOD Glucose-100 UreaN-21* Creat-1.0 Na-137 K-4.2 Cl-98 HCO3-31 AnGap-12 [2105-3-31] 05:00AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.3 IMAGING CT HEAD IMPRESSION: 1. Right facial soft tissue hematoma, without evidence of underlying fracture or intracranial injury. 2. Moderate atrophy of the brain parenchyma is more than expected for the patient's age. 3. Hypodensities in the right corona radiata are non-specific, but could be due to chronic small vessel ischemic disease. 4. Chronic paranasal sinus mucosal disease, without air-fluid level. CT SINUS IMPRESSION: 1. Right facial soft tissue hematoma, without evidence of underlying fracture. 2. Mild chronic paranasal sinus mucosal disease again noted. 3. Moderate brain atrophy redemonstrated. Shoulder films IMPRESSION: 1. Probable distal right clavicular fracture, but evaluation is slightly limited due to overlying catheter. 2. No fracture or dislocation involving the glenohumeral joint. 3. Displaced right lateral second rib fracture. CXR: IMPRESSION: 1. Acute fracture of the right second lateral rib. 2. Decreased size of small-to-moderate-sized bilateral pleural effusions, left greater than right. 3. Cardiomegaly without evidence of congestive heart failure. 4. Possible fracture of the distal right clavicle for which clinical correlation is recommended. [3-22] CT TORSO IMPRESSION: 1. Distal right clavicle fracture. 2. No evidence of pneumothorax, solid organ injury or extraluminal gas. 4. Stable appearance of cardiomegaly. 5. Tiny bilateral pleural effusions. 6. Multiple calcified fibroids. 7. Right renal hypodensity, which is incompletely characterized, but cystic. Further imaging with renal ultrasound is recommended. [2105-3-24] TTE: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinesis of the entire septum and inferior wall, hypokinesis of the anterior wall and anterolateral wall, and hypokinesis of the distal inferolateral wall. The basal inferolateral wall contracts best. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. The mitral valve leaflets do not fully coapt. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2105-3-17], the severity of mitral regurgitation is reduced. The other described abnormalities are unchanged. CXR [2105-3-24] IMPRESSION: Interval worsening of left pleural effusion with complete atelectasis of the left lower lobe. Small right pleural effusion with adjacent atelectasis. Cardiomegaly without frank volume overload. The study and the report were reviewed by the staff radiologist. Renal U/S [2105-3-25] IMPRESSION: 1.6-cm mid right renal cyst corresponds to hypodensity seen on CT. CXR [2105-3-26] FINDINGS: In comparison with the earlier study of this date, there has been placement of a new ICD extending to the general area of the apex of the right ventricle. Bilateral pleural effusions are seen with lower lung volumes. No evidence of pneumothorax. Micro Data [2105-3-22] 4:55 pm URINE Site: CLEAN CATCH FINAL REPORT [2105-3-24] URINE CULTURE (Final [2105-3-24]): 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 Blood cx [3-23] x 2, [3-26] NGTD Brief Hospital Course: 59 F with CAD s/p LAD BMS x 2 on [2105-3-16], CHF (EF 20%), pulm htn and asthma recently discharged three days ago now presents with syncope and hypotension. . 1. Syncope and hypotension. Hypotension most likely from combination of overdiuresis and antihypertensive medications as well as infection with leukocytosis and positive UA. She reports weight loss, feeling thirsty and lightheaded for the past three days. This was probably exacerbated by mild diarrhea prior to admission. Hyponatremia and ARF also consistent with volume depletion. Not likely adrenally insufficient since she has been on stable prednisone. Arrhythmia, seizure, stroke and hypoglycemia less likely. She was volume resuscitated with 2L NS fluid boluses. In the ED, RIJ was placed and she was initially on dopamine and neo but dopamine was rapidly weaned off. Upon transfer to floor, she was only on low dose neo which was weaned off the following day. UTI was treated as below. Diuretics and heart failure medications initially held but then cautiously retsarted as below. Baseline SBP 80s-90s. . 2. CAD. Pt had recent NSTEMI with 70-80% stenosis RCA on cath at OSH with likley recannulization. Here had some LAD stenosis last admission now s/p BMSx2. She has been compliant with asa + plavix. No sign of acute stent thrombosis. EKG on admission showed lateral STD consistent with strain in setting of hypotension. Cardiac markers were not significantly elevated and were flat. Continued asa, plavix, statin, cautiously restarted beta blocker. . 3. Chronic systolic CHF: Pt has severe systolic CHF with EF 20% with severe LV dilation, severe MR, and pulm htn. Upon admission, she was hypotensive and felt to be hypovolemic from possible overdiuresis. She was volume resuscitated with NS x 2L and her heart failure meds and diuretics were slowly reintroduced. She was continued on digoxin (level 0.8 on admission). Torsemide was restarted at 20mg then uptitrated to 20mg [Hospital1 ], captopril started then changed to enalapril 2.5mg [Hospital1 ] which was decreased from 20mg [Hospital1 ]. Spironolactone was also restarted. EP was consulted for consideration of ICD for primary prevention given low EF. They initially recommended repeat echo in 3 months but then recommended ICD as discussed below given development of complete heart block. . 4. Complete Heart Block: Pt developed complete heart block on [3-26] with hypotension SBPs 60s and HR 50s. ECG and telemetry c/w complete heart block with junctional escape. Block likely infra-His. Block resolved spontaneously after approximately 10-15 minutes and BP subsequently improved to SBPs 90s. Since EP was already consulted for BiV ICD for CHF with low EF, they were asked to re-evaluate patient given new heart block. BiV ICD was placed without complications. She was continued on Clinda x 72 hours post implantation. 5. UTI: Pt had complaints of dysuria with enteroccocus on urine cx sensitive to vanco and macrobid and ampicillin. She was treated with 5 days of vancomycin. She did not have any fevers in hospital. 6. ARF: ARF from hypovolemia as above. Improved rapidly with volume resuscitation and holding antihypertensives. . 7. Rib/Clavicle fractures: Pain controlled with tylenol prn. She was given sling for comfort and should follow up with Dr. [Last Name (STitle) ] in 2 weeks. 8. Asthma: Currently no wheezing. Continued prednisone 5mg daily, advair, inhalers prn. Asthma tolerated readdition of beta blocker. . 9. [Name (NI) 95969] Pt had eosinophilia on day of discharge, 9.9%. repeat CBC with diff should be checked as outpatient and workup could be further pursued as outpt. [Month (only) 116] be from asthma. FULL CODE Medications on Admission: 1. Buspirone 30 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO once a day. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO once a day. 19. GlipiZIDE 2.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. . Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 10. Venlafaxine 150 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2) Tab,Sust Rel Osmotic Push 24hr PO once a day. 11. Levoxyl 25 mcg Tablet Sig: Two (2) Tablet PO once a day. 12. Vagifem 25 mcg Tablet Sig: One (1) intravaginally Vaginal twice a week (). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP< 90. 17. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 18. Torsemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 90. 21. Zyrtec 5 mg Tablet Sig: One (1) Tablet PO once a day. 22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 23. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 24. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 25. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED) for 5 days: Please d/c after 5 days if FS regularly < 150. 26. Saline Sensitive Eyes Drops Sig: 1-2 drops Miscellaneous five times a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Complete Heart Block Acute on Chronic Congestive Heart Failure Acute Renal failure Distal Right clavicle Fracture Right facial Soft Hematoma Right second rib fracture Discharge Condition: stable. Discharge Instructions: You fell at home and fractured your right clavicle and right ribs. You were dehydrated and had complete heart block. A biventricular pacemaker, internal defibrillator was placed to regulate your heart rate. Do not put your left arm over your head for 6 weeks. Do not change the dressing over the pacemaker site or get the dressing wet. You can take a bath but no showers until after you are seen in the Device clinic. No lifting more than 5 pounds with your left arm for 6 weeks. Your blood pressure was low and your kidneys were dehydrated. We stopped your heart medicines and diuretics and your blood pressure and kidney function improved. We slowly restarted your heart medicines. Medication changes: 1.Tramadol: a medicine for pain to take for fractures 2. Torsemide: diuretic. We have decreased this medication from 60mg twice a day to 20mg twice a day. 3. Simethicone: a medicine for gas and heartburn 4. Pantoprazole: a medicine for gas and heartburn. We have increased this dose from 20mg once a day to 40mg twice a day. 5. Metoprolol Tartrate: Medication to protect your heart. We have discontinued your toprol XL and started this medication. Please take 12.5mg twice a day. 6. Glipizide: Diabetes Medication. We have increased this medication from 2.5mg once a day to 5mg once a daily. 7. Enalapril: Blood pressure medication. We have decreased this dose from 20mg twice a day to 2.5mg twice a day. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet No fluid restriction . Please call Dr. [First Name (STitle) 437] if you faint or feel dizzy, have any chest pain, increasing shortness of breath, increasing nausea, increasing redness of swelling around the pacer site, you get a shock from the defibrillator or any other concerning symptoms. Followup Instructions: Electrophysiology: DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2105-4-2] 1:00 [Hospital Ward Name 23] Clinical Center, [Hospital Ward Name 516], [Location (un) 436]. . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/time: Monday [5-11] at 1:20pm. [Hospital Ward Name 23] Clinical Center, [Hospital Ward Name 516], [Location (un) ] . Cardiology: [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437], MD Phone: [Telephone/Fax (1) 62] Date/Time: Date/Time:[2105-4-6] 3:00 . Primary Care: Please call Dr. [Last Name (STitle) 141] after you leave [Hospital 100] Rehab to schedule an appt. . Trauma Surgery: Dr. [Last Name (STitle) ] Phone: ([Telephone/Fax (1) 56365] Date/Time: Tuesday [4-7] at 2:00pm. Please get a Chest X-ray prior to this visit at Clnical Center [Hospital Ward Name ] [Hospital Ward Name ], [Location (un) 10043] at 1:00pm. Dr. [Last Name (STitle) ] is in the [Hospital Unit Name ], [Location (un) 470]. Use the parking garage next to [Hospital Unit Name ]. . Mammography: Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2105-6-15] 3:15 Completed by:[2105-3-31]	[ "5849", "2761", "5990", "4280", "41401", "V4582", "4168", "4240", "49390", "25000", "2449", "4019" ]
