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Admission Date: [2137-8-29] Discharge Date: [2137-9-7] Date of Birth: [2056-10-13] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[First Name3 (LF) 3561] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Hip fracture repair, intubation History of Present Illness: Mr. [Known lastname 724] is an 80 y/o man with T2DM, CRI with a baseline Cr 1.9, and dementia who presented after a witnessed fall in his nursing home with right hip pain. Reportedly this was a mechanical fall per witnesses. Pt is poor historian and does not recall event, but reportedly at time of fall denied CP, SOB, N/V, no LOC, no head trauma. He was unable to bear weight after the fall. He was sent to the [Hospital1 18] ER where a right hip XR showed an impacted femoral neck fracture. CXR showed subacute L rib fractures but no acute process. Knee XR pending final read. . ROS: currently denies CP, SOB, abd pain, n/v, no hip pain at rest but states mild hip pain if moves hip. Past Medical History: T2DM Diabetic nephropathy Parkinsons Dementia Anemia with unknown baseline hct 30, believed due to CKD CRI with reported baseline Cr 1.9, but none on file here Hyponatremia with reported baseline ~130 CHF HTN Depression BPH s/p TURP Irritable bowel syndrome h/o pancreatitis DJD Hiatal hernia Reflux esophagitis Social History: Lives in [Location 35689] House. Single. Family History: N/C Physical Exam: Vitals: 98.6, 168/88, 18, 100% RA, FS 129, wt 59kg General: NAD, resting flat on back, pleasant, conversant, oriented x 2 (believes he is at his NH) HEENT: no OP injection, MMM, no sinus tenderness Neck: supple, no LAD Pulmonary: CTAB anteriorly Cardiac: RRR, I/VI systolic murmur heard throughout precordium, s1s2 Abdomen: soft, NT, ND, +BS Extremities: no c/c/e, R leg shortened and externally rotated, mild R hip tenderness to palpation, R hip tenderness on rotation of hip. sensation grossly intact in BLE, DP 2+bilat Pertinent Results: [2137-8-29]: CXR: Subacute fractures involving the anterolateral left sixth and seventh ribs as detailed above. No radiographically evident pneumothorax seen. . [2137-8-29]: Right hip XR: Impacted femoral neck fracture. Marked degenerative changes in lumbar spine. . [2137-8-29] Right Knee XR: There are no signs for acute fractures or dislocations. There is joint space narrowing medially. Extensive vascular calcifications are present. There is no joint effusion. Limited cross-table lateral views of the right hip are markedly limited and provides limited diagnostic detail. Please refer to the AP view of the pelvis where there is a known right femoral neck fracture. . EKG: NSR at 70. nl axis, nl intervals (borderline PR about 200ms), no peaked T waves. no Q waves. TWF in III. No prior for comparison. . [2137-9-1] CT Abdomen and Pelvis W/O Contrast No evidence of retroperitoneal hematoma. Post-surgical changes are noted about the right hip as detailed above. Small pleural effusions and small pericardial effusions as noted. Signs of chronic pancreatitis. Sigmoid colonic wall thickening as noted above, nonspecific finding. . [2137-9-4] U/S RLE No DVT. . [2137-9-5] V/Q Scan No evidence of pulmonary embolism. . [2137-9-5] TTE The left atrium is mildly dilated. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . Micro Data: Blood cultures: No growth . Urine cultures: No growth . C diff: Negative . [2137-8-29] 06:15PM BLOOD WBC-4.9 RBC-2.63* Hgb-8.9* Hct-27.7* MCV-105* MCH-34.0* MCHC-32.3 RDW-15.3 Plt Ct-195 [2137-9-7] 04:18AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.7* Hct-28.9* MCV-94 MCH-31.7 MCHC-33.8 RDW-17.9* Plt Ct-190 [2137-8-29] 06:15PM BLOOD Glucose-131* UreaN-16 Creat-1.9* Na-127* K-5.0 Cl-93* HCO3-24 AnGap-15 [2137-9-7] 04:18AM BLOOD Glucose-64* UreaN-20 Creat-1.6* Na-136 K-4.6 Cl-108 HCO3-21* AnGap-12 [2137-9-1] 03:29AM BLOOD ALT-10 AST-29 AlkPhos-55 Amylase-30 TotBili-1.8* [2137-9-7] 04:18AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.9 [2137-9-5] 05:08AM BLOOD TSH-3.3 [2137-9-1] 11:20AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative Brief Hospital Course: 80 y/o man with T2DM, anemia, dementia, and CRI who presented s/p mechanical fall with subsequent right hip fracture. His hospital course was complicated by bleeding and hypotension along with atrial fibrillation. The following issues were addressed during this admission. . 1. Reason for MICU admission: The patient was initially transferred to the MICU for hypotension that was thought to be secondary to hypovolemia. The patient had pulled his foley catheter and had profuse bleeding from the catheter site. For this he was transfused and seen by urology. Initially the patient had a 3-way catheter with aggressive irrigation. Cystoscopy showed improved hemostatsis and bladder irrigation was stopped. Bleeding was stable. CT of abdomen/pelvis did not show retroperitoneal bleeding. No hemolysis. Hematocrit stable since [2137-9-1]. . 2. Hypotension: The patient had persistent hypotension despite cessation of bleeding from foley site as well as no signs of hematoma in the OR. The patient was actively resusitated with fluids and blood with improvement in his blood pressures. Patient received 4 units of PRBC on [9-1]. Blood pressures remained stable after that. Most likely he was hypotensive in setting of blood loss. . 3. Respiratory distress The patient had period of a apnea after returning from the OR and required reintubation. Given that the patient was clinically unstable from a blood pressure standpoint, he remained intubated. He did not have signs of respiratory compromise and maintained his saturations. Patient was quickly extubated on [2137-9-2] and remained stable. . 4. Thrombocytopenia The patient was noted to have a dramatic platelet drop, concern for possible HIT, heparin was initially held and appropriate studies were ordered. HIT returned negative. Platelet count increased slowly and remained stable after Hct stabilized. This was most likely in setting of blood loss. . 5. Right Hip fracture The patient was evaluated by orthopedics upon admission and taken to the OR on [8-31]. The operation was without complications but post-op had to be reintubated. Per ortho, there was no hematoma at the surgical site while in the OR. Pre-op betablocker was started for risk reduction but was limited by hypotension as above. After patient's hematocrit was stabilized, he was started on Lovenox for AC in the setting of recent ORIF of right hip. He will continue on Lovenox for 4 weeks. He will follow up with orthopedics in 2 weeks after discharge with Dr. [Last Name (STitle) 7376]. . 6. HTN Initially pt's outpt lisinopril and catapres were held and a perioperative BB was given, but discontinued with hypotension. Given his new onset atrial fibrillation, he was started on verapamil which was uptitrated to HR. . 7. Atrial fibrillation On [2137-9-5], the patient developed atrial fibrillation with a HR to the 130s. EKG revealed evidence of atrial fibrillation without any acute ST changes. Cardiac enzymes were drawn which did not indicate an ischemic etiology for his atrial fibrillation. A TSH was checked which was normal. The patient had a TTE which revealed mild left atrial enlargement and an EF greater than 60%. The patient also had a V/Q scan to r/o PE given his recent hip fx and surgery which was negative. He was started on verapamil as a nodal [Doctor Last Name 360] after IV diltiazem was successful in controlling his heart rate. . 8. Rib fractures These appeared subaccute on XR. Likely these are not from his admission fall, as appear subacute and also on L as opposed to R side. . Communication: case manager [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 15582] (w) [Telephone/Fax (1) 71590]; (c) [Telephone/Fax (1) 71591]. Per note call CM first. Secondary contact brother [Name (NI) ] [Telephone/Fax (1) 71592]. . Full code Medications on Admission: catapres 3 patch qweek lisinopril 10mgpo qday aricept 10mgpo qhs asa 81mg po qday sinemet 25/100: 0.5 tab [Hospital1 ] calcitriol 0.25mcg po qday celexa 20mg po qday cyanocobalamin 1000 mcg po qday epo 4000 units qweek lasix 20mg po qday ferrous gluconate 25mgpo qday glipizide 2.5mg po qday omeprazole 20mg po qday kayexelate 60mL (15g) po bid Discharge Medications: 1. Donepezil 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). 2. Carbidopa-Levodopa 25-100 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 3. Calcitriol 0.25 mcg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 4. Citalopram 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day) as needed. 6. Insulin Regular Human 100 unit/mL Solution [Hospital1 ]: per sliding scale Injection ASDIR (AS DIRECTED). 7. Cyanocobalamin 500 mcg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 8. Epoetin Alfa 2,000 unit/mL Solution [Hospital1 ]: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 9. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q6H (every 6 hours). 10. Magnesium Hydroxide 400 mg/5 mL Suspension [Hospital1 ]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Ferrous Sulfate 300 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO DAILY (Daily). 13. Olanzapine 5 mg Tablet, Rapid Dissolve [Last Name (STitle) ]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 14. Morphine Sulfate 2-4 mg IV Q4H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Right Hip fracture Hemorrhage Thrombocytopenia Hypotension Acute renal failure Dementia Discharge Condition: stable Discharge Instructions: Please take your medication as prescribed and follow up with Dr [Last Name (STitle) 5351]. Please call your doctor with any concerning symptoms. Followup Instructions: Dr [Last Name (STitle) 5351] Completed by:[2137-9-7]	[ "5849", "42731", "5859", "2875", "2761" ]
Admission Date: [2102-6-19] Discharge Date: [2102-6-27] Date of Birth: [2040-6-7] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[First Name3 (LF) 1283] Chief Complaint: DOE, Fatigue, Palpitations, syncope Major Surgical or Invasive Procedure: Mitral valve replacement History of Present Illness: This is a 61 year old female who presents with DOE, Fatigue, palpitaitons, and syncopal episodes. She had mitral valve prolapse which was followed by servial echo, but her sx have gotten to the point that surgical intervention is warrented Past Medical History: Cholesterol MV prolapse Multiple sclerosis BrCA CVA '[87] no residual RA MIgranes Asthma Social History: Former heavy smoker and drinker Lives alone Family History: CAD (brother died at age 61) Physical Exam: 96.8 70 16 98% 94/47 NAD RRR CTA-B Abd-benign Ext-warm, well perfused Pertinent Results: [2102-6-19] 12:31PM freeCa-1.11* [2102-6-19] 12:31PM HGB-12.5 calcHCT-38 [2102-6-19] 12:31PM GLUCOSE-92 NA+-140 K+-3.5 [2102-6-19] 12:31PM TYPE-ART PO2-468* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 [2102-6-19] 06:03PM GLUCOSE-51* NA+-142 K+-3.2* CL--110 TCO2-26 Brief Hospital Course: Pt was admitted to the CSRU after uneventful MVR. She did well post op, she did have some dehydration for which volume was given. Pressors were needed in the unit, but these were weaned succesfully. On POD 2 her PA catheter was d/c'ed and she was sent to the floor. Her wires were d/c'ed on POD 3 and her lopressor dose was increased. She was seen by PT but was somewhat slow to fully ambulate. By POD 8 she was doing very well on from the PT point of view, able to do stairs appropriatly. She was Stable from a cardiac point of view the entire post op period. She was sent home with lasix and lopressor and follow up instructions Medications on Admission: Albuterol Atenolol Chloroquine Flexeril Lipitor Lisinopril Mucinex ASA Singulair Flonase Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:120 Capsule, Sustained Release(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use while on percocet. Disp:60 Capsule(s) Refills:2 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Mitral Valve stenosis Discharge Condition: Good Discharge Instructions: You should notify your primary care doctor if you have increasing chest pain, shortness of breath, palpitation, or any other sign or symptom that is concering to you. You should see your doctors as directed below [Last Name (NamePattern4) 2138]p Instructions: You should see your cardiology within 1-2 weeks You should see your primary care doctor within a week or two as well: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 3183] You need to see Dr. [Last Name (Prefixes) ] in [2-24] weeks. Provider: [Last Name (Prefixes) ],[First Name3 (LF) 412] [Telephone/Fax (1) 170] Completed by:[2102-6-27]	[ "4240", "5180", "49390", "2720", "V1582" ]
Admission Date: [2194-12-16] Discharge Date: [2194-12-20] Date of Birth: [2150-10-24] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: diffuse exfoliating rash Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: 44 year old female with h/o HTN initially admitted to [Hospital 1562] Hospital on [2194-12-11] with 7 days of cough, fever, and 1 day of change in mental sttatus. Her family/friends noted she had slurred speech, few episodes of talking out of contexted causing them to bring her to the ED. She was covered with ceftriaxone/vancomycin for presumed meningitis (LP attempts unsuccessful) and admitted to the ICU, where she was subsequently intubated for hypoxia (O2 sat 80s RA) and change in mental status. CXR should multifocal opacities, and antibiotics were broadened to CTX/vanco/levo/doxy/ayclovir/metronidazole. Over the course of the next few days, she developed transaminitis (LFTs 600s), ARF (attributed to ATN, initiated dialysis [12-15], [12-16]), thrombocytopenia (plt 23 from 90s on admit), lactic acidosis (lactate 5). All bcx, spcx, ucx, BAL NGTD. Antibiotics narrowed to levofloxacin/linezolid/doxycycline (?when). On [12-12], pt was noted to be diffusely mottled. Over the course of the next 4 days, she developed diffuse, dependent purpura with areas of necrosis/skin sloughing. She was transferred to [Hospital1 18] [12-16] given concern for TEN. Currently, the patient is intubated and sedated. Past Medical History: 1) HTN 2) obesity 3) s/p C-section 4) s/p cholecystectomy 5) Osteopenia 6) ?glucose intolerance Social History: 1) HTN 2) obesity 3) s/p C-section 4) s/p cholecystectomy 5) Osteopenia 6) ?glucose intolerance Family History: Father with CAD and diabetes. Mother healthy Physical Exam: T Gen: obese, middle-aged female, intubated, sedated HEENT: anicteric, pinpoint pupils, symmetric bilaterally, pale conjunctiva, oral mucosa moist, neck supple, JVP ~ 7 cm Cardiac: tachycardic, no M/R/G appreciated Pulm: Decreased lung sounds at bases bilaterally, coarse ronchi throughout Abd: Obese, soft, hypoactive bowel sounds, no apparent tenderness Extremities: anasarca, cool extremities and fingers bilaterally, cyanosis/blackening of all 10 finger tips. 1+ DP bilaterally. Poor cap refill in fingers and toes bilaterally. Skin: Diffuse, patchy, non-palpable purpura, predominately over dependent areas involving ~ 50% of skin, with bullae/sloughing of ~ 10% of skin. No clear mucosal involvement. Neuro: Pupils equal, minimally reactive, moves all 4 extremities in responsive to painful stimuli, toes mute bilaterally, 1+ DTR throughout. Pertinent Results: Micro: [Hospital1 18] [12-16] bcx pending, ucx pending . [Hospital1 1562] bcx: [12-12] NGTD, [12-13] NGTD, [12-14] NGTD, [12-15] pending vag cx [12-13] (-) ucx [12-12] pending spcx [12-14] (-) BAL [12-15] negative . CXR ([Hospital1 18]) [12-16]: ETT, NGT, RSC in place. bilateral airspace opacity, perihilar predominance, c/w pulmonary edema . Renal U/S (OSH) [12-15]: negative . Head CT (OSH) [12-12] (-) . EKG [2194-12-13]: ST @ 128 bpm w/ PVCs q II, III, avF, non-specific TW changes Brief Hospital Course: A/P: 44 yoF w/ h/o HTN presents with rapidly progressive change in mental status in the setting of fever. Course c/b multisystem organ failure (renal, respiratory, liver) with coagulopathy and diffuse purpura fulminans. . . 1) Purpura Fulminans: Seen by dermatology and biopsied upon transfer with prelim path consistent with microthrombi. The felt that findings are most consistent with purpura fulminans, most commonly seen in setting of sepsis/DIC/meningococcemia. DDx includes TEN (although minimal total-body exfoliation), toxic shock, scalded skin syndrome. Initially duoderm dressings appllied and as skin started exfoliated and denuding, was cleaned with saline and silvadene with telfa applied to denuded areas. She had significant weeping of the wounds and was supported with IVF and albumins were monitored and last albumin was 2.4. She was treated for her possible underlying infection as below. Negative vaginal exam for tampon (vag cx, speculum exam negative at OSH). As area of skin involved progressed, she will be transferred to a specific burn unit to manage and monitor her skin breakdown. she has been on heparin gtt to prevent further microemboli and per rehumatology and hematology should be started on IVIG and steroids to treat possible acute antiphospholipid antibody syndrome which may also cause this presentation of microemoli. . 2) Sepsis: Improved hypotension off pressors X >24 hrs prior to transfer and no need for pressors while here and no evidence of lactic acidosis. Potential infectious sources include menignitis (including meningococcus given rapid clinical deterioration), pulmonary source (given report of cough, patchy infiltrates on CXR). Given presentation meningococcus was leading infection although Lp attempts at OSH and unable after repeated attempts and here not attempted given antibioitcs and rash covering back with thrombocyopenia. Initially broadly coverage again per ID reccomendations with Ceftriaxone/vanco/acyclovir/ampicillin to cover meningitis, levofloxacin to cover atypicals, doxycline to cover for tick-[Location (un) ] disease(RMSF). eventually levofloxacin, ampicillin and acycovir were stopped as not clinically consistent with those diagnoses. Ct of chest/abd/pelvis with contrast did not reveal any abscesses, large PEs or other infectious processes, although was consistent with ARDS. Crypto Ag(-), histo Ag(p), erhlichiae Ab(neg) per ID. cultures here including daily blood, urine and sputum have been negative. tissue culture with 1+PMn, but no anaerobic gorwth and aerobic cx still pending. Head MRI negative for septic emboli or temporal enhancement suggestive of herpes encephalitis, but did have scattered foci of FLAIR signal hyperintensity, nonspecific, which may relate to post infectious/inflammatory process, demyelination, or subacute or chronic infarction. TTe and TEE without signs of vegetations. IVF boluses used to maintain CVP >12, MAP >65. She was initially on droplet precautions, but no longer needed as has been treated over 24hrs. She was continued on sepsis dose steroids and then transitioned to steroids to treat possible auto-immune source of rash even though [Doctor First Name ] and ANCA were negative. She is currently on ceftriaxone 2gm IV q12hrs, vanc 1 gm pre levels<15, doxycycline 100mg IV q12. . 3) Transaminitis: Most likely secondary to shock liver, trending down while here Hepatitis A, B, C serologies (-) at OSH; EBV serologies indicating prior infection, and again repeated here although still pending. RUQ U/S did not shouw evidence of portal thrombosis and unremarkeable liver and s/p ccy. . 4) Thrombocytopenia: Plt 21 on admission and prior to d/c back up to 40. thought to be secondary to DIC (although PT/PTT wnl, D-dimer high, FDP and fibrinogen normal here) vs sepsis, consumption in the setting of widespread purpura. HIT was negative. Also initially concern for TTP, given ARF, MS change, fever, but with no shistocytes on smear, no haptoglobin less likely. . 5) ARF: Sediment at OSH c/w ATN, likely secondary to sepsis/renal hypoperfusion. Renal U/S at OSH (-). she continued to require daily HD here for fluid management. As infection resolves, she may recover renal function, although currently seems unlikley. . 6) CHF: Grossly total body fluid overloaded (in the setting of aggresive fluid resuscitation) although CVP 7, however given concern for sepsis/lactic acidosis, would not actively diurese at this time, particularly as patient is ventilated. normal EF on TTE, and as started weeping from wounds, slowed down diuresis attempts. She was started on afterload reduction with hydralazine, isordil and low dose metoprolol. . 7) Rahbdo: she had persistently elevated CKs likely from mircoemboli to muscles as well. Continued on IV hdration and remained stable. . 8) Anemia: HCT 28.8, microcytic. Likely secondary to volume resuscitation in the setting of marrow-suppression (sepsis, ARF). She was only transfused 1 uPRBC during her course here. . 9) F/E/N: Tube feeds started to help support nutrition, electrolytes morinotred twice a day and replete as needed. Insulin drip for close glucose monitoring. . 10) Ppx: IV H2 blocker, heparin drip . 11) Code: Full Code . 12) Communication: Father [First Name4 (NamePattern1) ] [Name (NI) ] cell [Telephone/Fax (1) 64766]), Sister [First Name8 (NamePattern2) 8513] [Name (NI) 64767] cell [Telephone/Fax (1) 64768]). Family includes husband (whom she is separated from), 2 sisters, son, mother, and father. Next of [Doctor First Name ] is adult son as separated from husband who has deferred decision making to son and father. . 13) Lines: Left radial a-line ([12-13]), RIJ cordis ([12-13]), Left IJ dialysis catheter ([12-16]) Medications on Admission: Meds (home): 1) metoprolol 50 mg PO TID 2) HCTZ 25 mg PO daily 3) Trazodone 50 mg PO daily 4) Wellbutrin 150 mg PO BID 5) Clarinex 5 mg PO daily 6) Motrin prn . Meds (on transfer): 1) Zyvox 600 mg IV BID 2) Protonix 40 mg IV daily 3) Procrit 1000 units after each hemodialysis 4) Doxycycline 100 mg IV q12h 5) Levofloxacin 250 mg IV daily 6) RISS 7) solumedrol 80 mg IV q8h 8) Albuterol/Atrovent MDIs prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: Three (3) units Injection TITRATE TO (titrate to desired clinical effect (please specify)). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID (3 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Midazolam 5 mg/mL Solution Sig: Two (2) mg/hr Injection TITRATE TO (titrate to desired clinical effect (please specify)). 12. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred (100) mcg/hr Injection INFUSION (continuous infusion). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Doxycycline Hyclate 100 mg IV Q12H 15. Pantoprazole 40 mg IV Q24H 16. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1100 (1100) units/hr Intravenous ASDIR (AS DIRECTED). 17. Vancomycin HCl 1000 mg IV ONCE Duration: 1 Doses 18. Ceftriaxone 2 gm IV Q12H Dose antibiotic after dialysis Discharge Disposition: Extended Care Discharge Diagnosis: purpura fulminans sepsis multi-organ failure thrombocytopenia shock liver acute renal failure Discharge Condition: fair, stable BP and HR, intubated on Pressure support 15/5 at 355 FIO2. Discharge Instructions: please continue aggressive skin care and managing sepsis as per d/c summary. Followup Instructions: please follow up with PCP after discharged from hospital. Completed by:[2195-1-4]	[ "0389", "5845", "4280", "2875", "4019", "99592" ]
Admission Date: [2155-10-11] Discharge Date: [2155-10-14] Date of Birth: [2155-10-11] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] is 3.675 kg infant born at 38 weeks gestation. Mother is a 34-year-old G2, P1, now 2. Prenatal screens O positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS negative. Pregnancy reportedly uncomplicated. No perinatal sepsis risk factors. Infant delivered vaginally with Apgars of 9 and 9. At newborn nursery, the infant was noted to be jittery. Glucose at that time was 17. He was transferred to the newborn intensive care unit with a repeat D-stick of 34. PHYSICAL EXAMINATION: Non-dysmorphic, anterior fontanel soft and flat. Eyes deferred. Palate intact. Neck supple with clavicles intact. Lungs clear to apex. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Abdomen soft. Positive bowel sounds. GENITOURINARY: Normal male. Testes down bilaterally. Patent anus with meconium and diaper hip stable. Essentially pink with peripheral acrocyanosis. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Stable. CARDIOVASCULAR: No issues. FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight 3.675 kg. Admitted to newborn intensive care unit with an initial glucose of 17. Repeat of 19 at which time the infant was fed. Follow up glucose at that time was 38. D10 bolus was given of capture the infant and was started on 80 cc per kg of D10W in addition to ad lib feeding of breast milk and Enfamil 20. Over the next 48 hours, D10 was discontinued and the infant has been ad lib feeding maintaining D-stick greater than 60. GASTROINTESTINAL: Bilirubin on day of life 2 was 15.3/0.5 Bilirubin at discharge was 12.1 INFECTIOUS DISEASE: CBC and blood culture obtained on admission. CBC was benign. Blood culture remained negative at 48 hours. HEMATOLOGY: Hematocrit on admission was 57.6. Repeat hematocrit on [10-13], was 65.4. On the day of discharge the Hct was 58.9 NEUROLOGIC: The infant has been appropriate for gestational age. SENSORY; Hearing screen has been performed with automated auditory brain stem responses and the infant ... PSYCHOSOCIAL: Parents have been interested and involved with this infant's care. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name (STitle) 2433]. Telephone No. [Telephone/Fax (1) 62420]. CAR SEAT POSITION SCREEN: Not applicable. FEEDS AT DISCHARGE: Continue ad lib feeding breast milk and Enfamil 20 calories. MEDICATIONS: Not applicable. STATE NEWBORN SCREEN: State Newborn Screens have been sent for protocol and have been within normal limits. IMMUNIZATIONS RECEIVED: The infant received Hepatitis B vaccine on [2155-10-13]. DISCHARGE DIAGNOSE: 1. Term infant. 2. Hypoglycemia resolved. 3. Hyperbilirubinemia. 4. Polycythemia resolved [Doctor First Name ] [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 62348] Dictated By:[Last Name (NamePattern1) 58682] MEDQUIST36 D: [2155-10-13] 21:34:15 T: [2155-10-13] 23:43:08 Job#: [Job Number 62421]	[ "V053" ]
Admission Date: [2152-2-2] Discharge Date: [2152-2-4] Date of Birth: [2128-3-15] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: skull mass at vertex of head Major Surgical or Invasive Procedure: bilateral craniotomy bilateral cranioplasty History of Present Illness: 23 y/o M with skull mass at vertex of head presetns for elective bilateral craniotomy and bilateral cranioplasty. Past Medical History: shoulder surgery, bipolar, insomnia Social History: +tobacco and ETOH Family History: NC Physical Exam: On Discharge: nonfocal Brief Hospital Course: 23 y/o M with no significant past medical history presents for elective bilateral craniotomies for resection of skull lesion at vertex. He was taken to the OR on [2-2]. He was extubated in the OR however did not wake up enough to adequately protect his airway so he was reintubated and trasnfered to the ICU for further management and care. He was extubated shortly after arrival to the ICU and post-operative Head CT showed expected post-operative change. On [2-3] he was doing quite well and was deemed fit for transfer to the floor. He also underwent an MRI scan on [2-3] which showed expected post-surgical changes. On [2-4] he was ambulatory in the halls, his pain was well controlled, and he was deemed fit for discharge to home. He was given instructions for follow-up and discharged. Medications on Admission: MVI, lamictal, melatonin Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:90 Tablet(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain Fever > 101.4. 5. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:24 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Skull mass at vertex of head Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? If you have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? If your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [8-1] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Follow up with Dr. [Last Name (STitle) 724] and Dr. [Last Name (STitle) 12513] in the BTC on [Hospital Ward Name 5074] on [2152-2-28] 09:30a. Completed by:[2152-2-4]	[ "3051" ]
Admission Date: [2113-7-21] [Month/Day/Year ] Date: [2113-7-23] Date of Birth: [2049-3-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 9662] Chief Complaint: Weakness Reason for ICU Transfer: Hypotension Major Surgical or Invasive Procedure: Femoral CVL insertion - [7-21], removed [7-23] History of Present Illness: 64yo M w/ PMHx of ESRD on HD (MWF), chronic aspiration, seizure disorder, history of CVA with residual left-sided weakness and dysarthria, upper extremity DVT, recently hospitalized at [Hospital1 18] with melena found to have gastritis with no active bleeding lesions, and h/o of Staph epidermidis treated with IV vancomycin until [7-20], presented to the ED with generalized weakness and hypotension. He reported feeling well prior to HD, but upon returning from HD, he reported generalized weakness. EMS was called. The patient was found cool and diaphoretic with BP 70/50 and HR 100. He only opened eyes when prompted, but was oriented x3. Repeat BP was 90/palp and HR 100. ECG and 12 lead reveal NSR with no ectopy and inverted T waves in the inferior leads as well as V4-V6. Blood sugar 157 mg/dl. In the ED, initial SBP in the 70s. The patient had a triple lumen catheter placed in the right femoral [2-23] difficult access. Pressure improved with fluids (1L) Patient with no focal complaints in the ED, but minimally responsive to voice. Has a cough, no fever, no chest pain. No abdominal tenderness. Patient also received vancomycin and cefepime. CXR did not show focal opacity. Pressures now in the 110s. Guiaic negative. EKG consistent with priors- lateral TWIs. Has been mildly tachycardic in 100-110. Pt received pressors and 1L IVF in the ED, and was transferred to the ICU. Past Medical History: - ESRD on HD (M/W/F at [Location (un) ]) - h/o multiple prior CVAs - per last dc summary ambulates at home, has residual left-sided weakness - UE DVT on coumadin - Seizure disorder - Chronic hepatitis B - Chronic aspiration with failed speech and swallow eval - family wants him to continue eating despite risks - HTN - CAD - h/o MSSA bacteremia after manipulation of fistula - hospitalization in [12-31] for incarcerated inguinal hernia complicated by ESBL Klebsiella bacteremia and PNA - Hyperlipidemia - GERD - S/p SBO [2109] - Hernia repair - Symptomatic Hypoglycemia Social History: Patient lives in [Location ] with his daughter, [Name2 (NI) ], who is a former [Hospital1 18] employee. He denies any recent use of alcohol, tobacco, illicit drugs, or herbal medications. He has a distant, but considerable smoking history per his daughter. [Name (NI) ] uses the toilet himself, but needs help cleaning himself, and does not cook or manage his finances. He is at HD on MWF and spends TU and [Doctor First Name ] in an adult day program. His daughter does not leave him alone by himself. Family History: Mother died at 45 with hypertension. Father died at 60 of unknown causes. He has eight living siblings, many of whom have hypertension. He has six children who are all healthy. Physical Exam: Admission exam: General: [Doctor First Name ], oriented, no acute distress [Doctor First Name 4459]: Sclera anicteric, MMM, oropharynx clear, [Doctor First Name 3899], PERRL Skin: Skin in right groin clean and dry at site of femoral catheter insertion. 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; trace edema Neuro: CNII-XII intact, dysarthria, 5/5 strength right upper/lower extremities, 4+/5 strength left upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally Pertinent Results: ADMISSION LABS: [2113-7-21] 02:00PM BLOOD WBC-7.2 RBC-3.34* Hgb-10.7# Hct-34.6 MCV-104* MCH-32.0 MCHC-30.8* RDW-17.4* Plt Ct-160 [2113-7-21] 02:00PM BLOOD Neuts-71.4* Lymphs-17.6* Monos-7.6 Eos-3.0 Baso-0.4 [2113-7-21] 02:00PM BLOOD PT-14.0* PTT-30.3 INR(PT)-1.3* [2113-7-21] 02:00PM BLOOD Glucose-201* UreaN-13 Creat-4.7# Na-139 K-3.8 Cl-104 HCO3-22 AnGap-17 [2113-7-21] 02:00PM BLOOD ALT-14 AST-17 AlkPhos-210 TotBili-0.1 [2113-7-21] 02:00PM BLOOD cTropnT-0.05* [2113-7-22] 04:00AM BLOOD cTropnT-0.04* [2113-7-21] 02:00PM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.2# Mg-1.6 [2113-7-21] 02:30PM BLOOD Lactate-1.9 K-3.7 [Month/Day/Year 894] LABS: [2113-7-23] 07:30AM BLOOD WBC-5.9 RBC-3.27 Hgb-10.2* Hct-33.1* MCV-101* MCH-31.2 MCHC-30.8* RDW-16.7* Plt Ct-184 [2113-7-23] 07:30AM BLOOD Glucose-72 UreaN-32* Creat-9.4# Na-138 K-5.8 Cl-102 HCO3-21* AnGap-21* [2113-7-23] 02:24PM BLOOD Glucose-155* UreaN-35* Creat-9.7* Na-139 K-4.6 Cl-100 HCO3-23 AnGap-21* [7-21] PCXR: Left-sided dual-lumen central venous catheter tip terminates within the proximal right atrium. The cardiac silhouette size is normal. The mediastinal and hilar contours, allowing for patient rotation, are likely unchanged. There is mild pulmonary vascular congestion. Minimal atelectasis is likely present at the lung bases. No focal consolidation, pleural effusion or pneumothorax is identified. The bones are diffusely sclerotic suggestive of underlying of renal osteodystrophy. Posttraumatic deformity of the distal clavicle on the right is unchanged. IMPRESSION: Mild pulmonary vascular congestion. No definite radiographic evidence for pneumonia. Brief Hospital Course: 64yo M w/ PMHx of ESRD on HD (MWF), chronic aspiration, seizure disorder, history of CVA with residual left-sided weakness and dysarthria, upper extremity DVT on coumadin, recently hospitalized at [Hospital1 18] with melena found to have gastritis with no active bleeding lesions and Staph epidermidis bacteremia s/p IV vanc treatment [7-20], who was admitted to the ICU for hypotension. Upon arrival in the MICU, he was more responsive and stated he was hungry. He denies chest pain, shortness of breath, abdominal pain, n/v. He reports a cough that has been chronic. He received an additional 750 cc, but no longer required pressors. His SBP ranged 80-110s and he remained asymptomatic. Vancomycin was discontinued, but he received cefipime overnight on [7-21] before d/c. He was transferred to the floor [7-22]. On the floor, he required no more IVF. SBP ranged 105-125. # Hypotension: Patient underwent HD on day of admission; it is likely that the patient's hypotension is related fluid shifts during HD. Patient was initially with SBPs in the 70s upon presentation to the ED and improved to 100s with 1L of fluid and some pressors in the ED. Patient's SBPs were stable in the 120s upon arrival to the ICU. He did have brief episodes of hypotension to the 80s systolic while in the ICU but required a total of only 750cc IVF while in the ICU. Troponins were cycled and at baseline, EKG unremarkable. No clear evidence of infection so antibiotics were NOT continued while in the ICU. ACEI was held. Blood cultures were NGTD. On the floor SBPs were stable 105-125. # ESRD on HD: M/W/F. Patient went to HD prior to arrival in the ED. Nephrology saw the patient in hospital. Home meds continued. # Hyperkalemia: Pt is normally on HD and has baseline K around 5. K was 5.8 on the morning of [7-23]. EKG was checked and showed now acute changes. Pt denied chest pain or palpitations, dizziness, lightheadedness, nausea. Pt was given kayexelate per nephrology, and K dropped to 4.5 at [Date Range ] labs. # UE DVT: Patient w/ clot in AVF previously on coumadin which was held in light of anemia. Decision was made by daugther not to continue coumadin in light of risk of bleeding per most recent PCP [Name Initial (PRE) 626]. # Anemia: HCT 33 upon [Name Initial (PRE) ], consistent with chronic anemia secondary to ESRD, patient's baseline HCT is in the low 30s. # GERD: H. pylori negative. Continued omeprazole. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Nephrocaps 3 CAP PO BID 2. Lanthanum 500 mg PO TID W/MEALS 3. LeVETiracetam 500 mg PO BID 4. Lisinopril 40 mg PO DAILY hypertension 5. Omeprazole 40 mg PO BID gastritis 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Pravastatin 40 mg PO DAILY 8. sevelamer HYDROCHLORIDE NF 800 mg Other TID:meals 9. Aspirin 81 mg PO DAILY 10. Ascorbic Acid 500 mg PO DAILY 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Senna 1 TAB PO BID:PRN constipation [Name Initial (PRE) ] Medications: 1. Aspirin 81 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Nephrocaps 1 CAP PO DAILY 4. Pravastatin 40 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Lanthanum 500 mg PO TID W/MEALS 7. Lisinopril 40 mg PO DAILY high blood pressure 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID:PRN constipation 11. Ascorbic Acid 500 mg PO DAILY 12. sevelamer HYDROCHLORIDE NF 800 mg Other TID:meals [Name Initial (PRE) ] Disposition: Home With Service Facility: [Location (un) 86] VNA [Location (un) ] Diagnosis: Primary Diagnosis: Hypotension (Low blood pressure) Secondary Diagnosis: end stage renal disease, seizure disorder, hypertension, gastroesophageal reflux disease / gastritis, chronic aspiration [Location (un) ] Condition: Mental Status: Confused - sometimes. Level of Consciousness: [Location (un) ] and interactive. Activity Status: Ambulatory - Independent. [Location (un) ] Instructions: Dear Mr. [Known lastname ], You were admitted for low blood pressure and weakness. It was a pleasure being involved in your care. You may continue your regular diet, activities, and dialysis upon returning home. For now, because your blood pressure is still on the low side of normal, PLEASE STOP TAKING LISINOPRIL (your blood pressure medication). Please check your blood pressure at home or at a CVS within the next 2 days, and if the top number is higher than 150, call Dr. [Last Name (STitle) ] to find out whether you should start taking your blood pressure medicine again. Please contact your primary care physician, [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7212], MD [Telephone/Fax (1) 2010], to schedule an appointment to check your blood pressure and decide whether you should start lisinopril again. We will send him a copy of your [Telephone/Fax (1) ] summary. Followup Instructions: 1. Please call your primary care physician to schedule an appointment within the next 1-2 weeks: Department: [Hospital3 249] With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7212], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 2. Please call your outpatient nephrologist, Dr. [First Name (STitle) ], for a follow-up appointment in the next 1-2 weeks 3. Department: NEUROLOGY When: THURSDAY [2113-9-21] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7025], MD [Telephone/Fax (1) 3294] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 3. Department: [Hospital3 249] When: TUESDAY [2113-10-3] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7212], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2113-7-24]	[ "40391", "2767", "41401", "2724", "53081" ]
Admission Date: [2146-5-15] Discharge Date: [2146-6-16] Date of Birth: [2146-5-6] Sex: F Service: Neonatology ID: [Known lastname 40567] Girl [Known lastname 34030] is a now 41 day old former 27 [6-17] week premature infant who was hospitalized at [Hospital6 1760] Neonatal Intensive Care Unit. The infant was born at the [Hospital6 2018] on [2146-5-6] and was transferred to [Hospital3 18242] secondary to lack of available bed space at the [Hospital6 1760] Nursery Intensive Care Unit. The patient was transferred back to the [Hospital6 649] Nursery Intensive Care Unit on [5-15]. HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 34030] was born on [2146-5-6] as the 1,025 gm product of a 27 6/7 weeks gestation, delivered by cesarean section secondary to concerns of chorioamnionitis as well as breech presentation. Mother presented with spontaneous premature rupture of membranes at 25 weeks gestation at which time she was treated with a course of Betamethasone as well as intrapartum antibiotics. Pregnancy was also notable for oligohydramnios at 19 weeks gestation. HOSPITAL COURSE: 1. Respiratory - The patient exhibited moderate hyaline membrane disease and was intubated and ventilated and treated with Surfactant times two doses. The patient had a good response and was extubated to CPAP on day of life #2. The patient did exhibit significant apnea of prematurity and was begun on caffeine therapy. The patient was taken off of CPAP on day 8 to 9 of life but was placed back on one day later for increased spells. The patient was last on CPAP from day 18 to day 22 of life and was last on nasal cannula flow through day 26 of life. At the time of this dictation the patient is on room air with occasional apneic episodes, being continued on caffeine therapy. 2. Cardiovascular - The patient did exhibit hypotension in the first 24 hours of life treated with Dopamine to a maximum of 20 mcg/kg/min. An echocardiogram revealed a large patent ductus arteriosus and following a course of Indomethacin, the clinical signs of the patent ductus arteriosus resolved and the patient quickly weaned off of Dopamine. The patient has been hemodynamically stable since that time. At approximately two to three weeks of life, a consistent systolic murmur was heard. An echocardiogram was performed on [5-28] which revealed no patent ductus arteriosus but did reveal left peripheral pulmonic stenosis. 3. Fluids, electrolytes and nutrition - The patient was initially maintained on parenteral nutrition and begun on enteral feeds on day of life #7. This was advanced easily to a maximum of 28 cal/oz breast milk. At that time on day of life #18, [2146-5-24], the patient had frankly bloody stool. Physical examination was largely reassuring, although complete blood count revealed a white count of 10 with 19 polys and 16 bands. Blood culture was sent, KUB was basically normal with just mild dilation of intestinal loops, and the patient was made NPO and begun on ampicillin, gentamicin and Clindamycin. The patient remained clinically well and follow up complete blood count revealed improvement in the differential. KUBs remained normal. Due to the initial left shift of the complete blood count it was decided to continue the patient on bowel rest and antibiotics for one week. After that time, antibiotics were discontinued and enteral feedings were introduced gradually with Pregestimil. These were advanced without difficulty and at the time of this dictation the patient is tolerating 150 cc/kg/day of 30 cal/oz of Pregestimil formula. Stools remain occasionally guaiac positive. Mother has decided to no longer breastfeed, but it is anticipated that if the patient remains stable for one to two additional weeks the formula can be transitioned back to regular Enfamil with close monitoring for tolerance. Weight at birth was 1,025 gm, weight on [2146-6-16] was 1,575 gms. 4. Gastrointestinal - The patient did exhibit mild hyperbilirubinemia of prematurity early in life treated with phototherapy through day #7 of life. As mentioned above, on day 18 the patient experienced a grossly bloody stool that was subsequently diagnosed as a nonspecific colitis, possibly secondary to formula intolerance. The patient was treated with bowel rest and antibiotics for one week and since then has been able to be readvanced on Pregestimil formula without difficulty. 5. Infectious disease - After birth the patient was treated with Ampicillin and gentamicin for one week secondary to presumed sepsis given maternal history of presumed chorio and the severity of illness in the first one to two days of life. A lumbar puncture at that time was negative for infection. As mentioned above, the patient was also treated with ampicillin, gentamicin and Clindamycin for one week from [5-24] through [5-31], day #18 through 25 of life, for a nonspecific colitis. 6. Neurological - The patient has maintained a normal neurologic examination throughout. Head ultrasounds were normal on day #7 and 26. A head ultrasound prior to discharge is anticipated. 7. Heme - The patient has received occasional transfusions of packed red blood cells, the last being on [5-23] and then again on [5-31]. The last hematocrit was on [6-3] and that was 37.8 with a reticulocyte count of 2.8%. The patient is on Fer-In-[Male First Name (un) ]. 8. HEALTH CARE MAINTENANCE - The patient has been maintained on Vitamin E supplements for prematurity. Newborn screen on [5-26] revealed elevated 17 OHP levels; repeat is pending. The patient had an ophthalmologic examination on [6-8] that revealed immature retinas in Zone 2 with follow up recommended in two weeks. Finally, in terms of access, the patient did have a PICC line placed during the episode of colitis that was removed on [6-7] without difficulty. CONDITION AT TIME OF SUMMARY: At the time of this summary the patient is hemodynamically stable with a murmur thought to be secondary to peripheral pulmonic stenosis. The patient is in room air with occasional apnea and bradycardiac episodes and is on caffeine therapy. The patient is tolerating 150 cc/kg/day of Pregestimil 30 formula with occasional guaiac positive stools. FEEDINGS: Pregestimil 30 (Pregestimil 24 + 4 cals/oz MCT Oil + 2 cals/oz Polycose) pg with po attempts. MEDICATIONS: 1. Fer-In-[Male First Name (un) ] 0.15cc po qd 2. Vitamin E 5 IU po qd 3. Caffeine 12 mg po qd PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37583], [Hospital ] Pediatrics [Telephone/Fax (1) 37584] DIAGNOSIS: 1. Prematurity at 27 6/7 weeks 2. Respiratory distress syndrome, resolving 3. Apnea of prematurity 4. Hypotension resolved 5. Patent ductus arteriosus, resolved 6. Peripheral pulmonic stenosis 7. Nonspecific colitis, resolved 8. Presumed sepsis, resolved 9. Retinal immaturity DR [First Name (STitle) 36400] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] 50.595 Dictated By:[Name8 (MD) 38043] MEDQUIST36 D: [2146-6-12] 14:31 T: [2146-6-12] 16:00 JOB#: [Job Number 40568]	[ "V290", "7742" ]
Admission Date: [2103-8-3] Discharge Date: [2103-8-13] Date of Birth: [2041-1-21] Sex: M Service: MEDICINE Allergies: Compazine / Benadryl Decongestant Attending:[Last Name (un) 2888] Chief Complaint: Chest and Abdominal Pain Major Surgical or Invasive Procedure: Pericardiocentesis with drain placement Pericardial drain removal Hemodialysis Attempted thrombectomy of HD graft in left arm by interventional radiology Placement of tunneled HD line through left IJ by interventional radiology History of Present Illness: 62 year old male with a pmh of ESRD s/p failed graft on HD, Hep C genotype 1, DMII, HTN, HLD who presents from an OSH with pericarditis complicated by pericardial effusion. . His OSH course is as follows: He had an admission prior to this [Date range (1) 27855] with pleuritic CP and rub, diagnosed with pericarditis. Also, new LBBB and tropI of 0.125. Echo showed small effusion and normal wall motion, mild AS, mild MR, unchanged from baseline. He was treated with NSAIDs. Due to LBBB, prolonged PR and underlying dCHF (between dialysis sessions) his dilt was stopped and coreg (3.125) was added. He was discharged on 50mg TID of indocin. . Several days after discharge he developed general weakness, vague diffuse low abd pain, and fatigue. Dialysis was complicated by hypotension (new) and required fluid. [8-2] admitted to OSH with hypotension of 75/50 and above symptoms. He was fluid resuscitated, fluid responsive. CT A/P showed diverticulosis (no inflammation) and a mod pericardial effusion (incidental). RUQ U/S with GB wall thickening, otherwise unremarkable. . He was admitted to the ICU, BPs maintained 100s-140s and HRs 50s-70s. Treated presumptively for adrenal insufficiency with hydrocortisone. Echo showed circuferential pericardial effusion (2.1-2.2 cm) reportedly without evidence of tamponade. His vitals remained stable and his labs were unremarkable (stable anemia HCT ~30) and WBC elevation of 19 after steroids. Creatinine 8.9, sodium 131. He was transferred from OSH ([Hospital1 1562]) to [Hospital1 18] for further management. . At [Hospital1 18], he was admitted to inpatient medicine. He is comfortable without any acute complaints. He does still have mild chest discomfort that has persisted throughout his admission at the OSH. He also has vague lower abdominal pain, but is otherwise without any acute complaints. No SOB, no orthopnea, no PND. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +Hypertension 2. OTHER PAST MEDICAL HISTORY: - ESRD secondary to FSGN, s/p failed graft placement and now temporarily off of the [Hospital1 ] list (due to current illness) on hemodialysis from FSGS; AV graft is thrombosed (he is dialyzed now through temp groin line) - Hepatitis C genotype 1, biopsy showed fibrosis grade I - Gout - s/p Partial parathyroidectomy (adenoma) - Neuropathy Social History: Lives in [Hospital1 1562] with his wife and daughter. [Name (NI) ] is a former smoker that quit many years ago. No alcohol or drugs. He is a cab driver. Family History: No renal disease in family, father with CAD age 50s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T:98.1 BP:120/72 P:64 R:18 18 O2: 99% - Pulsus 18 (doppler) General: Alert, oriented, no acute distress, mildly fatigued HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~8, no LAD Lungs: Clear to auscultation bilaterally, basilar crackles no wheezes, rales, ronchi CV: Normal rate, Regular rhythm, distant heart sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no clubbing, cyanosis, trace edema Neuro: Oriented. No gross deficits. . DISCHARGE EXAM: VS: Tm 98.1 BP 122/57 P 81-86, R18, 100%RA Pulsus: 8 Gen: well-appearing male in NAD HEENT: NCAT MMM EOMI anicteric Neck: Supple without LAD, JVD not discernable Pulm: CTA b/l without wheeze or rhonchi Cor: RRR (+)S1/S2 without m/g, former drain site c/d/i Abd: Soft, non-distended, non-tender to palpation, NABS Extrem: 1+ LE edema b/l, good distal pulses, warm and well perfused LUE fistula with palpable cords. RLE with increased edema, pain with passive movement. Neuro: CNII-XII grossly intact, moving all extremities, mentating well Lines/Drains: RUE PICC, tunneled HD catheter Pertinent Results: #ADMISSION LABS: [2103-8-4] 02:15AM BLOOD WBC-12.1# RBC-2.82 Hgb-8.7# Hct-27.6# MCV-98 MCH-30.9 MCHC-31.5 RDW-16.3* Plt Ct-302 [2103-8-4] 02:15AM BLOOD PT-16.5* PTT-67.6* INR(PT)-1.6* [2103-8-4] 02:15AM BLOOD [2103-8-4] 02:15AM BLOOD Glucose-202* UreaN-51* Creat-6.4# Na-132 K-4.6 Cl-97 HCO3-22 AnGap-18 [2103-8-4] 02:15AM BLOOD ALT-51* AST-49* CK(CPK)-46* [2103-8-4] 02:15AM BLOOD Albumin-2.8* Calcium-7.7* Phos-5.5* Mg-2.0 . #DISCHARGE/PERTINENT LABS: [2103-8-13] 03:24PM BLOOD Hct-28.2* [2103-8-13] 04:00AM BLOOD WBC-7.6 RBC-2.45* Hgb-7.8* Hct-24.4* MCV-100* MCH-31.6 MCHC-31.7 RDW-15.5 Plt Ct-294 [2103-8-12] 03:50AM BLOOD WBC-7.6 RBC-2.64* Hgb-8.2* Hct-26.0* MCV-98 MCH-30.9 MCHC-31.4 RDW-15.6* Plt Ct-272 [2103-8-11] 02:50AM BLOOD WBC-7.1 RBC-2.68* Hgb-8.4* Hct-26.4* MCV-98 MCH-31.4 MCHC-32.0 RDW-15.6* Plt Ct-253 [2103-8-10] 04:07AM BLOOD WBC-8.4 RBC-2.81* Hgb-8.5* Hct-28.1* MCV-100* MCH-30.3 MCHC-30.3* RDW-15.8* Plt Ct-292 [2103-8-9] 05:47AM BLOOD WBC-7.0 RBC-2.70* Hgb-8.4* Hct-27.1* MCV-100* MCH-31.1 MCHC-31.0 RDW-16.2* Plt Ct-285 [2103-8-8] 04:40AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.0* Hct-28.3* MCV-98 MCH-31.0 MCHC-31.7 RDW-16.5* Plt Ct-309 [2103-8-7] 04:23AM BLOOD WBC-9.7 RBC-2.97* Hgb-9.3* Hct-29.2* MCV-98 MCH-31.1 MCHC-31.6 RDW-16.9* Plt Ct-327 [2103-8-6] 05:12AM BLOOD WBC-11.8* RBC-2.94* Hgb-9.2* Hct-28.8* MCV-98 MCH-31.3 MCHC-32.0 RDW-17.2* Plt Ct-332 [2103-8-5] 06:30AM BLOOD WBC-12.2* RBC-3.07* Hgb-9.6* Hct-30.3* MCV-99* MCH-31.3 MCHC-31.6 RDW-17.6* Plt Ct-372 [2103-8-13] 04:00AM BLOOD PT-25.1* PTT-55.0* INR(PT)-2.4* [2103-8-12] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4* [2103-8-12] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4* [2103-8-11] 05:41PM BLOOD PTT-73.7* [2103-8-10] 07:36AM BLOOD PTT-87.1* [2103-8-10] 04:07AM BLOOD PT-17.7* PTT-64.0* INR(PT)-1.7* [2103-8-9] 05:47AM BLOOD PT-14.9* PTT-98.4* INR(PT)-1.4* [2103-8-8] 04:40AM BLOOD PT-15.0* PTT-40.6* INR(PT)-1.4* [2103-8-7] 04:23AM BLOOD PT-15.8* PTT-106.6* INR(PT)-1.5* [2103-8-6] 05:12AM BLOOD PT-13.8* PTT-30.6 INR(PT)-1.3* [2103-8-5] 06:30AM BLOOD PT-14.7* PTT-29.9 INR(PT)-1.4* [2103-8-7] 04:23AM BLOOD ESR-70* [2103-8-13] 04:00AM BLOOD Glucose-147* UreaN-53* Creat-8.9# Na-130 K-4.4 Cl-91* HCO3-30 AnGap-13 [2103-8-11] 02:50AM BLOOD Glucose-83 UreaN-25* Creat-5.7# Na-130 K-4.0 Cl-90* HCO3-31 AnGap-13 [2103-8-9] 05:47AM BLOOD Glucose-94 UreaN-35* Creat-6.2# Na-132 K-3.9 Cl-93* HCO3-33* AnGap-10 [2103-8-7] 04:23AM BLOOD Glucose-126* UreaN-45* Creat-6.6# Na-135 K-4.4 Cl-97 HCO3-29 AnGap-13 [2103-8-6] 05:12AM BLOOD Glucose-159 UreaN-105* Creat-10.6# Na-133 K-5.2 Cl-95* HCO3-21* AnGap-22* [2103-8-7] 04:23AM BLOOD ALT-36 AST-35 AlkPhos-36* TotBili-0.5 [2103-8-6] 05:12AM BLOOD ALT-45* AST-37 LD(LDH)-176 AlkPhos-40 TotBili-0.3 [2103-8-13] 04:00AM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.7 Mg-1.8 [2103-8-11] 02:50AM BLOOD Calcium-6.8* Phos-2.6# Mg-1.7 [2103-8-10] 04:07AM BLOOD TotProt-5.4 Calcium-7.6* Phos-5.0* Mg-1.8 [2103-8-8] 04:40AM BLOOD Calcium-7.5* Phos-6.3* Mg-1.9 [2103-8-6] 05:12AM BLOOD Albumin-2.8* Calcium-7.2* Phos-6.1* Mg-2.1 [2103-8-5] 06:30AM BLOOD Calcium-7.6* Phos-6.0* Mg-2.1 [2103-8-6] 05:12AM BLOOD %HbA1c-5.2 eAG-103 [2103-8-10] 09:21AM BLOOD Cryoglb-NEGATIVE [2103-8-6] 05:12AM BLOOD TSH-2.0 [2103-8-6] 12:55PM BLOOD dsDNA-NEGATIVE [2103-8-5] 06:30AM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:160 [2103-8-10] 04:07AM BLOOD PEP-NO SPECIFI [2103-8-9] 05:47AM BLOOD C4-32 [2103-8-6] 05:12AM BLOOD C3-73* [2103-8-7] 04:23AM BLOOD HIV Ab-NEGATIVE [2103-8-6] 12:55PM BLOOD C2-Test [2103-8-6] 09:30AM OTHER BODY FLUID WBC-2675* Hct,Fl-10.5* Polys-67* Lymphs-23* Monos-5* Eos-2* Atyps-1* NRBC-1* Macro-2* [2103-8-6] 09:30AM OTHER BODY FLUID TotProt-4.9 Glucose-129 LD(LDH)-1113 Amylase-32 Albumin-2.2 . #STUDIES: []2D-ECHOCARDIOGRAM: [2103-8-4]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a large pericardial effusion. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Large circumferential effusion with echocardiographic evidence of early tamponade physiology. . []2D-ECHOCARDIOGRAM (POST-PERICARDIOCENTESIS): [2103-8-6] Left ventricular wall thicknesses and cavity size are normal. There is an anterior space which most likely represents a prominent fat pad. No residual pericardial effusion identified. Compared with the prior study (images reviewed) of [2103-8-4], the pericardial effusion has resolved and tamponade physiology is no longer suggested. . []EKG [2103-8-3]: Sinus rhythm with first degree atrio-ventricular conduction delay. Borderline left axis deviation. Diffuse non-diagnostic repolarization abnormalities. [Last Name (un) ] QRS voltage in the precordial leads. Compared to the previous tracing of [2100-10-6] there is no diagnostic change. Rate PR QRS QT/QTc P QRS T 72 [Telephone/Fax (3) 27856]/455 0 -25 129 Brief Hospital Course: []BRIEF CLINICAL COURSE: 62M w/ hx ESRD s/p failed graft on HD, Hep C genotype 1, DMII, HTN, HLD who presents from an OSH with pericarditis complicated by pericardial effusion. The patient was intially admitted to a general medicine service. On [8-4], he developed atrial fibrillation and was found to have significant tamponade physiology, so was transferred to the cardiology service. A pericardiocentesis was performed on [8-6], and he was transferred to the CCU following the procedure. He was transferred back to the inpatient cardiology team on [8-9], and he was discharged on [2103-8-13]. . []ACTIVE ISSUES: # Pericardial Effusion: On the floor, the patient was found to have a pulsus paradoxus of 15mmHg. An echo demonstrated a large effusion with significant tamponade physiology. He developed atrial fibrillation at this time (see below) with rates in the 90s-100s, but beta blockers were not used given the patient's hypotension, which was thoguht to be secondary to the tamponade physiology. On [8-6], the patient underwent pericardiocentesis with drain placement. Approximately 720cc of bloody fluid was removed initially. An additional ~500cc of bloody fluid was collected from the drain in the following two days. In the CCU, the patient was nto hypotensive and did not demonstrate tamponade physiology. Hi pulsus was measured to be 6-12mmHg in the days following drainage. Echo following the pericardiocentesis demonstrated resolution of the effusion. The drain was removed on [8-7], and repeat echo demonstrated some fluid surrounding the heart, which was thought to be post-procedural inflammation as opposed to reaccumulation of an effusion. Back on the cardiology floor, the patient had stable pulsus checks daily and a repeat ECHO prior to discharge demonstrated stable pericardial effusion. In terms of the etiology of the pericarditis and pericardial effusion, uremia was thought to be unlikely by the nephrology consult service, given that the patient is regularly dialyzed. A viral etiology was thought to be most likely and we continued the patient on twice weekly colchicine dosing, though no specific pathogen was identified. Malignancy was considered, but the pericardial fluid showed no malignant cells on cytology. TB was considered, but PPD was negative. Cryoglobulinemia was considered given the patient's hepatitis C, and testing revealed negative cryoglobulins. Autoimmune etiology was considered, and testing revealed +[Doctor First Name ] but negative dsDNA. The patient will follow up with his outpatient cardiologist, his PCP, [Name10 (NameIs) ] surgery, and will return on [8-22] for a f/u ECHO to monitor. . # Atrial Fibrillation: On the medicine floor early in the patient's hospitalization, the patient developed atrial fibrillation. He converted to normal sinus rhythm, and remained in sinus rhythm during his CCU stay. Due to the risk of paroxysmal afib, he was started on heparin drip. This was continued during his CCU stay. His CHADS2 score was [12-29]. The cardiology floor team considered whether or not to anticoagulate the patient with warfarin, and they decided to continue bridge the patient to coumadin with a heparin drip; the patient was therapuetic at discharge. The patient was continued on carvedilol. He came into the hospital on diltiazem, but this was held in favor of the carvedilol. The patient also reportedly had LBBB on EKG at OSH. Here he had anterior fascicular block, which was consistent with prior EKGs. . # Mild Diastolic Heart Failure: As per OSH report, the patient has mild diastolic heart failure. Diastolic heart failure is not clearly mentioned in [Hospital1 18] records or ECHOs and may need to be reassessed after complete resolution of the current pericardial disease. . # ESRD on HD with Thrombosed [Last Name (un) ] graft: On admission to CCU, BUN>100 and Cr>10 with associated anemia thought to be secondary to the renal disease. The patient also has a graft in the left upper extremity which has clotted multiple times. It was stented in the past, but has re-thrombosed. A temporary HD line was placed at the OSH, and he did not miss dialysis. The temporary line was pulled after the patient was admitted to the CCU, and he was sent to IR for an attempted thrombectomy. IR removed a thormbus, but the graft reclotted within 10 minutes. Therefore, a tunnel line was placed in the LIJ into the brachiocephalic. However, there was stenosis at the confluence of the left innominate/SVC junction, and the tunnelled line obstructed the flow that had been previously able to get through this stenosed vessel. This resulted in edema of the patient's left arm. On [8-9], the patient returned to IR for balloon expansion of the brachiocephalic through the tunneled line. After the procedure, the edema subsided substantially within 24 hours. The patient was continued on his home Nephrocaps and Phoslo. He received Epo with dialysis. he was follwed by nephrology and received 3x weekly dialysis while here. . # HTN: Patient had relatively low pressures prior to admission to the CCU compared to baseline, likely secondary to atrial fibrillation and early tamponade. He was not at all hypotensive after the pericardiocentesis procedure. His hypertension was treated with lisinopril and carvedilol. His home diltiazem was discontinued. . # DM: Patient treated with insulin sliding scale. . # HLD: Simvastatin was continued. . # Hep C: The patient's LFTs were not elevated boyond his baseline. . # Gout: Inactive. . []TRANSITIONAL ISSUES: -patient will start back on his old HD regimen of TU, TH, SAT. Patient discharged on a monday after received HD, will f/u on Tuesday for HD session. -patient will have his INR monitored by Dr. [Last Name (STitle) 27857]. -The patient will return on [8-22] for f/u TTE to monitor for an evolving effusion. Medications on Admission: Preadmission medications listed are correct and complete Information was obtained from Patient 1. Indomethacin 50 mg PO TID (recently added for pericarditis) 2. Carvedilol 3.125 mg PO BID (this was started recently when dilt was being held, then it was held when dilt was restarted) 3. Omeprazole 20 mg PO DAILY 4. Diltiazem 60 mg PO QAM 5. Diltiazem 120 mg PO QPM 6. Calcium Acetate 667 mg PO TID W/MEALS 7. fenofibrate NF 160 mg Oral daily 8. Simvastatin 20 mg PO HS 9. Nephrocaps 1 CAP PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Lisinopril 10 mg PO DAILY - also took Lactulose 15cc PRN constipation until recently - was also on Hydrocortisone recently at OSH for pericarditis Discharge Medications: 1. Outpatient Lab Work Please check INR, CBC, on [2103-8-16] and fax results to [Last Name (LF) 27857],[First Name7 (NamePattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1105] at [Telephone/Fax (1) 27858] 2. Carvedilol 3.125 mg PO BID 3. Calcium Acetate 1334 mg PO TID W/MEALS RX calcium acetate 667 mg 2 tablet(s) by mouth Three times a day with meals Disp #120 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. Nephrocaps 1 CAP PO DAILY 6. Simvastatin 20 mg PO HS 7. Colchicine 0.3 mg PO TUESDAY AND FRIDAY RX colchicine [Colcrys] 0.6 mg 0.5 (One half) tablet(s) by mouth TUESDAY AND FRIDAY Disp #5 Tablet Refills:0 8. Warfarin 2 mg PO DAILY16 RX warfarin 2 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Omeprazole 20 mg PO DAILY 10. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Pericardial effusion DVT Secondary diagnosis End Stage Renal Disease Hepatitis C Hypertension Diabetes Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 24049], It was a pleasure taking care of you. You were admitted to [Hospital1 69] for having fluid around your heart that caused an irregular heart rhythm. You had the fluid removed and were monitored with multiple ultrasounds of your heart that showed no further fluid accumulation. You will follow up with your outpatient primary care physician, [Name10 (NameIs) ] cardiologists and you will get a routine echocardiogram. Please contact your primary care physician if you experience increased swelling or pain in your legs. We wish you and your family the best. Followup Instructions: Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 27859] Specialty: Primary Care When: Monday [2103-8-20] at 9:40am Address: [Last Name (un) 27860], UNIT [Unit Number ], [Hospital1 ],[Numeric Identifier 27861] Phone: [Telephone/Fax (1) 27862] This is a follow up appointment for your hospitalization. You will be reconnected with your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 27863], after this visit. You should also call your docotor's office tomorrow to discuss monitoring of your blood tests while you are on the blood thinner medication (coumadin) Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 27864], MD Specialty: Cardiology When: Wednesday [2103-8-29] at 1:45pm Location: CARDIOVASCULAR SPECIALISTS Address: 90 TER HEUN DR, STE#300, [Hospital1 ],[Numeric Identifier 19665] Phone: [Telephone/Fax (1) 19666] Department: CARDIAC SERVICES When: WEDNESDAY [2103-9-5] at 1 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital Ward Name ] CENTER When: FRIDAY [2103-10-12] at 10:30 AM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ECHO LAB When: WEDNESDAY [2103-8-22] at 1 PM With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: GZ [Hospital Ward Name ] BUILDING (FELBEERG/[Hospital Ward Name ] COMPLEX) [Location (un) 1951] Campus: EAST Best Parking: Main Garage	[ "40391", "25000", "2724", "4280", "42731", "41401", "V1582" ]
Admission Date: [2127-11-14] Discharge Date: [2127-11-22] Date of Birth: [2091-3-6] Sex: M Service: Medicine/MICU HISTORY OF PRESENT ILLNESS: The patient is a critically ill 36 year old male who was transferred from the [Hospital3 417] Hospital on [2127-11-15] for further management of presumed intoxication complicated by acute renal failure requiring dialysis, pancreatitis, hepatitis and meningitis. The patient has had a history of alcohol abuse in the past. He was sober for approximately seven years but, during the summer, the patient had started to abuse alcohol again. According to his wife, he had been in detoxification four to five times since the summer. On [2127-11-2], the patient drank alcohol, amount unknown, and then, on [2127-11-6], ingested approximately two pints of vodka according to [Hospital3 417] Hospital. The patient's wife noted that, after the ingestion, the patient had nausea, vomiting, diarrhea and abdominal pain. The patient then presented to [Hospital3 417] Hospital on [2127-11-8] and was found to be severely acidemic with arterial blood gases of 7.01/7/100 and a potassium of approximately 6 with a creatinine of 3.7. According to [Hospital3 418] Hospital, a toxicology screen was negative and alcohol was negative. The patient had low Tylenol levels. The wife had noted that, in the past, the patient had ingested Scope and cough syrup and had taken Tylenol P.M., regularly, approximately five pills at a time. She had also noted that a bottle of Shout was nearly empty. The patient was tested for ethylene glycol on [2127-11-9] after hemodialysis, and was negative. A formaldehyde antibody test was also sent to Quest Laboratories, which is currently pending. At the outside hospital, the patient was emergently dialyzed and intubated for a severe metabolic acidosis and impending respiratory failure. On presentation, the patient's liver function tests were normal but began to rise to an ALT of 1,579 and AST 2,719 on [2127-11-11]. Sputum and stool cultures were negative. An abdominal ultrasound and CT scan showed hepatomegaly. A head CT showed sinusitis but no acute intracranial pathology. In total, the patient was dialyzed four times. He was also noted to have hypercalcemia, with a total calcium of approximately 13. He was given one dose of pamidronate on [2127-11-15]. The patient was extubated on [2127-11-3]. He apparently was speaking, recognized his wife and then became somnolent. He was noted to have increased agitation and was given significant amounts of Ativan and Haldol. He was then transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for further management at the request of his wife. On presentation, the patient was somnolent and unresponsive to voice, but responded to pain. He moved all four extremities. His pupils were 3 mm and unresponsive to light. The patient also had a paradoxical breathing pattern and was intubated for both airway protection and respiratory distress. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Status post appendectomy. ALLERGIES: The patient has no known drug allergies. OUTPATIENT MEDICATIONS: None. MEDICATIONS ON TRANSFER: Vitamin K, nitroglycerin paste, Haldol and Catapres 0.2 mg. SOCIAL HISTORY: The patient smokes one pack per day. He is married with an 11 year old daughter. [Name (NI) ] works as a mechanic. He has a history of alcohol abuse and used cocaine occasionally. FAMILY HISTORY: The patient has a brother with hemochromatosis. LABORATORY DATA: On admission to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], white blood cell count was 14.7, hematocrit 28.8, platelet count 288,000, prothrombin time 13.7, partial thromboplastin time 32, INR 1.3, albumin 3.1, sodium 144, potassium 4.1, chloride 97, bicarbonate 31, BUN 65, creatinine 7.6 and glucose 125. Arterial blood gases: 7.52/38/114. HOSPITAL COURSE: The patient is a 36 year old critically ill male, intubated, with presumed ethylene glycol ingestion complicated by meningitis, unresponsive mental status, acute renal failure, on dialysis, hepatitis, pancreatitis and possible aspiration/ventilator associated pneumonia. 1. Cardiovascular/labile blood pressure: Since the patient presented to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], and at the outside hospital, he has been largely hypertensive with a systolic blood pressure at approximately 180 and diastolic pressure at approximately 100. The patient has been intermittently on a labetalol drip. At first, hypertension was partly attributed to withdrawal, however, now it appears that his hypertension may be neurologically driven. 2. Pulmonary/intubated with possible ventilator/aspiration pneumonia: On [2127-11-19], the patient had episodes of hypoxia and hypotension. After suctioning, multiple mucus plugs were seen. The patient was planned for a bronchoscopy but this was deferred because his hypoxia had resolved. A chest x-ray showed bilateral lower lobe infiltrates consistent with possible aspiration pneumonia. The patient is currently on vancomycin, levofloxacin and ampicillin. 3. Renal/anuric, acute renal failure: This was thought secondary to toxic ingestion. The patient is currently on hemodialysis. During his hospitalization, the patient has had significant hyperkalemia with a potassium of 7.4 and peaked T waves on electrocardiogram. On admission, the patient was noted to have red blood cell casts in his urine. A glomerulonephritis workup is in progress but has been largely negative thus far. The patient's BUN remains high and it is unclear at this point whether uremia is contributing to the patient's declining mental status. 4. Infectious disease/meningitis and increasing white blood cell count: Due to the patient's poor mental status, a lumbar puncture was done which showed 95 white blood cells, 3 red blood cells with a differential of 68% polycytes, 7% lymphocytes and 27% monocytes. The second tube showed 49 white blood cells and [Pager number ] red blood cells with 63% polycytes, 2% bands, 17% lymphocytes and 18% monocytes. Gram stain and culture have been negative thus far. Protein was 428, glucose 108. The Infectious Disease Service has been consulted and is following the patient closely. The patient is currently on intravenous levofloxacin 250 mg every other day, ampicillin and vancomycin to cover for Methicillin resistant Staphylococcus aureus, drug resistant Streptococcus pneumoniae, Listeria, atypical bacteria and Yersinia. There is a question of whether the family history of hemochromatosis may invoke Listeria, Yersinia, Vibrio and fungal cryptococci. The suspicion of hemachromatosis in the patient is low, with an iron of 26, low TIBC but ferritin of greater than 1,000. On [2127-11-18], a left subclavian catheter was positive for Methicillin sensitive coagulase negative Staphylococcus. The patient also had one peripheral blood culture with the same sensitivities. 5. Gastrointestinal/hepatitis and pancreatitis: The patient's hepatitis has been improving, however, his lipase continues to rise. The patient was continued on supportive care for pancreatitis. 6. Genitourinary: The patient has a Foley. 7. Hematology: The patient remains anemic but has no clear source of bleeding. The patient has been transfused two units of packed red blood cells on [2127-11-18]. 8. Neurology/unresponsive and comatose: The patient's mental status continues to decline. Upon presentation, he had reflexes and was moving all extremities. Currently, the patient does not have any spontaneous movement and pupils remain unreactive. Neurology was consulted. The meningitis is most likely a chemical meningitis but the patient is being empirically treated with antibiotics. The patient had an apnea test. Respiratory efforts were thought to be seen but it was unclear. The patient had an electroencephalogram and a repeat lumbar puncture planned for the future. 9. Toxicology/presumed ethylene glycol ingestion: Dr. [Last Name (STitle) ] was consulted and believed that this presentation is consistent with ethylene glycol ingestion, however, no crystals were seen on cerebrospinal fluid or urine samples. 10. Fluids, electrolytes and nutrition: The patient is on total parenteral nutrition. 11. Prophylaxis: The patient was on Protonix and Venodynes. 12. Code status: The patient was full code until [2127-11-22], when the family decided to make the patient comfort measures only. On [2127-11-22], the patient's wife, daughter and other members of the patient's family approached the medical team, including Dr. [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ], Dr. [First Name8 (NamePattern2) 4559] [Last Name (NamePattern1) 37053] and nurse, [First Name8 (NamePattern2) ] [Doctor Last Name 37054], and expressed their wish to withdraw ventilatory support from Mr. [Known lastname 37055]. This decision was made after considering the patient's wishes regarding a state of grave clinical prognosis. A priest was called to administer Last Rites. Many members of the family were present in the room. The patient was extubated at 12:10 on [2127-11-22] and the family gathered around him. The patient became asystolic at 12:17 and was pronounced at 12:32. The patient did not demonstrate any signs of discomfort. The medical examiner was called because there was suspicion of acute ingestion of a poison in this case. The medical examiner accepted the case under her jurisdiction and stated plans to pick up the body. [Doctor First Name ] [Known lastname 37055], the patient's wife, was called informing her of this situation. DISCHARGE DIAGNOSIS: Cardiopulmonary arrest secondary to possible ethylene glycol ingestion. DISCHARGE STATUS: Deceased. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2128-1-1] 09:12 T: [2128-1-3] 18:08 JOB#: [Job Number ]	[ "2762", "2767" ]
Admission Date: [2169-6-22] Discharge Date: [2169-6-28] Date of Birth: [2096-7-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: PICC line placed on [6-22]. S/p intubation and extubation. History of Present Illness: 72 M with CAD s/p CABG, ESRD on HD, HTN, DM. Pt awoke on the morning of admission with CP, SOB, called EMS who found pt to be in VT. Pt subsequently lost pulse, was given lidocaine 100mg bolus, and was transferred to [Location (un) 620] ED. There he persisted in VT, received amiodarone 300mg bolus, was started on amio drip, intubated for airway protection, had 2 cardioversions, had subsequent PEA, received epi, atropine, also received CaCl, bicarb, D50, insulin, kayexalate for empiric tx of hyperkalemia. Started on levophed for hypotension, and was transferred to CCU for further care. Notably pt recently hospitalized at [Location (un) 620] from [5-16] to [5-19] with CP/SOB, ruled out for MI and discharged home. Notably no dialysis during that hospitalization, planned for outpt dialysis. EKG showed baseline LBBB, s/p arrest EKG showing deep ST depressions in V2-3 post code. . Access: Hickman right chest. [Location (un) 620] ED attempted a subclavian on left but couldn't threat wire, L femoral line placed instead (has hx right fem-[Doctor Last Name ] graft). Past Medical History: - CAD, MI [11-28], (S/P cath with PTCA to OM in [4-30], s/p CABG [2163-1-6] [Location 1268], LIMA to LAD, SVG to PDA & OM) CATH performed on [2169-3-4] : Severe native three vessel coronary artery disease, Patent LIMA and vein grafts, widely patent OM stent. - CHF, EF 55% - DM - Hypertension - Hyperlipidemia - End stage renal disease, dialysis dependent, AV fistula in L arm. - Peripheral vascular disease s/p fem-[Doctor Last Name ] on right - s/p toe amputations . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension, PVD, ESRD . Cardiac History: CABG LIMA-LAD, SVG-OM, SVG-PDA Pacemaker/ICD: n/a Old EKG from [2169-3-29] similar with same T wave inversions, slightly less pronounced ST depressions V4-V5. TELEMETRY demonstrated: VT on rhythm strips from outside hospital, here in AFib with episodes of sinus tach. . 2D-ECHOCARDIOGRAM [4-30]: EF 55%. mildly dilated LA, moderate symmetric LVH, mod. dilated LV. mild LV systolic dysfunction with basal infero-lateral thinning and akinesis. mildly thickened AV. no AS. 1+AR. MV mildly thickened. 1+MR. [First Name (Titles) ] [Last Name (Titles) 33904]l effusion. Compared with the prior study (images reviewed) of [2167-2-24], no definite change (prior study was of poor quality to exclude above findings). . CARDIAC CATH [3-1]: 1. patent LIMA to LAD with no significant disease distal to the [Female First Name (un) 899]. The SVG to PDA and SVG to OM were also widely patent. The stent in the OM was widely patent and the 80% lesion in the lower pole was unchanged. 2. The native coronary arteries were not injected due to known severe disease. 3. Limited resting hemodynamics revealed an opening aortic pressure of 114/61mmHg. FINAL DIAGNOSIS: 1. Severe native three vessel coronary artery disease. 2. Patent LIMA and vein grafts, widely patent OM stent. . Social History: >100 pack year smoking hx, worked as a security guard. No etoh or drugs. Lives at home in [Location (un) 620]. Daughter in law is the only family member. Family History: father died of MI in 70's. Mother died in 80's of cerebral aneurysm. Divorced & estranged from remainder of family. Physical Exam: VS: T 96.9 BP 97/58 HR 104 (AFib) RR 16 O2 100% on CMV 600x20/8/100% Gen: elderly appearing male, intubated, sedated, nonresponsive. HEENT: NCAT. Sclera anicteric. Pupils small, equal, minimally responsive. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to visualize JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Equal breath sounds bilaterally with coarse crackles bilaterally. Abd: Soft, NTND. + BS. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: L groin with triple lumen in place, R groin with old scar. Extremities with chronic hemostatis, changes, multiple toe amputations. Minimal pitting edema. Pulses: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ Pertinent Results: LABORATORY DATA at OSH: WBC 13.5, HCT 32.6, Plt 137 Na 142, K 5.3, Cl 104, Co2 27, Bun 44, Cr 7.0, Gluc 192 Ca 11.8, Mg 2.0, Alt 35, AST 33, CK 98, MB 1.6, Trop T 0.240 (baseline) LAB DATA [Hospital1 18]: [2169-6-22] PT-14.1* PTT-53.3* INR(PT)-1.3* [2169-6-22] WBC-12.3* RBC-3.63* HGB-11.7* HCT-35.7* MCV-99* MCH-32.3* MCHC-32.8 RDW-17.8NEUTS-88.9 LYMPHS-4.2* MONOS-6.6 EOS-0.1 BASOS-0.1 GLUCOSE-188* UREA N-49* CREAT-7.8* SODIUM-141 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-29 ALBUMIN-3.6 CALCIUM-10.2 PHOSPHATE-6.7* MAGNESIUM-2.2 ALT(SGPT)-105* AST(SGOT)-127* LD(LDH)-274* CK(CPK)-165 ALK PHOS-82 AMYLASE-69 TOT BILI-0.6 [2169-6-22] 09:27AM CK-MB-13* MB INDX-7.9* cTropnT-0.49* [2169-6-22] 06:21PM CK(CPK)-126 CK-MB-15* MB INDX-11.9* cTropnT-0.91* [2169-6-22] TYPE-ART PO2-147* PCO2-38 PH-7.49* TOTAL CO2-30 BASE XS-6 IMAGING: CXR [2169-6-22]: Increased right lower lobe opacity, probably due to pulmonary edema or infection. (Initially read as wedge-shaped opacity). TTE [6-22]: Severe regional left ventricular systolic dysfunction - EF = 20-25%. Mild AR. Moderate-to-severe MR. Compared with the prior study (images reviewed) of [2168-5-2], LV systolic function has markedly deteriorated and severity of MR has increased. inferior and inferolateral hypokinesis was present on the prior study. CXR [2169-6-23]: More extensive left lower lobe opacity, probably due to atelectasis, although pneumonia cannot be excluded. Bilateral effusions and persistent right lower lobe process, suggesting edema versus infection. Brief Hospital Course: Mr. [Known lastname 33905] is a 72 yo M with history of CAD s/p CABG, ESRD on HD who presented with VT/ PEA/ cardiac arrest with prolonged resuscitation (CPR > 45min), intubated for airway protection, whose course was complicated by anoxic brain injury. Hospital course by problem: 1)Arrhythmia: The original rhythm (VT/ PEA/ cardiac arrest) was unclear as EMS found pt down and shocked him right away. The patient was treated with cardioversion, initially started on lidocaine, then started on amiodarone to prevent further episodes of VT. The patient briefly went into atrial fibrillation (although he had no documented history of this in the past), but remained in NSR throughout the remainder of his hospital course, with only occasional APBs and PVCs on telemetry. The etiology of original arrhythmia was most likely scar-induced. Electrolyte abnormality was unlikely given stable electrolytes at OSH. Ischemic etiology was unlikely given cardiac enzymes not commensurate with that of MI. 2)Hemodynamics: Upon admission the pt was initially hypotensive. BP was maintained with a levophed drip, which was slowly weaned as tolerated. Follow-up echo on [2169-6-22] showed EF of 20-25% with severe regional left ventricular systolic dysfunction, which had markedly deteriorated. Volume management was maintained via hemodialysis. 3) CAD w/3 vessel disease:The patient was maintained on ASA and statin given his history of CAD. 4)Poor oxygenation: CXR findings on [6-22] (above) were initally read as concerning for PE. But because PE could not be ruled out (as contrast could not be administered through the pt's IV site and the patient??????s family did not want to place a central line with a larger lumen for this purpose), patient was started on a heparin drip. The patient remained intubated for airway protection throughout his hospital stay. Ventilator settings were weaned as tolerated to FiO2 of 50%. Subsequent CXR findings (Above) showed evidence of a LLL infiltrate and + sputum stain of GPC on [6-22], and the patient was empirically treated for a PNA with vancomycin/levofloxacin/flagyl. On hospital day 2 neurology recommended that levo/flagyl be discontinued as these meds could decrease the seizure threshold (see below), and ceftriaxone was started instead. 4) Anoxic brain injury: On hospital day 2, the patient was observed to have twitching of his eyelids and chin. He was placed on 24 hour EEG monitoring, and neurology determined him to be in status epilepticus secondary to anoxic brain injury. The patient was started on dilantin and phenobarbitol and was placed on continuous EEG monitoring. After hospital day 3 there were no observed recurrences of this seizure-like activity. However, after performing serial neuro exams, the neurology team felt that the patient??????s overall prognosis was grim for a meaningful neurological recovery. 5) DM was controlled with an ISS. 6) FEN: On hospital day 2 tube feeds were started without complication. 7) Prophylaxis: The patient received heparin gtt initially for suspected PE, and was maintained on heparin drip for atrial fibrillation. Pt also received a PPI, and bowel meds prn for prophylaxis. 8)After much discussion with the primary team with input from neurology, on [2169-6-27] the patient??????s daughter and health care proxy decided to remove the ventilator and proceed with comfort level of care. Patient was extubated on [2169-6-27]. He passed away at 12:27 pm. Medications on Admission: Aspirin 81mg daily Lipitor 40mg daily Lisinopril 5mg daily Toprol 50mg daily Phoslo 1334 mg TID with meals ISS (regular) Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Ventricular tacchycardia arrest Atrial fibrillation Status epilepticus Anoxic brain injury Pneumonia End stage renal disease on hemodialysis Coronary artery disease Congestive heart failure Diabetes Hypertension Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2169-6-28]	[ "486", "40391", "4280", "4240", "42731", "25000", "41401", "V4581" ]
Admission Date: [2142-3-14] Discharge Date: [2142-3-20] Date of Birth: [2073-6-15] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2142-3-14] Ascending Aorta and Hemiarch Replacement with 28 millimeter Gelweave Graft History of Present Illness: This is a 67 year old female with a PMH significant for hypertension. Over the several years, she has complained of progressive dyspnea on exertion. She also admits to chest pressure which is nonradiating. Her symptoms do not occur at rest. A chest CT scan in [2142-1-21] revealed an ascending aortic aneurysm, measuring 5.4 centimeters. Subsequent cardiac catheterization confirmed dilated ascending aorta with normal coronary arteries and preserved cardiac output. Based on the above results, she was referred for cardiac surgical intervention. Past Medical History: Chronic Obstructive Pulmonary Disease/Asthma Hypertension Osteoarthritis Colon Polyps Seasonal Allergies s/p T&A AAA Social History: Denies tobacco. Drinks alcohol socially. Denies recreational drugs. Patient is single and lives alone on [Location (un) ]. Family History: Non-contributory. No family history of premature CAD. Physical Exam: Vitals: BP 157/75, HR 65, RR 20, SAT 100% on room air General: well developed female in no acute distress HEENT: oropharynx benign, EOMI Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: Echo [3-14]: Pre bypass: Left ventricular wall thickness, cavity size, and systolic function are normal(LVEF>55%). The ascending aorta is markedly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Moderate [2+]tricuspid regurgitation is seen. Post bypass: Perserved biventricular function lvef >55% no wall motion abnormalities. Trace AI. Proximal portion of ascending aortic graft visualized in good position. Remaining exam unchanged from baseline. CXR [3-20]: 1. Cardiomegaly, which is new in the interval. Upper zone vascular redistribution without evidence of frank pulmonary edema. These findings may be secondary to early congestive heart failure and volume overload, however, a pericardial effusion is also a possibility. 2. Interval worsening of bibasilar atelectasis. Stable small bilateral pleural effusions. [2142-3-14] 01:25PM BLOOD WBC-8.2 RBC-3.10# Hgb-9.5# Hct-26.5# MCV-85 MCH-30.7 MCHC-36.0 RDW-14.3 Plt Ct-125# [2142-3-19] 06:05AM BLOOD WBC-7.1 RBC-2.99 Hgb-8.9* Hct-25.9* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.1 Plt Ct-213 [2142-3-14] 01:25PM BLOOD PT-14.2* PTT-41.3* INR(PT)-1.3* [2142-3-20] 06:50AM BLOOD PT-11.7 INR(PT)-1.0 [2142-3-14] 01:25PM BLOOD UreaN-21* Creat-0.8 Cl-112* HCO3-22 [2142-3-19] 06:05AM BLOOD Glucose-119* UreaN-16 Creat-1.0 Na-137 K-3.9 Cl-98 HCO3-29 AnGap-14 Brief Hospital Course: On the day of admission, Ms. [Known lastname 27853] [Last Name (Titles) 1834] surgical replacement of her ascending aorta and hemi-arch by Dr. [Last Name (Prefixes) ]. The operation was uneventful and there were no complications. For further details, please see separate dictated operative note. Following the procedure, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She was weaned from inotropic support without difficulty. She maintained stable hemodynamics and was then transferred to the SDU on postoperative day one. Low dose beta blockade was resumed and advanced as tolerated. Diuretics were also started and she was gently diuresed towards her pre-operative weight. She was transfused with packed red blood cells for a postoperative anemia. Her lowest hematocrit was around 23%. Her chest tubes and epicardial pacing wires were removed on post-op day two. Over several days, she continued to make clinical improvements with diuresis and increased ambulation. Physical therapy followed patient during post-op course for strength and mobility. Intermittent episodes of paroxysmal atrial fibrillation were noted on telemetry on post-op day five. Beta blockade was further advanced while K and Mg levels were optimized. She was eventually started on Amiodarone and maintained sinus rhythm for >24 hrs prior to being discharge. On post-op day six she was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Lopressor 75mg twice a day, Advair 50-250 two puffs twice a day Discharge Medications: 1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO twice a day: 20mg [Hospital1 ] x 7 days then 20mg QD x 10 days. Disp:25 Packet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 20mg [Hospital1 ] x 7 days then 20mg QD x 10 days. Disp:25 Tablet(s) Refills:0 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x1 wk then 400mg QD x1 wk then 200mg QD. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Ascending Aortic Aneurysm - s/p Ascending Aorta and Hemiarch Replacement, Hypertension Osteoarthritis Asthma Colon Polyps 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. [Last Name (STitle) 1290] in [4-25] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [2-23] weeks - call for appt. Local cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [2-23] weeks - call for appt. Completed by:[2142-5-29]	[ "9971", "42731", "4019", "49390" ]