Admission Date: [2144-10-28] Discharge Date: [2144-10-29] Date of Birth: [2094-6-12] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 338] Chief Complaint: Shortness of breath, unresponsive Major Surgical or Invasive Procedure: [Last Name (un) 1372]-tracheal intubation History of Present Illness: This is a 50 year old female with PMH of multiple c-spine operations with hardware in place, perforated Zenker's diverticulum in [2140] with subsequent seeding of hardware and development of paravertebral abscess and polymicrobial spine osteo with complicated course requiring multiple spinal revision operations, recurrent infections attributed to esophageal perforations and development of paravertebral/retroesophageal abscess with prior esophageal communication (not communicating on MRI [2144-6-23]), on chronic opiates/benzos for pain/anxiety, and malnutrition presenting with tachypnea, fevers, congested cough, and cyanotic extremities. She was hospitalized from [2144-6-29] - [2144-7-4] for malnutrition and dark stools (guaiac negative) and had J-tube placement on [7-16]. She was found by her boyfriend to be nonverbal and tachypneic to the 40s when he came home from work this evening and she was brought to the hospital by ambulance. . In the ED, initial VS were T=99.2, HR=105, BP=139/86, RR=38, POx=99% on NC. Per the ED, the patient was breathing at a rate in the 40s, but satting well on nasal cannula, tachycardic, and normotensive. A CXR was unremarkable and she was given albuterol/ipratropium nebulizer treatments. She was also given vancomycin empirically with the plan to receive meropenem upon arrival to the ICU. The patient appeared anxious and lorazepam was administered given that she is on chronic high doses of benzodiazepines at home. Vascular access was obtained with a triple lumen inserted into her right groin, but no A-line was placed. She was then noted to have increased work of breathing and desaturated to 70-80% despite maximal nasal cannula. Given her complicated cervical neck pathology, anesthesia was called and performed [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-tracheal intubation through her left nostril and she was sedated on versed and fentanyl. She quickly dropped her blood pressures with sedation and Levophed drip was started. Upon transfer to the MICU vitals were noted to be afebrile, HR=144, BP=133/89, RR=43 over breathing her vent settings which was set at a RR=20 with a PEEP=8 and 100% FiO2. Past Medical History: - [5-15] Anterior cervical diskectomy and fusion at C5-6 with left iliac crest tricortical graft arthrodesis with anterior plating from C5 to C6 for C5/C6 disc herniation with severe R radiculopathy, RUE pain/weakness - [8-18] Esophageal Perforation thought due to ruptured Zenker's diverticulum, complicated by epidural abscess, cervical osteomyelitis, and infected hardware. Went for I and D, with removal of hardware at C5-C6, and revision of C5/C6 diskectomy, new C6/C7 diskectomy. Cultures grew out Strep viridans, Strep milleri, lactobacillus, Prevotella, MSSA. C/b wound infection, delirium, VRE-infected pleural effusion, C diff. Discharged on prolonged course of multiple abx. - Thrombosis of the L vertebral artery, discovered during hospitalization for esophageal perforation. - In [10/2141] developed bilateral upper extremity paresthesias and presented to the hospital with worsening cervical osteomyelitis, collapse of C5, C6 vertebral bodies, C7 subluxation causing cord compression and b/l UE radiculopathy -> [11-17] C4-T1 arthrodesis, C5-C7 corpectomies, hardware placement. Unfortunately, this procedure was complicated by recurrence of her posterior esophageal perforation, which was repaired with an SCM flap and stent placement, and another removal of her cervical hardware. - Reexploration in [1-/2142] after barium swallow revealed extravasation of contrast from one of the posterior drains in her neck. This revealed a large, persistent esophageal perforation. Stent was removed and new stent placed. Cultures grew MRSA and viridans streptococcus. She was discharged with a persistant neck fistula. - [12-22] - admission for AMS, fevers, and dysarthria, found to have prevertebral abscess, maintained on chronic suppressive antibiotics. - Otolaryngology surgery for chronic fistula and neck infection planned but not yet performed. - [5-/2144] - represented with AMS, slurred speech - no change in prevertebral collection on imaging, was found to have multifocal PNA, likely aspiration - advanced emphysema on [1-20] CT - Anxiety - PTSD - asthma - allergic Rhinitis - tonsillectomy Social History: She is smoker (up to 2-3ppd) but trying to quit now, no EtOH, no drugs. Has current supportive boyfriend. Formerly worked as a pharmacist. Family situation is stressful with two grown children with neuro-cognitive/psychiatric disabilities after they were assaulted by their father as children. A third child perished in this attack. Has visiting nurses daily, speech/swallow, and pain management who see her at home. Family History: Non-contributory Physical Exam: VS: Temp: 36.4, BP: 94/32, HR: 149, RR: 30, O2sat: 78% on vent GEN: intubated, sedated, paralyzed, cyanotic HEENT: Left sided blown pupil, right sided pupil noted to have only sluggish response to light, cyanotic lips, MMM RESP: rhonchorous breath sounds noted, poor air movement, thick respiratory secretions CV: tachycardic but regular ABD: soft, +BS EXT: mottled, cyanotic, Dopplerable upper and lower extremity pulses SKIN: cyanotic, cool to the touch in upper and lower extremities NEURO: Intubated, sedated, paralyzed, left blown pupil, right pupil sluggish Pertinent Results: [2144-10-28] 11:47PM GLUCOSE-160* UREA N-27* CREAT-0.7 SODIUM-153* POTASSIUM-4.3 CHLORIDE-130* TOTAL CO2-10* ANION GAP-17 [2144-10-28] 11:47PM ALT(SGPT)-239* AST(SGOT)-585* LD(LDH)-659* CK(CPK)-387* ALK PHOS-58 AMYLASE-46 TOT BILI-0.6 [2144-10-28] 11:47PM CK-MB-27* MB INDX-7.0* cTropnT-1.18* [2144-10-28] 11:47PM ALBUMIN-1.6* CALCIUM-6.9* PHOSPHATE-5.3* MAGNESIUM-1.7 [2144-10-28] 11:47PM WBC-26.1* RBC-3.67# HGB-10.3# HCT-33.6* MCV-92# MCH-28.0 MCHC-30.5* RDW-14.9 [2144-10-28] 11:47PM NEUTS-86.8* LYMPHS-9.1* MONOS-3.4 EOS-0.1 BASOS-0.6 [2144-10-28] 11:47PM PLT COUNT-242 Brief Hospital Course: This is a 50 year old female with PMH of multiple c-spine operations with hardware in place, perforated Zenker's diverticulum in [2140] with subsequent seeding of hardware and development of paravertebral abscess and polymicrobial spine osteo with complicated course requiring multiple spinal revision operations, recurrent infections attributed to esophageal perforations and development of paravertebral/retroesophageal abscess with prior esophageal communication (not communicating on MRI [2144-6-23]), on chronic opiates/benzos for pain/anxiety, and malnutrition presenting with tachypnea, fevers, congested cough, and cyanotic extremities. . The patient was found by her boyfriend to be nonverbal and tachypneic to the 40s when he came home from work this evening and she was brought to the hospital by ambulance. Shortly after arrival in the ED, the patient was intubated, sedated, and started on levophed. She was also given antibiotics, nebulizer treatments, and an anxiolytic prior to intubation. Upon transfer to the MICU vitals were noted to be afebrile, HR=144, BP=133/89, RR=43 over breathing her vent settings which was set at a RR=20 with a PEEP=8 and 100% FiO2. She was also noted to have an elevated lactate, an elevated troponin, acidemia, and elevated LFTs. . She was paralyzed with vecuronium and started on a cisatracurium drip on arrival to the MICU given her overbreathing and inability to synch with the vent. She was also noted to have a blown left pupil on exam and sluggish right pupil which were new for her suggesting an acute neurological event, but a head CT could not be performed given her medical instability. An EKG was performed which showed sinus tachycardia. Her blood pressures quickly continued to drop significantly on the vent requiring maximal pressor support with Levophed, vasopressin, phenylephrine, and epinephrine which were added and titrated up in that order. Despite all of this pressor support, the patient's extremities remained mottled/cyanotic and her blood pressure could no longer be measured noninvasively. Several attempts to place an A-line were unsuccessful given her poor pulses. . The patient's boyfriend, [Name (NI) ], arrived to the MICU at this point after being called in 30 minutes prior. After relaying the severity of her illness and unlikely chance of any functional recovery, it was decided to make the patient CMO. The pressors were stopped and the patient was extubated. Shortly thereafter I was called to her bedside and physical examination revealed no heart beat, breath sounds, or pulse. The patient's boyfriend was at bedside and she was pronounced dead on [2144-10-29] at 1:20AM. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], Dr. [Last Name (STitle) ] (PCP), and the medical examiner was notified of her passing. An autopsy will be performed by the medical examiner. The patient's sister, [Name (NI) ], was also called at [Telephone/Fax (1) 56405] and informed of her passing. Medications on Admission: 1. Tube feeds Tube feed recommendations: Fibersource HN at 20ml/hr, advance as tolerated to goal of 60 ml/hr. 1728 calories with 76 gram protein. No residual checks with j tube. cycle over 12 hours. 2. Hydromorphone 4-6 mg PO Q3H as needed for pain. 3. Minocycline 100 mg PO BID 4. Fluconazole 400mg daily 5. Lansoprazole 30 mg Tablet PO BID 6. Levothyroxine 50 mcg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 250 mg/5 mL Solution [Telephone/Fax (1) ]: Eight (8) ML PO TID (3 times a day). 8. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [Telephone/Fax (1) ]: Five (5) cc PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet [Telephone/Fax (1) ]: Two (2) Tablet PO DAILY (Daily). 10. Fluticasone 110 mcg/Actuation Aerosol [Telephone/Fax (1) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Ascorbic Acid 500 mg/5 mL Syrup [Hospital1 ]: Five (5) ml PO BID (2 times a day). Disp:300 ml Refills:0 13. Polyethylene Glycol 3350 17 gram/dose Powder [Hospital1 ]: One (1) packet PO DAILY (Daily) as needed for constipation. 14. Alprazolam 1 mg by mouth every four hours and 3mg at bedtime 15. Metoclopramide 16. Cyanocobalamin (vitamin B-12) [Vitamin B-12] 17. Nicotine 21 mg/24 hour once a day 18. Zinc 50 mg by mouth once a day Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.	[ "0389", "51881", "2762", "99592", "3051" ]
Admission Date: [2150-6-16] Discharge Date: [2150-6-22] Date of Birth: [2092-1-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 58 F c hepatitis C cirrhosis, hepatocellular carcinoma, with recent admission for esophageal variceal [First Name3 (LF) ] s/p banding who presents with hematemesis. She was recently admitted to [Hospital1 18] in [5-14] for large volume hematemesis requiring intubation and 4 units pRBC transfusion. EGD revealed 4 cords of grade 3 varices that were oozing and were [Date Range 43652] x 5. A repeat EGD approximately 2 weeks ago revealed 4 non-[Date Range ] grade 3 varices that were again [Date Range 43652] X 3. The day of admission patient again had hematemesis x 2 with 300 cc each time. Complained of weakness, lethargy, chronic abdominal pain. Presented to ED. . In the ED, T 98.4, BP 134/82, HR 62, RR 14, 100% RA. There was no further episode of hematemesis. Hct was 28.9, similar to 28.8 on most recent admission. Twi large bore PIVs were placed and the pt was given octreotide 50 mcg IV X 1 and started on a drip at 25 mcg/hr, protonix 40 mg IV X 1, ceftriaxone 1 gm IV X 1, and zofran 4 mg IV X 1. NGL lavage deferred. Liver fellow was contact[Name (NI) ] for emergent EGD. Transferred to MICU for further management. Past Medical History: - Hepatocellular ca (3.8x3.0x3.0 cm lesion in dome of the liver) - Hepatitis C - diagnosed in [2141], underwent tx c pegylated interferon and ribavirin in [2144] with sustained virologic response. Had a stable 1 cm hepatic dome nodule until [3-/2150] when nodule noted to be 3.8 cm on MRI with associated probable tumor thrombus of side branch L portal vein. AFP [2142]. Underwent selective chemo-embolization from the R hepatic artery. - Cirrhosis - liver bx showed mild portal predominantly mononuclear cell infiltrate with minimal periportal extension (Grade 1). No steatosis or necrotic hepatocytes. Moderate to focally marked portal fibrosis on trichrome stain, with focal bridging and bile duct proliferation (Stage 2-3). Complicated by portal HTN and extensive esophageal varices Social History: No tobacco, alcohol, or illicit drug use. Family History: N/C Physical Exam: VS - T 98.4, BP 103/60, HR 71, 94% 2L NC GEN - elderly woman looking anxious, speaking Arabic, interpreted by son [Name (NI) 43653] anicteric sclerae [Name (NI) 43654] CTA bilaterally HEART- regular rate, [3-12] early systolic murmur best heard at LUSB without radiation to carotids ABDOM- soft, tender at LUQ and LLQ, no rebound tenderness, bowel sounds present EXTRE- no edema NEURO- oriented x 3 Pertinent Results: [2150-6-17]: CXR IMPRESSION: 1. Volume overload. 2. No focal opacity worrisome for aspiration, hemorrhage or infection. 3. Calcified opacity corresponds to hepatocellular carcinoma treated with chemoembolization. [2150-6-17]: EGD Erythema and atrophy in the lower third of the esophagus and gastroesophageal junction Varices at the lower third of the esophagus and middle third of the esophagus (ligation) Varices at the fundus Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 58 F c HCC, HCV cirrhosis p/w GIB. The patient was intially admitted to the MICU. Emergent EGD in the MICU revealed 4 cords of grade 3 varices, 3 gastric ulcers, and gastric varices; banding x 5. HCT was 28.9 last night to 25.1 am of procedure, and 24 post procedure. She remained hemodynamically stable and was transferred to the floor for further management. . Upper GI Bleed: Patient had a bleed secondary to known esophageal and gastric varices with history of portal hypertension from cirrhosis and hepatocellular carcinoma. Emergent EGD in the MICU [2150-6-17] revealed 4 cords of grade 3 varices, 3 gastric ulcers, and gastric varices; banding x 5. Sge was treated with Octreotide gtt x72 hours, had 2 large bore peripheral IVs maintained. She was intially on IV PPI [Hospital1 ] intially, and then transitioned to PO. She was continued on carafate. She had post bleed Ceftriaxone 1gm IV daily x5 days ([Date range (1) 32263]). Nadolol 20mg daily was initially held for hypotention, but restarted on floor. Patient intially had [Hospital1 ] Hcts which remained stable but slowly trended down. She was transfused 1 unit PRBCs prior to discharge with plan to follow up Hct 1 week after discharge. She likely has slow oozing from varices and hypertensiv gastropathy. The patient is planned to have a repeat EGD 2 weeks from last one, likely 1 week after discharge. . HCV with HCC: Chronic, not candidate for transplant given worsening of hepatocellular carcinoma. S/p recent chemoemobolization. Also has portal vein thrombosis. MELD 11. on transplant list. - monitor coags - further management of HCC to be deferred to outpatient oncologist Dr. [Last Name (STitle) ] . Dispo: patient has been DNR/DNI since last admission. There was a question as to if the family wanted her to go home with Hospice. A palliative care consult was called and there was a family meeting with Dr. [Last Name (STitle) 497], Dr. [First Name (STitle) ], social worker and a translater with the family. The meaning of hospice was clarified and at this time are NOT interested in hospice care. They do agree with her being DNR/DNI, but do want intervention done if she bleeds. Medications on Admission: Nadolol 20 mg daily Omeprazole 20 mg [Hospital1 ] Carafate 1 gm tid Compazine 10 mg q6h prn Docusate 100 mg daily Senna 1 tab [Hospital1 ] prn Oxycodone [1-7] tab q 4-6h prn Caltrate 1 tab [Hospital1 ] Lorazepam 0.5 mg qhs prn Lactulose 15 ml [Hospital1 ] prn Citalopram 10 mg daily Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 3. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Lactulose 10 gram/15 mL Solution Sig: One (1) PO twice a day as needed for constipation. Disp:450 mL Refills:3 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simethicone 80 mg Tablet, Chewable Sig: [1-7] Tablet, Chewables PO QID (4 times a day) as needed for GI upset. 10. Outpatient Lab Work Hct check [6-25]. Please fax results to Dr. [Last Name (STitle) ] at fax [Telephone/Fax (1) 43655] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Upper GI bleed Esophageal varicies hep C cirrhosis Hepatocellular carcinoma Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital after vomitting blood. You were initially admitted to the ICU and had an EGD where they [Hospital 43652] the [Hospital ] vessels. Your blood level was also trending down, so you recieved a blood transfusion. You should have your blood level checked again on [2150-6-25]. You should have a repeat EGD next week as an outpatient. The Liver office will call you with the information regarding this sometime this week. Please call them if you dont hear from them by wednesday. Please call your doctor or return to the hospital if you have vomit blood or have blood in your stool, lightheadedness, fainting, or have any other concerning symptoms Followup Instructions: Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2150-7-9] 2:00 Provider: [Name10 (NameIs) ] [Name11 (NameIs) ] Phone:[Telephone/Fax (1) 463] Date/Time:[2150-7-9] 2:00 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2150-8-5] 3:00 Completed by:[2150-6-26]	[ "2851" ]
Admission Date: [2105-12-7] Discharge Date: [2105-12-30] Date of Birth: [2050-3-1] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: Headache Major Surgical or Invasive Procedure: [2105-12-7] Right craniectomy and placement of subgaleal drain [2105-12-7] R sided EVD placement [2105-12-8] Diagnostic cerebral angiogram [2105-12-16] R VP shunt History of Present Illness: This is a 55 year old male on 81 mg Aspirin with family history of AVM who collapsed at work this morning at 0945am. He presented to the emergency room and was initially perseverative and complaining of an headache per the Neurology service. He went to have a Head CT and became nauseous and began vomiting. He had no movement in the left upper or left lower extremity, he exhibited a left sided neglect, he was oriented to name only and his speech was slurred. He was found to have a large right sided basal ganglia hemorrhage and was intubated for airway protection. Past Medical History: PMHx:hypertension, increased cholesterol, depression Social History: Social Hx:lives at home with wife has a newborn and 4 year old children Family History: Family history of AVM Physical Exam: PHYSICAL EXAM: Gen: intubated, GCS 3T HEENT: Pupils: 3-2mm EOMs:unable to test Extrem: Warm and well-perfused. Neuro: Mental status: GCS 3T Orientation/Recall/Language: unable to test due to medication given for recent intubation Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields- unable to test III, IV, VI: Extraocular movements- unable to test V, VII: Facial strength appears grossly intact VIII: Hearing - unable to test IX, X: Palatal elevation- unable to test [Doctor First Name 81]: Sternocleidomastoid and trapezius - unable to test XII: Tongue midline- unable to test Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors .Pronator drift-unable to test Sensation: unable to test Left toe upgoing Coordination: unable to test Expired [2105-12-30] Pertinent Results: [12-7] CT Head: Large right basal ganglia hemorrhage with intraventricular extension. No evidence of obstructive hydrocephalus. 8-mm leftward shift of midline structures. Please refer to subsequent CTA head for further details. [12-7] CTA head: Large right putaminal intraparenchymal hemorrhage causing subfalcine herniation, originating from an arteriovenous malformation fed via the rightlateral lenticulostriate arteries and drained by subependymal veins. Catheter angiography is recommended to evaluate the AVM anatomy in further detail. [12-8] Cerebral Angiogram: IMPRESSION: [Known firstname 16745] [Known lastname 93799] underwent cerebral angiography which revealed a 3 x 3 x 2 cm nidus in the right basal ganglia which predominately drains into the deep venous structures and into the straight sinus. Based on the angio architecture this would be a Spetzler grade IV AVM and would not be amenable for surgery or embolization therapy. This was discussed with the patient and the plan would be to repeat an angiogram in a month's time in anticipation of radiosurgery. [2105-12-13] CXR IMPRESSION: AP chest compared to [12-7] through 9: Moderate cardiomegaly is slightly more pronounced today, but there is no pulmonary edema or change in borderline pulmonary vascular engorgement. I see no pleural effusion or pneumothorax. Right subclavian line ends in the mid SVC. [2105-12-14] LENIES: No DVT in both lower extremities. [2105-12-16] Head CT IMPRESSION: 1. Compared with [2105-12-7], there has been a right frontoparietal craniectomy, and there is interval increase in transcranial herniation of brain. 2. Redemonstration of right basal ganglionic hemorrhage with intraventricular extension. 3. Stable appearance of left transfrontal external ventricular drainage catheter with its tip in the region of foramen of [Last Name (un) 2044]; there is no hydrocephalus. [2105-12-16] Head CT: IMPRESSION: 1. Little change in basal ganglionic hemorrhage with intraventricular extension. 2. Ventricular shunt catheter terminates in the anterior [Doctor Last Name 534] of the left lateral ventricle, slightly less centrally than the prior exam. No hydrocephalus. 3. Unchanged transcranial herniation of brain at the frontoparietal craniectomy site. [2105-12-18] LENIS: 1. No deep vein thrombosis identified in either arm. 2. Thrombophlebitis of the right cephalic vein and also of the left basilic and left cephalic veins, all of which are superficial veins CT HEAD W/O CONTRAST [2105-12-19] 1. 9 mm of leftward shift of the normally midline structures (compared to 3 mm before). 2. Interval decrease in the size of a left intraventricular hemorrhage. 3. Unchanged right basal ganglia intraparenchymal hemorrhage. CT HEAD W/O CONTRAST [2105-12-20] 1. Interval minimal increase in leftward shift of midline components since [2105-12-19], with slightly increased effacement of the right lateral ventricle. Stable mild transgaleal herniation through the right craniotomy site. 2. Unchanged size and appearance of a large right basal ganglia hematoma. No new hemorrhage detected. 3. The quadrigeminal and suprasellar cisterns remain preserved. 4. Unchanged positioning of a left-sided VP shunt LENIES: [2105-12-21] IMPRESSION: No DVT in right or left lower extremities CT Head [12-24] 1. Continued evolution of right basal ganglial hematoma with stability of surrounding edema. 2. New, depressed appearance of brain parenchyma at the crainectomy site with increased leftward shift of midline structures and mild compression of brain stem. Although this indicated decrease in intracranial pressure, paradoxical enlargement of the left lateral ventricle. CXR [12-24] A right-sided PICC tip terminates at the lower SVC. A tubular structure projecting over the left hemithorax across the midline into the right hemi-abdomen most compatible with VP shunt. An endogastric tube courses inferiorly with its sideport projecting over the gastric bubble. The heart size is large, possibly exaggerated by AP technique. The mediastinal contours are within normal limits. The lungs are clear. There is no pleural effusion or pneumothorax. [12-24] Stool Cx Negative for CDIFF [12-24] CSF Cx Gram stain: No Polys no orgs. [12-25] NCHCT IMPRESSION: Since the previous CT examination, there is decrease in depression at the level of the craniectomy defect. Decreased mass effect on the right lateral ventricle is seen. Otherwise, the examination is stable. Brief Hospital Course: Mr. [Known lastname 93799] was intubated emergently in the Emergency department after vomiting in the CT Scanner. After review of his imaging studies and emergent left frontal EVD was placed and the patient was taken to the Operating room emergently for a right hemicraniectomoy, details of the procedure can be found in the operative report. Post operatively the patient was transported intubated to the intensive care unit. ICU Course: On [12-8] he underwent a diagnostic angiogram to better charecterize the right sided BG AVM which was too deep to saftely be embolized. On [12-9], he was successfully extubated and the subgaleal JP drain was removed. on [12-11], A CT of the head was performed which showed decrease in the size of the hematoma. A clamping trial of the EVD proved unsuccessful with his ICPs rising to the mid 20s. On [12-12], patient spiked a fever to 101.1, blood, urine and CSF cultures were sent;Dilantin was changed to Keppra to eliminate the source of fevers. On [12-13], EVD clamped and unclamped secondary to elevated and sustained ICPs. He was seen by speech and swallow and was cleared for po intake with supervision. He also had screening lenies which were negative. Another clamp trial was performed