Admission Date: [2177-3-18] Discharge Date: [2177-3-26] Date of Birth: [2116-5-16] Sex: M Service: CARDIOTHORACIC Allergies: Zocor / Lipitor / Crestor / Pravachol / Rhubarb Attending:[First Name3 (LF) 1283] Chief Complaint: DOE/fatigue Major Surgical or Invasive Procedure: CABGx4(LIMA->LAD,SVG->[Last Name (LF) ], [First Name3 (LF) ], PDA)/MV repair (30mm band) [3-18] History of Present Illness: 60 yo M with h/o CAD s/p MI and PCI in [2169], and ischemic cardiomyopathy with EF 35%. In [2176-7-28] hospitalized with chest pain, r/o for MI, but echo showed EF of 10%. Cath in [10/2176] showed 3VD. Past Medical History: ^chol., NSTEMI x 2, ischemic cardiomyopathy, CHF, HTN, s/p PTCA and stenting x 2, s/p T+A Social History: works as computer programmer no tobacco 3-4 beers 1-2 times per week Physical Exam: HR 84 RR 20 BP 124/80 WDWN M in NAD Lungs CTAB Heart RRR, no M/R/G apprec. Abdomen benign Extrem warm, no edema No varicosities Pertinent Results: [2177-3-26] 09:00AM BLOOD WBC-9.1 RBC-3.35* Hgb-10.4* Hct-30.4* MCV-91 MCH-31.1 MCHC-34.2 RDW-13.4 Plt Ct-381 [2177-3-25] 04:49PM BLOOD WBC-8.6 RBC-3.42* Hgb-10.8* Hct-30.1* MCV-88 MCH-31.7 MCHC-35.9* RDW-13.7 Plt Ct-360# [2177-3-26] 09:00AM BLOOD PT-24.9* PTT-31.4 INR(PT)-2.4* [2177-3-25] 03:49PM BLOOD PT-29.1* PTT-37.9* INR(PT)-3.0* [2177-3-25] 11:00AM BLOOD INR(PT)-3.6* [2177-3-24] 07:10AM BLOOD PT-15.6* PTT-26.0 INR(PT)-1.4* [2177-3-23] 08:00AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2* [2177-3-26] 09:00AM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-25 AnGap-12 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 102304], [Known firstname ] [Hospital1 18] [Numeric Identifier 102305]Portable TEE (Complete) Done [2177-3-25] at 2:50:26 PM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2116-5-16] Age (years): 60 M Hgt (in): 72 BP (mm Hg): 114/75 Wgt (lb): 210 HR (bpm): 70 BSA (m2): 2.18 m2 Indication: Atrial flutter. Coronary artery disease. Left ventricular function. Mitral valve disease. ICD-9 Codes: 427.32 Test Information Date/Time: [2177-3-25] at 14:50 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD Test Type: Portable TEE (Complete) Son[Name (NI) 930]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W999-9:9 Machine: Other Sedation: Versed: 0.5 mg Fentanyl: 25 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Mitral Valve - Peak Velocity: 1.3 m/sec Mitral Valve - Mean Gradient: 4 mm Hg Findings LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. No mass/thrombus in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. Mild spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Depressed LVEF. RIGHT VENTRICLE: RV function depressed. AORTA: No atheroma in ascending aorta. No atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral annular ring with normal gradient. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The posterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No TEE related complications. The rhythm appears to be atrial flutter. Cardiology fellow involved with the patient's care was notified by telephone. Conclusions Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. Mild spontaneous echo contrast is seen in the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. There is depressed right ventricular free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated and is not obstructing flow. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: No intracardiac thrombus. Depressed biventricular systolic function. Mild aortic regurgitation. Normally-functioning mitral annuloplasty ring. CHEST (PA & LAT) [2177-3-25] 5:18 PM CHEST (PA & LAT) Reason: evaluate for ? effusion [Hospital 93] MEDICAL CONDITION: 60 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate for ? effusion HISTORY: Status post CABG. FINDINGS: In comparison with study of [3-21], the right IJ central venous catheter has been removed. Some residual enlargement of the cardiac silhouette with some atelectatic streaks at the left base. No evidence of pleural effusion. Brief Hospital Course: He was taken to the operating room on [3-18] where he underwent a CABG x 4 and MV Repair. He was transferred to the ICU in critical but stable condition on milrinone, levophed, vasopressin and epinephrine. He was extubated on POD #1. He was transfused. His vasoactive drips were weaned to off by POD #3. He developed atrial flutter. He was pancultured for a fever. He was transferred to the floor on POD #3. He was seen by electrophysiology, and started on heparin and coumadin. He underwent TEE and cardioversion on [3-25] with return to NSR. He was ready for discharge home on POD #8. Medications on Admission: Dig 0.125', Coreg 6.25", ASA 325', Lisinopril 5', Lasix 20', MVI' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10 days: Sig: 40 mg (2 tabs) daily x 10 days then 20 mg (1 tab) daily ongoing as prior to surgery. Disp:40 Tablet(s) Refills:0 8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 days: check INR [3-27]. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: CAD/MR now s/p CABG/MVR Acute on Chronic systolic heart failure ^chol., NSTEMI x 2, ischemic cardiomyopathy, CHF, HTN, s/p PTCA and stenting x 2, s/p T+A Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) 914] 4 weeks Dr. [Last Name (STitle) 10740] 2 weeks Dr. [Last Name (STitle) ] 2 weeks Completed by:[2177-3-26]	[ "4240", "4280", "41401", "42731" ]
Admission Date: [2112-3-30] Discharge Date: [2112-5-10] Date of Birth: [2030-4-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: sepsis Major Surgical or Invasive Procedure: trach fluid collection aspiration fistula intubation multiple wound debridements History of Present Illness: This is an 81 year old male who was transferred from an OSH on [2112-3-30], POD 15 from a left colectomy for a lower GI bleed. (8 units of RBC transfused). On POD 8, the patient had an anastamotic leak and underwent a Hartmann's procedure with creation of an ascending colostomy. His post operative course was subsequently complicated by acute renal failure, small peripheral pulmonary emboli, HIT positivity on argatroban, and atrial fibrillation a\on an amiodarone drip. Past Medical History: HTN, hyperlipidemia, EF 60%, DM2 diet controlled, history of throat cancer s/p resection + xrt '[89], s/p empyema w/ CT drainage, legally blind right eye secondary to injury Social History: widowed, lives alone independently Family History: noncontributory Physical Exam: ON ADMISSION VS- T 98.6, P 61, BP 120/40, RR 18, O2 97% on ventillator Gen- NAD, intubated, sedated Heart- irregularly irregular Lungs- coarse rhonchi throughout Abdomen- soft, diffusley tender to palpationmidline incision with necrotic edges, ostomy pink with green stool Extremities- 2+ edema b/l Pertinent Results: [2112-3-30] 11:55PM TYPE-ART PO2-95 PCO2-50* PH-7.30* TOTAL CO2-26 BASE XS--1 [2112-3-30] 11:17PM URINE HOURS-RANDOM CREAT-97 SODIUM-39 [2112-3-30] 11:17PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.018 [2112-3-30] 11:17PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM [2112-3-30] 11:17PM URINE RBC-[6-7]* WBC-[3-2] BACTERIA-MOD YEAST-NONE EPI-0 [2112-3-30] 11:17PM URINE GRANULAR-<1 HYALINE-0-2 [2112-3-30] 11:12PM TYPE-ART PO2-86 PCO2-54* PH-7.26* TOTAL CO2-25 BASE XS--3 [2112-3-30] 10:04PM TYPE-ART PO2-105 PCO2-56* PH-7.25* TOTAL CO2-26 BASE XS--3 [2112-3-30] 10:04PM LACTATE-2.0 [2112-3-30] 10:04PM freeCa-1.05* [2112-3-30] 09:54PM GLUCOSE-135* UREA N-63* CREAT-2.6* SODIUM-139 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [2112-3-30] 09:54PM CALCIUM-7.5* PHOSPHATE-2.8 MAGNESIUM-2.1 [2112-3-30] 09:54PM WBC-22.1* RBC-3.15* HGB-9.4* HCT-28.9* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.0* [2112-3-30] 09:54PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-2 EOS-3 BASOS-1 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1* [2112-3-30] 09:54PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2112-3-30] 09:54PM PLT SMR-LOW PLT COUNT-104* [2112-3-30] 09:54PM PT-38.5* PTT-100.0* INR(PT)-4.2* Brief Hospital Course: Briefly, Mr. [Known lastname 77982] was transferred to [Hospital1 18] from [Hospital1 ] on [2112-3-30] after subtotal colectomy for LGIB requiring a massive transfusion of 8u pRBC. His [Hospital 18] hospital course is broken down by systems: Neuro He was intermittently sedated with fentanyl and propofol. His sedation was weaned to prn dilaudid and oxycodone liquid. Pain gradually became a nonissue. He should not require pain medication even for VAC changes. He was seen by neurology for dystonia, who recommended an MRI of the brain whcih showed an acute left parietal subcortical infarct. The neurologist felt that coumadinizing him with a goal INR 2.5- 3.5 would be best to prevent another stroke. The etiology of his stoke is presumed cardiac given his atrial fibrillation. His cognition gradually improved throughout his hospital course, as did his dystonia, for which he is on cogentin per neurology. At present, he is alert and can communicate effectovely. Cards On admission, Mr. [Known lastname 77982] had afib with RVR for which he was on an amiodarone gtt. He was evaluated by cardiology and weaned off amiodarone. After amiodarone was weaned, his rhythm was intermittently in and out of afib. He eventually stabilized on PO lopressor and PO amiodarone. In addition, he was intermittently on and off pressors, including levophed and pitressin. Eventually he stabilized and has been off of all pressors for over 2 weeks prior to discharge. Pulm The patient had a tracheostomy. He was gradually weaned on the ventillator. Eventually he was weaned to trach collar, which he has been tolerating for over 2 weeks. On [5-4], he did tolerate a Passy-muir valve trial. He requires supervision with the PM valve, because he desaturates. He does require suctioning intermittently. FEN/GI Tube feeds via Dobhoff, TPN, ostomy, serial abdominal debridements [4-4], [4-8], and abdominal VAC [4-12], 16, 17, 20, 24, 26 and Q 3 days thereafter. Last VAC change was [2112-5-8]. His abdominal wound has been healing very well with a VAC dressing. It is granulating nicely. There had been a fistulous connection between the ostomy and the wound. This has since closed off after a few vicryl sutures were placed at the bedside. He was seen and evaluated by plastic surgery who recommended outpatient skin grafting. He has been tolerating tube feeds at goal for over 2 weeks prior to discharge and his ostomy is productive. He gets his tube feeds via a Dobhoff. We did not feel that a PEG was a good idea in him beacause of his anatomy. He was hypernatremic to 153 at a maximum, but he did respond to free water boluses and his sodium has since stabilized. We have since decreased his free water boluses. GU He developed ARF and started hemodialysis at the referring institution x3 days. Daily CVVH was started at [Hospital1 18] via R fem HD catheter, and he was weaned off CVVH, intermittently on lasix, and he now makes appropriate urine output without any assistance. His azotemia gradually cleared. Withing the past week, we have started gradual diuresis to make him about a liter negative daily. His weights have been retruning to baseline of 98 kg. H Mr. [Known lastname 77982] was found to have small peripheral PEs and HIT at the referring institution, and was continued on an argatroban gtt. Eventually he was transitioned off the argatroban to coumadin. He was found to be HIT negative by seratonin release assay. He is currently on coumadin, goal INR 2.5- 3.5. ID The patient had a long and complicated infectious disease course. Meropenem ([4-16]) and vancomycin ([4-17]) for MRSA PNA, fluconazole for [Female First Name (un) ] torulopsis in the urine and sputum [4-19], flagyl empircally for C. diff (although he never tested positive) [4-20] Cultures include Klebsiella in blood at OSH [3-31] Wound cx: [Female First Name (un) ], klebs [4-3] Sputum: budding yeast, GNR, MRSA [4-10] Sputum: sparse klebs [Last Name (un) 36] to cipro/bactrim [4-14] Sputum: MRSA, Klebs [4-17] sputum: MRSA, 2+budding yeast, sparse GNR [4-20] sputum: MRSA and 1+budding yeast Eventually, all antiobiotics were stopped on [2112-5-4]. Endo Mr. [Known lastname 77982] was kept on a strict insulin sliding scale to keep his sugars within a tight range. Medications on Admission: lisinipril 20', acebutolol 400', allopurinol 300', lipitor 10', ASA 325', MVI Discharge Medications: 1. Maalox 200-200-20 mg/5 mL Suspension [Known lastname ]: One (1) ML PO TID (3 times a day) as needed for constipation. 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [Known lastname ]: One (1) Appl Ophthalmic PRN (as needed). 3. Polyvinyl Alcohol 1.4 % Drops [Known lastname ]: One (1) Drop Ophthalmic PRN (as needed). 4. Docusate Sodium 50 mg/5 mL Liquid [Known lastname ]: One (1) PO BID (2 times a day). 5. Oxycodone 5 mg/5 mL Solution [Known lastname ]: One (1) PO every eight (8) hours as needed for pain. 6. Acetaminophen 325 mg Tablet [Known lastname ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Zinc Sulfate 220 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 9. Allopurinol 100 mg Tablet [Last Name (STitle) ]: 1.5 Tablets PO DAILY (Daily). 10. Benztropine 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Amiodarone 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 13. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO ONCE (Once) for 1 doses: check daily INR. 14. Furosemide 10 mg/mL Solution [Last Name (STitle) ]: One (1) Injection [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 685]- [Location (un) ] Discharge Diagnosis: LGIB s/p colectomy anastomotic leak s/p exlap, Hartmann's renal failure pulmonary emboli sepsis rapid atrial fibrillation large abdominal wound dystonia CVA Discharge Condition: good Discharge Instructions: Please call or come to the ED with any fevers > 101, nausea, vomiting, abdominal pain, purulence from wounds, oliguria, hypotension, rapid atrail fibrillation, or any other worrisome issues. Please continue all medications as directed. Activity as tolerated. Followup Instructions: Please call the office of Dr. [Last Name (STitle) ] to schedule a follow-up appointment ([Telephone/Fax (1) 1483] Completed by:[2112-5-9]	[ "78552", "5845", "2760", "99592", "42731", "2767", "4019", "2724", "25000", "2859" ]
Admission Date: [2199-5-7] Discharge Date: [2199-5-10] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at scene. She was taken to an area hospital and later transferred to [Hospital1 18] for further care. Past Medical History: HTN Osteoporosis h/o Falls Rib fractures Pneumothorax Family History: Noncontributory Pertinent Results: [2199-5-7] 07:13PM GLUCOSE-186* LACTATE-3.3* NA+-138 K+-3.5 CL--96* TCO2-28 [2199-5-7] 07:10PM UREA N-8 CREAT-0.5 [2199-5-7] 07:10PM AMYLASE-51 [2199-5-7] 07:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2199-5-7] 07:10PM WBC-23.2* RBC-4.77 HGB-17.3* HCT-49.8* MCV-104* MCH-36.2* MCHC-34.7 RDW-15.2 [2199-5-7] 07:10PM PLT COUNT-304 [2199-5-7] 07:10PM PT-12.5 PTT-23.2 INR(PT)-1.1 [2199-5-7] 07:10PM FIBRINOGE-224 CHEST (PORTABLE AP) Reason: ? shoulder fx [Hospital 93] MEDICAL CONDITION: 86 year old woman with s/p fall from bed, unwitnessed, hit head, c/o neck pain but unreliable PE REASON FOR THIS EXAMINATION: ? shoulder fx REASON FOR EXAMINATION: Trauma. Portable AP chest radiograph compared to [2199-5-7]. The heart size is normal. The mediastinal contours are unremarkable. The aorta is calcified. The hila are slightly enlarged bilaterally, most likely due to dilatation of the pulmonary veins, which may be related to pulmonary hypertension. The lungs are essentially clear but over inflated, which may represent emphysema. There is no sizeable pleural effusion or pneumothorax. CT HEAD W/O CONTRAST Reason: S/P FALL UNWITNESSED EVAL FOR BLEED [Hospital 93] MEDICAL CONDITION: 83 yF s/p fall from bed, unwitnessed, hit head, forehead lac, unreliable physical exam REASON FOR THIS EXAMINATION: ? bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post fall from bed. COMPARISON: Non-contrast head CT from yesterday. FINDINGS: Again seen is stable focal hemorrhage in the splenium of the corpus collosum. There is no mass effect or shift of normally midline structures, or acute major vascular territorial infarction. The density values of the brain parenchyma again show periventricular white matter hypodensity consistent with chronic microvascular infarction. Again seen is enlargement of the lateral and third ventricles which may be related to communicating hydrocephalus or age-related involutional change. The surrounding soft tissue structures again show a large left parietal scalp hematoma and new soft tissue swelling overlying the left frontal bone. There is no skull fracture. IMPRESSION: 1. Stable hemorrhage in the splenium of the corpus callosum without evidence for new hemorrhage. 2. New soft tissue swelling overlying the left frontal bone. Stable left parietal scalp hematoma. 3. Again seen is enlargement of the lateral and third ventricles which may be related to communicating hydrocephalus or age-related involutional change. Clinical correlation is recommended. CT C-SPINE W/O CONTRAST Reason: S/P FALL EVAL FOR FX [Hospital 93] MEDICAL CONDITION: 86 year old woman with s/p fall from bed, unwitnessed, hit head, c/o neck pain but unreliable PE REASON FOR THIS EXAMINATION: ?fx CONTRAINDICATIONS for IV CONTRAST: None. C-SPINE TECHNIQUE: Multidetector axial CT images were obtained through the cervical spine. Coronal and sagittal reformatted images were obtained. COMPARISON: CT C-spine from [2199-5-7]. CT C-SPINE: There is no evidence of fracture, malalignment, or prevertebral soft tissue swelling. The vertebral bodies and disc space heights are normal. There are extensive degenerative changes in the cervical spine which are stable. Again seen are calcifications within the bilateral carotid arteries and within the posterior longitudinal ligament. Again seen is scarring in the bilateral lung apices. The visualized outline of the thecal sac is unremarkable; however, CT is not able to provide any intrathecal detail. IMPRESSION: No evidence for cervical spine fracture or malalignment. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: ? injury Field of view: 32 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 86 year old woman with s/p fall down flight of stairs REASON FOR THIS EXAMINATION: ? injury CONTRAINDICATIONS for IV CONTRAST: None. CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: 86-year-old woman with status post fall down flight of stairs. Rule out injury. COMPARISON: Not available. TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained following the administration of 130 cc of Optiray intravenously. Coronal and sagittal reformatted images were obtained. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen, adrenal glands, stomach, abdominal loops of large and small bowel are unremarkable. Kidneys enhance equally and excrete contrast normally. There is no free fluid in the abdomen, and no pathologically enlarged mesenteric or retroperitoneal lymphatic nodes. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary bladder are unremarkable. There is a high density material in the iliacus muscle, adjacent to the left ilium, likely representing hematoma. There is no free pelvic fluid. BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic lesions. There are extensive degenerative changes, as well as rotatory scoliosis. There is a compression deformity of vertebral body of L1 of uncertain chronicity, but most likely chronic, with extensive vertebral body sclerosis. There is a lucent line, in the left ilium, extending from the mid-aspect of the ilium, reaching the acetabular roof. There is no significant displacement. There is another lucent line extending to the superior-posterior aspect of the ilium, with minimal displacement of the fracture fragments. No other fractures are noted on this study. IMPRESSION: 1. No evidence of traumatic injury of solid abdominal organs. 2. Two separate, and apparently discrete, essentially non-displaced fractures of the left ilium, one of which involves the left acetabular roof, with associated iliacus muscle hematoma. 3. Chronic-appearing L1 compression fracture. COMMENT: Findings were discussed with the Trauma Surgery team at the time of the completion of the scan, at 20:15h, [2199-5-7]. Brief Hospital Course: She was admitted to the Trauma service. Neurosurgery and Orthopedic Surgery were consulted because of her injuries. Repeat head CT imaging was performed which revealed a stable intracranial hemorrhage; the injury was non operative. It was recommended that she follow up in 4 weeks with Dr.[Last Name (STitle) ], Neurosurgery, at which time she will have an MRI of her brain. She will also be evaluated for normal pressure hydrocephalus based on a finding on head CT. Orthopedic Surgery was consulted for her left ilium fracture; this injury was deemed nonoperative; she is to remain touchdown weight bearing and will require follow up with Dr. [Last Name (STitle) 1005] in 2 weeks. She was also started on bone prophylaxis with Calcium and Vitamin D. Physical and Occupational therapy were consulted and have recommended rehab stay after discharge from the hospital. Medications on Admission: Dilt 60 Celexa 10 Aricept 10 Lisinopril 10 Protonix 40 Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hold fro SBP <110 & HR <60. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [Hospital1 ] (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 9. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: s/p Fall Large left parietal sub-galeal hematoma Small intracranial hemorrhage left splenium/corpus collosum Nondisplaced left ilium fracture involving the acetabular roof Discharge Condition: Stable Discharge Instructions: You may ONLY touchdown weight bear on your left lower extremity. Followup Instructions: Follow up with Dr. [Last Name (STitle) ], Neurosurgey in 4 weeks. Inform the office that you will need an MRI of the brain w/ and w/out contrast and that also you will need evaluation for possible normal pressure hydrocephalus. Call [Telephone/Fax (1) 1669] for an appointment. Follow up with Dr. [Last Name (STitle) 1005], Orthopedic Surgery, in 2 weeks. Call [Telephone/Fax (1) 1228] for an appointment.	[ "4019" ]
Admission Date: [2157-12-26] Discharge Date: [2158-1-4] Date of Birth: [2094-10-13] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / aspirin Attending:[First Name3 (LF) 1505] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: Mitral valve repair(28-mm Physio II annuloplasty ring) [2157-12-28] History of Present Illness: This 63 year old hHispanic female has a history of asthma has had shortness of breath which has increased recently. She had new chest pain which radiated down the left arm and was admitted to [Hospital3 ] for further work up. She underwent cardaic catheterization. She was found to have mitral regurgitation with elevated pulmonary pressures and an ejection fraction of 80%. Her coronaries without stenosis. Past Medical History: hypertension insulin dependent diabetes mellitus complete heart block s/p c-section s/p L cataract surgery with lens implant s/[Initials (NamePattern4) ] [Last Name (un) 8509] surgery s/p R hand surgery s/p dual chamber pacemaker implant(St. [First Name4 (NamePattern1) 923] [Last Name (NamePattern1) 10550] 5820) Social History: Lives with: alone Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: none Illicit drug use: denies Race: Hispanic Family History: unremarkable Physical Exam: Pulse: 85 v paced Resp: 18 O2 sat: 100% RA B/P Right: 127/74 Left: Height: 67" Weight: 232 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Dental: multiple bridges Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] well-healed pacer site Heart: RRR [x] Irregular [] Murmur [x] grade __2/6 pan systolic____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] Edema [x] __2+ bilat___ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: TEE [2157-12-28]: Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinetic apical segments. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are moderately thickened. The mitral valve leaflets do not fully coapt and bileaflet restriction is appreciated. There is a central MR jet with Moderate to severe (3+) mitral regurgitation. There is no pericardial effusion. POSTBYPASS: The patient is AV paced on epinephrine & phenylephrine infusions. There is a well seated annuloplasty ring in the mitral position. The Mitral regurgitation is now trace to mild. The RV function is maintained. The LV function is mildly improved on inotropy, with EF 50%. The remaining valves are unchanged. The aorta remains intact. [2158-1-1] 06:10AM BLOOD WBC-8.6 RBC-3.30* Hgb-8.5* Hct-26.9* MCV-82 MCH-25.9* MCHC-31.7 RDW-13.7 Plt Ct-165# [2157-12-30] 02:14AM BLOOD PT-14.4* PTT-29.3 INR(PT)-1.3* [2158-1-1] 06:10AM BLOOD UreaN-15 Creat-0.6 Na-135 K-4.8 Cl-100 [2157-12-26] 07:38PM BLOOD ALT-50* AST-32 LD(LDH)-239 AlkPhos-47 TotBili-0.2 [2158-1-1] 06:10AM BLOOD Mg-2.2 [2157-12-26] 07:38PM BLOOD %HbA1c-7.4* eAG-166* Brief Hospital Course: The patient was transferred from [Hospital6 3105] on [2156-12-26]. She underwent preop testing including PFTs, Echo, and dental consult. On [2157-12-28] she had a mitral valve repair with a 28mm annuloplasty ring. The cross clamp time was 38 minutes and the total bypass time was 51 minutes. She tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol. She was extubated on the post op night and had her chest tubes discontinued on POD#1. She was transferred to the floor but had to return to the CVICU that night for hyperglycemia requiring an insulin drip. She was restarted on her preop NPH and was stable by the morning of POD#2. She was transferred back to the floor in stable condition. Pacing wires and chest tubes wer removed per protocol and sh3e was gently diuresed toward her preop weight. Her glucoses remained somewhat problem[Name (NI) 115] and the 70/30 insulin was downwardly adjusted to compensate. The evening dose was discontinued. In conversation she says at home she snacks at night and that is perhaps why her Morning glucoses in house have been low. the glucoses the morning after stopping evening NPH dosing her glucoses were in the mid 100s- the insulin can be adjusted at rehab as her intake changes. She continued to make good progress and was cleared for discharge to [Location (un) 16493]rehab in N. [Location (un) 7658] on POD 8. All follow up appointments were arranged. Medications on Admission: Xopenex 1.25 mg q 6 hours PRN Lisinopril 20 mg PO daily KCl QID Loratadine 10 mg PO daily Flonase 1 NU daily Duonebs Levoxyl 0.25 PO daily FESO4 325 mg PO daily Advair Novolin 60 U SC BID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units SC Injection TID (3 times a day): until ambulating frequently. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Fifty (50) units Subcutaneous Q AM. 14. Humalog 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous ac & HS: 120-160:2unitsac/0units HS;161-200:4units ac/2units HS;201-240:6units ac/4units HS,241-280:8units ac/6units HS. Discharge Disposition: Extended Care Facility: [Location (un) 39857] - [Location 9583] Discharge Diagnosis: hypertension mitral regurgitation s/p mitral valve repair [2157-12-28] insulin dependent diabetes nellitus complete heart block s/p permanent dual chamber pacemaker Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on 2/1512 1PM Cardiologist: Dr. [Last Name (STitle) 66588] on [2158-1-26] at 12:30 Please call to schedule appointments with your Primary Care Dr. [First Name11 (Name Pattern1) 1399] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ([0-0-]) in [3-23] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2158-1-4]	[ "2449", "4240", "4280", "4168", "49390", "4019", "25000", "V5867" ]
Admission Date: [2172-3-2] Discharge Date: [2172-4-3] Date of Birth: [2118-6-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4616] Chief Complaint: S/p Fall Major Surgical or Invasive Procedure: Bronchoscopy Transesophageal Echo Thoracentesis History of Present Illness: 53 yoM fell from standing and hit his head on a table. The patient does not remember the event very clearly but he states he remembers falling. When asked the symptoms that preceeded his fall he states that he may have had lightheadedness prior to the fall. In addition he is unable to answer what other symptoms he may have had prior to the fall but answers "yes" to all ROS questions. He has no other specific complaints, although he is hungry. At this current time he has no CP, SOB, HA, fever, chills, urinary symptoms, diarrhea, constipation, abdominal pain or any other symptoms. The patient presented after his fall to [Hospital6 302] where he was noted to be in atrial flutter with RVR, rate of 150. He rec'd ativan (no h/o recent ETOH use per patient, however, per home health nurses patient does still drink), dilt 10mg IV x 2, lopressor 50mg po x 1 and he was started on a diltiazem drip. He then underwent a CT of his head which was concerning for a subarachnoid hemorrhage. He underwent an MRI without contrast at [Hospital 15405] and was then transferred to the [Hospital1 18] ER. In the [Hospital1 ] ER he underwent repeat CT and this read as negative, his MRI was read as possible gyrohyperdensities in the L parietal lobe which could be infectious versus malignant. Repeat MRI with contrast was recommended. The patient was also given 60mg PO dilt and continued on a dilt drip at 5mg / hr. He was also given 2g calcium gluconate. He had a CXR with a L pleural effusion and was given vanc/zosyn/azithro. In the ED, initial VS: T 96.8 HR 80-110 BP 92/47 RR 16 O2 sat: 98%. VS prior to transfer to the floor: T 96.7 GBP 97/59 HR 103 96% on 4L. The patient has 2 PIV. Rec'd 3L of IVF and had 400cc UOP. Past Medical History: Seizure d/o (on valproic acid) Hyperlipidemia Schizoaffective disorder Asthma / COPD HTN ETOH abuse (per pt sober x 1 year) Social History: Patient lives alone. Has visting nursing aid 5 days/wk and visiting nurse 3 days/wk. He chain smokes. He has history of alcohol abuse but has not drank in over a year. He is largely independent of ADLs and can run simple errands by himself. Family History: Mother died almost 30 years ago. Patient has not had contact with his father. [Name (NI) ] has a single living sister [Name (NI) 2048] [Name (NI) ]. He has one sister who is deceased. Physical Exam: Vitals - T: 97.1 BP: 92/57 HR: 89 RR: 22 02 sat: 100% on 2L pulsus 8 GENERAL: NAD, Aox2, somewhat somnolent HEENT: MM slightly dry, JVP 8cm, no lymphadenopathy or thyromegaly, neck supple, no meningismus CARDIAC: RRR, soft heart sounds, no m/r/g LUNG: dullness at L base, diffuse transmitted upper airway sounds ABDOMEN: soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: AOx2 (place [Hospital 86] Hospital, unaware of date), appropriate, EOMI no nystagmus, no asterixis, mild resting tremor. normal sensation throughout, [4-8] stregnth in the upper and lower extremities Pertinent Results: ADMISSION LABS: [2172-3-2] 04:43PM LACTATE-1.3 [2172-3-2] 04:35PM GLUCOSE-99 UREA N-20 CREAT-0.6 SODIUM-140 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15 [2172-3-2] 04:35PM CK(CPK)-26* [2172-3-2] 04:35PM cTropnT-<0.01 [2172-3-2] 04:35PM TSH-2.8 [2172-3-2] 04:35PM VALPROATE-65 [2172-3-2] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2172-3-2] 04:35PM WBC-9.9 RBC-5.67 HGB-16.0 HCT-48.3 MCV-85 MCH-28.1 MCHC-33.0 RDW-16.8* [2172-3-2] 04:35PM NEUTS-75.4* LYMPHS-15.7* MONOS-7.0 EOS-1.2 BASOS-0.7 [2172-3-2] 04:35PM PLT COUNT-144* [2172-3-2] 04:35PM PT-13.3 PTT-25.9 INR(PT)-1.1 Path: [3-5] FNA from bronch of mediastinal mass: Fine needle aspiration of mainstem: Single fragment of atypical squamous cells, insufficient for diagnosis; please see cytology report (C10-[Numeric Identifier 63202]) for diagnosis [3-5]: Bronch cytology consistent with squamous cell carcinoma. [3-4] Bronch: Suspicious for malignant cells. Rare clusters of highly atypical epithelioid cells with high N:C ratios and prominent nucleoli. [3-4] Pleural fluid: Rare cluster of atypical epithelioid cells in a background of lymphocytes, neutrophils, macrophages and mesothelial cells. IMAGING: [2172-3-2] EKG: Atrial flutter with rapid ventricular response. Axis appears to be right axis deviation although is difficult to assess. Borderline low limb lead QRS voltage. Right bundle-branch block. Delayed R wave progression. Modest ST-T wave changes. Findings raise the consideration of possible chronic pulmonary disease, right ventricular overload and possible prior anterior wall myocardial infarction. [2172-3-3] EEG: This is an abnormal video EEG due to slowing and disorganization of the background rhythm with bursts of generalized suppression. In sleep, note is made of intermittent generalized sharp waves with bifrontal predominance with a triphasic morphology of unclear significance. No electrographic seizures were seen during this recording and this telemetry captured no pushbutton activations. [2172-3-3] MRI Brain w/ contrast: Focal enhancement and edema centered around the left postcentral gyrus is concerning for a mestastasis given the location and large pulmonary mass on the chest CT. Additional differential considerations would include infection or a primary brain tumor. The appearance would be unusual for a vascular malformation, despite the prominent superficial vessel, and also unusual for an evolving infarct. A repeat study with the leads removed and addition of perfusion sequences would be useful in further evaluation. [2172-3-3] CT Chest w/o contrast: 1. Locally invasive mass centered within the left hilum, extending to and abutting the left side of mediastinum, associated with secondary atelectasis of the left upper lobe and an organized left pleural effusion. Pulmonary metastases in the ipsilateral and contralateral lungs. These findings are compatible with stage IV disease. 2. Borderline-sized mediastinal adenopathy. 3. Small airways disease. CTA Chest w/ & w/o contrast: 1)Large infiltrating mass in the left hilum extending along the occluded left pulmonary vein into the left atrium and circumferentially encasing and infiltrating the left mainstem bronchus with compression of the lingular bronchus and subtotal compression of the left lower lobe bronchus causing atelectasis. 2)Mild mediastinal lymphadenopathy. 3)Multiple pulmonary nodules, presumed metastases, in both lungs. [2172-3-2] CXR: Left-sided pleural effusion with left basilar atelectasis. No overt CHF. Please note study is limited and if needed, a PA and lateral view can be performed to better assess [2172-3-3] TTE: The left atrium is mildly dilated. A highly mobile small to medium sized mass (0.8 x 0.8 cm) is seen in the body of the left atrium which appears to possibly be attached to the base of the anterior mitral valve leaflet (differential diagnosis included thrombus, myxoma, vegetation, papillary fibroelastoma). This is best seen in clips 9, 11, 126. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Small to medium sized mobile mass (0.8 x 0.8 cm) in the body of the left atrium which appears to be attached to the base of the anterior mitral valve leaflet (differential diagnosis included thrombus, myxoma, vegetation, papillary fibroelastoma). Low-normal left ventricular systolic function. A TEE may serve to better define the size and attachment of this mass. [2172-3-4] TEE: A mass is seen in the poterior wall of the left atrium near the site of the left upper pulmonary vein (not seen). The left atrial mass has a broad base measuring 2.5 x 0.8 cm with a miobile, stalk-like aspect measuring 3 x 0.7 cm- ? Thrombus versus extension of mass. The left atiral appendage is seen and is free of mass or thrombus. No mass or thrombus is seen in the right atrium or right atrial appendage. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is a small circumferential pericardial effusion. IMPRESSION: Heterogenous mass with broad base (2.5 x 1.8 cm) and mobile stalk (3 x 0.7 cm) seen in the left posterior atrial wall adjacent to entrance of the left lower pulmonary vein and possibly occluding the entrance of the left upper pulmonary vein (not seen). The mass may be entering the left atrium via the left upper pulmonary vein. No valvular vegetations seen. Mild mitral regurgitation. Normal biventricular systolic function. Small pericardial effusion seen. Bilateral pelural effusions seen. [2172-3-5] CT Abdomen/Pelvis: IMPRESSION: 1. Bilateral enhancing low-density renal lesions which are highly concerning for metastases. Focal renal abscesses could also have this appearance, and clinical correlation is recommended for signs of infection. Bilateral renal cell carcinoma and lymphoma are considered less likely. 2. Moderate left pleural effusion and persistent left lower lobe consolidation. No abnormal pleural enhancement. 3. Trace perihepatic ascites, and mild soft tissue edema and retroperitoneal stranding, consistent with mild volume overload. [2172-3-20] MRI w/o contrast: IMPRESSION: Markedly limited study due to motion. The left parietal abnormality appears to demonstrate slight further mass effect on the adjacent sulci and slightly increased edema. This is not typical for infarct. Gadolinium-enhanced images are recommended for further evaluation. A repeat diffusion images will also help for further assessment and differentiating mass lesion versus infarct in this location. Brief Hospital Course: 53 yoM w/ a h/o schizoaffective disorder presents s/p fall with atrial flutter with a rapid ventricular response, intracranial lesion, and lung mass who has new dx of squamous cell lung cancer with extension into left atrium. #. Squamous cell carcinoma of lung: New diagnosis found on imaging and subsequent lung biopsy after bronchoscopy. Tissue was consistent with advanced primary squamous cell lung cancer. Given left upper lobe collapse, a left bronchial stent was placed as well. His lung mass extended into his left atrium. This left atrial mass likely had broken fragments that embolized to the brain and bilateral kidneys. It is difficult to determine if these sites were definitely emboli vs. metastasis. Mutliple imaging over the course of his hospitalization could not accurately ascertain the difference. It was decided that the patient's functional status was too weak to tolerate chemotherapy. He completed a course of palliative XRT while in the hospital. He should follow up with thoracic oncology in the outpatient for further evaluation. The patient stated he wanted treatment despite his poor prognosis. He underwent 14 treatments of XRT prior to discharge. #. Atrial & Ventricular Ectopy: He developed atrial flutter in the MICU. He was amiodarone loaded in the MICU and started on verapamil. He continued to have breakthrough runs of aflutter so his Verapamil was uptitrated to to 360 daily. He had no further episodes of tachycardia in the final week of his hospitalization. This ectopy was largely secondary to his atrial mass. He was continued on a maintenance dose of amiodarone as well. #. Hypoxic respiratory failure: S/p intubation for 5 days. Extubated successfully on [2172-3-9] and had subsequent intermittent need for supplemental oxygen. He had one episode of desaturation to 80s on [3-15] and CXR showed new collapse of LUL near recent stent placement. IP team was consulted and decided to hold off on bronch for now as his hypoxia recovered with nebs and mucomyst. He was monitored closely and given aggressive chest PT, although his lung remained collapsed, he had no further episodes of desaturation. He will follow up with IP in the outpatient for a flex bronchoscopy. After several radiation treatments, patient was saturating in low 90s on room air and breathing comfortably for the week prior to his discharge. He did intermittently require O2. #. Pneumonia: He was placed on levofloxacin and Flagyl and completed a 10 day course. He had no further fever or signs of infection. # Weakness over right UE/LE: Suspect this is due to L parietal lesion. No mass effect from brain mass noted on repeat MRIs. He remained unable to lift his right hand against gravity. His muscle strengths are [3-9] in the right lower extremity, but [4-8] in both left upper and left lower extremities. His exam remained unchanged. He worked with physical therapy and patient will need aggressive treatment in rehab. In the case this may have been a ischemic CVA, the patient was placed on aspirin. He was seen by neurooncology and radiation oncology during his admission and will f/u as an outpatient for further care of brain lesion #. MS Change: Patient with known schizoaffective disorder to complicate what his baseline may be. Psychiatry was consulted and helped manage his psychiatry medications. EEG was performed twice ([3-3] and [3-4]) and both showed findings consistent with mild to moderate encephalopathy that was improving. This was likely a combination of medications, toxic/metabolic disturbances, and infection. Through the course of his hospital stay, his mental status improved where he became more alert and interactive. He was oriented to person and place near the end of his hospitalization. He appeared quite depressed as he began to understand the gravity of his illness. He continued to complain of poor sleep at night. #. Testicular mass: Has nodularity in right scrotum noted in the MICU which was not consistent with any metastatic mass by ultrasound. #. Schizoaffective disorder: Prolixin was altered (5 mg qAM and 10 mg qPM). His celexa was decreased to 20 mg daily (from 40 mg) as patient developed SIADH of unclear etiology. This resolved prior to full discontinuation of this drug. #. Right upper extremity DVT: RUE ultrasound found R basilic clot so PICC line pulled [3-13]. He was started on a heparin gtt. This continued for nearly two weeks in trying to decide the patient's disposition and whether the need for anticoagulation was a clear benefit to the patient. It was ultimately decided by the patient, health care proxy, and team that the patient would continue anti-coagulation with lovenox. #. SIADH: Patient's sodium hit a nadir at 119. His labs were consistent with SIADH. He was placed on a tight fluid restriction, given salt tablets, and given a one time dose of lasix, which improved his sodium. Once the heparin gtt was discontinued (which contained D5W) his sodium markedly improved to normal range. His fluid restriction was lessened to 2 liters per day and his salt tablets were discontinued. His mental status remained stable. #. Seizure Disorder: No seizure activity noted. Continued home valproate dosage. #. Code Status: [Hospital ] health care proxy decided that patient should be DNR/DNI with no escalation of care. The patient stated he did not want to be left to die and wanted treatment. However, at discharge he stated that he would not want to be intubated if it was felt that he wouldn't have a meaningful recovery and he agreed to be DNR/DNI. Medications on Admission: Depakote delayed release 500mg po qam, 1500mg po qpm Cogentin [Hospital1 ] Duonebs prn Celexa 40mg daily Trazodone 300mg po qhs Seroquel 200mg po qhs Symbicort [Hospital1 ] Advair 250/50 [Hospital1 ] Tyelnol prn Simvastatin 20mg daily Prolixin 5mg po bid Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. Divalproex 125 mg Capsule, Sprinkle Sig: Five (5) Capsule, Sprinkle PO BID (2 times a day). 5. Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule, Sprinkle PO QAM (once a day (in the morning)). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 10. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day) as needed for constipation. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 16. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 17. Fluphenazine HCl 2.5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 18. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 22. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs puffs Inhalation every four (4) hours. 25. Verapamil 180 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q24H (every 24 hours). 26. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. 27. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). 28. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety/sleep. 29. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital1 3894] Nursing & Rehabilitation Center - [Location (un) 5503] Discharge Diagnosis: Primary Diagnosis: Squamous Cell Carcinoma of Lung Right upper extremity DVT Mass in Brain Secondary Diagnosis: Schizophrenia 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: You were admitted because you fell and were found to have a mass in your head. You were monitored closely in the ICU. A CT scan of your chest showed a large mass in your chest as well. This was biopsied and found to be squamous cell carcinoma of the lung. This mass was invading your heart. This caused you to develop a fast heart rhythm. You were given medications to slow your heart rate down. You also developed blood clots in your right arm in the setting of a PICC line. You were started on a blood thinner called heparin. You were transitioned to another easier to use blood thinner called lovenox. You were transferred to the oncology floor and began palliative radiation to your chest. You should continue your medications unless otherwise indicated. It is important that you keep all of your doctor's appointments. Followup Instructions: You have the following appointments scheduled: Department: Interventional Pulmonary Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 3020] Date/Time: [2172-4-23] 10:00am You should also have follow-up in the thoracic oncology clinic. You should hear from the clinic on Monday with an appointment. If you do not hear from them, please call [0-0-] for an appointment.	[ "51881", "486", "5119", "2875", "2724", "4019" ]
Admission Date: [2161-11-29] Discharge Date: [2161-12-2] Date of Birth: [2087-11-5] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[Last Name (NamePattern4) 290] Chief Complaint: SOB, HYPOXIA, Major Surgical or Invasive Procedure: Pt was intubated History of Present Illness: . History of Present Illness: 74F with DM, chronic bronchiectasis c/b recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p L lower lobectomy admitted to [Hospital1 ]-[Location (un) 620] [11-14] with 2 days of fever, dyspnea, and chest heaviness. Noted to be hypoxic to 55% per transfer summary. CXR showed R-sided PNA. Initially managed on the floor and treated with zosyn and steroids. Zosyn switched to tobramycin & imipenem [11-22] when sputum Cx returned MDR pseudomonas. Eventually transferred to ICU for Afib with RVR, treated with diltiazem and digoxin. Bronch/BAL [11-23] also grew 2 strains of MDR pseudomonas and [Female First Name (un) ]. Intubated [11-24] with 7.5 ETT for hypercapnic resp failure, at which time ABG 7.34/89/82/48. She remained hemodynamically stable. However, WBC# rose from 14.3 on [11-27] to 28.1 today. ABG this AM 7.50/52/144/41 on 400/12/5/0.4. Transferred to [Hospital1 18] for further evaluation and treatment. . On the floor, patient denies pain or difficulty breathing. . Past Medical History: DM Chronic bronchiectasis c/b recurrent pseudomonal PNA COPD on home O2 Lung abscess s/p L lower lobectomy +PPD with remote TB exposure Diverticulitis Osteoporosis Social History: Social History (per med records): Lives at home. Independent. Drinks [1-24] glasses of wine per day. Former smoker, quit smoking ~50 years ago. Family History: Family History: Not assessed. Physical Exam: Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35 General: Awake, opens eyes, appears comfortable, no access muscle use Neck: No JVD Lungs: diffuse rhonchi bilat no wheeze/rales CV: reg rate nl S1S2 no m/r/g Abdomen: soft NTND hypoactive BS Ext: warm, dry +PP 1+ pitting edema of all distal ext Pertinent Results: [2161-11-29] 02:25PM BLOOD WBC-29.2# RBC-3.56 Hgb-10.8* Hct-34.0* MCV-95 MCH-30.4 MCHC-31.8 RDW-12.1 Plt Ct-262 [2161-11-30] 04:06AM BLOOD WBC-27.7* RBC-3.46* Hgb-11.0* Hct-33.6* MCV-97 MCH-31.8 MCHC-32.8 RDW-12.5 Plt Ct-279 [2161-12-1] 05:35AM BLOOD WBC-30.0* RBC-2.56# Hgb-8.1# Hct-24.9* MCV-97 MCH-31.4 MCHC-32.4 RDW-12.8 Plt Ct-279 [2161-11-29] 02:25PM BLOOD Neuts-94.6* Lymphs-1.8* Monos-3.4 Eos-0.1 Baso-0.1 [2161-11-30] 04:06AM BLOOD Neuts-95.4* Lymphs-1.5* Monos-2.5 Eos-0.5 Baso-0.1 [2161-12-1] 05:35AM BLOOD PT-13.9* PTT-150* INR(PT)-1.2* [2161-11-29] 02:25PM BLOOD Glucose-263* UreaN-61* Creat-0.3* Na-150* K-4.3 Cl-110* HCO3-36* AnGap-8 [2161-12-1] 05:35AM BLOOD Glucose-286* UreaN-76* Creat-0.4 Na-140 K-5.0 Cl-102 HCO3-35* AnGap-8 [2161-11-29] 02:25PM BLOOD ALT-20 AST-16 LD(LDH)-197 AlkPhos-52 TotBili-0.2 [2161-11-29] 02:25PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.0 Mg-2.7* [2161-11-30] 04:06AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.5 [2161-11-30] 04:06AM BLOOD TSH-2.1 [2161-11-29] 02:25PM BLOOD Tobra-2.0* [2161-11-30] 05:30PM BLOOD Tobra-1.0* [2161-11-29] 02:44PM BLOOD Type-ART Temp-36.9 Rates-[12-26] Tidal V-420 PEEP-5 FiO2-35 pO2-113* pCO2-52* pH-7.48* calTCO2-40* Base XS-13 -ASSIST/CON Intubat-INTUBATED [2161-11-30] 06:20AM BLOOD Type-ART pO2-128* pCO2-60* pH-7.42 calTCO2-40* Base XS-12 [2161-12-1] 05:48AM BLOOD Type-ART pO2-129* pCO2-63* pH-7.40 calTCO2-40* Base XS-11 [2161-11-29] 02:44PM BLOOD Lactate-1.6 [2161-11-30] 03:49PM BLOOD Lactate-1.2 [2161-12-1] 05:48AM BLOOD Lactate-1.3 [2161-12-1] 05:48AM BLOOD freeCa-1.09* [2161-11-29] 03:30PM BLOOD B-GLUCAN-Test [2161-11-29] 03:30PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test IMAGING : [2161-12-1] ABDOMINAL ULTRASOUND: The liver is diffusely heterogeneous in echotexture, but without focal lesions. There is no intrahepatic biliary ductal dilation. Common bile duct appears mildly dilated in the suprapancreatic portion, measuring 9-10 mm. The pancreatic duct tapers entering the pancreas but is not well seen distally There is normal antegrade flow in the main portal vein. The gallbladder is not distended, though there is marked gallbladder wall edema, which may reflect underlying liver disease or other causes of third spacing. There is no cholelithiasis identified. The spleen is normal in size, measuring 7 cm. Small amount of free fluid is identified in the left upper quadrant. The kidneys are symmetric in size, measuring 10.4 cm on the right and 10.9 cm on the left. There is no renal mass lesion, and no nephrolithiasis or hydronephrosis. The midline structures including the aorta, IVC, and pancreas, are obscured by overlying bowel gas. IMPRESSION: 1. Heterogeneous, coarse liver echotexture suggesting liver disease such as hepatitis or fibrosis. No focal liver lesions are identified. If further evaluation is desired, MRI could be considered when clinically feasible. 2. Mild dilation of suprapancreatic common bile duct, measuring 9-10 mm, without intrahepatic biliary ductal dilation. This is of dubious significance. MRCP could be performed if there is further concern. 3. Gallbladder wall edema, without associated distention or cholelithiasis to suggest acute cholecystitis. This may reflect third spacing, secondary to a number of causes, or may be from underlying liver disease. 4. Small amount of free fluid in the left upper quadrant adjacent to the spleen. 5. Obscuration of midline structures including the pancreas, aorta and IVC by overlying bowel gas. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Assessment and Plan: 74F with DM, chronic bronchiectasis c/b recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p L lower lobectomy transferred for further management of hypercapnic respiratory failure due to MDR pseudomonal PNA. . #Hypercapnic respiratory failure/Pneumonia - pt respiratory status detiorated after presentation to the ED and she was intubated. Pt was diagnosed with MDR pseudomonal PNA and was being treated with Abx. She had an acute episode on a-fib with RVR and was medically managed. Ultimately it was planned for her to have DC cardioversion and so she was placed on Heparin drip in preparation for TEE and cardioversion. The morning after starting the drip, it was noticed that the patient had a large melenic stool and an acute drop in her hemoglobin and hematocrit. GI was consulted and an EGD showed bleeding around the ampulla. It was unclear whether the bleeding was coming from around the ampulla or within the ampulla. A RUQ U/S was done to rule out hemobilia or hemorrhagic mass. The family was contact[Name (NI) ] at this time as goals of care have been a constant discussion. In addition, the patient was intubated, but clear and alert and she was aslo actively involved in the discussion of her care. The RUQ U/S was negative and IR and Surgery were notified for possible angiogram and intervention. As these events were developing, the family and pt were in active discussion with the medical team. The patient and family decided not to go ahead with the angiogram. The patient decided she wanted to be made CMO and be extubated. The patient was terminally extubated on [2161-10-31]. The patient died on [2161-12-2]. Medications on Admission: Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35 General: Awake, opens eyes, appears comfortable, no access muscle use Neck: No JVD Lungs: diffuse rhonchi bilat no wheeze/rales CV: reg rate nl S1S2 no m/r/g Abdomen: soft NTND hypoactive BS Ext: warm, dry +PP 1+ pitting edema of all distal ext Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "51881", "2760", "42731", "25000", "V5867" ]
Admission Date: [2161-2-21] Discharge Date: [2161-2-21] Date of Birth: [2095-7-1] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 106] Chief Complaint: Septic Shock Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Pt is a 65 y/o female unknown to [Hospital1 18], who was referred for cardiac cathetrization. She has a hx of CVA and bowel perforation 5 months ago s/p colostomy, and has not recovered well from this surgery and is cared for by her husband. She was noted to have N/V 2 days ago, and was told to increase her PO fluids. Temp at home was 99. She improved somwehat, but was noted by her husband to have decreased ostomy output. The evening prior to admission she begam clammy, vomited, and was unresponsive. EMS was called and she was difficult to intubate in the field. She was taken to [Hospital3 ], and there was suspicion for STE MI by EKG. Also coffee ground emesis but stable Hct. She was hypotensive and placed on pressors, and referred to [Hospital1 18] for cardiac cath. Cardiac cath did not reveal significant coronary lesions, but some mild global dysfunction. Given her clinical picture this was likely c/w sepsis. Past Medical History: CVA in '[53] w/ L-sided hemiparesis [8-/2160] had bowel perforation w/ colostomy Osteoporosis Social History: Cared for at home by her husband Family History: Mother w/ hx of CVA, Father w/ CAD Physical Exam: T=91 BP=96/65 HR=110 O2=95% GEN=Intubated LUNGS=normal BS's bilaterally CARDIAC=difficult secondary to BS's ABD=tense, no bowel sounds EXT=no edema, cold extremities, cyanotic toes/fingers NEURO=pupils fixed and dilated, absent corneal reflexes, absent gag reflex; positive doll's eye per surgery Pertinent Results: [2161-2-21] 09:53AM GLUCOSE-190* UREA N-32* CREAT-1.4* SODIUM-140 POTASSIUM-2.0* CHLORIDE-113* TOTAL CO2-12* ANION GAP-17 [2161-2-21] 07:40AM GLUCOSE-128* LACTATE-8.1* K+-1.8* [2161-2-21] 09:53AM WBC-0.4* RBC-3.77* HGB-11.9* HCT-37.5 MCV-100* MCH-31.5 MCHC-31.6 RDW-14.4 [2161-2-21] 10:18AM TYPE-ART PO2-69* PCO2-36 PH-7.03* TOTAL CO2-10* BASE XS--21 Brief Hospital Course: She was transferred to the CCU, where she was found to be hypothermic, has an elevated Lactate, and was hypotensive requiring 4 pressors and fluids wide-open. Her neuro exam revealed loss corneal and gag reflexes. Surgery was consulted about possible abdominal process at the etiology of her septic shock, but surgery felt that given her unstable picture and neurological impairements that surgery was not indicated. Her husband and son were notified, and it was felt that the patient's wishes were not to have aggressive measures. After discussion with the family and medical team, it was decided to withdraw care. Pressors were stopped, her ventilation was weaned down, and she was given Morphine for comfort. At 13:30 she was noted to have absent heart sounds, pulse, and was without spontaneous respirations or brainstem reflexes. She was pronounced dead at 13:30 by the medical resident Dr. [Last Name (STitle) ]. The attending, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], was notified. The family requested an autopsy. Discharge Disposition: Expired Discharge Diagnosis: Likely Septic Shock Discharge Condition: Deceased Completed by:[2161-2-21]	[ "0389", "78552", "51881", "2762", "99592", "4019" ]
Admission Date: [2174-4-6] Discharge Date: [2174-4-12] Date of Birth: [2122-4-4] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: trauma: pedestrian struck: R subgaleal hematoma small left apical ptx R inf rami fx R acetabular fractures 1 cm left anteromedial temporal cont right pararenal hematoma head laceration Major Surgical or Invasive Procedure: none History of Present Illness: 52 year old male struck by a car on [4-6] and was brought to [Hospital1 18] for further management. Patient was admitted to the TSICU under ACS for the following injuries: subgaleal hematoma, Right pubic ramus fracture, Right acetabular fracture, Left pneumothorax. Past Medical History: HCV per report; h/o Heroin use; chronic back pain; OSA (should wear CPAP, but does not at home) Social History: History of heroin use in past, reportedly been clean for some time. Family History: NC Physical Exam: Pt intubated upon admission [2174-4-6]: Vital signs: hr=82m bp=100/62, rr=20, 100 % oxygen saturation CV: normal chest: normal abdomen: normal skin: abrasions left shoulder, right knuckle abrasions, laceration scalp neuro: 3mm to 2mm sluggish Physical examination upon discharge: [2174-4-12] vital signs: t=98.3, hr=76, bp=130/70, rr=18, oxygen saturation 98% RA General: sitting in chair, conversant, NAD CV: ns1, s2,-s3, s-4 LUNGS: clear, diminshed BS left lateral ABDOMEN: soft, non-tender EXT: feet warm, + dp bil. mild left ankle edema lateral aspect, ecchymosis left calf., abrasions left knuckles, no spinal tenderness, mild tenderness left SI, muscle st lower ext., left +4/+5, right +5/+5, full dorsi/plantar flexion bil., hip flex. right +5, left +[5-5]. NEURO: alert + oriented x 3, speech clear, no tremors, full EOM's bil. SKIN: staples head Pertinent Results: CT Head [2174-4-6]: No hemorrhage or fracture. Large right subgaleal hematoma and laceration. CT C-spine [2174-4-6]: No fracture or malalignment in the cervical spine. Malpositioned NG tube with its tip at the vallecula anterior to the epiglottis. Repositioning was discussed with the trauma team at the time of initial review. Tiny left apical pneumothorax better assessed on the subsequent CT torso. CT abdomen and pelvis [4-6] 12: . Acute fractures of the right inferior pubic ramus and the anterior column of the right acetabulum with no significant surrounding hematoma. Probable nondisplaced fracture of the right sacral ala. 2. Locatized hematoma within the right anterior pararenal space tracking inferiorly into the space of Retzius, the source of this hemorrhage is unclear though no solid organ injury is evident. 3. Left chest tube in place with only trace left pneumothorax. Small areas of contusion in the lung as detailed above. Bibasilar opacities likely represent a combination of atelectasis and aspiration. CT Torso [2174-4-6]: Tiny left apical and basal pneumothoraces. Bilateral lower lobe opacities could be secondary to mild aspiration in the setting of intubation. Small quantity of hemorrhage in the right anterior pararenal space. No definite solid organ or hollow viscus injury. Right anterior acetabular and inferior pubic ramus fractures. Mild widening of the left sacroiliac joint. [2174-4-8]: x-ray of the ankle: . Mild soft tissue edema in [Last Name (un) 22044] fat pad. This can be seen in Achilles tendinopathy. 2. Mild lateral malleolar soft tissue swelling. 3. No fracture [2174-4-8]: ct of the chest: IMPRESSION: 1. Interval layering of hematoma with decreased component in the right anterior pararenal space and tracking inferiorly into the right paracolic gutter and pelvis. 2. No definite evidence of solid organ injury. No evidence of duodenal wall hematoma. No extraluminal oral contrast. 3. Small left pneumothorax with mild interval increase in size compared to prior. Chest tube with tip terminating at the left lung base. 4. Similar bibasilar opacities likely atelectasis and aspiration. Subtle increase in size of focal opacity in the left lower lung could be contusion. 5. Known fracture of the right inferior pubic ramus and anterior of the right acetabulum. [2174-4-10]: chest x-ray: This particular study was acquired using a somewhat lordotic technique creating many superimposed bony structures over the apices. Given this limitation, no pneumothorax is appreciated on the current study, although a small pneumothorax could be overlooked. There is interval decrease in the amount of left chest wall subcutaneous emphysema. A left subclavian central line continues to have its tip in the proximal SVC. Lung volumes remain low with no focal airspace consolidation, pulmonary edema, or pleural effusions. Overall cardiac and mediastinal contours are stable. Interval resolution of bibasilar patchy opacity is consistent with resolved atelectasis. [2174-4-11]: LS spine x-rays: FINDINGS: There is a transitional vertebra at the lumbosacral junction. At this level, there is hypertrophic spurring with intervertebral disc space narrowing. Less prominent narrowing is seen at the interspace just above this. These findings are consistent with degenerative change. No evidence of compression fracture or alignment abnormality. [2174-4-11]: x-ray of the pelvis: FINDINGS: In comparison with the study of [4-6], there is again a substantially displaced fracture of the right inferior pubic ramus. The right femoral neck fracture seen on CT is obscured due to a somewhat rotated position. [2174-4-11] 04:29AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.8* Hct-24.1* MCV-87 MCH-31.8 MCHC-36.5* RDW-13.7 Plt Ct-63* [2174-4-10] 03:03PM BLOOD Hct-25.9* [2174-4-10] 04:20AM BLOOD WBC-2.8* RBC-2.65* Hgb-8.6* Hct-23.0* MCV-87 MCH-32.3* MCHC-37.3* RDW-13.4 Plt Ct-47* [2174-4-6] 07:30PM BLOOD WBC-10.2 RBC-3.63* Hgb-11.3* Hct-32.7* MCV-90 MCH-31.2 MCHC-34.6 RDW-13.5 Plt Ct-82* [2174-4-11] 04:29AM BLOOD Plt Ct-63* [2174-4-10] 04:20AM BLOOD Plt Ct-47* [2174-4-9] 02:13AM BLOOD Plt Ct-33* [2174-4-11] 04:29AM BLOOD Glucose-88 UreaN-9 Creat-0.5 Na-140 K-3.5 Cl-105 HCO3-29 AnGap-10 [2174-4-10] 04:20AM BLOOD Glucose-99 UreaN-11 Creat-0.5 Na-141 K-3.1* Cl-105 HCO3-33* AnGap-6* [2174-4-7] 02:15AM BLOOD ALT-94* AST-93* LD(LDH)-315* AlkPhos-52 TotBili-0.2 [2174-4-6] 07:30PM BLOOD Lipase-83* [2174-4-11] 04:29AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0 [2174-4-10] 04:20AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8 [2174-4-6] 07:38PM BLOOD Glucose-140* Na-139 K-4.1 Cl-104 calHCO3-28 [2174-4-8] 05:09AM BLOOD freeCa-1.08* Brief Hospital Course: 52 year old gentleman, pedestrian struck, admitted to the the hospital intubated and sedated. Upon admission, he was made NPO, given intravenous fluids and underwent imaging. He was found to have a right acetabular fracture,right pubic rami fracture and a right subgaleal hematoma. He was also found to have a left pneumothorax after having a needle thoracostomy tube placed in the field. In the emergency department he had a chest tube placed and was admitted to the trauma intensive care unit where he was hemodynamically stable. On HD #2, he was extubated and placed on face tent with good oxygenation. His chest tube was placed to water seal and he was transfused 2 u of blood after his hematocrit dropped to 24.8. His Hct drop was thought to be from a pararenal hematoma that was found vs his pelvic fracture. He was started on IV equivalent of home methadone regimen, standing intravenous Tylenol, and dilaudid PCA for pain control. The orthopedic service was consulted and recommended non-operative management for pelvic fracture. C-spine and TLS spine cleared clinically at this time. He again was transfused with 2 units blood on HD #3 for down-trending of his hematocrit. He was re-scanned in this setting and his pararenal hematoma was found to be stable. His methadone was decreased in the setting of somnolence. He also had a cat scan scan of his head which showed new hyperdensity in the left temporal lobe. Neurosurgery was consulted and thought this hyperdensity was too small to require seizure prophylaxis or further imaging with MRI, and thought most likely to be contusion. His left chest tube was removed on HD #4. He was transferred to the surgical floor on HD#4 with stable vital signs and adequate control of his pain with oral analgesia. He is tolerating a regular diet. Serial hematocrits continued with evidence of improvement of his thrombocytopenia to 80,000 and stabilization of his hematocrit to 25. He was evaluated by physcial therapy and occupational therapy and was found to have impaired mobility related to his pelvic fracture. Upon evaluation, it was determined that he had left leg weakness and the inability to bear weight on his left leg. The left leg weakness was noted on physical examination upon admission. He underwent a lumbar spine x-ray which showed no compression fracture or alignment abnormality. The pelvix x-ray continued to show the displaced fracture of the right inferior pubic ramus. He was provided instruction in the use of the walker and has been ambulating with assistance. He is preparing for discharge to a rehabilitation facility with follow-up instructions with Orthopedics, and with the acute care service. Medications on Admission: xanax 2mg AM 4mg HS, methadone 50mg TID 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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 4. methadone 10 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: hold for incresed sedation, resp. rate <12. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety: hold for increased sedation ,resp. rate <12. 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. Discharge Disposition: Extended Care Facility: [Hospital1 ] Cape & Islands Discharge Diagnosis: Trauma: pedestrian struck Injuries: R subgaleal hematoma small left apical ptx R inf rami fx R acetabular fractures 1 cm left anteromedial temporal cont right pararenal hematoma 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 came to the hospital after being struck by a car and were found to have mulitple injuries including a acetabular fracture, pelvic fractur and a small bleed in your head. You were seen by the orthopedic service for the fractures who recommended non-operative management for both your pelvic and acetabular bone fractures. You were seen by physical therapy and recommendations made for discharge to an extended care facility. Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2174-4-28] at 2:00 PM With: ACUTE CARE CLINIC with Dr [Known firstname ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] 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. Department: ORTHOPEDICS When: TUESDAY [2174-5-3] at 10:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2174-5-3] at 11:00 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please follow-up with Dr. [First Name (STitle) ], cognitive neurologist, upon discharge from the rehabilitation center. You can schedule this appointment by calling # [Telephone/Fax (1) 6335] Completed by:[2174-4-12]	[ "2851", "2875", "3051" ]
Admission Date: [2163-10-30] Discharge Date: [2163-11-3] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Chest pain and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Most of the interview was conducted with telephone interpretor as patient is Russian speaking only. [Age over 90 ]yo female Russian speaking only resident of [Hospital1 5595] with CAD, CHF (EF 25%), HTN, and Afib, recently admitted with episode of PNA vs. CHF exacerbation on [2163-9-29], now presents with chest pain, abdominal pain and hypotension. The chest pain is located in the right side of the chest and radiates to the back. The pain is characterized as the same chest pain she has had for most of her life and is rated [2169-5-5], no radiations and nonpositional, no associated diaphoresis. She had one episode of n/v, early today. The emesis was clear without signs of blood or coffee grounds. She describes her abdominal pain as generalized, diffuse, x 2d. She denies any current abdominal pain. Her last bowel movement was three days prior to admission. In the ED, her BP was 98/66 and dropped to 60/40 sitting and 80/60 lying after ASA, SL NTG and lasix (given for ?ACS, CHF) ->1400 cc u/o. She begun dopamine to avoid fluid boluses given her CHF. The patient was subsequently given morphine for chest pain refractory to nitro which lead to further decrease in BP to 46/24 (15 min. after morphine was given). She failed a weaning trial of dopamine with BP of 79/50. She then received decadron 10mg IV along with levofloxacin 500mg IVx1 and Flagyl 500mg IV x1 for ?PNA, and sent to [Hospital Unit Name 153] for w/u. The patient also reports some baseline shortness of breath with a chronic cough that has been present for 2 years. The cough has periods of improvement and worsening. Recently, the cough has worsened over the last two weeks with some clear sputum production (since her recent discharge). The patient also reports some subjective fevers, and chills, but denies rigors. She is DNR/DNI. Past Medical History: 1. Sick sinus syndrome s/p pacemaker placement. 2. Coronary artery disease. 3. CHF with EF of 25% 4. Atrial fibrillation. 5. Hypertension. 6. Osteoporosis. 7. Dementia 8. R hemicolectomy for mussinous colon CA 1. Sick sinus syndrome s/p pacemaker placement. 2. Coronary artery disease. 3. CHF with EF of 25% 4. Atrial fibrillation. 5. Hypertension. 6. Osteoporosis. 7. Dementia 8. R hemicolectomy for mussinous colon CA Social History: The patient has never smoked cigarettes.She lives in the [Hospital1 10151] Center secondary to an inability to take care of herself. She is retired. She has a large family. She is Russian speaking. Physical Exam: PE: VS: Tc: 97.8 HR: 80 BP: 134/47 on left and 141/57 on right RR: 19 SaO2: 93% on 2L Gen: elderly women lying in bed at 30 degree angle with nasal canula in place. The patient appears to be relatively comfortable, in NAD. poor skin turgor HEENT: temporal wasting. pupils are 2mm bilaterally, reactive?, EOMI. mucous membranes very dry. Neck: supple, full ROM, JVP 8-10cm CV: RRR, S1, S2, no murmurs, rubs, gallops Chest: [Month (only) ] breath sounds on R>L. Egophony on R>L up 1/3 up scapula. bibasilar crackles. Abd: soft, NT, ND, BS+ bilaterally, no rebound, guarding, peritoneal signs. negative [Doctor Last Name ] signs. Ext: warm to palpation, with trace pulses, [Doctor First Name 15799] stasis, no c/c/e Neuro: pt appeared appropriate throughout. A+O not assess due to difficulty with language barrier. Pertinent Results: [2163-10-30] 11:20AM WBC-11.0# RBC-3.79* HGB-11.1* HCT-33.8* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.4* [2163-10-30] 11:20AM NEUTS-82.2* LYMPHS-12.4* MONOS-4.9 EOS-0.2 BASOS-0.2 [2163-10-30] 11:20AM PT-13.1 PTT-24.2 INR(PT)-1.1 [2163-10-30] 11:20AM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.4* [2163-10-30] 11:20AM ALT(SGPT)-15 AST(SGOT)-28 CK(CPK)-82 ALK PHOS-73 AMYLASE-51 TOT BILI-0.6 [2163-10-30] 11:20AM GLUCOSE-154* UREA N-56* CREAT-2.8# SODIUM-135 POTASSIUM-3.3 CHLORIDE-91 TOTAL CO2-30* ANION GAP-17 [2163-10-30] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2163-10-30] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [2163-10-30] 12:45PM URINE RBC-0-2 WBC-0 BACTERIA-MOD YEAST-NONE EPI-0 [2163-10-30] 01:20PM LACTATE-1.6 [2163-10-30] 11:20AM CK-MB-NotDone [2163-10-30] 11:20AM cTropnT-0.02* [2163-10-30] 05:36PM CK(CPK)-91 [2163-10-30] 05:36PM CK-MB-NotDone [2163-10-30] 05:37PM cTropnT-0.02* . . [2163-10-30] CXR: "1. Cardiomegaly and calcified unfolded aorta. There is no disproportionate mediastional widening. 2. Probable CHF. 3. More confluent opacity right apex --- question atypical distribution of CHF vs. pneumonia. 4. Osteopenia with partial wedging of multiple vertebral bodies. " . . Brief Hospital Course: A/P: [Age over 90 ]yo female resident of [Hospital1 5595] with CAD, HTN and recent admit for PNA and CHF exacerbation (admitted [2163-9-27]-discharged [2163-9-29]) presents with CP, abd pain and hypotension. 1: Hypoxia: We thought that her hypoxia might have been secondary to fluid overload/CHF or a pneumonia. We thus broadened her coverage by adding zosyn. She also received small doses of IV lasix with a small improvement. She eventually weaned from a NRB to 6L nasal cannula on the day of discharge. We advise continued weaning of her oxygen as tolerated by the patient. 2. Hypotension: We thought that the patient's hypotension was secondary to volume depletion as demonstrated by its rapid response with IV fluids. We held her antihypertensive medications initally and slowly added them as her pressure stabilized. 3. Chest pain: We were concerned that her chest pain might have been secondary to an acute coronary syndrome. She was ruled out with negative serial cardiac enzymes and the absence or ECG changes. We increased her 3. PNA: The patient was first started on levoquin but in light of her increasing hypoxia she was switched to zosyn to broaden her coverage. She remained afebrile and without a leukoctyosis was thus discharged on a 7 day course of levofloxacin. 4. Abd pain: The occurance of abdominal pain is conincident with her recent onset of constipation. The abd on exam is soft, and completely benign, without a suggestion of a surgical abdomen. The pain is most likely secondary to constipation. Her abdominal pain and distension improved significantly with the administration of an enema which resulted in a successful bowel movement. 5. Afib/Sick Sinus: Pt is s/p pacemaker placement. While in the ICU she was on telemetry and her heart rate did not decreased to less than 80. 6. CHF: We held her cardiac meds in light of her hypotension. On the day of discharge we had restarted metoprolol and we advise that the other medications be slowly added as her blood pressure tolerates. 7. Prophylaxis: The patient was continued on heparin SQ for DVT prophylaxis along with a PPI as per her outpatient regimen. Medications on Admission: 1. Metoprolol 100mg [Hospital1 ] 2. Amiodarone HCl 200mg PO once daily 3. Lisinopril 5mg once daily 4. Furosemide 40mg once daily 5. Pantoprazole 40mg Q24 hours 6. Albuterol neb Q6hrs PRN 7. Ipratroprium Bromide 0.02% neb Q6 hours Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-31] Puffs Inhalation every four (4) hours. 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [Hospital1 ] (2 times a day) for 4 days. 10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) mL PO twice a day. 17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Aspiration Pneumonia Hypertension Congestive Heart Failure Atrial Fibrillation Discharge Condition: Fair Discharge Instructions: Please take all of your medications as prescribed. Followup Instructions: Primary Care: Please follow up with a physician within one week of discharge from the hospital. At the time, please have your oxygen saturation checked and a CXR within two weeks to verify improvement of your pneumonia. Laboratory: Please have the levels of your potassium checked at [Hospital1 5595] with the results sent to the house physician.	[ "5070", "42731", "4280", "2767", "4019", "41401" ]
Admission Date: [2140-7-22] Discharge Date: [2140-8-29] Date of Birth: [2082-7-22] Sex: F Service: SURGERY Allergies: Amoxicillin / Wellbutrin Attending:[First Name3 (LF) 695] Chief Complaint: SOB, hypoxia Major Surgical or Invasive Procedure: paracentesis, thoracentesis History of Present Illness: 58F w/Alcoholic cirrhosis with consequent diuretic-refractory ascites, edema, hyponatremia, and pleural effusions presents from the IR outpatient clinic for admission because of fever to 101.7. Pt has known alcoholic liver disease with ascites worsening over the past 6 months. She is being worked up for liver [First Name3 (LF) ] here. Over the past week she has been increasingly fatigued walking across a room. Needs to sleep nearly-upright with multiple pillows because of breathing difficulty when lying down. Having daily fevers at nighttime. No chills, no nausea/vomiting/abdominal pain. Some non-productive cough. No sick contacts or contact with children. No dysuria or hematuria. No bloody stools, but does always have black stools, which she attributes to occasional lactulose use. When asked about weight changes she states she hasn't been able to recognize her body for 6 months. . This morning she presented to previously-scheduled outpatient session with IR for therapeutic thoracentesis and paracentesis to offload her ascites and pleural effusions, all thought to be secondary to decompensated cirrhosis. First such session was last week; at her last taps 1.75L of pleural fluid was removed from her chest, she did not require post-procedure albumin, and was able to go home the same day. Plan was not to be drained so soon thereafter, but increase in dyspnea this week prompted a return visit in just 1 week. At IR VS were 101.7 107/56 108 82%/3L. Because of the fever, she had just a diagnostic paracentesis, but she did have 1L straw-colored drained by thoracentesis due to O2 desaturation. O2 sat resolved to 90%/RA by the end of the procedure, and post-procedure CXR show some interval improvement of her R hydrothorax. Pleural and peritoneal fluid sent for analysis and culture, blood cultures also sent. Admitted for IV albumin, antibiotics for possible RUL PNA seen on CXR, and fluid optimization. Past Medical History: Papillary Thyroid Carcinoma s/p resection Alcohol Abuse Alcoholic Cirrhosis c/b ascites and edema no hepatic encephalopathy Celiac Sprue Psoriasis HTN (prior to diuretic therapy; not an active issue off diuretics now) Rosacea Hx Depression Social History: Hx alcohol abuse and daily smoking; stopped both recently. Family History: CVA, depression, alcohol abuse. Physical Exam: Admission Exam: Vitals: 101.3 99/44 69 18 96/3LxNC General: well-appearing pleasant woman sitting upright in bed w/2 pillows, frequently coughing, jaundiced. Walking around floor earlier tonight. [First Name3 (LF) 4459]: NCAT EOMI PERRL icteric sclera Neck: supple, no thyromegaly, JVD nondistended Heart: RRR 3/6 holosystolic murmur throughout precordium loudest LLSB L Lung: slightly diminished lung field w diffuse rales, base>apex R Lung: absent breath sounds except above 4th rib posteriorly; clear breath sounds above that level, with percussible air/fluid level. Bandaged site c/d/i, nontender. Abdomen: soft nontended +distended, tympanic superiorly but w/also w/persussible air/fluid level, bulging flanks. Bandage c/d/i, site nontender. Extremities: pitting edema to groin, psoriatic plaques R elbow L dorsal forearm, no spider angiomatas Neurological: AOX3, no asterixis . MICU Admission Exam: General: Alert, oriented, increased work of breathing, moderately uncomfortable [First Name3 (LF) 4459]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~10cm, no LAD Lungs: Clear to auscultation on left, right side with wheeze, particularly in the lower lung zone, with some crackle CV: Tachycardic Regular rhythm, 4/6 SEM, no rubs, gallops Abdomen: soft, non-tender, mildly distended, + ascites, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 3+ edema to mid thigh, no clubbing, cyanosis Pertinent Results: Admission labs: [2140-7-23] 05:40AM BLOOD Glucose-84 UreaN-20 Creat-1.2* Na-122* K-4.4 Cl-88* HCO3-27 AnGap-11 [2140-7-23] 05:40AM BLOOD WBC-8.1 RBC-2.20* Hgb-8.5* Hct-23.9* MCV-109* MCH-38.5* MCHC-35.4* RDW-15.8* Plt Ct-112* [2140-7-23] 05:40AM BLOOD PT-21.3* PTT-47.5* INR(PT)-2.0* [2140-7-23] 05:40AM BLOOD ALT-26 AST-66* LD(LDH)-253* AlkPhos-90 TotBili-6.4* [2140-7-23] 05:40AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.4 Mg-2.1 . [2140-7-25] 04:40PM BLOOD Type-ART pO2-90 pCO2-38 pH-7.43 calTCO2-26 Base XS-0 [2140-7-25] 04:40PM BLOOD Lactate-2.2* Brief Hospital Course: 57 F w/decompensated alcoholic cirrhosis and worsening ascites and R-sided pleural effusions initially admitted to the Liver service with fever for therapeutic [Female First Name (un) 576] and paracentesis. On [2140-7-25], she developed hypoxia post thoracentesis requiring NRB and was transferred to the MICU. Hypoxia was felt to be re-expansion pulmonary edema, potentially complicated by pneumonia given her fevers, worsening shortness of breath and hypoxia. In the MICU, she initially required 100% face mask. IP placed a pigtail catheter to drain re-accumulated right pleural effusion [2140-7-26]. Initially, 600cc of serosanguinous fluid was drained. The next day, 2L were drained. She was able to be weaned to 3L NC and went back to the medical floor for management of hyponatremia and worsening renal function. Creatinine increased from baseline of 1.0. It was felt that she was developing hepatorenal syndrome. On [8-9], a liver donor became available and patient accepted offer. She underwent ABO (A) incompatible liver (she was blood type O) with splenectomy on [2140-8-9]. Three JPs were placed. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Pheresis was done just prior to [Last Name (NamePattern4) ] for Anti A titer of 512. CVVHD was done intraop. Postop, she was transferred to the SICU intubated for management. She required blood products in the immediate postop period, but remained hemodynamically stable. LFTs increased initially as expected then trended down daily. Liver duplex on postop day 1 was normal. JP outputs were non-bilious. The JP in the splenic bed had the highest output and appeared bloody. Plasmapheresis continued daily based on Anti A antibody titers. Titers decreased to 4. A total of 13 treatments were done. ATG was given daily for a total of 7 doses (75mg each). Platelets were administered prior to ATG in the immediate postop period. Immunosuppression consisted of steroid taper per protocol, CellCept [Hospital1 ], ATG and Prograf which was started on postop day 1. Doses were adjusted per trough levels. Goal prograf level was 10. CVVHD was continued for hepatorenal syndrome. CVVHD was switched to HD via temporary HD line. Nephrology followed her throughout the hospital stay. Urine output increased around postop day 7 and dialysis was stopped ([8-19]). Urine output was approximately 2 liters, however, creatinine and BUN continued to increase up to 105. Dialysis was resumed on [8-24], and continued daily on [8-25] and [8-26]. This was repeated on [8-29]. The plan was for her to continue on hemodialysis at least twice weekly on Mondays and Fridays. On [8-25], the temporary dialysis line was exchanged for a tunnelled HD line in interventional radiology. A right-sided 23-cm tip-to-cuff hemodialysis line with tip was seen in the right atrium, ready for use. She was transferred out of the SICU on [8-20] to the medical surgical floor where diet was advanced and tolerated, but intake was insufficient. Therefore, a feeding tube was placed and tube feeds were started. Nutren 2.0 at 40cc/hour continuous was recommended by the dietician. This was well tolerated. She required intermittent sliding scale insulin for hyperglycemia due to steroids. Medial and lateral JPs were removed. The splenic bed JP drain output appeared milky. Fluid was sent for amylase. On [8-13], amylase was 537. This decreased to 76 on [8-24]. Drain output volume decreased from 900ml/day to 300ml/day. JP was removed on [8-26]. Incision was intact with staples. Lower extremity non-invasives were done on [8-25] for asymmetrical lower extremity swelling (Left>right). This was negative for DVT. Teds were applied. Lower legs appeared erythematous with puffiness of left dorsum. Physical therapy worked with her noting improved strength and balance. Medication teaching went well. A bed became available at [Hospital1 ] in [Location (un) 86] and she transferred there on [8-29]. Medications on Admission: (discharge meds [2140-7-3], confirmed with patient): 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lactulose (takes occasionally) Discharge Medications: 1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): follow printed taper schedule 17.5 start [8-30]. 3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH): Monday and Thursday. 8. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 13. insulin regular human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 14. Outpatient Lab Work every Monday and Thursday w results fax'd to [Telephone/Fax (1) 697] ([Hospital 18] [Hospital 1326] Clinic) cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough prograf level 15. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 17. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:1 box Refills:2 18. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous four times a day. Disp:1 box Refills:2 19. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous once a day. Disp:1 kit Refills:2 20. Insulin Syringes U100 Low dose with 25-26 gauge needle supply:1 box refill: 2 Discharge Disposition: Extended Care Facility: [Hospital1 ] - at [Hospital 1263] Hospital - [Location (un) 686] Discharge Diagnosis: etoh cirrhosis hepatorenal syndrome malnutrition 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 will be transferring to [Hospital1 ] Rehab in [Location (un) 86] Please call the [Location (un) 1326] Office [Telephone/Fax (1) 673] if you have any of the following: fever, shaking chills, nausea, vomiting, inability to take any of your medications, jaundice, increased abdominal pain, incision redness/drainage/bleeding, increased urine output,constipation/diarrhea, malfunction of dialysis catheter or any concerns You will need to have blood drawn for lab monitoring every Monday and Thursday You will require hemodialysis at least twice weekly (Monday and Friday) You may shower, but must keep the tunnelled dialysis line dry No straining/heavy lifting (nothing greater than 10 pounds) Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2140-8-31] 2:00 Provider: [Name10 (NameIs) ] SOCIAL WORKER Phone:[Telephone/Fax (1) 673] Date/Time:[2140-8-31] 2:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2140-9-7] 10:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2140-8-29]	[ "486", "5119", "5849", "2761", "2762", "40390", "4168", "5859", "2449", "311" ]
Admission Date: [2127-12-16] Discharge Date: [2127-12-24] HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old male admitted with failure to thrive. The patient lives in an independent living facility for long-term senior citizens. The patient was feeling weak for the last few days with lower social worker visited him and sent to the Emergency Room for issues of neglect, and weakness, and poor hygiene. The patient had no other complaints besides the weakness. The patient had no fevers or chills, nausea, vomiting, shortness of breath, cough, diarrhea, constipation, bright red blood per rectum, or night sweats. The patient with some weight loss, but he cannot define how much. Poor insight into state a cleaning lady once a week who came in strictly to clean the house but no other home care. The patient cleans and feeds himself. His son visits his twice per month. His last primary care visit was [2126-11-1]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Heart attack five years ago at [Hospital6 15291]. MEDICATIONS ON ADMISSION: The patient's medications on admission included Vasotec, digoxin, atenolol, Coumadin 2 mg, with other drugs (unknown doses). ALLERGIES: Allergy to CODEINE. SOCIAL HISTORY: The patient lives alone. He has three children. His daughter is [Name (NI) 5969] (telephone number [Telephone/Fax (1) 15292]). The patient is separated from his wife. [Name (NI) ] drinks no alcohol. He quit tobacco 20 years ago. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 95, heart rate 37, blood pressure 90/50, weight 86.2 pounds, 95% oxygen saturation on room air. In general, the patient was a cachectic and disheveled elderly man. Head, ears, nose, eyes and throat showed redness around eyes/erythema, pail sclerae. Oropharynx was clear. Neck was supple. Full range of motion. No lymphadenopathy. Chest revealed decreased breath sounds at bases. Heart revealed bradycardia, irregularly irregular. No murmurs, rubs or gallops. Positive first heart sound and second heart sound. Spine with an area of erythema at approximately T10, nontender. Abdomen was soft, nontender, and nondistended, positive bowel sounds. Positive inguinal hernia bilaterally. Extremities revealed dry flaky skin. Feet were hyperkeratotic skin, toes stuck together due to buildup of skin. Neurologic examination revealed alert and oriented times three; did not know day. Upper extremities with 5/5 strength. Lower extremities proximally with 3/5 and distally with 5/5 strength. Rectal was heme-negative. PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell count 6, hematocrit 41, platelets 167 (76% neutrophils, 0 bands, 17% lymphocytes). The patient's PT was 22.4, PTT 40.3, INR 3.5. Sodium 144, potassium 4.6, chloride 103, bicarbonate 31, blood urea nitrogen 28, creatinine 0.9, glucose of 96. Anion gap 15. Digoxin level 2.5. ASSESSMENT AND PLAN: A [Age over 90 ]-year-old male with failure to thrive. 1. FAILURE TO THRIVE: Due to inability to care for himself at home the patient will need placement options, increased nutrition, a Physical Therapy consultation. The patient will need Podiatry and Wound Care consultation. The patient with chest x-ray, urinalysis, and urine culture for possible urinary tract infection. The patient will need correction of electrolyte abnormalities, supplements, and Protonix, and subcutaneous heparin for prophylaxis. 2. CARDIOVASCULAR: The patient with atrial fibrillation and bradycardia. The patient was hypothermic, may be contributing to the bradycardia. The patient will be put on telemetry. We will hold his antihypertensive medications, hold Coumadin since INR was 3.5. HOSPITAL COURSE: The patient had an episode of oxygen desaturation to 70s and 80s even on 5 liters nasal cannula. The patient was put on a nonrebreather, taken to the Medical Intensive Care Unit for an overnight stay. The patient was stable in the Medical Intensive Care Unit and was discharged back to the floor and started on ceftriaxone and Flagyl intravenously. The patient with question of aspiration. A swallowing study showed poor reflex, and the patient failed the swallowing study. The patient had nasogastric tube placement for feedings, and upon questionable placement via chest x-ray the nasogastric tube was removed. Radiology report revealed nasogastric tube/Dobbhoff tube was in the duodenum. Gastrointestinal evaluation was done. The patient was not a candidate for a percutaneous endoscopic gastrostomy tube or surgical placement of G-tube or J-tube. The patient was getting nutrition via intravenous via "Quick Mix" and now getting oral thickened liquid diet and Boost in the full upright position in light of failed nasogastric tube, and since he cannot have a percutaneous endoscopic gastrostomy tube placed. The patient will continue to get nutrition orally at the nursing home. The patient had a run of nonsustained ventricular tachycardia and continued to have atrial fibrillation. The patient was taken off telemetry monitor, as the patient was not a candidate for pacemaker implant or arrhythmia surgery. The patient has been asymptomatic with tachycardia. The patient continued to have episodes of bradycardia and tachycardia. The patient was started on captopril 6.25 mg b.i.d. for congestive heart failure and hypertension. The patient has been given Lasix multiple times for episodes of questionable pulmonary edema and desaturations of oxygen saturation. These were most likely due to mucous plugging and aspiration of secretions. The patient's digoxin was discontinued for high levels. Podiatry consultation appreciated, the patient's feet were properly clean and dressed via Podiatry. The patient was to go to the nursing home on oral feeding with thickened liquids in the upright position. The patient will be followed by his attending, and do not resuscitate/do not intubate status was addressed. The patient would not like any intubation or invasive measures taken if he should be in a code situation. The attending will follow up with this. The patient's daughter also agreed with this and agreed to have the patient go to a nursing home. The patient asked to be kept comfortable and hoped he will gain his strength back, but has been made fully aware of his failing condition. He wished to "die peacefully" with family or friends surrounding him if this should happen. We hope he will regain some strength. If the patient's oxygen saturation drops he made need suctioning of secretions, but is not to be intubated and has been doing fine on oxygen via nasal cannula and face mask with humidification. The patient may need morphine for breathing comfort, but has not required any to date. On the day of discharge, the patient felt "fine" and was looking forward to going to the nursing home where he has a female friend/partner already staying there. DISCHARGE DIAGNOSES: 1. Failure to thrive. 2. Atrial fibrillation. 3. Congestive heart failure. 4. Hypothyroidism. 5. Pulmonary issues. CONDITION AT DISCHARGE: Condition on discharge was fair. MEDICATIONS ON DISCHARGE: 1. Levoxyl 0.025 mg p.o. q.d. 2. Captopril 6.25 mg p.o. b.i.d. 3. Levaquin 500 mg p.o. q.d. times 10 days. 4. Flagyl 500 mg p.o. t.i.d. times 10 days. 5. Protonix 40 mg p.o. q.d. 6. Morphine 0.5 mg to 2 mg as needed for breathing issues; not to be used if the patient is sedated or respiratory rate decreases below 10. DISCHARGE FOLLOWUP: The patient will be followed by Dr. [Last Name (STitle) ], his primary care physician. [Name10 (NameIs) ] note, the patient with high thyroid-stimulating hormone indicative of hypothyroidism. The patient was started on Levoxyl. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15293], M.D. [MD Number(1) 15294] Dictated By:[Last Name (NamePattern1) 4724] MEDQUIST36 D: [2127-12-24] 15:12 T: [2127-12-24] 15:11 JOB#: [Job Number 15295]	[ "4280", "42731", "42789", "4019", "412", "2449" ]
Admission Date: [2179-9-29] Discharge Date: [2179-10-22] Date of Birth: [2102-1-6] Sex: M Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 1055] Chief Complaint: 77M with history of CAD, AF, esophageal adenocarcinoma s/p XRT, resection and chemotherapy who initially presented with tachypnea [12-30] pericardial and pleural effusions and transferred to MICU after thoracentesis, pericardiocentesis and pericardial window with chest tube for pneumothorax. Stable respiratory status since transfer to floor. Major Surgical or Invasive Procedure: Pericardiocentesis Right Anterior Mini Thoracotomy and Pericardial Window Bronchoscopy Right heart catheterization PICC placement History of Present Illness: Admitted to [Location (un) ] from [Hospital ] Rehab with tachypnea and hypoxia. Per OSH records, patient had been experiencing shortness of breath, with O2 sats in the high 60's, RR in 40's. O2 sats improved with Lasix up to 90% on 2L, BP 98-109/40-60s, HR 70-80s. Pt was given cefepime and levaquin for R-sided infiltrate seen on CXR and underwent a US guided thoracentesis for R-sided effusion. 1 liter of serous fluid removed, post-procedure CXR showed 10% R apical pneumothorax. In addition, patient went into a-fib w/ hr into 160's. Patient given dig, amiodarone (loaded and drip x 6 hours) and diltiazem drip. Patient underwent echo which showed large pericardial effusion, sent to [Hospital1 18] for evaluation/pericardiocentesis. . Of note, patient recently discharged from [Hospital3 ] after 2 week hospitalization for bilateral pleural effusions and pneumonia. . On admission, patient states that he been feeling progressively SOB for the past week, and has noticed increased swelling of his lower extremities, making it difficult to walk. Denies any current chest pain, reports currently breathing comfortably. No F/C/N/V. H/o productive cough. + orthopnea. Past Medical History: HTN, lung disease, pleural tap 1L on right [9-29], COPD exacerbation, esophageal cancer- Barrett's, stage II, T1, N1, MO adenocarcinoma, s/p resection, chemo and radiation (completed approx. 2 months ago), J-tube in place for supplemental nutrition, PAF on coumadin (saw Mirbach for tachy thought to be a-fib/flutter after adenosine x1), h/o cardioversion, anemia, h/o kidney stones, "trigger finger", cataract surgery Social History: married w/ two sons, lives w/ wife [Name (NI) 382]. Former manager of phone company. + 60 pack year tob history, quit 6 months ago. +h/o ETOH, quit 6 months ago. Family History: Mom deceased at 78 from MI, Dad deceased from MS at 44. Brother w/ quad bypass 78. Physical Exam: 97.0/ 72/ 28/ 111/72 85kg/ 93% on 5L NC GEN:pale, awake, alert, sitting up in bed, breathing comfortably HEENT:atraumatic, anicteric sclerae, clear OP NECK:no carotid bruits, JVP about 10cm CV:muffled and distant HS, no murmurs appreciated, +pleural rub, +femoral pulses, faint but +DP and PT pulses. Pulsus of 9. LUNGS:diminished on R, crackles at bases, deeply productive cough ABDOMEN: soft, j-tube in place, site CDI, NABS, nt EXT:[1-29]+ pitting edema bilaterally on LE, UE edema bilaterally, + clubbing of nails, resting tremor of R leg NEURO:A/O X3, spontaneous movement x4. no focal deficits Pertinent Results: EKG: a-fib, low voltage in precordial and limb leads, no ST changes or TWI . Cath ([9-30]): Right heart catheterization demonstrated elevated right atrial and right ventricular end diastolic pressures which were approximately equal to pericardial pressures (12 mmHg0 suggestive of early tamponade. After pericardiocentesis, pericardial pressures returned to 0 mmHg. Cardiac output calculated using the Fick method demonstrated moderate to severely diminished cardiac index of 2.0L/min/m2 prior to pericardiocentesis, with improvement to 2.6L/min/m2 after pericardiocentesis. PA sat improved 48 to 58. . Echo ([10-11]): approximately 1 cm wide partially echo dense region around the heart (most prominent anteriorly) consistent with probable somewhat organized pericardial effusion and pericardial thickening. No definite echocardiographic signs of tamponade are identified but views are technically suboptimal. Echo ([10-6]): moderate sized pericardial effusion. No right ventricular diastolic collapse is seen. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade Echo ([10-2]): moderate pericardial effusion, anterior to RA and RV, consistent with loculation Echo ([9-30]): anterior space fat pad, but possible loculated anterior pericardial effusion Echo ([9-29]): large pericardial effusion with increased intrapericardial pressure, EF 50-60% . CXR ([10-11], 14:26): Probable small right apical pneumothorax. Status post placement of small bore chest tube. Moderate right and small left pleural effusions. CXR ([10-11], 10:30): Worsening atelectasis in the right lung. Lucency at right lung apex, without definitive visceral pleural line identification. Status post esophagectomy and pullup procedure. Improving left pleural effusion and enlarging right pleural effusion CXR ([10-10]): Bilateral pleural effusions and associated atelectases in both lower zones. No pneumothorax. CXR ([10-2]): mild pulmonary edema, moderate bilateral pleural effusions (R>L) CXR ([9-29]): bilateral pleural effusions (L>R), pulmonary edema on right side, RLL collapse . Cytology [10-11] - bronchial brushings - reactive bronchial epithelial cells. . Chest U/S [10-12] - bilateral pleural effusions . CT-Chest/abd/pelvis - [10-13] - Interval decrease in pericardial effusion and right-sided pleural effusion with left-sided pleural effusion, not significantly changed. Interval increase in size of right-sided pneumothorax compared to prior chest CT. Compressive atelectasis in both lungs with no specific evidence for aspiration. No evidence of GI or bowel obstruction. Cholelithiasis. Small nonobstructing stones in the right kidney. Low attenuation lesion in the left kidney that likely represents a cyst, that is not fully characterized on this noncontrast study. . [2179-9-29] 07:26PM GLUCOSE-128* UREA N-25* CREAT-0.6 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 [2179-9-29] 07:26PM CK(CPK)-13* [2179-9-29] 07:26PM CK-MB-NotDone cTropnT-<0.01 [2179-9-29] 07:26PM ALBUMIN-2.3* CALCIUM-7.4* PHOSPHATE-3.2 MAGNESIUM-1.5* IRON-28* [2179-9-29] 07:26PM calTIBC-212* VIT B12-933* FOLATE-14.0 FERRITIN-347 TRF-163* [2179-9-29] 07:26PM WBC-12.6* RBC-2.83* HGB-9.2* HCT-27.3* MCV-96 MCH-32.5* MCHC-33.7 RDW-15.8* [2179-9-29] 07:26PM RET AUT-2.8 [2179-9-29] 07:26PM PT-17.8* PTT-33.5 INR(PT)-2.2 [2179-9-29] 07:26PM BLOOD calTIBC-212* VitB12-933* Folate-14.0 Ferritn-347 TRF-163* [2179-10-1] 01:35AM BLOOD Type-ART Temp-37.1 pO2-66* pCO2-54* pH-7.40 calHCO3-35* Base XS-6 [2179-9-30] 10:45AM OTHER BODY FLUID WBC-444* Hct,Fl-2* Polys-22* Lymphs-10* Monos-7* Eos-1* Mesothe-1* Macro-59* [2179-9-30] 10:45AM OTHER BODY FLUID TotProt-3.6 Glucose-99 LD(LDH)-343 Amylase-16 Albumin-2.0 [2179-10-13] 02:26PM PLEURAL TotProt-2.1 LD(LDH)-88 Albumin-1.1 [2179-10-13] 02:26PM PLEURAL WBC-17* RBC-510* Polys-39* Lymphs-26* Monos-25* Meso-8* Macro-2* [2179-10-7] 06:06AM BLOOD WBC-8.8 RBC-3.16* Hgb-10.3* Hct-29.5* MCV-93 MCH-32.5* MCHC-34.8 RDW-16.5* Plt Ct-245 [2179-10-8] 05:11AM BLOOD WBC-12.1* RBC-3.27* Hgb-10.7* Hct-30.5* MCV-93 MCH-32.6* MCHC-35.0 RDW-16.4* Plt Ct-235 [2179-10-9] 05:00AM BLOOD WBC-13.8* RBC-3.12* Hgb-10.1* Hct-30.2* MCV-97 MCH-32.4* MCHC-33.4 RDW-16.1* Plt Ct-266 [2179-10-11] 05:15AM BLOOD WBC-8.6 RBC-2.71* Hgb-8.8* Hct-27.0* MCV-100* MCH-32.4* MCHC-32.5 RDW-15.9* Plt Ct-245 [2179-10-12] 04:15AM BLOOD WBC-10.3 RBC-2.80* Hgb-9.0* Hct-26.0* MCV-93 MCH-32.3* MCHC-34.7 RDW-16.2* Plt Ct-318 [2179-10-14] 03:52AM BLOOD WBC-9.6 RBC-3.40# Hgb-10.9# Hct-30.3# MCV-89 MCH-32.1 MCHC-36.0* RDW-16.0* Plt Ct-225 [2179-10-9] 05:00AM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.5 [2179-10-10] 06:51AM BLOOD PT-14.4* PTT-50.4* INR(PT)-1.4 [2179-10-10] 07:45AM BLOOD PT-14.3* PTT-32.8 INR(PT)-1.4 [2179-10-12] 04:15AM BLOOD PT-16.2* PTT-108.1* INR(PT)-1.8 [2179-10-13] 04:12AM BLOOD PT-15.1* PTT-74.0* INR(PT)-1.6 [2179-10-14] 03:52AM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.4 [2179-10-7] 06:06AM BLOOD Glucose-83 UreaN-21* Creat-0.5 Na-140 K-4.8 Cl-100 HCO3-35* AnGap-10 [2179-10-9] 05:00AM BLOOD Glucose-128* UreaN-16 Creat-0.5 Na-139 K-4.3 Cl-99 HCO3-34* AnGap-10 [2179-10-12] 04:15AM BLOOD Glucose-100 UreaN-22* Creat-0.4* Na-140 K-4.0 Cl-98 HCO3-37* AnGap-9 [2179-10-14] 03:52AM BLOOD Glucose-71 UreaN-18 Creat-0.5 Na-143 K-4.2 Cl-98 HCO3-33* AnGap-16 [2179-10-2] 02:16PM BLOOD ALT-10 AST-8 LD(LDH)-126 AlkPhos-66 TotBili-0.3 [2179-10-13] 04:12AM BLOOD TotProt-4.7* Calcium-8.2* Phos-3.3 Mg-1.5* [2179-10-11] 02:51PM BLOOD Type-ART Rates-/28 FiO2-100 pO2-194* pCO2-91* pH-7.26* calHCO3-43* Base XS-10 AADO2-450 REQ O2-75 Intubat-NOT INTUBA [2179-10-11] 09:48PM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-54* pH-7.47* calHCO3-40* Base XS-13 Intubat-INTUBATED [2179-10-12] 12:18AM BLOOD Type-ART Temp-37.4 Rates-20/26 Tidal V-450 PEEP-5 FiO2-50 pO2-102 pCO2-54* pH-7.46* calHCO3-40* Base XS-12 -ASSIST/CON Intubat-INTUBATED [2179-10-13] 04:12AM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-50 pO2-73* pCO2-58* pH-7.43 calHCO3-40* Base XS-11 Intubat-INTUBATED Vent-SPONTANEOU [2179-10-13] 01:43PM BLOOD Type-ART Temp-37.8 Rates-/72 FiO2-40 pO2-103 pCO2-75* pH-7.37 calHCO3-45* Base XS-13 Intubat-NOT INTUBA Comment-NEBULIZER [2179-10-14] 05:56AM BLOOD Type-ART Temp-36.7 FiO2-50 pO2-81* pCO2-61* pH-7.39 calHCO3-38* Base XS-8 [2179-10-14] 03:45PM BLOOD Type-ART Temp-36.7 pO2-118* pCO2-62* pH-7.37 calHCO3-37* Base XS-8 . Discharge Labs: [2179-10-22] 07:05a Na 137 Cl 98 BUN 18 Glc 114 K 4.6 Bicarb 33 Cr 0.5 Ca: 7.9 Mg: 1.6 P: 3.6 PT: 13.9 PTT: 62.7 INR: 1.3 ----------- [10-22] 12AM heparin dose: 1180 PTT: 60.8 ---------- [2179-10-21] 5:05p heparin dose: 1180 PTT: 65.2 ----------- [2179-10-21] 09:05a heparin dose: 1120 PT: 13.9 PTT: 53.8 INR: 1.3 Brief Hospital Course: 77 y/o male w/ long history of smoking, a-fib, htn, COPD, and esophageal cancer rx w/ chemo, surgery, and radiation; s/p thoracentesis, who presents with hypoxia, tachypnea, concern for tamponade on echo done at OSH. 1. Cardiac In terms of his vessels, he was stable, with no acute concerns to suggest ischemia. The patient had negative cardiac enzymes on admission. He was restarted on his beta blocker once his blood pressure was able to tolerate it, and was titrated up to a dose of metoprolol 25mg TID. In terms of his pump, the patient underwent a repeat echo immediately upon admission which showed a large circumferential effusion, with an estimated EF >55%. He underwent a pericardiocentesis on [9-30] with removal of over 300 cc of bloody exudative fluid. Cultures from the fluid were negative, and the preliminary report on the cytology of the fluid is negative for malignancy. The patient underwent subsequent repeat echoes which showed a stable, persistent anterior effusion. Thoracic surgery was consulted to evaluate patient for a pericardial window, felt that procedure would carry a higher risk given past surgery for esophageal cancer. Patient would need risk stratification prior to surgery. The patient had an echo on the day of discharge, which showed an increase in the pericardial effusion (loculated) w/ RA collapse and evidence of constrictive pericarditis as well. The decision was made for patient to undergo a pericardial window, and was taken to the OR on [10-7]. Will need to follow up on fluid cytology, pathology, and culture results. Report was negative for malignant cells. In addition, the patient had a history of atrial fibrillation, and underwent both electro cardioversion and chemical conversion with ibutilide at the OSH. Although in NSR on admission, the patient subsequently developed an atrial tachycardia/a-flutter rhythm with a heart rate up to 140's. Rate control was attempted with IV calcium channel blocker, IV metoprolol, and IV amiodarone; but ultimately required conversion again with ibutilide. The patient remained in NSR with effective rate control on amiodarone and metoprolol. Patient currently on TID Amiodarone but can be switched to once daily Amiodarone on [11-1]. The patient was restarted on heparin after an occluding thrombus was seen in his left cephalic vein. He is being transferred to rehab on heparin drip for bridge to coumadin. His goal PTT is 60-80 and his goal INR is [12-31]. Patient will need to have his INR followed closely as an outpatient once discharged from extended care facility. . 2. Pulmonary- the patient was admitted with hypoxia/tachypnea, likely secondary to bilateral effusions and ? infiltrate/infection seen on chest x-ray. The patient was placed on oxygen with a goal saturation in low-mid 90's given his history of COPD, with continuation of his Advair/Atrovent/spiriva/Xopenex. The OSHs were contact[Name (NI) ] for results from his thoracentesis-->which were c/w a transudative fluid, all cultures negative, however it was unclear as to whether any sample was sent for cytology. The patient underwent a chest CT, which showed significant consolidation on the right, a right hydropneumothorax from the prior tap at the OSH, bilateral pleural effusions, and changes consistent with pneumonitis form XRT. Given that the patient had recently been treated with Levaquin at the OSH, the patient was started on ceftriaxone to complete a ten day course, and azithromycin. Pulmonary was consulted, and they recommended completing the course of antibiotics and felt that further thoracentesis would be low yield, but that the patient should have a repeat CT in a few weeks to evaluate for resolution of his effusions. The patient underwent a repeat CT prior to pericardial window procedure, which showed an increase in his effusions bilaterally, thus pleural fluid was also removed during the procedure with samples sent for cytology/path/culture. The patient's breathing and oxygen saturation remained stable throughout his hospitalization, and his cough lessened in severity. The patient became acutely hypoxic and tachypneic on am of [10-11], requiring transfer back to CCU for intubation. CXR showed R apical pneumothorax, dart chest tube placed by thoracic service w/out much improvement on repeat CXR. Pulmonary reconsulted, decided patient will need bronch and that primary issues were no longer cardiac but rather pulmonary. Decision made to transfer patient to MICU team. While on the MICU service the pt's minichest tube was pulled on [10-14]. F/U CXR revealed a stable PTX. The pt was extubated on [10-14] and continued to do well from a respiratory standpoint with chest PT and pulmonary toilet. However post extubation pt continued to have recurrent atrial tach. Patient cardioverted on [10-2] w/ ibutilide (1.6 mg) and is now on amiodarone, rhythm mostly sinus with freq PACs. Beta blocker was re-added once his hypotension resolved. He was back in afib/flutter [10-15], unresponsive to IV metop and dilt drip, converted by EP with ibutilide. The pt is now stable in NSR on amiodarone. His respiratory status has been stable since transfer to the floor. His O2 sats are 94-96 on 2L NC. Patient can be weaned off supplemental O2 as tolerated. Patient started on standing Lasix for prevention of volume overload. . 3. ID- The patient was started on ceftriaxone and azithromycin for pneumonia, showed some improvement in his productive cough while on antibiotics and completed course. Cultures from his pericardial fluid were negative, cultures from pleural fluid negative from [10-13] following "very low numbers" of coagulase negative staphylococcus on [10-7]. Patient remained afebrile without a leukocytosis during remainder of his admission. . 4. Anemia- likely iron deficiency anemia in addition to element of anemia of chronic disease secondary to malignancy. The patient was transfused 2 units of PRBCs with appropriate increases in his HCT during admission. Iron studies were sent, which were c/w iron deficiency anemia, vitamin B12 and folate were normal. The patient had several episodes of guaiac positive brown stool, and although he states that he has had a colonoscopy within the past five years, he will likely need a GI workup as an outpatient. Although kidney function appeared normal with a creatinine of .5, the patient would likely benefit from iron/Epogen supplementation as an outpatient. Would recommend starting weekly Epoen injections. . 5. FEN- The patient was restarted on TF through his j-tube per nutrition recommendations. Evaluated with bedside speech and swallow evaluation as well as video swallow. He can have thin liquids and pureed consistency solids as per their recs. He MUST take small, single sips of thin liquids by cup or straw. He was noted to have a metabolic alkalosis, with an initial bicarb of 34 that rose to 37. This was thought to be secondary to contraction alkalosis as patient received some Lasix, in addition to a compensatory alkalosis for a respiratory acidosis from his COPD, and resolved without specific intervention. Bicarb 33 at time of discharge. Would monitor closely as patient started to standing Lasix to prevent volume overload. Patient required aggressive magnesium supplementation and should have his electrolytes monitored closely. . 6. Oncology- the patient was recently treated for Stage II esophageal cancer, s/p resection, chemo and XRT with intended cure. Heme/onc was consulted and recommended that patient undergo restaging with a PET scan as an outpatient. The patient did not show signs of metastasis on CT done here, and the preliminary cytology report from his pericardial fluid was negative for malignancy, however it was noted that this does not rule out a malignant effusion given the low sensitivity of cytology. The patient stated that he wants to continue his oncology care through [Hospital3 2358], and has a follow-up appointment scheduled with his oncologist for [2179-11-18]. . 7. Dispo: The patient was seen by PT/OT prior to discharge, and the patient should see his PCP after leaving extended care facility so that a follow-up echo can be arranged, in addition to Coumadin management and monitoring of his QT interval, as many of his medications cause a prolonged QT. Medications on Admission: Admit meds from OSH: Amiodarone gtt at 0.5mg/min Diltiazem gtt Furosemide 40mg daily Advair KCl Metoprolol 100mg tid Dulcolax MOM Albuterol [Name (NI) 10687] MVI Reglan Coumadin Levofloxacin Cefepime Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Terbinafine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 3 weeks. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. [Hospital1 10687] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) sliding scale Intravenous ASDIR (AS DIRECTED): Please continue heparin sliding scale w/ PTT goal 60-80 until INR therapeutic at 2-3. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times a day: Please continue this dose for 10 days through [2179-11-1] and then switch to 200mg once daily. 16. Epogen 20,000 unit/mL Solution Sig: One (1) injection Injection once a week. 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 19504] of [Hospital1 189] Discharge Diagnosis: pericardial effusion pleural effusion COPD a-flutter/a-fib s/p chemical conversion hypertension esophageal adenocarcinoma Discharge Condition: Stable Discharge Instructions: Please take all of your other medications as instructed. Please maintain your follow-up appointments as listed below. Please call your doctor or return to the hospital if you develop shortness of breath, chest pain, fever or chills. Please have a follow-up echo in about 4 weeks. Followup Instructions: 1. You have an appointment scheduled with your oncologist for [2179-11-18] at 9AM at the [Hospital3 ] with Dr.[Last Name (STitle) ] at [Telephone/Fax (1) 66282]. 2. Please follow up with your primary care doctor within [11-29] weeks of discharge from rehab facility. 3. Please contact Dr.[Last Name (STitle) ] with any questions by paging him at [Telephone/Fax (1) 8717], pager #[Numeric Identifier 9522]. Completed by:[2179-10-22]	[ "51881", "486", "496", "5180", "4280", "42731", "4019" ]
Admission Date: [2120-11-4] Discharge Date: [2120-11-12] Date of Birth: [2061-5-31] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2120-11-4] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to Ramus) History of Present Illness: 59 y/o female with multiple cardiac risk factors who experienced chest pain and admitted on [10-17] with a myocardial infarction. Underwent Cardiac Cath at that time which revealed Left main and three vessel disease. Stent was placed in RCA and now returns for surgical revascularization. Past Medical History: 1) Myocardial Infarction with PTCI/Stent to RCA [10-14] 2) Hypertension 3) Hyperlipidemia 4) s/p MVA ([10/2112]) with chronic neck pain 5) Carpal tunnel syndrome 6) Seborrheic psoriasis with postinflammatory hyperpigmentation of face Social History: No ETOH, +smoking history ([12-11] ppd), no illicit drugs. Family History: No history of MI or diabetes. Physical Exam: Preop General: Pleasant woman in NAD HEENT: EOMI, PERRL, NC/AT] Cardiac: RRR -c/r/m/g Pulm: CTAB -w/r/r Abd: Soft, NT/ND +BS Ext: W/D -c/c/e Neuro: A&O x 3, MAE, non-focal Discharge Gen NAD Neuro A&Ox3, MAE-nonfocal exam Pulm CTA bilat Cor RRR, S1-S2, sternum stable- incision CDI Abdm Soft/NT/ND/NABS Ext Warm & well perfused. Trace edema bilat. Left EVH site with steris CDI Pertinent Results: Echo [11-4]: PRE-BYPASS: Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the mid inferior wall. Overall left ventricular systolic function is mildly depressed. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: No change in biventricular systolic function with persistent wall motion abnormalities. No change in valve structure and function CXR [11-8]: [2120-11-4] 11:29AM BLOOD WBC-12.5* RBC-2.54# Hgb-7.8# Hct-21.8# MCV-86 MCH-30.6 MCHC-35.6 RDW-14.7 Plt Ct-215 [2120-11-8] 06:20AM BLOOD WBC-19.0* RBC-3.37# Hgb-10.3# Hct-29.1# MCV-86 MCH-30.7 MCHC-35.6 RDW-15.2 Plt Ct-302 [2120-11-4] 12:30PM BLOOD PT-14.2* PTT-39.0* INR(PT)-1.3* [2120-11-4] 12:41PM BLOOD UreaN-12 Creat-0.5 Cl-112* HCO3-25 [2120-11-8] 06:20AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-140 K-4.6 Cl-99 HCO3-31 AnGap-15 [2120-11-12] 06:00AM BLOOD WBC-15.4* [2120-11-11] 06:05AM BLOOD WBC-23.0# RBC-4.09 Hgb-12.1 Hct-36.1# MCV-88 MCH-29.5 MCHC-33.4 RDW-15.3 Plt Ct-604* [2120-11-11] 06:05AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-138 K-5.2* Cl-95* HCO3-30 AnGap-18 Brief Hospital Course: Ms. [Known lastname ] was a same day admit and was brought directly to the operating room where she underwent a Coronary Artery Bypass Graft x 3(LIMA-LAD, SVG-OM, SVG-Ramus). Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one chest tubes were removed and beta blockers and diuretics were started. She was gently diuresed towards her pre-op weight. Also on this day she was transferred to the SDU. On post-op day three epicardial pacing wires were removed. She was started on Folic Acid and Iron secondary to low HCT, but was not transfused. Over the next several days she slowly improved while working with physical therapy for strength and mobility. She cleared level five physical therapy and on post-op day 8 it was decidecd she was stable and ready for discharge home Medications on Admission: Lisinopril 5 qd, Plavix 75 qd, Nitro SL prn, Lipitor 80 qd, Lopressor 50 [Hospital1 ], Folic Acid, Methotrexate 2.5 (8 qtues), Etanercept 50 qMon/[Last Name (un) ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Last Name (un) ]:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Last Name (un) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. [Last Name (un) ]:50 Tablet(s) Refills:0 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (un) ]:30 Tablet(s) Refills:2 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (un) ]:30 Tablet(s) Refills:2 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (un) ]:30 Tablet(s) Refills:2 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (un) ]:30 Tablet(s) Refills:2 8. Methotrexate 2.5 mg Tablet Sig: Eight (8) Tablet PO Q Tuesday. 9. Enbrel 50 mg/mL (0.98 mL) Syringe Sig: One (1) Subcutaneous Q Monday/Thursday. 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). [Last Name (un) ]:180 Tablet(s) Refills:2 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. [Last Name (un) ]:14 Tablet(s) Refills:0 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day for 2 weeks. [Last Name (un) ]:56 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Myocardial Infarction, Hypertension, Hyperlipidemia, Carpal Tunnel Syndrome, Seborrheic psoriasis with postinflammatory hyperpigmentation of face, s/p MVA with chronic neck pain Discharge Condition: Good Discharge Instructions: no lotions, creams or powders on any incision no driving for one month shower over incision and pat dry call for fever greater than 100, redness or drainage no lifting greater than 10 pounds for 8 weeeks Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [First Name (STitle) 3510] in [12-11] weeks Dr. [Last Name (STitle) ] in [1-12] weeks Completed by:[2120-11-12]	[ "41401", "42731", "2724", "4019" ]
Admission Date: [2182-5-30] Discharge Date: [2182-6-5] Date of Birth: [2099-9-16] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 33015] Chief Complaint: Shortness of [First Name3 (LF) 1440] Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: . 82 year old male with complicated PMH including metastatic adenocarcinoma to liver of unknown primary (possibly cholangiocarcinoma), systolic HF with EF45%, CAD, CRI, MICU transfer following 3 day admission in the MICU. Has experienced functional decline in the setting of new dx of met. adenoca. found incidentally in 09. Of note, he was recently discharged from [Hospital1 18] on [2182-5-24] following 10 day admission for acute on CRI(peak Cr 4.7) thought related to prerenal phsyiology in setting of ESBL UTI. During admission, his home lasix and lisinopril were discontinued and his metoprolol and imdur were decreased. He was discharged to rehab to complete 2L NS infusion. He was evaluated by speech and swallow for dysphagia and palliative care was involved in goals of care discussion where family was clear about wishes for continued aggressive measures during that stay. . Pt returned to the ED on [2182-5-30] with following vitals: HR 116 BP 198/119 RR 28 POx 100 O2 sat. Found to have O2 sat of 94% on NRB. Patient was given 80mg IV lasix with 600cc output, nitro gtt, 4mg IV morphine, antibiotic coverage for suspected hospital acquired pneumonia (ceftriaxone 1gm, levaquin 750mg IV, and vancomycin 1gm IV). He was placed on CPAP with improvement. Labs were significant for troponin 0.36, creatinine 1.7, WBC 11.6 with left shift. EKG with ST changes laterally. . Pt was admitted to the ICU p/w s/s of flash pulmonary edema in the setting of hypertensive urgency, likely secondary to CRI where meds were decreased. He was diuresed with 80mg IV lasix. Due to low clinical suspicion regarding hospital-acquired pneumonia, pt was discontinued from ceftriaxone and vancomyin and kept on levaquin. Palliative care was involved. Pt now stable and ready for transfer to the floor. . Review of systems: denies CP, abdominal pain, nausea, vomiting, diarrhea Past Medical History: H/o PNA with MRSA GERD CAD: NSTEMI in [2180] that was medically managed CHF: Systolic dysfunction, EF 45-50% HTN Hyperlipidemia Parkinson's disease: Diagnosed in [2166], on dopamine agonists, disease course complicated by autonomic dysfunction Adenocarcinoma in the liver: Incidentally discovered in [2181], moderate to poorly differentiated adenocarcinoma metastasis from unknown primary Chronic renal insufficiency: Baseline Cr 1.3-1.6 BPH H/o mulitple UTIs: has been complicated by sepsis in the past Renal cysts on R Melanoma s/p excision (R ear) in [2177] Anterior subluxation of L4/L5 Incomplete paraplegia: [1-7] spinal stenosis, s/p surgery Depression, anxiety Social History: The patient is a retired sociology and IR professor. He has been residing in [Hospital 100] Rehab for several years now. He is a former smoker but quit 45 years ago. Rare alcohol. His wife and daughter live in the great [Name (NI) 86] area Family History: The patient has one daughter with breast cancer. No other h/o malignancy. Both his son and daughter have renal cysts Physical Exam: Physical Exam: . Vitals: T: 98.2 BP: 145/59 P: 68 R: 15 O2: 98% on 3L O2. Water balance: negative 2252 cc. . General: Alert, no acute distress, pleasant HEENT: Sclera anicteric, dry mucous membranes Neck: supple, JVP elevated to clavicle, no LAD Lungs: no accessory respiratory muscle use; rales in bilateral lobes with decreased [Name (NI) 1440] sounds; expiratory rhonchi CV: Regular rate and rhythm, normal S1 + S2, HS distant, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, chronic venous stasis changes in legs, well perfused, 2+ pulses, 3+ pitting edema to knees, slight resting tremor of both arms, mild cogwheeling Left brachial PICC line - appears to be pulled out, no erythema skin: pale Psych: alert and oriented to person, place, and time Pertinent Results: [2182-6-4] 07:48AM BLOOD WBC-7.0 RBC-3.37* Hgb-9.3* Hct-30.1* MCV-89 MCH-27.7 MCHC-31.0 RDW-16.5* Plt Ct-184 [2182-6-3] 07:25AM BLOOD WBC-8.1 RBC-3.42* Hgb-9.5* Hct-30.5* MCV-89 MCH-27.8 MCHC-31.2 RDW-16.6* Plt Ct-190 [2182-6-2] 06:25AM BLOOD WBC-8.5 RBC-3.36* Hgb-9.3* Hct-30.1* MCV-90 MCH-27.6 MCHC-30.8* RDW-16.6* Plt Ct-188 [2182-6-1] 04:30AM BLOOD WBC-8.1 RBC-3.18* Hgb-8.9* Hct-28.6* MCV-90 MCH-28.1 MCHC-31.2 RDW-16.7* Plt Ct-184 [2182-5-31] 03:35AM BLOOD WBC-12.5* RBC-3.40* Hgb-9.5* Hct-30.8* MCV-91 MCH-27.9 MCHC-30.8* RDW-16.6* Plt Ct-224 [2182-5-30] 09:30PM BLOOD WBC-11.7# RBC-4.02# Hgb-11.1# Hct-36.4# MCV-90 MCH-27.7 MCHC-30.6* RDW-16.6* Plt Ct-288# [2182-5-30] 09:30PM BLOOD Neuts-81.6* Lymphs-11.1* Monos-4.1 Eos-2.5 Baso-0.7 [2182-6-4] 07:48AM BLOOD Plt Ct-184 [2182-6-3] 07:25AM BLOOD Plt Ct-190 [2182-6-2] 06:25AM BLOOD Plt Ct-188 [2182-6-1] 04:30AM BLOOD Plt Ct-184 [2182-5-31] 03:35AM BLOOD Plt Ct-224 [2182-5-30] 09:30PM BLOOD Plt Ct-288# [2182-5-30] 09:30PM BLOOD Plt Ct-288# [2182-5-30] 09:30PM BLOOD PT-13.3 PTT-24.0 INR(PT)-1.1 [2182-6-4] 02:35PM BLOOD Glucose-143* UreaN-34* Creat-1.7* Na-138 K-4.1 Cl-99 HCO3-31 AnGap-12 [2182-6-3] 07:25AM BLOOD Glucose-129* UreaN-35* Creat-1.7* Na-137 K-4.2 Cl-99 HCO3-30 AnGap-12 [2182-6-2] 06:25AM BLOOD Glucose-153* UreaN-37* Creat-1.7* Na-138 K-4.3 Cl-100 HCO3-30 AnGap-12 [2182-6-1] 04:30AM BLOOD Glucose-145* UreaN-40* Creat-1.7* Na-140 K-4.2 Cl-101 HCO3-31 AnGap-12 [2182-5-31] 03:35AM BLOOD Glucose-220* UreaN-39* Creat-1.6* Na-141 K-4.8 Cl-103 HCO3-31 AnGap-12 [2182-5-30] 09:30PM BLOOD Glucose-246* UreaN-39* Creat-1.7# Na-139 K-5.3 Cl-103 HCO3-24 AnGap-17 [2182-5-31] 03:35AM BLOOD CK(CPK)-61 [2182-5-30] 09:30PM BLOOD CK(CPK)-74 [2182-5-31] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.36* [2182-5-30] 09:30PM BLOOD cTropnT-0.36* [2182-6-4] 02:35PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1 [2182-6-3] 07:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 [2182-6-2] 06:25AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 [2182-5-31] 03:35AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.2 [2182-5-30] 09:30PM BLOOD TotProt-6.9 Albumin-3.3* Globuln-3.6 Calcium-8.9 Phos-4.1 Mg-2.2 [2182-5-31] 04:34AM BLOOD Type-ART pO2-151* pCO2-41 pH-7.43 calTCO2-28 Base XS-3 [2182-5-31] 01:36AM BLOOD Type-ART pO2-113* pCO2-47* pH-7.39 calTCO2-30 Base XS-3 Intubat-NOT INTUBA [2182-5-30] 09:39PM BLOOD Type-[Last Name (un) ] Comment-GREEN TOP [2182-5-31] 01:36AM BLOOD Lactate-1.2 [2182-5-30] 09:39PM BLOOD Glucose-235* Lactate-2.7* Na-140 K-5.3 Cl-103 calHCO3-24 [2182-5-31] 01:36AM BLOOD O2 Sat-99 [2182-5-30] 09:39PM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-97 [2182-6-5] 05:33AM BLOOD WBC-5.7 RBC-3.21* Hgb-8.8* Hct-28.6* MCV-89 MCH-27.3 MCHC-30.6* RDW-16.4* Plt Ct-174 [2182-6-5] 05:33AM BLOOD Plt Ct-174 [2182-6-5] 05:33AM BLOOD Glucose-130* UreaN-32* Creat-1.7* Na-139 K-3.8 Cl-100 HCO3-29 AnGap-14 Brief Hospital Course: Pt is an 82 year old white male with complicated past medical history of metastatic adenocarcinoma, systolic heart failure with an ejection fraction of 45%, chronic renal insufficiency, parkinson's disease, transfer from 3 day medical intensive care unit admission who presents from rehab after recent admit for acute on chronic renal insufficiency, flash pulmonary edema in the setting of hypertensive urgency likely [1-7] to the holding of antihypertensive medication. . Acute pulmonary edema with acute on chronic systolic heart failure: likely due to flash pulmonary edema in setting of hypertensive urgency and acute exacerbation of heart failure. Prior to the MICU admission, lisinopril and lasix had been discontinued, while the imdur and BB had decreased. - [1-7] flash pulmonary edema in setting of HTN urgency. Prior to MICU, the lisinopril/lasix had been d/c'd, and imdur and BB decreased. Pt tolerated diuresis and responded well to IV lasix, which was later switched to PO administration. Creatinine levels held steady at around 1.6-1.7, with a baseline level at around 1.4-1.6. Strict input and output levels were maintained, and showed that pt was tolerating aggressive diuresis. The goal of diuresis for each day was approximately 500cc-1L per day. . There was also a suspected right lower lobe pneumonia that was treated with levofloxacin for a 1 week duration (renal dosage). Sputum and blood cultures were negative. . Aspiration Risk: Evidently a chronic issue, thought to be due to worsening decline of Parkinson's Disease as well as fluctuating mental status. Speech and swallow had evaluted patient and deemed him unable to take anything by mouth, and pt was kept NPO until family and patient could agree upon next step in management, with guidance from medical team. Lengthy family discussion occurred while hospitalized to discuss feeding options, including a repeat video swallow vs. a temporary NG tube. Pt and family ultimately decided for him to undergo repeat video swallow study which he passed, and the following recommendations were made: moist, ground solids, nektar thickened liquids, pills crushed with applesauce, and sips of thin liquids in between meals. If he is choking/coughing on the thin liquids, this should be discontinued. Patient should continue to be monitored by speech and swallow back at rehab. He is still a known chronic aspirator despite the results of video speech and swallow, and goals of care for nutrition should continue to be addressed at rehab. . Metastatic adenocarcinoma of unknown primary: thought to be due to cholangiocarcinoma. Pt is not a candidate for any chemotherapy due to multiple comorbidities and acute medical issues. Family still wants aggressive treatment. Palliative care was involved. . Dysphagia: Was evaluated on last admission by speech and swallow team as well. Due to chronic medical issues and worsening of parkinson's disease, patient's ability to swallow worsened during admission. He was unable to tolerate thickened liquids, and was ultimately sent for repeat video swallow analysis as per above. . Hypertension: Was controlled with hydralazine and isosorbide, with a goal SBP of 130-140 range. Aggressive BP lowering was avoided. . During this admission, pt also developed constipation, which was treated with senna, colace, dulculax, and finally enema. . Coronary artery disease: history of NSTEMI. Troponin mildly elevated on admission, likely [1-7] demand in setting of hypertensive urgency. Patient was given aspiring, beta blockers, imdur, statin, and diuresis. . Chronic renal insufficency: patient maintained a stable creatinine level that was close to baseline despite aggressive diuresis. . Prophylaxis: Subcutaneous heparin, aggressive bowel regimen, home PPI . Access: PICC, PIV x2 . Code: full . Communication: Patient, wife and daughter Medications on Admission: Docusate Sodium 250 mg PO daily Senna 8.6 mg Tablet PO BID Polyethylene Glycol One (1) packet PO DAILY Aspirin 325 mg PO DAILY Finasteride 5 mg PO DAILY Tamsulosin 0.4 mg SR 24 hr PO HS Pramipexole 0.125 mg PO tid Gabapentin 300 mg PO Q24H Omeprazole 40 mg PO once a day. Simvastatin 40 mg PO DAILY (Daily). Carbidopa-Levodopa 25-100 mg PO 5 TIMES DAILY Carbidopa-Levodopa 25-100 mg half a pill Tablet PO TID at 6 am, 11 am and 4 pm. Ferrous Sulfate 325 mg PO DAILY (Daily). Sertraline 25 mg PO once a day. Primidone 25mg PO once a day. Vitamin D 1,000 unit PO once a day. Acetaminophen 325 mg 1-2 Tablets PO Q6H prn pain Metoprolol Succinate 25 mg Tablet SR PO DAILY Isosorbide Mononitrate 30 mg SR 24 hr PO DAILY (Daily). Oxycodone 10 mg Tablet SR 12 hr PO Q12H (every 12 hours). oxycodone IR 10mg Q4H prn pain Morphine oral [Male First Name (un) ] 4mg Q6H Medications upon transfer to [Hospital Ward Name 121] 2: Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Levofloxacin 750 mg IV Q48H day #1 [5-31] Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain Metoprolol Tartrate 25 mg PO BID hold for HR <60 sBP<100 Order date: [5-31] @ 0054 Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing Morphine Sulfate (Oral Soln.) 4 mg PO Q6H pain Aspirin 325 mg PO DAILY Start Carbidopa-Levodopa (25-100) 1 TAB PO 5X/DAY Oxycodone SR (OxyconTIN) 10 mg PO Q12H Carbidopa-Levodopa (25-100) 0.5 TAB PO TID please administer at 6, 11, 16 OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Docusate Sodium 250 mg PO DAILY Polyethylene Glycol 17 g PO DAILY Finasteride 5 mg PO DAILY Pramipexole NF 0.125 mg Oral TID Furosemide 80 mg IV ONCE PrimiDONE 25 mg PO HS Gabapentin 300 mg PO HS Senna 1 TAB PO BID Heparin 5000 UNIT SC TID Sertraline 25 mg PO DAILY HydrALAzine 37.5 mg PO TID Give with 20 mg of isosorbide dinitrate Simvastatin 40 mg PO DAILY Insulin SC Sliding Scale Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheezing Tamsulosin 0.4 mg PO HS Isosorbide Dinitrate 20 mg PO TID 20 mg of hydralazine Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet [Month/Year (2) ]: [12-7] Tablet PO TID (3 times a day): please administer at 6, 11, 16 . 2. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (2) ]: One (1) Injection TID (3 times a day). 3. Carbidopa-Levodopa 25-100 mg Tablet [Month/Day (2) ]: One (1) Tablet PO 5X/DAY (5 Times a Day). 4. Finasteride 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 5. Lasix 40 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day. 6. Aspirin 325 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Day (2) ]: 2.5 Tablets PO DAILY (Daily). 8. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (2) ]: [12-7] PO DAILY (Daily). 9. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 10. Polyethylene Glycol 3350 100 % Powder [Month/Day (2) ]: One (1) PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Month/Day (2) ]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Pramipexole 0.125 mg Tablet [Month/Day (2) ]: One (1) Tablet PO TID (3 times a day). 13. Gabapentin 250 mg/5 mL Solution [Month/Day (2) ]: One (1) PO HS (at bedtime). 14. Simvastatin 40 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 16. Acetaminophen 160 mg/5 mL Solution [Month/Day (2) ]: One (1) PO Q6H (every 6 hours) as needed for pain. 17. Isosorbide Dinitrate 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO TID (3 times a day). 18. Oxycodone 10 mg Tablet Sustained Release 12 hr [Month/Day (2) ]: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 19. Oxycodone 5 mg/5 mL Solution [Month/Day (2) ]: One (1) PO Q4H (every 4 hours) as needed for pain. 20. Primidone 50 mg Tablet [Month/Day (2) ]: 0.5 Tablet PO HS (at bedtime). 21. Sertraline 50 mg Tablet [Month/Day (2) ]: 0.5 Tablet PO DAILY (Daily). 22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 23. Levofloxacin in D5W 750 mg/150 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q48H (every 48 hours). 24. Hydralazine 25 mg Tablet [Last Name (STitle) ]: 1.5 Tablets PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: acute pulmonary edema secondary to acute on chronic heart failure pneumonia . Secondary: metastatic adenocarcinoma with unknown primary systolic heart failure with EF of 45% coronary artery disease chronic renal insufficiency GERD high blood pressure hyperlipidemia parkinson's disease benign prostatic hypertrophy Discharge Condition: afebrile, vitals signs stable Discharge Instructions: You were admitted for shortness of [Hospital6 1440] due to fluid in the lungs. Following stabilization in the medicine intensive care unit, you were given a diuretic to remove this fluid in your lungs. You were found have a pneumonia and were treated with antibiotics. Also, you developed difficulty in regards to swallowing, making you at risk for aspiration pneumonia. Following a video swallow study, we decided to recommend 1) moist, ground solids 2) nektar thick liquids 3) sips of thin liquids in between meals 4) pills crushed with applesauce. . If you develop worsening shortness of [Hospital6 1440], CP, fever, chills, please contact your doctor or go to the emergency room. . Please continue to take 40mg lasix by mouth every day. Please continue all other medications prior to your admission to the hospital. . Followup Instructions: Please contact your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 27593] to schedule a follow up appointment within 1 week of discharge. Followup Instructions: Please make the following appointments within 1 week of discharge: . Primary Care Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 53953]	[ "486", "51881", "4280", "41401", "2724", "412", "53081", "5859" ]
Admission Date: [2115-5-22] Discharge Date: [2115-6-19] Date of Birth: [2038-1-11] Sex: F Service: MEDICINE Allergies: Morphine / Percocet Attending:[First Name3 (LF) 2074] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bipap Endotracheal Intubation Cardiac Catheterization w/ stent placement History of Present Illness: This is a 77 female with h/o atrial fibrillation (on coumadin), aortic stenosis (mod/severe), cardiomyopathy (LVEF 40-50%), DM2, who presents from rehab hospital with several days of increasing shortness of breath. She was recently discharged from [Hospital1 18] after a prolonged stay for a right psoas phlegmon s/p CT guided drainage. She was discharged 7 days PTA, and reports initially feeling well upon discharge. Beginning two days after arriving at rehab she began to get worsening lower back pain (same pain from abscess drain), that would cause her "BP to rise and HR to rise" and subsequently would get SOB. She then began PT and was doing well. . On Sunday (3 days PTA) she became significantly more SOB, and her family describes her as clamy. She had increasing orthopnea at this point, with worsening peripheral edema and wt gain. She [Of note, she had been maintained on lasix during her last hospitalization, but lasix was not continued as a standing order on discharge as she was felt to be euvolemic.] The following day she was given 20 mg lasix twice, and had a CXR done. She continued to gain weight and feel increasingly SOB, feeling as if "there was no more breath left." On the day of admission, be hospitalized. . She has not had any chest pain, cough, fever, chills HA, diarrhea, consitpation, urinary symptoms. She things her urine output was less at the rehab. She describes intermittent clamy feelings when getting SOB. She has had no appetite and decreased PO intake. . ROS: as above . ED COURSE: She was triaged with a requirement of 5L NC to maintain sats in mid 90s; she was afebrile, normotensive. She was found to be in AF with RVR (to 150s - 160s). She was given 40mg IV lasix, and then subsequently given 80mg IV lasix, to which she put out ~1L. She was given dilt 5mg IV x 3, and subsequently dilt 15mg IV x 1, with only modest effect on her HR. A CXR showed worsening CHF with pulm edema and a left pleural effusion. Her ECG showed AF at 115, no acute changes from prior. She was also given one dose of IV levaquin for presumed respiratory coverage. Past Medical History: AS HTN chronic AF on coumadin DJD with multiple joint replacements (R hip [2105], R knee [2108], L knee [2109], R shoulder [2111]) NIDDM S/P cholecystectomy [2106] Social History: 5 Children, very supportive. No tob/etoh/drugs. Family History: NC Physical Exam: VS- 97 122/74 130 22 97% 2.5L GEN- Pale elderly female lying in bed with family at side HEENT- Anicteric, dry MM, EOMI, PERRL, OP clear, upper dentures, no lower teeth NECK- supple, JVP to 9cm, no LAD CV- Irreg irreg, tachy, III/VI SEM at USB, hyperdynamic PMI CHEST- Decreased BS at bases (L>R) with rales [1-28] bilaterally, dullto percussion on left ABD- soft, obese, NT, ND, +BS EXT- 1+ pitting edema bilaterally, 1+ DP pulses bilaterally, scars over knees and right shoulder, well healed. PICC line in right forearm NEURO- AAO x 3, moving all extremities SKIN- no lesions noted MSK- palpable hardware right shoulder, nontender, no other joint effusions noted. Pertinent Results: [2115-5-22] 02:50PM BLOOD WBC-6.3 RBC-3.24* Hgb-10.6* Hct-32.2* MCV-99* MCH-32.8* MCHC-33.0 RDW-14.9 Plt Ct-274 [2115-5-23] 03:55AM BLOOD WBC-5.7 RBC-3.03* Hgb-9.7* Hct-29.9* MCV-99* MCH-32.1* MCHC-32.5 RDW-15.0 Plt Ct-264 [2115-5-26] 09:14AM BLOOD WBC-6.6 RBC-3.48* Hgb-11.1* Hct-34.6* MCV-99* MCH-31.7 MCHC-32.0 RDW-15.6* Plt Ct-234 [2115-5-22] 02:50PM BLOOD Hypochr-2+ Poiklo-1+ Macrocy-2+ [2115-5-26] 09:14AM BLOOD PT-24.4* PTT-32.3 INR(PT)-2.4* [2115-5-22] 02:50PM BLOOD Glucose-128* UreaN-21* Creat-0.7 Na-132* K-3.7 Cl-87* HCO3-39* AnGap-10 [2115-5-23] 03:55AM BLOOD Glucose-105 UreaN-22* Creat-0.8 Na-134 K-3.7 Cl-88* HCO3-40* AnGap-10 [2115-5-25] 06:25AM BLOOD Glucose-132* UreaN-20 Creat-0.7 Na-134 K-4.0 Cl-86* HCO3-45* AnGap-7* [2115-5-26] 09:14AM BLOOD Glucose-176* UreaN-20 Creat-0.7 Na-134 K-3.4 Cl-84* HCO3-47* AnGap-6* [2115-5-22] 02:50PM BLOOD CK(CPK)-69 [2115-5-23] 03:55AM BLOOD CK(CPK)-59 [2115-5-22] 02:50PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 66784]* [2115-5-23] 03:55AM BLOOD CK-MB-NotDone cTropnT-0.04* [2115-5-23] 03:55AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.5* [2115-5-24] 06:09AM BLOOD Calcium-9.2 Phos-3.0# Mg-2.1 [2115-5-26] 09:14AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.8 [2115-5-26] 09:14AM BLOOD Digoxin-1.5 [2115-5-26] 11:42AM BLOOD Type-ART pO2-115* pCO2-90* pH-7.38 calHCO3-55* Base XS-22 [2115-5-26] 05:17PM BLOOD Type-ART pO2-92 pCO2-80* pH-7.43 calHCO3-55* Base XS-22-- STUDIES: . Chest CT: This non-contrast-enhanced study demonstrates interval increase in size of bilateral pleural effusions, left slightly greater than right which are moderate in size. Mild basilar atelectasis. They are no pathologically enlarged nodes within the mediastinum, axillae, hila. Stable cardiomegaly. Coronary calcifications. No pericardial effusion. Ground-glass opacities again noted bilaterally, appear more prominent with associated septal thickening, likely presenting pulmonary edema. Again noted are few scattered nodules, less than 5 mm bilaterally. Previously seen lesion in right psoas not clearly visualized on this study. Probable dropped gallstone in hepatorenal recess. No evidence of pneumothorax. Osseous structures are stable. IMPRESSION: 1. Interval increase in size of bilateral moderate pleural effusions with associated bibasilar atelectasis. 2. Interval worsening of bilateral diffuse ground-glass opacity, likely representing pulmonary edema. No definite evidence of emphysematous change. 3. Bilateral tiny pulmonary nodules, unchanged. Recommend follow up to ensure stability. . MRI L-spine: FINDINGS: Again scoliosis of lumbar spine is seen. At T12-L1, increased signal is seen within the disc with some enhancement indicative of discitis. There is abnormal signal seen in the adjacent endplates indicative of marrow edema. Again paraspinal soft tissue abnormalities with fluid collection are seen indicative of abscess. Compared to the prior study, the paraspinal fluid collections have slightly decreased. The persistent signal changes and slight enhancement within the disc could be secondary to evolution of inflammatory change within the disc and [Known firstname ] not necessarily indicate worsening of discitis. Further followup is therefore essential. There is no evidence of new inflammatory changes seen within the spinal canal. Increased signal is seen within the L1-2 and L2-3 discs on the inversion recovery images which was not identified on the previous study. There is no enhancement seen in this region. This finding [Known firstname ] be secondary to technical differences or due to fluid within the disc from increased motion. Further followup is recommended to exclude inflammation at this level. Mild degenerative changes and bulging from L3-4 to L5-S1 level are again noted. The distal spinal cord shows normal signal intensities. No evidence of compression of the distal cord is seen. IMPRESSION: 1. Changes of discitis and osteomyelitis at T12-L1 level are noted with slightly increased endplate signal changes and subtle enhancement within the disc. This could represent evolution of inflammatory changes from discitis. No new soft tissue abnormalities are seen to suggest worsening of the inflammatory changes. 2. The paraspinal fluid collections are still noted indicating abscesses which are decreased in size from the previous study. 3. Increased signal is seen within the L1-2 and L2-3 discs which is a new finding since the previous study and it could indicate fluid within the discs or early inflammatory changes. Followup is recommended. . [6-11] CXR: FINDINGS: There has been no significant change in the mild pulmonary edema from the comparison study. Left retrocardiac opacity likely atelectasis and small left pleural effusion are unchanged. A left IJ catheter is again identified unchanged in position. ET tube is unchanged. NG tube projects below the diaphragm. IMPRESSION: No significant change from [2115-6-8]. . [2115-6-14] - Worsening CHF. Brief Hospital Course: This is a 77 female with h/o atrial fibrillation (on coumadin), aortic stenosis (mod/severe), cardiomyopathy (LVEF 40-50% on [5-2] TTE), DM2, who presented from rehab hospital with several days of increasing shortness of breath. She had recently been discharged from [Hospital1 18] after a prolonged stay for a paraspinal infection with multiple para-aortic retroperitoneal abscesses and right MSSA psoas abscesses s/p CT guided drainage, with T12-L1 discitis. No evidence of dissection, endocarditis, intraspinal or epidural involvement. She also had SOB during admission, with evidence of hypercapnia, and was found to have bilateral pleural effusions and mild pulmonary edema. She was treated with lasix with reasonable effect, but with residual SOB, thought to be [2-28] COPD or pulmonary HTN. She was discharged 7 days PTA, and reportedly initially felt well upon discharge. Beginning two days after arriving at rehab she began to get worsening lower back pain (same pain from abscess drain). She then began PT and was doing well. . On [5-19] she became significantly more SOB, and diaphoretic. She had increasing orthopnea, peripheral edema and wt gain, and was given 20mg lasix. Of note, she had been maintained on lasix during her last hospitalization, but lasix was not continued as a standing order on discharge as she was felt to be euvolemic. The following day she was given 20 mg lasix twice, and had a CXR done. She continued to gain weight and feel increasingly SOB, and was sent to the ED. . In the ED she was diuresed with 40mg and then 80mg IV lasix; she was found to be in rapid AF and was give a total of 30mg IV dilt. This was not effective, and she was started on a dig load. On the medical floor, her afib was controlled with digoxin and metoprolol. She was cautiously diuresed, and was treated for her abscess pain with tylenol #3. The next morning, she was noted to be less responsive. ABG at that time was 7.38/90/115. She was given Lasix 20 mg IV with 800 cc UOP over the next few hours, and her mental status improved. However at 5 pm she became unresponsive again and her ABG was 7.43/80/92. She was tachypneic but not hypoxic. MICU eval was called at that time for bipap, because per respiratory she needed bipap via mouth and not through her nose, and therefore could not get bipap on the floor. . In the MICU she was felt to have a mixed acid base status, with metabolic alkalosis with superimposed respiratory acidosis. It was felt that the metabolic alkalosis could have been due to diuresis on the floor. Her resp acidosis was thought to be due to obstructive disease of unclear etiology. She was given Bipap overnight ([5-26]), and her ABG in AM was 7.39/87/196. She subjectively felt better on 2L NC. She did not have any chest pain or fever. Her diuresis was held, and her lytes were repleted. . Over the next two days, intermittently on NC and BiPap with mixed contraction alkalosis and hypercarbic respiratory acidosis, thought to be chroinic, possibly [2-28] OSA. Cards consulted, who recommended L and R heart cath to evaluated filling pressures and to evaluate severity of AS for possible AVR. This was not possible at the time [2-28] respiratory status and inability to lie flat. . On [5-30], Neurology consulted to assess possible neuromuscular etiology of respiratory failure, which was thought unlikely [2-28] normal respiratory pattern, ability to take deep breaths, overall normal neurological exam. EMG demonstrated mild-mod generalized sensory polyneuropathy, but no findings suggestive of MG or proximal myopathy. SNIF test done, but uninterpretable in setting of pleural effusions. ENT evaluated, confirmed no vocal cord paralysis. PFTs done, which were incomplete [2-28] pt fatigue, with MIPs decreased with each inspiratory effort, with FEV1/FVC 167%, c/w restrictive pattern. . Over the next couple of days, continued to have respiratory distress, with intermittent need for BiPap, complicated by pt refusal to wear. Pt was also gently diuresed. CT chest demonstrated moderate bilateral pleural effusions, ground glass opacities with associated septal thickening c/w CHF, bibasilar atelectasis, old tiny pulmonary nodules. Head CT obtained [2-28] lethargy, demonstrated no evidence of acute bleed or mass effect. Brain MRI done, which demonstrated no significant abnormalities. Consideration given to thoracentesis, but IP felt not indicated at that time. Family discussion held [6-3], as pt not tolerating BiPap, and would likely require either intubation with possible progression to trach, or comfort measures. Family confirmed full code status, with intubation if necessary. Acetazolamide also given [2-28] decreased pH and hypercarbia. . Pt was electively intubated [6-6] [2-28] somnolence and difficulty acheiving adequate oxygenation with intermittent BiPap. She also experienced transient hypotension after intubation and sedatives, with no response to IVF, and was started on pressors. Found to have UTI, started on CTX [6-7]. . Repeat L-spine MRI done [6-7], to evaluated previous psoas abscesses. MRI demonstrated changes of discitis and osteomyelitis at T12-L1 level with slightly increased endplate signal changes and subtle disc enhancement, possibly representing evolution of inflammatory changes from discitis. No new soft tissue abnormalities seen to suggest worsening of the inflammatory changes. Paraspinal fluid collections are still noted, but decreased in size from the previous study. CRP increased from 14 on [5-29] to 87 on [6-9]. ID consulted, reviewed MRI with radiology. It was felt that new enhancement probably represent natural progression in setting of therapy. Recommend continuing nafcillin therapy for 8 weeks total post abscess drainage, (end date [6-28]), at which point CRP could be rechecked. Urine culture grew E. Coli, switched to Cipro on [6-7]. . As pt intubated, MICU team proceeded with preparation for cardiac cath, as described above. Coumadin reversed, LIJ placed, placed on heparin gtt. Was slowly weaned off pressors by [6-8]. [Last Name (un) ] stim test inappropriate, started on stress dose hydrocort/fludrocort on [6-8]. Pan-cultured to look for possible septic etiology for hypotension. Blood cultures have been no growth. Sputum cultures growing GNR at time of transfer. Pt also had loose stools, C. diff x 3 sent, which were negative. . Ms. [Known lastname 122] [Last Name (Titles) 1834] cardiac cath on [6-10], while intubated. AV area found to be 1.0cm2, with gradient of 20mmHg. Cath demonstrated 80% mid-LAD lesion, and 2 overlapping BMS. Placed on ASA, plavix x 1 month, integrillin x 6 hours, after which heparin gtt was restarted to re-bridge to coumadin for AF. Pt had residual small intermedius and ostial RCA disease that could be amenable to PCI if pt had recurrent evidence of myocardial ischemia. RA 18, PCWP 18, MAP 75, CI 2.7. No complications post-cath. . Ms. [Known lastname 122] was successfully extubated on [6-11] post-cath, and was called out to floor on [6-12]. Pt has appt with Dr. [Last Name (STitle) 66785] in ID on [6-26] at 12pm. Per ID, should have qwk CBC, BUN/Cr checked and FAXed to Dr. [First Name (STitle) ]. . On the floor, she continued to have episodes of Afib with RVR with tachy-brady syndrome and has only been cautiously diuresed because of marginal BPs on the floor. Today, pt was triggered at 9am for relative hypotension and was given back 500ccNS bolus. Cardiology recommended increasing beta-blockade for HRs but might need pacer for possible tachy-brady syndrome. Then, at 6:30 AM, she became tachypneic to the 40's with labored breathing and complained of a "panic attack". O2 sat was noted to be 48% on 3L NC. She was temporarily placed on a NRB with increasing O2 sats to 94% and weaned off quickly on the floor to O2 sats 93% on 5L NC. Her ABG showed 7.30/85/67 with bicarb 38. She was triggered and MICU consulted for further managment. She states that her breathing does feel shallow but denies any chest pain, nausea, vomiting. She has no other complaints now. She was transferred to ICU for initiation of BiPAP therapy. . . MICU COURSE: ## Respiratory: Pt. was transferred to the MICU for mental status changes in the setting of hypercarbia. The etiology of her hypercarbia is unclear - no history of COPD. She most likely presented with a CHF exacerbation. Pt. has AS, afib, and CHF which [Known firstname ] have contributed to her dyspnea. Her pleural effusions (L >R) could be limiting the expansion of her lung, causing a restrictive physiology. She also has evidence of pulmonary hypertension on last TTE. However, given pt's difficulty w/ ventilation and normal oxygenation - CHF is not the [Last Name ] problem. Concern for diaphragmatic dysfuction bilaterally during stay, but pt. unable to do Sniff test to assess diaphragms [2-28] pleural effusions. ENT saw pt. - no vocal cord paralysis. Neuro saw pt. and no neuromuscular disease appreciated. PFTs unable to be completed [2-28] to exhaustion, but pt. w/ restrictive pattern and MIPS decreased w/ each subsequent effort. Overall, probably has a poor LV fx, poor forward flow. It was decided that pt. would be electively intubated to do a cardiac catheterizatio nwhere she was found to have an LAD lesion that was stented. During intubation, pt's hypercarbia improved (PCO2 in 60s which is probably her baseline). After cardiac cath, pt. was sucessfully extubated and did not have the feeling of dyspnea anymore. . ## Acid/Base: Pt. w/ hypercarbia and high bicarb in MICU. Pt. w/ hypercarbia w/ CO2 of 90s-100s. Unclear what the cause was. Twice during her MICU stay she was found lethargic w/ high CO2. She was placed on bipap w/ some improvement. Pt. refused bipap when alert and oriented for the first few days, but then began using it with some regularity. Pt. was then intubated and hypercarbia improved - 60s, which is likely her baseline. In the beginning of MICU course, pt. give KCl aggressively to try to get rid of some bicarb - this improved somewhat. Once, pt. intubated, pt's bicarb began to trend down. Stable after extubation. . ## CHF - pt. w/ diastolic CHF w/ AS - Based on exam,labs, history, she most likely presented with a CHF exacerbation, due to long standing tight AS and diastolic failure. This is probably exacerbated by decreased diastolic filling with atrial fibrillation. Pt. continued to be fluid overloaded w/ b/l effusions. At times hard to diurese pt. secondary to hypotension. Goal was negative a liter a day. . ## CAD - Pt. w/ LAD lesion s/p 2 bare metal stents. Since cath, pt. has been breathing more comfortably so unclear if this is what was causing pt. to be so dyspneic. Pt. will need to be on ASA,plavix, and beta blocker. . ## Hypotension - initially hypotension seemed to be in the setting of intubation and then it was found that pt. had adrenal insufficiency. Pt. failed [Last Name (un) 104] stim. test so is on of steroids (started 7 dday course on [6-8]). . ## Anemia - Pt. w/ progressively declining crits over MICU stay, but no obvious source of bleeding. Pt. will need a c-scope/EGD as an outpatient or more urgently if crit does not increase . #Afib: pt has a fib and has been going into afib w/ RVR a few times in MICU. Pt. was controllled w/ IV medications PRN for rate control. Will continue pt's beta blockade now that she is no longer on pressors. Spoke to cards - no need for amio. Pt. initially on coumadin and then switched to heparin for cath. After cath, pt. switched back to coumadin. INRs will have to be followed. . # UTI - pt. w/ positive UA on [6-4] w/ ctx that are growing 2 strains of E.coli - Pt. on day [7-3] of abx on [2115-6-12]. . ## Abscess/Discitis: Had MSSA bacteremia with spinal discitis, numerous psoas abscesses s/p drainage on a previous hospitalization. Pt. had MRI to evaluate spinal abscesses while in MICU- stable abscesses, new L1-L2/L2-L3 increased signal in the disks [Known firstname ] indicate re-accumulating fluid in discs/early inflammatory changes. ID reviwed MRI w/ radiology and believe that pt. should have an 8 week course of abx total (first day [5-4]). Pt. will likely have to have a follow MRI per ID recs and then f/u w/ ID and possibly neurosurgery depending on MRI. Pt. will need to cont nafcillin day 21 (started on [5-23]). Overall, pt. is on day 40/56 of abx (was previously on oxacillin) in order to finish an 8 week course. (First day of 8 week course was [2115-5-4]). . ## DM2: At home, pt. on glipizide 5qd and pioglitazone 15 qd but will hold oral meds. Pt. w/ good glycemic control on insulin sliding scale . ## Hypercholesterolemia: cont lipitor 10 qd . ## FEN: TF while intubated and then switched to heart healthy/diabetic diet. Replete lytes prn . ## PPX: coumadin, PPI, bowel meds . ## CODE: full, discussed with pt and family. Per discussion today, family still wants BiPap and intubation as needed. . ## Communication: with pt and daughters. . ## Dispo: ICU for compromised ventilation CC: MICU call out after hypercarbic respiratory failure . HPI: This is a 77 female with h/o atrial fibrillation (on coumadin), aortic stenosis (mod/severe), cardiomyopathy (LVEF 40-50% on [5-2] TTE), DM2, who presented from rehab hospital with several days of increasing shortness of breath. She had recently been discharged from [Hospital1 18] after a prolonged stay for a paraspinal infection with multiple para-aortic retroperitoneal abscesses and right MSSA psoas abscesses s/p CT guided drainage, with T12-L1 discitis. No evidence of dissection, endocarditis, intraspinal or epidural involvement. She also had SOB during admission, with evidence of hypercapnia, and was found to have bilateral pleural effusions and mild pulmonary edema. She was treated with lasix with reasonable effect, but with residual SOB, thought to be [2-28] COPD or pulmonary HTN. She was discharged 7 days PTA, and reportedly initially felt well upon discharge. Beginning two days after arriving at rehab she began to get worsening lower back pain (same pain from abscess drain). She then began PT and was doing well. . On [5-19] she became significantly more SOB, and diaphoretic. She had increasing orthopnea, peripheral edema and wt gain, and was given 20mg lasix. Of note, she had been maintained on lasix during her last hospitalization, but lasix was not continued as a standing order on discharge as she was felt to be euvolemic. The following day she was given 20 mg lasix twice, and had a CXR done. She continued to gain weight and feel increasingly SOB, and was sent to the ED. . In the ED she was diuresed with 40mg and then 80mg IV lasix; she was found to be in rapid AF and was give a total of 30mg IV dilt. This was not effective, and she was started on a dig load. On the medical floor, her afib was controlled with digoxin and metoprolol. She was cautiously diuresed, and was treated for her abscess pain with tylenol #3. The next morning, she was noted to be less responsive. ABG at that time was 7.38/90/115. She was given Lasix 20 mg IV with 800 cc UOP over the next few hours, and her mental status improved. However at 5 pm she became unresponsive again and her ABG was 7.43/80/92. She was tachypneic but not hypoxic. MICU eval was called at that time for bipap, because per respiratory she needed bipap via mouth and not through her nose, and therefore could not get bipap on the floor. . In the MICU she was felt to have a mixed acid base status, with metabolic alkalosis with superimposed respiratory acidosis. It was felt that the metabolic alkalosis could have been due to diuresis on the floor. Her resp acidosis was thought to be due to obstructive disease of unclear etiology. She was given Bipap overnight ([5-26]), and her ABG in AM was 7.39/87/196. She subjectively felt better on 2L NC. She did not have any chest pain or fever. Her diuresis was held, and her lytes were repleted. . Over the next two days, intermittently on NC and BiPap with mixed contraction alkalosis and hypercarbic respiratory acidosis, thought to be chroinic, possibly [2-28] OSA. Cards consulted, who recommended L and R heart cath to evaluated filling pressures and to evaluate severity of AS for possible AVR. This was not possible at the time [2-28] respiratory status and inability to lie flat. . On [5-30], Neurology consulted to assess possible neuromuscular etiology of respiratory failure, which was thought unlikely [2-28] normal respiratory pattern, ability to take deep breaths, overall normal neurological exam. EMG demonstrated mild-mod generalized sensory polyneuropathy, but no findings suggestive of MG or proximal myopathy. SNIF test done, but uninterpretable in setting of pleural effusions. ENT evaluated, confirmed no vocal cord paralysis. PFTs done, which were incomplete [2-28] pt fatigue, with MIPs decreased with each inspiratory effort, with FEV1/FVC 167%, c/w restrictive pattern. . Over the next couple of days, continued to have respiratory distress, with intermittent need for BiPap, complicated by pt refusal to wear. Pt was also gently diuresed. CT chest demonstrated moderate bilateral pleural effusions, ground glass opacities with associated septal thickening c/w CHF, bibasilar atelectasis, old tiny pulmonary nodules. Head CT obtained [2-28] lethargy, demonstrated no evidence of acute bleed or mass effect. Brain MRI done, which demonstrated no significant abnormalities. Consideration given to thoracentesis, but IP felt not indicated at that time. Family discussion held [6-3], as pt not tolerating BiPap, and would likely require either intubation with possible progression to trach, or comfort measures. Family confirmed full code status, with intubation if necessary. Acetazolamide also given [2-28] decreased pH and hypercarbia. . Pt was electively intubated [6-6] [2-28] somnolence and difficulty acheiving adequate oxygenation with intermittent BiPap. She also experienced transient hypotension after intubation and sedatives, with no response to IVF, and was started on pressors. Found to have UTI, started on CTX [6-7]. . Repeat L-spine MRI done [6-7], to evaluated previous psoas abscesses. MRI demonstrated changes of discitis and osteomyelitis at T12-L1 level with slightly increased endplate signal changes and subtle disc enhancement, possibly representing evolution of inflammatory changes from discitis. No new soft tissue abnormalities seen to suggest worsening of the inflammatory changes. Paraspinal fluid collections are still noted, but decreased in size from the previous study. CRP increased from 14 on [5-29] to 87 on [6-9]. ID consulted, reviewed MRI with radiology. It was felt that new enhancement probably represent natural progression in setting of therapy. Recommend continuing nafcillin therapy for 8 weeks total post abscess drainage, (end date [6-28]), at which point CRP could be rechecked. Urine culture grew E. Coli, switched to Cipro on [6-7]. . As pt intubated, MICU team proceeded with preparation for cardiac cath, as described above. Coumadin reversed, LIJ placed, placed on heparin gtt. Was slowly weaned off pressors by [6-8]. [Last Name (un) ] stim test inappropriate, started on stress dose hydrocort/fludrocort on [6-8]. Pan-cultured to look for possible septic etiology for hypotension. Blood cultures have been no growth. Sputum cultures growing GNR at time of transfer. Pt also had loose stools, C. diff x 3 sent, which were negative. . Ms. [Known lastname 122] [Last Name (Titles) 1834] cardiac cath on [6-10], while intubated. AV area found to be 1.0cm2, with gradient of 20mmHg. Cath demonstrated 80% mid-LAD lesion, and 2 overlapping BMS. Placed on ASA, plavix x 1 month, integrillin x 6 hours, after which heparin gtt was restarted to re-bridge to coumadin for AF. Pt had residual small intermedius and ostial RCA disease that could be amenable to PCI if pt had recurrent evidence of myocardial ischemia. RA 18, PCWP 18, MAP 75, CI 2.7. No complications post-cath. . Ms. [Known lastname 122] was successfully extubated on [6-11] post-cath, and was called out to floor on [6-12]. Pt has appt with Dr. [Last Name (STitle) 66785] in ID on [6-26] at 12pm. Per ID, should have qwk CBC, BUN/Cr checked and FAXed to Dr. [First Name (STitle) ]. . On the floor, she continued to have episodes of Afib with RVR with tachy-brady syndrome and has only been cautiously diuresed because of marginal BPs on the floor. Today, pt was triggered at 9am for relative hypotension and was given back 500ccNS bolus. Cardiology recommended increasing beta-blockade for HRs but might need pacer for possible tachy-brady syndrome. Then, at 6:30 AM, she became tachypneic to the 40's with labored breathing and complained of a "panic attack". O2 sat was noted to be 48% on 3L NC. She was temporarily placed on a NRB with increasing O2 sats to 94% and weaned off quickly on the floor to O2 sats 93% on 5L NC. Her ABG showed 7.30/85/67 with bicarb 38. She was triggered and MICU consulted for further managment. She states that her breathing does feel shallow but denies any chest pain, nausea, vomiting. She has no other complaints now. She was transferred to ICU for initiation of BiPAP therapy. . 77 F c mild AS, diastolic CHF atrial fibrillation, recent psoas abscess, admitted to the MICU for hypercarbia and altered mental status s/p cardiac cath (LAD lesion) w/ 2 bare metal stents who has been on the floor with worsening CHF and afib with RVR. . ## Respiratory: The etiology of her hypercarbia is unclear, but likely due to CHF and COPD (undx'd previously). There is likely a component of obesity hypoventillation syndrome also involved (will need sleep study w/u as outpt). She most likely presented with a CHF exacerbation, in setting of AF with RVR, diastolic failure. Her pleural effusions (L >R) could be limiting the expansion of her lung, causing a restrictive physiology seen in PFTs. She has evidence of mild pulmonary hypertension on cath. There was concern for diaphragmatic dysfuction bilaterally. Pt. unable to do SNIF test to assess diaphragmatic strength 2/2 pleural effusions. ENT saw no evidence of vocal cord paralysis. No evidence of neuromuscular disease contributing to SOB. PFTs unable to be completed [2-28] to exhaustion, but c/w restrictive pattern. Recently, she had acute respiratory acidosis for unclear reasons, xfered back to MICU. Overnight, gases on Bipap and gases on nasal cannula seemed not to be different, but the patient's breathing seemed to be much more confortable on Bipap. Patient was diuresed as much as her blood pressure would allow, on standing lasix as well as lasix gtt. As above, the patient was made DNR/DNI, after discussion with family, but BiPAP was allowed. Patient was given intermittent breaks from bipap on nasal cannula, but her PCO2 became much worse after being taken off bipap. On [6-19], the patient went to IR suite for PICC line placement. She was required to be lying flat while getting the line placed and returned with significant respiratory distress. She was placed on Bipap and her respiratory status and gas exchange improved significantly. However, later that night, the patient developed "agonal type" respirations despite being on bipap, with 2-8 second pauses between respirations. The patient's family was informed that the patient was not doing well and [Known firstname ] pass soon--and DNR/DNI status was confirmed once again. The patient was given maximal non-invasive ventillatory support, but became progressively more somnolent and obtunted. Within a short time, the patient's respiration suddely ceased, and staff coudl not arouse the patient even with sternal rubs. The patient then became bradycardic to 30s, then went into PEA and passed shortly after with family by her side. . ## CHF - pt. w/ likely diastolic CHF with AF with intermittent RVR. Patient continued to be fluid overloaded during her stay despite maximum efforts to diurese her. . #Afib: Afib with RVR. frequent bursts into 160s/170s unresponsive to dilt and BB. Patient was placed on amiodarone, since dc cardioversion was thought to be not indicated by cardiology consultants. Sotalol was also suggested. After amiodarone, HR decreased to 120s-140s. Please see above regarding the rest of hospital course and conditions around patient decompensating and eventually expiring. . ## Abscess/Discitis: Had MSSA bacteremia with spinal discitis, numerous psoas abscesses. Pt. had MRI to reevaluate spinal abscesses - stable abscesses, new L1-L2/L2-L3 increased signal in the discs. ID favoring continuing 8 week course nafcillin, due to complete [6-28]. Patient was continued on IV abx, but expired as described above Medications on Admission: Atorvastatin 10, colace, protonix 40, fluticasone 110/actuation aerosol [Hospital1 ], dulcolax prn, metoprolol 75 [Hospital1 ], acetaminophen-codeine q4 prn, oxacillin 2g q4, glipizide 5 qd, coumadin 2.5 qhs, pioglitazone 15 qd Discharge Disposition: Expired Discharge Diagnosis: CHF Atrial fibrillation Discitis Osteomyelitis Obesity Hyperventillation syndrome Hypercarbic Respiratory Failrue Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2115-6-29]	[ "4280", "51881", "4241", "42731", "5990", "2761", "496", "41401", "25000", "4019" ]
Admission Date: [2188-9-6] Discharge Date: [2188-9-12] Date of Birth: [2126-11-6] Sex: M Service: CHIEF COMPLAINT: Status post right coronary artery stent secondary to myocardial infarction. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male intubated and sedated upon arrival. History was taken from medical records only. The patient without history of coronary artery disease presented to outside hospital with complaints of chest pain. The patient noted that he felt lightheaded and called EMS to be transported to outside hospital. Initial laboratories there showed a troponin I of less then 0.04. Electrocardiogram with bradycardia, left axis deviation and ST elevations in 2, 3 and AVF, V3-V5 and ST depressions in AVL, V2, V1 also with a right bundle branch block. He was given aspirin, morphine and fluids in the field and then the Emergency Department gave him atropine, started a Dopamine and heparin drip. At that point he went into a wide complex tachycardia, which was read as V fibrillation and was shocked with 200 jewels with conversion to junctional rhythm of 100 beats per minute and the patient at that point was hemodynamically stable. The patient was given a half a dose of Retavase for lytic therapy and was transferred to [Hospital1 69] for further evaluation and catheterization. The patient was intubated prior to arrival to [Hospital1 346]. In the [Hospital1 190] the patient was sinus tachy, normal axis, normal intervals, 2 to [Street Address(2) 2051] elevation in inferior leads and anterior leads. He was taken to the catheterization laboratory. Catheterization wet read showed a three vessel disease with left anterior descending coronary artery totally occluded, left circumflex was 40% lesion and right coronary artery with a 95% mid vessel lesion thought to be the culprit lesion. He had an angiojet and his right coronary artery was stented at that point at which point he was transferred to the Coronary Care Unit for further observation and management. PAST MEDICAL HISTORY: No past medical history was recorded. ALLERGIES: No known drug allergies. MEDICATIONS: The only medication was recorded was Benadryl prn. SOCIAL HISTORY: Recorded as two packs per day. FAMILY HISTORY: Father with myocardial infarction and mother with myocardial infarction and brother with myocardial infarction at the age of 59. PHYSICAL EXAMINATION: Vital signs upon arrival to the Emergency Department, pulse of 71 and blood pressure of 106/palp and afebrile. Generally he was a frail appearing male intubated and sedated. HEENT pupils are equal, round, and reactive to light and accommodation. No lymphadenopathy. No JVD. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops appreciated. Pulmonary was not examined. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities no clubbing, cyanosis or edema. LABORATORIES ON ADMISSION: Sodium 139, potassium 3.6, chloride 105, bicarb 27, BUN 10, creatinine 1.1, glucose 108, white blood cell 9.2, hematocrit 42.8, platelet 440, MCV 101. INR .91 and PTT of 28.2. The troponin I of less then 0.04. Chest x-ray showed EP tube in right main, opacity in retrocardiac, possible atelectasis versus pneumonia and on arrival his electrocardiogram was pending. His catheterization showed an RA of 23/24/22, RV of 33/23, PA 33/22, wedge of 22/24, [3-24], LV of 90/22, SVR 1082 and PVR of 25. His EF was 39% with hypokinetic anterolateral apical and inferior walls. HOSPITAL COURSE: The patient was status post stent mid right coronary artery. For his coronary artery disease three vessel disease. He was continued on aspirin and Plavix and did well. His beta blockers were initially held secondary to bradycardia and negative inotropic effects. At that point later on he was switched over two days later to beta blockers. On discharge date his beta blockers were switched over from Metoprolol 75 b.i.d. to Toprol XL 150 q.d. His lipids were checked and liver function tests were checked. He had an elevated AST, slightly elevated ALT at which point Lipitor was not started, but the day of discharge Lipitor was started given that his AST rise was most likely secondary to his myocardial infarction insult. He may need future percutaneous intervention on left anterior descending coronary artery and D1. His CKs were followed post intervention and the goal was to keep the CVP around 18 to 20. He did well after transfer to the Emergency Department and was extubated the next day and weaned off of his O2 and transferred to the floor. For his pump status he was later on started on Captopril and on the day of discharge his Captopril t.i.d. was switched to Lisinopril q.d. for after load reduction. Rhythm, his electrolytes were checked regularly. The goal was to keep his K over 4 and his magnesium over 2. Initially he was continued on the Lidocaine drip until the morning after admission to the Coronary Care Unit at which point he was discontinued off the Lidocaine. He had an atropine at bedside for possible bradycardia and secondary hypotension secondary to bradycardia, which was not used and his beta blockers as we noted earlier was held on the first day and later on started as he tolerated it. The day after admission he was started on Levaquin for presumed right lower lobe consolidation secondary to community acquired pneumonia. The patient did well and has been afebrile and white blood cell count decreasing daily since transfer to the floor. For him to continue a ten day course of Levaquin. He is now on day three of ten and will continue the next seven days when discharged to home or to rehab. Gastrointestinal, no issues. Tolerating his medications and his diet well. The patient was sent to rehab center for further evaluation and further treatment. FINAL DIAGNOSIS: Inferior myocardial infarction status post right coronary artery stent. RECOMMENDED FOLLOW UP: The patient is to follow up with his primary care physician and also with cardiologist in the next week or two for post discharge care. Call for an appointment. MAJOR SURGICAL INVASIVE PROCEDURES DONE: Status post right coronary artery stent and catheterization. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Plavix 75 mg po q..d 3. Levofloxacin 500 mg po q.d. for the next seven days, that will be a ten day regimen. 4. Protonix 40 mg po q.d. 5. Thiamine 100 mg po q.d. 6. Folic acid 1 mg po q.d. 7. Multivitamins one per day. 8. Lisinopril 10 mg po q day. 9. Atorvastatin 10 mg po q.d. 10. Toprol XL 150 mg po q.d. DIET: Cardiac diet as tolerated. The patient received physical therapy and medical teaching about his medications. ACTIVITIES: As tolerated, out of bed with assist initially. FOLLOW UP: As discussed above. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Name8 (MD) 12818] MEDQUIST36 D: [2188-9-10] 01:11 T: [2188-9-10] 13:32 JOB#: [Job Number 50072]	[ "5180", "9971", "486", "41401", "3051" ]
Admission Date: [2139-1-17] Discharge Date: [2139-2-16] Date of Birth: [2139-1-17] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname 16543]-[Known lastname 45978] is a former 32-4/7 week twin #1 male admitted to the Newborn Intensive Care Unit for prematurity. A 1760 gram male born to a 32-year-old G6 P0-2, SAB 5 white female. PRENATAL SCREENS: O+, antibody positive anti-E. RPR nonreactive. Hepatitis B surface antigen negative. GBS negative. Rubella immune mom with chronic hypertension treated with Aldomet. IVF pregnancy diamniotic-dichorionic twins. Pregnancy complicated by 1) cervical shortening treated with cerclage at 18 weeks. 2) Premature labor beginning two days prior to delivery treated with magnesium sulfate, betamethasone complete on [1-3]. Antepartum testing on the day of delivery revealed discordant growth and concern for fetal well-being of twin A, this twin, which was 1538 grams, less than 3rd percentile. Biophysical profile [4-14]. Nonstress test absent diastolic flow. Twin B was [2155] grams 38th percentile, biophysical profile [8-14]. Reactive nonstress test, normal diastolic flow. Therefore, proceeded to cesarean section under spinal anesthesia. This baby emerged vigorous who required blow-by O2 and suctioning only. Apgars 8 at 1 minute and 9 at 5 minutes. Baby was transferred to the Newborn Intensive Care Unit for additional care. PHYSICAL EXAMINATION ON ADMISSION: Premature male with mild retractions. Temperature 98.0, pulse 160, respiratory rate 60, blood pressure 46/27 with a mean of 35. O2 sat is 93% on room air. Anterior fontanel is soft, flat, nondysmorphic. Intact palate. Red reflex deferred. Clear breath sounds. Mild retractions, no murmur, normal pulses. Soft abdomen. Cord cut close to clamp, therefore unable to see vessels. No hepatosplenomegaly. Normal male genitalia. Testes descending. No hip click. No sacral dimple. Patent anus. Active, normal tone for age. REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby continued to exhibit grunting and mild respiratory distress. Was initially placed on nasal cannula O2 and then transitioned to CPAP of 6. Had an initial blood gas of 7.37, 46, cap gas. Baby required CPAP for approximately 24 hours and then transitioned to room air and had no further respiratory distress. He did exhibit some apnea and bradycardia of prematurity. He did not require methylxanthine treatment, and at the time of discharge, he has been free of apnea, bradycardia, and desaturations for greater than five days. Cardiovascular: Baby did not have any cardiovascular instability. Did not require pressor support. Had an intermittent murmur that has resolved. Baseline heart rate is 130s-140s with blood pressures systolics in the 60s-70s, diastolics in the 30s and means in the 40s. Fluids and electrolytes: Baby had significant hypoglycemia required IV fluid of D12.5 initially and boluses. Initial D stick was 8, repeat was 6, and subsequent ones were improving to greater than 50s. The hypoglycemia persisted. He was slowly weaned off IV fluids by day of life seven. He required additional enteral glucose with 4 calories of Polycose to maintain glucoses greater than 50. Polycose was discontinued on day of life 16, and D sticks have subsequently been stable at greater than 60. Endocrine was consulted secondary to prolonged hypoglycemia. They thought it was related to immaturity and intrauterine stress. Baby is currently eating a minimum of 150 cc/kg of Enfamil 24 with iron ad lib doing well with feeding. Baby is voiding and stooling. Last electrolytes were on day of life three, slightly hemolyzed: Sodium 143, potassium 6.0, 111, and 18. Previous electrolytes on day of life two: 141, 4.8, 107, 24. Discharge weight 2445, which is 25th percentile. Length 47 cm 25th-50th percentile. Head circumference 32.5 cm 25th-50th percentile. Baby is also receiving supplemental iron 0.2 cc po q day which equals 2 mg/kg/day. Gastrointestinal: Baby required single phototherapy for physiologic jaundice. Showed no signs of hemolysis. Peak bilirubin was 7.7/0.3 on day of life five. Rebound bilirubin was 6.3/0.3. There have been no further issues. Hematology: Baby did not require any blood products during this admission. Infectious Disease: Baby initially had a sepsis evaluation because of his respiratory distress and hypoglycemia. He had initial white count of 6.4 with 34 polys, 3 bands, platelet count of 210, and hematocrit of 45.4. Nucleated red blood cells is [Pager number ]. Baby was started on ampicillin and gentamicin. Baby was clinically well and cultures remained negative therefore antibiotics were discontinued at 48 hours. He has had no further issues with infection. Neurology: Because of the concerns of intrauterine growth, baby had a head ultrasound on day of life four that was within normal limits. No evidence of intraventricular hemorrhage. Baby's clinical examination is appropriate for gestational age. Sensory: Audiology hearing screen passed. Ophthalmology examination none indicated based on gestational age of greater than 32 weeks. Psychosocial: Parents have been visiting, have sibling at home. Mom is still being followed for hypertension, and they look forward to transitioning both children home. CONDITION ON DISCHARGE: Stable. DISCHARGE/POSITION: Home with family. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 45979] [Last Name (NamePattern1) 21056], [Hospital 13820] [Hospital3 1810], telephone number no[Serial Number 45980]. CARE RECOMMENDATIONS: Continue feeding Enfamil 24 with iron ad lib. MEDICATIONS: Fer-In-[Male First Name (un) ] 0.2 cc po q day. CAR SEAT POSITION SCREENING: Passed. STATE NEWBORN SCREEN: Sample of [1-28] showed borderline elevated 17 OH progesterone of 82 with the range being less than 80. Repeat was sent on [2-5] which is still pending at the time of this dictation. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [2139-2-3], Synagis given prior to discharge on [2139-2-16]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease. 2. 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, family and other caregivers should be considered for immunization against influenza to protect infant. FOLLOW-UP APPOINTMENTS: Dr. [First Name8 (NamePattern2) 45979] [Last Name (NamePattern1) 21056] within 1 week DISCHARGE DIAGNOSES: 1. Former premature 32-4/7 week 2. Twin #1. 3. Sepsis ruled out. 4. Respiratory distress secondary to transient tachypnea of the newborn. 5. Hypoglycemia, treated, resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Doctor First Name 45981] MEDQUIST36 D: [2139-2-16] 03:32 T: [2139-2-16] 04:12 JOB#: [Job Number 45982]	[ "7742", "V053" ]