which was well tolerated for * amt of time. On [12-15] the patient was much more spontaneous verbally and neurologically improved. His cultures remained negative and he has a helmet to wear when OOB. On [12-16] he went to the OR for a ventricular peritoneal shunt palcement. On [12-17] he spiked fevers up to 102.5, chest x ray revealed a left lower lobe infiltrate. He was pan cultured and started on Vanc and Zosyn. Given that the shunt was freshly placed, no CSF was sent. On [12-18] he fever spiked again overnight and remained on antibiotics. Over the weekend, patient continued to spike temperatures and was more lethargic on exam. He continued to follow commands on the R side. His head CT on [12-19] showed increase in cerebral edema and midline shift. On [12-20], he was placed on decadron and a repeat head CT showed slight decrease of cerebral edema with stable midline shift. His shunt setting was changed to 2.0. He is currently afebrile. On [12-21], his exam remained unchanged. Screening LENIS were negative. On [12-22] his alertness was improved. He was afebrile and his WBC was decreasing, so his empiric antibiotics were discontinued. He was stable and was transferred to a step down bed. Baclofen was started to improve his spasticity. He was re-evaluated by speech and swallow and a video swallow was attempted but he was too sleepy. A video swallow was reattempted on [12-23] AM and although the patient was awake on exam, he was sleepy by the time of the video swallow. He had brief periods of bradycardia overnight and his Mag was replaced. He was aysmptomatic. On the morning of the 22nd he was noted to have a wbc of 22.6 with increased lethargy and sunken cranial flap. His episodes of bradycardia peristed. He was sent to CT scan and then transferred back to the ICU. His shunt was tapped under aseptic technique and csf sample was sent. He was noted to be more awake on the evening of the 22nd. Multiple cultures were sent including stool, sputum and blood. Stool cultures were negative for CDiff. A repeat CT head on [12-25] showed slight increase in ventricular size. EEG monitoring began on [12-24] for evaluation of seizures. ID recommended to start Vancomycin, Cefepime and flagyl until final cultures were obtained. He was slightly more awake on [12-25]. On [12-27] patient's WBC dropped to 11, his final C. diff culture came back negative and his antibiotics were discontinued. He will be seen again by Speech and swallow to determine wether he needs a PEG. On [12-28] he was transferred to the SDU. He did well with a bedside swallow evaluation by nursing and on [12-29] he had a speech and swallow evaluation - which confirmed that a PEG would be needed. The clinical team discussed with the wife regarding the PEG and the plan was to do so this week. On [12-30] around 5am, the RN was bathing him when he became unresponsive, his pupils dilated but remained reactive, vital signs showed he was hypotensive with a SBP in the 60's. Neurosurgery was called and evaluated the patient immediately. He was hypotensive and had a faint pulse. Neurosurgery called a code blue. Chest compressions were started, patient was intubated, and multiple pressors were given without result. A surface echo was performed which showed failed right ventricular function and an EF of < 10% in the left ventricle. The patient was pronounced at 0613 on [2105-12-30]. The family consented to an autopsy. Medications on Admission: Lovastatin ASA 81 Prozac Niaspan Discharge Medications: None Discharge Disposition: Expired Facility: [Hospital3 7665] Discharge Diagnosis: Right basal ganglia hemorrhage with intraventricular extension Cerebral edema with compression Hydrocephalus Arteriovenous malformation Pneumonia Fevers Lethargy Dysphagia Left sided hemipalegia Cardiac arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2105-12-30**]	[ "486", "51881", "2761", "4019", "2724", "42789" ]
Admission Date: [2140-8-26] Discharge Date: [2140-9-7] Date of Birth: [2089-3-28] Sex: M Service: TRANSPLANT SURGERY CHIEF COMPLAINT: Left lower extremity cellulitis with heel ulcer. HISTORY OF PRESENT ILLNESS: This is a 51-year-old man presenting with a left heel ulcer and left lower extremity cellulitis for three days. The heel ulcer had been present for about six months. In that time, the patient has had numerous bouts of cellulitis treated with elevation and antibiotics. Of note, this patient had a kidney/pancreas transplant on [2130-10-11], by Dr. [Last Name (STitle) 15473], which was complicated by delayed graft function. The patient denied any recent fever, chills, nausea, vomiting, change in bowel habits, flu-like symptoms. He is a poor historian. As per the daughter, there have been some recent mental changes. PAST MEDICAL HISTORY: End-stage renal disease secondary to diabetes mellitus. Diabetic retinopathy and diabetic neuropathy. Peripheral vascular disease. Coronary artery disease. Hypertension. History of cellulitis. PAST SURGICAL HISTORY: As mentioned kidney/pancreas transplant of [2130-10-20]. Coronary artery disease status post cardiac catheterization in [2139-12-2]. He has had a right femoral anterior tibial bypass in [2129]. Left femoral anterior tibialis bypass in [2131]. He had both first digit finger amputations, first and second toe amputations. Latissimus pedicle. Left arm fistula. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Prograf 3 twice a day, Prednisone 10 once a day, Azathioprine 100 mg once a day, MS Contin 15 twice a day, Percocet p.r.n. pain. SOCIAL HISTORY: He has heavy alcohol use. REVIEW OF SYSTEMS: He is short of breath. He denied any chest pain or changes in appetite. He did notice a 25 lb weight loss however in the last month. PHYSICAL EXAMINATION: Vital signs: He was afebrile, pulse 83, blood pressure 110/90, respirations 20, oxygen saturation 99% on room air. General: He was slightly agitated with a slight tremor. He was mildly confused. He was alert and oriented times two. Head and neck: Normocephalic, atraumatic. Heart: Regular, rate and rhythm. Chest: Lungs showed basilar crackles, right greater than left. Abdomen: Obese, soft, nontender, nondistended, with decreased bowel sounds. He had a midline scar. Extremities: He had 2+ edema of the left lower extremity with erythema and warm to touch below the knee. He had a 1 cm ulcer on the left heel with a serous discharge but no frank pus, and did not probe all the way to the bone. He does have amputated first and second left foot toes. He has a left forearm scar from an occluded radiocephalic AV fistula. He has bilateral amputated first digits. Pulse exam: Palpable dorsalis pedis pulses bilaterally. Neurological: Cranial nerves intact with no obvious deficits. Rectal: Deferred. HOSPITAL COURSE: The patient was admitted to Transplant Surgery. A Vascular consult was obtained for his peripheral vascular disease. A Podiatry consult was obtained for the osteomyelitis on his foot. He had blood cultures and ulcer swab sent. He was started on intravenous fluids and given intravenous antibiotics of Vancomycin, Levofloxacin and Flagyl. On [8-26], later that evening, the Podiatry Team saw him. They scheduled him for operative intervention on the 27th to debride his left foot, and he was adequately prepped preoperatively for this procedure. On the 27th, however, the patient was found to be somnolent and reactive only to pain. He was noticed to have a systolic blood pressure of about 80, and he was transferred to the SICU and given significant fluid resuscitation. While in the SICU, the patient's condition stabilized significantly to the point where on [8-30], the patient was able to be brought to the Operating Room for debridement and partial calcanectomy on the left side for a left foot osteomyelitis. Please refer to the previously dictated operative note for the details of this procedure. Over the next few days, the patient's cellulitis gradually improved. He tolerated an oral diet and generally was doing well. On [9-2], on postoperative day #3, the patient was brought back to the Operating Room by Podiatry for another debridement and closure of the wound left from the initial surgery. The patient tolerated the procedure well and was brought back to his room without complication. Finally on [9-4], the patient had a PICC line placed for long-term antibiotic treatment as an outpatient. On the day of discharge, [9-7], the patient is afebrile, tolerating a regular diet without any significant complaints. He is making good urine. His physical exam is benign with the left lower extremity without any infection whatsoever. The gauze about his left foot has been clean, dry, and intact for several days now. He is going to be discharged to a rehabilitation facility of his choice on intravenous Vancomycin and Zosyn for a total course of six weeks. DISCHARGE LABORATORY DATA: White count 4.6, hematocrit 27.6, platelet count 302; coagulation factors within normal limits; sodium 140, potassium 3.9, chloride 107, bicarb 23, BUN 18, creatinine 1.7, glucose 97; LFTs within normal limits; he has a pending ESR to monitor long-term osteomyelitis treatment. DISCHARGE DIAGNOSIS: 1. Left foot osteomyelitis status post debridement and secondary closure. 2. Status post pancreatic transplant, status post kidney transplant. 3. Insulin-dependent diabetes mellitus 4. Diabetic nephropathy. 5. Diabetic neuropathy. 6. Diabetic retinopathy. 7. Peripheral edema. 8. Coronary artery disease. 9. Peripheral vascular disease. 10. Hypertension. 11. Cellulitis. 12. Status post cardiac catheterization. 13. Status post bilateral femoral anterior tibial bypass. 14. Acute renal failure. 15. Hyperkalemia. 16. Metabolic acidosis. 17. CIWA protocol for alcohol withdraw. 18. Sepsis. 19. Central venous line placement. 20. PICC line placement. FOLLOW-UP: He is recommended to have follow-up with Dr. [Last Name (STitle) ] in one week; he should contact him at [Telephone/Fax (1) 1784], to arrange an appointment. He should also follow-up with Dr. [Last Name (STitle) 15473] on [9-28], 1:20 p.m. He should also contact the Podiatry Department and follow-up with them as needed. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d., Lopressor 25 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Morphine MS Contin 15 mg q.12, Azathioprine 100 mg p.o. q.d., Prograf 1 mg p.o. b.i.d., Thiamin 100 mg p.o. q.d., Folate 1 mg p.o. q.d., Percocet [12-3] tab p.o. q.4-6 hours as needed for pain, Prednisone 5 mg p.o. q.d., Zosyn 4.5 g IV q.8 hours for 4 weeks, Vancomycin 1 g IV q.12 x 4 weeks, Ativan 1 mg p.o. q.i.d. p.r.n. anxiety, Insulin sliding scale as per the discharge work sheet. DISCHARGE INSTRUCTIONS: He should have twice weekly lab work of CBC, CHEM10, LFTs and FK506. These results should be forwarded to Transplant Surgery and to Infectious Disease. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15475], M.D. [MD Number(1) 15476] Dictated By:[Last Name (NamePattern1) 1179] MEDQUIST36 D: [2140-9-7] 13:09 T: [2140-9-7] 13:11 JOB#: [Job Number 108106] cc:[Hospital 108107]	[ "0389", "2767", "5849" ]