Admission Date: [2168-4-16] Discharge Date: [2168-5-13] Date of Birth: [2107-2-8] Sex: M Service: MEDICINE Allergies: Penicillins / Benadryl / zidovudine / Enalaprilat Attending:[First Name3 (LF) 2024] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: endoscopic retrograde cholangiopancreatoscopy fiducial placement Cyberknife History of Present Illness: 61M w/ HIV, HCV cirrhosis, HCC, CAD, cholelithiasis and small gallbladder polyps p/w RUQ pain. He has had worsening RUQ pain w/o radiation since Sunday. Oxycodone with ES tylenol helps somewhat but will only bring the pain from 8 to [5-15]. He [Month/Year (2) ] any f/c/n/v/night sweats. He believes he has lost some weight. He has not seen his bowel movements but does not know if they are acholic, or with blood/melena. He [Month/Year (2) ] any jaundice. The pain is a "gripping" type of pain, occasionally sharp, and is constant. It is not related to PO intake or bowel movements. Sitting up and putting pressure on his abdomen exacerbates the pain. He [Month/Year (2) ] any chest pain or dizziness. His SOB is at baseline. Of note, he recently completed a course of abx for HCAP and is currently being treated for cdif. ER: 98.3, 106, 125/76, 20, 94% 3L. ROS:otherwise negative Past Medical History: - HCV cirrhosis c/b HCC, s/p TACE [6-1], RFA [6-17] - HIV diagnosed 20 years ago, on HAART - HLD - HTN - CAD, s/p cath at [Hospital1 2025] without intervention, mild CAD noted - 3 years ago, no caths since - Inclusion body myositis, diagnosed in [2154], on chronic prednisone - cholelithiasis - Small gallbladder polyps - s/p cataract surgery [2160] - recent Cdif [3-17] - recent pins place in hip @ OSH Social History: lives with [Last Name (un) 1063] [First Name8 (NamePattern2) 5969] [Last Name (NamePattern1) 40593] [Telephone/Fax (1) 40594], who is his HCP uses electric wheelchair no tobacco social etoh no illicits Family History: mother died of colon cancer age 42 father died at age 86 from suicide Physical Exam: ADMISSION EXAM VS: Tm 98.5, BP 120-132/87, HR 78-95, RR 18-20, O2 Sat: 98% 2L/BiPap overnight I/O: [Telephone/Fax (1) 40598]0/2300 + 3 BM Gen: NAD, chronically ill appearing, emaciated male, hunched over in bed. HEENT: NCAT, sclera anicteric, OP clear CV: RRR, no m/r/g appreciated Lungs: anterior exam, mild crackles. no wheezes appreciated; air movement throughout. Ab:+BS, soft, no TTP in RUQ, no rebound/guarding, no mass/hsm Ext:no c/c/e Skin:atrophic LE Neuro:A&O x 3, strength in UE is [3-10], CN II-XII intact. Strength in LE: knee extension 0/5; hip abduction/adduction and hip extension [3-10]. [Last Name (un) ] and plantarflexion [4-9]. Equal bilaterally. Sensation intact. Unable to ambulate. Finger to nose intact. Speech normal. DISCHARGE EXAM Vitals - T:98.5 BP:110/78 HR:105 RR:20 02 sat:100% 2L GENERAL: middle aged male appearing comfortable CARDIAC: RRR, S1/S2, no mrg LUNG: decreased air entry on the left base, right sided scattered wheezes. ABDOMEN: nondistended, +BS, non tender to palpation, no rebound/guarding Chest: Tenderness along left costal margion and left sternal border improving. Pertinent Results: ADMISSION LABS [2168-4-16] 03:30PM GLUCOSE-122* UREA N-8 CREAT-0.7 SODIUM-131* POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-16 [2168-4-16] 03:30PM estGFR-Using this [2168-4-16] 03:30PM ALT(SGPT)-171* AST(SGOT)-149* ALK PHOS-643* TOT BILI-1.2 [2168-4-16] 03:30PM ALBUMIN-3.5 [2168-4-16] 03:30PM ALBUMIN-3.5 [2168-4-16] 03:30PM LACTATE-2.1* [2168-4-16] 03:30PM WBC-13.7# RBC-4.43 HGB-11.3* HCT-38.8* MCV-88 MCH-25.6# MCHC-29.2 RDW-14.8 [2168-4-16] 03:30PM NEUTS-89* BANDS-0 LYMPHS-7* MONOS-1* EOS-1 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [2168-4-16] 03:30PM PLT SMR-HIGH PLT COUNT-434# [2168-4-16] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2168-4-16] 03:30PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 DISCHARGE LABS: [2168-5-13] 06:15AM BLOOD WBC-8.1 RBC-3.35* Hgb-8.1* Hct-27.6* MCV-82 MCH-24.3* MCHC-29.5* RDW-18.5* Plt Ct-356 [2168-5-13] 06:15AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134 K-3.3 Cl-99 HCO3-26 AnGap-12 [2168-5-13] 06:15AM BLOOD ALT-24 AST-30 AlkPhos-235* TotBili-1.0 [2168-5-13] 06:15AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.3 MICRO: [2168-5-8] STOOL C. difficile DNA amplification assay- negative; FECAL CULTURE-NO ENTERIC GRAM NEGATIVE RODS FOUND, NO SALMONELLA OR SHIGELLA FOUND; CAMPYLOBACTER CULTURE- negative [2168-5-2] BLOOD CULTURE - no growth [2168-5-2] BLOOD CULTURE - no growth [2168-5-2] STOOL C. difficile DNA amplification assay- negative; FECAL CULTURE-NO ENTERIC GRAM NEGATIVE RODS FOUND, NO SALMONELLA OR SHIGELLA FOUND; CAMPYLOBACTER CULTURE-negative; Cryptosporidium/Giardia (DFA)-NO CRYPTOSPORIDIUM OR GIARDIA SEEN. [2168-4-30] BLOOD CULTURE - no growth [2168-4-29] BLOOD CULTURE - no growth [2168-4-29] BLOOD CULTURE - no growth [2168-4-28] BLOOD CULTURE - ENTEROCOCCUS FAECIUM [2168-4-27] BLOOD CULTURE - no growth [2168-4-27] BLOOD CULTURE - ENTEROCOCCUS FAECIUM [2168-4-26] BLOOD CULTURE - ENTEROCOCCUS FAECIUM, STAPHYLOCOCCUS EPIDERMIDIS [2168-4-26] BLOOD CULTURE ENTEROCOCCUS FAECIUM, STAPHYLOCOCCUS EPIDERMIDIS SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| STAPHYLOCOCCUS EPIDERMIDIS \| \| AMPICILLIN------------ =>32 R CLINDAMYCIN----------- =>8 R DAPTOMYCIN------------ S S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 4 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>64 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R 2 S [2168-4-21] IMMUNOLOGY HIV-1 Viral Load/Ultrasensitive--1 Viral Load/Ultrasensitive (Final [2168-4-21]): HIV-1 RNA is not detected. [2168-4-20] BLOOD CULTURE - no growth [2168-4-20] BLOOD CULTURE - no growth [2168-4-16] BLOOD CULTURE - no growth [2168-4-16] BLOOD CULTURE - no growth [2168-4-16] URINE CULTURE- no growth PATHOLOGY: COMMON BILE DUCT STENT PATHOLOGY [2168-4-25] POSITIVE FOR MALIGNANT CELLS, consistent with poorly differentiated carcinoma PERTINENT STUDIES # CXR [2168-4-16]: No significant interval change from prior with continued chronic elevation of left hemidiaphragm and associated left basilar opacity likely reflective of atelectasis. Right PICC tip terminates in the mid SVC. # RUQ U/S [2168-4-16]: 1. Limited study. Gallbladder could not be visualized. 2. Cirrhosis with ill-defined 15-mm nodule in the left lobe, without a clear correlate on the prior MR. 3. Stent in the CBD without intrahepatic biliary dilatation. CT or MRI is recommended for further evaluation of the gallbladder, as well as the left lobe hepatic nodule. # MRI ABDOMEN WITH CONTRAST [2168-4-17] 1. Interval increase in the size of the hepatic mass in the left lobe of the liver which causes more extensive obstruction of the left lateral segment bile ducts and has increased intraductal extent into the primary bifurcation of the biliary system. 2. Stable right-sided renal cysts, hepatic cyst in the left lateral segment, and gallstones. 3. Rounded, expanded lesion in the right 9th rib at the level of the costochondral junction that demonstrates heterogeneous signal on T2 weighted images and post contrast enhancement. Dedicated CT examination is recommended to rule out metastasis. 4. Slight increase in size of satellite lesion (9 x11mm) in the border of segment V/VIII that shows increased signal on T2 weighted images, arterial hyperenhancement and washout pattern. # FIDUCIAL PLACEMENT [2168-4-19] 1. Two gold fiducial markers placed within liver mass as described above. 2. Bilateral atelectasis in the lung lower lobes. 3. Soft tissue density surrounding the right 8th rib, favor nondisplaced fracture with callus formation (please refer to the body of the report). # CXR [2168-4-19] Mediastinal silhouette with left mediastinal shift, most likely due to left lower lung atelectasis/volume loss, is unchanged. Lung volumes remain very low. Small amount of pleural effusion is most likely present bilaterally. Catheter projecting over the right upper abdomen is redemonstrated. Elevation of left hemidiaphragm is unchanged. There is no pneumothorax. # ERCP [2168-4-25] Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: 2 previously placed plastic stents placed in the biliary duct were found in the major papilla. The Cotton [Doctor Last Name ] stent was removed using a snare. A double pigtail stent was removed using a rat tooth forceps. Evidence of a previous sphincterotomy was noted in the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree Fluoroscopic Interpretation: A moderate diffuse dilation was seen at the right main hepatic duct and left main hepatic duct. The dilation was greater on the left than right intra-hepatic ductal system. There was a large filling defect in the common hepatic duct c/w known HCC invading and causing bleeding within the biliary tree. Impression: Previously placed plastic stents were removed Evidence of a previous sphincterotomy was noted in the major papilla. There was a large filling defect in the common hepatic duct c/w known HCC invading and causing bleeding within the biliary tree. Multiple balloon sweeps were performed and large amount of blood clots and blood was extracted. Given tumor in the common hepatic duct and a double pig tail biliary stent was placed # CTA CHEST [2168-4-27] 1. Progressive left lung and right lower lobe collapse. This is likely related to chronic mucoid impaction, and possible underlying tracheobronchomalacia. 2. No pulmonary embolism. # TTE [2168-4-28] There is mild symmetric left ventricular hypertrophy. There is mild global left ventricular hypokinesis (LVEF = 45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No obvious vegetations seen # CHEST (PA & LAT) Study Date of [2168-5-4] IMPRESSION: Complete left upper and lower lobe collapse. Bronchoscopy is suggested. # RIB BILAT, W/AP CHEST Study Date of [2168-5-4] IMPRESSION: 1. Near-complete whiteout of the left lung with areas of cystic changes in the left upper lobe which are better evaluated on prior chest CT. 2. There are subacute fractures of several of the left lower ribs, which demonstrate some bridging callus. # CHEST (PORTABLE AP) Study Date of [2168-5-6] FINDINGS: Whereas the left hemithorax was previously completely opacified, there is now marked improved aeration of the left upper lobe, with residual atelectasis involving the left lower lobe. Small-to-moderate pleural effusion on the left is difficult to compare to the previous study for change due to the presence of complete lung collapse on the prior exam. Partial atelectasis of the right lower lobe is present, manifested by a right retrocardiac opacity and inferior displacement of the right hilum. Small right pleural effusion is not appreciably changed. Brief Hospital Course: 61M w/ HIV, Hep C cirrhosis, HCC with recent admission for CAP, presented with RUQ pain and increasing bilirubin with progression of HCC on imaging, s/p ERCP with stent placement on [4-25] resulting improvement in tbili. Pt had placement of fiducial and completed [2-6] rounds of cyberknife treatment. His hospital course was complicated by VRE bacteremia and complete left lung collapse, requiring brief ICU stay. Pt has opted to transition to home hospice. ACTIVE ISSUES: # Complete Left Lung Collapse: Pt has poor baseline lung capacity secondary to inclusion body myositis and diaphragmatic weakness. During his hospitalization, he had increasing difficulty clearing his secretions, due to his myositis, immobility and pain from subacute rib fractures. On two occasions, he developed increasing respiratory distress, initially requiring ICU admission, where he was placed on BiPAP. The etiology of his respiratory decompensation was thought to be secondary to mucous plugging. His respiratory status improved with chest PT, suctioning, standing nebs, acapella device and incentive spirometry. Pt was also encouraged to get out of bed and his rib pain was well controlled with medications. At time of discharge, he was stable on 2 liters of supplemental oxygen via nasal canula with oxygen saturation maintaining in the mid 90s. He continues to require BiPAP at night secondary to his myositis. # VRE and Staph epidermidis Bacteremia: Pt was found to be bacteremic with multiple blood cultures positive for VRE and s. epidermidis on [4-19]. The etiology was likely a biliary source, possibly secondary to fiducial placement, or pneumonia given chest CT findings of complete left lung collapse. Surveillance cultures cleared on [4-29]. He was initially on vancomycin and then transitioned to Daptomycin. He completed a 14 day course of treatment. # Left Lower Chest pain: Pt developed left lower rib pain during his hospitalization. His rib xray revealed multiple subacute fractures, likely responsible for his pain. He was treated with pain medications and his pain improved. # RUQ pain: He was admitted with worsening RUQ pain. On MRCP, the patient's HCC lesion was enlarged and causing mass effect on his biliary system (the likely the etiology of his pain) so he underwent ERCP and is s/p stenting with resulting improvement in his LFTs and Tbili, despite lack of improvement in pain because the lesion was still large. Thus, he underwent cyberknife [5-4], which provided dramatic improvement in his pain. # Diarrhea: Pt continue to have diarrhea throughout his hospitalization. His C diff assay was negative on multiple occasions, as were stool studies. His diarrhea was thought to be secondary to his antibiotics. He was ultimately started on Imodium with improvement in his symptoms. CHRONIC CARE # HIV: Currently, HIV is undetectable in his blood. CD4 count is 1000. For his HAART, his dosing was confirmed with pharmacy given liver failure, thus, he was continued on Leviva, Zetia and Truvada # Hep C cirrhosis c/b HCC: slight elevation in LFTs, which were normal in [2168-3-6]. After discussion with the patient and his HCP, he decided to transition to DNR/DNI and ultimately would like to go home with hospice. # Cdiff: Pt had recent C diff infection and was on PO vanc at time of admission. His course was continued and repeat PCR showed no evidence of C diff. # Inclusion body myositis: Pt has limited mobility at baseline and requires BiPAP nightly. He was continued on prednisone with Bactrim prophylaxis. TRANSITIONS IN CARE # Code Status: DNR/DNI # Contact: [Name (NI) 5969] [Name (NI) 40593], HCP and Partner, [Telephone/Fax (1) 40594] # ISSUES TO DISCUSS AT FOLLOW UP: During this hospitalization, pt expressed a desire to change code status to DNR/DNI and transition to hospice. Ultimately, he would like to receive home hospice but does not have the necessary support at this time. His plan is to be discharged to rehab for 2 weeks. At that time, a friend will be moving to [Name (NI) 86] and will be able to provide home health care for the patient. He should be discharged from rehab to home with hospice. He would like to continue all medications at this time, but is aware that he has the option of discontinuing any or all of them. He would like to forgo any further treatment for his HCC, but should he change his mind, he should have a repeat ERCP in 6 to 8 weeks with Dr. [Last Name (STitle) ]. Medications on Admission: Fexofenadine 60 mg po bid Prednisone 15 mg po daily Heparin sq tid Pseudoephedrine 30 mg po bid Sertraline 50 mg po daily Bactrim DS daily Lansoprazole 30 mg daily Fosamprenavir 1400 mg po bid Truvada 200-300 daily Vitamin D daily Calcium daily Multivitamin Vancomycin 250 mg po qid (until [2168-4-30]) Oxycodone 5 mg po q6h prn pain Tylenol ES 500 mg po q6h prn pain Xanax 0.25 mg po tid prn anxiety Ambien 5 mg po qhs prn insomnia Alb/atrovent inh q6h prn NTG 0.4 mg sl q5 mins x 3 prn pain Anusol prn Discharge Medications: 1. fexofenadine 60 mg Tablet [Month/Day/Year ]: One (1) Tablet PO BID (2 times a day). 2. prednisone 5 mg Tablet [Month/Day/Year ]: Three (3) Tablet PO DAILY (Daily). 3. pseudoephedrine HCl 30 mg Tablet [Month/Day/Year ]: One (1) Tablet PO BID (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution [Month/Day/Year ]: 5000 (5000) units Injection TID (3 times a day). 5. sertraline 50 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. fosamprenavir 700 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q12H (every 12 hours). 9. Truvada 200-300 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. cholecalciferol (vitamin D3) 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO TID (3 times a day). 12. multivitamin Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 13. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours). 15. oxycodone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for moderate pain. Disp:1 Tablet(s) Refills:0 16. sodium chloride 3 % Solution for Nebulization [Last Name (STitle) ]: One (1) neb Inhalation Q 8H (Every 8 Hours). 17. Tylenol 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO every six (6) hours as needed for fever or pain: Do not take more than 2 grams/24 hours. 18. lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety/nausea. 19. Ambien 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime as needed for insomnia. 20. Anusol-HC 2.5 % Cream [Last Name (STitle) ]: One (1) application Rectal three times a day as needed for hemorrhoids. 21. Imodium A-D 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day as needed for diarrhea. 22. docusate sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice a day as needed for constipation. 23. senna 8.6 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: PRIMARY hepatocellular carcinoma hospital acquired pneumonia bacteremia SECONDARY: inclusion body myositis HIV Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for right sided abdominal pain, which was likely from progression of your cancer. You did receive cyberknife radiation treatment to your tumor, which helped improve your pain. During your hospitalization, you were also treated for a pneumonia and an infection in your blood stream, for which you received antibiotics. You had several episodes of difficulty breathing, which we treated with breathing treatments and chest physical therapy. It is important that you continue these treatments at home Please note the following changes to your medications: # Use Sodium Chloride 3% nebulizers every 8 hours # START ativan 0.5 mg every 6-8 hours as needed for anxiety; STOP taking xanax # START imodium 2-4 times daily as needed for diarrhea # Use your incentive spirometer and acapella device every hour while you are awake Followup Instructions: Department: RADIOLOGY When: THURSDAY [2168-6-9] at 11:55 AM With: RADIOLOGY MRI [Telephone/Fax (1) 590] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2168-6-13] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD [Telephone/Fax (1) 8770] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2168-5-14]	[ "486", "2724", "4019", "41401" ]
Admission Date: [2127-9-15] Discharge Date: [2127-9-23] Date of Birth: [2069-2-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: s/p Motor Vehicle Collision Major Surgical or Invasive Procedure: Chest tube- Right History of Present Illness: Mr. [Known lastname ] is a 58 year-old man transferred from [Hospital3 ] after a he was the restrained driver of a car that struck a telephone pole with significant damage to the front of the car, with airbag deployment. Per report , he was reportedly ambulatory at the scene but disoriented and intoxicated. Past Medical History: Hypertension s/p Appendectomy Social History: Pt lives in [Location 7661] with his wife. [Name (NI) ] 2 children in the [Country 13622] Republic and 3 in US. Pt works at [Hospital3 ]. Family History: Non-contributory Physical Exam: Physical Exam on Admission: . Vitals: HR 90, BP 180/80, RR 18 O2: 96% HEENT: Pupils 1 mm b/l. Airway: intact Chest: Equal and bilateral breath sounds. Left and right chest wall tenderness. Abd: Epigastric tenderness. Reducible right ventral hernia. Rectal: Normal tone, no gross blood. MSK: No long bone deformities. Pelvis stable. Spine: No tenderness, no step-offs. Pertinent Results: Labs on Admission: WBC 13.0, Hgb 12.7, Hct 36, Platelets 246, Sodium 138, Potassium 3.6, Chloride 102, Bicarb 23 Ethanol 153 Hematocrit trend: [2127-9-16] 33.5 [9-18] 24.5 [9-22] 29.3 . Chest X-Ray [2127-9-19]: IMPRESSION: 1. No evidence of pneumothorax. 2. Interstitial pulmonary edema. 3. Bilateral small pleural effusions, right greater than left. . CT abd/pelvis [2127-9-15]-IMPRESSION: 1. Hepatic lacerations/contusions which given the number of segments involved, and the depth of penetration would likely represent grade III injury. There is associated hemoperitoneum. No active extravasation is noted. 2. Grade I splenic laceration with a small amount of perisplenic hematoma. 3. Fluid adjacent to the pancreas without evidence of pancreatic injury possibly representing blood tracking into this region from other injuries as described above. Recommend attention to this area on followup imaging. 4. Right anterior rib fractures in ribs four through six, with subcutaneous emphysema, tiny right pneumothorax and small right hemothorax. 5. Patchy airspace opacity in the right lower lobe, likely a combination on atelectasis and aspiration. Small foci of pulmonary contusions in the right middle lobe. . CT Head [2127-9-15]-IMPRESSION: No evidence of fracture, hemorrhage or mass effect. Old right cerebellar infarct. . Echo, transthoracic [2127-9-16]-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%). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. . Gallbladder Scan [2127-9-18]-IMPRESSION: Nonvisualization of the gallbladder 30 minutes following morphine administration. . MRCP [2127-9-21]-IMPRESSION: 1. Segment VIII liver laceration with some free fluid around the liver in patient status post MVC. 2. Cholelithiasis with thickened edematous gallbladder wall and pericholecystic fluid which may be secondary to the recent trauma. 3. Pericholecystic hepatic enhancement which may represent a perfusion abnormality. 4. Right pleural effusion. . KNEE (AP, LAT & OBLIQUE) LEFT [2127-9-22]- No acute fracture, dislocation Brief Hospital Course: Mr. [Known lastname ] was admitted to the Trauma intensive care unit with the following injuries: right-sided rib fractures, right hemothorax, grade III hepatic laceration, and a grade I splenic laceration. . # Respiratory Distress- # [Hospital 74469] hospital day 2, Mr. [Known lastname ] was intubated for declining mental status and increased work of breathing. A right-sided chest tube was placed for right hemothorax and put out 600ml in the first 24 hours. He was extubated on HD3. Chest tube was discontinued on HD4 and he was saturating well on room air prior to discharge. . # Hepatic/Splenic Lacerations- Serial hematocrits and abdominal exams were performed to monitor the evolution of hepatic and splenic lacerations. Hematocrit dropped to 29 on HD1 from 36 on admission and reached a nadir of 24.6 on HD4. Hematocrit was stable at 29 prior to discharge and his abdomen was soft and non-tender. Repeat CT revealed decreased size of hepatic and splenic lacerations. . # Tachycardia- Mr. [Known lastname ] had tachycardia on HD2. Cardiac enzymes were negative for ischemia. Cardiology was consulted and recommended benzodiazepines for alcohol withdrawal as well as a beta-blockade. Transthoracic echo was obtained and was normal with an EF > 55%. Tachycardia improved by hospital day 3. . # Acute cholecystitis- Mr. [Known lastname ] developed a fever on HD3. He was started on vancomycin and Zosyn. Blood cultures were sent and revealed Klebsiella in [12-24] bottles. Urine culture was negative. CT abdomen and pelvis revealed thickening of gallbladder wall. A HIDA scan was positive. Pancreatic enzymes were elevated. An MRCP revealed no dilation of intra or extra-hepatic ducts. Vancomycin was discontinued and he was started on levofloxacin. He was afebrile with soft, non-tender abdomen prior to discharge. He was discharged with oral levofloxacin to complete a 2 week course. He will follow-up with Dr. [Last Name (STitle) ] in 2 weeks in Trauma clinic. . Left Ankle Pain- Mr. [Known lastname ] reported left ankle pain. Orthopedics was consulted and recommended plain films which were negative for fracture. He was given a CAM boot for walking. He will follow-up with Dr. [Last Name (STitle) 1005] in 4 weeks in orthopedics clinic. . # Alcohol Use- Social work was consulted and discussed alcohol counseling and treatment programs which Mr. [Known lastname ] [Last Name (Titles) ]. Medications on Admission: Hydrochlorothiazide 25mg PO daily Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: Take this medication as prescribed by your primary care doctor. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Do not take other medications containing tylenol (acetaminophen) at the same time. 4. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:30 Tablet(s) Refills:0 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 11 days. Disp:11 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p Motor Vehicle Collision Right anterior rib fractures in ribs four through six Right hemothorax Grade III hepatic lacerations Grade I splenic laceration Acute cholecystitis Discharge Condition: Good Discharge Instructions: You were admitted to the hospital after a motor vehicle accident. You were found to have bleeding from your liver and your spleen. You were admitted to the intensive care unit and required a breathing tube. Because you had fluid surrounding your right lung, a chest tube was placed and was later removed. You had tests done which showed possible gallbladder infection. For this reason you were started on antibiotics. You should continue taking the antibiotic Levofloxacin until [2127-10-4]. You should see Dr. [Last Name (STitle) ] in 2 weeks. You were seen by the orthopedic surgeon Dr. [Last Name (STitle) 1005] for your left ankle pain. X-rays were ordered and did not show any fracture. You were given a boot for walking. You should follow-up with Dr. [Last Name (STitle) 74470] in 4 weeks. You may take Tylenol for pain but do not exceed 2 grams (2000mg) per day. You may take Dilaudid (hydromorphone) for pain but it is important not to drive, drink alcohol or take sedative medications while taking Dilaudid. Dilaudid causes constipation- therefore it is important to take a stool softener (Colace) while taking Dilaudid. . Please call your doctor or return to the hospital for: * Fever (Temp > 101), chills * Abdominal pain * Nausea or vomiting * Chest pain * Shortness of breath * Worsening ankle pain * Any other symptoms that concern you Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in Trauma Clinic in 2 weeks. Call ([Telephone/Fax (1) 376] to make an appointment. . Please see Dr. [Last Name (STitle) 1005] in orthopedics clinic in 4 weeks. Call ([Telephone/Fax (1) 2007] to make an appointment. . Please see your primary care provider at your earliest convenience.	[ "4019" ]
Admission Date: [2169-10-11] Discharge Date: [2169-10-21] Date of Birth: [2109-8-8] Sex: F Service: [Year (4 digits) 662] Allergies: Naprosyn / Keflex / Shellfish / Glucophage / Tetracycline / Penicillins / Erythromycin Base / Ciprofloxacin / Biaxin / Bactrim / Vancomycin / Latex / Duoderm Cgf / Morphine Sulfate / Levofloxacin Attending:[First Name3 (LF) 689] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Intubation and extubation History of Present Illness: This is a 60 year old female with past medical history of asthma, CAD, AF, and embolic stroke who presented from [Location (un) 620] with respiratory failure. Per report the patient called EMS today reporting dyspnea. When they arrived she was very short of breath and appeared cyanotic with diffuse crackles. Therefore, she was put on NIPPV and transferred to [Hospital1 ] [Location (un) 620] where she was intubated with succinylcholine etomidate. Given pink, frothy secretions from the tube and bilateral fluffy infiltrates presumed etiology was heart failure exacerbation so the patient received 80 mg of IV furosemide and was transferred to [Hospital1 18]. En route the patient was hypotensive on propofol, which was discontinued. On arrival she was agitated and received fentanyl/midazolam for sedation before receiving linezolid and pipercillin-tazobactam due to concern the patient's infiltrates were due to pneumonia. Initial ABG here was 7.23/ 71 / 406 on AC with Tv 450, RR 16, PEEP 5, and 02 100%. The patient was noted to have high peak pressures (>30) with high plateaus raising concern for auto-PEEP. Therefore, he received 10 mg IV vercuronium. He also received an unclear amount of fluid for transient hypotension. With increasing her minute ventilation pH rose to 7.9 and CO2 dropped to 60. He was transferred to the MICU. Of note, the patient had a VERY similar presentation on [2169-8-5] in which the patient was admitted for multifocal pneumonia with concern for volume overload. During that hospitalization she had very quick resolution of her chest radiograph and was discharged on a course of linezolid / piperacillin-tazobactam. On arrival to the MICU the patient was intubated and sedated. Paralysis was coming off but patient still not interacting/ reacting in a meaningful way. Some spontaneous movements. Past Medical History: Left MCA territory embolic infarct, likely of cardioembolic etiology in [2166-5-16] Atrial fibrillation on sotalol and coumadin CAD - MI [2155] @ age 44, [2156], and NSTEMI in [2164] (Trop T 0.06) Sick sinus syndrome status post dual-chamber pacemaker MVR Hyperlipidemia Diabetes mellitus, type 2 Obesity Hypertension Asthma Ostructive sleep apnea on BIPAP Mild pulmonary HTN 36/18 on cath in [8-21] Social History: Significant for the absence of current tobacco use (quit at age of 22) No heavy alcohol. Family History: Per OMR - Her father died of CAD in his 50's, he had his first MI at age 41. She has multiple younger brothers with "heart problems." Physical Exam: VS: 95.9 Temp: BP:102/62 HR:72 RR 18, and O2sat 93 % on vent GEN: Intubated, sedated, markedly hirstute, NAD HEENT: anisocoria (appears old), not following commands, occasionally aoviding noxiious stimuli or maoning. NO LAD or masses appreciated. RESP: Crackles bilaterally with prolonged espiratory phase. CV: Distant heart sounds, regular, not taychcardic ABD: Soft, NT, ND, BS+ EXT: cool, large (3-2 cm) round, smooth edged ulcer on right anterio thigh with erythema and granulation tissue but no acute pus. NEURO: intubated and sedating, moving all four extremities equally. Pertinent Results: =================== LABORATORY RESULTS =================== WBC-15.5# RBC-4.56 Hgb-12.4 Hct-38.7 MCV-85RDW-16.9 Plt Ct-203 PT-23.8* PTT-29.8 INR(PT)-2.3* Glucose-306* UreaN-25* Creat-1.3* Na-139 K-4.7 Cl-102 HCO3-27 ALT-27 AST-35 LD(LDH)-367* AlkPhos-143* TotBili-0.9 Calcium-8.6 Phos-2.6* Mg-1.8 URINE: Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 ============== OTHER RESULTS ============== Admission EKG: A paced at 80. IVCD. No acute ST changes. Chest Radiograph [2169-10-11]: IMPRESSION: 1. Hilar prominence with bilateral lung opacities is concerning for pulmonary congestion/edema with possible pneumonia. 2. Tubes positioned appropriately Chest Radiograph [2169-10-13] 3:31 AM(post extubation): IMPRESSION: AP chest compared to [10-12]: The patient has been extubated, lung volumes are normal, and the lungs are clear following resolution of heterogeneous opacification in both lower lungs yesterday. Given the rapid clearance, these findings were not due to hemorrhage or pneumonia or noncardiogenic edema. Cardiac edema and toxic inhalation or massive aspiration, the likely causes. Heart size is top normal and unchanged. No pleural abnormality. Transvenous right atrial and right ventricular pacer leads in standard placements. Chest Radiograph [2169-10-13] 6:59 PM (post reintubation) IMPRESSION: 1. Interval intubation and placement of NG tube. 2. New diffuse bilateral alveolar opacities. Given the time course, this most likely represents pulmonary edema. Transesophageal Echo [2169-10-14]: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. At least mild-moderate mitral regurgitation. Dilated ascending aorta. Compared with the report of the prior study (images unavailable for review) of [2169-8-7], an [Year (4 digits) 34486] jet of at least mild-moderate mitral regurgitation is now seen. Due to the [Year (4 digits) 34486] nature of the mitral regurgitation jet, if clinically indicated a cardiac MRI [Telephone/Fax (1) 9559] may be best able to assess the severity of mitral regurgitation. CT Chest W/O Contrast [2169-10-14]: IMPRESSION: 1. Multifocal ground-glass opacities, compatible with multifocal pneumonia. 2. Small bilateral pleural effusions. 3. Unchanged multilobulated right hepatic hypodense lesion, compatible with the previously described biliary cystadenoma. 4. 1.3 cm simple left renal cyst. 5. Status post cholecystectomy. . CXR [10-16]: 1. Significant interval clearing of the lungs. Despite previous description as multifocal pneumonia, the apparent rapid resolution of these infiltrates suggest that this more likely may be due to pulmonary edema. 2. Interval extubation and removal of the NG tube. . [10-19] Renal CTA: 1. No evidence for renal artery stenosis. No significant atherosclerotic disease. 2. Complex hepatic cyst, unchanged in size compared to [Month (only) 216] [2168], and also previously characterized by ultrasound. If further characterization is required, this could be accomplished by MRI. 3. Status post cholecystectomy. 4. Left parapelvic cysts, with additional exophytic cyst arising posteriorly from the interpolar region of the left kidney. . Brief Hospital Course: 60 y.o. female with [Hospital 7235] medical problems and recent admission for "pneumonia" now readmitted for pneumonia and CHF. . 1. Acute on Chronic Diastolic CHF: Patient presented with bilateral infiltrates consistent with multifocal pneumonia vs CHF. She was empirically treated with antibiotics and furosemide with improvement but difficulty assessing exactly what process was predominant. Quick resolution and reappearance of infiltrates was thought to be more consistent with diastolic CHF. After her first extubation proceeded uneventfully the patient rapidly decompensated on arrival to the medical floor with severe hypoxia and needed to be reintubated urgently. It is unclear what precipitated these episodes of decompensation though hypotension was considered possible. Cardiac enzymes remained negative. Echocardiogram showed MR [First Name (Titles) 151] [Last Name (Titles) 34486] jet. Cardiology recommended gentle diuresis and gentle volume resuscitation as needed to maintain SBP>100. They also recommended starting an ACE inhibitor or CCB as an outpatient. Given her predispositoin for flash pulmonary edema, we obtained a renal CTA to rule out renal artery stenosis, and this was negative. Pt's blood pressure remained around SBP 100 but we were able to restart her home lasix dose 20mg (every other day) prior to discharge with stable pressure. She will have follow up with cardiology within 1 week. . 2. Multifocal Pneumonia: Given diffuse infiltrates that waxed and waned dramatically these were thought less likely to be multifocal pneumonia so though the patient received linzeolid and pip-tazo at presentation these were rapidly discontinued. On [10-14] when CT showed clear infiltrate CAP coverage with ceftriaxone/azithro was restarted. Levo was discontinued when CXR on [10-16] did not show clear consolidation and pt's oxygenation status improved significantly with diuresis in MICU. Additionally, pt reported an "allergy" to levo, among multiple other antibiotic allergies, though reaction seemed to only be diarrhea. . 3. Afib w/ RVR: Was well controlled on sotalol. She was continued on coumadin, had supratherapeutic INR to 4.1 in setting of levofloxacin use. Coumadin was held and restarted when INR dropped to 1.6. She was bridged on heparin drip and discharged on lovenox course with INR of 1.6, instructed to check INR at home and to adjust coumadin as needed for goal >2. Discharged on coumadin 5mg daily (home dose 3mg). . #. Chest pain - pt had one episode of CP after coming to the floor, ECG unchanged from previous and no acute findings on right sided ECG, cardiac markers slightly elevated but stable over 2 draws. Cardiology was consulted and recommended interval repeat cathetrization as outpt, last cath a few years ago was clean and low likelihood of stenosis. Markers likely elevated due to repeated cardiac stress, not concerning at this time for ischemia. She was given full dose ASA and high dose statin while being ruled out, and monitored on tele without any major events. Pt was chest pain free for the rest of the hospital stay. Returned to home dose ASA and statin on discharge, cardiology outpt f/u. . 5. HTN: Held home lasix and help captopril that was started during this admission (per cardiology recs) given hypotension to SBP 90s. Likely in setting of overdiuresis. Gave gentle 250cc fluid boluses with caution given easy predisposition for flash pulm edema. Prior to discharge, BP stabilized and we restarted home lasix dose 20mg qod. . 6. Hx embolic stroke: continue levetiracetam at home doses . 7. DM: On large doses at home, on sliding scale in the hospital with well controlled blood sugars . Medications on Admission: -Albuterol Q4hrs PRN -Fluticasone 110 mcg/spray 2 puffs [Hospital1 ] -Sotalol 80 mg [Hospital1 ] -Calcium Carbonate 500 mg PO QID PRN heartburn -Levetiracetam 250 mg PO BID -Warfarin 3 mg PO daily -[Hospital1 54306] 2 mg PO BID -ASA 162 mg PO daily -Humalog 75-25 15-20 in AM and 15-20 PM -Humulin N 35-42 QHS PRN -Atorva 20 -Atroven 17 mcg/actuation Q6hrs PRN Discharge Medications: 1. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain fever. 4. aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-17] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 7. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day as needed for heartburn. 8. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: take 5mg today ([10-21]), measure INR and take 3mg daily after INR >1.8. 9. [Month/Day (4) 54306] 2 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Humalog 100 unit/mL Solution Sig: 75-25 Subcutaneous twice a day: take 15-20 in AM, 15-20 in PM. 11. Humulin N 100 unit/mL Suspension Sig: Thirty Five (35) u Subcutaneous at bedtime. 12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [12-17] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. Lovenox 100 mg/mL Syringe Sig: 100mg injection Subcutaneous twice a day for 4 days: please use 1 injection in AM, 1 injection in PM. Disp:8 Refills:0 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day. Discharge Disposition: Home Discharge Diagnosis: Primary: Flash pulmonary edema . Secondary: diastolic CHF MVR DM2 HTN asthma OSA 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 [Hospital1 18]. You were admitted with respiratory distress and found to have flash pulmonary edema (acute accumulation of fluid in your lungs) and had to be intubated twice for this. You were extubated and stabilized in the ICU and then transferred to the medical floor. We did not see a pneumonia on your last chest x-ray and did not continue the antibiotics started in the ICU. We diuresed you gently and started you back on lasix when your blood pressure stabilized. Your INR was very high (>4) in the beginning of your admission and we held your coumadin, we restarted it and prior to discharge your INR was 1.6. We started a heparin drip the day before you left to cover you while your INR came back to normal. You will be discharged with Lovenox to bridge your anticoagulation until your INR is at goal >2, you should take coumadin 5mg today and remeasure your INR at home. You can return to your home dose of 3mg daily when your INR is in the acceptable range. Our cardiologists saw you while you were in the hospital and recommended that you start a medication called an ACE inhibitor after you leave the hospital, you should discuss this with your cardiologist at your appointment. You did not have a heart attack while you were at the hospital. . You should follow up closely your PCP and cardiologist within 1 week of leaving the hospital. . We have made the following changes to your medications: - Take coumadin 5mg tonight ([10-21]) and remeasure your INR at home, you can return to your home dose of 3mg daily after your INR is >2 - Start lovenox, take 1 injection in the morning and 1 in the evening (12 hours apart), you are given 4 days of doses, check your INR daily and continue your coumadin, take lovenox until your PCP appointment [Name Initial (PRE) ] Take lasix 20mg EVERY OTHER day . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . We recommended home services for you prior to discharge (PT and nursing) but you declined these. Followup Instructions: Please follow up at your already [Name8 (MD) 1988] appointments with your PCP and your cardiologist. . You summarized them as below: PCP [Name Initial (PRE) ] [Name Initial (NameIs) 3816] @12:15 Electrophysiology/Cardiology - Thursday @2:00 Dr. [Last Name (STitle) 32878] - [10-31] @2:00 Pleases call Dr. [Last Name (STitle) ] to schedule an appointment within the next 2 weeks Completed by:[2169-10-21]	[ "51881", "4280", "412", "V1582", "2724", "41401", "42731", "25000", "32723", "4168" ]
Admission Date: [2189-4-15] Discharge Date: [2189-4-17] Date of Birth: [2133-2-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Right arm swelling. Major Surgical or Invasive Procedure: Venography of right arm/chest. Angioplasty of right subclavian/brachiocephalic thrombus. TPA infusion. History of Present Illness: Patient is well-known to the Transplant service. He has ESRD secondary to anti-GBM disease, and recently was admitted for thrombectomy of his left AV Vectra graft. Ultimately, that failed and a right subclavian Permacath was placed for dialysis access. He now returns having been seen at his dialysis center after successful dialysis, but with noticeable pain-free right arm swelling. Past Medical History: 1. ESRD: [2-5] anti-GBM disease, on HD since [3-7] 2. DM2: dx [2177] 3. HTN 4. Chronic low back pain [2-5] herniated discs 5. CHF 6. Peripheral neuropathy 7. Anemia 8. h/o nephrolithiasis 9. s/p cervical laminectomy 10. h/o depression 11. h/o MSSA bacteremia 12. s/p L AV graft: [7-7] Social History: Lives w/ wife, son, daughter-in-law, and three grandchildren in [Name (NI) 86] area, has been unemployed [2-5] disability, smokes tobacco 1 ppd x45 years, past alcohol, no recreational drug use. Family History: 1. DM 2. Renal failure Physical Exam: AVSS. Gen: NAD, A&O x3 Chest: CTA, RRR Abd: S, NT, ND Ext: trace RUE edema, otherwise warm and well-perfused Pertinent Results: [2189-4-15] 07:00AM BLOOD PT-27.6* INR(PT)-2.8* [2189-4-17] 02:18AM BLOOD WBC-6.7 RBC-2.81* Hgb-8.4* Hct-26.8* MCV-95 MCH-30.0 MCHC-31.5 RDW-17.5* Plt Ct-432 [2189-4-17] 02:18AM BLOOD PT-22.3* PTT-35.2* INR(PT)-2.2* [2189-4-17] 02:18AM BLOOD Glucose-120* UreaN-40* Creat-9.3* Na-142 K-4.8 Cl-100 HCO3-29 AnGap-18 [2189-4-17] 02:18AM BLOOD Calcium-8.9 Phos-6.0* Mg-1.7 Brief Hospital Course: Patient was seen in the ER and ultrasound revealed that he had a right IJ thrombus, and that the tip of the Permacath was in the right IJ. This is despite having an admission INR of 2.8. He was admitted for work-up of the thrombus and possible resiting of the dialysis line. On HD #2, patient went to IR for venography to delineate the extent of thrombus and catheter position, as well as to look for central stenoses or other reasons for his failed left arm AV graft and new clot in right system. IR found an occlusion of the right subclavian/brachiocephalic, performed angioplasty of the presumed thrombus and left a venous sheath in place for TPA thrombolysis with the intention of follow-up venography on HD #3. Incidentally, the Permacath was seen to be in good position. Subsequent to this, discussion between Dr. [First Name (STitle) ] and the patient's nephrologist concluded that the risk of bleeding outweighed the possible benefit of thrombolysis; TPA administration was stopped. On HD #3, the patient had his sheath removed, was dialyzed successfully through the Permacath and he was discharged home. Medications on Admission: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each hemodialysis). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each hemodialysis). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: DVT of right internal jugular/subclavian/brachiocephalic veins. Discharge Condition: Stable. Mild residual swelling of right arm. Discharge Instructions: DC to home. Continue with hemodialysis via right subclavian Permacath. Continue with outpatient Coumadin and INR checks with goal INR 2 - 3. Elevate right arm when possible to reduce swelling. Followup Instructions: Follow-Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2189-4-23] 10:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 544], M.D. Date/Time:[2189-6-12] 11:30 Completed by:[0-0-0]	[ "4280", "40391", "25000" ]
Admission Date: [2130-1-16] Discharge Date: [2130-1-20] Date of Birth: [2052-5-31] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7729] Chief Complaint: Melanoma Major Surgical or Invasive Procedure: [2130-1-16] 1. Right modified radical neck dissection. 2. Right parotidectomy with facial nerve monitoring/dissection. History of Present Illness: The patient is a 77-year-old male who in [2125] was found to have a lesion overlying the right angle of the mandible. Interestingly, he also had the same region biopsied in [2116]. In both cases, the lesion was read as lentiginous compound melanocytic nevus, dysplastic type, with apparent complete excision. The pathology from [2125] was interpreted as a darkly pigmented lentiginous junctional nevus with architectural disorder and moderate cytologic atypia and numerous pigment-laden macrophages extending to the tissue edge. He underwent a re-excision of the lesion in [2126-4-10] which showed residual atypical dysplastic nevus cells. This was completely excised and there was a scar consistent with a prior excision. He did well until [2129-10-11] at which time he was noted to have a swelling in the region of the tail of the right parotid. A CT scan was obtained that demonstrated a 3-cm mass involving the lower aspect of the right parotid. He was presented at the Multidisciplinary Cutaneous [Hospital ] Clinic at which time surgery and probable postoperative radiation was recommended. Past Medical History: Past medical history remarkable for coronary artery disease with cardiac catheterization showing 2 completely blocked arteries that were not stentable. He has angina with exertion, but this is largely controlled with topical worn Nitro patch. He rarely has to take sublingual nitroglycerin. He underwent a transient global attack in [2127-10-11] and has subsequently been on Plavix. He has hypercholesterolemia, treated with Lipitor, and is status post appendectomy in [2117] and cholecystectomy in [2119]. He is status post herniorrhaphy and has a history of chronic thrombocytopenia of unclear etiology, with most recent platelet count being 101,000. Social History: He is widowed from his first wife and has a daughter, age 52. [Name2 (NI) ] has been remarried for the past couple of decades, and he and his new wife have a 19-year-old son. [Name (NI) ] does not smoke and drinks a glass of wine per night. Family History: The family/social history: There is no family history of melanoma. His father had [Name2 (NI) 499] cancer. Physical Exam: Elderly man in no acute distress. NECK: There was a soft tissue mass approximately 3 cm in diameter in the tail of the right parotid gland. There is a surgical scar anterior to this over his right jawline without surrounding pigmentation. There is no cervical, supraclavicular, bilateral axillary or bilateral inguinal adenopathy. LUNGS:CTA-B CV: reveals a 1/6 systolic ejection murmur. ABD: Without masses, tenderness, or organomegaly. NEURO: CN-II-XII intact grossly Pertinent Results: [2130-1-16] 04:45PM CK-MB-4 cTropnT-<0.01 proBNP-236 [2130-1-16] 04:52PM freeCa-1.09* [2130-1-16] 04:52PM HGB-13.8* calcHCT-41 [2130-1-16] 04:52PM GLUCOSE-142* LACTATE-2.1* NA+-138 K+-3.7 CL--102 [2130-1-16] 04:52PM TYPE-ART PO2-207* PCO2-34* PH-7.46* TOTAL CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [2130-1-16] 07:48PM CK(CPK)-276* [2130-1-16] 07:48PM CK-MB-4 cTropnT-<0.01 Brief Hospital Course: 77 yo M with history of CAD and recent diagnosis of melanoma who is s/p parotidectomy w/ neck node dissection. Had ST depressions intraoperatively and transferred to ICU for monitoring overnight. #. ST depressions: Anesthesia noted ST depressions intraoperatively. Patient remained without chest pain or dyspnea. His post-op EKG was significant for new RBBB and associated diffuse T-wave inversions. The patient was transferred to the ICU post-operatively for close hemodynamic monitoring overnight. He had three negative sets of cardiac enzymes over twelve hours and no further ECG changes. He remained asymptomatic throughout and was transitioned to his home cardiovascular medications except plavix and discharged from the ICU on POD#1. #. Melanoma s/p parotidectomy and node dissection: Patient felt well post-op aside from hoarseness and some irritation from his foley catheter. He received prophylactic antibiotics peri-operatively and throughout his hospital stay. His JP drains were removed on POD#3 and #4 when drainage was <30cc/day. He recieved DVT prophylaxis throughout his hospitalization and was restarted on his home dose of plavix on discharge. Patient is being discharged: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, incision clean, dry and intact, and ambulating well. Medications on Admission: 1) Nitropatch 0.2 mg/hr DAILY (on in AM and off at bedtime) 2) Plavix 75 mg DAILY 3) Niaspan ER 1000 mg QHS 4) Atorvastatin 20 mg QHS 5) Lisinopril 5 mg DAILY 6) Metoprolol Succinate 100 mg DAILY 7) Nitroglycerin SL 0.4 mg PRN 8) Folic acid 1 mg DAILY 9) Aspirin 81 mg DAILY 10) ICaps MV 2 tabs [Hospital1 ] Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Metastatic melanoma, right neck/parotid. Discharge Condition: Stable, A&O, ambulating Discharge Instructions: OK to shower but do not soak incision until follow up appointment, at least. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Your stitches/staples will be reomoved at your follow-up appointment. Followup Instructions: [First Name4 (NamePattern1) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 41] Date/Time:[2130-1-24] 10:00	[ "9971", "41401", "2875", "4019", "2724" ]
Admission Date: [2140-7-16] Discharge Date: [2140-8-5] Date of Birth: [2095-12-26] Sex: F Service: MEDICINE Allergies: Macrodantin / Heparin Agents Attending:[First Name3 (LF) 1377] Chief Complaint: Transfer from [Hospital3 ] for variceal bleeding. Major Surgical or Invasive Procedure: EGD Dobhoff Post-Pyloric Feeding Tube History of Present Illness: Ms. [Known lastname ] is a 44yo F with ETOH abuse, HCV, h/o IVDA presented to OSH with intermittent hematemasis and on [2140-7-14] is for TIPS. Pt has been having black tarry stools and hematemasis since [2140-7-11]. At OSH, initial hct 31, INR 1.9, TB 3.2, AST 99, ALT 41, alk phos 99,plt 43,000, ETOH 173. Pt was given vitamin K 10mg SC and was admitted and started on octreotide. Pt received 2 units PRBC for hct 25.9 and 6 bags of platelets for platelets of 37K on [7-15]. Pt underwent EGD [7-15] and showed 4 grade [3-12] distal esophageal varices, which were banded and there was a concern for a couple of gastric varices. On day of admission, she had 400cc of melanotic stools with clots, and her hct was noted to have dropped from 33.5 to 18 with SBP in 70s. Pt was given 4 units PRBC, central line placed and was transferred to [Hospital1 18] for TIPS. . Currently, denies any n/v, abdominal pain, chest pain, or sob. Past Medical History: 1. Hepatitis C 2. DM II c/b neuropathy 3. EtOH abuse 4. Tobacco abuse 5. h/o IVDA quit more than 20 years ago Social History: h/o IVDA 20 years ago, drinks 2 glasses of wine daily, + smoking. Family History: non-contributory Physical Exam: PE: 100.6, 82, 62/46, 14, 97% on RA, CVP 4 GEN: AOx 3, answering questions appropriately HEENT: + scleral icterus, PERRL, EOMI, No JVD appreciated. Skin: jaundiced CV: RRR without m/r/g LUNGS: CTA bilat, no wheezes, rhonchi, crackles. ABD: obese, hypoactive BS, NT. EXT: palpable pulses bilaterally. No edema Neuro: AOx 3, CN II to XII grossly intact. moving extremities. grossly normal sensation to touch. No asterixis. Pertinent Results: [2140-7-16] 10:03PM GLUCOSE-176* UREA N-20 CREAT-0.6 SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 [2140-7-16] 10:03PM CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-2.7* [2140-7-16] 10:09PM LACTATE-4.3* [2140-7-16] 10:09PM TYPE-[Last Name (un) ] PO2-47* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 [2140-7-16] 10:03PM HCT-30.8# [2140-7-16] 07:53PM HGB-8.8 calcHCT-26 [2140-7-16] 06:43PM HGB-9.1* calcHCT-27 [2140-7-16] 04:26PM LACTATE-3.4* [2140-7-16] 03:39PM WBC-4.5 RBC-2.35# HGB-8.2# HCT-21.9* MCV-93 MCH 34.8* MCHC-37.3* RDW-19.0* [2140-7-16] 03:39PM PLT COUNT-114# [2140-7-16] 02:49PM HCT-25.2# [2140-7-16] 11:11AM GLUCOSE-128* UREA N-23* CREAT-0.6 SODIUM-145 POTASSIUM-4.3 CHLORIDE-113* TOTAL CO2-20* ANION GAP-16 [2140-7-16] 11:11AM ALT(SGPT)-35 AST(SGOT)-109* LD(LDH)-263* ALK PHOS-65 AMYLASE-30 TOT BILI-10.4* [2140-7-16] 11:11AM LIPASE-20 [2140-7-16] 11:11AM WBC-7.6 RBC-3.70* HGB-12.1 HCT-34.0* MCV-92 MCH-32.6* MCHC-35.5* RDW-19.0* [2140-7-16] 11:11AM NEUTS-75.5* LYMPHS-18.4 MONOS-5.8 EOS-0.1 BASOS-0.3 [2140-7-16] 11:11AM PLT SMR-VERY LOW PLT COUNT-57* [2140-7-16] 11:11AM PT-23.9* PTT-43.2* INR(PT)-2.4* . Imaging at OSH: Liver u/s with doppler: Coarse echogenic liver, suggestive of fatty liver but cannot exclude a micronodular cirrhosis in the appropriate clinical setting. Mild splenomegaly. patent portal vein. no vevidence of varices or portal hypertension. A small amount of ascites. 14.cm echotextures. Spleen 13.8cm. . CXR [2140-7-16]: RSC in SVC. No acute cardiopulm processes. . Abdominal ultrasound [2140-7-18]: IMPRESSION: Very limited study. TIPS stent is patent but velocities could not be obtained due to respiratory motion and therefore satisfactory baseline data could not be obtained. . Feeding tube placement [2140-7-20]: IMPRESSION: Successful placement of post-pyloric feeding tube in the fourth portion of the duodenum. . Abdominal Ultrasound [2140-7-29]: IMPRESSION: 1. Patent TIPS with slightly increased velocities. 2. New 4 cm echogenic wedge-shaped structure in the right lobe. Given its development since examinations of 9 and 11 days ago, it is unlikely to be a mass, however, MRI can be performed on a nonemergent basis for further characterization. 3. Slight increase in ascites. . Portable CXR [2140-7-31]: There has been interval extubation and removal of right-sided vascular catheter and sheath. Right PICC line has been placed, terminating in the proximal superior vena cava. Cardiac silhouette is upper limits of normal in size allowing for low lung volumes. Previously present mild pulmonary edema has resolved. There is improved aeration in the left retrocardiac region with residual patchy opacity containing several air bronchograms. Although possibly due to resolving atelectasis and dependent edema, infectious pneumonia is also possible in the appropriate setting. Minor right basilar atelectasis is noted as well as a possible small right pleural effusion. . Renal U/S [2140-7-31]: FINDINGS: The right kidney measures 12.2 cm and the left 11.2 cm. The renal parenchymal thickness and echogenicity are normal. There is no evidence of hydronephrosis or calculi. Small amount of ascites is noted. . IMPRESSION: Unremarkable renal ultrasound. . EGD [2140-8-3]: IMPRESSION: 1. A feeding tube passing into duodenum was noted. No significant varices noted in esophagus. Granularity, friability, erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach 2. Duodenum was not entered due to the feeding tube. No bleeding noted in stomach. 3. Otherwise normal EGD to second part of the duodenum. Brief Hospital Course: # Alcoholic Cirrhosis/Acute Alcoholic Hepatitis: Admitted to [Hospital3 ] from outside hospital after recent variceal bleed s/p variceal banding. Here, repeat EGD was performed which showed previously banded esophageal varices and gastric varices with stigmata of recent bleeding. No new bands placed. Subsequently underwent uncomplicated TIPS on [2140-7-16]. Completed 5 day course of octreotide and 7 day course of levofloxacin for SBP prophylaxis. Unfortunately, patient continued to decompensate, with rising bilirubin and INR. She was treated with lactulose and rifaximin for encephalopathy. Ultrasound [7-18] and [7-20] both showed patent TIPS. . Given rising bili/INR, she was given a trial of pentoxyfilline and ursodiol for suspected acute alcoholic hepatitis. Corticosteroids not given because of recent bleeding. However, her synthetic function did not improve, and her creatinine subsequently rose from 0.6 to 3.0. A diagnostic paracentesis was performed (on [7-29]), which demonstrated no evidence of SBP. Her pentoxyfilline and ursodiol were discontinued as there was no clear improvement on treatment. She was started empirically on octreotide/midodrine for possible hepatorenal syndrome. Nephrotoxic medications were held and she was given volume repletion both with normal saline and albumin. Creatinine subsequently improved to 1.2-1.4 at the time of discharge. . For nutritional support a post-pyloric feeding tube was placed and tube feeds were intiated per nutrition recommendations. She will be discharged for continued nutritional support to meet caloric goals. . She was seen by social work for substance abuse support. In addition, she was provided with information on post-discharge support services. . MELD at time of discharge was 33, driven by a bilirubin of 19.8, creatinine of 1.4, and an INR of 2.9. . Diuretics held given renal failure and lack of ascites on ultrasound, s/p TIPS. . # s/p Upper GI bleed: Initial hct was 34 which drifted down to 25 then 21.9 on day of admission. She underwent EGD a few hours after arrival, and it showed 3 esophageal variceal bands and gastric varices which had recent stigmata of bleeding but no active bleeding. She was supported with blood products and underwent TIPS as above. Her hematocrit subsequently remained stablized with no further evidence of active GI bleeding. Repeat EGD on [2140-8-3] prior to discharge showed no significant varices in the esophagus. There was noted granularity, friability, erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach consistent with portal gastropathy, but no active bleeding. . # Acute renal insufficiency: As outlined above, developed rising creatinine, initially concerning for hepatorenal syndrome (HRS), with UOP <30 cc/hour in setting of known ETOH cirrhosis. Started empirically on midodrine/octreotide. However urine sodium >10, so was not completely consistent with HRS. Paracentesis [7-29] demonstrated no evidence of bacterial peritonitis. Urinalysis demonstrated no eosinophils. Ultrasound on [7-30] showed no hydronephrosis, but did show a new echogenic wedge shaped structure in right lobe, of unclear clinical significance. No other evidence of infarcts/ischemia were noted, and lupus anti-coagulant was sent and was negative as well. Renal service was consulted and nephrotoxic medications were held. She was repleted with IV fluids and renal function subsequently improved, with creatinine trending down from 3.0 to 1.4, with good urine output. . # Hypotension: Initially likely from GIB, hypovolemia. Subsequently remained stable in low 90's-100's systolic, in setting of chronic liver disease. Initially started on Zosyn and Vancomycin as well as Levaquin for concern for infectious etiology, however antibiotics subsequently discontinued as no infectious source identified. Of note, blood cultures from [7-17] grew 1/4 bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. This was considered contaminant and repeat blood cultures were negative. . # HCV: Repeat HCV viral load on this admission ([2140-7-21]) showed no HCV viral RNA. . # DM II: On Metformin prior to hospital admission. Covered as inpatient on sliding scale insulin and glargine. Discharged on glargine 24units/night, and the patient demonstrated how to use SSI at home. Metformin and alternative oral hypoglycemics contra-indicated in setting of her cirrhosis. . # HIT antibody positive: HIT antibody sent due to thrombocytopenia, and was noted to be positive on this admission; however, she could not be anti-coagulated given her recent variceal bleed and coagulopathy from liver disease. All heparin products were held. Platelet count remained low secondary to liver disease, but stable, with no clear evidence of clinical thrombosis. . # Nutritional Deficiency: Post-pyloric dobhoff placed for nutritional support to meet caloric goals. Tube feeds will continue upon discharge with outpatient services arranged. . # Communication: [Name (NI) ] (boyfriend [Telephone/Fax (1) 72890]), [Name (NI) ] (mother) [Telephone/Fax (1) 72891]. Medications on Admission: MEDS at home: metformin 500 [Hospital1 ]. . MEDS on Transfer: Protonix 40mg IV BID MVI po daily Thiamine 100mg qday Folate i mg po daily nicotine patch 14gm qday nadolol 20mg qday oxazepam q2 prn for agitation per CIWA [6-18] 10mg 13-20 20mg Octreotide gtt Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:90 Capsule(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 container Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Health Services Discharge Diagnosis: Primary Diagnoses: 1. Alcoholic Cirrhosis 2. Acute Alcoholic Hepatitis 3. Esophogeal Varices with Variceal Bleed Secondary Diagnoses: 1. Nutritional Deficiency 2. Acute Renal Failure 3. HIT antibody Positive Discharge Condition: Liver cirrhosis requiring ongoing nutritional support. Discharge Instructions: You were admitted for alcoholic cirrhsosis and variceal bleed. Your liver is extremely sick, and it is important that you continue to abstain completely from alcohol. Alcohol cessation is required for you to be a candidate for a liver transplant. Information on substance abuse centers has been provided to you to help with this. Nutrition is also very important, and a feeding tube was placed for nutritional support. You were set up for services at home to continue the tube feeds. Please call your primary physician or return to the ER if you develop fever >101, abdominal pain, bright red blood per rectum, melanotic stools, or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] [2140-8-23] @ 2:15pm. You may call to confirm your appointment at [Telephone/Fax (1) 2422]. Please follow-up with your primary physician [Name Initial (PRE) 3390]: [Name10 (NameIs) 72892],[Name11 (NameIs) ] [Name Initial (NameIs) ] [Telephone/Fax (1) 50168] in [2-9] weeks after discharge. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2140-8-6]	[ "2851", "5849", "5990", "51881", "3051" ]
Admission Date: [2199-4-23] Discharge Date: [2199-4-24] Service: SURGERY Allergies: Keflex / Bactrim Attending:[First Name3 (LF) 148] Chief Complaint: Hemodynamic instability with right retroperitoneal bleed. Major Surgical or Invasive Procedure: Arteriogram of right kidney. Coil embolization of right lower pole renal artery branch bleed. History of Present Illness: 93-y.o. male h/o CAD, COPD, and worsening renal insufficiency, recently admitted to [Hospital1 18] [Date range (1) 19174] for worsening renal insufficiency leading to volume overload. He underwent a R renal biopsy on [2199-4-10]. His renal failure was managed with steroids, the volume overload with diuretics, and a UTI with meropenem from [Date range (1) 19175]. His aspirin was held for 5days pre- and post- renal biopsy. He has been doing well at rehab until last evening when began to experience R flank and abdominal pain. Brought to [Location (un) 620] ED where hemodynamically borderline, Hct 26.5 (prior 28.5 on [4-18]), and CT non-contrast showed R retroperitoneal hematoma. Bolused 2L [Hospital 19176] transferred to [Hospital1 18] ED, received 2u PRBC en route. On arrival initial BP 70/40 and emergent surgical consult requested. Pt currently reports notable R-flank pain, denies abd pain, and has mild dyspnea. Denies chest pain. Remaining interview truncated for placement of CVL. Past Medical History: CAD s/p velocity stent x2 to RCA [2190] Diastolic CHF (EF 55% [2-/2199]) Hypertension Hypercholesterolemia COPD on 2L home O2 Chronic renal insufficiency (recent exacerbation s/p R renal bx) L parotid cancer BPH Obesity PAST SURGICAL HISTORY: EVAR [4-/2193] Debridement and closure of R3 toe [2-/2199] Bilateral cataracts [5-/2189] and [4-/2190] Social History: Retired. The patient is widowed, two children, 4 grandchildren, 7 great-grandchildren. -Tobacco history: 40+ pack year history, quit in [2148], smoke a pipe until [2181] -ETOH: none currently, whiskey daily for many years, stopped two months ago -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Sister and brother had strokes. Father had CAD. Mother had an "enlarged heart." Physical Exam: On admission: Dopamine gtt 15 T 96.5 P 124 BP 122/68 RR 22 O2sat 100 on NRB A&Ox3, uncomfortable and moaning Lungs CTAB Heart RRR / tachy Abdomen soft, NT, ND, ecchymoses across lower abdomen bilaterally (c/w subcutaneous injections) R flank diffusely tender No L CVA tenderness Pertinent Results: [2199-4-23] 05:23AM WBC-20.0# RBC-2.99 HGB-8.7* HCT-26.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.8 [2199-4-23] 05:23AM NEUTS-88.0* LYMPHS-8.9* MONOS-3.0 EOS-0 BASOS-0 [2199-4-23] 05:23AM PLT COUNT-78# [2199-4-23] 05:23AM PT-13.7 PTT-31.2 INR(PT)-1.2* [2199-4-23] 05:23AM GLUCOSE-184* UREA N-132* CREAT-2.5* SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 [2199-4-23] 05:23AM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-38* TOT BILI-0.4 [2199-4-23] 05:23AM LIPASE-51 [2199-4-23] 05:23AM ALBUMIN-2.1* [2199-4-23] 05:23AM cTropnT-0.08* [2199-4-23] 06:55AM HCT-33.7# [2199-4-23] 11:54AM TYPE-ART PO2-78 PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 [2199-4-23] 11:54AM LACTATE-5.1* [2199-4-23] 12:10PM WBC-31.1# RBC-3.25 HGB-9.5* HCT-27.6* MCV-85 MCH-29.1 MCHC-34.4 RDW-15.6* [2199-4-23] 12:10PM PLT COUNT-123# [2199-4-23] 01:44PM TYPE-ART PO2-78 PCO2-45 PH-7.35 TOTAL CO2-26 BASE XS-0 [2199-4-23] 01:44PM LACTATE-4.8* [2199-4-23] 04:16PM WBC-27.9* RBC-3.30* HGB-9.5* HCT-27.4* MCV-83 MCH-28.8 MCHC-34.7 RDW-15.7* [2199-4-23] 04:16PM PLT SMR-LOW PLT COUNT-83* [2199-4-23] 04:52PM TYPE-ART PO2-185* PCO2-47* PH-7.39 TOTAL CO2-30 BASE XS-3 [2199-4-23] 04:52PM LACTATE-4.7* [2199-4-23] 08:40PM WBC-30.9* RBC-3.63* HGB-10.5* HCT-29.3* MCV-81* MCH-28.9 MCHC-35.9* RDW-15.9* [2199-4-23] 08:40PM PLT COUNT-85* [2199-4-23] 08:54PM TYPE-ART PO2-111* PCO2-50* PH-7.38 TOTAL CO2-31* BASE XS-3 [2199-4-23] 08:54PM LACTATE-4.3* Brief Hospital Course: On [2199-4-23] morning, the patient was admitted to the SICU for retroperitoneal bleed and started on norepinephrine gtt for hemodynamic instability. Family was [Name (NI) 653], and the surgical team discussed and confirmed DNR/DNI status and treatment wishes with patient and family. According to patient's wishes, he underwent endovascular arteriographic coil embolization by interventional radiology. Throughout the day, the patient received a total of 11 units PRBC, 6 units FFP, and 2 units platelets to maintain hemodynamic stability. He remained stable on norepinephrine gtt after the procedure. On [2199-4-24] early morning, he suffered respiratory distress with increased oxygen requirement, and CXR showed near complete opacification of the right lung, likely secondary to mucous plug. Bronchoscopy was offered, which would have required intubation with low likelihood of successful extubation, and patient and family understood and declined in accordance to DNR/DNI wishes. Over the subsequent few hours, the patient suffered respiratory failure and expired at 0715. The family declined autopsy. Medications on Admission: prednisone 60 mg daily ASA 81 mg daily metoprolol 50 mg [Hospital1 ] lisinopril 2.5 mg daily, isosorbide dinitrate 40 mg TID doxazosin 2 mg daily lasix 120 mg daily simvastatin 20 mg dailiy nitro SL PRN spiriva 18 mcg daily atrovent PRN albuterol PRN omeprazole 20 mg dailyi lidocaine 5% patch colace 100 mg [Hospital1 ] vit D2 50,000 units Qweek cyanocobalamin 1000 mcg daily calcium carbonate 500 mg TID acetaminophen PRN senna PRN trazadone 50 mg QHS PRN Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Retroperitoneal bleed. Respiratory failure. Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None needed. Completed by:[2199-4-24]	[ "5845", "51881", "4280", "41401", "V4582", "40390", "5859", "2724", "496", "V1582" ]
Admission Date: [2189-11-20] Discharge Date: [2189-11-30] Date of Birth: [2114-4-27] Sex: M Service: MEDICINE Allergies: Levaquin / Shellfish Derived / Latex / Aranesp Attending:[First Name3 (LF) 9002] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Lumbar Puncture Paracentesis History of Present Illness: 75 yo M hx CAD s/p NSTEMI, a. fib not on Coumadin with 1 day hx generalized fatigue, weakness, poor PO, decreased UOP. Patient was in his USOF on Weds when he saw his new PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. On [Holiday ] Eve, his daughter brought him to dinner at her house and noticed that after walking down the stairs that he was having difficulty walking. His daughter also notes that he just seemed "off" that night. He did not sleep well that night, and today he felt lethargic, but otherwise denied fevers, abdominal pain, dysuria, headaches, neck pain and diarrhea. Decreased urine output was noted today. In the ED, patient's altered mental status improved and he did not receive CT head. CXR revealed pleural effusions but no obvious consolidation. FAST was positive for fluid in ruq and luq. Troponin was elevated but consistent with prior falues. EKG was paced without ischemic changes. UA was clean. Saturating was 80% according to EMS, but 100% on 4 l in the ED. He was hypotensive to the 80s/50s in the ED and responded to 3 L NS. Cardiology was consulted and advised Medicine bed. When bed was assigned, patient became hypotensive with MAP of 58. He was initially started on dobutamine which was later transitioned to levphed. He received Vanco and Zosyn in the ED. He has had 2 recent hospital stays this month. The first at [Hospital1 18] was from [10-29] through [11-4] was for NSTEMI which was felt to be related to demand ischemia in the setting of afib with RVR. He was not started on anticoagulation given prior GI bleeding. Failure to thrive workup was not pursued given that he had a recent colonoscopy/egd, CT head and chest at [Hospital 6451] hospital within the past year. The second hospital stay was from [11-6] to [11-8] for hypotension in the setting poor po intake. He was thought to have food poisoning. Po intake improved with zofran and fluids. The patient's hypotension was not symptomatic, wht SBP ranging from 90 to 100. Right pleural effusion was noted in the setting of smoking history, and thoracentesis was deferred until patient could follow up as an outpatient. In the ICU, Mr. [Known lastname 64592] is feeling well and has no specific complaints. He says that his neck feels stiff but that this is chronic. He has [Last Name ] problem with neck ROM. ROS was otherwise essentially negative. The pt denied recent fevers, night sweats, chills, headaches, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: 1) CAD (cath in [2161] showed 3-vessel disease, patient states he had MI [09] years ago), presented with NSTEMI believed to be secondary to demand 2) Atrial fibrillation (not on Coumadin given h/o GI bleeding) 3) [Company 1543] Kappa KDR701 dual-chamber placement 4) Cirrhosis (classified as cryptogenic although patient has history of heavy EtOH use 35 years ago) 5) chronic kidney disease with baseline Cr 2.7 6) angiodysplasia of stomach and small intestine with serial endoscopic cauterization ([2186]) 7) GI bleeding chronic anemia (multifactorial, thought to be [12-29] kidney disease + GI bleeding) 8) prior TIA ([4-3], ? [8-5]) 9) melanoma, right forearm 10) multiple BCCs 11) Diverticulosis 12) Colon polyps 13) Left carotid stenosis with stent ([2184]) 14) BPH ([3-4]) 15) Gout 16) Pneumonia ([12-3]) 17) portal gastropathy 18) low grade esophageal varices 19) remote appendectomy Social History: Lives independently, across the street from daughter. Smoked 1.5 packs/day x 15 years, quitting 35 years ago. Former heavy EtOH use, sober x 35 years. No drugs. Pt previously worked as a letter carrier for the United States Postal Service. Family History: Notable for MI. Both parents lived to be >[Age over 90 ] years old. Physical Exam: Vitals: T: 92.1 BP: 132/98 P: 76 R: 20 SaO2: 100% RA General: Awake, alert, NAD, Oriented x3 HEENT: NCAT, PERRL, EOMI, pale conjunctivae, no scleral icterus, MMM, no lesions noted in OP Neck: supple, JVP at clavicle Pulmonary: decreased breath sounds at right base, otherwise CTA Cardiac: distant HS, RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted, no shifting dullness Extremities: 1+ RLE edema, no LLE edema Skin: mild erythema at left foot Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. [3-1] quadriceps and gastroc bilaterally. Grip [3-31]. Sensation intact to gross tough throughout. Pertinent Results: [2189-11-24] 04:41AM BLOOD WBC-7.2 RBC-2.28* Hgb-8.1* Hct-24.8* MCV-109* MCH-35.6* MCHC-32.6 RDW-19.0* Plt Ct-52* [2189-11-20] 04:40PM BLOOD WBC-2.5* RBC-2.84* Hgb-9.6* Hct-31.1* MCV-110* MCH-33.9* MCHC-30.9* RDW-18.4* Plt Ct-77* [2189-11-24] 04:41AM BLOOD Neuts-94.4* Lymphs-3.9* Monos-1.6* Eos-0.1 Baso-0 [2189-11-20] 04:40PM BLOOD Neuts-73.6* Lymphs-15.3* Monos-8.8 Eos-1.9 Baso-0.3 [2189-11-24] 04:41AM BLOOD Plt Ct-52* [2189-11-24] 04:41AM BLOOD PT-15.3* PTT-44.7* INR(PT)-1.3* [2189-11-20] 04:40PM BLOOD PT-13.4 PTT-45.2* INR(PT)-1.1 [2189-11-24] 04:49PM BLOOD Glucose-168* UreaN-86* Creat-3.2* Na-147* K-3.2* Cl-119* HCO3-16* AnGap-15 [2189-11-24] 04:41AM BLOOD Glucose-110* UreaN-85* Creat-3.5* Na-148* K-3.5 Cl-118* HCO3-16* AnGap-18 [2189-11-20] 04:40PM BLOOD Glucose-110* UreaN-82* Creat-3.1* Na-142 K-4.6 Cl-111* HCO3-20* AnGap-16 [2189-11-23] 04:09AM BLOOD ALT-54* AST-48* LD(LDH)-271* AlkPhos-170* TotBili-0.9 [2189-11-21] 02:42AM BLOOD ALT-68* AST-74* LD(LDH)-282* CK(CPK)-72 AlkPhos-241* TotBili-1.0 DirBili-0.5* IndBili-0.5 [2189-11-21] 02:42AM BLOOD CK-MB-NotDone cTropnT-0.30* [2189-11-20] 11:33PM BLOOD CK-MB-NotDone cTropnT-0.28* [2189-11-20] 04:40PM BLOOD cTropnT-0.32* [2189-11-24] 04:41AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 UricAcd-8.4* [2189-11-23] 04:09AM BLOOD Albumin-3.1* Calcium-8.8 Phos-4.7* Mg-2.1 [2189-11-21] 09:11AM BLOOD Ammonia-75* [2189-11-20] 11:33PM BLOOD TSH-15* [2189-11-21] 02:42AM BLOOD T4-5.3 [2189-11-20] 04:40PM BLOOD CRP-33.4* [2189-11-21] 03:36PM BLOOD Cortsol-19.3 [2189-11-22] 05:12PM BLOOD HIV Ab-NEGATIVE [2189-11-24] 04:41AM BLOOD Vanco-24.8* [2189-11-22] 03:27AM BLOOD Vanco-8.3* [2189-11-22] 03:38AM BLOOD Type-ART Temp-36.1 pO2-168* pCO2-27* pH-7.38 calTCO2-17* Base XS--7 [2189-11-20] 09:58PM BLOOD Type-ART Temp-32.7 FiO2-21 O2 Flow-15 pO2-511* pCO2-27* pH-7.40 calTCO2-17* Base XS--5 Intubat-NOT INTUBA Comment-NON-REBREA [2189-11-20] 09:58PM BLOOD Glucose-105 Lactate-0.9 Na-140 K-4.4 Cl-116* calHCO3-17* [2189-11-21] 09:55AM BLOOD O2 Sat-68 [2189-11-24] RENAL ULTRASOUND: Small echogenic right kidney, with normal-appearing left kidney. No hydronephrosis. ULTRASOUND (ABD) [2189-11-22]: Moderate ascites with appropriate spot for paracentesis marked in the right lower quadrant. [2189-11-23] LENI: No evidence of DVT in bilateral lower extremity. [2189-11-21] CT HEAD W/O CONTRAST: No acute intracranial hemorrhage or mass effect. Hypodense white matter changes- current CT is significantly limtied due to motion. Pt. appears to have pacemaker on concurrent PXR Chest, whick precludes MR study. Hence, a close follow up with motion elimination when the pt. is cooperative, can be onsidered for better assessment for any intracranial abnormality. [2189-11-25]: ECHO - The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2189-10-30], there is no significant change. As noted in the prior study, there is evidence of plaque in the descending thoracic aorta. [2189-11-26]: Duplex/Doppler Hepatic US - FINDINGS: The liver is shrunken and has a coarse echotexture and an irregular outline in keeping with liver cirrhosis. No focal liver lesions are seen. There is extensive ascites, and a right-sided pleural effusion. The common bile duct is not dilated, and there is no intrahepatic bile duct dilatation. The main portal vein, left, and right portal veins are patent with hepatopetal flow. The main, right, and left hepatic veins are patent. The IVC is patent and demonstrates normal flow. The gallbladder contains gallstones, however, there is no evidence of acute cholecystitis. The spleen measures 9.8 cm longitudinally, and there is no focal abnormalities. Brief Hospital Course: # Systemic Inflammatory Response Syndrome: No obvious source for infection but leukopenic and hypothermic on admission. (WBC 1.8, T 92.1). Both have improved w/ empiric antibiotcs (vanc/zosyn). The patient underwent a paracentesis which was negative for SBP, although had been on antibiotics for 3 days prior to paracentesis, so it is feasible that the infection had already been partially treated. He further underwent an LP which was negative for infection, blood cultures that did not reveal a source, and urinalysis/urine culture that was also not revealing. CXR was performed that revealed bilateral pleural effusions but no pneumonia. Possible partially treated SBP is the most likely source for infection in this patient, especially given the non specific symptoms of fatigue and the presentation including confusion. The patient was treated with an empiric course of vanc/zosyn for 6 days given no clear etiology. After antibiotics were discontinued, the patient did not develop any further signs or symptoms of SIRS. The patient was initially admitted to the medical intensive care unit because of hypotension and he transiently received levophed(low doses), discontinued at 6 a.m. on [11-24]. Please note that the patient's systolic blood pressure appears to range between 95-110 mmHg. The patient further received stress dose steroids after a cortisol stim test that tapered to completion on [2189-11-26]. # End Stage Liver Disease: Cirrhosis, labeled as cryptogenic but patient with previous history of heavy alcohol use. Lactulose as needed for confusion has been somewhat effective. Liver team was consulted and the patient was followed by Dr. [Last Name (STitle) 497] and his time while an inpatient. The patient had a duplex/doppler ultrasound that showed patent hepatic veins and braches as well as moderate ascites. # Pancytopenia: Leukopenia has resolved and likely related to infection. Thrombocytopenia is possibly related to liver disease, however, his platelets drifted to a nadir of 31. We monitored his fibrinogen, FDP, and LDH for concern of developing disseminated intravascular coagulopathy. The patient's anemia was likely due to his chronic kidney injury. The patient's platelets have risen for the past several days, now at 89. During this time, the patient's fibrinogen also continued to rise. His platelets began to recover after antibiotics were discontinued. It is possible that the antibiotic administration contributed to his worsening of thrombocytopenia. The patient appears to have a baseline hematocrit around 29-30. On [2189-11-25] patient was found to have a hematocrit of 23.9 and was transfused 2 units of pRBCs. His hematocrit bumped appropriately to 28.5 and has remained stable around 28. HCT on discharge was 29.2. # Hypoxia Patient was transiently hypoxic upon presentation, though this promptly resolved. The patient has bilateral pleural effusions but his oxygenation improved w/o intervention. Possibly as MS improved he had some atelectasis that resolved. # Altered Mental Status: Patient presented with altered mental status. He was evaluated by neurology and they believed his altered mental status to be due to a toxic-metabolic abnormality. With the improvement in mental status with lactulose treatment and the elevated ammonia level, his altered mental status was likely due to hepatic encephalopathy. We would recommend continuing lactulose 30gm PO TID prn for confusion. # Acute on Chronic Renal Injury: Baseline creatinine appears to be 2.7, though we have limited data from [2189-10-27] only. The patient was admitted with a creatinine of 3.1, reached a peak of 3.5. Initially thought to be related to pre-renal vs. hepatorenal although creatinine did not improve w/ fluid resuscitation. Renal ultrasound w/ small right kidney but no hydroneprhosis. Uric acid slightly elevated. Renal was consulted and followed the patient during his hospitalization. As the patient's overall condition improved, his creatinine also returned to baseline. Upon discharge, his creatinine was 2.1. Initially, the patient's lasix, nadolol, spironolactone, and finasteride were held due to renal failure. His lasix was able to be added back on but at half of his usual home dose. The patient will start sodium bicarb tablets 650mg PO BID. # Coronary Artery Disease: NSTEMI earlier in [2189-10-27] with medical management. No signs of ischemia on EKG upon presentation. The patient underwent transthoracic echo with preserved systolic function early in his hospitalization and had a second echo towards the conclusion of his hospitalization - both showed preserved LV EF of 55-60% and borderline diastolic heart failure. Patient initially presented on aspirin and a statin. Due to his decreasing platelet level, his aspirin was discontinued as was all heparin products. Due to patient's blood pressure around 100 mm Hg, beta blocker was not restarted during hospitalization. We would recommend that both aspirin and beta blocker be restarted as tolerated. #Atrial Fibrillation: Not on coumadin given history of GI bleed and presence of melena. Patient has remained rate controlled and intermittently paced. # Hypernatremia: Patient initially was not taking much oral food or liquid given his mental status, but is now tolerating a regular diet. Hypernatremia is likely from the initial restriction of free water. He had a free H2O deficit is 2.7 liters. Patient was given D5W and had slow correction of his hypernatremia. Of note, patient reports that he drinks 32 water bottles per week (1 pint bottles) in addition to other fluids. # Hypothermia: Throughout the hospitalization the patient was hypothermic. He initially had rectal temperatures around 32.7 degrees celcius while in the intensive care unit. He initially was treated with the use of a Bair hugger while in the intensive care unit as well as on the medical floor. As the patient's condition improved, his temperature moderately improved. He remained with temperature between 95-96 degrees fairenheight, though rectal temperatures were 97. The patient was always warm and well perfused with temperatures of 94-95 PO farenheit. We would recommend obtaining rectal temperatures for a true core temperature. # FEN/GI: Initially recommended soft (dysphagia); Nectar prethickened liquids per speech and swallor recommendations, however, as his condition improved he was transitioned to thin liquids and regular solids. Medications on Admission: - ATORVASTATIN 40 mg po daily - ESOMEPRAZOLE MAGNESIUM 40 mg po daily - FINASTERIDE 5 mg po daily - FUROSEMIDE 40 mg po BID - LEVOTHYROXINE 25 mcg po daily - NADOLOL 20 mg po daily - SPIRONOLACTONE 50 mg [Hospital1 ] - ASPIRIN 81 mg po daily - CHOLECALCIFEROL (VITAMIN D3) 800 units po daily - FERROUS SULFATE 325 mg po daily 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Lactulose 10 gram/15 mL Solution Sig: Forty Five (45) ML PO Q8H (every 8 hours) as needed for confusion. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Hydrocortisone 2.5 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for pruritis. 14. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Altered Mental Status Systemic Inflammatory Response Syndrome End Stage Liver Disease Acute on Chronic Kidney Injury Pancytopenia Hypoxia Hypernatremia Discharge Condition: Mental Status: Alert, sometimes confused Ambulatory Status: out of bed to chair with assist Discharge Instructions: You presented to the hospital with low blood pressure, fatigue, confusion, and weakness. Because your blood pressure was so low, you were initially admitted to the intensive care unit where you received antibiotics. You began to improve, and there was suspicion that you may have had an infection in your abdomen. Fluid was taken from your abdomen, but did not show any infection. As you were already on antibiotics, we cannot be sure if there was initially an infection causing your symptoms. Your liver function was noted to be worsening, and you were seen by Dr. [Last Name (STitle) 497], the hepatologist (liver doctor), while you were in the hospital. Your kidney function also was more impaired than usual when you arrived to the hospital. With the help of the kidney doctors, your kidney function returned better than its baseline. You were taken off of antibiotics and were stable without fever or other signs of infection. Your confusion may have been due to an infection in your abdomen, or your confusion may have been due to a build up of ammonia that your liver could not break down. You should continue to take the medicine lactulose if you are found to be confused. We discontinued several of your medicines while you were in the hospital: (1) Aspirin 81mg by mouth daily (2) Nadolol 20mg by mouth daily (3) spironolactone 50mg by mouth twice daily (4) finasteride 5mg by mouth daily Some of these medicines will be slowly reintroduced into your regimen by Dr. [Last Name (STitle) 497]. We also introduced new medications while you were in the hospital: (1) hydrocortisone 2.5% topical cream, apply to affected areas [Hospital1 ] (2) clotrimazole cream, apply to affected area over buttocks and back [Hospital1 ] (3) sarna lotion, apply to topical area QID prn itch. (4) lactulose 30 gm PO TID prn confusion The following medications were changed while you were in the hospital: (1) Lasix 20 mg PO BID Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9001], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2189-12-3] 7:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2189-12-11] 2:20 Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2189-12-21] 10:20 Completed by:[2189-11-30]	[ "0389", "5849", "78552", "2760", "5119", "2859", "42731", "4168", "99592", "40390", "5859" ]
Admission Date: [2166-6-25] Discharge Date: [2166-9-3] Date of Birth: [2121-3-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Worsening angina Major Surgical or Invasive Procedure: [2166-6-27] Urgent coronary bypass grafting x2 with a reverse saphenous vein graft from the aorta to the first diagonal coronary artery; reverse saphenous vein graft from the aorta to the left anterior descending coronary artery [2166-7-2] Placement of PICC Line [2166-7-7] Tracheostomy [2166-7-14] PEG placement History of Present Illness: Mr. [Known lastname 85300] is a 44 year old Jehovah Witness with known coronary artery disease s/p DES of OM lesion [2166-3-6], grade 1 diastolic dysfunction, and chronic pericarditis who presented to outside hospital with increasing angina on exertion. Cardiac catheterization at [Hospital6 ] revealed significant LM disease. Patient was deemed to be poor surgical candidate and was subsequently transferred to the [Hospital1 18] for further evaluation and treatment. Past Medical History: - Coronary Artery Disease, s/p inferior MI(STEMI), s/p Drug eluting stent to obtuse marginal - History of positive PPD, negative CXR [10-11] - Chronic pericarditis - Hypertension - Hyperlipidemia - Type II Diabetes Mellitus Social History: Originally from [Country 2045], lives with wife and 2 children. Denies tobacco and ETOH. Family History: Denies premature coronary artery disease Physical Exam: Pulse: 87 BP: 102/77 RR: 25 O2 sat: 100% Height: 74 inches Weight: 86 kg General:A&Ox3 Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: 2+ Left:2+ Carotid Bruit none Right: 2+ Left:2+ Pertinent Results: [2166-6-26] Echocardiogram: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal to mid inferolateral wall, hypokinesis of the anterolateral wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2166-6-26] Chest CTA: 1. Acute pulmonary embolus in the left descending pulmonary artery, extending in the lingula, and basal truncus, involving more than half of the vessel lumen. No evidence of right heart strain. 2. No pneumonia. No evidence of active, or chronic granulomatous disease. [2166-6-26] Lower Extremity Ultrasound: No evidence of deep vein thrombosis in either leg. [2166-6-26] Carotid Ultrasound: Right ICA with no stenosis. Left ICA with no stenosis. [2166-6-27] Intraop TEE: PRE-CPB: 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). There is moderate lateral hypokinesis. 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. The pericardium may be thickened. Prior to bypass, there was an episode of hypotension with EKG changes. TEE showed severe hypokinesis of the anterior and anteroseptal walls, with an LVEF of 10 %. CPR was initiated and the patient emergently placed on cardiopulmonary bypass. POST-CPB: On infusions of vasopressin, Epi, Norepinephrine, Milrinone. In sinus rhythm. Improved anterior wall on inotropic support, with LVEF now 35%. MR [First Name (Titles) ] [Last Name (Titles) ] remain trace. There is no change in the aortic contour post decannulation. [2166-7-1] Head CT Scan: 1. Limited study due to patient motion. A small hypodensity in the right parieto-occipital lobe is of indeterminate age, likely chronic. No acute intracranial hemorrhage or acute major vascular territorial infarction. 2. Marked paranasal sinus disease as above. [2166-7-2] EEG: This is an abnormal video EEG study because of severe diffuse background slowing and disorganization. These findings are indicative of severe diffuse cerebral dysfunction, which is etiologically non-specific. There were no epileptiform discharges or electrographic seizures. [2166-7-2] MRI Head/Brain: 1. Innumerable punctate foci of signal on the diffusion-weighted images, many of which are also bright on FLAIR suggestive of multiple acute, likely embolic, infarcts. A more confluent area of FLAIR signal abnormality in the right posterior temporal lobe could be another area of older infarct. 2. Scattered punctate foci of susceptibility artifact could represent areas of microhemorrhage or calcification. [2166-7-6] Abd Ultrasound: Limited view of pancreas. No evidence of cholelithiasis or intra-or extrahepatic biliary dilatation. Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study [2166-9-1] 1:25 PM [Hospital 93] MEDICAL CONDITION: 45 year old man s/p decannulation Final Report INDICATION: Evaluate for aspiration in patient with history of aspiration. FINDINGS: Barium passes freely through the oropharynx without evidence of obstruction. The patient demonstrates a slow oral phase and weak swallow with weak pharyngeal muscle contraction. There is penetration and aspiration of thin barium without penetration or aspiration of nectar or thick barium. The patient does sense the aspiration and coughs appropriately. He has an increased residue in both the valleculae and piriform sinuses, which spills over in between swallows. For more details please see the speech and swalllow division note in OMR. There is again noted an opacity projecting over the tracheal air column that likely represents an endoluminal lesion, possibly tracheal polyp or other mass lesion. Recommend further evaluation with direct visualization or Neck CT. IMPRESSION: 1. Aspiration of thin barium without aspiration of thick or nectar barium which represents some improvement from the prior study. 2. Lesion projecting over the trachea that may represent tracheal polyp or other mass lesion. Recommend further evaluation with dedicated CT of trachea or direct visualization for further evaluation. Radiology Report CHEST (PA & LAT) Study Date of [2166-8-12] 10:26 AM [Hospital 93] MEDICAL CONDITION: 45 year old man with s/p cabg FINDINGS: In comparison with the study of [7-31], the lungs are now essentially clear except for some mild atelectatic changes at the left base. No vascular congestion. Tracheostomy tube remains in good position, and the PICC line again extends to the lower SVC or cavoatrial junction. DR. [First Name11 (Name Pattern1) 1569] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11006] Admission [2166-6-25] 07:02PM BLOOD WBC-6.9 RBC-4.41* Hgb-12.6* Hct-38.9* MCV-88 MCH-28.5 MCHC-32.3 RDW-15.0 Plt Ct-274 [2166-7-7] 01:46AM BLOOD WBC-17.9* RBC-1.66* Hgb-4.8* Hct-15.9* MCV-96 MCH-28.7 MCHC-30.0* RDW-21.0* Plt Ct-515* [2166-8-4] 05:00AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.1* Hct-27.0* MCV-87 MCH-26.2* MCHC-29.9* RDW-17.6* Plt Ct-544* [2166-6-25] 07:02PM BLOOD PT-11.1 PTT-26.1 INR(PT)-0.9 [2166-7-7] 01:46AM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3* [2166-7-13] 05:02AM BLOOD PT-15.7* INR(PT)-1.4* [2166-6-25] 07:02PM BLOOD Glucose-131* UreaN-17 Creat-1.1 Na-142 K-3.9 Cl-105 HCO3-28 AnGap-13 [2166-7-5] 05:02AM BLOOD Glucose-143* UreaN-24* Creat-0.7 Na-148* K-3.7 Cl-114* HCO3-29 AnGap-9 [2166-8-4] 05:00AM BLOOD Glucose-110* UreaN-15 Creat-0.5 Na-137 K-4.4 Cl-100 HCO3-30 AnGap-11 [2166-6-25] 07:02PM BLOOD ALT-23 AST-27 LD(LDH)-143 AlkPhos-63 Amylase-86 TotBili-0.2 [2166-7-7] 01:46AM BLOOD ALT-426* AST-267* LD(LDH)-569* AlkPhos-588* Amylase-478* TotBili-0.4 [2166-7-24] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158* Amylase-106* TotBili-0.3 [2166-6-26] 05:25AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0 [2166-7-22] 12:35PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.7 Mg-2.5 Discharge [2166-8-31] 07:35AM BLOOD WBC-5.0 RBC-3.93* Hgb-10.3* Hct-32.4* MCV-83 MCH-26.1* MCHC-31.7 RDW-17.1* Plt Ct-374 [2166-8-31] 07:35AM BLOOD Plt Ct-374 [2166-8-18] 06:13AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2* [2166-8-31] 07:35AM BLOOD Glucose-140* UreaN-25* Creat-0.8 Na-138 K-4.6 Cl-101 HCO3-30 AnGap-12 [2166-7-24] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158* Amylase-106* TotBili-0.3 [2166-8-31] 07:35AM BLOOD Mg-2.0 [2166-6-25] 07:02PM BLOOD %HbA1c-8.3* eAG-192* Brief Hospital Course: Mr. [Known lastname 85300] was admitted to the cardiac surgical service. Given severe left main disease and unstable angina, he remained on Integrilin and Nitroglycerin. Preoperative evaluation was notable for mildly depressed LV function and pulmonary embolus - see result section for additional details. After extensive discussion with the patient and his family about risks and benefits especially refusal of blood products, he agreed to proceed with surgical revascularization. On [6-27], Dr. [Last Name (STitle) 914] performed coronary artery bypass grafting surgery. Operative course was notable for hypotensive cardiac arrest following induction of anesthesia. See operative note for additional details. Following surgery, he arrived to the CVICU in critical condition, on multiple pressors. Given labile hemodynamics, he required insertion of IABP. The IABP was eventually removed on postoperative day two, and inotropic support was gradually weaned over several days. Given severe anemia and refusal of blood products, Epogen was administered. Initially unresponsive, Neurology was consulted. Head CT scan was unrevealing, and EEG showed no evidence of seizure activity. Neurology initially attributed his severe obtundation to possible hypoxic-ischemic injury related to hypotensive cardiac arrest and persistently severe anemia. MRI of brain was notable for multiple emboli and infarcts. Given that there was no intervenable etiology of his unresponsiveness neuro initially signed off. Due to prolonged ventilation, Dobhoff feeding tube and PICC line were placed. Tracheostomy was eventually performed on [7-7], with subsequent PEG placment on [7-14]. Mr. [Known lastname 85300] transferred from the ICU to the floor on [7-16] (POD #19). He intermittently spiked fevers which subsided and he was treated for staph PNA. Neuro was re-consulted to evaluated his bilateral leg weakness on [7-16]. His leg weakness was believed to be due to low flow state and profound anemia with a HCT of 9. No clinical diagnostic evidence was found to support an etiology for this persistant lower extremity immobility. Over the course of his hopsital stay he slowly began moving his lower extremities and is now able to move his lower extremities and partial weight bear. He was eventually weaned from the vent to a trach collar and finally decanulated on [2166-8-21].He was evaluated and followed throughout his hospital stay by speech and swallow pathologists for Passy-Muir valve trails and he had mutiple video swallow evaluations. He is presently taking po's and receiving cycled tube feeds at night which can be weaned off when taking adeq oral nutrition. His most recent video swallow [9-1] revealed a tracheal lesion that Radiologist recommend follow up for tracheal polyp vs mass. Per Dr.[Last Name (STitle) 914], Mr.[Known lastname 85300] should have follow up done with his referring physician. Physical therapy and Occupational therapy continued to work with Mr.[Known lastname 85300]. He continues to make slow improvements toward regaining his lower extremity strength and functioning. [Last Name (un) ] Diabetes service was consulted for glucose management. He remains in stable condition. Dr.[Last Name (STitle) 914] cleared Mr.[Known lastname 85300] on POD# 67 from his original surgery, for discharge to [Hospital ] rehabilitation. All follow up appointments were advised. Medications on Admission: Aspirin Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 6. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO TID (3 times a day). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-4] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg PO Q8H (every 8 hours) as needed for pain. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 21. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. 22. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. Discharge Disposition: Extended Care Facility: [Hospital3 ] Discharge Diagnosis: Coronary Artery Disease s/p Urgent coronary bypass grafting x2 with a reverse saphenous vein graft from the aorta to the first diagonal coronary artery; reverse saphenous vein graft from the aorta to the left anterior descending coronary artery. Endoscopic vein harvesting of the left leg. s/p cardiac arrest s/p Percutaneous endoscopic gastrostomy tube placement/Percutaneous tracheostomy tube placement Intra-op Cerebral Vascular Accident Anemia Pneumonia Past medical history: Diabetes Mellitus s/p inferior Myocardial Infarction(STEMI) s/p DES to LCX OM1(90% stenosis) PPD+ negative CXR [10-11] Chronic pericarditis Hypertension Hyperlipidemia Discharge Condition: Alert and oriented x3 Upper extremities [5-7] strengths, full range of motion Lower extremities limited motion and generalized weakness. Able to stand. Incisional pain managed with Ibuprofen Incisions: Sternal - healed, no erythema or drainage Edema - none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: NEED UPDATED APPOINTMENT W/RH Surgeon: Dr. [Last Name (STitle) 914] on Tuesday [2166-9-16] at 2:30 PM [Hospital Ward Name ] 2A Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Wednesday [10-1] @ 8:00 AM Please call to schedule appointments with: Primary Care Dr. [Last Name (STitle) 85301] [Doctor Last Name 85302] in [1-4] weeks ****Please have tracheal lesion work up with referring/primary care physician**** 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:[2166-9-3**]	[ "41401", "51881", "9971", "2851", "V4582", "412", "4019", "2724", "25000" ]
Admission Date: [2111-6-9] Discharge Date: [2111-6-16] Date of Birth: [2087-1-8] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: 2 days of headache and neck pain Major Surgical or Invasive Procedure: Exploration of neck wound with posterior decompression and evacuation of hematoma IVC filter placement History of Present Illness: This is a 24 year old man admitted to the Neurosurgery Service on [2111-5-14] following flu like symptoms including neckache and headache. Imaging of head and spine demonstrated Chiari malformation/cervical and thoracic syringomyelia. Suboccipital craniectomy was performed on [2111-5-22]. Post operative course was complicated by R pulmonary artery PE. He was also treated for possible pneumonia. There was some L arm weakness and L sided arm and leg numbness several days post operatively without clear cause identified despite CT brain/repeat imaging of c-spine. He was discharged to rehab on [2111-6-2]. He had been progressing well at rehab. INR had been low (1.45) and increased coumadin given. Also covered over last several days with therapeutic doses of lovenox. Rehab notes indicate anticipation of discharge home today. Unable to participate in OT today due to neck pain and referred for MRI. The patient notes increasing neck discomfort and headache over the last 2 days. He has persistent LUE weakness much the same as previously. Denies fall at rehab. MRI was performed at [Hospital1 ] which showed postoperative changes and small R paraspinal hematoma. He was transferred here for further care. The patient admits to some low mood recently. Overwhelmed by current illness. Appetite has been okay. He has no complaints of fever, cough, rhinorrhoea, nausea, vomiting, diarrhoea, urinary symptoms. Past Medical History: -Chiari I malformation with cervical/thoracic syringomyelia s/p suboccipital craniectomy with posterior fossa decompression ([2111-5-22]) -PE -pneumonia Asthma Social History: [Hospital ] rehab. Previously living alone in [Location (un) 47]. Working at a school for children with autistic spectrum disorders. Has girlfriend. Mother resident in [Name (NI) 531]. Lifetime non-smoker. Denies EtOH and drugs. Family History: Noncontributory Physical Exam: T-98.6 BP-137-138/76-83 HR-62-106 RR-20 O2Sat 96-97% RA Gen: Lying in bed on left side HEENT: NC/AT, moist oral mucosa, thick coating around inside of lips Neck: Well healed midline posterior cervical wound without warmth or discharge. Generalised tenderness to palpation midline neck. Decr ROM. Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Decr CE bilat; decr AE bilat; clear to auscultation, no added sounds aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, flat affect. Oriented to person, place, and date. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, nystagmus bilat extremes of horizontal gaze. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 4 4+ 4- 5- 5- 5- 5- 5 5 5 5 5 5 5 Sensation: Intact to light touch sl decr on left foot, vibration and proprioception intact bilat LE. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes downgoing R, up on L. Coordination: finger-nose-finger normal. Gait/Romberg: Deferred Pertinent Results: 135 98 12 111 AGap=16 4.3 25 0.9 estGFR: >75 (click for details 78 20.5 D 15.8 368 D 43.1 N:91.4 L:6.3 M:1.8 E:0.2 Bas:0.3 PT: 20.8 PTT: 34.3 INR: 2.0 OSH MRI of c-spine shows rounded fluid collection in paraspinal muscles on R side of cervical spine with fluid level. Possible hematoma ?acute versus subacute. Post-operative changes with seroma. CT neck: Large complex fluid collection in the surgical bed with characteristics consistent with new hemorrhage in this region. The mild enhancement could be post-operative, though infection cannot be excluded. NCHCT:No intracranial hemorrhage. Postsurgical change in the 4th ventricle, posterior fossa, and C1 related to recent surgery for chiari malformation. CXR: decr lung volumes, no consolidation MRI c-spine [6-10]: New hemorrhage into the fluid collection within the surgical bed, causing increasing compression of the cervicomedullary junction and an increase in the size of the syrinx. The new enhancement of the dural graft could represent inflammation or infection. Brief Hospital Course: 24y man s/p posterior decompression for [Doctor Last Name 1193] Chiari Malformation type 1 on [2111-5-22] with increasing neck pain and headache. Examination showed progressive LUE weakness and MRI of c-spine showed hematoma in operative site. On the day of admission, he had decreased O2 saturation in ABG; CTA done and acute PE was ruled out. Aspiration pneumonia was indicated and is treated with ceftriaxone for 10 days. His ABG improved to normal after the surgery. Bilateral lower extremity ultrasound was also performed which no evidence of DVT. The patient was taken to the OR for evacuation of hematoma on [2111-6-10], following reversal of INR and IVC filter placement. The following day ([6-11]) patient was extubated, placed in a soft collar and transferred to the step down unit. A hematology consult was then obtained. Hematoloy recommended coumadin for possible hypercoagulable state for 6 months while pulmonology recommended no anticoagulation. After thorough discussion, it was agreed that the patient should be anticoagulated and a heparin drip was to be started POD 7 to reduce the risk of head bleed. On [6-12] a speech and swallow consult was obtained and after performing a bedside swallow they recommended that the pt be advanced to a diet of thin liquid (by cup) and soft consistency solids and pills were to be given whole or crushed. Culture from the operating room showed no growth, blood culture showed no growth; and sputum cultures were positive for GNR and GPC, which was treated with ceftriaxone and placed on aspiration precautions. On [6-13] patient's surgical drain was removed. Patient is to continue on ceftriaxone until [2111-6-20] and to have his soft collar in place for 2 weeks Medications on Admission: Coumadin 5mg po qhs Flexeril 5mg po tid prn Colace 100mg po bid Bisacodyl 5mg po qd Protonix 40mg po qd Tylenol 650mg po q4h prn Percocet-5 5/325 [1-20] q4h pr prn Hydromorphone 1-2mg po q6h prn Nystatin 5ml po qid prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for neck pain. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): SC injection. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gm Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: 1) Posterior cervical hematoma 2) Aspiration Pneunomia 3) Chiari malformation type I s/p posterior fossa/Chiari decompression including C1 and partial C12 laminectomy. Discharge Condition: Stable Discharge Instructions: PLEASE START IV HEPARIN DRIP / PO COUMADIN ON [2111-6-17]. 1) HEPARIN DRIP: PLEASE START WITH 800 UNITS/HR; NO BOLUS; ADJUST HEPARIN DOSE TO PTT GOAL 40-60; CHECK PTT Q6H UNTIL 2 CONSECUTIVE THERAPEUTIC THEN CAN BE CHECKED QD; D/C HEPARIN WHEN COUMADIN THERAPEUTIC. 2) COUMADIN GOAL IS INR 2.0 - 3.0. PLEASE HAVE YOUR STAPLES REMOVED BETWEEN [6-23] - [2111-6-26] ?????? Do not smoke ?????? Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have your incision checked daily for signs of infection ?????? Please wear soft cervical collar for two weeks from your date of surgery. * You may shower briefly and pat dry your incision with CLEAN towel. ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? 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: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: You have been scheduled to see Dr [First Name (STitle) ] [Last Name (NamePattern4) 9151], MD (Phone:[Telephone/Fax (1) 1669]) on [2111-9-1] at 11:00. Please have a brain MRI done in RADIOLOGY (Phone:[Telephone/Fax (1) 327]) on [2111-9-1] 10:00 prior to your appointment with Dr [Last Name (STitle) ]. Completed by:[2111-6-16]	[ "5070", "49390" ]
Admission Date: [2144-3-18] Discharge Date: [2144-3-25] Date of Birth: [2068-1-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1850] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 76 yo woman with known h/o HTN, hypercholesterolemia, PVD, B12 deficiency and recent diagnosis of positive anti-[Doctor Last Name ] antibody with cranial neuropathy and respiratory failure secondary to paraneoplastic disorder related to a neuroendocrine tumor. Patient was recently admitted to [Hospital1 18] [Hospital Unit Name 153] for progressive respiratory failure from progressive diaphragmatic weakness, and returns from rehab 9 days after discharge with a new multifocal pneumonia. Patient is sent here for further work-up of her PNA and possible bronchoscopy. Per daughter, patient was noted to have increased respiratory effort over the last week and on CXR was found to have a white-out of the left lung, thought to be secondary to pna. She also was with low grade temps to 100 and O2 desaturations requiring ventilator adjustments and increased FiO2. Patient is scheduled for chemo early next week at [Hospital3 ] (Dr. [Last Name (STitle) 2036]. She is hard of hearing, but otherwise oriented and at baseline, denies any pain or other complaints. Per daughter patient is more comfortable today than yesterday. She also notes that she has had increased secretions over last few days. ED nurse [First Name (Titles) 8706] [Last Name (Titles) 58716]a since admission as well, although was constipated last week and started on bowel meds. She was started on Ceftaz on [3-14] and then on amikacin on [3-15] for presumed double coverage for pseudomonas. Of note on arrival from rehab she came on SIMV 450/18/7.5/80% Past Medical History: - Paraneoplastic disease as above with cranial neuropathy and respiratory failure - Respiratory failure, trach and vented - HTN and bilateral renal artery stenosis - High cholesterol - PVD - eye surgery? - Hyponatremia/SIADH - Depression - Iron deficiency anemia - B12 deficiency - DVT left leg, [11/2143], on coumadin - S/p PEG tube - perivascular white matter changes on MRI consistent with small vessel disease. - adenexal cyct seen on CT at OSH, not further explored surgically Social History: currently at [Hospital6 58717], had been living independently previously. No tobacco, rare EtOH. Supportive family. Daughter [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16844] is HCP, phone [Telephone/Fax (1) 58711] Family History: No stroke, seizure, neurological disease. No DM. +MI in sister age 79. [Name2 (NI) ] cancer in sister, age 16. Physical Exam: VS: T 98.8 BP146/63 P63 R18 Currently on AC 550/18/5/100% with Sats of 93-95% and PIPS of 28 and plateau 25 and ABG 7.56/43/56/40/94% Gen: Pleasant elderly woman in NAD, sleepy but arousable HEENT: PERRL, 3mm bilaterally, anicteric, MMM Neck: Supple, floppy, trach in place Cardiac: RRR, S1, S2 no murmur Lungs: coarse BS throughout, good air mvmt on vent Abd: Soft,+BS, slightly distentded, G tube inplace, no tenderness Extr: no edema, R heel ulcer wrapped, dropped foot on right Neuro: sleepy but arousable, decrease strength of all muscles, but sensation intact and withdraws foot to touch Pertinent Results: [2144-3-18] 10:51PM TYPE-ART TEMP-37.6 RATES-16/0 TIDAL VOL-450 PEEP-10 O2-50 PO2-90 PCO2-49* PH-7.51* TOTAL CO2-40* BASE XS-13 -ASSIST/CON INTUBATED-INTUBATED [2144-3-18] 09:58PM TYPE-ART TEMP-37.6 TIDAL VOL-550 PEEP-10 O2-100 PO2-317* PCO2-38 PH-7.60* TOTAL CO2-39* BASE XS-14 AADO2-375 REQ O2-65 -ASSIST/CON INTUBATED-INTUBATED [2144-3-18] 09:54PM URINE HOURS-RANDOM CREAT-51 SODIUM-<10 [2144-3-18] 09:54PM URINE OSMOLAL-674 [2144-3-18] 04:20PM TYPE-ART O2-100 PO2-56* PCO2-43 PH-7.56* TOTAL CO2-40* BASE XS-14 AADO2-631 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-TRACH/VENT [2144-3-18] 04:20PM LACTATE-1.4 [2144-3-18] 04:20PM O2 SAT-94 [2144-3-18] 03:23PM TYPE-[Last Name (un) ] PO2-43* PCO2-45 PH-7.54* TOTAL CO2-40* BASE XS-13 [2144-3-18] 12:15PM LACTATE-1.6 [2144-3-18] 12:08PM GLUCOSE-113* UREA N-47* CREAT-0.4 SODIUM-131* POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-40* ANION GAP-7* [2144-3-18] 12:08PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.0 [2144-3-18] 12:08PM WBC-38.1# RBC-3.31 HGB-10.0* HCT-29.6* MCV-89 MCH-30.1 MCHC-33.6 RDW-16.6* [2144-3-18] 12:08PM NEUTS-73* BANDS-19* LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 [2144-3-18] 12:08PM PLT COUNT-273 [2144-3-18] 12:08PM PT-19.1* PTT-45.7* INR(PT)-2.3 [2144-3-18] 11:36AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2144-3-18] 11:36AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2144-3-18] 11:36AM URINE RBC-[12-13]* WBC-[12-13]* BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2144-3-18] 11:36AM URINE WAXY-<1 WBCCAST-<1 . . CXR: new multifocal opacities RUL, LUL and peri-hilar area with possible left sided effusion * EKG: NSR @81, nl axis, flat t in III, twi V1. no prior ekg. Brief Hospital Course: A/P: 76 yo woman transferred to [Hospital1 18] from [Hospital ] rehab after developing new multifocal pneumonia, leukocytosis and low grade temps. . # Respiratory Failure: secondary to multifocal pneuomia, on top of her underlying diaphragmatic weakness caused by the paraneoplastic syndrome. While in the hospital she was maintained on a ventillator via her tracheostomy. A bronchoscopy was performed and showed normal airways. Her sputum grew out serratia and pseudomonas and she was treated with zosyn. The patient was initially also treated with gentamycin for double pseudomonas coverage but her culture showed gentamycin resistance. . # Leukocytosis: in addition to the pneumonia as a source of infection, the patient had one blood culture positive for klebsiella on [2144-3-18]. The klebsiella was also sensitive to zosyn. Her blood cultures from [2144-3-19] were negative. The plan for antibiotics was to continue zosyn for a total of 2 weeks. A PICC line was placed by IR on [2144-3-23]. . # Paraneoplastic syndrome secondary to neuroendocrine tumor: Discussed plan with Dr [First Name (STitle) ] who agreed that chemo therapy should be held until after the patient completes her course of treatment. * # HTN: The patient's ACEI was initially held given the questionable history of bilateral renal artery stenosis, labile BPs which were thought to be secondary to her autonomic dysfunction from paraneoplastic source, and concern for infection/sepsis. Her ACEI was restarted while in hospital and she maintained normal blood pressures. . # DVT in [2143-11-25]: The patient was continued on her home dose of coumadin. Her INR rose to 4.8 on [2144-3-24] and her coumadin was held. On [2144-3-25] her INR was 4.2. The presumption was that the increasing INR was secondary to antibiotics and decreased GI flora. No external signs of blood loss and hct stable at 27. Patient was discharged to an acute care rehab where her coumadin can be held and her INR can be rechecked in 2 days. Plan to hold coumadin for an INR > 3.5. Goal INR [2-27]. Medications on Admission: Norvasc 5mg qd Lisinopril 10mg qd Ceftaz 1gm q8hrs Amikacin 500mg qd x10days Robitussin 10ml qid lasix 40mg qd mucomyst nebs q4hrs vitamin c 500mg [Hospital1 ] Prozac 20mg qd senakot 2tabs qd neupogen 300mcg/ml q24 simethicone 80mgqid lactulose 30ml tid coumadin 5mg qd FeSO4 325 daily Colace 100mg [Hospital1 ] compazine 5mg q6hrs morphine sulfate 2mg q4hrs dulcolax/fleet prn hepartin 500units Discharge Medications: 1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for INR > 3.5. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation Q4H (every 4 hours) as needed. 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed. treatment 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) treatment Miscell. Q4-6H (every 4 to 6 hours). 16. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 17. Zosyn 4.5 g Recon Soln Sig: 4.5 gram Intravenous every eight (8) hours: last day of antibiotics will be [2144-4-1]. Discharge Disposition: Extended Care Facility: [Hospital3 ] Hospital - [Location (un) 701] Discharge Diagnosis: Pneumonia -- paraneoplastic disease secondary to neuroendocrine tumor -- HTN -- DVT in left LE -- hyperlipidemia -- PVD -- SIADH/hyponatremia -- Small vessel disease on MRI -- Stage II decubitus ulcer -- right heel with ulcer and drop foot -- Anemia Discharge Condition: Stable on trach ventillation Discharge Instructions: Take all your medications as prescribed Call your primary care doctor or go to the ER if you are having trouble breathing, fevers, lethargy, or any other worrisome symptoms Followup Instructions: Call Dr. [First Name8 (NamePattern2) 7810] [Last Name (NamePattern1) ] for a follow up appointment after you are discharged from the rehab hospital. Please call for an appointment: [Telephone/Fax (1) 18067]. [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 5799]	[ "4019", "2724" ]
Admission Date: [2179-3-12] Discharge Date: [2179-4-12] Date of Birth: [2106-7-8] Sex: M Service: MICU CHIEF COMPLAINT: Transferred from outside hospital for thrombocytopenia. HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old gentleman who was transferred from [Hospital6 2561] for concern for TTP. Patient initially had presented on [2179-2-28] with a [2-2] day history of URI symptoms and was found to be hypotensive and admitted with pneumonia and sepsis. Patient required intubation and was treated with ceftriaxone, azithromycin, and Flagyl with improvement over the next few days. Patient was extubated. During that time, patient also had a troponin leak and a catheterization was done that showed one-vessel disease with a RCA occlusion of 70-80%. Patient also had an abdominal CT at the outside hospital that showed a questionable adrenal mass, however, patient was discharged home on [3-6] on Augmentin and Flagyl. A couple of days later the patient began to have copious diarrhea stating about 15-20 bowel movements in a 24-hour period, and also developed altered mental status and fever up to 106 degrees. The patient returned back to [Hospital6 ], where he was found to have mild elevation of his creatinine to 2.7, and he was intubated for airway protection during the performance of a lumbar puncture since patient was oversedated. The lumbar puncture at the outside hospital showed no evidence of any infection, however, the patient was started on ceftriaxone and p.o. vancomycin. Subsequently, the patient developed thrombocytopenia with schistocytes and was transferred to [Hospital1 18] for further evaluation, questionable plasmapheresis. PAST MEDICAL HISTORY: 1. TIA/CVD. 2. Hypertension. 3. Hyperlipidemia. 4. CAD - Catheterization on [2179-2-28] that showed 70-80% mid RCA stenosis and 40-50% LAD stenosis. 5. Obesity. 6. Chronic lower back pain with sciatica. 7. Mild CHF with an EF of 45%, apical hypokinesis. 8. Questionable seizure disorder. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Diltiazem 30 mg p.o. q.i.d. 6. Phenobarbital 120 mg p.o. q.h.s. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home with his wife and was a retired city worker in [Hospital1 8]. Patient has two children. Denies any tobacco, alcohol, or IV drug use. PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 101.4, pulse 96, blood pressure 108/62, respiratory rate 20, and O2 saturation 100% on AC 14 x 650, FIO2 of 35%, PEEP of 5. General: Intubated, sedated. Heart: S1, S2 regular rate and rhythm, no murmurs, rubs, or gallops heard. Lungs: Coarse bilateral sounds heard anteriorly. Abdomen is soft, obese, positive bowel sounds, nondistended. Extremities: [1-1]+ edema, 2+ femoral pulses bilateral. Neurologic: Was following commands on admission, but was sedated for intubation. LABORATORIES ON ADMISSION: White count 15.6, hematocrit 26.0, platelets 35. Sodium 140, potassium 3.0, chloride 106, bicarb 21, BUN 34, creatinine 1.5, glucose 160. AST 1203, ALT 1783, alkaline phosphatase 99, total bilirubin 1.3, total protein of 4.5, and albumin 2.1. PT 12.7, INR 1.1, PTT 23. ABG: 7.51, 20, 164. HOSPITAL COURSE: 1. Respiratory - The patient was initially intubated for airway protection after being sedated during the procedure of a LP. Patient had a LP done because he presented with an acute mental status change. The LP showed no evidence of infection, however, through the course of the hospital stay, it became difficult to extubate the patient and an attempt was made to wean him off his vent, but patient was not successful, and so patient was eventually trached. On his trach, patient has been on pressure support of 20 with PEEP of 5, and is slowly being weaned. On the day of this discharge summary, patient is on pressure support of 10 and PEEP of 5 with a FIO2 of 40% and patient seems to be doing well. We will continue to wean his vent settings as tolerated. 2. Thrombocytopenia - Patient presented with acute thrombocytopenia with the initial thinking of TTP. However, since the patient was exposed to Heparin in the outside hospital, a HIT antibody was sent, which returned positive. Patient also had a right upper extremity ultrasound that was done due to increased swelling of his right upper extremity and he was found to have a right subclavian thrombus. The patient was started on lepirudin drip as per the Hematology/Oncology team for anticoagulation. Patient's platelets slowly rose and at the time of this discharge summary, the patient's platelets were 139. Patient was also started on Coumadin as patient is going to require about six months of anticoagulation with goal INR of [2-2]. Patient will be on both lepirudin drip and Coumadin until his INR hits 4. At that time his lepirudin drip will be stopped and patient will continue Coumadin. 3. Infectious disease - Patient presented febrile with an elevated white count. Blood cultures were drawn at the time of arrival to [Hospital1 18] and the patient was 6/6 bottles positive for Enterococcal bacteremia. Patient was initially started on gentamicin and ampicillin for broad coverage. The source of the infection was unclear, but it was thought to be secondary to nosocomial exposure in the outside hospital and ID team was also consulted for concern that patient may have seeded in his right subclavian thrombus and possible cardiac valve. During his hospital course when it was difficult to extubate him, a chest x-ray was obtained that showed possible left lower lobe pneumonia and patient was thought to develop vent-associated pneumonia. Patient was started on vancomycin and cefepime for vent-associated pneumonia, and the ampicillin was stopped since the vancomycin would cover for the Enterococcal bacteremia. As per discussion with the ID team, it was decided that patient will complete a six-week course of gentamicin 120 mg IV b.i.d. and vancomycin 1 gram IV b.i.d. as tolerated. If patient develops renal insufficiency, the gentamicin will be stopped and patient will continue vancomycin. Patient also had a transesophageal echocardiogram that was done to rule out endocarditis. No vegetations were seen, however, there was a highly mobile complex atheroma of 3 x 0.7 cm located in the distal aortic arch and proximal descending aorta. After discussing these findings with the ID team and the fact the patient had endovascular infection, it was decided that we will still continue the six-week course of antibiotic. Patient will get a total of two weeks of cefepime 2 grams IV q.8 for vent-associated pneumonia, which should be stopped on [2179-4-4]. 4. Cardiology - There was some concern that patient may have developed endocarditis given his high degree of bacteremia. Patient received a transesophageal echocardiogram that was unremarkable except for this mobile complex atheroma found in the aortic arch and the proximal descending aorta. It was decided that he would anticoagulate for this finding. Patient also has a history of hypertension and patient was on Lopressor 75 mg p.o. b.i.d. at the time of this discharge summary. 5. Neurologic: Patient was initially intubated due to oversedation and decreased mental status during the procedure of a LP. However, after intubation, patient's motor function did not improve and patient continued to have decreased mental status with occasional spontaneous movement of the head. Patient did not respond to any commands. The Neuro team was consulted, who recommended obtaining a MRI and an EEG, both of which were unremarkable. The concern came for Guillain-[Location (un) ] syndrome versus ICU polyneuropathy. At the time of this discharge summary, ongoing discussions were held with the Neuro team regarding performing an EMG to rule out Guillain-[Location (un) ] syndrome. In addition, there was some concern about patient having a seizure since the patient was on Keppra 500 mg p.o. b.i.d., which the Neuro team recommended to continue. 6. Renal - Patient initially presented with acute renal failure of unclear etiology. However, through the course of the hospital stay, the patient's creatinine improved. At the time of this discharge summary, his creatinine was 0.9 with a BUN of 29. Patient was making good urine and was self diuresing over a liter per day. 7. Hyperglycemia - Patient was on an insulin drip initially, but as we stopped the hydrocortisone, patient was switched over to regular sliding scale insulin and patient's blood sugars had been well controlled at this point. 8. Adrenal hemorrhage: Patient developed some adrenal hemorrhage as per the abdominal CT done at the outside hospital. This is most likely in the setting of HIT antibody positive. Patient also had a Cortrosyn stim test that was done, that did not respond as expected. Patient received a seven-day course of hydrocortisone 100 mg IV q.8. Patient appeared clinically stable and so no further imaging was done, however, it may be considered as an outpatient to obtain a repeat abdominal CT to assess any changes of the adrenal hemorrhage. 9. GI: Patient had decreased mental status and was unable to swallow. Patient had a PEG tube that was placed and was receiving tube feeds. Please note that this discharge summary describes the hospital course events from [2179-3-12] to [2179-4-2]. Please see additional discharge summary for the rest of the hospital course. [Known firstname ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern4) ] MEDQUIST36 D: [2179-4-1] 11:14 T: [2179-4-1] 11:18 JOB#: [Job Number 55207]	[ "4280", "486" ]
Admission Date: [2164-6-5] Discharge Date: [2164-6-22] Date of Birth: [2092-5-15] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2736] Chief Complaint: Fatigue, fever, and lethargy Major Surgical or Invasive Procedure: ICD pacemaker lead extraction with attempt at vegetation removal via femoral access History of Present Illness: The patient is a 72 yo woman with h/o CAD s/p CABG in [2157], sick sinus syndrome s/p PM/ICD placement in [2163], and dilated cardiomyopathy with EF of 35%, who presented to [Hospital3 ] Hospital on [6-3] with fever and lethargy. The patient was reportedly feeling unwell for approximately one month prior to admission. On the day of admission, she was at a family [Holiday ] dinner and was noted to be lethargic, weak, and pale. EMS was thus called, and she was brought to [Hospital3 ] Hospital for further evaluation. . At the OSH, the patient was initially febrile to 102 and her K+ in the ED was 7.6. She was in respiratory distress and was placed on BiPAP and was noted to have a LLL infiltrate on CXR. Blood cultures subsequently grew GPCs in clusters in [5-14] bottles, and a TTE demonstrated a vegetation on her AICD lead. She was started on Vancomycin and Ampicillin. The decision was made to transfer her to [Hospital1 18] for lead extraction. . Review of systems is positive for headache and mild shortness of breath. Otherwise, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia 2. CARDIAC HISTORY: -CABG: 3-vessel CABG in [2157] at the [Hospital1 756] -PERCUTANEOUS CORONARY INTERVENTIONS: [2157] and [2163] -PACING/ICD: Placed in [2163-5-12] for NSVT and sick sinus syndrome 3. OTHER PAST MEDICAL HISTORY: Dilated cardiomyopathy with an EF of 35% (TTE in [2163]) CRI with ARF in [2163] requiring 2 sessions of HD (baseline Cr 1.2) Retinopathy Hypothyroidism Cataract disease Gout Rubeosis iritis Carotid stenosis Insomnia Cholelithiasis Anemia Syncope Social History: The patient lives with her husband. She previously smoked tobacco and quit 10 years ago. She does not drink EtOH regularly (1 drink/year on their anniversary) Family History: Her mother passed away in her 50s from a CVA and renal failure. Her father died from cardiac disease at a relatively young age (not specified). Sister passed away of cancer and one brother had "kidney problems". Physical Exam: On admission: VS: T=99.6, BP=104/55, HR=65, RR=20, O2 sat=96% on 2L GENERAL: elderly female, hard of hearing, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, tachycardic, normal S1, S2. II/VI holosystolic, blowing murmur heard best in 5th LICS mid-clavicular line. No thrills, lifts. No S3 or S4. No ICD pocket tenderness. LUNGS: No chest wall deformities, mild kyphosis. Resp were unlabored, no accessory muscle use. Crackles to mid lungs bilaterally, R>L. ABDOMEN: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP pulses dopplerable bilaterally On discharge: Pertinent Results: On admission: [2164-6-5] 05:25PM BLOOD WBC-16.4* RBC-3.11* Hgb-8.7* Hct-28.5* MCV-92 MCH-28.1 MCHC-30.6* RDW-20.0* Plt Ct-247 [2164-6-5] 05:25PM BLOOD Neuts-87.2* Lymphs-7.8* Monos-4.5 Eos-0.3 Baso-0.2 [2164-6-5] 05:25PM BLOOD PT-30.8* PTT-30.1 INR(PT)-3.0* [2164-6-5] 05:25PM BLOOD Glucose-204* UreaN-40* Creat-1.5* Na-137 K-4.7 Cl-101 HCO3-26 AnGap-15 [2164-6-5] 05:25PM BLOOD ALT-15 AST-52* LD(LDH)-235 AlkPhos-33* TotBili-0.4 [2164-6-5] 05:25PM BLOOD Albumin-2.9* Calcium-8.8 Phos-2.7 Mg-2.1 [2164-6-5] 05:25PM BLOOD %HbA1c-7.7* eAG-174* Hct and WBCs [2164-6-6] 04:15AM BLOOD WBC-13.9* Hct-27.4* [2164-6-7] 05:34PM BLOOD WBC-12.6* Hct-25.0* [2164-6-8] 03:06PM BLOOD WBC-16.5* Hct-28.0* [2164-6-9] 03:32PM BLOOD WBC-11.6* Hct-26.3* [2164-6-10] 06:11AM BLOOD WBC-9.8 Hct-26.2* Creatinine [2164-6-6] 04:15AM BLOOD Creat-1.3* [2164-6-7] 05:34PM BLOOD Creat-1.2* [2164-6-8] 03:06PM BLOOD Creat-0.8 [2164-6-10] 06:11AM BLOOD Creat-1.0 INR [2164-6-5] 05:25PM BLOOD INR(PT)-3.0* [2164-6-6] 04:15AM BLOOD INR(PT)-1.9* [2164-6-7] 12:45AM BLOOD INR(PT)-1.4* [2164-6-8] 04:24AM BLOOD INR(PT)-1.3* [2164-6-10] 06:11AM BLOOD INR(PT)-1.2* . . . Discharge labs: [2164-6-21] 04:36AM BLOOD WBC-9.0 RBC-3.06* Hgb-9.6* Hct-28.6* MCV-94 MCH-31.5 MCHC-33.7 RDW-18.5* Plt Ct-349 [2164-6-21] 04:36AM BLOOD Plt Ct-349 [2164-6-21] 04:36AM BLOOD Glucose-97 UreaN-36* Creat-1.6* Na-135 K-4.0 Cl-94* HCO3-30 AnGap-15 [2164-6-16] 04:23PM BLOOD ALT-18 AST-41* AlkPhos-42 TotBili-0.4 [2164-6-21] 04:36AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9 . MICROBIOLOGY Blood and urine cultures: no growth IMAGING TTE [6-18]: . . The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. A mitral valve annuloplasty ring is present. The gradient across the mitral valve is increased (mean = 17 mmHg). There is a moderate-sized vegetation on the mitral valve ([Name Prefix (Prefixes) ] [Last Name (Prefixes) ] of the anterior leaflet, 0.8 cm). Mild to moderate ([2-12]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [6-11]/201, the tricupsid valve vegetation is not clearly seen (may be because of poor image quality rather than resolution). The degree of pulmonary hypertension and RV dilation has decreased. The mitral vegetaiton appears similar. . . EKG: The rhythm appears to be intermittent atrial paced and sinus but low amplitude wave forms make assessment difficult. Left bundle-branch block with left axis deviation. Since the previous tracing of [2164-6-6] the rate is slower and ectopy is absent. Brief Hospital Course: This is a 72 year old female with h/o CAD s/p CABG in [2157], DM2, SSS s/p PM/ICD placement in [2163-6-11] and dilated cardiomyopathy who presented to [Hospital3 ] Hospital on [6-3] with fever and lethargy, found to have vegetations on AICD leads, Mitral valve and Tricuspid valvee and Enterococcal sepsis, was transfered to [Hospital1 18] [6-5] where ICD leads were extracted and IV antibiotics were initiated for endocarditis. Now discharged to rehab and planned for completion of 6 week course of antibiotics. . #. enterococcal endocarditis with ICD lead + MV + TV vegetations: Patient presented to OSH with fevers to 102 and lethargy,Blood cultures revealed entercocci in [9-17] bottles as well as in her urine culture. TTE showed vegetations involving the AICD leads, likely [3-14] enterococci urosepsis. She was started on vancomycin and ampicillin at the OSH. She was then transferred to [Hospital1 18] on [6-5] for AICD lead extraction. Prior to the procedure, her antibiotic regimen was switched to ampicillin/gentamicin upon learning the sensitivities of the organisms from the OSH culture. During the procedure, heavy vegetations were seen involving the leads as well as the mitral and tricuspid valves. Once the leads were extracted, great efforts were made to snare these vegetations via femoral access, but we were unable to remove them from their location in the right ventricular cavity. With increased concern for embolization, she was monitored in the CCU, with continued airway protection with ET tube as well as central access with a subclavian line. Due to post-procedure hypotension, her home anti-hypertensives were discontinued and she was maintained briefly on a dopamine gtt. Post-procedure TTE confirmed the location of residual vegetations on tricuspid and mitral valves. She was extubated without complication the next day, with mental status intact. Daily surveillance blood cultures were all negative and her repeat urine culture was negative as well. IV antibiotic therapy with ampicillin/gentamicin was continued and planned for a total of 6 weeks. Peak and trough levels of gentamicin were checked and therapeutic. Her renal function was monitored closely during this time and worsening renal function prompted change from gentamycin to ceftriaxone. PICC line was placed for continued Abx administration, her subclavian line was pulled after confirmation of this line placement. Patient was afebrile throughout her [Hospital1 18] course accept for a single spike of fever on [6-16] to 100.7. Urine and Bcx remained negative. CXR was without focal infiltrate. Most recent TTE on [6-18] showed mild-mod MR [First Name (Titles) 151] [Last Name (Titles) 1506] mitral valve vegetation, vegetation was no longer seen on the tricuspid valve but this may be because of poor image quality rather than resolution. There was moderate TR and moderate pulmonary artery systolic hypertension and RV dilatation which were improved from [6-11] study. Patient was seen by cardiac surgery who recommended repeating TTE after completion of Abx course for assessment of need for valve repair surgery. She will need to have this ECHO done per her outpatient cardiologist and the report sent with pt to her appt with Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ]. Patient is discharged on continue ampicillin and ceftriaxone for total 6 week course, last day [2164-7-17]. . Follow-up Plan: -- Monitor fever curve and WBC -- Close follow-up with Dr. [Last Name (STitle) ] in the [Hospital1 18] Infectious Disease outpatient clinic with weekly CBC w/ diff, chem 7 (most important BUN,Cr) and LFT's. -- Continue on ampicillin and ceftriaxone for total of 6 weeks, last day [2164-7-17] . # Congestive Heart Failure. Admission TTE with LVEF= 25-30%, 2+ mitral regurgitation, 1+ tricuspid regurgitation. Due to initial episodes of hypotension diuretic regimen held. On [6-11] patient noted to be dyspneic and tachypneic. CXR consistent with pulmonary edema with bilateral pleural effusions. Patient was at that point 4 L positive since admission. Repeat TTE with worsening valvular function, Moderate to severe [3+] TR. Severe PA systolic hypertension. Patient aggressively diuresised with Lasix ggt + daily Metalozone with good result. Patient diuresed well and at time of transfer saturating 93-97% on 2L. Weight at time of discharge is 65.7, she appears clinically euvolemic. Patient was continued on home digoxin, carvedilol. ACEi and diurises are currently held in the setting of renal failure. Digoxin was decreased to three times a week because of renal function. EF at time of discharge is 40%. OUTPATIENT Follow-up plan: -- Monitor weights daily, I/O and diurese as needed to maintain clinical euvolemia. -- Monitor renal function, restart ACEi when renal function improves and stabilizes -- Diuretic regimen at time of discharge: held . #. RHYTHM: The patient has a history of sick sinus syndrome, prompting the original placement EP study in [2163] which showed inducible polymorphic VT. AICD was placed for primary prevention in the setting of depressed LV function (EF = 25-30%). Recent ICD interrogation did not show life threatening arythmia in the prior year. Telemetry during her hospital course showed multiple VPB's and runs of accelerated idioventricular rythm but no life threatening arrythmias. Patient will require continued telemetry monitoring while she is at rehab and at discharge per her outpatient cardiologist. She will see Dr. [Last Name (STitle) 75381] in [Month (only) ] at which point it will be determined whether re-implantation of ICD is indicated. . Out patient follow up plan - continue telemetry monitoring - follow-up with Dr. [Last Name (STitle) ] on [2164-8-1] at 1:40 PM #. Acute on Chronic renal insufficiency - baseline creatinin 1.2, trended up to peak of 2.4 in the setting of agressive duresis for heart failure and pulmonary edema. Cr:BUN ratio changes were consistent with pre-renal etiology evolving to ATN. There was no periheral eosinophilia. Microscopy of the urine showed rare muddy-brown cast.Patient was also on gentamycin at the time, levels were theraputic but as contribution of gentamycin to ATN could not be ruled out this was switched to ceftriaxone. Diuresis was held upon achievment of euvolemia, ACE-I was also held. Creatinin is trending down to 1.6 on day of discharge. OUTPATIENT FOLLOW_UP ISSUES: -- Close monitoring of renal function. -- please check Cme-7 on [6-23]. #. Elevated INR: Patient was not on anticoagulation on admission, but her INR was 3.0. No evidence of liver injury or failure at the OSH. Given her improving clinical condition, this was unlikely to be DIC or acute liver failure. LFTs and DIC labs were unremarkable. She was given vitamin K with good result, reversing her INR appropriately for her lead extraction procedure. INR remained stable throughout remainder of her stay. #. Normocytic anemia: Hct was stable, without signs of active bleeding. She was given 2 units of pRBCs prior to the procedure, with an unimpressive Hct bump. However, her Hct remained stably low and was followed closely. Fe studies wnl. HCT did note to trend down on [4-3]. Patient transfused with 2u prbc with appopriate bump in HCT to 28. HCT stable prior to transfer 28.6 #. DM2: Patient takes Amaryl and janumet at home with 20 units of Glargine at hs, with last HbA1c > 7. Glucose at OSH trended in 200s-300s in the setting of infection, with initiation of Lantus to 40 (from 20) units nightly. Peri-procedurally, her Lantus dosing was decreased to 15 units nightly, but then increased again to her home dose once she was eating more consistently. At time of transfer sugars were well controlled on Lantus 30 units QHS with supplemental ISS. She should be transitioned back to pills upon discharge. #. CORONARIES: She is s/p 3-vessel CABG in [2157]. She was otherwise asymptomatic, ruled out for MI at OSH, and was without EKG changes compared to prior. She was continued on her ASA 325mg and statin. #. Hyperlipidemia: She was continued on statin, niacin, but her fenofibrate was held. #. Hypothyroidism: She was continued on levothyroxine. . Medications on Admission: -Lisinopril 10 mg daily -Lasix 20 mg daily -Coreg 6.25 mg [Hospital1 ] -Synthroid 150 mcg daily -Fenofibrate 200 mg daily -Calcium plus D one tablet [Hospital1 ] (500/200) -Niaspan ER 500 mg [Hospital1 ] -Digoxin 0.125 mg daily -ASA 325 mg daily -glimepiride 4 mg daily -Lipitor 20 mg daily -Janumet unknown dose - Lantus 20 units at bedtime Discharge Medications: 1. Ampicillin 2 g IV Q6H 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO BID (2 times a day). 10. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 12. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 15. CeftriaXONE 1 gm IV Q12H 16. Outpatient Lab Work Please check labs weekly starting on [6-27], Chem-7, CBC, LFT's with results faxed to [Doctor Last Name 2808] from Infectious Disease at [Hospital1 18] [Telephone/Fax (1) 1419] 17. Outpatient Lab Work Please check chem-7 and CBC tomorrow [2164-6-23] 18. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 19. Humalog 100 unit/mL Solution Sig: 0-14 units Subcutaneous four times a day: check FS before meals and at hs per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: Primary: Endocarditis Infected pacemaker and ICD Acute Systolic Congestive Heart Failure: EF 40% ACE inhibitor has been held because of acute kidney injury Coronary Artery Disease Acute on Chronic Kidney Injury . Diabetes Mellitus Secondary diagnoses: Hypothyroidism Ventricular Tachycardia Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [Known lastname 69742] it was a pleasure taking care of you. . You were admitted to the [Hospital1 18] for treatment of infection of your ICD, pacemaker and heart valves. The pacemaker/ICD was removed in the operating room and you had some trouble with low blood pressures, fluid overload and kidney failure. Your blood pressure is now stable and your kidney function is improving. We have held some of your medicines and decreased others while your kidneys are not working well. You were started on IV antibiotics for a planned 6 week course to treat the infection on your heart valves. You will need an echocardiogram again after the antibiotics are finished on [7-17]. Please have Dr. [Last Name (STitle) 89111] arrange this (he has been contact[Name (NI) ]) and you will need While hospitalized an ultrasound of your heart demonstrated that your heart was not pumping forward as well as it could and as a result fluid was pooling in your lungs and extremities. We placed you on medications to faciliate diuresis. At time of discharge your breathing was much improved. . CHANGES TO YOUR MEDICATIONS To treat infection: 1. Start taking Ampicillin and Ceftriaxone; plan to complete 6 week course, last day [7-17] to treat the infection on your heart valves Start taking Gentamycin; plan to complete 6 week course . To prevent damage to your kidneys: 2. Stop Lisinopril and Furosemide until kidney function stabilizes. 3. Decrease Digoxin to three days a week instead of daily until your kidney function improves. 4. Stop taking fenofibrinate and glimepiride 5. Start taking tylenol as needed for minor pain 6. Start taking Lorazepam as needed for anxiety 7. Increase Vitamin D to 1000u daily 8. STart senna and colace as needed to prevent constipation 9. STop taking glimepiride and Janumet. Continue Glargine insulin while you are in the rehabilitation at 30 units. You can restart pills once you are home to control your blood sugar. . Again it was a pleasure taking care of you. Please contact with any questions or concerns. Followup Instructions: Cardiologist: Dr. [Last Name (STitle) 56071] ([Telephone/Fax (1) 34149]): please make a follow up appt for when you get out of rehabilitation. . Department: INFECTIOUS DISEASE When: THURSDAY [2164-7-12] at 2:10 PM With: [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: INFECTIOUS DISEASE When: FRIDAY [2164-8-3] at 9:30 AM With: [Name6 (MD) 2324] [Name8 (MD) 2323] MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) Basement, [Hospital1 18] Department: CARDIAC SURGERY When: MONDAY [2164-7-23] at 1 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE Department: CARDIAC SERVICES When: WEDNESDAY [2164-8-1] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2164-6-23]	[ "5845", "5990", "V4581", "25000", "2724", "2449", "4168", "4280" ]
Admission Date: [2105-10-15] Discharge Date: [2105-10-22] Date of Birth: [2047-11-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: seizures Major Surgical or Invasive Procedure: intubation [2105-10-17] History of Present Illness: Mr. [Known lastname ] is a 57 year old RHM with prior L MCA infarct ([2102]) and seizure disorder who now presents following a seizure. He was at home having coffee with his son this morning when he had sudden onset right arm rhythmic contractions. He also seemed disoriented according to his son who brought him to the [Hospital1 ] [Name (NI) 620] ED where opon pulling into the parking lot the movements generalized to GTC movements with LOC. He was given 1mg Ativan IV which stopped the movements. Head CT performed at [Location (un) 620] was without acute process. Neurology was contact[Name (NI) ] by the [Name (NI) 620] [Name (NI) ] attending and he was given an additional 1g Keppra IV, and then transferred to [Hospital1 18] for further care. . At present the patient has a productive speech deficit and is able to appropriately answer yes or no to questions. His naming is not intact. He reports he does not feel back to his usual self (unable to describe further). His speech is worse than usual. He denies any headache. His right side is more weak than usual. He denies any bowel or bladder incontinence. No oral trauma. . On general review of systems, He denies any recent fevers, chills, he denies diarrhea or constipation. No cough or SOB. No chest pain, rashes, arthralgias or myalgias. Past Medical History: -Left hemispheric stroke in [Month (only) ]/[2102] -Epilepsy sinc [2100], last seizure was [8-9] -?HTN after the stroke patient has been taken med for high blood pressure -Dyslipidemia -Two cataract surgery. -Left hemispheric stroke in [Month (only) ]/[2102] -Epilepsy sinc [2100], last seizure was [8-9] -?HTN after the stroke patient has been taken med for high blood pressure -Dyslipidemia -Two cataract surgery. Social History: Widower. Has a son. Since stroke can not do ADLs. Heavy alcohol use until stroke. +tobacco use. Family History: non-contributory Physical Exam: Exam on Admission: Vitals: T 97, BP 156/78, HR 90, R 14, 98% RA Gen- well appearing on gurney in the ED, NAD HEENT: NCAT, MMM, anicteric, OP clear Neck- no carotid bruits, no nuchal rigidity. CV- RRR, no MRG Pulm- soft crackles at bases bilat. Abd- soft, nt, nd, BS+ Extrem- no CCE . Neurologic Exam: MS- eyes open, attends examiner, appropriately answers yes or no questions. He follows all axial and appendicular commands. Dense anomia- attempting to say the words, but visibly frustrated with inability to do so. No evidence of apraxia. No neglect. . CN- PERRL 3-->2mm, could not visualize fundi, EOMI no nystagmus, face appears symmetric with symm strength, palate elevates symm, hearing intact to FR bilat, SCM and trap full strength, tongue protrudes at the midline. . Motor- right arm > leg hemiparesis. R hand flexor contracture. No adventitious movements noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 5 5 5 5 5 5 5 5- 5 5 5 5 5 R 3 4 3 3 4 3 3 3 - - 4 4 4 . Sensory- + sensory neglect of right side to DSS. detailed sensory exam was limited d/t productive speech deficit. . Coordination- unable to perform FNF or HKS on right. . Reflexes: 3+ on right [Hospital1 ], tri, brachiorad, patellar. 2+ right achilles. 2+ left [Hospital1 ], tri, brachiorad, patellar. . right great toe upgoing, left downgoing. . Gait testing deferred given marked R hemiparesis. Pertinent Results: [2105-10-16] 05:50AM BLOOD WBC-17.6* RBC-4.72 Hgb-14.6 Hct-40.3 MCV-85 MCH-31.0 MCHC-36.3* RDW-14.0 Plt Ct-272 [2105-10-16] 05:50AM BLOOD Neuts-84.2* Lymphs-8.6* Monos-6.6 Eos-0.2 Baso-0.5 [2105-10-16] 05:50AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-138 K-3.3 Cl-96 HCO3-29 AnGap-16 [2105-10-17] 06:45AM BLOOD ALT-24 AST-22 AlkPhos-88 TotBili-0.8 DirBili-0.3 IndBili-0.5 [2105-10-17] 09:31AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2105-10-17] 06:45AM BLOOD TotProt-6.6 Albumin-4.3 Globuln-2.3 Calcium-9.3 Phos-4.0 Mg-2.1 [2105-10-20] 02:32AM BLOOD Triglyc-144 . [2105-10-17] Sputum Culture: E. Coli . EEG [2105-10-15]: IMPRESSION: Markedly abnormal EEG due to the prominent slowing broadly over the left hemisphere with very frequent epileptiform sharp wave discharges in the parieto-temporal region, recurring every one to two seconds for much of the record though less as time went on. In the early portions of the record this appeared most suggestive of PLEDs (periodic lateralized epileptiform discharges), usually a sign of an acute lesion with epileptogenic potential. No faster rhythms suggestive of ongoing seizures were evident. The background appeared better on the right though it was frequently disrupted or disorganized . CTA [2105-10-17]: IMPRESSION: 1. No Pulmonry Embolus. 2. Left lower lobe complete atelectasis with mucous plugging of the airways. 3. Right upper lobe and basilar atelectasis. . Transthoracic Echo [2105-10-22]: The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2105-8-31], the left ventricle is now small and hyperdynamic. Brief Hospital Course: Mr. [Known lastname ] was admitted with status epilepticus. His Keppra dose was initially increased and he was given Ativan for his seizures. The Keppra was then changed to Trilptal and he was loaded with Depakote. He was then started on a Propofol drip. On the morning of [2105-10-17] he experienced and episode of hypoxia. He was intubated after a likely aspiration event. He transferred to the medicine service for further management of his seizures and aspiration. His respiratory distress was likely secondary to aspiration from sedation as he had received large amounts of ativan. He had a CTA which was negative for PE and cardiac enzymes were negative suggesting this was not an MI. He was started initially on Vancomycin, Ceftriaxone and Flagyl for his aspiration pneumonia. This was changed to Vancomycin and Unasyn on [2105-10-18]. On [2105-10-19], Acyclovir was added for possible HSV encephalitis. . For his seizures, his propofol was increased in order to suppress seizure activity as recommended by the neurology team. He was started on Levophed for hypotension. He continued to have frequent seizure activity as monitored by his continuous EEGs. He was loaded with Dilantin on [2105-10-20]. An LP was attempted on [2105-10-18] by the medicine team and was unsuccessful. An LP was attempted on [2105-10-20] by the Neurology team and was unsuccessful. His antibiotics were changed to include bacterial meningitis coverage with Vancomycin, Ceftriaxone and Ampicillin. . In the early morning of [2105-10-22], his telemetry [Location (un) 1131] changed. A 12-lead ECG showed an abnormal appearing QRS. The rhythm was regular without clear p waves and there were diffuse ST depressions in V2-V6 with ST elevations in leads II and AVL. 2 gm of magnesium were given. An ABG with calcium was checked and the ionized calcium was normal. Cardiology was consulted for aid in evaluation and management of changes in the ECG. Over the course of that morning, his propofol was decreased as was recommended by neurology. His levophed requirements continued to increase and he was persistently hypotensive. An echo was checked and showed a small, hyperdynamic LV. At 1pm, the patient was noted to be markedly hypotensive. He was started on a second and then third pressor. He then lost a pulse. A code blue was initiated. After 30 minutes of resuscitative efforts the patient was still in asystolic and was pronounced dead at 1:42pm. Medications on Admission: asa 81mg keppra 2000mg IV q12hr Lorazepam 1 mg IV Q4H:PRN seizure > 5min Seizure > 5min or more than 2 seizures in 30min. Lorazepam 1 mg IV Q6H Oxcarbazepine 600 mg PO BID - not getting b/c no NGT in place Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Simvastatin 80 mg PO DAILY Order Fludrocortisone Acetate 0.1 mg PO DAILY Heparin 5000 UNIT SC TID Valproate Sodium 500 mg IV 12hr Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: 1. Status Epilepticus . Secondary Diagnoses: 2. Aspiration Pneumonia 3. prior L MCA stroke Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired	[ "51881", "5070", "5180", "4019", "2724" ]
Admission Date: [2146-5-24] Discharge Date: [2146-6-1] Date of Birth: [2081-3-30] Sex: M Service: Cardiology CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 7053] is a 65-year-old diabetic male who was referred for cardiac catheterization following a positive stress test. He had an episode of chest tightness while at work sitting at his desk approximately one month ago. It lasted for about 10 minutes and resolved after he took aspirin and Tums. He has not had any further chest pain but has had some left hand tingling each night while lying in bed. He also has had some shortness of breath after climbing two flights of stairs. He went to go see his local cardiologist and was referred for a stress test. This test had to be stopped prematurely due to fatigue and marked dyspnea in addition to chest pain. He did become hypertensive during his stress test and had electrocardiogram changes that were suggestive, but not diagnostic, in the lateral leads and was hence referred for cardiac catheterization. He denies any claudication, orthopnea, edema, paroxysmal nocturnal dyspnea, or lightheadedness. PAST MEDICAL HISTORY: 1. Hypertension. 2. Insulin-requiring adult-onset diabetes mellitus. 3. Arthritis. PAST SURGICAL HISTORY: Past surgical history was negative. ALLERGIES: He is allergic to CELEBREX. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Glucophage 850 mg p.o. b.i.d. 3. Glyburide 2.5 mg p.o. q.d. 4. NPH 20 to 25 units subcutaneous q.h.s. 5. Zestril 10 mg p.o. q.d. PERTINENT LABORATORY DATA ON PRESENTATION: Admission laboratories revealed his white blood cell count was 8.4, hematocrit was 31.6, platelets were 236. Blood urea nitrogen and creatinine were 19 and 1. Potassium was 4.7. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination his heart rate was 60, his blood pressure was 160/70. His neck was without bruits. His heart had a regular rate and rhythm without murmurs. The lungs were clear to auscultation bilaterally. The abdomen was obese with no palpable masses. His extremities demonstrated no varicosities and had normal pulses. HOSPITAL COURSE: The patient was admitted for an inpatient cardiac catheterization on [2146-5-24]. This was significant for multiple vessel disease including a long proximal severe narrowing of the left anterior descending artery and a long severe stenosis of the diagonal. In addition, he had a 60% lesion in his right coronary artery and another 60% lesion in his posterior descending artery. Due to the distribution of the patient's disease, it was felt that he was a candidate for cardiac surgery. Six hours following his catheterization, a heparin drip was started. In addition, Cardiac Surgery was consulted. The following day, he was taken to the operating room. There, he had coronary artery bypass graft times three. His grafts were left internal mammary artery to left anterior descending artery, saphenous vein graft to left anterior descending artery first diagonal (?), and saphenous vein graft to distal right coronary artery. The patient's procedure itself was unremarkable. Postoperatively, he was taken intubated to the Cardiac Surgery Intensive Care Unit. He was atrially paced with Neo-Synephrine and propofol drips. That evening, he was kept on a ventilator with his Neo-Synephrine running at a lower rate. Later that day, he was extubated without incident and was subsequently weaned off his Neo-Synephrine. By the second postoperative day, his chest tube was discontinued, and he was transferred to the floor. On the floor, the patient had an unremarkable hospitalization. All of his diabetes medications were restarted. His Foley catheter was discontinued, and his pacing wires were removed. The patient was a bit slow to progress with his ambulation and required more diuresis than is typical. By the fifth postoperative day, he was finally weaned off of his oxygen and was ambulating adequately in the hallway. However, he had a rise in his white blood cell count from 9000 to 14,000. For this reason, he had a urinalysis that was sent that was negative for signs of infection. By the following day, his white blood cell count had normalized to 10,000. For this reason, we believed that he was safe to be discharged home. Finally, he had some very mild hyperkalemia with a potassium of approximately of 5 to 5.2 despite his Lasix therapy. His potassium repletion was held for two days, and the decision was made to continue to replete him as an outpatient but at a lower dose. He will have visiting nurse assistance to draw potassium in two days and telephone the results to his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ]. His telephone number is [Telephone/Fax (1) 13687]. DISCHARGE STATUS: The patient was discharged to home. MEDICATIONS ON DISCHARGE: 1. Glyburide 2.5 mg p.o. q.d. 2. Enteric-coated aspirin 325 mg p.o. q.d. 3. Glucophage 850 mg p.o. b.i.d. 4. NPH 20 units subcutaneous q.h.s. 5. Lopressor 25 mg p.o. b.i.d. 6. Lasix 20 mg p.o. b.i.d. (times seven days). 7. Potassium chloride 20 mEq p.o. q.d. (times seven days). 8. Colace 100 mg p.o. b.i.d. 9. Percocet 5/325 one to two tablets p.o. q.4-6h. p.r.n. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [First Name (STitle) ] in approximately two weeks. In addition, he was to follow up with Dr. [Last Name (STitle) 70] in six weeks. DISCHARGE DIAGNOSES: 1. Coronary artery disease; now status post coronary artery bypass graft times three. 2. Adult-onset diabetes mellitus, insulin-requiring and controlled. 3. Hypertension. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 9638] MEDQUIST36 D: [2146-6-1] 12:06 T: [2146-6-4] 06:32 JOB#: [Job Number 42570]	[ "41401", "4019", "25000", "2859" ]
Admission Date: [2161-2-13] Discharge Date: [2161-3-5] Date of Birth: [2104-8-2] Sex: M Service: NEUROLOGY Allergies: Alcohol Attending:[Doctor Last Name 15044] Chief Complaint: referred to ED for DVT, admitted for fever Major Surgical or Invasive Procedure: intubation, extubation, lumbar puncure History of Present Illness: 56-year-old male with metastatic rectal cancer with ongoing chemo--C6D15 of FOLFOX on [2161-2-2]--s/p brain radiation, s/p resection in [9-/2158], presented with an alleged thrombus in right common iliac vein seen on routine staging CT. He was referred to the ED by his outpatient oncologist. Patient reports no symptoms at home--no respiratory difficulty, no leg swelling or warmth or swelling--besides his mild fatigue that has been going on for months. A few days ago he had a fever that then spontaneously resolved. No coughs, no dysuria. No sick contact. [Name (NI) ] chills, headache, visual changes, chest pain, shortness of breath, abdominal pain, diarrhea, constipation, weakness, numbness, tingling. In the ED, initial vitals were T 99.8, HR 87, BP 121/76, RR 16, 100%RA. Exam was unremarkable. LENIS were negative. He was about to be discharged when he spiked a fever to 102F. WBC was 10.5 with 16% bands--patient received Neulasta on [2161-2-5] and had 24% bands last week. CXR, urinalysis was unremarkable. Received vanco and cefepime in the ED. Admitted for further management. Past Medical History: Rectal adenocarcinoma: - diagnosed in [2158] - neoadjuvant capacitabine and radiation from mid-[5-15] to [2158-7-6] by [First Name8 (NamePattern2) 324] [Last Name (NamePattern1) ], M.D., followed by surgical resection and a colostomy; completed 4 cycles of adjuvant capacitabine on [2159-1-28] - chest CT on [2160-5-26] showed pulmonary metastases, and a right lung biopsy showed adenocarcinoma, treated with bevacizumab and FOLFOX since [2160-9-8] - headache in summer [2160], head CT and MRI on [2160-9-16] disclosed a 2-3 cm mass in the right cerebellum, resected by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2160-9-17], followed by Cyberknife radiosurgery to the resection cavity on [2160-10-10] Social History: Cantonese-speaking. He is married. Lives with wife and son in [Name (NI) ]. He does understand some english, speaks little english. Family History: non-contributory Physical Exam: Gen: middle-aged Chinese man in no acute distress HEENT: EOMI, PERRL, sclerae anicteric, OP moist without lesion Neck: supple, no LAD Lungs: CTAB CV: normal rate, regular rhythm, normal S1/S2, no m/r/g Abd: soft, nontender, nondistended, BS present Ext: no swelling, no warmth, no tenderness, 2+ bilateral pedal pulses Neurological exam on first evaluation by neurology team [2161-2-15]: Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty (via interpreter on telephone). Language is fluent with intact repetition and comprehension. Normal prosody. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Full strength of neck flexors and extensors. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Decreased proprioception at toes bilaterally and decreased vibration (5-6 seconds). Patient reported pinprick intact throughout. -DTRs: 1+ at biceps, triceps, brachioradialis, 0 at patellars and achilles bilaterally. However, patient was unable to relax legs appropriately for testing despite repeated attempts. Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. No truncal ataxia. -Gait: Good intiation. Wide-based, unsteady. Short stride. Falls in all directions. Romberg positive. [2-18] Neurological exam: awake, alert, appears ill. His RR is 22-24, and his SaO2 is 100%. Speech is fluent. PERRL 3->2 mm bilaterally, EOMI bilaterally without nystagmus, bifacial weakness, palate elevates symmetrically, tongue midline movements intact. He reports feeling diffusely weak, with some giveway weakness and other real weakness. He can keep his bilateral arms lifted above gravity, but both drift down to the bed. No myoclonus or tremor. Decreased pinprick sensation in his bilateral legs to [1-10] way up the lower leg, normal in the bilateral hands. Trace reflexes in the bilateral brachioradialis, otherwise 0 and symmetric in the biceps, triceps, knees, and ankles. [Doctor First Name ] Tri [Hospital1 ] WE FE IP H Q DF R 4- 4 5- 4- 3+ 3- 3+ 5 3- L 4- 4 5- 4- 3+ 3- 3+ 5 3- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Neurological exam at time of discharge: Cognitively intact, no limitations Mild bifacial weakness, L>R, otherwise cranial nerves normal Reflexes diffusely absent Strength: at least [3-13] in all muscle groups. Deltoids, Biceps, Triceps, gastrocs are 4+ to 5-, some effort dependence Pertinent Results: [2161-2-13] 04:55PM WBC-10.5# RBC-3.84* HGB-11.9* HCT-35.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-16.4* [2161-2-13] 04:55PM NEUTS-51 BANDS-16* LYMPHS-14* MONOS-9 EOS-0 BASOS-0 ATYPS-2* METAS-2* MYELOS-5* PROMYELO-1* [2161-2-13] 04:55PM PLT SMR-LOW PLT COUNT-142* [2161-2-13] 04:55PM PT-12.1 PTT-27.4 INR(PT)-1.0 [2161-2-13] 04:55PM GLUCOSE-151* UREA N-7 CREAT-1.2 SODIUM-140 POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-28 ANION GAP-12 IMAGING STUDIES: # LENIS [2161-2-13]: no DVT # Head CT [2161-2-13]: There has been previous right occipital craniectomy with slight interval increase in hypodensity within the cerebellar resection bed. There is no hemorrhage, mass effect, shift of midline structures, or evidence of major vascular territorial infarction. Unchanged bilateral basal ganglia calcifications. There is mild right maxillary sinus mucosal thickening (3:2). IMPRESSION: 1. No hemorrhage or mass effect. 2. Apparent increase in hypodensity at right occipital craniectomy site. MRI w/ gadolinium recommended to evaluate for tumor recurrence. # CXR [2161-2-13]: (prelim) no acute cardiopulmonary process # MRI spine [2161-2-15]: Evaluation of the cervical spine demonstrates no evidence for osseous metastatic disease. Multilevel spondylosis is seen including a disc osteophyte complex at C5/C6 and C6/C7. There is also a left paracentral disc protrusion which is broad-based at C6/C7 extending into the foramen. There is moderate stenosis at these two levels. There is a small nonspecific lesion in the right thyroid lobe measuring approximately 7 mm. There is no epidural disease seen. Evaluation of the thoracic and lumbar spine demonstrates mild marrow hypointensity. There is high signal within the sacrum which may be related to prior radiation to the rectum. No convincing evidence for epidural or intradural metastatic disease is seen. There is a central to left paracentral disc protrusion at L4-L5 causing left lateral recess narrowing and then abutting the left L5 nerve root. There is heterogeneous appearance to the iliac wings bilaterally which again may be related to prior radiation. The pre- and para-vertebral soft tissues are unremarkable. IMPRESSION: No evidence for metastatic disease. Degenerative changes in the cervical and lumbar spine as detailed. Probable post-radiation sequela in the sacrum. EMG: Clinical Interpretation: Abnormal study. The electrophysiologic abnormalities are most consistent with a moderate generalized neuropathy with demyelinating and axonal features. The sural nerve is spared. Given the time course of progression, the findings are consistent with an acquired neuropathy such as [First Name9 (NamePattern2) 7816] [Location (un) ] syndrome. The low amplitude motor responses may or may not be due to axonal involvement; a follow-up study would clarify the extent of axonal involvement if indicated. PRIOR STUDIES: # Torso CT [2161-2-12]: 1. New DVT in the R common iliac v, appears to emanating from the R internal iliac v. The thrombosis extends to near the confluence of the common iliac. Recommend urgent DVT ultrasound in the lower extremities. 2. Interval decrease of lung disease burden. Decrease of mediastinal and hilar LAD. 3. Post-radiation changes in the perirectal region. No bowel obstruction. Brief Hospital Course: 56M with rectal carcinoma s/p resection, chemoradiation who was referred to ED for R common iliac DVT and was found to be febrile. He was treated with Lovenox, empiric antibiotics, however developed progressive weakness initially concerning for spinal cord compression (MRI pan spine showed no cord compression, while MRI of head showed a stable cerebellar herniation through craniotomy site without evidence of infection). His exam progressed to bilateral leg weakness, worsened bilateral hand and lower leg numbness, tongue numbness, and dysphagia to liquids and solids and patient developed progressive loss of reflexes. He underwent LP and was diagnosed with GBS. He was transferred from Medicine Service to Neurology Service on [2161-2-22]. # GBS Patient with ascending weakness, loss of reflexes and CSF with albuninocytologic dissociation. His NIF and vital capacity apparently declined while in medical ICU and he was intubated on [2161-2-20] based on above and in setting of tachypnea. Completed 4 days of IVIG on [2161-2-21]. His strength slowly improved, however there remained mild assymetry of L > R weakness (including face) as well as more proximal vs. distal weakness. He has made steady improvement throughout his recovery phase, and is at least antigravity strength in all muscle groups at the time of discharge. # Weakness and parathesias: Overnight [2-14] patient developed neurologic sxs concerning for cord compression of the low cervical or high thoracic vertabrae, however normal spinal MRI without compression. [Month (only) 116] also be complicated by cerebellar mets and chemo induced neuropathy. Neurology and neurosurgery followed the patient and he was maintained on standing dexamethasone which was subsequently discontinued given negative imaging. He failed a speech and swallow and was determined to be likely aspirating on [2-17] so was changed to Levo/Flagyll. He subsequently proved to have steadily improving oropharyngeal control, and was taking all calories PO at the time of discharge. Of note, at admission the patient did have diarrhea, though he was camplobacter negative. Also on [2-18] the patient developed dyspnea with a RR to the low 20s and maintance of oxygen saturation in the 90s on RA. He developed urinary retention (bladder scan with 500cc) though also may have been holding in his urine due to physical difficulty using urinal. He developed difficulty managing his secretions with NIFs -20 to -30 and was then transferred to the ICU. A bedside LP was attempted on [2-17] and was unsuccessful. On [2-18] the patient had an IR guided LP revealing elevated protein with 1 WBCs. A diagnosis of GBS was made based on progressive weakness and loss of reflexes (see above for GBS management). # DVT: R common iliac thrombus seen on outpatient CT. LENIS showed no lower clot. Enoxaprin was initially started and then held starting [2-16] for an LP. He was switched to Heparin SC TID during that interval and changed back to Lovenox on [2-18]. He continues on treatment doses of Lovenox. # Fever: Given recent chemotherapy, was initially concerning for infection. However, patient was not neutropenic. Bandemia reflects recent Neulasta administration. No evidence of sepsis. CXR, u/a, UCx were unremarkable. Fever might also be related to DVT or chemo itself. At admission patient was maintained on Cefepime/Vanc. After switch to Levofloxacin he spiked and was thus changed back to Cefepime/Vanc before being changed to Levo/Flagyll as above with plan to continue for 7 days. Following completion of this course he remained fever-free. All of infectious evaluations proved to be unrevealing including BCx, UCx, Stool Cx, C.diff Assay, Legionella antigen, sputum and BAL washings. Antibiotics were thus discontinued on [2-22]. He continued to have intermittent low grade fevers (101F) which were attributed to DVT. # Rectal cancer: No intervention done this admission. Patient should follow up with Dr.[Name (NI) ] office one month following discharge from the hospital. This appointment has already been made. # elevated blood glucose: Hemoglobin A1C of 6.5 suggests glucose intolerance. He was maintained on an insulin sliding scale. It is suggested that Metformin be started discharge. # FULL CODE (confirmed with interpreter at admission) and confirmed with Dr. [First Name (STitle) ] (outpatient oncologist) Medications on Admission: ranitidine 150 mg [Hospital1 ] Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe [Hospital1 ]: 0.7 ml Subcutaneous Q12H (every 12 hours). 2. Sodium Chloride 0.65 % Aerosol, Spray [Hospital1 ]: [1-10] Sprays Nasal QID (4 times a day) as needed for dry nose. 3. Senna 8.6 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Acetaminophen 650 mg Tablet [Month/Day (2) ]: One (1) Tablet PO every four (4) hours as needed for fever or pain. 6. Metoprolol Tartrate 25 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: [First Name9 (NamePattern2) 30065] [Location (un) ] syndome Secondary: Pelvic DVT Additional: Rectal adenocarcinoma, metastases to the cerebellum s/p resection. Discharge Condition: Mental status - intact Strength - diffusely weak, distal > proximal. At least [3-13] in all muscle groups, with scattered 4/5s in bilateral [Hospital1 ]/tri/gastrocs. Near-daily improvement in exam throughout his recovery period. Reflexes diffusely absent Sensory - intact to fine touch, position, temperature. Discharge Instructions: You were admitted to [Hospital1 18] with a clot in your left leg and fevers. You were evaluated for multiple causes of the fever, but they were negative. You were temporarily treated with antibiotics, but in the end were treated for the blood clot with a blood thinner. You also developed progressive weakness in your arms and legs, and difficulty swallowing, and were diagnosed with [Last Name (un) 30836] [Location (un) ] syndrome (also known by the acronym AIDP). For this you were treated with IVIG (immunoglobulin) and required temporary intubation (breathing tube to make sure you do not suffocate). Your weakness improved somewhat, but will likely require several weeks (perhaps as long as 12 weeks) to return to normal. In addition, while at the hospital, you were found to have signficantly elevated blood sugars. This may be related to stress or an underlying early diabetes. You should follow up with your primary care doctor regarding this. Please follow up with all of your appointments. Should you develop any symptoms concerning to you or some of the listed below, please call your doctor or go to the emergency room. Followup Instructions: NEUROLOGY: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [3-25] at 2pm. [Location (un) 8661] Building, [Location (un) ], [Hospital1 18] [Hospital Ward Name 516]. Call ([Telephone/Fax (1) 1703] with any questions. ONCOLOGY: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [First Name8 (NamePattern2) 916] [Last Name (NamePattern1) ] on [4-1], 3:30pm. Call ([Telephone/Fax (1) 694] with any questions. PCP: [Name10 (NameIs) ] your PCP within [Name Initial (PRE) ] week of discharge from rehab to review the many changes to your medical care over the last few weeks. Completed by:[2161-3-5]	[ "5070", "51881" ]
Admission Date: [2112-7-6] Discharge Date: [2112-7-15] Date of Birth: [2112-7-6] Sex: M HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname 10208] was delivered at 37-6/7 weeks weighing 3010 g and was admitted to Neonatal Intensive Care Unit from Labor and Delivery for respiratory blood group, antibody negative, received RhoGAM at 20 and 28 weeks, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, Rubella immune, afebrile, with rupture of membranes seven hours prior to delivery. She had chronic abruption observed in house early in her pregnancy. Spontaneous vaginal delivery . Apgar scores were 8 and 9. He received blow-by oxygen only. He was transferred to the Newborn episode in the newborn nursery at about 3 hours of life. Measurements revealed birthweight 3010 g (which was the 50th percentile), length of 50 cm (which was the 75th percentile), and a head circumference of 33.5 (which was also the 50th percentile). PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed a pale, pink, nondysmorphic male with palate intact. Bilaterally equal breath sounds. No murmur. In respiratory distress. The abdomen was soft and nontender with a 3-vessel cord. No hepatosplenomegaly. Back and spine were normal. Hips were stable. Red reflex was present. Anterior fontanel was open and flat and molding of the head was also noted. The child was placed on CPAP for respiratory support. He also received a bolus of IV normal saline for poor perfusion. HOSPITAL COURSE: 1. RESPIRATORY: Intubated after around 12 hours of life and received one dose of surfactant for persistent respiratory distress and oxygen requirement, self- extubated within the next 12 hours and remained on CPAP since then. He was taken off CPAP to nasal cannula on [7-11]. He remained intermittently tachypneic and on nasal cannula oxygen until [7-13]. By [7-14] he was oxygenating well in room air except with bottle feeding. Spent 24 hours nursing exclusively with no desaturations prior to discharge. 2. CARDIOVASCULAR: No murmurs. No issues. Blood pressure was stable. 3. FLUIDS/ELECTROLYTES/NUTRITION: He was initially started on D-10-W at 60 cc/kilo per day, and the first set of electrolytes were sodium of 143, potassium of 3.6, chloride of 107, and bicarbonate of 22. Feedings advanced once respiratory status stabilized. Difficulty oxygenating with bottle feeds prior to discharge as noted above. Currently, he is breast feeding ad lib; parents counseled re: feeding cues, expected frequency/duration of feeds, signs of milk transfer. Discharge weight 2835 g (4.5% below birthweight). 4. INFECTIOUS DISEASE: He received ampicillin and gentamicin for seven days based on respiratory distress and prolonged distress, presumed pneumonia. The complete blood count showed a white blood cell count of 17.9 (73 neutrophils and 2 bands). Blood cultures remained negative. 5. GASTROINTESTINAL: He is on full feeds and tolerating them. No abdominal distention. Blood sugar has been stable. The initial bilirubin was 6/0.3 on day two, peaked at 15.8/0.9 on day five and responded well to phototherapy, down to 9.7/0.7 day six at which time lights were discontinued with a rebound of 7.6/0.4 on day seven. His blood group was A negative, and Coombs was negative. 6. NEUROLOGICAL: No issues. 7. HEMATOLOGY: His initial hematocrit was 51, and a platelet count of 299. WBC diff as noted above. Pink and well perfused at discharge. 8. GENITOURINARY: Underwent circumcision [7-14] with subsequent suture placement by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] for persistent bleeding a few hours later. Wound/suture site is clear without sign of infection or bleeding at discharge. Passed hearing screen in both ears. Passed car seat test. Received hepatitis B vaccine [2112-7-14]. State screen sent per routine. Discharged home in stable condition with parents, to follow up with primary pediatrician Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3450] in [Location (un) ] on [2112-7-16] at 10am. Discharge diagnoses: 1. Respiratory distress syndrome, resolved. 2. Presumed pneumonia, resolved. 3. Status post sepsis evaluation with negative blood cultures. 4. Exaggerated physiologic hyperbilirubinemia, resolved. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] 50-563 Dictated By:[Name8 (MD) 42804] MEDQUIST36 D: [2112-7-12] 16:35 T: [2112-7-12] 16:39 JOB#: [Job Number 42805]	[ "486", "V290" ]