Admission Date: [2131-4-14] Discharge Date: [2131-5-14] Date of Birth: [2083-1-21] Sex: F Service: Kidney Transplant Surgery Service CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female status post kidney and pancreas transplant, history of chronic diarrhea, history of C. diff colitis, toxic megacolon, status post subtotal colectomy in [2129-10-24], status post ileostomy reversal in [2129-12-24], status post ventral hernia repair in [2130-3-24], peritoneal dialysis catheter in [2130-3-24], status post placement of multiple IJ catheters, history of bowel obstruction here now with acute onset of abdominal pain, nausea, and vomiting, and no fever. PAST MEDICAL HISTORY: Diabetes type 1, CAD, blind, hypertension, osteopenia, depression, gastroparesis, anemia, colitis, EF of 40%, MR, history of VRE, angina, zoster. PAST SURGICAL HISTORY: CABG, pancreas transplant, appendicitis, subtotal colectomy, ileostomy takedown, bilateral vitrectomies, PD cath placement, a gastric resection in [2130-7-24] with repair of 2 hernias, and a bowel resection in [2130-7-24]. MEDICATIONS AT HOME: Prednisone 5 p.o. daily, Bactrim on Monday/Wednesday/Friday, Lomotil p.r.n., sodium bicarbonate 1300 b.i.d., aspirin 81 daily, enalapril, loperamide, Lopressor, MVI, Protonix 40 daily, Epogen, midodrine, Lasix 160 daily, Rapamune 4 mg daily. LABORATORIES ON ADMISSION: White count 5.7, hematocrit 50.2, platelet count 168. Sodium 140, potassium 4.2, chloride 95, CO2 of 27, BUN 32, K 4.3, glucose 84. AST 40, ALT 19, alkaline phosphatase 176. RADIOLOGIC STUDIES: A chest x-ray was within normal limits. A KUB on admission revealed multiple loops of dilated small bowel indicating small bowel obstruction. A CT of the pelvis with contrast revealed high-grade small- bowel obstruction with transition point identified at the site of surgical anastomosis within the left lower quadrant; a moderate amount of ascites; a distended gallbladder, which contained tiny gallstones but no evidence of gallbladder wall thickening to suggest acute cholecystitis; unremarkable appearance of the pancreas and renal transplant. A chest x-ray on admission demonstrated low lung volumes; no acute cardiopulmonary process; prominent and dilated small- bowel gases in the upper abdomen representing partial image. HOSPITAL COURSE: She was taken to the OR on [4-14] by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] for a small-bowel obstruction at the level of the ileorectal anastomosis. She underwent resection of the ileorectal anastomosis, a Hartmann procedure, and ileostomy under general anesthesia. She returned to the SICU postoperatively in stable condition. Please see operative report for full details. The pathology report of the ileorectal anastomosis demonstrated congestion and autolysis of the mucosa with fibrous peritoneal adhesions. A neurology consult was obtained on [4-16] due to right eye deviation. The patient was examined, and assessment and recommendations included on physical exam her eyes looking to the right. Recommendations included continuation of holding sedation. Recommendations included obtaining a head CT to make sure that she did not have ophthalmic bleed causing eye findings as well as an EEG. A head CT on [4-16] demonstrated probable small left frontal subdural hematoma, left facial swelling; and no evidence of herniation. Of note, she continued to third space secondary to the small-bowel obstruction. IV Zosyn and linezolid were continued. A urine culture on admission demonstrated greater than 100,000 colonies of Klebsiella, resistant to Bactrim; otherwise, pansensitive. Blood cultures were negative. Peritoneal fluid intraop was cultured, and results were negative for growth on the aerobic and anaerobic bottles. A MRSA screen was done that was negative as well as a VRE screen that was negative. A repeat urine culture on [4-25] demonstrated 10:100,000 colonies of yeast; and she required IV levofloxacin. A cardiology consult was obtained for tachycardia into the 130s as well as for postop hypotension with systolic's in the 60s. Cardiology's recommendations included volume resuscitation with gradual wean of pressors as well as holding beta blockers and starting aspirin when surgically appropriate. Troponins were checked with peaking at 1.92 on [4-15]. Recommendations from cardiology included keeping hematocrit greater than 30 and with improvement of the blood pressure restarting Lopressor 25 mg b.i.d.. Nitrates and calcium channel blockers were recommended to be held. There was noted that she had diffuse 3-vessel disease. Her colostomy was putting out anywhere from 2 liters to 1-1/2 liter per day. Stoma was pink. The enterostomal nurse specialist followed the patient throughout this hospital course. The patient was followed by nutrition, and TPN was started as the patient was n.p.o. postoperatively. Nephrology followed the patient throughout this hospital course. She required hemodialysis. Her pancreas transplant continued to function; and amylase and lipase remained in the range of 39 and 30 with a slight increase to 71 and 39, respectively, throughout this hospital course. Blood sugars remained controlled in the 80s to low 130s. Her blood pressure improved and pressors were weaned off. She was restarted on aspirin and beta blocker. Her hematocrit remained in the range between 28 and 25. This trended downwards toward the end of her hospital stay to 22, for which she was restarted on Epogen. She required labetalol as well as hydralazine for blood pressures in the 169/72 range. The patient was extubated on [4-24]. An NG tube remained in place. A postpyloric feeding tube was placed, and the patient was started on Nepro at 30 cc per hour goal. TPN was discontinued. She underwent a bedside swallow eval for which she showed signs of aspiration with thin liquids only after taking a small amount of food. Given her altered mental status, suggestions included a trial of nectar-thick liquids and ground-solid consistency with one-to-one supervision only. She continued on postpyloric feedings. Physical therapy was instituted, and the patient was assisted out of bed her. Her blood pressures continued to be labile and hypertensive. She continued to receive intermittent dialysis. Repeat blood cultures were done for a temperature spike on [5-6] - on postop day #23 - up to 101.1. These cultures demonstrated staph coag negative isolated from 1 set only. A urine culture was also done which showed contamination with mixed flora as well as staph coag negative 10:100,000 organisms. Repeat blood cultures were done that were negative. On [4-27], the patient again experiencing difficulty with her mental status post extubation with some aphasia as well as confusion. Neurology was consulted. Recommendations included holding the narcotics and sedating medications as well as repeating a head CT. Repeat head CT with contrast demonstrated possible left frontal convexity. Extra-axial high-density collection seen on [4-16] was no longer identified. No new intracranial hemorrhage was noted. There was interval improvement in the ethmoid sinus opacification and scalp swelling. Physical therapy worked with her to increase strength. Electrolytes were corrected. She remained on dialysis with gradual improvement and improvement of her mental status. Vital signs remained stable. Her Foley catheter was removed. The patient intermittently complained of pain in her abdomen. She received IV Dilaudid with improvement. On [5-3], she underwent an abdominal CT with contrast that demonstrated no evidence of bowel obstruction. No CT findings to explain the patient's abdominal pain; although the study was limited without IV contrast. There was unchanged appearance of the pancreatic and renal transplant, a small 2- x 1.1-cm fluid collection was noted in the abdomen midline to the subcutaneous tissues. A repeat swallow eval on [4-30] was done. The patient passed this study without signs of aspiration. Diet was advanced slowly to regular food with thin liquids. A psychiatry consult was obtained on [2131-5-2]. It was felt that the patient was experiencing some delirium and night where she would be calling out and was very agitated. Recommendations included Seroquel 12.5 mg to 25 mg at bedtime and consideration for Haldol if Seroquel was ineffective. To continue search for delirium, the patient had blood cultures repeated. These were subsequently found to be negative. A repeat urine culture was sent off. This was negative. Stool was sent for C. diff as the patient continued to have stool outputs of approximately 2 liters. Stool cultures for C. diff were negative. The ET nurse followed the patient for frequent pouch changes. It was felt the patient's pouch was overfilling with stool and gas. A convex wafer was used with an econ seal with a drainable pouch to gravity drainage. The patient experienced quite a bit of peristomal excoriation with evidence of a yeast infection. Nystatin powder was applied. The patient underwent a repeat abdominal CT that demonstrated no evidence of bowel obstruction. On [5-4], these patient's blood pressure decreased to 71/40. She was bolused with IV fluids without improvement. Cardiology was consulted. Of note, EKG changes were noted, but were not different than the prior EKGs on [4-15]. It was felt that systolic blood pressure was possibly related to sepsis or medications. Repeat blood cultures were done and subsequently found to be negative. Of note, the patient's beta blocker had been increased the previous day, and other anti-hypertensives had been reinstituted. Her pre hospitalization medications were reinstituted. Seroquel was also suspected. She was transferred to the SICU for pressor support on [2131-5-5] Seroquel was stopped. Haldol was stopped. The patient was ultrafiltrated while in the SICU. Her blood pressure improved On [2131-5-5], psychiatry was consulted again for evaluation for delirium versus depression. The patient requested her [Hospital ] hospital desipramine and was upset that she had been removed from desipramine. Psychiatry's recommendations included holding desipramine given anticholinergics effects and history of multiple bowel obstructions. Low-dose Haldol was recommended. No evidence of delirium was noted at that time. White blood cell count was normal at 4.9, hematocrit 25. Haldol was given, and the patient appeared to be calmer. Social work followed the patient. She was transferred back to the medical surgical unit where she gradually improved and was able to ambulate independently. Her tube feeds continued. She continued to pass large amounts of brown, loose stool. The patient was continued on Haldol and was alert and oriented, and she was still requesting desipramine. After much discussion with the patient's outpatient psychiatrist, desipramine 25 mg p.o. was restarted. She remained in the hospital pending rehab placement. Upon further review, physical therapy cleared the patient for home. The patient and her husband were instructed in ostomy pouch changes. She continued to have large volume stool output, requiring low- dose Imodium b.i.d.. Remeron 7.5 mg was started. A podiatry consult was obtained on [2131-5-12] for left 2nd toe eschar. This was debrided, and normal saline wet-to-dry dressings were initiated b.i.d.. There was no evidence for surgical intervention on the right foot. Eschar was debrided to the soft tissue. There was no erythema or edema noted. The underlying tissue was viable. On [2131-5-14] the patient was discharged home. Haldol was stopped. The patient was instructed in how to change her colostomy pouch as well as perform postpyloric feedings at home. Both she and her husband received education. Desipramine was increased to 50 mg after discussion with outpatient psychiatrist. Antibiotics were stopped. Immunosuppression continued throughout this hospital course. She remained on Imuran 25 mg every other day, prednisone 5 mg daily; and Rapamune was titrated to 4 mg p.o. daily for a level of 10 while on 6 mg. DISCHARGE DIAGNOSES: Small-bowel obstruction; status post pancreas transplant; status post renal transplant, nonfunctioning; end-stage renal disease; depression; anxiety; Klebsiella urinary tract infection. DISCHARGE FOLLOWUP: The patient was scheduled to follow up in the outpatient transplant clinic. DISCHARGE MEDICATIONS: Included Bactrim single strength every Monday/Wednesday/Friday, prednisone 5 mg p.o. daily, Imuran 25 mg p.o. every other day, Atrovent MDI b.i.d., Flovent 2 puffs b.i.d., [Doctor First Name ] 60 mg p.o. b.i.d., loperamide 20 mg p.o. daily, Protonix 40 mg p.o. daily, atorvastatin 10 mg p.o. daily, mirtazapine 7.5 mg p.o. at bedtime, Rapamune 6 mg p.o. daily, aspirin 325 mg p.o. daily, metoprolol 25 mg p.o. b.i.d., simethicone 80-mg tablets p.o. p.r.n. q.4h., Reglan 5 mg p.o. q.i.d. a.c. and h.s. for nausea, midodrine 10 mg p.o. q. Monday/Wednesday/Friday prior to hemodialysis, and desipramine 50 mg p.o. daily. Tube feedings at home were to continue with Nepro full strength with 25 grams benne protein at 40 cc per hour for a 12-hour cycle per day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD,PHD[Numeric Identifier ] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2131-5-18] 17:04:26 T: [2131-5-19] 12:20:02 Job#: [Job Number 92760]	[ "41071", "0389", "5990", "9971", "99592", "40391", "V4581", "2859" ]