Admission Date: [2115-2-1] Discharge Date: [2115-2-6] Date of Birth: [2056-4-16] Sex: M Service: Medicine The patient is a 58-year-old male with a history of COPD on home oxygen, diastolic dysfunction, obesity, type 2 diabetes, who presented on [2115-2-1], to the emergency department complaining of one days duration of shortness of breath. His ABG on 6 liters was pH 7.24, pCO2 114, pO2 123. The patient states that his shortness of breath is above his baseline, reports exercise intolerance, chest tightness, denies fevers and chills, denies upper respiratory symptoms. He complains of chronic cough with scant sputum production. PAST MEDICAL HISTORY: 1. COPD on 3 liters home oxygen. Pulmonary function test in [Month (only) 359] showed FVC of 1.7 liters (39%), FEV1 0.5%, which is 18% of predicted, ratio of FEV1 to FVC is 45% of predicted. 2. Diastolic dysfunction, ejection fraction 55%. 3. Obesity. 4. Diabetes. 5. Diverticulosis. 6. C6-C7 disc herniation. 7. History of thrombocytopenia on heparin with negative heparin dependent antibodies. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: Atrovent 2 puffs inhaler q.i.d., Prilosec 20 b.i.d., albuterol 4 puffs inhaler q.i.d., Serevent 2 puffs inhaler b.i.d., Flovent 4 puffs inhaler b.i.d., Combivent p.r.n., Norvasc 5 mg p.o. q.d., Metformin. SOCIAL HISTORY: Lives with wife and two children. Positive smoking 160 pack year, currently smokes one pack a day. Heavy alcohol use in the past, none in 5 years. No history of DTs. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.8, pulse 116, blood pressure 136/86, respirations 20, 86% on 6 liters. General - elderly appearing man in mild respiratory distress. HEENT - clear oropharynx, moist mucous membranes. Neck - no lymphadenopathy. Lungs - decreased breath sounds and decreased respiratory effort bilaterally. Heart - tachycardiac, regular rate and no murmurs, rubs or gallops. Abdomen is soft, distended, positive bowel sounds, no tenderness. Extremities - 1+ pitting edema. LABS ON ADMISSION: White count 10, hematocrit 34.8, platelets 196, sodium 142, potassium 4.7, chloride 95, bicarb 44, BUN 18, creatinine 0.6, glucose 201. ABG on 6 liters pH 7.23, pCO2 114, pO2 123. Chest x-ray shows mild CHF. EKG normal sinus rhythm at 120 beats per minute, no apparent ischemia. HOSPITAL COURSE: 1. Respiratory distress: The patient was initially admitted to the medical intensive care unit for Bi-PAP. The patient initially refused Bi-PAP on the following morning, house officer was notified that the patient was somnolent and nonresponsive. The patient was subsequently intubated for hypercarbic respiratory failure. The patient was started on azithromycin and prednisone 60 mg p.o. b.i.d. The patient was diuresed with Lasix and had one liter of fluid out on day one. The next day the patient extubated himself and his repeat ABG was pH 7.45, pCO2 58, pO2 62 on three liters nasal cannula. The patient showed no signs of respiratory distress and was subsequently transferred to one of the general medical teams. The patient continued having respiratory status at baseline. His prednisone was continued at 60 mg p.o. b.i.d. The patient received nebulized treatments as well as his regular inhalers and finished a three day course of azithromycin. His respiratory function appeared to be at baseline. The patient reported shortness of breath only with exertion. The patient was subsequently discharged with a prednisone taper and close outpatient follow up. 2. Diastolic dysfunction, likely secondary to a combination of COPD and obstructive sleep apnea. A trial of CPAP was offered to the patient, however, the patient refused and it is recommended that the patient have an outpatient sleep study due to likely diagnosis of obstructive sleep apnea. 3. Diabetes. The patient's finger stick blood sugars were somewhat elevated in the range of 200 to 300 secondary to prednisone. The patient was continued on his regular dose of Metformin and was covered with regular insulin sliding scale. 4. Neurologically the patient was put on CIWA protocol, but has not required any Valium and did not show any signs of alcohol withdraw. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. COPD with acute exacerbation, status post intubation for hypercarbic respiratory failure. 2. Type 2 diabetes. 3. Hypertension. 4. Obesity. 5. Smoking. DISCHARGE MEDICATIONS: Prednisone taper, the patient is to take 60 mg of prednisone q.d. for one more day followed by 40 mg of prednisone q.d. x3 days, 30 mg q.d. x3 days, 20 mg q.d. x3 days, 1 mg q.d. x3 days and then stop. No other changes in his medications were made. FOLLOW UP PLANS: The patient is to follow up with his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 1391] within 1 to 2 weeks after the hospitalization while still on prednisone taper. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5613], MD Dictated By:[Name8 (MD) 4937] MEDQUIST36 D: [2115-2-6] 11:42 T: [2115-2-11] 13:57 JOB#: [Job Number 109511]	[ "51881", "4280", "25000", "53081", "4019" ]
Admission Date: [2127-11-20] Discharge Date: [2127-12-2] Date of Birth: [2057-9-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: 70 year old white male with chest pain. Major Surgical or Invasive Procedure: Cardiac catheterization CABGx4(LIMA->LAD, SVG->OM, PDA, PLV)[2127-11-24] LUE partial fasciotomy [2127-11-24] History of Present Illness: Thiw 70 year old male with DM type 2 on insulin, HTN, hyperlipidemia, prior tobacco use and stable exertional angina for many years developed pain similar to his typical angina while undergoing a knee MRI. He took a nitroglycerin and the pain didnt resolve, it was sub sternal, radiating up to his neck, accompanied by diaphoresis. He was taken to he ED where he was found to have inferior ST depressions and mild 1mm anterior ST changes in v1-2. He received heparin, IIb/IIIa inhibitor, ASA, and beta blocker and his chest pain resolved for one hour. He was transferred to [Hospital1 18] for urgent cardiac catheterization and management of NSTEMI. CXR at OSH also showed pulmonary edema. He required treatment with IV Lasix for low o2 sats. Past Medical History: 1. Diabetes Melitis type 2 2. HTN 3. Hyperlipidemia 4. CAD, stable exertional angina on NTG sl at home Social History: Married, 50 pack/yr history of pipe smoking, 3 drinks/ week Family History: Father with angina in 60s, MI at 82 Physical Exam: BP 155/88 Pulse 80 Resp 97% on 100% FM, 90% on 4L Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally, no crackles or wheezes CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [1-30] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2127-12-1] 10:05AM 9.6 3.39* 10.8* 31.4* 92 31.7 34.3 15.4 334 BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT) [2127-12-2] 05:50AM 20.7* 2.7 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2127-12-2] 05:50AM 73 26* 1.6* 142 4.2 105 25 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2127-12-2] 05:50AM 2.3 Brief Hospital Course: 70 year old with HTN, hyperlipidemia, longstanding angina presents with SSCP found to have NSTEMI. In catheterization he had 60% LMCA, total occlusion of LAD, 95% ulcerated circ, 90% PLV. Also presenting with acute pulmonary edema felt to be due to ischemic MR, resolved with Lasix. He had new onset atrial fibrillation. Dr. [Last Name (STitle) ] was consulted and on [2127-11-24] he underwent CABGx4 with LIMA->LAD, SVG->PDA, PLV, OM. Cross clamp time was 90 mins and total bypass time was 73 mins. He was transferred to the CSRU on Milrinone, Epidural, Propofol, Insulin, and Neo. While in the OR, the IV in his left arm infiltrated and he needed a partial fasciotomy which was performend by Dr. [Last Name (STitle) 5385]. He was extubated on his post op night and went into afib on POD #1. He weaned off all of his drips and was slowly improving. He was transferred to the floor on POD#2 and had his fasciotomy closed on POD#3. He continued to progress and was anticoagulated as he still had occasional runs of AF at a controlled rate. He was discharged to home in stable condition on POD# 8. Medications on Admission: ASA Cartia VT 240 Daily Lisinopril 5 daily Insulin (in AM: 28 units Humalin N and 6 units Humalin R, in PM: 14 units Humalin N) Lipitor 40mg 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. 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. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:14 Capsule, Sustained Release(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 days: Then take as directed by PCP for INR goal of [1-20].5. Disp:90 Tablet(s) Refills:0 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Eight (28) units Subcutaneous q AM: Then take 14 units sc q PM. Disp:15 15 Refills:0 12. Insulin Regular Human 100 unit/mL Cartridge Sig: Six (6) units Injection q AM. Disp:3 3 Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary artery disease. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 1295] for 2-3 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 5385] for next Tues. [12-9]. [2127] Completed by:[2127-12-2]	[ "41071", "4280", "42731", "4240", "41401", "4019", "V1582" ]
Admission Date: [2114-3-9] Discharge Date: [2114-4-9] Date of Birth: [2114-3-9] Sex: F Service: NEONATOLOGY ADMISSION DIAGNOSES: 1. Prematurity (34 weeks). 2. Small for gestational age (birth weight 1560 grams). MATERNAL HISTORY: [Known firstname 65784] [Known lastname ] is a 25-year-old G1 P0 mother with BNS, B positive, antibody negative, HBS antigen negative, RPR NR, GBS unknown, rubella immune. She had amniocentesis in the first trimester, which showed fetal karyotype of 46 XX. She had an uneventful pregnancy. However, when she was seen on [2114-3-8] at [Hospital1 18] for a 3D ultrasound scan, she was noted to have fetal IUGR (9%), low AFI (8) and was therefore monitored at the antepartum testing unit before being sent to labor and delivery for evaluation. She was also noted to have borderline hypertension of 130 to 140/80 to 85 along with proteinuria attributed to pre-eclampsi a. In view of unclear etiology for IUGR, TORCH screen was sent on the mother. CMV IgM was negative, but IgG positive. Toxo IGG a nd IGM were negative, HSV 1 and 2 pending. She proceeded for elective cesarean section at 34 weeks in view of poor fetal growth. BIRTH HISTORY: Baby was [Name2 (NI) ] by elective cesarean section (mother not in labor). She was [Name2 (NI) ] in good condition, requiring no resuscitation at birth. Apgar scores were 9 and 10 at 1 and 5 minutes respectively. PHYSICAL EXAMINATION ON ADMISSION: On arrival to NICU she continued to be active, had mild oxygen requirement with no obvious respiratory distress. Growth birth weight 1560 gram (10th percentile), length 39.5 cm (11 to 10th percentile), head circumference 29.5 cm (10 to 25th percentile). Examination, general, small for gestational age, active, alert, vigorous. HEENT no dysmorphic features, sutures and fontanelle normal. No cleft, neck supple. Respiratory, breathing comfortably. No retractions. Bilateral equal breath sounds. Cardiovascular, pink, well perfuse. Normal pulses. Femoral pulses were normal, no murmur. Abdomen, soft, nondistended, no hepatosplenomegaly. Neuro, tone and reflexes normal. Extremities and spine normal. Hip not examined, stable on subsequent examination. HOSPITAL COURSE: 1. Respiratory. After a brief period of oxygen requirement soon after birth, baby [Name (NI) ] showed no evidence of respiratory distress and continued to breath comfortably in room air throughout her hospital stay. She did not have evidence of apnea of prematurity. 2. Cardiovascular. She remained hemodynamically stable wiht a normal cardiac examination throughout this admission 3. Fluid, electrolyte, nutrition. She was initially started on IV fluids at 60 ml per kilo per day. Feeds were introduced on the third day of life and gradually advanced so that she was on full feeds by day of life 4. This was further advanced to a maximum of 150 ml per kilo per day of breast milk PE/30 with ProMod for better weight gain. She has been on exclusive oral feeds since [3-30] and is currently on ad lib breast mi lk of Enfacare 26 kcal/oz. Weight at discharge is 2130 grams, wit h good growth in the week prior to discharge. 4. GI. She did not have any gastrointestinal problems during h er hospital stay. Liver function testing was within normal limits ([4-3]: Alt 12; AST 23; Alkaline phosphatase 208; total bilirub in 0.3; conjugated bilirubin 0.1)) 5. Heme. She did not receive any blood products during her hospital stay. There was no thrombocytopenia or neutropenia wi th the commencement of valganciclovir therapy. [2114-4-7] CBC showed: WBC 6,700 (PMN=13%, ANC 871), Plt 209K; Hct 29%. _____________. 6. Neurological: An initial ultrasound scan showed echodensity in the caudothalamic notch, thought to be consistent with a germi nal matrix hemorrhage, as well as mineralizing vasculopathy in bas [Doctor Last Name ] ganglia. CT ([3-21]) and MRI ([3-22]) were normal (the latter show ed a right poserior parietal developmental venous anomaly, a norm [Doctor Last Name ] variant). A repeat ultrasound on [4-3] showed complex cystic changes in the caudothalamic notch, thought to be suggestive o f CMV infection. Neurological examination showed hypertonicity i n symmetric distribution. 7. Infectious diseases. The infant had no episodes of suspecte d or proven bacterial sepsis. She was, however, investigated for CMV in view of maternal positive IgG serology and her small fo r gestational age status. Initial urine was CMV antigen positive , but CSF CMV pcr was negative, as was ophthalmology examination and initial ultrasound. Following the abnormalities on the sec ond ultrasound, as described above, CMV investigations were repeat ed. At that time, serum CMV viral load was 2580 copies, confirming congenital CMV infection. CSF CMV pcr is pending at the time o f this dictation. In light of the evidence of CMV infection with growth restriction and cranial ultrasound abnormalities, she w as started on valgancyclovir therapy orally for an anticipated course of 6 weeks. Valganciclovir levels have been sent and ar e pending at the time of discharge. 8. Sensory: Ophthalmology examination on [3-21] showed no eviden ce of chorioretinitis. Two auditory evoked response screens were performed, on [3-16] and [4-3], and were normal. 9. Psychosocial: No concerns. CONDITION ON DISCHARGE: Asymptomatic. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [First Name (STitle) 65785] [Name (STitle) 65786] (dim [Hospital ] Health Center [Telephone/Fax (1) 3581]) CARE AND RECOMMENDATIONS FEEDS AT DISCHARGE: Breast milk 26, EnfaCare 26 ad lib po feeds. MEDICATIONS: 1. Valganciclovir 30 mg PO BID (equivalent to 15 mg/kg/dose PO BID) 2. Ferrous sulfate 0.15 ml PO once daily CAR SEAT POSITION SCREENING: Passed. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [2114-4-2]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria; 1) [Month (only) ] at less than 32 weeks, 2) [Month (only) ] between 32 and 35 weeks with 2 of the following; daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants more than 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP APPOINTMENT SCHEDULE RECOMMENDED: 1. With primary care pediatrician 1 to 2 days following discharge. 2. VNA. 3. Early intervention (Bay Cove Early Intervention [Telephone/Fax (2) 65787]) 4. [Hospital3 1810] Infectious Disease Clinic - Appointmen t made for [4-24](Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 50148] [Telephone/Fax (1) 50149]) 5. [Hospital3 1810] Neonatal neurology clinc (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ul, appointment made for [7-11]) 6. [Hospital3 1810] ophthalmology clinic (Dr. [Last Name (STitle) 65788] [Telephone/Fax (1) 65789]) 7. [Hospital3 1810] Infant Follow-Up Program (will contact ) 8. She should receive weekly CBC, liver function tests and BUN/Cr while on valganciclovir DISCHARGE DIAGNOSES: 1. Prematurity (34 weeks gestation). 2. Small for gestational age. 3. Congenital cytomegalovirus infection REVIEWED BY: [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ] , MD [MD Number(2) 56576] Dictated By:[Doctor Last Name 65790] MEDQUIST36 D: [2114-4-3] 07:34:20 T: [2114-4-3] 08:37:44 Job#: [Job Number 65791]	[ "V053" ]
Admission Date: [2132-11-29] Discharge Date: [2132-12-1] Date of Birth: [2084-5-28] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[First Name3 (LF) 30] Chief Complaint: fever and hypotension at HD. Major Surgical or Invasive Procedure: Femoral tunneled catheter replacement History of Present Illness: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and h/o MRSA line sepsis [5-6] and presumed recurrence [10-6] though cx negative a/w F and hypotn at HD. Patient states he has been having fevers w/ rigors at the last 3 HD sessions. Today blood cx were obtained, vanc was given, and patient was transferred to [Hospital1 18] following dialysis. VS on arrival: T 98.6 hr 140 bp 113/42 rr 12 O2 95% RA. While in the ED bp dipped as low as sbp 81. Patient received a total of 3.3 L NS. On ROS, patient reports c/o N and V x couple times over the past couple days (w/o blood). + chills at HD. He was c/o back pain at HD. + cough w/o sputum. No c/o SOB or CP and no sick contacts. [Name (NI) ] D. No urinary sx (makes about 4 oz urine qd). No rash, HA, neck stiffness. No skin ulcers. . Past Medical History: 1. ESRD s/p failed transplant [7-4] now collapsing glomerulonephritis, HD qMWF at [Location (un) 4265] 2. Amyloidosis 3. Sarcoidosis 4. Hx of pulmonary aspergillosis - on itraconazole, followed by pulm 5. Hx of hyperkalemia 6. Hep B, C, ? D 7. HTN 8. Hx of IV drug use 9. h/o sinusitis requiring drainage 10. recent epistaxis requiring intubation 11. SPEP/UPEP positive 12. paroxysmal atrial fibrillation - off BB, on coumadin 13. h/o C diff [3-8] 14. MRSA line sepsis ([5-6]), new tunneled fem line [5-6], TTE neg for veg 15. h/o purulent ascites [3-8] while on PD 16. gynecomastia 17. iron deficiency anemia 18. renal osteodystrophy 19. adrenal insufficiency - on prednisone 5 mg po qd 20. h/o UE DVT [3-8] 21. h/o pancreatitis [3-8] ECHO [5-6]: EF > 55%, 1+ MR Social History: Lives with girlfriend, on disability; 1 packper day x30 years of tobacco use, still currently smoking.No alcohol, but previous history of abuse. Family History: Diabetes Physical Exam: Tm 100.8 in ED Tc 98.8 hr 102 bp 109/57 rr 13 O2 98% on 2 L NC genrl: sleepy but easily arousable, shaking chills heent: perrla (3->2mm), periorbital edema (patient reports common w/ volume overload, op clear - mmm, no sublingual icterus cv: rrr, no m/r/g pulm: bibasilar crackles, no wheeze/ronchi back: no focal spinal tenderness, no CVA tenderness abd: nabs, soft, tender to palpation of RLQ w/o rebound/guarding, scar overlying RLQ from "jumping out a window when he was young and cutting his skin in the process," o/w NT / ND, no masses/hsm extr: no [Location (un) ], dry skin, unable to palpate DP or PT pulses neuro: a, o x3, strength grossly [6-5] bilaterally UE/LE, sensory grossly intact in UE/LE Pertinent Results: [2132-11-29*] 04:40PM WBC-10.3 RBC-4.83# HGB-15.8# HCT-45.1# MCV-93 MCH-32.7 MCHC-35.0 RDW-14.4 [2132-11-29] 04:40PM NEUTS-88.5* BANDS-0 LYMPHS-7.4* MONOS-2.3 EOS-1.5 BASOS-0.4 [2132-11-29] 04:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2132-11-29] 04:40PM PLT SMR-NORMAL PLT COUNT-291# [2132-11-29] 04:40PM GLUCOSE-130* UREA N-20 CREAT-6.8* SODIUM-139 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20 [2132-11-29] 04:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-1.3* [2132-11-29] 05:20PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.017 [2132-11-29] 05:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-NEG [2132-11-29] 05:20PM URINE RBC-0-2 WBC-[4-5] BACTERIA-MOD YEAST-NONE EPI-[4-5] [2132-11-29] 04:53PM LACTATE-1.6 K+-3.7 [2132-11-29] 11:10PM PT-26.5* PTT-150* INR(PT)-5.2 [2132-11-29] 04:40PM CK(CPK)-22* [2132-11-29] 04:40PM cTropnT-0.12* [2132-11-30] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.09* [2132-11-30] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.09* [2132-11-30] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.08* [2132-11-30] 05:00AM BLOOD ALT-23 AST-30 CK(CPK)-19* AlkPhos-139* Amylase-144* TotBili-0.4 [2132-11-30] 11:11AM BLOOD ALT-19 AST-26 LD(LDH)-177 CK(CPK)-29* AlkPhos-122* TotBili-0.4 [2132-11-30] 11:11AM BLOOD CK(CPK)-28* [2132-12-1] 06:20AM BLOOD AST-32 LD(LDH)-132 AlkPhos-118* TotBili-0.3 . CHEST (PORTABLE AP) [2132-11-29] 4:49 PM Reason: please eval lung fields for infiltrates [Hospital 93] MEDICAL CONDITION: 48 year old man with ESRD now with hypotension and lactatemia . REASON FOR THIS EXAMINATION: please eval lung fields for infiltrates HISTORY: End-stage renal disease, now hypotension and lactic acidemia. Question infiltrate. The patient has a history of sarcoid and aspergillomas as well as renal transplant based on the chest CT report from [2131-12-11]. CHEST, SINGLE AP VIEW. There is [Hospital1 ]-apical scarring with upper zone infiltrates. There are calcifications superimposed over the mediastinum and hila and some pleural plaquing in the right mid and lower zones. There is blunting of the left costophrenic angle. Appearances are unchanged compared with [2132-10-21]. No superimposed CHF, infiltrate, or gross effusion is identified. Apparent oral contrast in the bowel. IMPRESSION: Appearances are suggestive of scarring related to previous infection and the presence of calcified nodes is suggestive of prior granulomatous infection. ECG [2132-11-29]: This Ecg received late and out of sequence Baseline artifact Sinus tachycardia ST-T configuration consistent with early repolarization pattern/ normal variant although baseline artifact makes assessment difficult Since previous tracing of same date, sinus tachycardia rate slower, not suggestive of right atrial abnormality and ST-T wave changes decreased [2132-11-30]: HISTORY: Right lower and left lower quadrant pain. COMPARISON: CT from [2132-5-12]. TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to pubic symphysis were acquired following the administration of oral and 150 cc of IV Optiray. Nonionic contrast was administered secondary to patient's debility. Coronal and sagittal reconstructions were performed. CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated at the lung bases is diffuse pleural thickening with calcifications consistent with prior asbestos exposure. Calcified left paraaortic lymph node is also seen, and additionally, there appears to be calcification along the pericardium. The liver, pancreas, spleen, adrenal glands, stomach, and loops of large and small bowel are all unremarkable. Within the gallbladder, there are at least 2 calcified 2-mm structures, likely representing gallstones. Gallbladder otherwise is collapsed without evidence of pericholecystic fluid. The kidneys again demonstrate multiple subcentimeter low-attenuation lesions, stable in the interval, and too small to fully characterize. No hydronephrosis is noted. Extensive atherosclerotic calcifications are seen within the abdominal aorta, but the aorta is normal in caliber. There is no free air or free fluid. There is no evidence of bowel obstruction. Again demonstrated within the retroperitoneum are several prominent lymph nodes within the aortocaval and left paraaortic region. The largest lymph node measures approximately 14 mm, and is relatively stable since the prior examination. There is no free air or free fluid. CT OF THE PELVIS WITH IV CONTRAST: Transplanted kidney is seen within the right lower quadrant, without evidence of hydronephrosis, renal masses, or perinephric fluid collections. A focal area of hypoenhancement/cortical scarring is again noted within the lateral aspect of the kidney, unchanged. Rectum, sigmoid colon, and pelvic loops of bowel all appear unremarkable, and the appendix is normal in caliber, filled with contrast. Prostate and bladder are within normal limits. There is no free fluid. No pelvic or inguinal lymphadenopathy is demonstrated. A left common femoral central venous catheter is demonstrated with tip in the inferior aspect of the inferior vena cava. BONE WINDOWS: No suspicious lytic or sclerotic lesions are present. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in confirming the above findings. IMPRESSION: 1. No abnormality noted within either lower quadrant to account for the patient's pain. Stable appearance of the transplanted kidney. 2. Calcified pleural thickening in both lower lobes consistent with prior asbestos exposure. 3. Stable prominent lymph nodes within the retroperitoneum. 4. Stable appearance of the native kidneys with multiple subcentimeter cysts seen, which may represent acquired cystic renal disease vs. polycystic kidney disease. 5. Cholelithiasis. [Hospital 102855] MEDICAL CONDITION: 48 year old man with ESRD on HD, s/p multiple episodes of MRSA line sepsis, now w/ fever, GPC on blood cx. REASON FOR THIS EXAMINATION: Please change left shoulder hemodialysis catheter over a wire HEMODIALYSIS CATHETER CHANGE INDICATION: Endstage renal disease on hemodialysis, now with left femoral tunneled dialysis catheter and MRSA line sepsis. Details of the procedure and possible complications were explained to the patient and informed consent was obtained. RADIOLOGISTS: Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) 380]. Dr. [Last Name (STitle) 380], staff radiologist, was present for the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, two Amplatz super stiff wires were advanced into the indwelling left femoral tunneled dialysis catheter. The cuff of the catheter was released by blunt dissection and the catheter was removed over the wire. A new 14-French tunneled dialysis catheter was then placed over the wires with the tip positioned in the IVC just above the confluence of the common iliac veins. This was confirmed by injection of small amount of contrast material. No extravasation of the contrast material was seen. The catheter was secured to the skin. The patient tolerated the procedure reasonably well. There were no immediate complications. CONTRAST MATERIAL: 20 cc of nonionic contrast material were used. IMPRESSION: Exchange of a left femoral tunneled dialysis catheter for a new tunneled dialysis catheter over the wire. Brief Hospital Course: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and h/o MRSA line sepsis in [5-6] and presumed recurrence in [10-6] admitted with fever and hypotension at HD. . # Sepsis: Bcx was drawn at HD on [11-29], and vanc was given, and patient was transferred to [Hospital1 18] following dialysis. Pt's BP drifted down to 81, tachy at 140 but afebrile in the ED. Patient received a total of 3.3 L NS. Because of hypotension, the patient was observed in the MICU overnight. The patient was continued on IV vanc and gent x i was given. The patient did not require any pressors but received stress dose steroids. Pt had abd tenderness and was covered with flagyl and cipro transiently as there was a concern for GI abscess, but was discontinued on the day of transfer to the floor on [11-30] as the CT of abdomen was negative for any intra-abdominal inflammatory processes or abscess. Bcx 1/4 bottles from [11-29] grew Staph coag negative species and sensitivities pending. Surveillance blood cultures were drawn and were negative to date. On [11-30], the patient had the femoral dialysis catheter exchanged over the wire and tolerated it well. The cath tip culture is negative to date. The patient was continued on iv vancomycin and random vanc levels were checked and if the level<15, additional 1gm of vancomycin was given. The patient was discharged with 14 days of vancomycin to be administered at dialysis or when vanc level <15. . # Troponin leak: No c/o chest pain and unremarkable EKG. Nevertheless, in the MICU enzymes were cycled to confirm CK/CKMB did not increase. . # ESRD: s/p failed transplanted kidney. Continued HD Tues, Thurs,Fri. Renally dosed meds. Continued tacrolimus and Bactrim for prophylaxis. - Hyperphosphatemia- Continued sevelamer and calcium acetate. Renal felt that given elevated calcium simultaneously, the patient may have vit D toxicity. Renal will decrease vit D administration during dialysis. - Hypercalcemia- See above. Per Renal, no acute need for treatment. No IVF given already received 3 L in the MICU. . # PAF: Coumadin was held due to elevated INR 5.2. Once hypotension was resolved, the patient was started on metoprolol for rate control. The patient's INR at time of discharge was 3.1. The patient was instructed to start coumadin 1mg every other day when the level <3.0. INR is to be checked during dialysis and requested to fax the results to Dr. [Name (NI) 2427], pt's PCP. [Name10 (NameIs) ] patient has an appointment with Dr. [Last Name (STitle) 2427] on [2132-12-5]. . # HTN: Once hypotension resolved with fluids in the MICU, the patient was noted to be hypertensive on the floor. The patient was not taking any antihypertensives as an outpatient recently given hypotension (he has been on Lopressor and diltiazem in the past). We restarted Lopressor, and the patient will f/u with Dr. [Last Name (STitle) 2427] for further HTN management. . # H/o pulm aspergillosis: Continued itraconazole. . # Hep B/C: No acute issues. . # Adrenal insufficiency- The patient received stress dose steroids in the MICU. On the floor, the patient was continued on prednisone 5mg qday. . # Depression: Continue sertraline . # PPX: home PPI, bowel reg, and no sc heparin given elevated INR. . # FEN: IVF given in the MICU for hypotension. Continued renal diet. Repleted 'lytes/prn. Continued thiamine, Nephrocaps, and folic acid. . # Full code . # Communication: GF [Doctor Last Name 2808] [Telephone/Fax (1) 102392] Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 2. Thiamine HCl 100 mg PO DAILY 3. Folic Acid 1 mg PO DAILY 4. Itraconazole 200 mg PO BID 5. Calcium Acetate 1200 mg PO TID W/MEALS 6. Pantoprazole Sodium 40 mg PO Q24H 7. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY 8. Prednisone 5 mg PO DAILY 9. Tacrolimus 0.5 mg daily 10. Docusate Sodium 100 mg PO BID 13. Sevelamer HCl 1600 mg PO TID 14. Lactulose 30 ML PO TID 15. Warfarin Sodium 1 mg PO every other day. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD (). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMON,WED,FRI (). 11. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 14. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous during dialysis on Tues, Thurs, Sat for 14 days: please administer vancomycin 1000mg iv during dialysis and prn if vancomycin level <15. . Disp:9000 mg Refills:0 16. Outpatient Lab Work Vancomycin random level at dialysis. Also, please check INR and fax results to Dr. [First Name8 (NamePattern2) 2426] [Last Name (NamePattern1) 2427] to adjust coumadin dose. Fax number is [Telephone/Fax (1) 3382]. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO every other day: Take this when your INR is <3.0. Check your INR at dialysis on [2132-12-2]. . Disp:3 Tablet(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: Line sepsis/bacteremia End-stage Renal Disease Adrenal insufficiency Paroxysmal atrial fibrillation Discharge Condition: Stable, afebrile. Discharge Instructions: Return to the emergency department if you develop fever, chills, severe abdominal pain, nausea, vomiting, or any other worrisome symptoms. . Keep your follow-up appointments. Discuss with your primary care physician regarding your hypertension management and coumadin. . Take your medications as instructed. Have dialysis unit check your vancomycin level at dialysis and administer vancomycin. Also, have your INR checked at dialysis tomorrow and start coumadin if your INR<3.0. Followup Instructions: Dialysis at Gambor on Tues, Thurs, and Sat as previously scheduled. . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Date/Time:[2132-12-5] 3:30 . Provider: [Name10 (NameIs) ] [Doctor Last Name ], OD Phone:[Telephone/Fax (1) 253] Date/Time:[2133-2-17] 3:00	[ "99592", "78552", "40391", "42731", "2762", "V5861" ]
Admission Date: [2162-6-20] Discharge Date: [2162-6-23] Date of Birth: [2091-1-24] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: R sided weakness, intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo L handed M with history of kidney stones, BPH, and pelvis fracture from a fall presents wtih acute R face, arm and leg weakness today found at OSH to have a L basal ganglia hemorrhage. He was transferred from [Hospital ] hospital to [Hospital1 18] for further evaluation and managment. He was well until today, no recent illnesses. He was out gardening today, ~11:30-noon as he was walking back in the house he suddenly felt like something was wrong but not sure what. Then he made brunch for he and his wife. [Name (NI) ] cooking he felt somewhat clumsy with his R hand, though he is L handed so it wasn't a big deal. While eating his wife noticed his speech was slurred, his R face was drooped, and he was weak in his R arm. He had trouble getting his R arm even up to the table. Then when he stood he was dragging his R foot. At that point, his wife convinced him that he needed to go to the hospital, as she suspected he was having a stroke. He went to [Hospital ] hospital by ambulance. There he was noted to have R face/arm/leg weakness. CT head showed a 3cm.1.3cm.2.6cm hemorrhage in the L basal ganglia, primarily putaminal. He was transferred for further neurological management. There blood pressure was close to SBP 200s. He did not receive any antihypertensive or other medications at the OSH. He was never sleepy or confused. He never had trouble coming up with words, just slurred speech. R face, arm, and leg weakness has gradually improved overall with slight fluctuation such as transiently more weak in ambulance on the way here. He takes allopurinol and ibuprofen daily, no antiplatelet or anticoagulant medications. No trauma. no known history of hypertension, and he says he has been seeing his doctor over the last few years with normal BP checks. ROS: Denies fevers, neck stiffeness, vision changes (blurry, double or other), swallowing difficulties, numbness/tingling, difficulty sensing temperature. He has been able to walk though dragging R leg. No recent travel. Past Medical History: BPH Recent prostate biopsy normal. Kidney stones Fall off ladder 3 years ago with no LOC, but had a pelvis fracture. osteoarthritis After calling PCP it appears patient has had BPs in the 140s/90s for the last few years, and last [Month (only) ] a measurement of 170/100 Social History: Lives with wife [Name (NI) 4457], who is his health care proxy if he could not make decisions for himself. Her contact information is [Name (NI) 4457] [Name (NI) ], home phone [Telephone/Fax (1) 85360] or patient's cell which she will take [Telephone/Fax (1) 85361]. He is a retired carpenter. He smoked for 15yrs, average [2-6] PPD, and quick 30 years ago. One alcoholic drink per day (i.e. one shot). Denies drug use. Have 5 grown children and 8 grandchildren Family History: No family history of bleeding or clotting disorders, vascular malformations or aneurysms, or brain tumors. Children and grandchildren all healthy. Physical Exam: Physical Exam: T98.5 Hr 96 BP 172/120 -->155/90s RR 16 O2 98% RA Gen: Awake, alert, not in distress, sitting up in bed. Non-toxic appearance. Skin: No rashes Heent: NCAT, mucous membranes moist, oropharynx clear. Neck: Supple, no meningismus. Full ROM without pain. No cervical bruit. Back: no spinal tenderness Resp: Clear to auscultation bilaterally CV: Regular rate, normal S1/S2, no murmurs, rubs, or gallops Abd: Abdomen soft. Extrem: Warm and well-perfused. Arthritic changes in joints especially PIP and DIP joints (appears to be osteoarthritis). RLE slightly externally rotated on the bed. Neuro: MS - Awake, alert, interactive. Oriented to person, place (hospital, city, state, and room number in ED), and date (day/month/year). Speech is fluent. Intact registration, recall 0/3 and [2-7] with clues. Repetition, naming, comprehension intact. Attentions is considered to be appropriate. No left-right confusion. Cranial Nerves - Pupils R 3.5--->3 and L 3-->2 both briskly reactive (likely physiologic anisocoria); EOMs smooth and full, no diplopia; no nystagmus; optic disc margins sharp on funduscopic exam, Visual field full with confrontation test, intact facial sensation V1-V3, R UMN facial droop less apparent with spontaneous than forced smile, slight dysarthria, hearing intact to finger rub bilaterally, palate elevation is symmetric, and tongue protrusion is symmetric and full movement. Sternocleidomastoid and trapezius are strong and normal volume. Tone - Normal Strength - Pronator drift on R Delt [Hospital1 ] Tri WrEx FEx FFlx IO [Location (un) ]/IP Quad Ham Gastr TA [First Name9 (NamePattern2) ] [Last Name (un) 938] R 4+ 5 5 5* 5- 5 4+ 4+ 4+ 5 5- 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Note wrist extensor shakey on R but unable to break it Reflexes - Biceps Triceps Brachioradialis Patellar Ankle R 2+ tr 2+ 2+ 2+ L 2+ 2+ 2+ 2+ 2+ Plantar responses extensor bilaterally Sensation - Intact to light touch, temperature. Mildly decreased vibration and JPS bilaterally at the big toes. Vibration symmetric and intact at knees. Romberg negative. Coordination - Finger to nose intact with no dysmetria out of proportion to weakness. RAMs slightly slumsier on the R, again in proportion to weakness. Gait - Narrow based and stable with slight circumduction and foot drop of RLE. Unable to walk on toes. Pertinent Results: [2162-6-20] 09:48PM CK-MB-3 cTropnT-<0.01 [2162-6-20] 02:40PM cTropnT-<0.01 [2162-6-20] 02:40PM TSH-1.6 [2162-6-20] 04:45PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.016 [2162-6-20] 04:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2162-6-20] 02:40PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-99 [2162-6-20] 02:40PM WBC-9.2 RBC-5.21 HGB-15.0 HCT-45.4 MCV-87 MCH-28.7 MCHC-33.0 RDW-13.3 Imaging: CT head [6-20]: IMPRESSION: No short interval change of 1.3 x 3 cm left external capsule hemorrhage with minimal mass effect. No new foci of hemorrhage. No evidence of herniation or midline shift. MRI/A brain [6-21]: MRI OF THE BRAIN: A 33 x 13 mm left basal ganglia hemorrhage with minimal surrounding vasogenic edema, is stable in size and location compared to CT scan of [2162-6-20], previously 13 X 34mm. There is minimal local mass effect without shift of normally midline structures. Ventricles are normal in size and configuration. Suprasellar and basal cisterns are patent. No area of abnormal enhancement or abnormal vascular structures are seen within the area of the hemorrhage. No area of abnormal enhancement or abnormal vascular structures are seen within the remainder of the brain parenchyma. A small hypointense focus in the right posterior temporal region on axial FLAIR likely represents encephalomalacia. BRAIN MRA: Arteries of the anterior and posterior circulation appear normal without evidence of stenosis, occlusion or aneurysm greater than 3 mm. IMPRESSION: Left basal ganglia hemorrhage with surrounding edema is stable in size and appearance since CT scan of [2162-6-20]. No underlying mass or vascular malformation identified. MRA is normal. Brief Hospital Course: 71 yo M with h/o kidney stones, BPH, prior pelvic fracture, oseoarthritis admitted with acute onset R face, arm and leg weakness secondary to L basal ganglia hemorrhage. Overall strength has gradually improved since onset. The patient had a head CT at the OSH which showed the hemorrhage and he was transferred to [Hospital1 18]. He was admitted to the Neuro ICU The CT head repeated here shows stable size of hemorrhage 3cm.1.3cm.2.6cm. He is not on antiplatelet or anticoagulant medications, but does take NSAIDs for arthritis. Platelet number is normal here. Blood pressures have been ~SBP160s/100s. His bleed was in a typical location for a hypertensive bleed. He did not report that he had a history of HTN, however on taking to his PCP his pressures over the last few years have ranged in the 140s/90, and his last measurement was in [12-14] with a measurement of 170/100. To rule out other possible etiologies the patient had an MRI/A of the brain which showed Left basal ganglia hemorrhage with surrounding edema as stable in size and appearance since CT scan on [2162-6-20]. There was no underlying mass or vascular malformation identified. MRA was normal The patient spent the evening in the ICU. His right sided weakness improved, and he was primarily left with some difficulty with rapid alternating movements and coordination in his right hand and foot. He was restarted on his home medication and started on HCTZ for blood pressure. The patient was awake and alert the entire time and did not suffer a headache. He was transferred to the floor on [2162-5-22]. While on the floor, SBP remained elevated. HCTZ was discontinued and pt. was started on lisinopril 10mg daily. BP improved on day of discharge and K and Cr were wnl. Given ICH, ibuprofen was discontinued. ASA 81 mg was not started for primary cardiac prevention, however if felt it would be appropriate, could be started at 1 month after discharge. The above findings were communicated to patient's PCP. Medications on Admission: Flomax 1 tab po qday Alloporinol 300mg po qday (not sure of dose) ibuprofen 600mg po qday for arthritis pain Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Left basal ganglia hemorrhage, likely hypertensive in origin. Discharge Condition: Neurological exam at time of discharge notable for: MS: Impaired FAS and Luria sequence. Impaired recall at 5 minutes ([3-10]) items. CNs: intact Motor: bilateral FE 4+/5 weakness. Sensory: intact. Gait: Mild extension of RLE and abduction but overall normal stride and armswing. Discharge Instructions: You were admitted to [Hospital1 18] with right sided weakness. You were found to have a bleed on the left side of your brain. This was felt to be due to your persistently elevated blood pressure. You underwent an MRI of your brain that did not reveal an underlying mass or another reaason for your bleed. Your weakness and incoordination improved thoughout the hospital stay. The following changes were made to your medications: - Started on Lisinopril 10mg daily (you will need to follow up with your PCP regarding blood pressures and checking your kidney function and your potassium). - Your Ibuprofen was stopped. - ASA 81 mg can be started in 1 month if it is deemed of benefit for primary CAD prevention in this patient. You were discharged home. Followup Instructions: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] within 10 days of discharge. Please call [Telephone/Fax (1) 51033] to set up your appointment that is most convenient for you. NEUROLOGY: [Hospital1 18], [Hospital Ward Name 23] building. Provider: [Known firstname ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2162-7-23] 1:30 Completed by:[2162-6-29]	[ "4019" ]
Admission Date: [2141-7-14] Discharge Date: [2141-7-20] Date of Birth: [2066-10-6] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: 74 years old female admitted, underwent right lobe liver resection for metastic breast cancer. Major Surgical or Invasive Procedure: 74 years old female admitted, underwent right lobe liver resection for metastic breast cancer. History of Present Illness: Ms. [Known lastname 27935] is a 74-year-old female with a history of breast cancer approximately 20 years ago who presents with a large right-sided hepatic tumor. The preoperative biopsy and immunostaining have characterized this as consistent with a breast primary. She underwent a CT abdomen/chest, bone scan, and CT pet, which did not demonstrate any extrahepatic disease. The plan is to proceed with right hepatic lobectomy this coming Friday. Past Medical History: Her past medical history is significant for coronary artery disease. She had a CABG performed in [2134]. She had a breast cancer in the past, hypertension, and osteoporosis. She has noted previously a CABG, a right breast excision, right mass excision in the breast, and left lumpectomy with radiation therapy and chemotherapy in [2119] for a stage III breast cancer. Social History: Pt lives alone in [Hospital3 ]. Family History: non-contributory Physical Exam: AVSS NAD, comfortable alert, follows commands neck supple PERRLA EOMI CTA bilaterlly RRR no MRG nl s1 s2 soft, incision c/d/i, JP intact no c/c/e pulses 2+ Pertinent Results: CBC: [2141-7-14] 03:19PM BLOOD WBC-11.1* RBC-3.79* Hgb-11.6* Hct-34.5* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.3 Plt Ct-188 [2141-7-19] 06:20AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.0* Hct-28.0* MCV-91 MCH-29.3 MCHC-32.2 RDW-13.6 Plt Ct-264 P7: [2141-7-14] 03:19PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-141 K-4.0 Cl-112* HCO3-21* AnGap-12 [2141-7-19] 06:00PM BLOOD K-3.5 COAGS: [2141-7-14] 03:19PM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1 LFT's: [2141-7-14] 03:19PM BLOOD ALT-317* AST-333* AlkPhos-48 TotBili-0.5 [2141-7-19] 06:20AM BLOOD ALT-234* AST-100* AlkPhos-96 TotBili-0.8 SPECIMEN SUBMITTED: FNA LIVER CORE BX. Procedure date Tissue received Report Date Diagnosed by [2141-5-23] [2141-5-23] [2141-5-26] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 18795]/cwg Liver, core needle biopsy: Adenocarcinoma; see note. Note: Immunohistochemistry stains are positive for estrogen receptor and cytokeratin CK-7, and negative for cytokeratin CK20. GCDFP shows no definite specific staining. This immunophenotype is most consistent with metastatic breast carcinoma in the appropriate clinical setting. Clinical correlation is suggested. Trichrome stain confirms the presence of fibrosis surrounding foci of cancer. Iron stain is non-contributory. Path [2141-7-14]: pending @ discharge - preliminary read - metastatic CA, negative margins. Brief Hospital Course: This is a 74 yo Female admitted to [Hospital1 18] s/p R hepatic lobectomy for metastatic lobectomy on [2141-7-14]. Operation was uncomplicated with EBL=600. She received 1unit PRBC and 4 L crystalloid. Pt was extubated in stable condition to the PACU awake and alert on POD#0. Pain was well controlled on morphine PCA. Epidural was d/c'd [12-28] hypotension and Pt was transfered to the SICU. On POD#1 pt was comfortable with pain well controlled, lungs were clear, and pt tolerated sips of clears. Her NGT was d/c'd and she was transferred to the floor. On POD#2 her JP continued to have serosanguinous drainage. On POD#3 pt was ambulatory with PT and continued to do well. She had poor strength and mobility anticipated rehab placement versus home with PT services. By POD#5, Pt passed flatus but had still not moved her bowel. Her PCA and Foley were d/c'd and her diet was advanced to a regular diet. On POD#6 pt was ambulatory, comfortable, tolerated a regular diet, and discharged to rehab. Medications on Admission: Evista NF 60 mg Oral daily Atorvastatin 20 mg PO DAILY Atenolol Discharge Medications: Oxycodone-Acetaminophen [11-27] TAB PO Q4-6H:PRN Evista NF 60 mg Oral daily Atorvastatin 20 mg PO DAILY Atenolol 25 PO Daily Discharge Disposition: Extended Care Facility: [Hospital 24806] Care Center - [Hospital1 1562] Discharge Diagnosis: Metastatic Breast CA Discharge Condition: Stable Discharge Instructions: Please [Name8 (MD) 138] M.D. for Temp>101.5, breakdown of abdominal wound, redness or increased pain at incision site, or change in symptoms. No heavy lifting, no driving while on narcotics. Followup Instructions: Follow-up w/ Dr. [First Name (STitle) ] in [11-27] weeks in [Hospital Ward Name ] 7. Please call [Hospital 18] [Hospital 1326] clinic to schedule. Completed by:[2141-7-19]	[ "4240", "V4581", "4019", "2720" ]
Admission Date: [2196-5-4] Discharge Date: [2196-5-13] Date of Birth: [2143-5-24] Sex: M Service: MEDICINE Allergies: Compazine / Methotrexate / Ceftazidime Attending:[First Name3 (LF) 21731] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Transesophageal [First Name3 (LF) ] History of Present Illness: Mr. [Known lastname ] is a 52yo M with Crohn's disease s/p multiple surgeries with resultant short gut syndrome and TPN dependency who was recently admitted to [Hospital1 18] for evaluation of low grade fevers. The pt has a history of multiple line infections, MV endocarditis and osteomyelitis for which the pt is on chronic vancomycin. The pt initially presented to the ED on [2196-4-21] at which time he was started empirically on levofloxacin and sent home. Fevers continued at home and the pt was subsequently admitted to [Hospital1 18] on [2196-4-26] with Tmax of 102 in the ED. Of note, the pt also had elevated LFT but with normal US and normal ERCP. The pt was placed on unasyn with gradual reduction in fever curve. At the time, an extensive workup was performed, however the pt was discharged with continuing low grade fevers. The pt was discharged on [2196-4-29] with continuing low grade temperatures. Since his discharge from [Hospital1 18], the pt reports continual low grade fevers. The pt has a 24hour RN service who had recorded a Tmax of 102 this AM as well as sx of disorientation. The pt admits to fevers as above but denies any chills, rigors, night sweats, chest pain, palpitations, abd pain, n/v, head ache, photophobia, neck stiffness. The pt admits to chronic diarrhea secondary to his short gut syndrome but there has not been any change in his stool frequency or characteristic. The pt does report orthopnea and some LE edema which has been ongoing for over one year. The pt does report some mild weight gain over the course of the last couple of months but no change in his appetite. The pt denies any heat or cold intolerance, or flushing. In the ED, the blood cultures were drawn, UA and urine cultures were sent and a CXR was performed. LFT and ESR was added on. A TTE and CT scan of the chest, abd and pelvis was also performed. Past Medical History: 1. Crohn's disease s/p multiple surgeries with resultant ileostomy and shortgut syndrome dependent on TPN with chronic hypocalcemia, vitamin D deficiency. 2. [Hospital1 ]: Staph epidermidis C4-C5 Osteomyelitis (On Chronic Vancomycin), Endocarditis with Mitral Valve [Hospital1 ], [Hospital1 ] Polymicrobial Line Sepsis, Previous RLL PNA, LE Cellulits 3. Respiratory - COPD (Baseline PaCO2 of 48), H/O ARDS with Intubations/Tracheostomy ([2192] and [2193]). 4. Severe MR 5. CKD (Baseline Cr 1.3 to 1.4) 6. Anemia of Chronic Inflammation (on EPO) 7. Mild Dementia 8. Chronic Pain (Fentanyl 50 mcg Patch) 9. Restless Leg Syndrome 10. Steroid-Induced Osteoporosis 11. Multiple Spinal Compression Fx 12. Peripheral Neuropathy 13. UGIB/Duodenal Ulcer ([2193]) 14. Depression 15. Bilateral SVC Thrombi. Social History: Lives alone; 24[Hospital 8018] nursing care with multiple nurses; fully intact ADLs; ambulates without assistance; never married; has no children; has worked many odd jobs; he has five brothers and one sister that are very supportive. His three brothers, [Name (NI) ], [Name (NI) ], and [First Name8 (NamePattern2) ] [Name (NI) ], are all his health care proxies. He smokes one to one and a half packs per day; has a 60-pack-year history of smoking. He reports minimal alcohol use and previous use of marijuana but denies any IVDU. Pt does admit to previous blood transfusions, he has never exchanged sex for money and he does not remember if he has ever had an HIV test. Full code. Family History: F: Crohn's disease M: TIA in her 70s GF: DM Physical Exam: GEN: middle aged caucasian male wearing baseball cap and lying on stretcher. Pt appears comfortable in NAD. Pt conversing fluently in full sentences. No accessory muscle use. Skin: warm to touch, slight jaundice, no obvious rashes or lesions. HEENT: EOMI, slightly icterics, mmm, op clear Neck: full rom, difficult to assess suppleness due to some guarding by pt. CV: [1-24] holosystolic murmur heard best over the LLSB without radiation. Chest: clear to auscultation bilaterally, line site on left chest appears to be clean and intact without signs of erythema, induration, tenderness, or discharge. Abd: soft, NT, ND, ostomy bag full of greenish-brown stool and air in the bag. stoma is pink and moist. BS+ Ext: wwp, trace to +1 pitting edema bilaterally, PT +1 bilaterally Brief Hospital Course: A/P: 52yo M with Crohn's disease s'p multiple surgeries complicated by shortgut syndrome and dependency on TPN with hx of multiple line infections, endocarditis and osteomyelitis. . 1. Fever: Initially felt to be septic with SBP in 90's. Cultures were initially negative, clear CXR, fungal cx negative. TEE was performed which showed reappearance of MV [Month/Day (4) ] and worsening MR. [Name13 (STitle) ] was started on daptomycin, ambisome. Then found to have fungal elements on blood smear, and then had a fungal culture consistent with malassezia furfur. In addition gram + cocci seen on the same blood smear and Staph epi grew out of 1 culture. Further identification is pending to determine if it is a contaminant of the same organism that was present in his osteomyelitis.Initially had wanted to have his Hickman pulled, but per IR this would be a very difficult and involved procedure and they prefer to treat through the line if possible. After ID conference discussion plan is to treat with ambisome 3mg/kg IV daily for 6 weeks, daptomycin 400 mg IV daily for 10 more days, then transisiton to vancomycin 1g IV qod ongoing. He will need to have f/u fungal cx with lipid supplemented media after 6 weeks to document clearance. A). Cards: The pt has a history of endocarditis for which he has previously undergone medical treatment. Given the dependency on TPN, the pt is at significant risk for possible endocarditis, especially with fungal organisms. TEE showed slightly worsened MR [First Name (Titles) ] [Last Name (Titles) 16169] MV [Last Name (Titles) ]. Will plan 6 weeks ambisome with f/u cx. Daptomycin 400 mg IV daily for 10 more days, then vancomycin 1g IV qod. Had initially been diuresed for CHF, now euvolemic. . B). Pulm: The fever is unlikely to be due to a pulmonary source given his lack of focal signs or symptoms including lack of cough, sputum. Initialy appeared in CHF after transfer out of [Hospital Unit Name 153]. Diuresed well, now euvolemic. . C). GI/Liver: Patient's Crohn's disease appears to be stable, without evidence of a hepatobiliary source by LFTs. No abdominal pain, and able to take some pos. . D). Musculoskeletal: The pt has a known history of osteomyelitis for which he is on chronic treatment with vancomycin QOD (which is an unusual dose given his creatine clearance would suggest a once daily to [Hospital1 ] dosing). No neck or back pain. . E). Lines: As stated above, the pt has an existing Hickman catheter for his TPN and history of multiple line infections. Will hold off on pulling Hickman at this time and will need to be pulled if fungal BCx comes back positive after 6 weeks. . 4. Renal: The pt has a history of CKD with creatinine baseline in 1.2 range, now elevated at 1.8, looks dry on exam, giving IVF now, will recheck chem 10 tomorrow, K elevated at 5.9 [5-13], giving IVF and recheck today. Will need to have potassium free TPN on discharge and repeat chem 10 [5-14]. . 5. FEN: low salt diet, replete electrolyts with cautions. . 6. PPx: heparin sub Q TID for DVT prophylaxis, protonix for GI ppx. Pt does not need bowel regimen given his chronic diarrhea. . 7. Code status: full code Medications on Admission: MEDICATIONS: 1. Niferex 150mg [Hospital1 ] 2. Protonix 40mg once daily 3. Imodium 4mg Q6hours 4. Vitamin C 500mg once daily 5. Tums 1250mg 5x/day 6. Rocaltrol 0.25mg once daily 7. Vitamin D 50,000u Qweek 8. Zestril 20mg once daily 9. Vancomycin 1gm IV Q48hours 10. Unasyn 3g IV Q8hours 11. Tylenol 12. Risperdal 0.25mg [Hospital1 ] 13. Norvasc 2.5mg once daily 14. Zofran 4mg IV Q8hours PRN N/V 15. Erythropoietin 10,000SQ weekly 16. Glutamine 10 g powder 3x/day 17. Sandostain LAR depot30mg IM Qmonthly 18. Ativan 1mg QHS PRN 19. Ambien 5-10mg QHS PRN . ALLERGIES: NKDA Discharge Medications: 1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO 5X/D (5 times a day). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Glutamine 10 g Packet Sig: One (1) Packet PO TID (3 times a day). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 9. Opium 10 % Tincture Sig: 0.6 ML PO QID (4 times a day). 10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 11. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 12. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 13. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale sliding scale Injection ASDIR (AS DIRECTED). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 10 days. Disp:qs 10 days Refills:0 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 17. Amphotericin B Liposome 50 mg Suspension for Reconstitution Sig: Two Hundred (200) mg Intravenous Q24H (every 24 hours) for 6 weeks: Will need mycolytic blood cultures with oil supplemented media after completion. Disp:qs 6 weeks Refills:0 18. Vancomycin 1,000 mg Recon Soln Sig: 1,000 mg Intravenous every other day: Please start on [2196-5-23] (day after finishes daptomycin course). Disp:qs 1 month Refills:3 Discharge Disposition: Home Discharge Diagnosis: Fungemia with Malassezia furfur Bacterial/fungal endocarditis Mitral valve regurgitation Crohn's disease Short gut syndrome osteoporosis Dependence on TPN Discharge Condition: stable Discharge Instructions: Please continue your regular medications. In addition please continue ambisome 200 mg IV daily for next 6 weeks. Please continue taking daptomycin for next 10 days then will change to vancomycin 1g IV every other day ongoing. You will need to have your creatinine checked every week and faxed to Dr. [Last Name (STitle) 22874] at [Telephone/Fax (1) 1419]. After 6 weeks of therapy with ambisome you will need mycolytic blood cultures with oil supplemented media to make sure you have cleared your fungal infection. Please continue to perform an amphotericin lock of your Hickman catheter daily when not recieving medications or TPN (3cc of 1mg/ml amphotericin B to lock your Hickman catheter). Followup Instructions: 1. Please have your Chem 7 checked [2196-5-14], as your K had been elevated [5-13]. Please also have weekly Chem 10 drawn and faxed to Dr. [Last Name (STitle) 22874]. 1. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2196-6-2] 11:00 2. Please follow up with Dr. [Last Name (STitle) 5717] in [11-22] weeks. 3. Please also follow up with Dr. [Last Name (STitle) 79] in [12-25] weeks.	[ "4280", "5849", "496", "99592", "2859" ]
Admission Date: [2160-11-13] Discharge Date: [2160-11-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [Known lastname 22656] is an 85 year-old man with a history of hypertension and coronary artery disease who presented with angina, now being transferred to the CCU after bieng found to have left main coronary artery disease. Six months prior to admission, began experiencing "palpatations", described as chest pressure over the left nipple. It would occur in the morning and occasionally throughout the day and would be worsened by his morning weight lifting. Each episode would last ~5-10 minutes. They were not associated with SOB, diapheresis or nausea. He contact[Name (NI) ] his PCP he referred him to a cardiologist (Dr. [Last Name (STitle) ]. A stress MIBI was performed and reportedly positive per the patient though we do not have the report. He was then prescribed SL nitro which he took twice daily, with or without symptoms though he does believe that taking it with symptoms did help. Four months ago he underwent cataract surgery, at which time he stopped aspirin. The surgery was uneventful. Three months prio to admission, the angina resolved and he ran out of nitro. Two weeks prior to admission he stopped aspirin in preparation for spinal stenosis surgery. Five days prior to admission, he again began to experience palpatations. He was in [State 108] for his surgery and, upon describing his symptoms to the anesthiologist, was cancelled. He flew back to [Location (un) 86] on [11-13] and called his PCP who referred him to the ED for further evaluation. In the ED VSS, EKG showed old LBBB per his PCP. [Name10 (NameIs) ] CP resolved with SL NTG x1. He was given ASA 325mg and started on a heparin gtt. Overnight, he was continued on nitro and heparin gtts and had stuttering chest pain. On the morning of transfer he was loaded with Plavix 600mg and sent for cardiac cath where he was found to have a 80% ulcerated left main lesion. ROS (-) PND/orthopnea (+) Edema, chronic (-) Fevers/chills/weight change (+) Sinus congestion with Flomax (-) Cough (+) Occasional heart burn (+) Constipation (BM every 2-3 days) (-) Nausea/vomiting/diarrhea (-) Bloody stools (+) "Black stools" (+) Chronic leg pain, anteriorly, though secondary to spinal stenosis Negative colonoscopy in [2155], per patient PSA normal, per patient Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes (-) Dyslipidemia (+) Hypertension 2. CARDIAC HISTORY: -CABG: None. -PCI: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Old LBBB (old per PCP) - History of paroxysmal atrial fibrillation (patient denies) - BPH - Spinal Stenosis - Cataracts, s/p surgery - History of nephrolithiasis - History of bilateral hip fracture, s/p repair (right in [10-3]; left in [12-4]) Social History: Orginially from [Country 2784]. Retured from teaching mechanical engineering at [University/College ]. Quit smoking 45 years ago, rare EtOH, no drugs. Married. Family History: (+) HTN, (+) CAD. Physical Exam: VS: Afebrile, 127/55, 56, 12, 95% on room air GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and left faintly reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at LUSB LUNGS: Anteriorly clear. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches; skin intact. SKIN: No rashes. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Laboratory values: [2160-11-13] 06:05PM BLOOD WBC-6.2 RBC-4.64 Hgb-13.8* Hct-39.2* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.2 Plt Ct-142* [2160-11-16] 04:09AM BLOOD WBC-6.3 RBC-4.13* Hgb-12.5* Hct-35.4* MCV-86 MCH-30.4 MCHC-35.4* RDW-14.2 Plt Ct-144* [2160-11-13] 06:05PM BLOOD PT-13.0 PTT-30.5 INR(PT)-1.1 [2160-11-16] 07:59AM BLOOD PT-12.8 PTT-50.3* INR(PT)-1.1 [2160-11-16] 07:59AM BLOOD FDP-0-10 [2160-11-16] 07:59AM BLOOD Fibrino-344 D-Dimer-As of [10-28] [2160-11-15] 11:12AM BLOOD ESR-10 [2160-11-13] 06:05PM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 [2160-11-16] 04:09AM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-140 K-4.2 Cl-107 HCO3-26 AnGap-11 [2160-11-14] 04:00PM BLOOD ALT-11 AST-15 CK(CPK)-51 AlkPhos-60 Amylase-38 TotBili-0.9 [2160-11-13] 06:05PM BLOOD CK(CPK)-71 [2160-11-14] 02:39AM BLOOD CK(CPK)-57 [2160-11-14] 10:33AM BLOOD CK(CPK)-50 [2160-11-13] 06:05PM BLOOD cTropnT-0.02* [2160-11-14] 02:39AM BLOOD CK-MB-NotDone cTropnT-0.03* [2160-11-14] 10:33AM BLOOD CK-MB-NotDone cTropnT-0.03* [2160-11-14] 04:00PM BLOOD cTropnT-0.03* [2160-11-15] 02:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 [2160-11-16] 07:59AM BLOOD D-Dimer-476 [2160-11-14] 04:00PM BLOOD VitB12-277 [2160-11-15] 11:12AM BLOOD Triglyc-44 HDL-60 CHOL/HD-3.0 LDLcalc-109 [2160-11-15] 11:12AM BLOOD CRP-15.3* [2160-11-14] 10:11PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.050* [2160-11-14] 10:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Imaging/Studies: CXR - 1.2 cm nodular opacity in the left upper lung zone, concerning for lung mass. Followup imaging is recommended. ECG - Sinus rhythm with a first degree A-V block. Old left bundle-branch block. ECHO - The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%), mostly secondary to left bundle branch block-related septal motion. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Symmetric LVH with borderline global systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. CT head w/o - IMPRESSION: Loss of [Doctor Last Name 352]-white matter differentiation in the medial right frontal lobe, MR [First Name (Titles) 151] [Last Name (Titles) 4639]n-weighted imaging is recommended to rule out acute infarction. MRI/A head: IMPRESSION: 1. Acute right anterior cerebral artery territorial infarct. 2. Tiny small areas of slow diffusion in the right parietal, right medial occipital, left parietal and the left frontal regions indicate multiple small infarcts, which could be embolic in nature. MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head. Brief Hospital Course: 85M presenting with chest pain admitted initially to cardiology service. Patient continued to have chest pain and underwent emergent catheterization and found to have left main disease. He was transferred to the CCU to await CABG, but had a R ACA stroke and CBAG was deferred. He was discharged to rehab in stable condition. # Coronary Artery Disease: Initially presented with concern for unstable angina; ruled out by cardiac enzymes; ECG was difficult to interpret in setting of LBBB. Medically managed overnight with heparin gtt, nitro gtt, ASA, BB, statin. Caridac cath on [11-14] showed LMCA ulcerated lesion of 70% and tortuous aorta. Given LMCA lesion and its nature, patient was transferred to CCU for further observation prior to possible CABG. He was continued on ASA, heparin gtt and metoprolol and high dose statin. Nitro gtt was started to maintain patient symptom free and maintain BP <120. ASA was decreased to 81 mg QD. Patient was also started on Integrillin drip on [11-15] which was discontinued on [11-16], given no further catheterization. Metoprolol was started low dose, and he is charged on 25mg toprol daily. ACEI held for now. Can start amlodipine 5mg if neeeded at rehab. # CVA: On [11-15] patient was noted to have LLE paresis and LUE weakness, urinary incontinence on routine vitals check. VS were stable. Given that these findings were new, neurology consultation was immediately obtained. Last normal exam was 3 hrs prior to observation of symptoms. Heparin was temporarily stopped given concern for intracranial hemorrhage (ICH). CT head confirmed no ICH and heparin gtt was restarted. Given unclear timing of the event, tPA was not administered. MRI of head showed acute infarct in the Right ACA territory consistent w/ exam. Given relatively small size of infarction and being outside of 5hr window, pt did not undergo MERCI retrieval. By [11-16], patient's exam markedly improved w/ [3-1] distal and 4+/5 proximal LLE. At time of discharge pt's exam was [3-1] upper and lower extremity strength. Per Neurology recommendations patient was started on coumadin for total duration of at least 3mo. Patient discharged on Lovenox as bridge to therapeutic INR on coumadin. Patient discharged to rehab and has neurology follow up in 3 months. . # Acute on Chronic Diastolic Heart Failure: On admission, patient had 2+ lower extremity edema dn elevated JVP to 10cm, no prior history of heart failure. Echo showed symmetric LVH with borderline global systolic function, EF 50-55%, likely secondary to LBBB. Mild mitral regurgitation and mild pulmonary hypertension were also noted. Given CVA, no lasix was admininistered to maintain pressures > 120 systolic. ACE-I was also held due to concern for hypotension, and betablocker dose dose was decreased temporarily while hypotetnsive, but was titrated back up to 12.5 mg [Hospital1 ]. Patient was provided with [Male First Name (un) ] stockings. . # Sinus bradycardia: Bradycarid to the 50's throughout admission. Patient has reported history of PAF but patient denies this. Patient remained in sinus rhythm throughout hospitalization. Given history of Atrial fibrillation, patient will require 2wk monitoring of HR to assess for duration of anticoagulation. If goes into atrial fibrillation, will likely need life-long anticoagulation, to be determined by out patient cardiologist. . # Acute Anemia: Patient was found to have Hct decreased from 39 to 34 post cath. No active sources of bleeding were identified, however pt had one guiac positive stool on [11-17]. HCT improved to 35 by [11-16] and remained stable for the remainder of hospitalization. . # Spinal Stenosis: Surgery was delayed until cardiac disease issues were resolved. Patient was treated w/ oxycodone/acetaminphen and IV morphine prn for pain control. . # Hypertension: Patient was hypertensive on admission. He was continued on home regimen of norvasc, quinopril and motoprolol prior to catheterization w/ SBPs in 140-150 range. ACE-I and CBB were held in setting of relative hypotension. amlodipine can be restarted as needed. . # Lung Nodule: Noted on CXR as incidental finding, no priors for comparison. Patient will require CT as outpatient for further evaluation. . # Right Buttock Prior Decub Ulcer Site: Patient reports this is site of prior decub which occured during hip fracture surgery. Per his report, was difficult to heal. On exam, a well healed, erythematous area was noted. Skin care w/ frequent repositioning and dry dressings was performed. . # Propylaxis: DVT - lovenox 90mg sq [Hospital1 ] transitioned to warfarin. Continue lovenox until therapeurtic INR ([12-30]) for 2 days. Protonix 40mg PO daily while in ICU, discontinued on discharge. . # Code: FULL CODE Medications on Admission: Norvasc 10mg daily flomax quinapril 20mg daily Aspirin 81mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose adjust for goal INR [12-30]. x 3 months (until [2160-2-9]). 8. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours): 90 mg sq [Hospital1 ]. Continue until therapeutic on coumadin (INR [12-30]) for 2 days. 9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnoses: Unstable Angina Left Main Coronary Artery Disease Right Anterior Cerebral Artery Stroke Secondary Diagnoses: Left Bundle Branch Block Hypertension Spinal Stenosis Possible history of Atrial Fibrillation BPH Discharge Condition: Good, vitals stable. Discharge Instructions: You were admitted with chest pain and you had a cardiac catheterization which showed a blockage the main left artery of the heart which cannot be fixed with a stent. The cardiac surgeons saw you and determined that you would be a candidate for bypass surgery. Unfortunately, you had a small stroke as a complication of the catheterization. Because of this, you will need to go to rehab to regain your strength before considering heart surgery. Several medications were adjusted: - Atorvastatin 80mg daily should be taken every day - Toprol 25mg daily - You were started on Coumadin for your stroke, this is a blood thinner that prevents clots from forming. Lovenox will be administered until the coumadin levels are therapeutic - Quinipril has been held. If you have chest pain, shortness of breath, high fever, pain at your groin, severe abdominal pain, dizziness or lightheadedness or any other concerning symptom, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: CARDIOLOGY: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2160-12-5] at 10:30AM NEUROLOGY: Dr. [First Name (STitle) ] [Name (STitle) ] Phone:[Telephone/Fax (1) 2574] [2161-2-17] at 2:00pm CARDIAC SURGERY: Dr. [Last Name (STitle) 81943] [Name (STitle) ] ([Telephone/Fax (1) 6876] on [12-18] (thursday) at 1:30 [Initials (NamePattern4) ] [Hospital Unit Name ], [Location (un) ], suite A at [Hospital1 18] on the [Hospital Ward Name ]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "41401", "4019", "2875", "4280", "42789" ]
Admission Date: [2124-8-18] Discharge Date: [2124-8-29] Date of Birth: [2045-2-15] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9554] Chief Complaint: transferred for preoperative evaluation and management of MSSA endocarditis complicated by aortic root abscess. Major Surgical or Invasive Procedure: 1) cardiac catheterization [2124-8-18] 2) temporary pacemaker implantation [2124-8-18] 3) electrophysiology study [2124-8-24] 4) PICC placement History of Present Illness: 79 yo male with bioprosthetic AVR in [2116], CAD s/p CABG x2 in the past(cath [2124-8-18] all three grafts are patent), bifascicular block, recent redo total L hip who was transferred to [Hospital1 18] on [2124-8-18] from OSH where he was admitted [8-7] with acute MSSA endocarditis. The patient was intially admitted to [Hospital 4068] hospital on [8-7] s/p fall at home with sepsis, MS changes and hypotension SBP in 70's, CVP 5. He was diagnosed with LLL PNA which was initially thought to be the source of his infection and was given Ceftriaxone/Vanc and IV hydration with response (no pressors). Blood cx then grew MSSA and Abx were changed to Oxacillin on HD #2. Pt continued to be febrile and on HD #4 Gentamycin/Rifampin were added. (Initial TEE [8-9] showed no vegetations, repeat TEE [8-17] was positive for AVR vegetations with valve ring abscess). His outside hospital course was complicated by 1) enzyme leak without ECG changes for which he was started on [Last Name (LF) ], [First Name3 (LF) ], heparin 2) anemia (guaiac +) for which patient received trnasfusions 3) plt drop 145 -->95-->72 over two days - heparin products were held, HIT Ab later came back negative, and he was restarted on SQ heparin without problems 4) PR prolongation HD #8 The patient was seen by orthopedic consultants and his L hip was aspirated but culture was negative for infection. Past Medical History: 1. CAD s/p CABG [2096], [2109] 2. bioprosthetic AVR [2116] 3. Bilateral carotid EA; left in [2106] 4. CRI baseline Cr 1.3 5. prostate cancer diagnosed [3-31] [Doctor Last Name ] 3 and 3 6. MDS (dx [11/2118]) 7. DJD 8. bilat THR; left THR revision [2124-6-30] 9. chronic LE ulcers 10. s/p appy 11. s/p chole 12. s/p enzyme leak likely demand ischemia on [2124-8-8]-peak trop of 5.2. Family History: Non contributory Physical Exam: At the time of presentation to the CCU General: lethargic, tired-looking, oriented to self and year only, does not always answer questions appropriately HEENT: NC, AT, sclera white, conjunctiva pink, EOM intact, PERRLA, MM moist without lesions Neck: JVD at about 10 cm Pulm: CTA bilaterally CV: regular, 2/6 SEM best heard at the apex and along LSB Abd: +BS, soft, NT, ND Extr: no c/c/e, bilateral calcaneal eschars R>L R groin; no bruit, no ecchymosis, no hematoma Hands: no splinter hemorrhages, no [Last Name (un) 1003] lesions, no Osler nodes. Pertinent Results: [2124-8-18] 08:21PM WBC-9.8 RBC-3.21* HGB-10.0* HCT-30.9* MCV-96 MCH-31.1 MCHC-32.2 RDW-15.3 [2124-8-18] 08:21PM PLT COUNT-261 [2124-8-18] 08:21PM PT-15.4* PTT-28.1 INR(PT)-1.5 [2124-8-18] 08:21PM FIBRINOGE-684* [2124-8-18] 08:21PM TSH-1.8 [2124-8-18] 08:21PM HAPTOGLOB-132 [2124-8-18] 08:21PM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-247 ALK PHOS-79 TOT BILI-0.3 [2124-8-18] 08:21PM ALBUMIN-2.3* CALCIUM-6.7* PHOSPHATE-11.5* MAGNESIUM-1.6 [2124-8-22] 04:01PM BLOOD CRP-15.52* [2124-8-22] 04:01PM BLOOD ESR-82* [2124-8-21] 08:06PM BLOOD VitB12-332 [2124-8-20] 04:59AM BLOOD LD(LDH)-615* TotBili-0.6 DirBili-0.1 IndBili-0.5 [2124-8-23] 03:22AM BLOOD ALT-7 AST-15 LD(LDH)-253* AlkPhos-82 TotBili-0.3 [2124-8-25] 04:33AM BLOOD ALT-12 AST-25 AlkPhos-88 TotBili-0.3 [2124-8-26] 05:54AM BLOOD Glucose-99 UreaN-26* Creat-2.2* Na-139 K-3.6 Cl-107 HCO3-21* [2124-8-26] 05:54AM BLOOD PT-16.2* PTT-38.0* INR(PT)-1.7 [2124-8-20] 04:59AM BLOOD Ret Man-1.1 [2124-8-18] 08:21PM BLOOD HEPARIN DEPENDENT ANTIBODIES-negative R knee joint fluid [8-22]: no crystals, moderately bloody, WBC 211, RBC [Numeric Identifier 47330], Poly 63%, Lymphs 19%, Mono 18%. Microbiology: Blood cultures 8/20 x1, and [8-20] x 2 - no growth (final) Blood cultures 8/23 x2, [8-23] x2 - no growth to date Stool for c diff x 2 - negative R knee joint fluid [8-22] - no growth (final) L heel eschar swab [8-22] - no growth L heel eschar swab [8-23] - rare growth coagulase negative Staph L heel foot culture [8-23] - rare growth coagulase negative Staph [8-18] CARDIAC CATHETERIZATION - right dominant, three vessel native coronary artery disease. (LMCA distal 50% lesion amid diffuse disease throughout the vessel. LAD 80% origin stenosis, totally occluded mid vessel; D2 branch 70% lesion. LCX was totally occluded proximally. RCA had a total occlusion mid vessel.) Resting hemodynamics revealed a mean PCW pressure of 7mmHg suggesting low normal filling pressures. CO was 3.9 l/min. Graft angiography revealed patent LIMA to LAD, SVG to OM, and SVG to RPDA. The three vein grafts from the patients prior CABG in [2091] were stump occluded. [8-19] CT head - negative for intracranial process 8/22 L hip and R knee films - moderate effusion of R knee. Bilateral heel films - no osteomyelitis. [8-21] TEE - Mild global depression of the left ventricular systolic function (LVEF 45%). Moderate sized mobile echogenic structure most consistent with a vegetation (1.6 x 1.3 cm) attatched to the base of the anterior mitral valve leaftet/junction of the mitral and aortic annulus. Thickened mitral valve leaflets with moderate mitral regurgitation. There is an aortic root abscess. The aortic bioprosthesis appears well seated with mild to moderate aortic insufficiency. [8-22] CT bilateral LE - Soft tissue abnormality in each heel extending down to the calcaneal cortical surface; osteomyelitis cannot be excluded. [8-22] CT abdomen/pelvis - Negative for emboli; bilateral pleural effusions (L>R), intra-abdominal soft tissue stranding; calculus in lower pole of right kidney; 4 cm simple renal cyst in right kidney. [8-24] Bone scan - Osteomyelitis of the posterior aspect of the left calcaneus. Activity in L hip c/w post-surgical changes, but an infectious process cannot be ruled out. Tracer activity in the shoulders, knees, feet, lumbar spine c/w degenerative changes. [8-25] Renal US - No eidence of renal mass or hydronephrosis. 2 mm non-obstructing stone in the lower pole of the right kidney. Brief Hospital Course: 1. MSSA endocarditis s/p bioprosthetic AV - The patient was admitted to the CCU service. Infectious disease was consulted and has followed the patient throughout his stay. The patient was continued on Oxacillin, Rifampin and renally dosed Gentamycin. Gentamycin was stopped one day early 08/25 per ID recommendations (expected end of therapy [8-24]) because of worsening renal function. Oxacillin/Rifampin were continued with the plan to complete a 6wk course (expected end [9-20]) until the patient and family decided to change his code status to CMO. The antibiotics were stopped the day of transfer to hospice. The patient initially continued to spike fevers but has been afebrile since [2124-8-21]. His WBC also has remained within normal limits. Blood cultures from the OSH collected [8-11] and [8-16] had no growth. Blood cultures 8/20 and [8-20] final results were also negative. Blood cultures 8/23 and [8-23] show no growth to date. LFTs were monitored in this paitent on Oxacillin and were WNL. CT surgery was consulted regarding valve replacement because it was felt that given aortic root abscess and conduction abmormalities the patient may benefit from early surgical intervention. CT surgery was reluctant to operate because of concern that the patient may have another site of active infection separate from his cardiac abscess. This prompted extensive work up to r/o another site of infection. Dental service was consulted to evaluate the patient prior to surgery and they recommended extracting 2 molars prior to surgery. On [8-27] per family's request, the patient's status was changed to "comfort measures only". 2. CAD - 3VD s/p CABGx2 s/p enzyme leak on [8-7] CK peak 582, MB peak 5.2, index only 1.0, TropI peak 5.3 likely due to demand ischemia. The patient had cardiac catheterization performed on [2124-8-18] which revealed that all 3 venous grafts were patent. The patient was continued on [Date Range ], low dose beta-blocker, and lipitor. ACEI was not continued because of worsening Cr. The patent has been tachycardic with HR in 90-100 most of the time. This was attributed to infection and his tachycardia was not controlled for that reason. TSH was checked and was normal. 3. RBBB with bifascicular block, AV conduction delay secondary to aortic abscess. Temporary pacing wire was placed [2124-8-18]. The patient has been monitored on telemetry and has had no events during his stay. His EKGs were carefully monitored for PR or QT prolongation but have been stable. PR about 240-260 msec and QTc 450-480 msec. Mr. [Known lastname ] [Last Name (Titles) 1834] electrophysiology study on [8-24] which showed AVN and HIS disease, but given the dynamic nature of his problem in the context of abscess, the decision was made to re-evaluate the patient in 2 weeks and to leave temporary pacer wire in place for now. On [8-27] he and his family decided to change his code status to CMO and further w/u was discontinued. HIs pacer was turned off on [8-29] before he went to hospice. 4. HTN - The patient's blood pressures have been controlled with low dose beta-blocker. Procardia 10 mg po qd was added on [8-21] to help with afterload reduction/improve forward flow. 5. CHF - EF40%; The patient has been euvolemic through most of his hospital stay. The goal has been to keep i/o's even. He was given small amounts maintenance fluids at a slow rate on the days he was NPO for procedures. 6. MS changes/confusion - were thought to be likely due to infection. The patient has had waxing/[Doctor Last Name 688] mental status and was oriented only to self, year (occasionally to month and place). Psychiatry was consulted to r/o other causes of MS changes and to assist with medical management. They did not feel that the patient is depressed and recommended adding Haldol 2.5 mg IV bid to his regimen while monitoring QT prolongation. CT of head was negative on [8-19] and was also negative at the outside hospital. The patient was not given any sedating medications. His mental status continued to wax/wane but overall has improved throughout the hospital stay. On discharge he was given prescriptions for morphine, haldol, ativan and scopalamine. 7. Renal - The patient's creatinine slowly increased from Cr 1.3 to 2.5 on [8-27]. Renal consult was obtained on [2124-8-24]. It was felt that deteriorating renal function is secondary to Gentamycin toxicity and contrast that he received. The patient's antibiotics were renally redosed. They were dc'd on the day of dc to hospice. 8. Anemia - The patient received blood transfusions on [9-22], [8-25], [8-26] to keep Hct at goal >30 . Anemia was thought to be multifactorial due to CRI, blood loss during EP study, and possibly due to MDS. CT abd/pelvis done because of concern for thromboemboli did not show any retroperitoneal hemorrhage. 9. Thrombocytopenia at the outside hospital with Plt count 145->95->72 over 2 days (HIT Ab negative x 1 at OSH). Heparin products were initially held but heparin sc was restarted on [8-22] after HIT serology came back negative. The patient was not fully anticoagulated because he was >2 months after his hip surgery. 10. S/p left THR revision [2124-6-30] - Orthopedic surgery was consulted. Plain hip films were done and did not show obvious pathology. Of note, left hip was aspirated at the outside hospital and was negative. 11. R knee pain/effusion - R knee was tapped [2124-8-23] by Orthopedic surgery and fluid culture was negative results suggestive of non-inflammatory effusion. Rheumatology was consulted [2124-8-25] and they recommended Tylenol but this was not scheduled b/o concern that it would mask fevers. 12. Left calcaneal pressure ulcers was suspected to be a source of bacteremia. Podiatry consulted was consulted and ordered bilateral heel films. CT [8-22] showed no evidence of OM. The decision was made to proceed with bone scan which was done on [8-24] and showed finding c/w OM of left heel. The patient was discharged to hospice with instructions on dressing changes for his ulcers. 13. Nutrition - the patient has had poor po intake while in the hospital. ALB 2.3 He passed video swallowing evaluation [8-23]. His oral meds were dc'd per patient and family request on [8-28]. 14. Prophylaxis - Has been receiving prophylaxis with PPI, bowel regimen, pneumoboots. 15. On [8-27] after discussion with Dr. [Last Name (STitle) ], the family decided to change the patient's status to comfort measures only. Hospice consult was requested. A hospice was found and the patient was transferred on [8-29]. Medications on Admission: Outpatient medications: Zestril 40 qd, Lopressor 50 [Hospital1 ], Zocor 20 qd, Lopid 600 [Hospital1 ], [Hospital1 ] 325 qd, Coumadin 2 mg po qd, Valium prn Transfer medications: Folate, MVi, Zocor, [Hospital1 ], Heparin gtt, Lopressor 25 [Hospital1 ], Rifampin 300 q8 (started [8-10]), Gent 40 IV q 8 (started [8-10]), Oxacillin 2 q4 Discharge Medications: 1. Morphine Sulfate 20 mg/mL Solution Sig: One (1) PO Q2hours as needed for pain, SOB. Disp:30 cc Refills:2 2. Ativan 2 mg Tablet Sig: 0.5-1 Tablet PO q2hours as needed for agitation: if haldol ineffective or if actively dying. Disp:30 Tablet(s) Refills:2 3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal every seventy-two (72) hours as needed for secretions. Disp:30 patches Refills:0 4. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Last Name (un) 14710] Home Discharge Diagnosis: 1. Endocarditis, Staphylococcus aureus, methicillin sensitive 2. Aortic root abscess 3. Bifascicular block with new PR segment prolongation 4. Acute renal failure 5. Status post left total hip revision 6. Left calcaneal ulcer 7. Aortic insufficiency 8. Right knee effusion 9. Hypertension Discharge Condition: Comfort measures only, pacer turned off, antibiotics discontinued. Discharge Instructions: Please keep Mr. [Known lastname ] [Last Name (Titles) ]. Followup Instructions: None [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ] MD [MD Number(2) 2139]	[ "41071", "2875", "5845" ]
Admission Date: [2168-8-10] Discharge Date: [2168-8-17] Date of Birth: [2100-11-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Tunnelled Catheter Placement History of Present Illness: 67m with htn, cad, afib, cva, esrd on hd presents with fevers and sepsis. He apparently was found to be febrile at HD so was transferred to the the ED. In ED, attempts at subclavian and IJ's failed and a femoral line was placed. A CT abdomen/pelvis was attempted, but contrast extravasated out into the abdominal wall, for which surgery was consulted. At the time of admission, the patient was able to anwer basic questions and follow commands, but seemed confused and was not cooperative with the interpreter. His daughter was [Name (NI) 653] who said that although normally fairly oriented, he generally becomes confused in the setting of fever. She also noted that she'd seen him the day prior to admission and that he had no complaints and was acting his normal self. She said he'd had no f/c, ha, neck pain, chest pain, sob, increased cough (has been coughing since recent admit for aspiration pneumonia), abd pain, n/v/d. He makes no urine. He was initially admitted to the MICU and transferred out to the floor after 24 hours. . Currently, he has had no positive blood cultures for 48 hours and is being maintained on vancomycin 1g QHD for MRSA sepsis. He has no complaints, denies weakness, pain, shortness of breath, chest pain, fevers, chills, nausea or vomiting. History taken through bedside phone translator for Haitian Creole. Past Medical History: 1) Left occipital lobe CVA [2-22] p/w change in MS [First Name (Titles) ] [Last Name (Titles) ], chronic CVAs now on coumadin for likely embolic nature 2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2 sec pauses, best managed with metoprolol 75 tid per cards 3) Chronic eosinophilia unknown etiology, strongyloides sent in [2-22] for w/u as well as SPEP/UPEP 4) h/o GI Bleed in [2167-7-20] while on asa, plavix, IIb/IIIa post-cath--no EGD or C-scope performed in f/u yet 5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [First Name (STitle) 805] 6) h/o bacteremia w/ MSSA (last bacteremia [11-22] with coag neg staph sensitive to oxacillin but resistent to PCN- treated w/vanco) 7) h/o pulling out groin lines 8) HTN, controlled 9) CAD s/p NSTEMIS, 2 LAD stents, CABG [2164]: last ECHO [2167-8-27], EF >55% 10) Hyperlipidemia 11) Diverticulosis 12) Severe Hyperparathyroidism, presumed adenoma, not on vitamin D for this concern 13) chronic anemia 14) chronic transudative pleural effusions 15) h/o neurocysticercosis calcified Social History: Lives in nursing home. No tobacco, etoh, illicit drug use. Transfer paper work from nursing home lists [First Name4 (NamePattern1) ] [Known lastname ] as the relative or guardian ([Telephone/Fax (1) 32722]. Family History: Mother with hypertension. No history of no strokes, seizures, or heart disease Physical Exam: t 96.7, bp 130/86, hr 88, rr 12, spo2 99% 2lNC gen- chronically-ill appearing male, pleasant, non-tox, NAD heent- anicteric but muddy, op clear with mmm neck- no jvd/lad cv- irreg irreg, II/VI midsystolic murmur at the RLSB. no r/g. PMI wnl. Lungs- no resp distress or acc muscle use, poor air movement, mild rales in bases l>r abd- soft, nt, nd, +BS. Ext- 1+ pitting edema LLE, none right, warm/dry nails- no clubbing, [Doctor First Name 15569] nails neuro- Knows name, knows at hospital, CN V, VII-XII in tact, although the patient squints his right eye (he is capable of opening both eyelids wide). EOM difficult to assess s/s compliance. No asterixis. DTR's in tact and equal bilaterally. Seems to be weaker on the left side. Pertinent Results: [2168-8-10] 11:00AM BLOOD WBC-14.3# [2168-8-10] 05:00PM BLOOD WBC-27.4# [2168-8-10] 07:00PM BLOOD WBC-21.5* [2168-8-11] 03:38AM BLOOD WBC-18.0* [2168-8-12] 02:00AM BLOOD WBC-11.6* [2168-8-12] 03:41PM BLOOD WBC-9.7 [2168-8-14] 05:00AM BLOOD WBC-7.0 . [2168-8-14] 05:00AM BLOOD PT-21.2* PTT-36.1* INR(PT)-2.1* [2168-8-10] 11:00AM BLOOD Glucose-68* UreaN-19 Creat-3.8* Na-139 K-3.6 Cl-96 HCO3-33* AnGap-14 . [2168-8-10] 11:00AM BLOOD cTropnT-0.14* [2168-8-10] 05:40PM BLOOD CK-MB-NotDone cTropnT-0.17* [2168-8-11] 03:38AM BLOOD cTropnT-0.16* [2168-8-13] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.13* [2168-8-14] 12:15AM BLOOD CK-MB-NotDone cTropnT-0.12* [2168-8-14] 05:00AM BLOOD CK-MB-2 cTropnT-0.12* . [2168-8-14] 05:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.4 [2168-8-11] 03:48AM BLOOD Type-[Last Name (un) ] Temp-36.2 Rates-2/ pO2-31* pCO2-52* pH-7.40 calTCO2-33* Base XS-5 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] . CXR: IMPRESSION: AP chest compared to most recent prior chest film [2168-7-11]: Consolidation in the lung bases has improved and small left pleural effusion has decreased. Small region of prior right apical consolidation has cleared. Moderate enlargement of the cardiac silhouette has decreased. There is no pneumothorax. No change in alignment of sternal wires including fracture of the most superior and the off-line configuration to the most inferior two. . CT Abd/Pelvis: IMPRESSION: 1. Complete extravasation of administered contrast into the patient's right lower quadrant in an extraperitoneal location. The likely explanation for this finding is that the right femoral CVL tip was positioned in the right inferior epigastric vein, which ruptured upon contrast administration. 2. Slightly limited exam due to the lack of intravenous contrast, but no definite acute intraabdominal abnormalities identified. . ECG Study Date of [2168-8-10] 10:25:58 AM Shaky baseline. Probable atrial fibrillation with rapid heart action and tachycardia. Inideterminate axis. Non-specific ST segment depression in leads V4-V6, either rate-related or ischemic. Compared to the previous tracing of [2168-7-10] atrial fibrillation was previously present with likely continuation to the present. Low voltage in the limb leads as before. ST segment depressions were previously present. . TTE: Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The ascending aorta is mildly dilated. 5. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 7. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 8. No evidence of endocarditis seen. 9. Compared with the prior study (images reviewed) of [2168-5-31], tricuspid regurgitation and pulmonary hypertension are worse. . Tunnelled Cath Report: IMPRESSION: Successful placement of a tunneled left groin hemodialysis catheter for a left temporary triple-lumen hemodialysis catheter. Brief Hospital Course: 67m with cad, afib, esrd here with fevers and elevated WBC found to have MRSA sepsis now on Vancomycin IV. . #MRSA Baceteremia -- Pt met SIRS criteria with fever, wbc, and occasional tachycardia. There was no evidence of severe sepsis or septic shock, with pt actually hypertensive and no other end-organ disease noted during MICU stay. Possible primary sources for MRSA sepsis would be his HD line which was removed and site replaced. WBC is now wnl. -D/w renal, do not feel it's necessary to pull L femoral catheter at this time (placed on [8-11]) even though 1 pos Blood cx on [8-12]. -Vanco for MRSA bacteremia administered during dialysis, s/p Gentamicin 80mg QHD X 2 doses with HD for synergy. - Decision made to defer TEE due to risk/benefit ratio in his case - he has a h/o a GI bleed that has not been worked-up and is at high risk for aspiration so would need to be intubated for the procedure. Will plan to treat empirically for endocarditis with 6 wks of Vanc (through [2168-9-23].) - Last positive blood cx [8-12], afebrile, hemodynamically stable . # Chest Pain - Has had intermittant episodes of CP. Unlikely to be cardiac in origin as without ECG changes, prior cycled enzymes neg (elevated trop but his trop is elevated at baseline). GI causes are also in the differential and after giving maalox, symptoms resolved. Possible that the patient is having gastritis. Ordered PPI and maalox/benadryl/lidocaine mix. Patient is no longer symptomatic. . #Contrast extravasation -- Felt to be due to superficial placement of CVL. Currently asymptomatic. NTD per surgery. . #CAD -- No active ischemia, con't asa, atorvastatin, metoprolol, lisinopril. patient ruled out for mi. . #Afib -- Con't metoprolol - decreased dose to 12.5mg [Hospital1 ] due to episode of bradycardia to 30s (asymptomatic). Warfarin held for several days for the possibility of procedures but he was restarted on 3 mg po qd on [8-16]. . #ESRD -- Con't HD on MWF. Con't sevelamer, nephrocaps . #HTN -- Con't lisinopril, metoprolol, clonidine, amlodipine . # Anemia -- Microcytic, likely a mixed picture of iron-deficiency and ACD - added iron supplement . #FEN -- Renal diet; vol even . #PPx -- boots, aspiration precautions . #Code -- full, confirmed with family . # Dispo -- d/c to nursing home with 6 wks antibiotics - needs to have ongoing safety labs (CBC, Chem 10, LFTS, INR, Vanc trough) followed by Dr. [Last Name (STitle) ] - PCP and ID [Name9 (PRE) 32723] scheduled . #Contact -- [Doctor Last Name ], daughter, [Telephone/Fax (1) 32724]. [Name (NI) ], wife, ([Telephone/Fax (1) 32722]. Medications on Admission: -Lisinopril 10mg daily -Folic Acid 1mg daily -Docusate 100mg [Hospital1 ] -Nephrocaps -Sevelamer 800mg TID -Warfarin 3mg daily -Lactulose 30cc daily -Trazodone 50mg qHS -Cinacalcet 30mg daily -Aspirin 325mg daily -Clonidine 0.2mg TID -Amlodipine 5mg daily -Atorvastatin 80mg qHS -Metoprolol Tartrate 25mg [Hospital1 ] -Calcium Carbonate 500mg [Hospital1 ] Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Lactulose 10 g/15 mL Solution Sig: Thirty (30) cc PO once a day as needed for constipation. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months. 16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous QHD (each hemodialysis) for 6 weeks: through [2168-9-23]. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: MRSA bacteremia Chest pain Atrial fibrilation ESRD on HD HTN Anemia Discharge Condition: Hemodynamically stable. Discharge Instructions: Please return to the hospital for fevers, chest pain, shortness of breath. . Please take all medications as prescribed. Followup Instructions: Provider: [First Name4 (NamePattern1) 247] [Last Name (NamePattern1) 248], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2168-9-1] 10:40 Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2168-9-20] 9:00 Please have the following labs drawn weekly at dialysis and have them faxed to Dr.[Name (NI) 32725] office: ([Telephone/Fax (1) 9190] CBC with diff CHEM 10 AST, ALT, Alk phos, TBili, INR, Vancomycin level prior to dialysis . Continue to have dialysis Monday, Wednesday and Friday [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "4240", "40391", "42731", "V5861", "2724" ]
Admission Date: [2138-1-1] Discharge Date: [2138-1-7] Date of Birth: [2078-12-12] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Prozac Attending:[First Name3 (LF) 922] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2138-1-1] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to RCA) History of Present Illness: 59 y/o female with exertional chest pain that started in [6-16]. Underwent stress test and had no chest pain or SOB. But nuclear images revealed perfusion defect involving distal inferior wall and apex. She continued to be medically managed and initially refused cardiac cath, but finally underwent one in [12-17]. Cath revealed three vessel coronary artery disease. Past Medical History: Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes [Last Name (LF) ], [First Name3 (LF) ], Gastroesophageal Reflux Disease, Depression, Anxiety, Chronic back pain s/p laminectomy, chronic headache, s/p tubal ligation Social History: Denies tobacco or ETOH use. Family History: Non-contributory Physical Exam: VS: 67 20 218/102 5'4" 177# Gen: WD/WN female in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, ?Bruit Chest: CTAB Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused 1+rt leg edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: [1-4] CXR: Increasing pleural effusions (left greater than right). Superimposed atelectasis or consolidation cannot be excluded at the left base. [1-2] Head CT: There is no evidence of acute hemorrhagic changes, unchanged extensive chronic small microvascular ischemic disease as described above. Bilateral dense arteriosclerotic calcifications noted in both carotid siphons as well as in the vertebral arteries. Please make note of MRI with diffusion- weighted sequences is more sensitive in order to demonstrate acute or subacute ischemic events. [2138-1-1] Echo: Pre Bypass: The left atrium is moderately dilated. A left atrial appendage thrombus cannot be excluded. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with Severe Apical Hypokinesis/akinesis, moderate septal and inferior hypokinesis throughout. LVEF 40%. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Post Bypass: The patient is initally AV-paced on phenylepherine, later A paced on epinepherine (0.01 mcg/kg/min) and nitroglycerin (0.5 mcg/kg/min) infusions. Overall LV function is unchanged to slightly improved LVEF 45%. There is improvement in inferior hypokinesis, which is now mild to moderate. Apical cap is still severely hypokinetic to akinetic, but other apical segments are now moderately to severely hypokinetic (previously severely hypokinetic). There is trace mitral regurgitaton. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2138-1-1] 02:18PM BLOOD WBC-10.6# RBC-2.94# Hgb-8.6# Hct-24.3# MCV-83 MCH-29.1 MCHC-35.3 RDW-13.3 Plt Ct-109* [2138-1-3] 03:07AM BLOOD WBC-19.3# RBC-3.36 Hgb-9.8* Hct-27.8* MCV-83 MCH-29.1 MCHC-35.2* RDW-14.2 Plt Ct-132* [2138-1-6] 05:00AM BLOOD WBC-9.6 RBC-3.09* Hgb-8.9* Hct-26.4* MCV-85 MCH-28.7 MCHC-33.6 RDW-15.0 Plt Ct-216 [2138-1-1] 02:18PM BLOOD PT-15.2* PTT-35.8* INR(PT)-1.3* [2138-1-5] 03:12AM BLOOD PT-13.1 PTT-24.4 INR(PT)-1.1 [2138-1-1] 03:44PM BLOOD UreaN-15 Creat-1.0 Cl-116* HCO3-21* [2138-1-6] 05:00AM BLOOD Glucose-156* UreaN-24* Creat-1.2* Na-141 K-3.8 Cl-105 HCO3-27 AnGap-13 [2138-1-6] 05:00AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9 Brief Hospital Course: Ms. [Known lastname 8738] was a same day admit and on [1-1] she was brought to the operating room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She remained intubated overnight. On post-op day one she was weaned from sedation, but was slow to wake up and had decreased response on left side. Neurology was consulted and a head CT was performed. CT revealed no CVA. The following day patient was more alert and had improved movement on left side. Chest tubes and epicardial pacing wires were removed per protocol. Patient required bedside swallow d/t difficulty swallowing. She required tube feeds and over a couple of days her swallowing improved and was able to tolerate regular diet. On post-op day three she was transferred to the telemetry floor for further care. Medications were adjusted and electrolytes replete. She worked with physical therapy for strength and mobility. Repaeat head CT was negative. On post-op day six she appeared to be doing well without deficits on left side, and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Lisinopril 40mg qd, Lopressor 100mg [Hospital1 ], Nifedipine 60mg qd, NTG SL prn, KCL 40mg qd, Spironolactone 25mg qd, Aspirin 500mg qd, Lipitor 80mg qd, Imdur 60mg qd, Glyburide 10mg [Hospital1 ], Tricor 48mg qd, Conidine 0.1mg qd, Fioricet Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:1 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:1 7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). Disp:4 Patch Weekly(s) Refills:0 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Hypertension, Hyperlipidemia, Diabetes [Last Name (LF) ], [First Name3 (LF) ], Gastroesophageal Reflux Disease, Depression, Anxiety, Chronic back pain s/p laminectomy, chronic headache, s/p tubal ligation Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon or while taking narcotic pain medicine. Followup Instructions: Wound check on [Hospital Ward Name 121] 6 in 2 weeks Dr. [Last Name (STitle) 914] in 4 weeks Dr. [Last Name (STitle) ] in [1-12] weeks Dr. [First Name (STitle) ] in [12-11] weeks Completed by:[2138-1-7]	[ "41401", "25000", "4019", "53081", "2724", "2859" ]
Admission Date: [2156-4-23] Discharge Date: [2156-4-27] Date of Birth: [2071-1-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: Transfer from OSH for hypoxia, hypotension, bilateral PE, s/p MICU Major Surgical or Invasive Procedure: None History of Present Illness: 85 year-old female, Russian-speaking, with hypertension presented to [Hospital ] Hospital with nausea, vomiting, "trembling", found to have bilateral PE, and transferred to [Hospital1 18] for further management. She felt well yesterday. This morning upon wakening she developed shaking, nausea/vomiting, headache, and overall felling unwell. She was noted by her family to be pale and cool. She was taken to OSH by EMS. At OSH, fluctuating oxygen saturation as low as 83% RA. During ED course developed syncope vs. presyncope, sBP to 80s with standing, fluid responsive. CTA chest reveal bilateral PE, small. Received fondaparinux 7.5mg SC at 11:45am [2156-4-23], 1.5L NS, Zofran, morphine. CT head per records within normal limits. Transferred to [Hospital1 18] for further management. . In the ED, 99.1 92 124/73 96% 2L NC. Physical examination notable for comfortable appearing female. Laboratory data significant for chemistry panel within normal limits, hematocrit 35.5, WBC 11.0 with bandemia (10%), INR 1.7, lactate 2.0, unremarkable UA. OSH CTA chest uploaded, again showing small bilateral PE. EKG with sinus rhythm at 89, without evidence of right heart strain or ischemia. Received Tylenol, IVF (total not known). On transfer to MICU, 100.8, 95/58, 85, 26, 100 2L NC. . In the MICU, patient was accompanied by her son and husband. [Name (NI) ] translated for patient. She felt well. She denied chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, lower extremity edema or swelling. Denied recent sick contacts. Pt was monitored in the MICU overnight. Given pt was stable, she was called out of the MICU and transferred to the medicine floor on [2156-4-24]. On arrival to the floor, pt felt well. Reported small headache and min. shortness of breath, but no other acute complaints. . Review of systems: (+) Per HPI. Recent 2lb weight loss, unintentional. Dry cough for several weeks. Intermittent discomfort left ankle - s/p fracture several months ago. (-) Denies fever, chills, night sweats. Denies sinus tenderness, rhinorrhea, sore throat. Denies dysuria, urinary frequency. Denies rashes or skin changes. Past Medical History: Hypertension Hypercholesterolemia s/p fracture to left ankle several months ago after slipping on ice; managed non-operatively, able to ambulate Denies prior malignancy. ?recent unexplained hypercalcemia - was supposed to see endocrinologist on day of admission. Social History: Denies tobacco, alcohol use. Emigrated from [Country 532] in [2142]. Former engineer. Lives with her husband. [Name (NI) ] lives in close proximity. Family History: Son with multiple lower extremity blood clots following period of immobilization. Mother with multiple blood clots. Niece passed due to pulmonary embolism. No family history of malignancy. Physical Exam: PHYSICAL EXAM on admission: VS - Temp 98.9F, BP 118/43 , HR 78, R 22, O2-sat 95% NC 1L GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, + peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-17] throughout, sensation grossly intact throughout. . PHYSICAL EXAM on discharge: VS - VS: Tc 96.3 Tm:98.6 BP:108/62 HR:69 RR:18 O2 sat 97% RA Exam: General: Sitting on bed, coughing Cardiac: RRR Pulm: CTA Abdomen: soft, NT Ext: Mild pedal edema, symmetric bilaterally, [Location (un) 28048] sign absent Pertinent Results: [2156-4-26] 06:55AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.5* Hct-34.1* MCV-89 MCH-29.9 MCHC-33.6 RDW-14.2 Plt Ct-156 [2156-4-27] 07:05AM BLOOD WBC-5.5 RBC-3.87* Hgb-11.4* Hct-34.3* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.4 Plt Ct-179 [2156-4-26] 06:55AM BLOOD PT-13.4 INR(PT)-1.1 [2156-4-25] 07:40AM BLOOD Glucose-94 UreaN-16 Creat-0.8 Na-144 K-3.6 Cl-112* HCO3-28 AnGap-8 [2156-4-26] 06:55AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-143 K-4.1 Cl-113* HCO3-23 AnGap-11 [2156-4-26] 07:15PM BLOOD CK-MB-2 cTropnT-<0.01 [2156-4-27] 02:25AM BLOOD cTropnT-<0.01 [2156-4-25] 07:40AM BLOOD WBC-15.6* RBC-3.99* Hgb-11.8* Hct-35.6* MCV-89 MCH-29.6 MCHC-33.2 RDW-14.1 Plt Ct-135* [2156-4-24] 03:59AM BLOOD WBC-19.8# RBC-3.97 Hgb-12.0 Hct-35.0* MCV-88 MCH-30.1 MCHC-34.2 RDW-14.0 Plt Ct-150 [2156-4-23] 03:15PM BLOOD WBC-11.0 RBC-3.98* Hgb-12.2 Hct-35.5* MCV-89 MCH-30.6 MCHC-34.4 RDW-14.0 Plt Ct-175 [2156-4-24] 03:59AM BLOOD Neuts-79* Bands-9* Lymphs-7* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2156-4-23] 03:15PM BLOOD Neuts-89* Bands-10* Lymphs-0 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2156-4-24] 03:59AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2156-4-25] 08:45AM BLOOD PT-14.1* PTT-58.1* INR(PT)-1.2* [2156-4-25] 07:40AM BLOOD PT-14.3* PTT-70.7* INR(PT)-1.2* [2156-4-24] 03:59AM BLOOD PT-16.8* PTT-39.4* INR(PT)-1.5* [2156-4-23] 03:15PM BLOOD PT-18.6* PTT-43.1* INR(PT)-1.7* [2156-4-25] 07:40AM BLOOD Glucose-94 UreaN-16 Creat-0.8 Na-144 K-3.6 Cl-112* HCO3-28 AnGap-8 [2156-4-24] 03:59AM BLOOD Glucose-107* UreaN-21* Creat-1.1 Na-142 K-3.8 Cl-109* HCO3-24 AnGap-13 [2156-4-23] 03:15PM BLOOD ALT-132* AST-180* AlkPhos-90 TotBili-0.9 [2156-4-23] 03:15PM BLOOD cTropnT-<0.01 [2156-4-23] 03:15PM BLOOD proBNP-590 [2156-4-25] 07:40AM BLOOD Albumin-3.1* Calcium-8.7 Phos-1.9# Mg-2.0 [2156-4-24] 03:59AM BLOOD Calcium-8.3 Phos-4.0# Mg-1.5* [2156-4-23] 03:15PM BLOOD Albumin-3.4* Calcium-8.7 Phos-1.8* Mg-1.5* [2156-4-23] 03:21PM BLOOD Lactate-2.0 . Studies: -[2156-4-23]: CTA at OSH -[2156-4-24]: There is normal compressibility, flow and augmentation of bilateral common femoral, superficial femoral and popliteal veins. There is normal color flow of the calf veins. IMPRESSION: No evidence of lower extremity DVT. -[2156-4-24]: There is unchanged mild cardiomegaly. Mediastinal contours are unremarkable. There is no evidence of appreciable pulmonary edema. Small bilateral pleural effusions are present as well as minimal bibasilar atelectasis. Overall, no significant changes compared to prior CT was noted. Brief Hospital Course: 85F with hypertension with bilateral pulmonary emboli, relative hypotension, bandemia, low-grade fever in context of recent malaise, nausea/vomiting x1 day. She was initially admitted to the MICU for close monitoring and transferred to the medicine floor the next day. . -Active issues: #. PE: appeared to be small, bilateral on CTA from OSH. There was no evidence of right heart strain on EKG. Pt was hemodynamically stable throughout her hospitalization. Pt was initially started on the heparin drip, then was changed to Lovenox while pt was started on Coumadin and INR was still <2. Pt had bilateral lower extremity US and there was no evidence of DVT. Of note, per pt and family, pt had received routine cancer screening. Her last mammogram was in [2155] and the result was WNL, and her last colonoscopy was in [2154], significant for polyps. Pt also reported ongoing outpatient malignancy workup for hypercalcemia, however while pt was in the hospital, her Ca level was only from 8.3-8.7. Pt has significant family history of blood clots, can consider w/u as outpt for hypercoagulation and to best determine the duration of Coumadin treatment. - Recommend continue lovenox until INR > 2 for 48 hours, then d/c lovenox - goal INR [3-18] . #. Bandemia( WBC 11 10% bandemia) in the context of low-grade fever. Her Lactate was 2.0. There was no clear evidence of infection. Given nausea, vomiting on arrival to OSH ED, there was a possibility for gastroenteritis. There was no clear infiltrate on chest CTA. Pt was initially started on Tamiflu, Vancomycin/Cefepime which was then changed to Levofloxacin for empiric treatment and droplet precaution. Urine culture with mixed bacteria, likely d/t contamination. Her Flu screening and Legionella screening were negative. Her CXR did not show any evidence of acute process. The above antibiotics were stopped with these negative result. However, the levofloxacin was continued to complete a 5 day course for empriric treatment of community aquired pneumonia. At the time of discharge, she was afebrile and her blood cultures were still pending. . #. Hypotension/hypoxia: pt demonstrated relative hypotension with baseline hypertension. Unlikely to be due to PE given small size on CTA chest. [Month (only) 116] be related to poor PO intake, nausea/vomiting. Given fever, elevated lactate septic shock was on the differential, thus pt was admitted into the MICU for close monitoring. Her EKG did not show any evidence of ischemic changes.Pt was placed on oxygen supplement via NC, and gradually weaned off as tolerated. We also held home anti-hypertensives (hold HCTZ, Propanolol, Lisinopril), added back Lisinopril as BP improved. At the time of discharge, we were still holding HCTZ and Propanolol. The patient was instructed to see her primary care doctor [First Name (Titles) 5001] [Last Name (Titles) 9533] blood pressure medications. On the day before discharge, she had an episode of weakness and dizziness that spontaneously resolved. Her blood glucose and orthostatic blood pressure were normal. An EKG was obtained that showed some minor changes from a previous and so cardiac enzymes were obtained which were negative. A cardiology fellow was requested to review the EKG and felt that the changes were not worrisome in nature and that if she continued to be symptomatic to consider an outpatient echo. The symptom did not recur during her hospital stay. . #. Anemia: HCT was stable at 35 and normocytic. Baseline unknown. Pt was instructed to follow up as outpatient with PCP. . # Disposition: D/C home with PCP follow up as outpatient for the above issues. Medications on Admission: Simvastatin 40mg PO daily HCTZ 25mg PO daily Detrol 2mg PO daily Aspirin 325mg PO daily Propranolol 20mg PO daily Lisinopril 2.5mg PO daily Calcium/vitamin D Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:6 injection Refills:1 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Please take 1 pill on Tuesday and 1 on Wednesday. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: hypoxia, hypotension, bilateral PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: independent Discharge Instructions: Dear Ms.[Last Name (Titles) 32737], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for shortness of breath, low blood pressure, and was found to have small blood clots in your lung. We started you on blood thinning medications and it is very important for you to follow up with your primary care physician to check the level (your INR) to ensure the medication (Coumadin) is at the appropriate dosage. You also had a fever, you were started on antibiotics. We would like for you to continue levaquin until Wednesday [2156-4-28]. As for your blood pressure, it was on the lower side, so we held your blood pressure medications except Lisinopril. Please talk to your primary care physician to discuss this matter and determine when to restart some of your home blood pressure medications. Also you should follow up with your primary care physician for anemia. In summary, the following medication changes were made: -Started Lovenox twice a day -Started Coumadin -Started levofloxacin for 2 more days (for pneumonia) -Held HCTZ due to low blood pressure -Held Propanolol due to low blood pressure -Held Detrol -Decreased aspirin to 81 mg (since started coumadin) Followup Instructions: - Please go to Dr.[Name (NI) 32738] office anytime on Thursday to have your INR checked at [Location (un) 270] Family Practice in [Location (un) 47]. phone ([Telephone/Fax (1) 32739]. It is very important that you keep this appointment to measure your INR, a measure of anticoagulation. Please make a follow-up appointment at that time.	[ "486", "4019", "2720", "2859" ]
Admission Date: [2159-9-29] Discharge Date: [2159-10-6] Date of Birth: [2082-12-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1974] Chief Complaint: nausea/vomiting: transferred from an outside hospital for ERCP Major Surgical or Invasive Procedure: endoscopic retrograde cholangiopancreatography History of Present Illness: The patient is a 76 year old woman with history of CAD s/p CABG in [2155], bioprosthetic AVR, afib (on anticoagulation), DM who initially presented to [Hospital ] hospital on [2159-9-27] with nausea and vomiting. The patient reports that she was in her USOH until [2159-9-23] when she developed acute onset of nasuea, non-bilious, non-bloody vomiting and abdominal pain. She initially attributed these symptoms to food poisoning and did not seek medical attention. She endorsed subjective fevers, chills, and sweats. She denies any diarrhea. She was noted to have some jaundice. On presentation to the OSH ED, her T was 102, SBP was in 70's. The patient was admitted to the ICU with sepsis, hypotensive. Admission labs: WBC 10.9 (up to 20 the next day with 20% bands), Hct 38 (down to 28 the next day), Cr 1.8, ALT 277, AST, 248, T bili 5.6 (direct 3.0). ABG 7.28/32/151 (on 4L NC). No lactate documented. She was resuscitated with fluids (5L IV NS in the ED) and started on Unasyn, Flagyl, pressors. Blood culture from [9-27] grew GNR in [1-18] bottles. The patient also received Vitamin K and 4 units FFP for elevated INR of ? 10 per report on admission. Most recent INR 2.5. Femoral line was placed at the OSH. She was ruled out for MI with 3 set of cardiac enzymes. Because of elevated liver enzymes, CT of the abd was done. CT abd was of limited quality, but showed pancreatic swelling. US of RUQ showed CBD of 7 mm. GI was consulted and felt that the patient had ascending cholangitis. Transfer to [Hospital1 18] for possible ERCP was then arranged. . Of note, on admission, the patinet was also noted to have right arm weakness for for approximately one week prior to admission. Neurology was consulted and by their exam felt that she had a subacute left basal ganglia infarct vs. subacute left cortical infarct involving temporal lobe, less likely right polyneuropathy. MRI/MRA brain, carotid US and metabolic work up were recommended. Head CT and carotid US were done (see results below). Past Medical History: 1. CAD s/p 3 vessel CABG in [2157] 2. s/p chole [2155] 3. Aortic Valve Replacement (bioprosthetic) [2157] 4. Diabetes mellitus 5. Atrial fibrillation, on coumadin 6. Hiatal hernia 7. Hypercholesterolemia 8. White coat hypertension 9. S/p C-section x 2 10. GxP8 Social History: Lives with husband. She has 2 daughters and 6 sons. [Name (NI) ] husband is currently admitted to [Hospital3 ] with MI and CHF. Never smoked. No EtOH. Family History: non-contributory Physical Exam: Upon arrive to ICU: Vitals: 97.1 98/37 66 26 98% (5L NC) Gen: overweight woman, lying in bed, NAD, visibly short of breath with sitting up in bed or talking HEENT: NC, AT, MMM, OP clear w/o lesions, pupils equal and round, no scleral icterus. Neck: supple, no LAD, JVD difficult to asses CV: regular, loud S2, no m/r/g Chest: midline scar c/w open heart surgery Lungs: bibasilar crackles, no wheezes Abd: modline lower abd vertical scar from prior c-sections, RUQ scar from cholecystectomy, + BS, obese, soft, ND, mildly tender in LUQ Ext: cold, DP pulses dopplerable, no edema Neuro: alert and oriented x3, speech fluent, extinguishes to double simultaneous stim on right CNII-XII intact Motor: normal tone and bulk, left arm [4-20] arm flex/extend, hand grip, finger abduction; right arm [3-21] flex, [4-20] extend, [4-20] hand grip, [3-21] finger abduction, could not grip pen with dominant hand; lower ext [4-20] symmetric hip flex, ankle plantar/dorsiflexion Sensation: light touch intach to hands and legs Reflex: 2+ bicep bilat, 0 bilat patellar and ankles, toes equivocal Coord: FTN normal on left, limited on right Skin: No exanthems Lines: Right femoral w/o signs/symtpoms of infection. . Pertinent Results: Outside Hospital reports: Carotid US: bilateral moderate ICA stenosis (20-49%). . CT abd/pelvis: limited study, edema around pancreas Head CT: "old right sided infarct" . EKG [2159-9-27]: afib with RBBB pattern; ST depressions in V3-V6 not seen on prior EKG but cannot be interpreted with RBBB . [2159-9-27]: Blood cultures 2/2 bottles of E. coli: resistant to gentamicin, sensitive to quinolones . On admission: [2159-9-29] 05:51PM GLUCOSE-116* UREA N-39* CREAT-2.0* SODIUM-136 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-15* ANION GAP-19 [2159-9-29] 05:51PM ALT(SGPT)-173* AST(SGOT)-111* LD(LDH)-316* ALK PHOS-197* AMYLASE-48 TOT BILI-4.4* [2159-9-29] 06:19PM LACTATE-2.5* [2159-9-29] 05:51PM ALBUMIN-2.9* CALCIUM-6.7* PHOSPHATE-3.7 MAGNESIUM-1.9 [2159-9-29] 05:51PM WBC-30.2* RBC-3.33* HGB-9.5* HCT-27.5* MCV-83 MCH-28.4 MCHC-34.4 RDW-15.3 [2159-9-29] 05:51PM PT-26.2* PTT-33.0 INR(PT)-2.7* . [2159-9-29]: Chest Xray: Mild CHF. Bibasilar atelectasis and bilateral pleural effusions. . [2159-10-1]: ERCP report: mild inflammation of the major papilla, mild biliary duct dilation, biliary stent placed successfully. Brief Hospital Course: 1)SEPSIS: On admission, patient presented hypotensive, with rapidly rising WBC, bandemia. Blood cultures from OSH with found to be E. coli. Presentation, exam, and elevated LFTs were consistent with cholangitis. Had received 6 liters of normal saline prior to transfer. The patient was fluid bolused for volume resusitation and levophed was continued to keep the MAP >60. Initial broad spectrum antibiotics were used until sensitivity data was available. ERCP team was notified and recommended close monitoring prior to proceeding with ERCP. The patient continued the empiric steroid regimen while on pressors. She maintained adequate urine output. Her vital signs improved. She underwent ERCP on [2159-10-1] with peri-procedural intubation. No biliary stone was found. A stent was placed in the bile duct. She was weaned off pressors and the empiric steroids were stopped after 5 days of therapy as the patient was no longer hypotensive and she had not failed [Initials (NamePattern4) ] [Last Name (NamePattern4) 104]-stim test. After her pressors were stopped, the femoral central venous catheter that had been placed prior to transfer was removed. Patient was transferred to the floor where she continued to do well. She was transitioned to PO levaquin for a 2-week course. Hemodynamically remained stable. . 2) CV: S/p CABG in [2157]. The patient r/o for MI with three sets of enzymes at the OSH. She remained chest pain free. EKG with old RBBB. The patient was monitored on telemetry during her ICU stay. Her aspirin was held for the ERCP then restarted post-procedure. Her home statin and zetia was held while her transaminases were elevated. After her blood pressure stabilized, an ACE inhibitor was introduced. She was intermittently hypertensive and her ACEI was uptitrated and imdure was restarted. Lasix was restarted at 20mg [Hospital1 ], lower than her home dose as she is not taking full POs yet. . Rhythm. The patient has a history of paroxysmal a fib with RBBB (old) per EKG. Intially, anticoagulation was held pre-ERCP and her INR was allowed to drift down. Following the procedure, she was briefly heparin loaded while her coumadin was restarted with goal INR of [1-18].5. Inr on d/c was 2.2. Amiodarone was held as transaminases were up and can be restarted as outpt. . 3) CVA: Patient with new subacute neurological deficits which developed approximately 10 days prior to transfer. The neurology consult at the prior hospital recommeded cartid ultrasound, MRI/MRA. She was not hemodynamically stable for MRI during at the OSH. Carotid ultrasound did not reveal significant (i.e. >50%)ICA stenosis. As she will be anticoagulated with regard to the atrial fibrillation, the MRI was deferred to an outpatient evaluation. . 4) Acute Renal failure: Creatinine upon transfer was 2. Her baseline was unknown. Urine lytes were consistent with pre-renal azotemia. Her medications were dose adjusted. Her creatinine trended down. Upon discharge, her creatinine was 0.9. . 5) DM, Non-insulin dependent: Once eating, restarted metfromin . . Communication: Patient. Daughter [Name (NI) ](HCP) ([Telephone/Fax (1) 68847]. Medications on Admission: Glucophage 500 daily ASA every other day Coumadin 3 mg po qd Imdur 30mg daily Lasix 40 qam and 20 qpm Amiodarone Lipitor 80 daily Zetia 10 daily Citracal + D Colace 100mg daily Fish Oil caps Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:90 Tablet(s) Refills:0 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Iron Oral 9. Citracal + D Oral 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Fish Oil Oral 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cholangitis Sepsis Stroke Diabetes Type 2 Acute Renal Failure Hypertension Discharge Condition: Good--afebrile, tolerating food. Discharge Instructions: Call Dr. [Last Name (STitle) ] or return to the hospital if you experience abdominal pain, nausea, vomitting, fevers, chills, inability to eat, or any other symptoms that concern you. Please note, you should not take lipitor, zetia or amiodarone until you see Dr. [Last Name (STitle) ] given recent abnormalities in liver function tests. Also note that you should take lisinopril in place of cozaar for now. Discuss with Dr. [Last Name (STitle) ] about switching back. Followup Instructions: You will follow up with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 68848] on [2159-10-12]@2:15pm. Please call Dr. [Last Name (STitle) ] of GI at ([Telephone/Fax (1) 10532] to set up an appointment to have the biliary stent removed in [3-22] weeks. You should have an outpatient MRI done to evaluate for stroke.	[ "0389", "5849", "42731", "78552", "25000", "4019", "2720", "99592" ]
Admission Date: [2137-11-11] Discharge Date: [2137-11-21] Date of Birth: [2073-2-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: Transfer from OSH for post cardiac arrest evaluation. Major Surgical or Invasive Procedure: Inplantable cardioverter defibrillator (ICD) placement Intubation and extubation Central venous line PICC line placed and removed History of Present Illness: Ms. [Known lastname ] is a 64 year-old woman with a history of idiopathic cardiomopathy who presents on transfer after cardiac arrest. Per OSH discharge summary, patient presented after found by her boyfriend at home with unresponsiveness after hearing a thump. 911 was called immediately and when EMS arrived (~5 minutes after arrest) they patient was noted to be in vfib, apneic and pulseless. CPR, ALCS (shock x4) and intubation were perfomed. At the OSH ED, patient was noted to be in sinus. Based on EMS records, time between initial rhythm and 4th (successful) shock was ~9 minutes. OSH course: Evaluated by cardiology. Noted to have troponin peak of 0.30. A TTE was performed and showed an LVEF of 30% (unchanged from prior). To work-up an elevated WBC (13.4), a chest CT was done and showed extensive multifocal pulmonary opacities involving most of the LLL aand portions of the upper lobes. She was treated with vancomycin, unasyn and azithromycin. Regarding her neurologic status, patient was noted to be unresponsive after admission (no purposeful movementswith sluggish pupils) with a head CT being grossly normal. The patient's hematocrit was noted to drop from 30.8 on admission to 25.5 so a unit of pRBC was transfused. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes (-) Dyslipidemia (+) Hypertension . 2. CARDIAC HISTORY: -CABG: None. -CARDIAC CATH without flow limiting lesions ([7-17]). -PACING/ICD: None. -CHF: Idiopathic dilated CM with EF of 30% (echo [7-17]). -History of LBBB 3. OTHER PAST MEDICAL HISTORY: - Anemia, iron deficiency - Sarcoidosis - Glaucoma Social History: -Tobacco history: None currently -ETOH: Occasional -Illicit drugs: Unclear -Widower Family History: Father died of MI in 60s Physical Exam: VS: T=98.8 BP=145/75 HR=83 RR=16 O2 sat=100% on vent GENERAL: Intubated and on mild sedation. Responds to painful stimuli but does not have purposeful movements. HEENT: NCAT. Sclera anicteric. Pupils 4mm --> 2mm and brisk bilaterally. NECK: Supple. CARDIAC: Palpable RV lift and prominent LV PMI. Regular rate. No obvious murmur. +S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored on the ventilatro. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Midline line rectangular patch with skin changes. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Amission labs: [2137-11-11] 05:51PM GLUCOSE-78 UREA N-18 CREAT-0.9 SODIUM-146* POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-25 ANION GAP-12 [2137-11-11] 05:51PM ALT(SGPT)-55* AST(SGOT)-44* LD(LDH)-263* CK(CPK)-400* ALK PHOS-58 TOT BILI-0.9 [2137-11-11] 05:51PM CK-MB-2 cTropnT-0.03* [2137-11-11] 05:51PM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.2 [2137-11-11] 05:51PM WBC-13.0# RBC-3.52 HGB-8.9# HCT-26.8# MCV-76# MCH-25.2# MCHC-33.1 RDW-22.5* [2137-11-11] 05:51PM PT-13.2 PTT-33.7 INR(PT)-1.1 [2137-11-11] 05:51PM RET MAN-1.3 OSH Labs: K: 3.2 --> 4.1 --> 3.3 Mg: 1.6 --> 2.1 Cr: 1.2 --> 1.0 ALT: 79 --> 55 WBC: 8.6 --> 14.5 (25% bands) HCT: 29.3 --> 25.5 (MCV 73) PLT: 366 --> 386 INR: 1.1 Trop: 0.01 --> 0.30 --> 0.11 BNP: 358 D-Dimer: 2467 UA: 30-40 WBC Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2137-11-21] 08:50AM 10.3 3.79* 9.3* 28.2* 74* 24.6* 33.0 21.2* 430 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [2137-11-21] 08:50AM 255* 10 0.8 136 3.6 101 28 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos TotBili [2137-11-13] 05:49AM 39 32 256* 265* 69 1.0 CHEMISTRY Calcium Phos Mg [2137-11-21] 08:50AM 8.7 3.4 1.8 PITUITARY TSH [2137-11-18] 04:10AM 1.6 [2137-11-12] 5:21 pm SPUTUM Source: Endotracheal. FINAL REPORT [2137-11-15] GRAM STAIN (Final [2137-11-12]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [2137-11-15]): OROPHARYNGEAL FLORA ABSENT. ENTEROBACTER CLOACAE. 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. KLEBSIELLA OXYTOCA. SPARSE GROWTH. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| KLEBSIELLA OXYTOCA \| \| AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S 2 I GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S EMS tracings: Ventricular fibrillation with NSR initiated after fourth shock. ECG ([2137-11-11]): NSR at 89. LBBB. 2D-ECHOCARDIOGRAM ([7-17]): 1. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed with some preservation of basal inferior and basal lateral wall motion. 2. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. CARDIAC CATH ([7-17]): 1. No angiographically apparent flow limiting coronary artery disease. 2. Normal left and right sided filling pressures. 3. Depressed LV function of 30% with global hypokinesis. TTE ([11-12]): The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %) with somre preserved contraction of the basal inferolateral and anterolateral walls. 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([12-12]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Global left ventricular cardiomyopathy. Moderate diastolic dysfunction with elevated filling pressures. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [2135-8-11], the severity of mitral regurgitation has increased. Estimated pulmonary artery pressures are elevated (previously undetermined). EEG ([11-14]): Abnormal portable EEG due to the slow and disorganized background. This indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no prominent focal abnormalities, but encephalopathies may obscure focal findings. There were no epileptiform features. The background was not at all flat or markedly suppressed, findings that might be associated with continued Propofol use or with a severe anoxic encephalopathy. Those are still possible causes of the encephalopathy, but they are less likely, and the EEG is not strongly suggestive of them. MRI head ([11-15]): The FLAIR and T2 as well as diffusion images demonstrate increased signal in both thalami. There is no evidence of restricted diffusion seen without evidence of abnormalities on the ADC map. These findings could be indicative of subacute changes of hypoxia. Bilateral chronic lacunes identified. Changes of small vessel disease are seen in the pons and in the periventricular region. There is moderate ventriculomegaly without significant sulcal prominence. There are no chronic blood products seen. IMPRESSION: Signal changes bilaterally in the thalami without evidence of restricted diffusion are likely due to subacute changes from hypoxic event. Moderate ventriculomegaly is seen. No mass effect or signs of herniation seen. Mild mucosal thickening in the sinuses. Shoulder X-ray ([11-17]): Single view of the right shoulder shows no fracture, dislocation, or subluxation of the shoulder and the adjacent ribs are intact. Brief Hospital Course: 64F with female with DM, htn, and history of idiopathic cardiomyopathy presenting on transfer after vfib arrest. # Ventricular fibrillation cardiac arrest: The patient received 4 shocks in the field and was in sinus rhythm at the OSH. Here she remaiend in sinus rhythm without further arrhythmia. Her carvedilol was increased to 25 mg po bid. After her other medical issues improved (as below) she had a dual chamber ICD placed on [10-21]. She received 1 mg IV vanc and 1 gm cefazolin prior to placement and will need to complete three days of cefalexin for to prevent infection post placement. She has a follow up appointment scheduled with the device clinic. # Neurologic function: The patient suffered a cardiac arrest and was initally intubated on transfer. She was extubated after 9 days on the ventilator and one failed extubation attempt earlier in the hospital stay. While on the ventilator and after extubation she initally has some agitation, but this decreased as her mental status cleared and she continued to gain neurologic function. She has been working with PT, OT, and speech therapy. She has been getting 1 mg po haldol at night to decrease nighttime agitation, and 0.5 mg po ativan for insomnia if she cannot sleep after the haldol. As she improves, this can likely be stopped. She will follow up with Dr. [First Name (STitle) ] as an outpatient. # Chronic systolic and diastolic heart failure: The patient has a history of idiopathic cardiomyopathy with an EF of 30%. Per her PCP she has class II heart failure. She underwent a TTE which showed an EF of 30% and global left ventricular cardiomyopathy with moderate diastolic dysfunction with elevated filling pressures, mild to moderate mitral regurgitation, and mild pulmonary hypertension. Her losartan was increased to 100 mg daily. Her carvediolol was increased to 25 mg po bid. She was continued on her home dose of lasix at 20 mg daily as she did not appear to volume overloaded. # Hypertension: The patient's SBPs were found to be elvated so her carvedilol was increased to 25 mg po bid and her losartan was increased to 100 mg daily. She was continued on lasix 20 mg daily. Prior to discharge her SBP ranged from 130's to 150's. # Anemia: The patient has known iron deficiency anemia; she had recieved one unit of pRBC at OSH. Her Hct ranged from 24.3 to 28.8 and she did not receive further tansfusion here as she was not having active ischemia. Her Hct on discharge was 28.2. # Pneumonia/Pulmonary: The patient had a leukocytosis on admission of 13.0. She had blood cultures and urine cultures which were negative. Her CXR showed a possible LLL infiltrate. A sputum culture from [11-12] showed enterobacter cloacae and klebsiella oxytoca which was sensitive to ceftriaxone. While the culture and sensitivities were pending she was treated with zosyn (she had been started on this at the OSH on [11-9]) until [11-16] when she was switched to ceftriaxone to complete a 10 day course of antibiotic therapy for a pneumonia. The patient suffered a cardiac arrest and was initally intubated on transfer. She was extubated after 9 days on the ventilator and one failed extubation attempt earlier in the hospital stay. It was thought that her inital failure to tolerate extubation was due to a combination of the pneumonia, her mental status, and her copious secretions. She was given a scopolamine patch to decrease her secretions and as her pneumonia was treated and her mental status improved she was able to tolerate extubation. # Diabetes: The patient is on januvia and metformin as an outpatient. During her hospitalization these medications were held. She had qid finger sticks for monitoring of her blood glucose and was covered with sliding scale insulin. By the end of her stay she was eating more and her sugars were higher so she was restarted on her januvia and metformin at discharge. Medications on Admission: MEDICATIONS (home): 1. Coreg 3.125 [Hospital1 ] 2. Cozaar 50mg daily 3. Lasix 20mg daily 4. Potassium 10mEq daily 5. Januvia 50mg daily 6. Metformin 500mg [Hospital1 ] 7. Ibuprofen 800mg PRN 8. Cosopt 2% both eyes daily MEDICATIONS (on transfer): Lopressor 2.5mg IV q4H Insulin gtt Nitropaste Protonix 40mg IV daily Versed gtt Unasyn 1.5g Q6H Vancomycin 1G [Hospital1 ] Azithromycin 500mg IV daily SC heparin Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia: Give at least one hour after haldol if needed. 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic once a day: Place in both eyes. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for agitation. 12. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID (4 times a day) as needed for skin tear. 13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for ICD implant for 10 doses. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Primary - Ventricular fibrillation resulting in cardiac arrest Secondary - Dialated idiopathic Chronic systolic heart failure Diabetes Hypertension Discharge Condition: Stable Discharge Instructions: You were tranferred to this hospital after you had a cardiac arrythmia which caused you to pass out and have low oxygen delivery to your brain. You were intubated on arrival Medication changes: 1. Your losartan was increased to 100 mg daily. 2. Your coreg was increased to 25 mg twice daily. 3. While in rehab you will be given subcutaneous heparin injections three times daily for deep vein thrombosis prophylaxis, but you will not need to take this upon discharge from rehab. 4. You will be given haldol 1 mg po every night to decrease agitation (however this can be stopped as you improve and your night time agitation abates). You can also be given 0.5 to 1 mg po haldol as needed for agitation at other times. 5. You can be given 0.5 mg ativan po for insomnia as needed. 6. You can take 1-2 puffs of albuterol as needed for shortness of breath or wheezing. 7. You will need to take 10 more doses of cephalexin 500 mg every 6 hours for prevention of infection given your recent ICD placement. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L per day Call your primary doctor or go to the emergency room if you experience fevers, chills, chest pain, shortness of breath, dizziness, or activity from your ICD. Followup Instructions: An appointment has been made for you to follow up with cardiology: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2137-11-29] 10:00 An appointment has been made for you to follow up with Dr. [First Name (STitle) ] from neurology: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD Phone:[Telephone/Fax (1) 1690] Date/Time:[2137-12-23] 3:30 You will need a referral for this appointment; please see you primary care doctor prior to this for the referral. His office his located on [Location (un) ] in [Location (un) 86] on the [Location (un) ] [Apartment Address(1) 14414]. It is important that you keep these appointments. Please call to reschedule if you cannot make them. Completed by:[2137-11-21]	[ "51881", "2760", "4280", "25000", "4019" ]
Admission Date: [2148-7-1] Discharge Date: [2148-7-9] Date of Birth: [2067-2-19] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: weakness Major Surgical or Invasive Procedure: [2148-7-5] Aortic valve replacement ([First Name8 (NamePattern2) 6158] [Male First Name (un) 923] tissue), coronary artery bypass graft surgery x2 (Left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal), left carotid endarterectomy History of Present Illness: 81M developed weakness and nausea lasting minutes. EMS was called and the patient was found to be in A-fib with rapid ventricular response. He was admitted to an OSH for workup. Stress test was abnormal and cardiac cath revealed 2vessel CAD and aortic stenosis. He is transferred for surgical evaluation. Past Medical History: hypertension hyperlipidemia hypothyroidism colon cancer, s/p resection partial colectomy ~20yo Social History: Lives with:wife Cigarettes: Smoked no [] yes [x] last cigarette 40yo Hx:13-14yr ETOH: < 1 drink/week [x] Family History: noncontributory Physical Exam: Pulse:68 Resp:18 O2 sat: 97%RA B/P 136/87 Height: 5'9" Weight:168 LBS General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x]decreased Heart: RRR [x] Irregular [] Murmur [x] grade III/VI______ Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: (L)LE superficial varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit (B)-soft bruits, pulses- Right: 1+ Left:1+ Brief Hospital Course: Transferred in from outside hospital for surgical evaluation due to coronary artery disease, aortic stenosis, and carotid stenosis. His preoperative workup include CT scan, echocardiogram, and dental clearance. Vascular surgery was consulted for carotid stenosis on left 80-99% and was started on heparin for anticoagulation. On [7-5] he was brought to the operating room for aortic valve replacement, coronary artery bypass graft and L carotid endartectomy. See operative report for further details. He received vancomycin and cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management on propofol and phenylephrine. He was weaned off phenylephrine and was started on nitroglycerin and then nicardipine for hypertension management. He remained intubated overnight and was weaned from propofol but due to anxiety was placed on precedex for weaning from ventilator, he awoke neurologically intact, was extubated without complications, and then precedex was stopped. He was weaned off all drips and started on betablockers and diuretic. He continued to progress and was transferred to the floor in the afternoon. On post operative day two, physical therapy worked with him on strength and mobility.Chest tubes and pacing wires removed per protocol. He had intermittent A Fib and was started on amiodarone.Continued to make good progress and was cleared for discharge to [Hospital3 7665] in [Hospital1 3597], NH on POD #4. All f/u appts were advised Medications on Admission: methyldopa 250 [Hospital1 ] asa 81mg daily zocor 10mg hs cozaar 50mg daily HCTZ 12.5 levothyroxine 50mcg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [12-17] Puffs Inhalation Q6H (every 6 hours). 6. methyldopa 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks: 400 mg [Hospital1 ] through [7-15], then 400 mg daily [Date range (1) 88761]; then 200 mg daily ongoing. 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: please monitor weight and creatinine. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO twice a day: hold for K+ > 4.5. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic stenosis s/p AVR Carotid stenosis s/p Left CEA Paroxysmal atrial fibrillation Non ST elevation myocardial infarction (troponin 0.23 OSH) Hypertension Hypothyroidism Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Left neck Edema 1+ BLE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Completed by:[2148-7-9]	[ "4241", "41071", "41401", "42731", "4019", "2724", "2449", "V1582" ]
Admission Date: [2106-5-6] Discharge Date: [2106-5-20] Date of Birth: [2045-9-16] Sex: M Service: DISCHARGE DIAGNOSES: Dyspnea. Renal cell carcinoma. HISTORY OF PRESENT ILLNESS: Sixty-year-old male with history of renal cell carcinoma with recent CT scan showing right subcranial/hilar mass 6.9 x 3.5 cm with right lower lobe bronchus obstruction and right lower lobe collapse presented on the admission date to Interventional Pulmonary for bronc. The IP team felt that the patient appeared too ill for a procedure at that point. The exact details were unknown, directly admitted for further work up, initially to the service at which point, he denied any nausea, vomiting, fever or chills, no increased shortness of breath except his increased cough, complained of rib cage diffuse pain and dry cough times two days which increased with rib pain and he also has noticed a loss of seventeen pounds in the past few months. PAST MEDICAL HISTORY: His past medical history is significant for renal cell carcinoma, diagnosed in [5-/2104], radical right sided nephrectomy, RAF, left renal mass, two cycles vial II. He was on UPenn's experimental protocol, XRT plus steroids for T5 lytic lesions, resection lung mass in 02/[2105]. Other past medical history, hypertension, rosacea, status post vasectomy. HOME MEDICATIONS: His home medications were Oxycodone 5 mg every six hours PRN, Norvasc PO 10 mg every day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with his wife, CEO of his own company, occasional alcohol, no tobacco. PHYSICAL EXAMINATION: Vital signs on admission, temperature 99.3 F, heart rate 60, blood pressure 164/88, respiratory rate 22, O2 saturation 93% on five liters nasal cannula. On examination, he was a pleasant gentleman in no acute distress, well developed male. HEENT, dry oral mucosa. The neck was supple. Heart, decreased heart sounds, regular rate and rhythm, no murmurs, gallops or rubs. Lungs, very small breath sounds felt on the right side, especially basilar up to one-half up to the right side, left side with mild rales, mostly rales. Abdomen, bowel sounds were present, mild hepatomegaly but nontender, nondistended abdomen. Extremities, no clubbing, cyanosis or edema. Neurologic, he was alert and oriented times three and grossly intact neurologically. LABORATORY DATA: Laboratory studies on admission, white blood cell count 5.8, hematocrit 34.4 with previous one 34.7, platelet count 159,000, INR 1.2, PTT 23.7, sodium 132, potassium 5.0, chloride 97, bicarbonate 21, BUN 34, creatinine 1.6, which was 1.3, the last check, glucose 238, ALT 38, AST 45, alkaline phosphatase 99, total bilirubin 0.7, albumin 2.5 and the blood cultures were drawn and were pending at the time of admission. Chest x-ray showed right lower lobe collapse/consolidation and large right pleural effusion questionably on preliminary. HOSPITAL COURSE: His course was respiratory alkalosis, post-obstructive right lower lobe infiltrate with strep pneumo in two out of two blood cultures from admit. He defervesced on Levofloxacin and Flagyl, persistent O2 requirement so sent to bronc on [2106-5-10], by IP and he is now since he has been sent to IP, he was status post removal of endobronchial lesion, right bronchus intermedius and post-procedure had respiratory distress requiring intubation, which he was sent to the MICU and since did okay post-extubation. He was sent back on the floor but now on [Hospital Ward Name 517], admitted to the [Hospital Ward Name 517] [Hospital1 139] team. Since being admitted to [Hospital Ward Name 517] [Hospital1 139] team, he underwent another interventional pulmonary procedure, initially, it was planned on him questionably getting a stent done in place but the procedure was basically a similar procedure to the previous one, no stent was placed. The patient tolerated the bronchoscopy well without any problems. His O2 requirements actually have improved prior to his discharge. The other thing is that he has remained on Levo and Flagyl. The plan is continuing him for a three week course. He is going to continue another two weeks post-discharge and continuation to be decided by primary physician. [Name10 (NameIs) ] plan is to wean him off his O2 nasal cannula, once he gets admitted to the rehabilitation to keep O2 saturations greater then 92%. On the day of discharge, he has been weaned down from six liters to five liters now to four liters nasal cannula. Prior to his discharge, he had an ultrasound done, which was with a questionable right sided effusions, which were found not to be effusions and mostly tissue and no need for tap at the time by IP service. The patient was planned on following up with Oncology later on and to continue his Levo-Flagyl since his cultures have been negative so far. His acute renal failure that he presented on admission has resolved and he is now down to 0.7, it was thought to be probably most likely secondary to pre-renal state, given BUN and creatinine ratio close to 20 and also the patient being dry on examination. The patient's hypertension is controlled with outpatient medications. The patient's pain medications controlling the patient's rib pain. No acute new problems on discharge. ID wise, his pneumococcal/pneumonia/CAP plus post-obstructive pneumonia was as noted, to continue his Levofloxacin and Flagyl since when he was taken off Flagyl and was taken to the unit from the, he required Clindamycin for a day and then he was taken off the Clindamycin but then when he was brought to the [Hospital1 139] service, he actually spiked a temperature. With the elevated temperature and leukocytosis, it was felt that the patient could benefit from some anaerobic coverage. At that point, Flagyl was added, which was last week, prior to discharge. The patient's elevated blood pressures resolved since and he was continued on the Levo-Flagyl for resumed post-obstructive pneumonia. In terms of heme, his hematocrit has remained relatively stable. He received two units of packed red blood cells last week and since then, his hematocrit has remained relatively stable. It is thought that his low hematocrit is probably secondary to decreased PO intake, nutritional problem and also could be related to his eighteen pound weight loss over the past few months. He has normal LFT's normal platelets and he refused digital rectal examination but we are guaiacing all of his stools. In terms of his neurologic, per MRI on [5-7], there was no sign of cord compression from his metastases and there was plan of following up for XRT per Rad/Onc but Rad/Onc have decided for now that he is not a candidate for the time being and to be followed up by Oncology for further follow-up and possibly maybe later on become a candidate at Oncology and Rad/Onc's discretion. He also has a tachycardia with ectopy, which has been pretty stable. We repleted his electrolytes PRN and his tachycardia has remained sinus tachycardia since admission and on discharge date, he still continues with the mild tachycardia. The patient is being discharged to rehabilitation facility for further rehabilitation care, stable condition. FINAL DIAGNOSES: Renal cell carcinoma, status post IP intervention times two with debridement. Follow-up with PCP and primary oncologist as prescribed and the patient was sent to rehabilitation on the following medications, Neutra-Phos PRN and following his magnesium and phosphorous close, Trazodone 12.5 mg PO at bedtime, PRN, Codeine 15 mg IV every four to six hours PRN, Heparin subcutaneous every eight hours, 5,000 units, Metronidazole 500 mg PO every eight hours for fourteen more days and Pantoprazole 40 mg PO every twenty-four hours, Amlodipine 10 mg PO every day, Metoprolol 50 mg PO twice a day, Levofloxacin 500 mg PO every twenty-four hours for another twelve days, Docusate 200 mg PO twice a day, Senna one tablet PO twice a day, Oxycodone 5 mg PO every four to six hours PRN for pain and also continue on insulin sliding scale per protocol. Follow-up is as discussed above. The patient is going to the rehabilitation center today. [Doctor Last Name 2511],[Name8 (MD) ] MD. [MD Number(2) 12441] Dictated By:[Name8 (MD) 6112] MEDQUIST36 D: [2106-5-19] 08:11 T: [2106-5-19] 08:15 JOB#: [Job Number 12442]	[ "5849", "4019" ]
Admission Date: [2135-6-25] Discharge Date: [2135-7-7] Date of Birth: [2084-5-28] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[First Name3 (LF) 3705] Chief Complaint: CC:[CC Contact Info 35172] Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 51 yo male with a h/o ESRD on HD due to amyloidosis (last HD Thursday) who is transferred from [Hospital ] Hospital for persistent hypotension. Per Dr.[Name (NI) 4857] note in OMR, [Hospital1 1501] called to [Hospital1 18] HD unit on [6-24] to report that [Known firstname ] had disconnected his recently placed PD catheter. He was transported into [Hospital 2793] Clinic and had 'transfer set' changed. Due to break in sterility, 1 gram IP Vancomycin was infused empirically. Catheter was taped down such that it would be more difficult for patient to tamper with. Upon returning to his [Hospital1 1501], Mr. [Known lastname ] [Last Name (Titles) ] was noted to have increasing lethargy and hypotension and was transported to [Hospital ] Hospital, arriving at 3:45 p.m. At time of arrival, he was reported as seeing bright blurred colors in front of eyes and complaining of pain in fingers. His initial BP was recorded as 54/40. With fluid resuscitation, BP's gradually increased from 60's to 80 systolic, but then dropped to 68/42, prompting initiation of dopamine gtt. HR remained in 70's until initiation of dopamine gtt, then increased to 90's. Prior to transfer, he received ASA 162 mg, hydrocortisone 100 mg IV, and gentamycin 150 mg IV, and dopamine gtt titrated up to 8 mcg/kg/hour for target SBP >100. Blood cultures were drawn. On arrival in the [Hospital1 18] ED, T 97.8, HR 83, BP 75/38, RR 18, SpO2 100% on 3L NC O2. He received cefepime 2 grams IV and morphine 4 mg IV for 6 out of 10 pain in his fingers. Past Medical History: ESRD secondary to amyloidosis -failed LRRT in [7-5] now on hemodialysis (right groin line) inferior vena cava stent Sarcoidosis Pulmonary aspergillosis - on chronic voriconazole Type 2 Diabetes, on insulin Chronic Hepatitis C Hypertension Sinusitis Paroxysmal atrial fibrillation, Clostridium difficile [3-8] MRSA line sepsis Renal osteodystrophy Adrenal insufficiency Upper extremity deep vein thrombosis ([2132]) Pancreatitis Bilateral below the knee amputation Right index and fifth finger amputations Social History: Smoked 1 pack per day X 30 years but quit. History of alcohol abuse, but stopped 4 years ago. Previous drug use with cocaine (+IV drug use), has been clean since about [2127]. Girlfriend [Last Name (un) 102399] is involved in his care. Lives in a care home in [Location (un) 669]. Mother lives nearby. Family History: Mother, brother with diabetes. No h/o kidney disease Physical Exam: VS: T 96.8, BP 110/67, HR 95, SpO2 100% on 3L HEENT: clear OP, MMM, sclerae anicteric CV: S1, S2, RRR, 2/6 systolic murmur best auscultated at LLSB, Resp: Lungs clear b/l but with poor air movement throughout. Abd: PD catheter intact, distended and diffusely tender, diminished bowel sounds Extrem: Right femoral catheter clean, dry, no erythema or induration. B/l BKA well healed, skin somewhat dry. No edema. Missing digits of his hands with necrotizing segments distally. Neuro: alert, oriented to self, place, year but not date; unable to provided details of prior day or of his medical history Pertinent Results: [2135-6-25] 04:54AM GLUCOSE-88 UREA N-37* CREAT-6.0* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-18* ANION GAP-22* [2135-6-25] 04:54AM CALCIUM-10.2 PHOSPHATE-8.3* MAGNESIUM-2.0 [2135-6-25] 04:54AM CORTISOL-128.7* [2135-6-25] 04:54AM WBC-9.3 RBC-3.95* HGB-11.3* HCT-39.6* MCV-100* MCH-28.6 MCHC-28.6* RDW-19.8* [2135-6-25] 04:54AM NEUTS-81.4* BANDS-0 LYMPHS-17.2* MONOS-1.0* EOS-0.4 BASOS-0 [2135-6-25] 04:54AM PLT COUNT-359 [2135-6-25] 04:54AM PT-14.5* PTT-34.7 INR(PT)-1.3* [2135-6-25] 01:37AM COMMENTS-GREEN TOP [2135-6-25] 01:37AM LACTATE-0.6 [2135-6-25] 01:25AM GLUCOSE-75 UREA N-35* CREAT-5.9* SODIUM-138 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19 [2135-6-25] 01:25AM CK(CPK)-74 [2135-6-25] 01:25AM CK-MB-NotDone cTropnT-0.35* [2135-6-25] 01:25AM CALCIUM-10.1 PHOSPHATE-7.7* MAGNESIUM-2.0 [2135-6-25] 01:25AM WBC-11.3* RBC-4.11* HGB-11.8* HCT-41.1 MCV-100* MCH-28.8 MCHC-28.8* RDW-20.0* [2135-6-25] 01:25AM NEUTS-79.2* BANDS-0 LYMPHS-18.2 MONOS-1.8* EOS-0.7 BASOS-0.1 [2135-6-25] 01:25AM PLT COUNT-356 [2135-6-25] 01:25AM PT-12.9 PTT-33.2 INR(PT)-1.1 [2135-6-25] 01:00AM GLUCOSE-70 UREA N-35* CREAT-5.7# SODIUM-139 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-16 ANION GAP-22* [2135-6-25] 01:00AM estGFR-Using this [2135-6-25] 01:00AM CK(CPK)-170 [2135-6-25] 01:00AM cTropnT-0.29* [2135-6-25] 01:00AM CK-MB-8 . CXR [6-25]: IMPRESSION: Persistant right upper lobe ground glass opacity, possibly infectious. Brief Hospital Course: Mr. [Known lastname ] is a 50 year old man with history of end stage renal disease secondary to amyloidosis, paroxysmal atrial fibrillation, Type 2 diabetes on insulin admitted to the MICU for hypotension and lethargy in the context of having the transformer set changed of his peritoneal dialysis catheter. # Change in mental status: Patient has progressive obtundation with no obvious source on previous head CT. Repeat head CT showing no evidence of acute intracranial process ([6-27]). Exam was reportedly non focal, pt [Name (NI) 9830]0, and did not follow commands. Pt currently non-responsive. Family contact and decision made not to progressive with aggressive intervention for diagnosis (i.e. no MRI, no intubation for imaging, no LP). Etiology thought to be secondary to sepsis, ?meningitis for which he was covered empirically with cefepime/vancomycin and also with acyclovir. Additional etiology ?recent hypoglycemia, pt on IVF with dextrose. Despite this therapy he continued not to respond. After, several family meetings and involvment with social work and palliative care a decision was made to make pt DNR/DNI with no escalation of care. Over the last few days, pt's breathing became more labored and his oxygen saturation declined. As pt was DNR/DNI/no ICU transfer his respiratory status was made comfortable. Despite continued broad spectrum antimicrobials and continued dialysis sessions and treatment of transient hypoglycemia, pt's mental status never improved and he was not reactive even to sternal rub. On [2135-7-6], after meeting with pt's girlfriend, HCP, and after discussion with patient's family, decision was made to change the patient's status to CMO. Pt was then placed on a morphine gtt and he passed away on [2135-7-7] at 6am. # Hypotension: The initial differential included distributive shock due to infection vs. endocrine vs. cardiogenic. Given his history of line infections and bacteremia and recent violation of sterile PD catheter field, infectious etiology was considered most likely. Exam on admission was significant for diffuse abdominal tenderness, concerning for peritonitis. Also considered was the HD line in right groin as possible source of bacteremia. He had no other localizing symptoms. He was started on vanc/cefepime as patient has h/o colonization with both MRSA, pseudomonas. Blood cx were drawn at [Hospital ] Hospital, as well as at [Hospital1 18] - no growth to date at time of discharge. An attempt was made to obtain peritoneal fluid for cell count, cultures. He was on a dopamine gtt titrated to MAP > 65, also received fluids at the OSH ([Location (un) ]) and in the ED. His dopamine was titrated off and he was transferred to the medical floor where his blood pressures were stable, however his mental status rapidly deteriorated. # ESRD: The patient has been on dialysis secondary to amyloid, currently on HD with plan for transition to PD. He is status post peritoneal dialysis catheter placement [6-10], needs 2-3 weeks to heal prior to use. Renal consult was following while he was in the ICU. He was continued on his sevelamer at an increased dose secondary to hyperphospetemia, cinecalcet. His vanc was dosed at HD. HD sessions were continued until [2135-7-6] and the renal team was very involved with the patient's care. # Finger ischemia: The ischemia is consistent with history of extensive microvascular disease. He is not currently anticoagulated given bleeding risk. He has previously been seen by Plastic Surgery who felt his finger segment will auto-amputate. He generally receives oxycodone PRN pain # Thrombosis: The patient has known extensive inferior vena cava clot burden to level of right atrium and likely involvement of superior vena cava. There is a high degree of risk associated with anticoagulation in this patient related to history of hemodynamically signficant epistaxis, recurrent epistaxis, and hemoptysis related to fungal lesion in left upper lobed of the lung. The risks/benefits of anticoagulation have been discussed at length during previous hospitalization, with decision not to anticoagulate. # DM2 uncontrolled with complications: The patient had several episodes of hypoglycemia while on the floor which required amps of D50 to correct. Pt was placed on a D5 gtt. # PAF: The patient is currently in NSR. His beta blocker was originally held in the setting of his hypotension. # Sarcoidosis: The patient was on chronic prednisone. # Pulmonary aspergillosis: The patient was continued on his chronic suppressive voriconazole. Medications on Admission: 1. Albuterol neb q4 hours 2. Metoprolol 12.5 mg [Hospital1 ] 3. Omeprazole 20 mg daily 4. Prednisone 5 mg qAM 5. Prednisone 2.5 mg qHS 6. Bactrim 160/800 mg QHD 7. Colace 100 mg [Hospital1 ] 8. Senna 8.6 mg [Hospital1 ] 9. Nephrocaps 10. Bacitracin Zinc 500 unit/g Ointment [Hospital1 ] 11. Sodium Chloride nasal spray [Hospital1 ] 12. Voriconazole 200 mg Tablet [Hospital1 ] 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H 14. Lantus 100 unit/mL Cartridge Sig: Eight (8) units qHS and sliding scale 15. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID 16. Lactulose 15 mL [Hospital1 ] 17. Bisacodyl 5 mg PO daily 18. Oxycodone 5 mg q4 hours PRN 19. Cinacalcet 30 mg daily Discharge Medications: N/A pt expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Hypotension Secondary: ESRD [3-5] to amyloidosis Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a	[ "0389", "2767", "25000", "42731", "4019", "V5867" ]
Admission Date: [2116-7-12] Discharge Date: [2116-7-24] Service: HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old female with a history of coronary artery disease status post percutaneous transluminal coronary angioplasty nine years ago at [Hospital6 33] who presented to [Hospital6 33] on [7-6] with acute onset of chest pain, back pain and bilateral arm pain. She was admitted with unstable angina symptoms and placed on an oxygen, nitroglycerin beta blocker. Her cardiac catheterization revealed severe three vessel coronary artery disease with a 50% left main stenosis and is referred to the Coronary [Hospital1 69] for revascularization. The patient is a resident of the [Hospital 2670] Nursing Home where she was admitted with fibromyalgia rheumatica. Prior to this diagnosis she lived independently at [Last Name (un) 42670]. She also had a urinary tract infection and she had been treated with Ceftriaxone preoperatively. The patient is DNR/DNI. PAST MEDICAL HISTORY: Significant for coronary artery disease status post percutaneous transluminal coronary angioplasty with 95% left circumflex lesion in [2106], type 2 diabetes, fibromyalgia rheumatica, gastritis, osteoarthritis, Alzheimer's disease, rheumatoid arthritis, hypothyroidism. MEDICATIONS AT HOME: Darvocet N 100 q 4 h prn pain, nitroglycerin patch, Glucophage 500 mg po q.d., Pepcid 20 mg b.i.d., Synthroid either 25 micrograms or 50 micrograms b.i.d., Prednisone 5 mg po b.i.d. MEDICATIONS AT OUTSIDE HOSPITAL: Synthroid 50 micrograms once a day, Celexa 20 mg once a day, Neurontin 300 mg twice a day, Glucophage 500 mg q.d., Aricept 5 mg q.o.d., Prednisone 5 mg b.i.d., Lovenox 80 mg b.i.d., Ceftriaxone two doses, Nitropaste, Accupril 5 mg q.d., Lipitor 20 mg q.d., Trazodone 25 mg q.h.s., aspirin 81 mg q.d., Atenolol 12.5 mg q.d., sliding scale of regular insulin. PHYSICAL EXAMINATION: On admission she was afebrile 97.2 with a heart rate of 58, blood pressure of 118/52, respiratory rate 18, 92% on room air. She was an elderly white female in no acute distress. Her lungs were clear bilaterally. Her neck was within normal limits without any evidence of JVD. Her heart was a regular rate and rhythm. She had good breath sounds bilaterally. Her extremities showed 1+ pitting pedal edema and she had multiple ecchymosis over frail skin. Neurologically she was grossly intact, alert and oriented, conversant and appropriate. HO[Last Name (STitle) ] COURSE: In summary the patient is an 84 year-old former DNR who was taken to the Operating Room for a coronary artery bypass graft with Dr. [Last Name (Prefixes) ] where an saphenous vein graft to left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery and saphenous vein graft to DM bypass was done. Cross clamp time was 39 minutes, bypass time was 72 minutes. Neurological: The patient was in the Intensive Care Unit postoperatively where she remained until [2116-7-21]. She was slow to wake up. She showed left sided weakness and symptoms of possible stroke. A neurology consult was immediately obtained after a suspicion grew to point toward a stroke and a CT scan done showed that she might have had a right or middle cerebral artery watershed event. The patient's treatment was maintain her perfusion pressure, which was done in the unit and to keep her symptomatically in good support. Neurology will follow up with her upon discharge. Cardiovascular: The patient had several premature ventricular contractions immediately postoperatively and was put on a Lidocaine drip, which was switched over to Amiodarone. The patient then in the Intensive Care Unit had atrial fibrillation during the latter half of her Intensive Care Unit stay. Her beta blocker was started of Lopressor and this resolved on its own with Amiodarone and Lopressor. She was weaned off drips and was maintaining her own blood pressure upon discharge in sinus rhythm. Respiratory: The patient was slowly extubated due to her sedate state and questionable neurological status immediately postoperatively. The patient woke up and demonstrated adequate awareness she was immediately extubated and did well. Gastrointestinal: Consideration was given toward tube feeds by postoperatively four to five while the patient was still sedate, however, she was then extubated and she was allowed to take a diet as tolerated. Otherwise she was given gastrointestinal prophylaxis in the form of Prevacid 30 mg po q.d. Infectious disease: The patient had no acute infectious disease issues and received Vancomycin perioperatively. Hematology: The patient's hematocrit was stable. She received several blood transfusion during her hospital stay. She will be discharged to home with deep venous thrombosis prophylaxis. Extremities: The patient is fluid overloaded and will require ambulation, physical therapy and help with diuresis. Fluid, electrolytes and nutrition: The patient's electrolytes and balanced fluids showed that she has interstitial edema of her skin. She will be given a diuretic. Her preop weight and postop weight are relatively similar, however. The patient is to follow up with her primary care physician for all medical issues. On [7-21] the patient was transferred out of the Intensive Care Unit and on to the floor and all rehab services were contact[Name (NI) ] as well as the social worker. She was doing well on the floor in no acute distress. On [7-23] no complications occurred. On [7-24] she was given a chance for rehab screen and is discharged to home in excellent condition. DISCHARGE MEDICATIONS: Regular insulin sliding scale starting at 150 going up by 3 for every 50 mg increase per deciliter of blood sugar. Amiodarone 400 mg po b.i.d. for thirty days and then q.d., Lopressor 12.5 mg po b.i.d. to be titrated to a heart rate of 70 so long as the blood pressure tolerates it. Lasix 20 mg po b.i.d. times five days and then q.d. times one week. K-Ciel 20 milliequivalents po b.i.d. times five days and then q.d. times one week. Aricept 5 mg po q.h.s., heparin subQ 5000 units b.i.d., Gabapentin 300 mg po t.i.d., Captopril 6.25 po q.d., Prevacid 30 mg po q.d., Glucophage 500 mg po q.d., Colace 100 mg po b.i.d., Prednisone 10 mg po q day, Synthroid 50 micrograms q.d., Prevacid 30 mg po q day. Upon discharge the patient is in good and excellent condition and will follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for surgical issues and four weeks Dr. [First Name (STitle) ] [Name (STitle) ] her primary care physician and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 42671] at [Telephone/Fax (1) 42672] for all neurological issues. The patient understands the discharge plan and is in good condition. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2116-7-24] 08:01 T: [2116-7-24] 08:14 JOB#: [Job Number 42673]	[ "41401", "42731", "25000", "2449" ]
Admission Date: [2160-4-27] Discharge Date: [2160-5-7] Date of Birth: [2094-2-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: AMS, fever Major Surgical or Invasive Procedure: Lumbar puncture Intubation and extubation Picc line placement and removal History of Present Illness: Mr [Known lastname ] is a 66M with parkinson's s/p brain implant transferred from nursing home with malaise, AMS, fevers. The pt was at baseline and not complaining of any problems yesterday from [6-24]. Around 8 PM on [4-26], the pt was noted by nsg home staff to be in bed, lethargic and not responsive to voice, which is different from his alert/verbal baseline. There was some question of seizure activity because he was found with both arms clenched and rigid in upward position. Vitals at the time were 97.8, 74 24 120/60 96% on 2 L. When EMS arrived he was noted to be unresponsive, with eyes open but pupils glossy but reactive. RR was 22, 99% on RA. He was transferred to [Hospital3 2783] where vitals were 100.7 160/80 79 20 95% and he was noted to be weak and not responding to verbal stimuli initially, later was responding to son who reported he was at baseline. He was given zosyn 3.375 mg, 2 mg ceftriaxone. Pt was placed on BiPAP as family was considering de-escalating goals of care from full code. On arrival to the [Hospital1 18] ED, initial VS were 118/49 71 16 100%. ABG showed 7.25 pCO2 94 pO2 198 HCO3 43. UA showed sm leukocytes, mod blood. Pt arrived here with somewhat improved abg, but worsening resp rate and didn't seem to be protecting airway. Discussions with family did not lead to reversal of full code and so patient was intubated. Pt was started on vanc/zosyn/ceftriaxone/cefepime at meningitis dosing, started on a propofol drip. Blood and urine cultures were sent, LP was attempted but was unsucessful. On arrival to the MICU, patient's VS were T100 66 140/62. He is intubated and sedated. Review of systems: unable to complete due intubation/sedation Past Medical History: -parkinsons -stroke, residual L-sided deficit -brain stimulator -GERD -spinal fusion -HTN -CAD -depression -recent hospitalization x4 wks at [Hospital1 2025] for "assault" at nsg home Social History: Lives in [Doctor Last Name ] View Care and Rehabilitation Center. Uses wheelchair. tob/etoh/illicits hx unknown Family History: unknown Physical Exam: Admission Physical Exam: Vitals: T100 66 140/62 General: intubated, sedated HEENT: Sclera anicteric, MMM, pupils minimally reactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: sedated Discharge physical exam: Vitals: T 98.4 70s 164-171/80s 20 97% on RA General: Interactive, following all commands and answering all questions appropriately. HEENT: PERRL, anicteric sclera, OP clear. Able to turn neck left and right 45 degrees without pain. Very stiff muscles at times CV: S1S2, RRR, 2/6 systolic murmur over RUSB, non harsh not radiating Lungs: Poor air movement and rhoncorous with basilar crackles. Ab: Positive BS??????s, NT, mildy distended. No HSM. Ext: No c/c. Edema improved. [12-24]+ pulses. Tight quadricceps. Hands flexed and contracted Neuro: Alert, oriented to day / date / month / year and ??????[Hospital 61]??????. 5/5 strength in upper extremities. [3-27] in lower extremities Pertinent Results: Admission Labs: [2160-4-27] 03:30AM BLOOD WBC-6.7 RBC-4.73 Hgb-14.8 Hct-47.1 MCV-100* MCH-31.2 MCHC-31.3 RDW-13.5 Plt Ct-202 [2160-4-27] 03:30AM BLOOD Neuts-75.3* Lymphs-20.0 Monos-4.4 Eos-0.2 Baso-0.2 [2160-4-27] 03:30AM BLOOD PT-10.3 PTT-30.7 INR(PT)-0.9 [2160-4-27] 03:30AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-141 K-4.5 Cl-97 HCO3-35* AnGap-14 [2160-4-27] 04:11AM BLOOD Type-ART pO2-198* pCO2-94* pH-7.25* calTCO2-43* Base XS-10 [2160-4-27] 03:29AM BLOOD Lactate-1.9 [Hospital3 ]: [2160-4-27] 04:40AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2160-4-27] 04:40AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2160-4-27] 04:40AM URINE RBC-83* WBC-13* Bacteri-NONE Yeast-NONE Epi-<1 [2160-4-27] 06:29AM BLOOD Type-ART Temp-37.8 Tidal V-448 PEEP-6 FiO2-100 pO2-368* pCO2-61* pH-7.35 calTCO2-35* Base XS-6 AADO2-290 REQ O2-54 -ASSIST/CON Intubat-INTUBATED ABGs: [2160-4-27] 10:26AM BLOOD Type-ART pO2-117* pCO2-40 pH-7.51* calTCO2-33* Base XS-8 Comment-ADD ON [2160-4-27] 10:26AM BLOOD Lactate-2.1* CSF: [2160-4-27] 01:15PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-0 Polys-0 Lymphs-96 Monos-4 [2160-4-27] 01:15PM CEREBROSPINAL FLUID (CSF) WBC-12 RBC-1* Polys-2 Lymphs-92 Monos-6 [2160-4-27] 01:15PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-80 [2160-4-27] 01:15PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Negative Discharge Labs: Specimen hemolyzed: [2160-5-6] 06:55PM BLOOD WBC-6.3 RBC-4.43* Hgb-13.8* Hct-43.4 MCV-98 MCH-31.0 MCHC-31.7 RDW-13.9 Plt Ct-248 [2160-5-7] 10:12AM BLOOD Na-140 K-5.2* Cl-95* [2160-5-6] 06:55PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 Microbiology: [2160-4-27] 1:15 pm CSF;SPINAL FLUID GRAM STAIN (Final [2160-4-27]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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 [2160-4-30]): NO GROWTH. VIRAL CULTURE: NO VIRUS ISOLATED. [2160-4-27] MRSA SCREEN - Negative (final) [2160-4-27] BLOOD CULTURE x2 - No growth [2160-4-27] URINE CULTURE - Negative (final) [2160-4-30] BLOOD CULTURE x2 - No growth Imaging: CXR [4-27]: FINDINGS: A frontal supine view of the chest was obtained portably. Low lung volumes result in bronchovascular crowding. Part of the lung fields are obscured by bilateral pacemakers. The endotracheal tube ends 4.3 cm above the carina. Opacity at the left lung base may represent a small effusion and atelectasis or infection. The cardiac silhouette is difficult to evaluate due to the left lung opacity. The upper lung zones are clear. No large pneumothorax. A nasogastric tube follows the expected course, although the tip is not visualized, possibly in the proximal duodenum. IMPRESSION: Left lower lung opacity may represent small left pleural effusion and atelectasis or infection. CT Head [4-27]: CT HEAD: Study is limited by intracranial leads and patient motion. There is no large acute hemorrhage, mass effect, or large territorial infarct obvious in the parts of brain where well seen. Prominent ventricles and sulci are compatible with global age-related volume loss. Basal cisterns are patent. There is no shift of midline structures. No acute osseous abnormality is identified. Fluid in the ethmoid air cells and and nasal cavities may be related to intubation. IMPRESSION: Limited study due to patient motion and streak artifact from intracranial leads. No acute intracranial large hemorrhage or mass effect identified. Consider repeat study when the pt. is co-operative. Radiology Report CHEST (PORTABLE AP) Study Date of [2160-4-28] 3:57 AM FINDINGS: As compared to the previous radiograph, the endotracheal tube is in correct position and unchanged. The bilateral pectoral pacemakers are also unchanged. Unchanged elevation of the left hemidiaphragm with cranially displaced stomach. No pneumothorax. No other acute changes in the lung parenchyma. The aspect of the cardiac silhouette is constant. Neurophysiology Report EEG Study Date of [2160-4-27] IMPRESSION: Abnormal EEG due to the presence of a slow, disorganized background mostly in the theta and delta frequency ranges. This finding suggests the presence of a moderate diffuse encephalopathy which indicates widespread cerebral dysfunction but is non-specific as to etiology. No focal or epileptiform features were seen. [2160-4-30], Right upper extremity US Somewhat limited study due to difficulty in patient positioning. Right forearm cephalic vein thrombophlebitis. No DVT in the right upper extremity. CXR [5-1] - IMPRESSION: Left PICC line in the left internal jugular vein. Recommend re-positioning. Persistant left perihilar opacity, likely aspiration. [2160-5-1], CT C spine w/o contrast: Multilevel, multifactorial degenerative changes are noted, with narrowing of the disc space, anterior and posterior osteophytes, and facet and uncovertebral degenerative changes. The patient is status post surgery at C3, C4, C5, and C6 levels. No obvious canal stenosis is noted. Multilevel foraminal narrowing is noted. No obvious acute fracture is noted in the cervical vertebral bodies. Lucencies noted in the osteophytes anteriorly, may relate to orientation of the osteophytes. There is no large amount of prevertebral soft tissue swelling. Evaluation is somewhat limited due to the scoliosis and motion-related artifacts. There are areas of increased attenuation in the lungs on both sides, part of which may relate to motion. This can be better assessed with dedicated chest imaging. IMPRESSION: 1. Scoliosis, diffuse osteopenia and motion-related artifacts limit accurate assessment. Within this limitation, no obvious large fracture. Lucencies noted in the osteophytes likely relate to the oblique orientation of the osteophytes. Correlate clinically to decide on the need for further workup with MRI if not contraindicated for better assessment. 2. Status post surgery with anterior and posterior fusion hardware. No obvious loosening noted. Other details as above. [2160-5-2] CXR: As compared to prior study, left perihilar consolidation has decreased and small likely consistent with aspiration as opposite to pneumonia. Left lower lobe consolidation is unchanged, associated with pleural effusion. The right lung is unchanged in appearance as well as the bilateral deep brain stimulators. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 66yo male with PMH of Parkinson's Disease, stroke, and s/p bilateral deep brain stimulator placement, who was admitted for altered mental status. # Altered mental status/encephalopathy: The patient had multiple possible etiologies for his altered mental status. Most likely given questionable pneumonia on CXRay and in the setting of intubation and hypercarbic respiratory failure, it was felt that pt had aspiration event vs pna vs both. There was some question of seizure activity given his rigid state, however no overt seizure activity was observed and it was felt that this rigidity was at baseline due to to parkinson's and dystonia. EEG revealed diffuse slowing but no epileptiform activity. Infectious causes were likely given fever at OSH. Patient was started on ceftazidime and vancomycin which was broadened to include meningitis coverage plus acyclovir for possible HSV encephalitis. LP showed lymphocytosis initially concerning for viral infection. However, this slight leukocytosis with lymphocytic predominence could be due to hardware. HSV PCR was negative and preliminary viral cultures were negative. Thus, antibiotics were downtitrated and acyclovir discontinued. Low concern for stroke given patient was observed to be close to baseline motor skills. Head CT from OSH showed no evidence of intracranial bleed. The patient ultimately was placed on a regimen of ceftazidime and levofloxacin to cover for health care associated pneumonia. He remained afebrile and his mental status improved dramatically. It is unclear whether this was due to the treatment of an acutal pneumonia or the resolution of an acute aspiration chemical pneumonitis event. Given how sick he was, requiring intubation and the improvement while on antibiotics, it was felt to be most reasonable and safest to complete an 8-day course for HCAP with ceftazidime and levofloxacin. Blood and urine cultures were negative. No evidence of metabolic abnormalities to cause AMS based on electrolyte panel. PICC line was placed to finish course of abx: ceftazidime and levofloxacin, last day [5-5]. . # Hypercarbic respiratory failure: Patient was unable to protect his airway in the setting of altered mental status. This may have been from pneumonia or aspiration event as above as no other sources were identified. Per the patient's son, the patient had respiratory problems since discharge from [Name (NI) 2025] in [Month (only) 956], which the son was concerned could be due to cervical spine injury. Patient was successfully extubated and weaned from supplemental oxygen. By the time of discharge, he had O2 saturation levels around 97% on room air. . # Parkinson's disease: Advanced, requiring deep brain stimulator placement. The patient was initially unable to take home Sinemet, baclofen, and pyridostigmine due to NPO status. These were provided later via NG tube. His DBS stimulators were evaluated by the Neurology team who recommended continuing his baclofen and pyridostygmine at home dosages. Pt was evaluated by speech and swallow team and his diet was changed to thin liquids and ground solids. His pills were crushed and the patient tolerated this diet without difficulty. . # Hx CAD, native vessel: No evidence of active ischemia. Continued atenolol, aspirin. Defer statin to outpatient setting. # Ileus: At the time of admission, the patient had bilious drainage from his NG tube with a benign abdominal exam. LFTs were wnl but for an elevated LDH. NGT stopped draining bilious fluid and tube feeds were initiated as tolerated. Patient was subsequently cleared by speech and swallow evaluation and advanced diet per their recommendations to ground solids and thin liquids. . # Neck stiffness: Son [Name (NI) 112335] concerned about leftward positioning of neck. Patient with intermittent stiffness and pain which resolved with muscle relaxants. CT scan of neck showed no evidence of acute fracture with a limited study based on motion artifact but with chronic degenerative changes, osteophytes, osteopenia, and scoliosis present. The patient was able to turn his head and complained of no pain over cervical area on palpation. He did have intermittent episodes when his neck became stiff, appeared more dystonic, and this was accompanied by diaphroesis. He also complained of some leg pain and on examination there were intermittent episodes where his legs were stiff as well. These episodes resolved with time and also with muscle relaxant medications. Thus, his baclofen was increased, he was started on flexeril, and he was continued on clonezapam. These medications resolved his symptoms. During these episodes, the patient felt uncomfortable, but was still very much responsive and at his mental baseline; his vital signs were stable, with good O2 saturations >93% on room air. Speaking with Dr. [First Name (STitle) 7951] and reviewing the [Hospital1 2025] discharge summary, these are chronic issues. Reviewing the [Hospital1 2025] discharge summary, imaging was not remarkable for fracture and ortho-spine was consulted which found no acute injury and no need for surgical intervention. Here, neurology and ortho-spine were consulted and reviewed the imaging and reached similar conclusions, feeling that outpatient management was the best option for these chronic issues, and agreed with muscle relaxants as well as outpatient Botox injection versus trial of cervical traction for this patient. Despite these recommendations, the son remained very upset about his dad's neck, and feels that these occurred acutely after alleged assault at nursing home. There are a lack of records regarding this alleged assault and discussion with outpatient neurologist confirmed that rigidity and parkinson's are chronic issues. The son became verbally aggressive toward staff and providers and was demanding in terms of his requests for surgical intervention at times insinuating litigation if we did not act in accordance with his wishes, and stated that he felt that these issues were new and occurred after a nursing home "assault" and did not feel that dystonia, muscular stiffness, torticollis, or severe Parkinson's was contributing to the patient's clinical picture. The patient and his son are aware that ortho-spine and neurology here evaluated the patient during this hospitalization and offered to see the patient again as an outpatient. Dr. [First Name (STitle) 7951] (the patient's outpatient neurologist) was alerted to the plan of care and the patient will follow up with him after discharge. . # Hypertension, benign: Pt was started on lisinopril. Continued on atenolol and lasix. . # Edema: Pt with mild swelling throughout, despite being net negative while here. Most likely, this is related to his being bed bound. Pt continued on lasix. . Transitional: -Follow up with neurology for parkinson's disease, neck stiffness. Consider Botox injection to neck. -Increased dose of baclofen and started Flexeril, per Neurology recommendation. -Outpatient neurologist: Dr. [First Name (STitle) 7951] (neurology) [Telephone/Fax (1) 112336] -Continue 1:1 supervision during meals with ground solids and thin liquids. Aspiration precautions. -Last potassium level here was slightly elevated at 5.2, but this specimen was moderately hemolyzed. All K levels here were normal, except for those which were hemolyzed specimens. -Consider follow-up chest x-ray. The last chest x-ray here, on [2160-5-3], showed 1) PICC line tip over proximal/mid SVC. No ptx detected. 2) Increased markings left lung -- ? inflammatory or infectious pneumonitis. The appearance is improved compared with [2160-5-1] and similar or slightly improved compared with [2160-5-2]. -CT of the C-spine on [2160-5-2] showed: 1. Scoliosis, diffuse osteopenia and motion-related artifacts limit accurate assessment. Within this limitation, no obvious large fracture. Lucencies noted in the osteophytes likely relate to the oblique orientation of the osteophytes. Correlate clinically to decide on the need for further workup with MRI if not contraindicated for better assessment. 2. Status post surgery with anterior and posterior fusion hardware. No obvious loosening noted. Other details as above. Medications on Admission: -albuterol PRN -atenolol 100 mg -baclofen 15 mg q hs -baclofen 20 mg q daily -carbidopa-levodopa 25-100 1 tab 9x/day between the hours of 6AM and 10 PM -Clonazepam 0.5 mg q 8 hrs PRN -clonazepam 0.5 mg q HS -Ferrous sulfate 220 mg [Hospital1 ] -lasix 20 mg q day until [5-3] -lidocaine 5% topical to lower back -MV daily -omeprazole 20 mg PO daily -polyvinyl alcohol 1.4 solution opthalmic 2 drops to each eye TID -pyridostigmine bromide 30 mg [Hospital1 ] -sinemet 25-100 [12-24] tab one hour after scheduled dose PRN, may not exceed 4 times in 25 hrs -vitamin D 1000 mg daily -lorazepam 0.25 mg daily for anxiety or rigidity -nystatin to groin daily -fragmin [Numeric Identifier 16351] unit/0.2 mg solution sq daily -cymbalta 60 mg delayed release particles by mouth 60 mg daily -docusate 200 mg daily -ducolax 5 mg daily prn constipation -mgOH 400 mg daily prn constipation -miralax 17 mg daily -senna 8.6 mg daily -acetaminophen 650 mg TID -aspirin 81 mg daily -oxycodone 15 mg q 4 hrs prn pain Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. 2. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q2HRS (): Please give between 0600 and 2200 for total 9 tablets daily. . 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed. 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution Sig: Two [Age over 90 ]y (220) mg PO twice a day. 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lidocaine 5 % Ointment Sig: apply over lower back Topical every six (6) hours as needed for pain. 9. multivitamin Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. polyvinyl alcohol 1.4 % Drops Sig: Two (2) drops Ophthalmic three times a day: to both eyes. 12. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Sinemet 25-100 mg Tablet Sig: 0.5 Tablet PO prn: 1 hr after scheduled dose prn, may not exceed 4 times in 25 hrs . 14. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 15. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO once a day as needed for anxiety or rigidity. 16. nystatin 100,000 unit/g Powder Sig: One (1) application Topical once a day: groin. 17. Fragmin 25,000 unit/mL Solution Sig: continue dosing per LTC facility Subcutaneous once a day. 18. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 19. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO once a day. 20. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 21. magnesium hydroxide 400 mg/5 mL Suspension Sig: Four Hundred (400) mg PO once a day as needed for constipation. 22. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 23. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 24. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 25. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. 26. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 27. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 28. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a day. 29. oxycodone 5 mg/5 mL Solution Sig: Fifteen (15) mL PO Q4H (every 4 hours) as needed for pain. 30. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Doctor Last Name ] View Care and Rehabilitation Center Discharge Diagnosis: Primary: Pneumonia, aspiration, hypertension, Musculoskeletal stiffness and rigidity Secondary: Parkinson's Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [Last Name (Titles) 112337], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for altered mental status and respiratory failure requiring intubation. It is unclear what caused this, but it was thought to most likely be an aspiration, a pneumonia, or a combination of the two. Tests were run to check for infection in your blood, urine, and cerebrospinal fluid, and these tests have all come back negative. You improved on antibiotics, and it was decided to have you finish a course of antibiotics for presumed pneumonia. Your blood pressure was also found to be high and you were started on a new blood pressure medication. You experienced some neck and body stiffness that seems related to a dystonia and your parkinson's disease. We obtained imaging of your neck, which did not reveal any acute fracture as best as we could tell, and neurology and orthopedic spine services were consulted which felt that there was no acute surgical intervention that needed to be performed. They felt that this neck stiffness could be better managed with medications. Medication changes: START Lisinopril for high blood pressure INCREASE Baclofen to three times a day for neck stiffness START Flexeril for neck stiffness Followup Instructions: Please follow up with your extended care facility physician who can continue to coordinate your care. The following appointment was made for you: Name: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 112338],MD Specialty: Neurology When: Friday [5-9] at 3pm Address: [Apartment Address(1) 112339], [Location (un) ],[Numeric Identifier 13108] Phone: [Telephone/Fax (1) 25666] Completed by:[2160-5-7]	[ "5070", "5990", "2760", "53081", "41401", "2859", "311" ]