Admission Date: [2113-2-22] Discharge Date: [2113-2-28] Date of Birth: [2070-10-31] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8263] Chief Complaint: transfer for liver disease Major Surgical or Invasive Procedure: -patient was intubated prior to arrival -arterial line placement History of Present Illness: 42yo M with h/o cryptogenic cirrhosis, refractory ascites requiring large volume paracenteses (most recently [2-17]), and portal HTN who present to OSH [2-20] with generalized weakness and SOB. He noted progressive dyspnea and decreased PO intake but denied CP, orthopnea, and PND. He reported generalized abdominal pain but denied hemetemesis, nausea, melanotic stools and dysuria. he reported regular bowel movements, medication compliance, and dietary adhearance. . In the ED at OSH, pt was afebrile with HR in 70s (beta blocked), hypotensive to 70s systolic, and satting well on RA. He received 3L NS, 50g albumin, Zosyn 3.375g and was started on peripheral dopamine before a right IJ was placed and converted to levophed. A diagnostic paracentesis was done with no evidence of SBP. The pt was transferred to the MICU where he was treated for septic shock of unclear etiology He remianed on levophed, rec'd additional 100g albulin and was treated with vanc/zosyn for ? HCAP vs UTI. He had oliguric ARF with FEUrea 6% and UNa<10, c/w either pre-renal azotemia vs HRS. Nephrology was consulted and he was started on midodrine and octreotide. Pt was also seen by GI who recommended transplant evaluation. The pt developed worsening dyspnea and work of breathing and was inubated on [2-21]. Transferred to [Hospital1 18] on levophed and propofol gtt w/intermittent sedation. . On arrival to the MICU, pt is intubated and sedated and hypothermic. An A line was placed in left radial artery. Past Medical History: -Cryptogenic cirrhosis c/b encephalopathy, refractory ascites, SBP, portal hypertension and edema. His current MELD score is 14, Child's class C Social History: - Lives with his sister in east [Hospital1 ] - Smokes 1 pack per day for many years: pre-contemplative - No current alcohol use. Last EtOH use 24 yo - Occasional MJA Family History: - Uncle with Liver disease [2-23] alcohol Physical Exam: ADMISSION EXAM Vitals: T:95 BP:92/39 P:70 R: 18 O2: 100% on vent General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS [2113-2-22] 01:10AM BLOOD WBC-12.0# RBC-2.22# Hgb-7.1# Hct-21.7# MCV-98 MCH-31.9 MCHC-32.7 RDW-16.4* Plt Ct-89* [2113-2-22] 01:10AM BLOOD Neuts-83.4* Lymphs-8.5* Monos-7.3 Eos-0.7 Baso-0.1 [2113-2-22] 01:10AM BLOOD PT-32.0* PTT-79.6* INR(PT)-3.1* [2113-2-22] 01:10AM BLOOD Glucose-122* UreaN-102* Creat-4.8# Na-126 K-5.5* Cl-95* HCO3-15* AnGap-22* [2113-2-22] 01:10AM BLOOD ALT-58* AST-128* LD(LDH)-187 CK(CPK)-131 AlkPhos-217* Amylase-23 TotBili-7.0* [2113-2-22] 01:10AM BLOOD Albumin-4.0 Calcium-8.6 Phos-6.9# Mg-2.6 TTE [2113-2-22] At least moderate-severe mitral and tricuspid regurgitation. No vegetations visualized. Moderate pulmonary artery systolic hypertension. If clinically indicated, a TEE would better assess the etiology of the mitral regurgitation and the presence of vegetations. LEFT ANKLE X-RAY [2113-2-22] 1. Marked soft tissue swelling. 2. No radiographic evidence for osteomyelitis. If there is continued concern, recommend further evaluation with MRI. Brief Hospital Course: Mr. [Known lastname 14800] is a 42y/o gentleman with cryptogenic cirrhosis complicated by encephalopathy, refractory ascites, SBP, portal hypertension and edema who was transferred from an OSH for transplant evaluation. He was initially admitted to the OSH with dyspnea and abdominal pain, and was found to be hypotensive requiring pressors. He had severe acute renal failure that was concerning for hepatorenal syndrome so he was transferred to [Hospital1 18]. Here, his hypotension was worked up; he was felt to be in septic shock and was treated with broad-spectrum antibiotics with no clear source (team considered gall bladder source, SBP, pneumonia, UTI, left heel infection). His course was marked by severe encephalopathy; he was minimally responsive off all sedation for days despite the use of Lactulose and Rifaximin. In addition, he had severe kidney injury despite HRS treatment, for which dialysis was recommended. He was evaluated by the Hepatology team, who felt that he was not a candidate for liver transplant. Family meetings were held, and it was felt that the patient would not want hemodialysis, especially if there was no hope of reversing his underlying liver disease. On [2113-2-25*], the decision was made to transition to comfort-focused care. He was extubated and pressors/antibiotics/non-comfort meds were stopped. A morphine drip was started. A scopolamine patch was placed. He was transferred to the general medical floor where he expired. Medications on Admission: ALBUTEROL SULFATE - (Prescribed upon d/c ) - 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth once a day EPLERENONE - (Prescirbed upon d/c) - 25 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) FUROSEMIDE - (Prescibed upon d/c ) - 20 mg Tablet - 2 Tablet(s) by mouth twice a day LACTULOSE - (Prescibed upon d/c ) - 10 gram/15 mL Solution - 30 ml by mouth PANTOPRAZOLE - (Prescibed upon ) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every twenty-four(24) hours RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice a day SILDENAFIL [VIAGRA] - (Prescibed upon d/c) - 100 mg Tablet - 1 Tablet(s) by mouth as directed Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired	[ "0389", "78552", "51881", "5849", "2762", "5990", "2761", "99592", "3051", "2767", "2875", "2859" ]
Admission Date: [2195-8-20] Discharge Date: [2195-9-14] Date of Birth: [2133-1-5] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: Right weakness and speech changes Major Surgical or Invasive Procedure: Intubation [2195-8-22] Placement of external ventricular drain [2195-8-22] Extubation [2195-8-25] Supraclavicular LN Bx at bedside [2195-8-25] PICC placement [2195-8-26] Revision of EVD to ventriculo-peritoneal shunt [2195-9-4] PEG tube insertion [2195-9-8] History of Present Illness: Mr. [Known lastname 12511] is unable to provide his own history due to comprehension difficulties and confusion; history provided by his wife. Mr. [Known lastname 12511] is a 62 y/o right handed man with a PMH significant for HTN and DMII, who presents to ED with acute onset of right sided weakness, speech changes and confusion this morning. He awoke today in his usual state of health and was having breakfast around 7:15 AM. He went to get something around 7:20 AM, but he did not return, so his wife went to check on him around 7:25 AM. She found him standing in the doorway, leaning as he was unable to move. He was unable to move the right side of his body and was also unable to walk. His speech was also noted to be slurred and he was acting confused. His wife called EMS and gave him ASA 81 mg x 1 due to concern that this may be a stroke. He was brought to the [Hospital1 18] ED, where a Code Stroke was called. STAT CT head showed the left IPH, so neurosurgery was consulted. His initial BP was also in the 180s, so he was given Labetalol 20 mg IV for blood pressure control in the setting of hemorrhage. Past Medical History: -HTN -DMII Social History: Per his wife- he lives with his wife and works as a clerk at a temple. No smoking, alcohol, or illicit drug use. Family History: per his wife- he does not have a family history of strokes. Physical Exam: At admission: Vitals: T: 97.4 R: 20 BP: 180/118 SaO2: 82% RA --> 100% 3L O2 General: Awake, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: anterior lung fields cta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, ND, +BS Extremities: warm, well perfused, 1+pitting edema noted in RLE Skin: no rashes or lesions noted. Neurologic: NIH Stroke Scale score was: 13 1a. Level of Consciousness: 0 1b. LOC Question: 1 1c. LOC Commands: 1 2. Best gaze: 0 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 1 7. Limb Ataxia: 0 8. Sensory: 2 9. Language: 1 10. Dysarthria: 1 11. Extinction and Neglect: 2 Mental Status: Awake, oriented to person. Able to choose hospital out of list of places. No response when asked for year. Unable to provide history. Can follow midline commands. Does not follow any commands on the right. Occasionally follows appendicular commands on the left, but not consistently. Right sided neglect- identifies his right hand as the examiners. Does not respond to stimuli on his right. Language: speech is sparse, no fluent speech appreciated. The speech he did produce was dysarthric. He was only able to name "key". He repeated simple sentence once but then was not able to repeat. Occasionally comprehended simple commands on the left but very inconsistent. Cranial Nerves: PERRL 3 to 2mm. Less response to threat on right- possible right hemianopia. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOMI without nystagmus. Mild right nasolabial fold flattening. Palate elevates symmetrically and tongue protrudes in midline. Remainder of cranial nerve testing limited by comprehension difficulties. Motor: Normal bulk, tone throughout. Right sided drift. Formal strength testing on right limited by comprehension, but he was able to sustain both right arm and leg antigravity. Left sided strength is full. Sensory: right hemisensory loss of light touch and pain. Unable to assess proprioception and vibration due to comprehension difficulties. DTRs: [Name2 (NI) ] reflexes 2+ and symmetric. Patellar reflexes 2+ and symmetric. Unable to elicit ankle jerks. Toe downgoing on left and there was no response on right. Coordination: unable to assess due to difficulties with comprehension. Gait: deferred due to acute IPH At discharge: HEENT: Bandage on left top of head, staples removed from drain procedures, no erythem or drainage surrounding site Pulm: CTAB CV: RRR Abd: soft, mild tenderness to deep palpation, +BS, PEG site c/d/i Ext: no c/c/e Neuro: drowsy, opens eyes to voice, dense R neglect. L gaze preference although eyes cross midline with VOR. No verbal output. Inconsistently follows some simple midline commands. Unclear if comprehension is intact. Able to mimic some gestures. No movement on R, spontaneous mvmt on left with power [6-11] throughout left side. Grimaces to noxious on R, withdraws on L. Pertinent Results: Admission labs: [2195-8-20] 09:47AM BLOOD WBC-4.7 RBC-3.90* Hgb-13.6* Hct-38.7* MCV-99* MCH-34.9* MCHC-35.1* RDW-12.4 Plt Ct-236 [2195-8-20] 09:47AM BLOOD PT-11.6 PTT-23.4 INR(PT)-1.0 [2195-8-20] 09:47AM BLOOD Glucose-262* UreaN-22* Creat-1.6* Na-140 K-4.0 Cl-99 HCO3-26 AnGap-19 [2195-8-21] 03:26AM BLOOD Calcium-8.9 Phos-2.4* Mg-1.6 . Other pertinent labs: [2195-9-7] 04:17AM BLOOD ALT-63* AST-42* LD(LDH)-217 AlkPhos-72 TotBili-0.5 [2195-9-7] 04:17AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.4 Mg-2.4 [2195-9-1] 06:05AM BLOOD Osmolal-286 [2195-9-6] 06:41AM BLOOD Osmolal-294 [2195-9-6] 02:41PM BLOOD Osmolal-295 [2195-9-6] 09:45PM BLOOD Osmolal-295 [2195-9-7] 04:17AM BLOOD Osmolal-296 [2195-9-7] 10:44AM BLOOD Osmolal-299 [2195-8-20] 09:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge labs: Na 136 Cl 103 BUN 16 Glc 241 K 4.3 CO3 25 Cr 0.8 Ca: 8.5 Mg: 1.9 P: 2.6 WBC 4.1 Hgb/Hct 9.1/26.9 Plt 257 . Urine: [2195-9-6] 05:32PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.028 [2195-8-20] 10:40AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2195-9-6] 05:32PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG [2195-8-20] 10:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2195-9-1] 08:40AM URINE Hours-RANDOM UreaN-720 Na-122 K-52 Cl-89 [2195-8-20] 04:52PM URINE Hours-RANDOM Creat-45 Na-135 K-40 Cl-125 HCO3-10 [2195-9-1] 08:40AM URINE Osmolal-586 [2195-8-20] 04:52PM URINE Osmolal-536 [2195-8-20] 11:12AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . CSF: [2195-8-24] 09:30AM CEREBROSPINAL FLUID (CSF) WBC-60 RBC-4000* Polys-93 Lymphs-2 Monos-3 Plasma-2 [2195-8-24] 09:30AM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-159 LD(LDH)-51 Misc-CEA = 2 NG [2195-8-24] 09:30AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL . . Microbiology: [2195-9-6] 5:32 pm URINE Source: Catheter. FINAL REPORT [2195-9-7] URINE CULTURE (Final [2195-9-7]): NO GROWTH. [2195-9-6] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2195-8-24] 9:30 am CSF;SPINAL FLUID SOURCE: LP/EVD. FINAL REPORT [2195-8-30] GRAM STAIN (Final [2195-8-24]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2195-8-30]): NO GROWTH. [2195-8-20] MRSA SCREEN MRSA SCREEN-NEGATIVE . . Pathology: [8-24] CSF: ATYPICAL. Rare atypical epithelioid cells, cannot exclude involvement by metastatic carcinoma. . CELL BLOCK OF FNA OF RT SUPRACLAVICULAR LN FNA, right supraclavicular lymph node, cell block: Tumor cells present consistent with adenocarcinoma of lung; see note. Note: Tumor cells on immunostains are positive for CK7, TTF-1, and focally positive for CK20, and negative for CK5/6 and p63. . [8-26] FNA, Right supraclavicular lymph node: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic adenocarcinoma. . . Radiology: [8-20] Admission NC Head CT: IMPRESSION: Large left frontal/parietal parenchymal hemorrhage with minimal mass effect. The presence of underlying mass or AVM cannot be assessed on this study. . [8-20] Admission Head CTA: IMPRESSION: 1. Stable large left frontal/parietal parenchymal hemorrhage with minimal increase in rightward shift of normally midline structures. 2. Stenosis of the distal left MCA, likely atherosclerotic disease.No vascular lesion underlying the hematoma. . [8-23] Head MRI: IMPRESSION: Stable appearance of the left parietal intraparenchymal hematoma with apparent areas of restricted diffusion along the margins could represent artifact from blood products versus ischemia. Numerous enhancing foci in bilateral occipital lobes and the right parietal/frontal lobe concerning for metastatic disease. In light of this finding, suspicion for the left parietal intraparenchymal hemorrhage representing a hemorrhagic metastasis is raised. . [8-24] CT Abd/Pelvis with and without contrast: IMPRESSION: 1. Right upper lobe mass measuring 6.2 cm in craniocaudal dimension traveling along a bronchovascular distribution with multiple lobulations, the largest of which is 2.8 x 2.4 cm in the axial dimension with confluent right paratracheal lymphadenopathy measuring 4.5(CC) x 2.5(TV) cm. Smaller right upper lobe nodules and right hilar node are also noted. 2. 3.6cm right supraclavicular node. This lesion is amenable to ultrasound- guided biopsy 3. 2.5 x 1.6 cm left adrenal lesion, likely reflecting metastatic disease. 4. Nasogastric tube located within the stomach; however, side port is at the level of the GE junction and could be advanced as on prior CXR. . [8-24] CT Chest with contrast: IMPRESSION: 1. Right upper lobe mass measuring 6.2 cm in craniocaudal dimension traveling along a bronchovascular distribution with multiple lobulations, the largest of which is 2.8 x 2.4 cm in the axial dimension with confluent right paratracheal lymphadenopathy measuring 4.5(CC) x 2.5(TV) cm. Smaller right upper lobe nodules and right hilar node are also noted. 2. 3.6cm right supraclavicular node. This lesion is amenable to ultrasound-guided biopsy 3. 2.5 x 1.6 cm left adrenal lesion, likely reflecting metastatic disease. 4. Nasogastric tube located within the stomach; however, side port is at the level of the GE junction and could be advanced as on prior CXR. . CT HEAD W/O CONTRAST Study Date of [2195-9-2] 5:11 AM IMPRESSION: Overall, minimal change re-demonstrating a large left parenchymal hemorrhage and associated mass effect. There is no new intracranial hemorrhage. . CHEST (PORTABLE AP) Study Date of [2195-9-3] 9:02 AM IMPRESSION: Right apical opacity could related to summation of structures. A dedicated PA and lateral radiograph may be obtained if a pneumonia is a clinical concern. . CT HEAD W/O CONTRAST Study Date of [2195-9-3] 10:00 AM IMPRESSION: No evidence of new hemorrhage. Overall, minimal interval change since the prior study, with no change in position of ventricular catheter or size of the ventricles. Large left parenchymal hemorrhage, with associated edema and mass effect with mild uncal herniation on the left, unchanged from prior study. . CT HEAD W/O CONTRAST Study Date of [2195-9-4] 11:19 AM IMPRESSION: Recent placement of a left frontal approach VP shunt with the tip of the catheter terminating in the midline, slightly more anterior than on the prior study with associated postop pneumocephalus and small amount of intraventricular hemorrhage in the occipital [Doctor Last Name 534] of the right lateral ventricle. Large left parenchymal hemorrhage, with associated edema and mass effect, unchanged from prior study. . CT HEAD W/O CONTRAST Study Date of [2195-9-5] 5:01 PM IMPRESSION: 1. Large left parietal intraparenchymal hemorrhage with increasing vasogenic edema leading to worsening mass effect, with increased subfalcine herniation. Distortion of the upper portion of midbrain on the left side.Rec. close followup for worsening/multicompartmental herniation. 2. Unchanged position of the VP shunt without surrounding hematoma. . Portable Abdominal Xray [2195-9-6] IMPRESSION: No evidence of obstruction. A moderately large amount of retained stool is identified throughout the colon. VP shunt and nasogastric tube are identified, incompletely visualized. . Hip 2 view Xray [2195-9-8] One AP view of the pelvis and two more views of the left hip are essentially normal. No bone destruction. No fractures. Joint spaced preserved. Small area of calcification adjacent to the left hip that is of unknown etiology but doubtful significance. . Abdomen Xray [2195-9-9] Two views of the abdomen are provided. There is no evidence of free air beneath the hemidiaphragms. There is unremarkable bowel gas pattern with retained contrast within the colon. The lung bases appear unremarkable. A PEG tube is seen overlying the area of the stomach. A VP shunt is also visualized on the right side. IMPRESSION: No evidence of free air. . Abdomen Xray [2195-9-10] FINDINGS: Supine and left lateral decubitus views of the abdomen are provided. There is no evidence of free air on the decubitus film. However, there are multiple air-fluid levels, which appear to be colonic in nature. The supine film shows a distended large bowel up to 8 cm. These findings suggest a colonic ileus. Air is seen into the descending and sigmoid colon arguing against an obstruction. In comparison to yesterday, there is no barium seen within the colon. IMPRESSION: Air-filled colonic loops suggestive of an ileus. . Abdomen Xray [2195-9-12] Comparison is [2195-9-10]. Gas pattern is now normal without evidence of dilated bowel. There is no evidence of free air. Soft tissues are unremarkable. IMPRESSION: Normal study. . Neurophysiology: EEG Study Date of [2195-8-21] IMPRESSION: This is an abnormal EEG due to the presence of an unvarying 9 Hz alpha frequency background. Clinical correlation is recommended as this may represent this patient's usual background, but in the context of a severe subcortical disturbance, the usual regulators of background activity may be disturbed. There is no evidence of ongoing or incipient seizure activity seen. . EEG Study Date of [2195-8-25] IMPRESSION: This is an abnormal continuous ICU monitoring study because of focal attenuation and moderate diffuse background slowing over the left hemisphere, mild diffuse slowing over the right hemisphere, and frontal intermittent rhythmic delta activity. These findings are indicative of mild diffuse cerebral dysfunction, which is etiologically non-specific, as well as more severe focal dysfunction over the left hemisphere which is consistent with the patient's history of left parietal hemorrhage. Frequent rhythmic bifrontal delta activity (frontal intermittent rhythmic delta activity, FIRDA) was seen more frequently after midnight. FIRDA can be seen with diffuse encephalopathies, midline structural lesions, hydrocephalus, or increased intracranial pressure. FIRDA was less frequent in the early morning recording. . EEG Study Date of [2195-8-26] IMPRESSION: This is an abnormal continuous ICU monitoring study because of focal attenuation and moderate diffuse background slowing over the left hemisphere and mild diffuse slowing over the right hemisphere. These findings are indicative of mild diffuse cerebral dysfunction, which is etiologically non-specific, as well as more severe focal dysfunction over the left hemisphere, which is consistent with the patient's history of left parietal hemorrhage. Intermittent rhythmic bifrontal delta activity (FIRDA) was seen, characteristic of diffuse encephalopathy, midline structural lesions, hydrocephalus, or increased intracranial pressure. Compared to the prior day's recording, the focal slowing and attenuation were unchanged, and FIRDA was present but did not increase in frequency over the course of the recording. . EEG Study Date of [2195-8-27] IMPRESSION: This is an abnormal continuous ICU monitoring study because of focal attenuation and moderate focal background slowing over the left hemisphere and mild diffuse slowing over the right hemisphere. These findings are indicative of mild diffuse cerebral dysfunction, which is etiologically non-specific, as well as more severe focal dysfunction over the left hemisphere which is consistent with the patient's history of left parietal hemorrhage. Frontal intermittent rhythmic delta activity (FIRDA) can be seen with diffuse encephalopathies, midline structural lesions, hydrocephalus, or increased intracranial pressure. Compared to the prior day's recording, there is no significant change. No electrographic seizures were present. Brief Hospital Course: 62 y/o right handed man with a PMH significant for HTN and DMII, who presented to the ED with acute onset of right sided weakness, speech changes and confusion [8-20]. Code Stroke called, TPA was not given as IPH noted on NCHCT. His exam at admission was notable for right sided neglect, nonfluent aphasia but also with receptive defecits, possible right hemianopia, mild right NLF flattening, right sided hemiparesis and hemisensory loss. Patient was admitted to the ICU. His NCHCT showed a large left frontoparietal IPH that extended from the thalamus to the cortex and on further imaging was found to have multiple cerebral mets. An EVD was inserted due to worsening ICH and it was not possible to remove this due to high ICP spikes. Staging CT-torso revealed a large lung mass and associated adrenal metastasis. Lymph node biopsy came back as adenocarcinoma. Patient had spontaneous movement on the left side and had eyes open GCS E4 V2 M5 and due to poor prognosis oncology felt that no chemotherapy or XRT was indicated at this time. Family maintained desire to actively treat and patient was transitioned to the floor on [2195-8-30]. Due to the plan for rehab, patient had a revision of his EVD to a VP shunt on [2195-9-4] after a further failed attempt at clamping this. Patient deteriorated and was transferred back to th ICU on [2195-9-5] due to increasing somnolence and CT showed worse edema and herniation. Patient was treated with IV mannitol to good effect and dexamethasone was increased. Patient was latterly able to obey very simple commands inconsistently. He was tapered off the mannitol and remained neurologically stable. The patient had a PEG placed on [2195-9-8]. After PEG placement the patient developed a mild ileus that resolved with conservative treatment. Tube feeds were subsequently restarted and tolerated well. The patient is now being tapered off the steroids as well. He is being transferred to rehab on [2195-9-14]. . # Neuro: Patient has risk factor of HTN and presented to the ED with acute onset of right sided weakness, speech changes and confusion on [2195-8-20] and although Code Stroke was called patient was noted to have a large ICH on CT-head. Admission exam was notable for right sided neglect, nonfluent aphasia but also with receptive defecits, possible right hemianopia, mild right NLF flattening, right sided hemiparesis and hemisensory loss. His NCHCT showed a large left frontoparietal IPH that extended from the thalamus to the cortex. Patient was transferred to the neuro ICU. Given his history of HTN, with SBP of 180s on arrival, the most likely etiology was intially thought to be hypertensive. CTA did not show any findings to suggest AVM. The patient's conscious level decreased and repeat CT showed worsening of the ICH and associated edema and midline shift. He underwent an elective intubation and EVD placement on [2195-8-22]. CSF showed normal protein, glucose. Cell count and diff showed 60 WBCs and 4000 RBCs, PMN predominant. Gram stain showed PMNs but no organisms grew on culture. Beta-2 microglobulin, protein electrophoresis were negative. Cytology with flow cytometry showed rare atypical epithelioid cells suspicious for metastases. CEA was negative. [8-23] MRI head with contrast was done that showed numerous enhancing foci in the bilateral occipital lobes and the right parietal/frontal lobe, concerning for metastatic disease. CT torso showed a 6.2 cm right upper lobe mass, multiple lymph nodes, including a right supraclavicular lymph node and a left adrenal lesion. On [2195-8-25], an ultra-sound guided supraclavicular lymph node biopsy was done at the bedside that showed metastatic adenocarcinoma, presumed to be primary lung cancer. The medical oncology service was called for a formal evaluation of the patient's condition. Given the patient's relatively severe neurological deficits due to the IPH, as well as the extent of spread of the cancer, the med onc team did not see a role for them to pursue any treatment at present. Patient self-extubated by coughing [2195-8-25] and maintained his airway well with reassuring sats on room air thereafter. Despite efforts to clamp the EVD, ICP rose to >25 and this continuied to drain blood tinged CSF and it was not possible to be removed. Patient was empirically treated with IV levetiracetam and on [2195-8-26], the LTM showed some delta rhythmic activity in the frontal lobes however that resolved. LTM did not demonstrate electrographic seizures and levetiracetam was latterly stopped. Patient initially required nicardipine drip for BP and latterly transitioned to home meds. A number of family meetings regarding Mr [Known lastname 12512] prognosis and goals of care were undertaken. Due to high tumour burden and edema, patient was started on dexamethasone and this was titrated down. A family meeting was held on [8-27] with the wife, daughter, and son (via phone) with the medical oncology team and Neuro ICU team regarding the metastatic adenocarcinoma diagnosis and prognosis. Subsequent family meetings were undertaken and latterly the decision was made to pursue aggressive treatment. The patient was transferred to the stroke step down unit on [2195-8-30] with the EVD in place. Due to the plan for rehab, patient had a revision of his EVD to a VP shunt on [2195-9-4] after a further failed attempt at clamping this. Patient deteriorated and was transferred back to th ICU on [2195-9-5] due to increasing somnolence and CT showed worse edema and herniation. Patient ws treated with IV mannitol to good effect and dexamethasone was increased. Patient was latterly able to obey very simple commands. The mannitol was stopped and the patient remained neurologically stable. Currently the patient is being tapered off of dexamethasone as well given he continues to remain stable neurologically. . ONCOLOGY: The medical oncology service was called for a formal evaluation of the patient's condition. Given the patient's relatively severe neurological deficits due to the IPH, as well as the extent of spread of the cancer, the med onc team did not see a role for them to pursue any treatment. A family meeting was held on [8-27] with the wife, daughter, and son (via phone) with the medical oncology team and Neuro ICU team regarding the metastatic adenocarcinoma diagnosis and prognosis. Oncology currently feel no palliative treatment is indicated and the situation will be reviewed at rehab. The neuro-oncology fellow Dr. [Last Name (STitle) 12513] was informed about the patient and he suggested that the patient follow up in Brain [Hospital 341] Clinic. . # CVS: Stable. Patient was initially very hypertensive an required a nicardipine drip. Latterly was transitioned to his home medications. Patient had hydrochlorothiazide stopped due to hyponatremia. His home atenolol was changed to labetalol and he was continued on prior home meds amlodipine and lisinopril. . # Pulm. Patient was intubated for EVD placement on [2195-8-22]. Self-extubated by coughing [2195-8-25] and maintained good sats on room air thereafter. There are no signs of pneumonia and respiratory status is stable on room air. . # GI: Due to his large ICH, patient failed multiple swallow evaluations. An NG tube was inserted and tube feeds were started. Patient had a PEG inserted [2195-9-8]. After the PEG was placed, the patient did not tolerate tube feeds well and developed abdominal pain and distention. Imaging suggested a mild ileus. He was treated conservatively with increased bowel regimen and placing the PEG to gravity. The ileus resolved and he is now tolerating TFs well. . # Renal:Cr 1.6 on presentation and improved to normal with hydration. HCTZ was stopped due to hyponatremia that has now resolved. . # Endo: Patient has a hx of DM. Due to poor glycemic control on dexamethasone, an Insulin IV infusion was started for tighter glucose control. This was latterly stopped on [2195-9-2] and changed to lantus and HISS s/c and lantus was uptitrated. This will need to monitored closely at rehab as the steroids are tapered down. . # ID: Patient had low grade fevers intermittently in ICU that resolved. There were no signs of infection. Patient was treated with IV Cefazolin for prophylaxis when the EVD was placed and it was subsequently stopped when the EVD was removed. . . Code: FULL . Communication: wife [Name (NI) 12514]: [Telephone/Fax (1) 12515]; [Name2 (NI) ]ter [Name (NI) 11556] [Telephone/Fax (1) 12516]; son [Name (NI) 12517] [Telephone/Fax (1) 12518]. Wife prefers that all updates goes [First Name9 (NamePattern2) ] [Last Name (un) 12517] as she speaks limited English. Medications on Admission: -Amlodipine -Glipizide -Metformin -HCTZ -Lisinopril Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for PAIN/FEVERS. 6. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 8. insulin regular human 100 unit/mL Solution Sig: One (1) UNITS PER SLIDING SCALE Injection four times a day: Per sliding scale. 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. dexamethasone sodium phosphate 4 mg/mL Solution Sig: Two (2) mg Injection Q8H (every 8 hours) for 5 days: Please give until 2359 on [2195-9-14]; then decrease frequency to q12 hours for 2 days([Date range (1) 12519]), then qHS x 2 days ([2196-9-17]) and stop. 14. morphine 5 mg/mL Solution Sig: Two (2) mg Injection Q2H (every 2 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary diagnoses: Large intrcranal hemorrhage secondary to hypertension in the context of bleeding cerebral metastasis s/p EVD and VP shunt insertion, PEG placement Metastatic adenocarcinoma of lung . Secondary diagnoses: Hypertension Diabetes mellitus Type 2 Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Neuro: drowsy, opens eyes to voice. right homonymous hemianopsia; L gaze preference although eyes cross midline. Follow only 1 or 2 simple commands inconsistently. No movement on R, spontaneous mvmt on left. Right upper and lower ext is flaccid. LUE and LLE have [6-11] power. Grimaces to noxious on R, withdraws on L. Discharge Instructions: You were admitted for an intracranial bleed. Unfortunately it was discovered that this bleed was due to one of several metastatic brain lesions from a primary lung adenocarcinoma. For the brain bleed it was necessary to place a drain to decrease the pressure within the skull. Initally this was a drain to outside the skull and then it was changed to a VP shunt. Please follow up with neurosurgery in clinic and have a repeat head CT on [10-8]. We are currently tapering down the steroids you have been on as your neurological exam has been stable. A feeding tube (PEG) was placed in order for you to receive medicines and nutrition safely. The medical oncology team visited you during your stay. Currently there is no therapy that they can recommend given your neurological impairment at this time. On your behalf we spoke to the neuro-oncology fellow. He recommended that you follow up in their Brain [Hospital 341] clinic as listed below. Followup Instructions: Neuro-oncology: Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2195-9-21] 9:30 Radiology: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2195-10-8] 8:45am Neurosurgery: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7746], MD Phone:[Telephone/Fax (1) 3666] Date/Time:[2195-10-8] 9:45 If indicated after rehab, the number to call at thoracic oncology for an appointment to consider chemo/XRT is [0-0-] [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632**]	[ "4019", "25000", "42789", "32723" ]
Admission Date: [2177-8-30] Transfer Date: [2177-9-2] Date of Birth: [2177-8-30] Sex: F Service: NEONATOLOGY TRANSFER DIAGNOSES: 1. Premature female infant, 31-1/7 week's gestation. 2. Status post rule out sepsis. 3. Hyperbilirubinemia. HISTORY OF PRESENT ILLNESS: [Known lastname 52213] is the former 1,640 gm female, born by normal vaginal delivery, weighing 1,640 gm, to a 32-year-old gravida 6, para 3, living 3 female. Pregnancy complicated by prolonged and premature rupture of membranes on [8-24], mother was beta complete and received antibiotics prior to delivery. There was a tight nuchal cord x 1 and meconium at delivery which was unusual for an infant of this gestational age. Apgar scores were 8 and 9, and the infant was admitted to the [Hospital3 ] Special Care Nursery. MOTHER'S PRENATAL SCREENS: Noncontributory. Mother was A+. On admission, the baby weighed 1,640 gm, length 43.5 cm, head circumference 28 cm, all appropriate for gestational age. PHYSICAL EXAM: Essentially within normal limits. PROBLEMS DURING HOSPITAL STAY - 1) RESPIRATORY: The infant was initially placed on nasal cannula for less than 24 hours and weaned directly to room air where she remained for the rest of her hospital stay. She had several episodes of apnea/bradycardia on the first day of life, but since that time has not had any episodes. 2) CARDIOVASCULAR: She has been cardiovascularly stable with no murmur. 3) FEEDING AND NUTRITION: The infant is currently on a total of 120 cc/kg/D of D10W with 2 mEq sodium chloride and 1 of potassium chloride/100 cc. Of this, she is getting upwards of 60 cc/kg of mother's milk or preemie Enfamil 20 cal/oz. We are increasing the PO feeds at 20 cc/kg [Hospital1 ]. 4) INFECTIOUS DISEASE: The infant initially had some meconium at birth, and her initial blood count was remarkable for a white blood count of 37,000 with 68 polys and 0 bands. Repeat CBC the following day had a white count of 30,000 with 57 polys, 0 bands, and today the white count was 31,500 with 51 polys and 1 band. Her blood cultures have remained negative. Mother had no infection, and the infant had been on ampicillin and gentamicin for 48 hours and with negative blood cultures, the antibiotics have been discontinued. 5) HEMATOLOGIC: Mother A+. Baby's bilirubin on [9-1] was 4.9/0.3 and today's is 7.6/0.3, and we were to start phototherapy. Her hematocrit is 50.2 with a platelet count of 349,000. 6) SOCIAL: Mother relates that the father of the baby left her the day the infant was born. She lives with her mother and two other children in [Name (NI) ], and for this reason she would like us to transfer the baby closer to home. The baby is being transferred to [Hospital 1121] Hospital today in the care of Dr. [First Name (STitle) 52214]. DISCHARGE MEDS: None. Upon discharge from [Hospital 1121] Hospital, the patient will be followed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of [Hospital ] Pediatrics. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 38370] Dictated By:[Last Name (NamePattern1) 38304] MEDQUIST36 D: [2177-9-2] 09:00 T: [2177-9-2] 08:09 JOB#: [Job Number 52215]	[ "7742", "V290" ]

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