Admission Date: [2102-11-20] Discharge Date: [2102-11-27] 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) 12] Chief Complaint: AMS and tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 59F with PMH of stage 4 colon CA s/p R hemicolectomy in [2098], s/p chemo with recurrence and currently consented for phase I trial who was referred by PCP for increasing confusion, abdominal pain, and poor po intake. In the ED, initial vital signs were 97.8 151 124/79 16 98% on RA. She was found to be oriented x2, jaundiced, and endorsed RUQ pain. Her exam was notable for jaundice, sinus tachycardia, palpable mass in RUQ, abd nt, guaiac neg stools, and +asterixis. Labs were notable for WBC 24.3 with left shift, positive UA, ammonia level 61, VBG 7.50/40/51/32, Lactate 3.0, Na 129, K 3.0, Cr 0.6, ALT: 39 AP: 756 Tbili: 9.4 Alb: 3.1 AST: 164, negative Utox. Head CT showed no acute process. CTA chest was performed to rule out PE, which was a suboptimal study, that showed Small R pleural effusion with RLL atelectasis, multiple b/l pulmonary nodules up to 6mm slightly increased in size from prior, but no no central PE. It also showed innumerable hepatic metastases infiltrating and enlarging entire liver, increased in number and size since previous CT with marked compression of intrahepatic IVC, hepatic veins, and portal veins, no biliary ductal dilation. There was moderate increased perihepatic ascites. RUQ US was notable extensive intrahepatic mets, patent main portal vein. She was given 3.5L fluids and started on vancomycin and aztreonam for empiric abx coverage. Of note, her HR was noted to be 144 at her most recent onc visit on [11-8]. She had complained of pain in her knees and back, reportedly taking [5-28] vicodin per day. Her pain med regimen was changed at that time to 10mg oxycontin [Hospital1 ] with oxycodone for breakthrough. She had also complained of nausea relieved by lorazepam 1mg approx [Hospital1 ]. She did not complain of abdominal pain at that time, and no confusion was noted. Her vital signs on transfer were 129 112/77 20 100%. On arrival to the [Hospital Unit Name 153], her vitals were 97.7, 130/74, 127, 18, 94% on RA. She complained of feeling tired and weak over the last few days with nausea, no vomiting or diarrhea. She also endorsed increased urinary frequency over the last few days, dizziness, and confusion. She denies fever or chills. Her history is unreliable however, as she is only oriented to self and hospital. Past Medical History: 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 11. Klembsiella UTI ([6-27]--[2102-7-2] admit) Past Oncologic History: ertinent Oncologic history (include past therapies, surgeries, etc): [2098-7-7] when she was diagnosed with adenocarcinoma of the colon at the splenic flexure 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 ---- [2100-8-11] 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. --[2100-8-29] MRI showed 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, Avastin started on C2 --[2101-11-1]; disease progression seen on CT scan. Started on Erbitux/CPT-11. Rec'd a total of 7 cycles. treatment was complicated by hypomagnesemia and severe diarrhea with several doses of chemotherapy being held. --[2102-6-14] CT with interval progression and >20% increase in hepatic disease burden, no new disease sites, CEA rising -- [2102-6-20] C1D1 Capecitabine 1500mg PO BID -- [6-27]--[7-2] admitted for confusion and Klebsiella UTI -- [2102-7-17]-started on CapeOx. C1 c/b n/v during infusion, resolved with antiemetics. C2 ([8-8]) developed intractable n/v, hives during infusion. admitted for observation. C3 ([8-29]) was given per desensitization protocol in the ICU. developed n/v, tachycardia, fever. --[2102-9-20]-consented for phase 1 protocol 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. EtOH: 2 glasses of wine per day Tobacco: 1ppdx10yrs, quit 20yrs ago 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: ADMISSION EXAM: Vitals: 97.7, 130/74, 127, 18, 94% RA General: jaundiced appearing caucasian female, in NAD, comfortable HEENT: Sclera mildly icteric, MMM and pink, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD Chest: port at the left subclavian appears nonerythematous, nontender CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breath sounds at the right base, clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: portruding RUQ irregular mass, diffusely tender, no guarding or rebound, BS present, no fluid wave or distention, nontympanic, small umbilical hernia. 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, gait deferred Pertinent Results: ADMISSION LABS: [2102-11-20] 01:37PM BLOOD Lactate-3.0* [2102-11-20] 01:37PM BLOOD Type-[Last Name (un) ] pO2-51* pCO2-40 pH-7.50* calTCO2-32* Base XS-6 Comment-GREEN TOP [2102-11-20] 01:26PM BLOOD LtGrnHD-HOLD [2102-11-20] 01:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2102-11-20] 01:26PM BLOOD Albumin-3.1* Calcium-10.3 Phos-2.0* Mg-1.9 [2102-11-20] 01:26PM BLOOD Lipase-13 [2102-11-20] 01:26PM BLOOD ALT-39 AST-164* AlkPhos-756* TotBili-9.4* [2102-11-20] 01:26PM BLOOD Glucose-112* UreaN-16 Creat-0.6 Na-129* K-3.0* Cl-83* HCO3-29 AnGap-20 [2102-11-20] 01:26PM BLOOD PT-17.6* PTT-44.2* INR(PT)-1.6* [2102-11-20] 01:26PM BLOOD Neuts-85.7* Lymphs-8.0* Monos-6.1 Eos-0.1 Baso-0.2 [2102-11-20] 01:26PM BLOOD WBC-24.3# RBC-4.10# Hgb-11.5# Hct-35.3# MCV-86 MCH-28.0 MCHC-32.5 RDW-19.4* Plt Ct-481# MICRO: [2102-11-20] URINE URINE CULTURE-PENDING INPATIENT [2102-11-20] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2102-11-20] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] IMAGING: [11-20] CT Head IMPRESSION: No hemorrhage or edema. No change from prior. [11-20] CXR IMPRESSION: 1. Interval increase in right basilar atelectasis. 2. Unchanged appearance of port overlying the left chest with tip in the mid SVC. [11-20] CT Chest/Abd/Pelvis IMPRESSION: 1. Increased number and size of innumerable hepatic metastases, with apparent compression of the intrahepatic IVC and hepatic/portal vein branches on this non-venographic examination, consistent with progression of metastatic disease 2. Slightly increased pulmonary nodules up to 6 mm, attention at follow-up. No pulmonary embolism. 3. New pelvic peritoneal implant and periumbilical nodules, consistent with metastatic disease. 4. Volume overload. [11-20] RUQ u/s IMPRESSION: 1. Extensive, innumerable intrahepatic metastases throughout both lobes of the liver consistent with known metastatic disease. 2. Patent main portal vein with hepatopetal flow. Reversal of flow in the right portal veins. Difficult to assess whether appropriate direction of flow or reversal in the left portal vein. Brief Hospital Course: 59F with Stage IV Colon CA refractory to treatments with advanced hepatic metastasis who presented with altered mental status in the setting of rapidly declining liver function. Attempts were made to treat her encephalopathy, but her liver function continued to worsen and she remained confused despite treatment. She is unable to care for herself and lacks capacity to make informed decisions. Family meeting was held with her healthcare proxies and it was determined that patient should receive Comfort Focused Care with transition to inpatient hospice. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. bimatoprost NF* 0.03 % OU QHS 1 drop topical at bedtime. apply to eyelashes 2. Dexamethasone 8 mg PO DAILY take on day 2 and day 3 after chemotherapy 3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety 4. Omeprazole 20 mg PO DAILY 5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN breakthrough pain hold for oversedation or RR <12 6. Oxycodone SR (OxyconTIN) 10 mg PO Q12H hold for oversedation or RR<12 Discharge Medications: 1. OxycoDONE (Immediate Release) 5-10 mg PO Q4H Pain 2. HydrOXYzine 25 mg PO Q6H:PRN itching 3. Ibuprofen 800 mg PO Q8H 4. Lactulose 30 mL PO BID:PRN constipation 5. Ondansetron 4-8 mg IV Q8H:PRN nausea 6. Sarna Lotion 1 Appl TP QID:PRN itching 7. Senna 1 TAB PO BID:PRN Constipation 8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety Discharge Disposition: Extended Care Facility: Blueberry [Doctor Last Name ] Healthcare - [Hospital1 ] Discharge Diagnosis: Primary: Encephalopathy, Liver Failure Secondary: Colon Cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 805], It was a pleasure caring for you at [Hospital1 827]. You were admitted because of confusion and decline in your liver function. We transitioned our care to focus on your comfort and safety. You should continue pain medications, anti-nausea medications, and any other medications needed to keep you comfortable. Please contact your hospice providers with any questions or concerns about your symptoms. Followup Instructions: Please contact your hospice providers with any questions or concerns about your symptoms. Completed by:[2102-11-27]	[ "2762", "2761", "53081", "4280" ]
Admission Date: [2172-3-24] Discharge Date: [2172-3-30] Date of Birth: [2152-10-20] Sex: M Service: [Doctor Last Name 1181] ADMISSION DIAGNOSIS: Liver failure due to acetaminophen overdose. HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old male with history of polysubstance abuse/dependence, who presented to outside hospital with nausea and vomiting secondary to intentional Tylenol and Motrin overdose. Patient is being transferred back to General Medicine floor after a second short MICU stay. On [2172-3-19], the patient was in a motor vehicle accident, which totalled uncle's girlfriend's car. Uncle is quite upset and chastised him. In addition to this, the patient had been feeling more depressed over the past few weeks due to legal problems. On [2172-3-20], the patient impulsively took 50-100 tablets of Tylenol as well as Motrin. From [3-20] until [3-23], the patient felt sick and went to outside hospital Emergency Department 2-3x before admitting to his acetaminophen overdose when a tox screen returned positive for Tylenol. Tylenol level on admission to outside hospital Emergency Department was 44.75 with ALT of 14,064, AST of 7,042. The patient was also found to have acute renal failure, possibly due to Motrin overdose. That same day, the patient was transferred to [Hospital1 ] MICU, and given Mucomyst x15 doses. While in the MICU, the patient was evaluated by Transplant, Liver Service, Toxicology, and Psychiatry. According psychiatric consult, the patient now regrets the OD and does not want to die. Seemed relieved when told there was a chance of survival. In the MICU, his LFTs trended down, no acidosis or encephalopathy, lactate 3.2, creatinine 2.3, INR of 5.7. Thus, the patient is determined not to be a candidate for an urgent transplant, and on [2172-3-25], he was transferred to General Medicine floor. The patient's liver enzymes continued to trend downward and ARF improved with hydration. The patient was then transferred back to the MICU overnight for closer observation. Overnight, his condition continued to improve. Today he developed cellulitis in the left hand from IV and was started on Keflex 500 mg IV q8h. The patient was seen by Liver Service, which recommended switching to oral Mucomyst. This evening he was transferred back to the General Medicine floor. PAST MEDICAL HISTORY: Mild asthma. The patient is on no medications for this. MEDICATIONS UPON TRANSFER: 1. Acetylcysteine 20%, 6,000 mg po q4h. 2. Cephalexin 500 mg po q6. 3. Pantoprazole 40 mg po q24. 4. Docusate sodium 100 mg po bid. 5. Senna one tablet po hs. 6. Ondansetron 2-4 mg IV q6 prn. 7. Insulin-sliding scale per insulin flow sheet. ALLERGIES/ADVERSE REACTIONS: No known drug allergies. SOCIAL HISTORY: The patient left high school [Male First Name (un) 1573] and is studying to get a GED. He is single, never married, no children, no current girlfriend. The patient has two sisters, and is currently living with mother. [Name (NI) ] grew up in a home with alcoholism and violence. Drug use began as a teen and has involved heavy use of cocaine, LSD, ecstasy, marijuana, and heroin. The patient denies alcohol abuse, recent detox for heroin. Has used needles, and has a history of multiple arrests for various charges, but never incarcerated. FAMILY HISTORY: No family history of liver disease. PHYSICAL EXAMINATION: Patient's vital signs: Temperature 99.0, pulse 58, blood pressure ranging from 120-140 systolic and 50-80 diastolic, respiratory rate 14, and O2 saturations is 98% on room air. General appearance: Patient appeared stated age, alert, cooperative, and within no apparent distress. Skin: Jaundice, normal hair distribution, multiple ecchymoses on arms. HEENT: Normocephalic, atraumatic, scleral icterus, no nystagmus. Extraocular eye movements full. Pupils are equal, round, and reactive to light. Lips and membranes unremarkable. Pharynx benign. No tonsillar exudates. Neck is supple, full range of motion, no thyromegaly. Lungs are clear to auscultation and percussion, no crackles/rhonchi/rubs/wheezing. Cardiovascular: S1, S2 normal intensity, no jugular venous distention, no clicks/murmurs/rubs. Abdomen: Soft, nontender, diminished bowel sounds. Liver span within normal limits. Extremities: Left hand: 2+ edema, tender to palpation, erythema on dorsum of hand, radial/popliteal/dorsalis pedis/posterior tibial pulse 2+ bilaterally, no cyanosis, no clubbing, and no edema. Neurologic: Cranial nerves II through XII are grossly intact. Motor: Muscle bulk and tone within normal limits. Strength 3/5 bilaterally and throughout. Coordination: Fine and repetitive finger movements intact. MENTAL STATUS EXAMINATION: Patient is alert and oriented to person, place, and time. Mental status examination within normal limits. LABORATORIES AND DIAGNOSTICS: Complete blood count: White count 5.2, hemoglobin 13.1, hematocrit 37.5, platelets 112. PT 19.3, PTT 38.2, INR 2.5. Blood chemistries: Sodium 137, potassium 3.3, chloride -105, bicarb 23, BUN 22, creatinine 1.6, glucose 91. Calcium 8.7, phosphate 2.5, magnesium 1.9, ALT 2593, AST 297, LD 299, alkaline phosphatase 130, T bilirubin 14.0. HOSPITAL COURSE: A 19-year-old man with a history of polysubstance abuse/dependence, who presented to outside hospital with nausea and vomiting secondary to intentional acetaminophen and Motrin overdose. The patient is transferred to [Hospital1 69] with liver failure and acute renal failure. 1. Gastrointestinal: On admission to outside hospital, acetaminophen level of 44.75 with ALT of 14,064 and AST of 7,042. Patient transferred to [Hospital3 ] MICU on [2172-3-24] with liver failure and INR of 5.7. The patient was placed on IV Mucomyst and IVF. The patient responded well to IV Mucomyst with LFTs trending down and was subsequently transferred to the medicine floor on [2172-3-25]. Liver consult felt that patient was not an urgent candidate for transplant and Toxicology recommended use of Mucomyst until the patient's INR was less than 2. On the floor, the patient's LFTs continued to trend down but the patient determined to need closer monitoring, and was transferred back to the MICU that same day. The patient was transferred back to the Medicine floor on [2172-3-26], and placed on po Mucomyst, bowel regimen, and continued IVF. From [Date range (1) ], the patient's LFTs continued trending down, and on [3-29], the patient's INR was less than 2.0. The patient's T bilirubin fluctuated from 12 to 14 during this time, and he experienced occasional bouts of nausea mostly related to Mucomyst ingestion. In addition to this, the patient had no abdominal pains and all stools were guaiac negative. Mucomyst was discontinued on [3-29]. On [3-30], the patient was discharged to home with followup with PCP. 2. Renal: Patient transferred to [Hospital3 ] MICU on [2172-3-24] with acute renal failure and creatinine of 2.3. Acute renal failure likely secondary to nonsteroidal anti-inflammatories overdose. The patient was treated supportive with IVF from [3-24] to [3-28]. IVF was discontinued on [3-28]. During this time, the patient's renal function gradually improved from a creatinine of 2.3 to 1.6, and continued to remain around 1.6 on discharge. Patient will have follow up with primary care physician regarding renal function. 3. (ID): During second MICU stay, the patient developed left hand cellulitis, possibly from his IV. The patient was placed on renally dosed cephalexin 500 mg po q6h on [2172-3-26] x7 days. From [Date range (1) 47979] resolved without complications. On [3-30], only slight swelling visible in left hand. The patient will continue with antibiotics for three more days outpatient. 4. (Psych): Patient is seen by Psychiatry on admission and setup with one-to-one sitter. Psychiatry determined that the patient regretted the overdose and did not want to die. The patient was relieved when told of chance of survival. Sitter was discontinued on [3-28] per second recommendation. The patient will have intensive followup in outpatient psychiatric facility. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home with outpatient psychiatric followup. DISCHARGE DIAGNOSES: 1. Acetaminophen overdose. 2. Hepatitis from acetaminophen suicide attempt. DISCHARGE MEDICATIONS: 1. Diphenhydramine HCL 25 mg po q6h prn. 2. Pantoprazole SOD sesquihydrate 40 mg po q day x10 days. 3. Cephalexin monohydrate 500 mg po q6h x3 days. 4. Docusate sodium 100 mg po bid x7 days. 5. Ursodiol 300 mg po tid x7 days. FOLLOW-UP PLANS: 1. The patient will follow up with new primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] located in [Street Address(2) 47980], Unit B210, [Location (un) 47981], [Numeric Identifier 47982]. 2. Psychiatric outpatient facility, Metalsedge Recovery Center, [Street Address(2) 47983], [Location (un) 47981], [Numeric Identifier 47984]. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1775] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1776] Dictated By:[Last Name (NamePattern1) 9336] MEDQUIST36 D: [2172-3-30] 15:25 T: [2172-4-1] 13:52 JOB#: [Job Number 47985] cc:[Telephone/Fax (1) 47986]	[ "5845", "49390", "311" ]
Admission Date: [2170-10-22] Discharge Date: [2170-10-25] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Nausea and headache with walking trouble. Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 88-year-old right handed female with a past medical history significant for atrial fibrillation on Coumadin, hypertension, hyperlipidemia, diabetes type 2, pulmonary hypertension, was recently seen at [Hospital1 18] with an episode of vertigo on Wednesday, [2170-10-17], who now returns six days later with persistent nausea, left-sided occipital headache and difficulty with walking. The patient had her first episode last Wednesday on [2170-10-17]. She describes the episodes as follows: She woke up after breakfast and went to go brush her teeth. While standing in the bathroom, she had the sudden onset of vertigo and the clock was spinning in the clockwise direction. This sensation lasted for about 3 minutes, but she could not stand during it and had to sit on the edge of the toilet seat and felt that she would fall off if she did not hold on to the seat. The episodes started to slow down and then ceased at approximately 3 minutes. Following this, she then noted a headache in the left occipital/parietal area and she felt very nauseous. At this point, she was able to stand without falling and noted no dysarthria, dysphagia, diplopia, or any other concerning brain stem findings or visual symptoms and because of her history of a-fib, she called her son who advised her to call EMS and then she came into [Hospital1 18], where she was seen by neurology. After being seen by neurology, she was complaining of mild headache and mild nausea; however, her symptoms of vertigo had resolved. On exam at the time, she did have a relatively normal exam that was notable only for left cervical and trapezius tenderness and evidence of cervical spondylosis with weakness in the C5, C6, and C7 distribution bilaterally with some evidence of myelopathy. A CTA and CT was performed. It did not show any evidence of stroke or vessel blockage. It was felt that this is possibly a peripheral process and the patient was discharged home with followup. Over the past five days, the patient has not had significant improvement in her two primary symptoms, which are nausea and her headache. She has not had any further episodes of vertigo; however, she remains extremely nauseous and is unable to keep most food or liquids down. She stated that she has not eaten much in the past three to four days because of this. She notes the nausea is significantly worse when she stands up and it is somewhat improved when she lies flat with her eyes closed. She still complains of her headache, which again she describes as partially a pressure like sensation, non-throbbing, and non-positional. She localizes it primarily to the posterior side of her head on the left side. The patient had continuous nausea for the last couple of days. Today and yesterday, she felt that the nausea increased. She had one episode of emesis, which was this morning. In addition, she did not get out of bed all day. She gave two reasons for not getting out of bed, one when she rose up, she would become extremely nauseous and want to lie flat again. The second reason was that she felt very unsteady if she tended to stand up, she felt that if she leaned in one direction or the other, she would be pulled down to the floor. She was able to walk yesterday with a walker, which is unusual for her, as she has never needed a walker prior to this. The patient describes the headache as a numb, throbbing, aching/pressure. She does not believe there is a positional component. The patient does have a history of migraine headaches, which she had from puberty to menopause. She described the headaches as predominantly a throbbing unilateral headache. She would get some nausea and vomiting with the headache. There was photophobia and phonophobia. She described this headache as different from her prior migraines, as she did not have photophobia or phonophobia. Based on her continuing symptoms, she called her PCP, [Name10 (NameIs) 1023] then spoke with one of our outpatient neurologists, who recommended that she come into the emergency room and be evaluated again by neurology. The patient notes that she feels somewhat improved after getting a dose of Zofran, although this medication has made her somewhat sleepy. On neuro ROS, the pt reports the mild pressure headache in the left occiput as above, no loss of vision, blurred vision, diplopia, dysarthria, dysphagia, tinnitus or new hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, paraesthesia. Has long standing increased urinary frequency with occasional incontinence. No bowel incontinence or retention. On general review of systems, the pt denies recent fever or chills. Some occasional night sweats, and a 9lb weight loss over the last 6-8 months. Denies cough, shortness of breath. Denies chest pain or tightness, occasional palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: 1. Pulmonary hypertension noted first in [2166] 2. Diabetes mellitus has been taking oral hypoglycemics until [2170-5-8] when she started insulin 3. Atrial fibrillation. Has been on warfarin for five years as well as atenolol and digoxin. 4. Hypertension. 5. Hypercholesterolemia. 6. Hypothyroidism. 7. Recurrent urinary tract infections. 8. Dyspnea on exertion. 9. Hearing loss. 10. Basal cell carcinomas. 11. Osteopenia. 12. Nosebleeds. These are fairly new and have just started recently. Social History: Ms. [Known lastname ] was born in [Location 8398]at age four, she moved to [State 760] where she graduated from high school. She then finished nursing school and has [Name8 (MD) ] RN from [Location 85679]. She then entered a master's program in public health at [University/College 85680]. However, because of the war, she went back to surgical nursing until the war was over. She then married and had three children with whom she is quite close. She has lived in [State 2748] for many years and has a home on [Hospital3 ]. She recently moved to [Location (un) 86] to live close to her family. The husband of many years died in [2168-1-8]. SMOKING HISTORY: She used to smoke in the past for about 4 years in her 40s. She drinks only socially. No drugs. Family History: Her mother died at age 85 of dementia. Her father died at age 75 of complications of diabetes. She had two younger brothers, both of whom have died. One had a myocardial infarction and one had small bowel cancer. Physical Exam: Vitals: T:98.5 P:80 R: 16 BP:187/87 SaO2: 98% RA General: Awake, cooperative, NAD. Lying in bed HEENT: NC/AT, no scleral icterus noted, dry mucous membranes, no lesions noted in oropharynx, no temporal tenderness Neck: Supple, no carotid bruits appreciated. limited range of motion in horizonal direction, left cervical tenderness and over trapezius Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: [Last Name (un) 3526] [Last Name (un) 3526] Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [Doctor Last Name 1841] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [2-7] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. The patient has surgical pupils bilaterally. VFF to confrontation. Funduscopic exam revealed no papilledema. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, some decrease wasting in intrinsic muscles of hand, EDB wasting, slightly increased tone in the legs No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 4+ 5- 5- 5 5 5- 5- 4+ 5 5- 5 5 R 4+ 5- 5- 5 5 5- 5- 4+ 5 5- 5 5 Sensation: Intact to light touch. Decreased cold/pin at feet to mid thigh in stocking pattern. Vibration reduced to knees. Slight decrease in proprioception is reduced in the big toes bilaterally. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was upgoing bilaterally -Coordination: Slightly intention tremor worse on the left than the right. Overshoot on the left with mirror movements. HKS worse on left. -Gait: Unable to stand without immediate retropulsion, cannot test Romberg. Able to lean on me and take broad base steps but if let go immediate retropulsion. Pertinent Results: [2170-10-22] 03:55PM BLOOD WBC-6.4 RBC-3.90* Hgb-11.4* Hct-35.2* MCV-90 MCH-29.2 MCHC-32.4 RDW-14.8 Plt Ct-142* [2170-10-25] 05:55AM BLOOD PT-21.7* PTT-29.9 INR(PT)-2.0* [2170-10-22] 03:55PM BLOOD ESR-21* [2170-10-25] 05:55AM BLOOD Glucose-122* UreaN-27* Creat-1.0 Na-141 K-4.1 Cl-108 HCO3-24 AnGap-13 [2170-10-22] 03:55PM BLOOD ALT-28 AST-41* AlkPhos-113* Amylase-59 TotBili-0.6 [2170-10-22] 03:55PM BLOOD cTropnT-<0.01 [2170-10-23] 05:00AM BLOOD %HbA1c-7.3* eAG-163* [2170-10-23] 05:00AM BLOOD Triglyc-86 HDL-61 CHOL/HD-2.7 LDLcalc-84 MRI of head: Acute left cerebellar infarct in a left AICA/PICA distribution with hemorrhagic components on a background of moderate microangiopathic small vessel disease involving the supratentorial white matter and brainstem. Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: The pt is a 88 year-old right-handed female with a history of a.fib on Coumadin, HTN, HLD, diabetes type 2, pulmonary HTN, who was recently seen at [Hospital1 18] with an episode of vertigo on Wed, [2170-10-17], now returns 6 days later with persistent nausea, left sided occipital headache and difficulty with gait. The patient first episode was last Wednesday, while she was brushing her teeth she had the sudden onset of clockwise vertigo, which lasted for about 3-5 minutes. This was then followed by a sensation of nausea and a left sided occipital headache. Based on her history of a.fib she was concerned that this may represent a stroke and she came to the [Hospital1 18] ED. Her vertigo had resolved, and she had a normal exam with the exception of left cervical/trapezius tenderness and evidence of cervical spondylosis with weakness in c5/6/7 distribution bilaterally and some evidence of myelopathy. A CT and CTA was performed which did not show evidence of a stroke or vessel blockage. Over the last 5 days the patient has remained persistently nauseous. In addition she became more nauseous yesterday, this morning, and also was having more difficulty getting out of bed. She stated that if she stood up an leaned in either direction she would be pulled down. Based on this she was advised by her PCP and outpatient neurology to come back to the ED. NEUROLOGY: On admission she felt somewhat improved after receiving Zofran. She still had a non-positional, aching headache in the left occiput. She has root signs at c5/7 bilaterally and evidence of mild myelopathy. She does have worse end-intention tremor on the left side, and mild dysmetria on HKS. She cannot stand up without retropulsion and has a broad based gait when assisted. Her repeat head CT shows evidence of a large left sided cerebellar infarct, with swelling and effacement of the left side of the 4th ventricle. This is likely the swelling of a PICA infarct from last Wednesday, now evidenced by her left sided cerebellar signs. If this occurred 5-6 days ago she was likely she was at her maximal swelling and therefore was admitted to the ICU care for frequent neuro checks and monitoring. Her initial INR was 2.9 and therefore with the development of hemorrhagic transfermation on CT her coumadin was held. The plan was to hold this until dropping to 2.0 and then to restart. The following day the patient had an MRI and was transferred to the step down unit. MRI confirmed some hemorrhagic transformation. Patient had complete resolution of nausea and headache after tranfer to the floor. Coumadin was restarted on the day of her discharge and her INR was 2.0. Her BP meds were restarted and after PT/OT evaluted her and found her safe to be discharged home with home PT. Cardiovascular: Patient has a history of CHF, pulm HTN, an Echo done on [7-17] demonstrated 1+AR, 2+MR, severe pulm artery HTN, and sig pulm regurg. Patient was initially allowed to autoreg and given a half dose of her home atenolol. On day 2 of admission she was re introduced to her full dose of atenolol for control of her afib. Patient's LDL was 84 and she was increased on her lipitor. Follow-up: In addition to home PT/OT, patient will be following up with PCP and an appt was scheduled to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], neurologist who oversaw her care during this admission. Medications on Admission: torsemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a day as needed for edema Lipitor 10 mg Tab 1 (One) Tablet(s) by mouth once a day Nateglinide 120 mg Tab 1 (One) Tablet(s) by mouth twice a day Lantus Solostar 100 unit/mL (3 mL) Sub-Q Insulin Pen 10 units at bedtime Januvia 100 mg Tab 1 (One) Tablet(s) by mouth once a day in morning Vitamin D-3 1,000 unit Chewable Tab Allopurinol 100 mg Tab 2 (Two) Tablet(s) by mouth once a day Atenolol 50 mg Tab 1 (One) Tablet(s) by mouth twice a day lisinopril 10 mg Tab 1 Tablet(s) by mouth twice a day Levothyroxine 50 mcg Tab 1 (One) Tablet(s) by mouth once a day Warfarin 2.5 mg Tab 1 (One) Tablet(s) by mouth once a day 5 mg Q Mon and Friday, 2.5 mg the other 5 days. Has been checked monthly unless abnormal Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR). 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK ([Doctor First Name ],TU,WE,TH,SA). 10. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for Edema. 11. Lantus 100 unit/mL Cartridge Sig: Five (5) unit Subcutaneous at bedtime. 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. nateglinide 120 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Outpatient Lab Work INR every Friday and Monday - frequency can be altered per PCP and if the INR stable. 15. Outpatient Physical Therapy 16. Outpatient Occupational Therapy Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Left cerebellar stroke 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 on [10-22] with persistent headache and nausea plus trouble with walking. You were initially admitted to ICU because of your cerebellar stroke and need for close monitoring but you were able to be transferred to the neurology floor the next day. Given the stroke, Coumadin was initially held during this admission but it was restarted on the day of discharge and your INR was 2.0 on the day of your discharge. There is no change to your meds including your Coumadin dosing. Your headache and nausea abated during this admission and you were evaluated per physical and occupational therapists who recommended discharge home with home services. Followup Instructions: Please call your physician to schedule [Name9 (PRE) 702] and you will need at least twice weekly INR checks initially to ensure therapeutic/tight dosing of your Coumadin. You are also scheduled to follow-up with Dr. [Last Name (STitle) ], neurologist who oversaw your care during this admission: Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 2574] Date/Time:[2170-12-19] 2:00 [Hospital Ward Name 23] Building, [Location (un) 858]. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2170-10-25]	[ "42731", "4019", "2724", "25000", "2449", "4168", "V5861", "V5867" ]
Admission Date: [2132-1-14] Discharge Date: [2132-1-28] Date of Birth: [2074-6-22] Sex: F Service: SURGERY Allergies: Cyclobenzaprine / Codeine / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 148] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: Per OSh report (as patient is intubated and sedated on arrival to [Hospital1 18]) 57F with recurrent episodes of abdominal pain, nausea, and vomitting ove the at least the past several months. Would only last < 12 hours at each time with epigastric pain, radiating to the back. No prior evidence of gallstones on abdominal ultrasounds. She presented witha similar episode to [Hospital6 ] on [2132-1-5] but with very severe pain and an episode of diarrhea. She had been afebrile, tender in epigastric area, with admission labs of lipase > 3500, amylase >1100, AST 428 AP 153 ALT 327 TB 1.5 Lactate 4.0 Cr 1.0 WBC 22.6, BE 9.1. CT at the time just showed acute pancreatitis, and was given a presumptive diagnosis of gallstone pancreatitis based on history and labs. Transferred to the ICu that day and subsequently intubated for worsening respiratory distress. The patient then spiked a fever, had positive blood cultures, and started on antibiotics. At some pont she was on pressors which have since been dicontinued. For nutrition got TPN for a few days, then enteral feeding, which is now stopped to due to vomitting yesterday. Had ERCP with sphinctertomy done before transfer; all biliary ducts filled normally as well as duodenum. WBC decreased and then began to [First Name8 (NamePattern2) ] [Last Name (un) 7162], 35.6 on transfer. Pab [Last Name (un) ] Klebsiella from FNA pancrease [1-10]. Urine Cx [Female First Name (un) 564], Blood culture [1-4] & 16 Klebsiella. OSH CT scans demonstrate no signs of gas aroudn the pancreas, just extensive edema and nonenhancement with some necrosis. Past Medical History: DM2, htn, hypothyroid, obesity Social History: married, banker, no smoking or etoh Physical Exam: intubated, sedated sclera nonicteric, no jaundice decreased bs, coarse, mild rhonchi b/l RRR obese, soft, nondistended +1 pedal edema Pertinent Results: 7.44 pCO2 37 pO2 69 HCO3 26 BaseXS 0 138 104 16 174 4.3 26 0.7 Ca: 7.7 Mg: 2.2 P: 3.5 ALT: 21 AP: 120 Tbili: 0.5 Alb: 2.0 AST: 29 LDH: 355 Dbili: TProt: [Doctor First Name ]: 26 Lip: 63 wbc 28.7 8.1 494 hct24.7 N:82 . [2132-1-23] 06:45AM BLOOD WBC-19.7* RBC-2.85* Hgb-8.8* Hct-26.0* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.6 Plt Ct-557* [2132-1-23] 06:45AM BLOOD Glucose-59* UreaN-18 Creat-0.6 Na-136 K-3.9 Cl-101 HCO3-27 AnGap-12 [2132-1-14] 10:45PM BLOOD ALT-21 AST-29 LD(LDH)-355* AlkPhos-120* Amylase-26 TotBili-0.5 [2132-1-21] 01:46AM BLOOD ALT-65* AST-73* LD(LDH)-254* AlkPhos-105 Amylase-48 TotBili-0.3 [2132-1-14] 10:45PM BLOOD Lipase-63* [2132-1-23] 06:45AM BLOOD Lipase-113* [2132-1-23] 06:45AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.5 [2132-1-15] 05:17PM BLOOD Lactate-0.9 . [Hospital1 18] ECHOCARDIOGRAPHY REPORT GENERAL COMMENTS: The patient appears to be in sinus rhythm. Left pleural effusion. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Preserved [Hospital1 ]-ventricular systolic function. No evidence of vegitation on the aortic or mitral valves. . Radiology Report CT CHEST W/CONTRAST Study Date of [2132-1-15] 12:33 AM IMPRESSION: 1. Necrotizing pancreatitis involving greater than two-thirds of the pancreas. CT severity index is [9-1] . 2. Large acute fluid collection extending superiorly around the gastric fundus. 3. Splenic vein thrombosis, with development of collateral flow through a prominent left gastroepiploic vein. 4. No pseudoaneurysm identified. 6. Multifocal ground glass and airspace consolidations consistent with multifocal pneumonia. 7. Prominent right mammary lymph node. Correlation with mammography or history of breast cancer is recommended. This finding was entered into the radiology critical results reporting system on [2132-1-16]. 8. Fatty infiltration of the liver. . Radiology Report CT PELVIS W/CONTRAST Study Date of [2132-1-25] 12:48 PM IMPRESSION: 1. Progressively enlarging pancreatic collections and peripancreatic fluid in the setting of extensive pancreatic necrosis. 2. Gas within the gallbladder lumen, wich would be expected following instrumentation (ie. ERCP) though no documentation is on the OMR at time of dication. Differential would also include cholecystitis due to gas-forming organism. 3. Improved right pleural effusion and resolved abdominal ascites. Brief Hospital Course: 57 obese female with severe necrotizing pancreatitis, developing pseudocyst, intubated for almost 10 days with respiratory failure. No signs of gas on CT scan, pseudoaneursym or erosion into blood vessels. We will keep the patient intubated and sedated, likely bronch/BAL, introduce nutrition via enteral feeds after reassessment, continue antibiotics for positive blood cultures, urine culture, and presumptive pneumonias. Culture data: -OSH Urine Cx: [Female First Name (un) 564] -[1-4] & [1-7] OSH BCx: Klebsiella -[1-10] OSH FNA pancreas: Klebsiella -[1-13] BCx [2-27] GPCs in clusters--coag neg staph -[1-14] Sputum no orgs, no growth -[1-15] BCx pending . ID: Continue meropenem at 500mg q6h iv for likely polymicrobial process (at least 2 weeks given bacteremia at OSH, day 1 here [1-14], day 1 OSH [1-6]) -Continue fluconazole at 200mg q24h iv (prophylactic dose) [1-22]: afebrile, on floor doing well. -2 weeks total [Last Name (un) 2830] & fluco: END DATE [2132-1-28] . IMAGING: [1-13] CXR: Bilateral lower lobe atelectasis and small bilateral pleural effusions [1-14] CT torso: necrotizing pancreatitis with fluid collection and possible erosion into stomach. b/l pleural effusions and basilar atelectasis [1-14] TEE: wnl [1-15] CXR: improved b/l atelctasis [1-16] CXR: b/l pleural effusions, B atelectasis [1-18] CXR: mildly improved pleural effusions [1-25] CT PELVIS: Progressively enlarging pancreatic collections and peripancreatic fluid in the setting of extensive pancreatic necrosis. . [1-13]: admitted to TSICU. CT torso done [1-14]: Pt went to IR for placement of post-pyloric feeding tube. TF's were started and advanced toward goal. Attempt at esophageal balloon placement was made and failed. ID consult was obtained. Surgery was deferred. [1-15]: A-line switched [2-25] (+) culture [1-16]: attempted to wean PEEP and PS but did not tolerate well. [1-17]: attempt at aggressive diuresis lasix drip + diamox, goal negative 2-3L (-1866 on [1-17]), aggressive pulmonary toilet, goal=extubate sun/mon. A-line pulled [2-25] not working. vent pressure settings weaned but ABG with hypoxia to PO2 71: inc FiO2, inc pressure settings [1-18]: attempted to wean PS but again unsuccessful (increased WOB and tachypnea), placed new Aline, cont Lasix Gtt [1-20] extubated diuresis, goal 2-3L neg: overshot -4.4 L [1-20], -700 [1-21] . GI / ABD: pancreatitis, medical management. stable, no abd pain. Her pain improved and she was nontender on palpation. NUTRITION: replete with fiber via post-pyloric feeding tube, restarted 4hrs s/p extubation. consider speech/swallow c/s prior to advancing diet today given long intubation. The NJ feeding tube was D/C'd on [1-21] and her PO diet was advanced. She was tolerating a low fat diet on [1-22]. RENAL: UOP and Cr stable. lasix gtt -4.4 L neg [1-20], met alkalosis: s/p 2 doses diamox [1-20], Hco3 31. She was transited from lasix drip to lasix bolus on [1-21]. HEMATOLOGY: stable anemia ENDOCRINE: Insulin gtt, NPH 20/20: transition to RISS [1-21]; synthroid changed to PO dose ID: meropenem, fluconazole; ID following; WBC trending down She was discharged in good condition, tolerating a PO diet, reporting no abdominal pain and blood sugars well controlled on [Hospital1 ] NPH. She will need a follow-up CT scan and pseudocyst drainage and cholecystectomy at the end of the month. Medications on Admission: levoxyl 100, prozac 20, lisinopril 20, metformin 1000", asa Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) Units Subcutaneous twice a day. Disp:1800 Units Refills:2 7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection four times a day: See Sliding Scale. Disp:qs Refills:2 8. One Touch Ultra System Kit Kit Sig: One (1) Miscellaneous four times a day. Disp:qs Refills:2 9. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:150 Refills:2 10. One Touch Test Strip Sig: One (1) In [Last Name (un) 5153] four times a day. Disp:150 Refills:2 11. Insulin Syringe [1-25] mL 29 x [1-25] Syringe Sig: One (1) Miscellaneous four times a day. Disp:150 Refills:2 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Acute severe pancreatitis Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([11-6] lbs) until your follow up appointment. Followup Instructions: Dr. [Last Name (STitle) ] on [2-15]. Pt needs to have a repeat abdominal CT with PO and IV contrast with Pancreas protocol for evaluation of pseudocyst. His office will call you with a time for the appointment. Call [Telephone/Fax (1) 1231] with questions or concerns. Completed by:[2132-1-28]	[ "51881", "486", "99592", "25000", "4019", "2449" ]
Admission Date: [2199-3-3] Discharge Date: [2199-3-12] Date of Birth: [2117-5-3] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 759] Chief Complaint: Atrial fibrillation with RVR, fever. Major Surgical or Invasive Procedure: Endotracheal extubation. History of Present Illness: This is an 81-year-old woman with history of atrial fibrillation on coumadin, coronary artery disease s/p PCI w/ DES on plavix and left carotid endarterctomy who was admitted to the neurology service on [2199-3-3] as a transfer from [Hospital ] Hospital. She presented to [Hospital ] Hospital with unsteadiness, vomiting, and hypertension to 230/90 and was found to have a 19mm/x12mm midline cerebellar hemorrhagic stroke. She was intubated and transfered to [Hospital1 18]. Past Medical History: Atrial fibrillation for many years, on coumadin TIA one year ago MI in [9-21] s/p DES x2 Left carotid endarterectomy in [2198-6-14] Uterine cancer in [2188] Right breast cancer in [2196] s/p surgery and radiotherapy Hypertension Retinal hemorrhage of the right eye ?Congestive heart failure Social History: Retired, lives with daughter and her husband. [Name (NI) ] tobacco or alcohol use. Family History: Mother and father had strokes at ages 66 years old and 84 years old respectively. Physical Exam: Vitals: T: 101 (101.3) BP: 136/85 P: 126 (81-160) R: 25 O2: 92% on 4L NC General: Alert, seems paranoid, oriented to person HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: expiratory wheezes anteriorly, crackles at L base CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, + pedal edema Pertinent Results: Labs at Admission: [2199-3-3] 12:14AM BLOOD WBC-10.8 RBC-4.25 Hgb-12.4 Hct-34.2* MCV-80* MCH-29.2 MCHC-36.4* RDW-15.3 Plt Ct-269 [2199-3-3] 12:14AM BLOOD Neuts-91.3* Lymphs-4.7* Monos-2.7 Eos-0.6 Baso-0.6 [2199-3-3] 12:14AM BLOOD PT-20.4* PTT-33.3 INR(PT)-1.9* [2199-3-3] 12:14AM BLOOD Glucose-159* UreaN-11 Creat-0.8 Na-129* K-3.7 Cl-93* HCO3-28 AnGap-12 [2199-3-3] 07:37AM BLOOD ALT-16 AST-22 LD(LDH)-223 AlkPhos-100 Amylase-36 TotBili-0.6 [2199-3-3] 07:37AM BLOOD Albumin-3.5 Calcium-8.2* Phos-2.8 Mg-1.9 [2199-3-7] 09:41AM BLOOD Triglyc-281* HDL-47 CHOL/HD-6.0 LDLcalc-180* . Micro Data: [2199-3-10] BLOOD CULTURE negative [2199-3-10] URINE CULTURE negative [2199-3-9] BLOOD CULTURE negative [2199-3-8] BLOOD CULTURE negative [2199-3-8] BLOOD CULTURE negative [2199-3-7] STOOL C DIF negative [2199-3-7] URINE CULTURE negative [2199-3-6] BLOOD CULTURE negative [2199-3-6] BLOOD CULTURE negative [2199-3-3] MRSA SCREEN negative [2199-3-3] BLOOD CULTURE negative [2199-3-3] BLOOD CULTURE negative . Studies: . CT Head ([3-3]): 1. Right cerebellar parenchymal hemorrhage with mild surrounding edema and mass effect upon the fourth ventricle. 2. Extensive chronic small vessel ischemic change. . CTA Head ([3-3]): Unchanged right medial cerebellar hemispheric hematoma. No evidence of aneurysm or arteriovenous malformation. . MRA Head and Neck ([3-3]): Right cerebellar hemispheric hematoma again seen. There is minimal enhancement around the periphery and slight vascular prominence. These findings may be related to the hematoma itself, rather than revealing its etiology. If there is clinical concern of a possible arteriovenous malformation, a catheter arteriogram would be the most sensitive study. . CT Head ([3-6]): No significant change of the right cerebellar parenchymal hemorrhage with mild surrounding edema and mass effect upon the fourth ventricle. . TTE ([3-7]): The left atrium is moderately dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . CXR ([3-9]): Severe cardiomegaly and mild pulmonary vascular congestion are improved since early on [3-8], unchanged since 9:40 p.m. that day. No pneumothorax. Pleural effusion, if any, is minimal. Brief Hospital Course: An 81 year-old woman with past history of atrial fibrillation, CAD s/p recent stents presenting from OSH with cerebellar hemorrhage in the setting of coumadin. . She was admitted initially to the neuro ICU. She was extubated on [3-4] and her coumadin-induced coagulapathy was reversed with FFP. She was transfered out of the ICU on [2199-3-5]. She was started on vancomycin and Zosyn on [3-4] for question of LLL PNA. She was also noted to be in atrial fibrillation with RVR and diltiazem ggt was started for better rate control in the setting of HR to the 150s. The drip was able to be stopped and changed to po metoprolol and diltizem once stabilized and patient was transferred to the floor on the morning of [3-9]. Floor course is outlined by problem below. . 1. Atrial fibrillation with rapid ventricular response. As above, patient has a history of atrial fibrillation; she developed RVR in the setting of fever and possible infection. A TSH was checked that was normal. At time of transfer to the medical floor, her rate was controlled with BB and CCB. However, she intermittently had runs of RVR to the 140s, during which her oxygen requirements increased and she became dyspneic. She was given IV dilt prn and the oral diltiazem increased to achieve better rate control. Metoprolol was stopped due to side effects (patient said this caused "hallucinations"). At a dilt dose of 90 mg qid, adequate rate control was achieved during both rest and exertion. With improved rate control, her oxygenation also improved and she was able to be weaned off of O2. Her coumadin has been held per neurology recs for at least two weeks. She will follow-up in neurology clinic at [Hospital1 18] in one to two weeks at which time coumadin may be restarted. . 2. Cerebellar hemorrhage. She underwent repeat head CT prior to transfer to floors; there was no interval change. Neurology service continued to follow and recommended for goal SBPs in the 120-160 range. They said it was okay to continue clopidogrel and recommended holding warfarin for at least two weeks after the cerebellar bleed. She has follow-up scheduled in neurology clinic with Dr. [Last Name (STitle) ]. . 3. Fever. There was question of LLL pneumonia and left pleural effusion at time of transfer. She had no cough and there was no leukocytosis. Given her hypoxia (likely related to RVR) at time of transfer, we were not comfortable stopping the antibiotics. She was continued on vancomycin and Zosyn for one day and this switched to oral levofloxacin when her symptoms improved. She will complete a 7-day course for presumptive HAP. . 4. Left pleural effusion. This was concerning for parapneumonic effusion in the setting of fever. Given her history of malignancy there was concern of malignant effusion. Procedure service was consulted and ultrasound imaging showed that there was not sufficient fluid collection to drain. Furthermore, fluid appeared non-loculated, layering out on decubitus films, and its appearance was felt to be less likely consistent with empyema or malignant effusion. Drainage was not attempted. The effusion resolved with conservative measures and on repeat CXR was significantly reduced in size. . 5. Coronary artery disease s/p drug eluting stent. We continued her outpatient clopidogrel and statin. . 6. ?Congestive heart failure. She had cardiomegaly on CXR but was found to have normal systolic function on TTE; TTE did show mild symmetric left ventricular hypertrophy. She is on [Hospital1 ] lasix at home; once her heart rate and blood pressure were stable, we restarted her outpatient lasix at 40 mg twice daily. . 7. Hypertension. Goal SBP was 120-160. We held her irbesartan to avoid hypotension. . 8. Urinary retention. This was noted when her foley was removed; she was found to have PVRs of 500-600 ccs initially. Overnight however, she started to void on her own. Bladder scan showed a post-void residual of 250cc. She continued to void without difficulty on day of discharge. If needed, she can follow-up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] urology clinic. She has been provided with contact information for scheduling an appointment if necessary. Medications on Admission: Coumadin 5 mg T/F; 2.5mg on other days Plavix 75 mg qday Metoprolol 50 mg [Hospital1 ] Lasix 40 mg [Hospital1 ] Irbesartan 75 mg [Hospital1 ] Simvastatin 20 qday Discharge Medications: 1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:60 Capsule, Sustained Release(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Please complete 7-day antibiotic course on [3-14]. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnoses Hemorrhagic cerebellar infarct Atrial fibrillation with rapid ventricular response . Secondary Diagnoses History of transient ischemic attack Myocardial infarction in [2198-9-14] s/p DES x2 on clopidogrel Left carotid endarterectomy [2198-6-14] History of uterine cancer in [2188] History of breast cancer in [2196] s/p surgery and radiotherapy Hypertension History of retinal hemorrhage in right eye Discharge Condition: Vital signs stable. Afebrile. Satting well on room air. Discharge Instructions: You were hospitalized for treatment of hemmorrhagic stroke. There was bleeding into the cerebellum. We stopped the anticoagulation and your symptoms improved. We noticed that your heart rate was difficult to control during this admission. The rapid heart rate responded to diltiazem, so we started you on diltiazem and stopped the metoprolol. With this treatment, the atrial fibrillation was better controlled. We were concerned on chest x-ray that there was pneumonia. We have started you on antibiotics for treatment of healthcare-associated pneumonia. Please complete a seven-day course of antibiotics. . We have made the following changes to your medicines: 1. We started diltiazem at a dose of 360 mg once daily. 2. We started levofloxacin at a dose of 250 mg once daily. Please complete a seven-day course on [3-14]. 3. We stopped metoprolol. 4. We stopped coumadin. Please restart this medicine when instructed to do so by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ]. 5. We started vitamin D and calcium for bone health. 6. We stopped irbesartan. Please restart this medicine when instructed to do so by Dr. [Last Name (STitle) ]. . Please note your follow-up appointments below. . Please call your doctor or come to the emergency room if you experience change in mental status, lightheadedness or dizziness, chest pain, or other symptoms that are concerning to you. Followup Instructions: 1. Please follow-up with Dr. [First Name (STitle) ] in [2-15] weeks: [Telephone/Fax (1) 10508]. 2. Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. 3. Please follow-up in neurology clinic with Dr. [Last Name (STitle) ] in 2 weeks. Call the office to schedule an appointment: ([Telephone/Fax (1) 8951]. 4. Please follow-up in urology clinic if you notice any concerning urinary symptoms, such as difficulty urinating. The number is [Telephone/Fax (1) 921] and the physician's name is Dr. [Last Name (STitle) ]. Completed by:[2199-3-12]	[ "486", "5119", "4019", "42731", "V5861", "412", "41401", "V4582", "2859", "4280" ]
Admission Date: [2156-9-23] Discharge Date: [2156-10-6] Date of Birth: [2092-12-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: CC: dyspnea, hypoxia Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: Ms. [Known lastname 47417] is a 63 y/o woman with PMH of stage IV breast cancer with cutaneous & liver mets who presents to the ED with worsening dyspnea. The patient states that she began therapy with Megace on [2156-7-21]. Following initiation of therapy she noticed lower extremity edema which progressed over several weeks; she discontinued therapy on [2156-8-13] but the edema persisted. Over the past several weeks, she has noticed increasing dyspnea on exertion. She has 14 stairs in her home and has noted increased difficulty in climbing them. At times, she must stop to rest halfway up the flight. She denies orthopnea, PND, chest pain, palpitations, and dizziness/lightheadedness. She was given HCTZ to "help with fluid" per her report; she has been taking 25 mg daily without much improvement in her edema. . In addition, the patient had two separate bleeds from her external tumor which were substantial per her report. On [9-13] and [9-20], the patient bled from her tumor, requiring multiple washcloths and prolonged application of pressure to stop the bleeding. She denies any hematuria or blood in her stools. . In the ED, the patient was afebrile and 91% on RA; sats increased to 97-98% on 3L NC. She had borderline low blood pressures in the 80s/40s but maintained her mentation and urine output; baseline BPs in the 100s per her report. She has continued HCTZ as above at home. CTA of the chest demonstrated no pulmonary embolism but a large R sided pleural effusion. Blood cultures were sent, and she received levofloxacin 500 mg IV X 1 for treatment of pneumonia. She also received 1 L NS and was transferred to the [Hospital Unit Name 153] for further management. On arrival to the [Hospital Unit Name 153], the patient states that her breathing is "much better." She appears comfortable and is only complaining of chest wall pain and back pain due to "all the moving around." . ROS: Feels thirsty. Appetite and PO intake good per her report. No headache, sore throat, trouble swallowing, nausea/vomiting, abdominal pain, diarrhea, constipation, bloody stools, dysuria, or hematuria per her report. . Past Medical History: * Stage IV breast cancer with mets to skin, bone, and liver diagnosed in [2151]. Prior chemotherapy regimens included: Lipodox, Navelbine (mitotic inhibitor), gemcitabine, Taxotere, oral CMF (cyclophosphamide/MTX/5FU), Adriamycin given weekly until [9-16], and oral etoposide ([2155-9-23]). She has also previously been on hormonal therapy with Femara, Faslodex, exemestane (start [Date range (1) 47418]), and Xeloda without success. * Anemia: Previously aranesp dependent. Social History: Lives with sister. [Name (NI) 1403] in the trust industry with multiple nonprofit organizations; she worked up until Saturday when she felt too poorly to work. Never smoker. No alcohol use. . Family History: Father passed away with pancreatic cancer. Mother lived into her 90s with Alzheimer's. Grandmother had breast cancer but also lived into her 90s. Physical Exam: Afebrile, blood pressure ranging between 80-95 systolic, tach to 110 intermittently sats above 90% on 2 lpm. Gen: Pleasant, cachetic, pale female in NAD. HEENT: op clear NECK: Supple. CV: RRR. nl S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: decreased to auscultation but comfortable respiration ABD: benign, +sister [First Name8 (NamePattern2) ] [Name2 (NI) ] nodule EXT: 2+ pitting edema to the thigh bilaterally, feet warm & well perfused. 2+ dp pulses bilaterally. R arm lymphedema. SKIN: extensive chest wall erythema, ulceration and tumor. NEURO: grossly intact. Pertinent Results: [2156-10-4] 12:21 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [2156-10-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Pending): [2156-10-1] 1:53 pm STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2156-10-3] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2156-10-3]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2156-9-24] 4:35 pm PLEURAL FLUID PLEURAL FLUID FORPH. FINAL REPORT [2156-9-30] GRAM STAIN (Final [2156-9-24]): 4+ (>10 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 [2156-9-27]): NO GROWTH. ANAEROBIC CULTURE (Final [2156-9-30]): NO GROWTH. Pleural fluid cytology: Positve for malignant cells consistent with metastatic breast cancer Pleural fluid found to be exudative ([1-14] lights criteria were positive)> CT chest [2156-9-23]: CONCLUSION: 1. No pulmonary embolism or aortic dissection. 2. Large bibasal effusions with passive atelectasis at the lung bases, more on the right. Small lung nodules in right middle lobe worrisome for metastases. 3. Extensive metastatic disease involving the breasts and the subcutaneous tissues of the chest and abdomen. 4. Metastatic disease in the liver and evidence of prior chemoembolization. Abdominal lymph nodes are incompletely covered/ assessed on this chest CTA and may be further evaluated with a dedicated CT abdomen. CXR [2156-9-27] (two days following Thoracentesis). IMPRESSION: Bilateral pleural effusions, slightly increasing. [2156-9-30] 07:15AM BLOOD WBC-14.6* RBC-3.61* Hgb-10.6* Hct-31.9* MCV-88 MCH-29.5 MCHC-33.4 RDW-17.0* Plt Ct-440 [2156-9-29] 05:01AM BLOOD WBC-17.8* RBC-3.48* Hgb-10.5* Hct-30.6* MCV-88 MCH-30.1 MCHC-34.2 RDW-16.9* Plt Ct-370 [2156-9-24] 12:09PM BLOOD WBC-35.5# RBC-3.26# Hgb-9.5# Hct-28.4# MCV-87 MCH-29.0 MCHC-33.2 RDW-15.9* Plt Ct-418 [2156-9-23] 09:30PM BLOOD WBC-28.8# RBC-2.49# Hgb-6.6# Hct-21.9# MCV-88 MCH-26.7# MCHC-30.3 RDW-16.5* Plt Ct-663* [2156-9-24] 03:11AM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2156-9-24] 03:11AM BLOOD PT-13.0 PTT-20.3* INR(PT)-1.1 [2156-9-24] 03:11AM BLOOD Ret Man-2.8* [2156-9-30] 07:15AM BLOOD Glucose-91 UreaN-49* Creat-1.1 Na-133 K-4.8 Cl-98 HCO3-23 AnGap-17 [2156-9-23] 09:30PM BLOOD Glucose-113* UreaN-63* Creat-1.3* Na-133 K-5.0 Cl-93* HCO3-20* AnGap-25* [2156-9-24] 03:11AM BLOOD ALT-36 AST-47* LD(LDH)-281* CK(CPK)-32 AlkPhos-402* Amylase-42 TotBili-0.1 [2156-9-23] 09:30PM BLOOD CK(CPK)-35 [2156-9-23] 09:30PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 35250]* [2156-9-30] 07:15AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.7* [2156-9-24] 03:11AM BLOOD Albumin-2.7* Calcium-8.2* Phos-5.3* Mg-3.1* Iron-12* [2156-9-24] 03:11AM BLOOD calTIBC-289 Ferritn-144 TRF-222 [2156-9-25] 06:02AM BLOOD Lactate-5.9* [2156-9-24] 01:15AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.029 [2156-9-24] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2156-10-4] 12:21PM PLEURAL WBC-165* RBC-215* Polys-24* Lymphs-55* Monos-15* Macro-2* Other-4* [2156-9-24] 04:35PM PLEURAL WBC-181* RBC-49* Polys-48* Lymphs-35* Monos-6* Atyps-2* Other-9* [2156-10-4] 12:21PM PLEURAL TotProt-2.0 LD(LDH)-106 [2156-9-24] 04:35PM PLEURAL TotProt-2.6 Glucose-137 LD(LDH)-137 CXR [2156-10-4] - IMPRESSION: No evidence of pneumothorax. Interval increase in size in the moderate-to-large left pleural effusion with decrease on the right side. SINGLE AP PORTABLE VIEW OF THE CHEST: Comparison is made with prior studies from [9-25] and 17. Left subclavian vein catheter remains in place. Moderate-to-large bilateral pleural effusions and bibasilar atelectasis are grossly unchanged, accurate comparison is difficult to be made due to difference in position of the patient. Cardio-mediastinal contours are unchanged. Brief Hospital Course: Ms. [Known lastname 47417] is a 63 yo female with unresectable invasive breast cancer s/p multiple chemotherapeutic agents, who was admitted with dyspnea due to pleural effusions and anemia. Breast cancer/palliative care. Ms. [Known lastname 47419] desire is to concentrate on comfort and palliative care. She has reached a stage where she in non-treatable with regards to her breast cancer. Her chest wall lesions were infected on arrival, and have a great liklihood of recurrent infection and bleeding. She should continue on oral and topical antibiotics indefinitely. She will require pain management and antianxiety medications for supportive care. Hospice will be involved in her ECF care. She initially desired to return home with hospice, but she is full assist, and her elderly sister is not capable of 24 hour care (hospice can only be present approx 2 hours daily). Hence she was transferred to rehab with hospice. Shortness of breath. This is secondary to malignant pleural effusions. She is arranged for follow up with interventional pulmonary for pleurodesis, and to call prior to appointment if symptoms worsen. This is if the patient desires a thoracentesis. Initial workup included the following: PE was ruled out by CTA chest. Cardiac enzymes were negative. The pleural effusion was tapped by IP and was found to be exudative. Cytology from thoracentesis was positive for malignant cells. Repeat thoracentesis was done on [2156-10-4] for relief of symptoms. Patient was maintained on [2-15] Lit NC while in hospital with O2 sats greater than 92%. Hypotension. Multifactorial, but stable. Patient was hypotensive to SBP of 80s on admission. She was bolused IVFs and given blood transfusions with improvement of her blood pressure. Her BP is usually between 75-85 systolic, asymptomatic and mentating well. She was treated initally with vanco/zosyn and then started on levofloxacin. Anemia: Patient had a Hct of 21.9 on admission with MCV of 88 with a baseline crit of 30 - 35. Anemia studes revealed an anemia of chronic disease. Patient also reported several episodes of bleeding from cutanous breast metastases requiring pressure to be applied to stop the bleeding. Was guiaic negative in ED. Patient was transfused 2 units to keep Hct greater than 25. Hct remained stable. LE Edema. Patient has had increasing LE edema and DOE over past month, likely related to a combination of chronic disease with decreased oncotic pressure as well as possible IVC compression from liver metastases. Pt requests ACE wraps bilaterally for comfort. ARF. Patient has creatinine of 1.3 on admission with baseline of 0.8. Cr did not improve with IVF. Etiology of ARF remained unclear. Chest wall infection at breast cancer site. Patient had elevated WBC that improved with initiation of zosyn/ vanco and topical flagyl. This was switched to levofloxacin. She remained afebrile during hospitalization. Atrial fibrillation. Patient went into afib on [9-25]. She was rate controlled with Digoxin and started on PO digoxin. A digoxin level was 1.4 on [2156-9-28]. However, digoxin was stopped on [9-29] because of the difficulty with monitoring digoxin levels due to difficulty drawing blood, absence of symptoms while in atrial fibrillation, and patients' desire for hospice care. Code Status: Patient decided to be DNR/DNI and will discharge to local ECF with hospice care. Palliative care followed her in the hospital and hospice will care for her further needs. ### The patient does not have a primary care doctor, she used to follow up with Dr [Last Name (STitle) ] in clinic. Medications on Admission: HCTZ 25 mg daily vicodin prn pain (mainly used at night) Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 hour PRN as needed for Shortness of breath or anxiety. Disp:30 mg Refills:0 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Metronidazole 1 % Gel Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): to chest . 9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. oxygen continuous at 2-4 L by nasal canula to keep sats > 94% 13. Adaptic Bandage Sig: [1-13] Topical twice a day. 14. Xeroform Petrolatum Dressing 5 X 9 Bandage Sig: [1-13] Topical twice a day. 15. Sof-[Last Name (un) ] Sponge Sig: Four (4) Topical twice a day. 16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 17. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO Q2H (every 2 hours) as needed for for pain. 18. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for cough. 19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea or vomiting. 20. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Location (un) 38] Landing Discharge Diagnosis: 1. metastatic (Stage IV) breast cancer, involving chest wall, skin, liver, lungs, pleura. 2. Pleural effusion 3. Chest wall cellulitis 4. atrial fibrillation 5. Anemia Discharge Condition: comfortable, with chronically low blood pressures in the 80-95 systolic range Discharge Instructions: You were hospitalized with shortness of breath, related to fluid in your lung space conpressing your lungs. This has improved since thoracentesis. As you know, you have metastatic breast cancer. You will be going to an inpatient extended care facility, for supportive and comfort care during the remainder of your illness. Your hospice company will work with you and the extended care facility to assure you remain comfortable and have good pain control. Followup Instructions: Please followup with interventional pulmonology on [10-12] at 9am to discuss management of the fluid in your lungs, if you wish to. Please have a chest xray done before that appointment in the [Hospital Ward Name 23] building at [Location (un) 830] (you can walk in at any time). The number for interventional pulmonology is [Telephone/Fax (1) ]. If you feel short of breath before the [10-12] and desire fluid removed from the lungs, please call this number and press option 1 to schedule a sooner appointment. Provider: [Name10 (NameIs) ],ROOM TWO IP ROOMS Date/Time:[2156-10-12] 9:00 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2156-10-12] 9:00 Call Dr. [Last Name (STitle) ] at [0-0-] to arrange a follow up appointment with him if you desire.	[ "5849", "486", "5180", "42731" ]
Admission Date: [2116-8-12] Discharge Date: [2116-8-22] Date of Birth: [2040-7-14] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 106] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: Alcohol septal ablation DDI pacer placement History of Present Illness: 76yoF with h/o HOCM, HTN, and severe MR but otherwise healthy who was having DOE for 1 wk, no chest pain. She was diagnosed with HOCM by a doctor [First Name (Titles) ] [Last Name (Titles) ] and as taking Atenolol daily for this, no previous interventions. She was very active until about a week ago at which point she notes worsening fatigue and DOE with walking, generalized weakness, chest pressure immediately upon lying down (relieved with sitting up) but denies any exertional CP or other anginal symptoms. . About 2 wks ago she saw her PCP who referred her to a Cardiologist 2d ago, who sent her to the ED. There, she had a CXR showing pleural effusions and pulmonary edema with a BNP of 8141, negative Troponins, and EKG with NSR and unchanged non-specific TW changes. She was admitted to [Hospital1 1516] service where they diuresed her and gave her beta blockers. Echo showed severe sLVH with small LV cavity, EF >75%, severe resting LVOT gradient in the 130's, [Male First Name (un) ] of mitral leaflets and 3+ MR, all consistent with HOCM of the elderly (and not due to abnormal myofibrils). On [2116-8-14] she went to cath which showed clean coronaries and elevated R heart pressures and had an alcohol septal branch today which was tolerated well. She did however had some widening of her QRS during the procedure and new appearance of RBBB for which a temporary pacer wire was placed. She is admitted to CCU for further monitoring. . Cardiac ROS as above: she was very active working 5d a week and getting on the treadmill until the past week. She has been generally weak, fatiguable on exertion and DOE even at minimal walking distances. She reports chest pressure substernally immediately when lying down but not with exertion and nothing reminiscent of an MI. She's had minimal pitting edema around her ankles. She felt palpitations with minimal exertion. . ROS otherwise states she was nauseous with food, but otherwise her ROS is negative all other systems. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, denies HTN/HL, smoking, FHx 2. CARDIAC HISTORY: - HOCM: diagnosed 2.5 yrs ago in [State 760], for which she was taking Atenolol only, until [7-/2116] at which point she had EtOH ablation - severe MR - Denies AMI's, CABG, caths 3. OTHER PAST MEDICAL HISTORY: - osteoperosis Social History: SOCIAL HISTORY Moved here from NJ a yr ago and wants to move back. Very active without cane and walker at baseline, has a son - Tobacco history: Smoked [1-2]/day for a few years but back in the [2084]'s, not smoking - ETOH: Recovering alcoholic, drank for 10 yrs but not now - Illicit drugs: None Family History: FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Was healthy - Father: Deceased at 84, asthma, died of aneurysm in stomach Physical Exam: ON ADMISSION: 95.8 p72 102/41 96% 2L NC Large but not obese F in no distress, laying flat with son at bedside. Pleasant, alert, conversant, appears well. EOMI, no scleral icterus, lips are dry appearing. External jugulars are grossly distended and jugular pulsations are noted mid earlobe while laying flat (cannot raise up as pt post cath) RRR with frequent PVC's and subsequent pauses. S1/S2 are clear at BUSB's with a mid systolic crescendo murmur, moving towards the apex the murmur is louder, loudest at midclavicular line, and at apex is a whooshing, almost mechanical sound. Do not hear S3/S4 Lungs grossly clear anterolaterally without w/c/r Abd overweight, soft NT ND, benign Minimal pitting edema around the ankles not extending upwards. Extremities are warm, no mottling. RUE with temporary pacer wire wrapped. Bilateral radials and DP's are palpable. L groin cath site is nontender, no ecchymosis, palpable femoral, but does have an audible bruit. CN 2-12 grossly intact, no focal neuro deficits noted, but have deferred full neuro exam given bedrest, she is alert/attentive/conversant . On Discharge: VS: T 98.5 BP 122/50 (104-129/50-91) HR 63 (63-72) RR 18 O2 95 RA GENERAL: WDWN F in NAD. HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP of 7 cm. CARDIAC: rrr, no m/r/g appreciated LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds in bases ABDOMEN: Soft, NTND. EXTREMITIES: t1+ pitting edema in [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]/l SKIN: no rashes PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Labs on admission: . [2116-8-12] 04:15PM BLOOD WBC-8.4 RBC-3.85* Hgb-11.5* Hct-30.2* MCV-79* MCH-29.8 MCHC-38.0* RDW-13.3 Plt Ct-232 [2116-8-12] 04:15PM BLOOD Neuts-68.6 Lymphs-19.3 Monos-5.0 Eos-6.2* Baso-0.8 [2116-8-13] 05:35AM BLOOD PT-12.1 PTT-27.9 INR(PT)-1.0 [2116-8-12] 04:15PM BLOOD Glucose-98 UreaN-26* Creat-1.1 Na-137 K-4.1 Cl-100 HCO3-26 AnGap-15 [2116-8-12] 04:15PM BLOOD ALT-18 AST-27 LD(LDH)-340* AlkPhos-62 TotBili-1.9* [2116-8-13] 05:35AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.2 Iron-28* [2116-8-14] 03:24PM BLOOD Type-ART pO2-94 pCO2-39 pH-7.41 calTCO2-26 Base XS-0 . Labs on discharge: . [2116-8-21] 08:40AM BLOOD WBC-9.5 RBC-3.64* Hgb-10.5* Hct-29.3* MCV-80# MCH-28.7 MCHC-35.7 RDW-13.1 Plt Ct-408# [2116-8-21] 08:40AM BLOOD Glucose-123* UreaN-11 Creat-0.8 Na-137 K-3.7 Cl-100 HCO3-27 AnGap-14 [2116-8-21] 08:40AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 [2116-8-21] 08:40AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 . Other labs: . [2116-8-13] 05:35AM BLOOD cTropnT-<0.01 [2116-8-12] 04:15PM BLOOD cTropnT-<0.01 [2116-8-12] 04:15PM BLOOD proBNP-8141* . [2116-8-16] 09:11AM URINE RBC-85* WBC-14* Bacteri-FEW Yeast-NONE Epi-<1 . URINE CULTURE (Final [2116-8-18]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S . BLOOD CULTURE: NGTD, 2 cultures pending. . [8-12] CXR: Interval development of mild interstitial pulmonary edema and small bilateral pleural effusions. Unchanged opacity projecting over the right posterior hemidiaphragm, which again may represent a Bochdalek hernia. . [8-13] ECHO: Severe symmetric LVH with small LV cavity size and hyperdynamic LV systolic function. Consequently the mitral leaflets and chordae are pulled towards the hypertrophied upper septum during systole and a severe resting LVOT gradient develops. Findings are more consistent with hypertrophic cardiomyopathy of the elderly than hypertrophic cardiomyopathy due to abnormal myofibrils. Moderate to severe mitral regurgitation. Unable to determine pulmonary artery systolic pressures. . [8-15] CXR: The tip of the temporary pacemaker lies in the first part of the right ventricle. The heart is not enlarged. A left pleural effusion is present. Small right effusion is also seen. The lung fields appear clear. There is no evidence of failure, atelectasis at the left base is noted. . [8-19] CXR: Cardiomegaly is stable. Left transvenous pacemaker leads are in standard position in the right atrium and right ventricle. There has been improvement of now mild vascular congestion. Mild left greater than right pleural effusions associated with atelectasis are grossly stable allowing the difference in positioning of the patient. . Labs on Discharge: [2116-8-22] 07:27AM BLOOD WBC-9.5 RBC-3.11* Hgb-8.8* Hct-26.0* MCV-84 MCH-28.3 MCHC-33.9 RDW-12.5 Plt Ct-425 [2116-8-22] 07:27AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-136 K-4.1 Cl-99 HCO3-28 AnGap-13 Brief Hospital Course: ASSESSMENT AND PLAN 76yoF basically healthy but with 2.5 yr h/o HOCM now with worsening DOE, postural chest pressure, now s/p alcohol septal ablation and DDI pacemaker placement. . # Hypertrophic Obstructive Cardiomyopathy: Patient had knon history of HOCM treated with atenolol and presented with 1 week hx of SOB and DOE raising concern for acute LVOT obstruction. Unclear what her precipitant as patient had been taking beta blockers, was not dehydrated, was in normal sinus rhythm and was not on any significant afterload reducing medicaitons. Patient was taken to the Cath lab for an alcohol septal ablation which she tolerated well. She received a temporary pacing wire during the procedure which was discontinued after 48 hours without pacing requirment. Patient's symptoms improved post operatively. Her LE edema improved with diuresis with 20mg daily IV lasix. Ms. [Known lastname 88536] was discharged on her home dose of torsemide 10mg daily and atenolol was increased to 100 mg. . # Bradycardia: Post alcohol ablation patient had a temporary pacing wire placed per protocol. AFter 48 hours without pacing requirement the temp wire was discontinued. Twenty minutes later patient had an asystolic arrest. CODE BLUE was called with atropine x3, chest compressions, Dopamine gtt and transcutaneous pacing resulting in ROSC. A second transvenous pacer was placed and patient paced at 70 bpm. Telemetry from the event showed complete heart block. The following day the patient had a second event with asystolic pause on telemetry, unresponsiveness and PEA arrest. As CPR was about to be administered transcutaneous pacer began firing and patient had ROSC. Following these events the patient was very disoriented and anticholonergic symptoms likely secondary to atropine administration. A permanent DDI pacer was placed and Ms. [Known lastname 88536] remained without bradycardic events without events on tele for the next 4 days of her hospital course. Follow up with device clinic and electrophysiology were obtained. # Fevers: post-ablation patient developed fevers to 101 and elevated WBC initially felt to be secondary to stress response. Patient subsequently had an asystolic arrest with persistant hypotension as described above and was covered with vanc/cefepime for ? sepsis. In the following days pressor support was weaned and antibiotics d/c'd as cultures were no growth and concern for infection had decreased. Upon arrival on the floor, Ms. [Known lastname 88537] fever recrudesed and Vanc/Cefepime were restarted for 1 day. On [8-19], Ms. [Known lastname 88537] UA came back positive for Enterococcus sensitive to vanco, ampicillin, and macrobid. As Ms. [Known lastname 88536] also had symptoms of urgency, was previously catheterized, and all other micro data was unrevealing-Ms. [Known lastname 88536] was transitioned to macrobid for a symptomatic UTI. Pyelonephritis was not seen as likely as she lacked CVA tenderness and presently despite the fever, she was without systemic symptoms. She remained afebrile until discharge # Anemia: Labs initially consistent with chronic disease with an overlying acute drop from septal ablation. Patient recieved 1 unit pRBC with appropriate rise in HCT and was stable. # CP: Mrs [Last Name (STitle) ] experienced pain in her chest following CPR which was treated NSAIDS. She was discharged to rehab for physical therapy. # Outstanding issues on discharge: -2 Blood cultures pending and require f/u -Pt will complete a 7 day course of antibiotics on discharge for UTI Medications on Admission: Alendronate 70mg qweek Atenelol 50mg daily Torsemide 10mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 3. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays in both nostrils Nasal once a day. 5. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 3 doses. Disp:3 Capsule(s) Refills:0 6. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 ] and Rehab Discharge Diagnosis: Hypertrophic Obstructive Cardiomyopathy Diastolic Congestive Heart Failure Hypertension (High Blood Pressure) Osteoporosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 88536], It was a pleasure taking care of you at [Hospital1 18]. You were admitted with a condition known as hypertrophic obstructive cardiomyopathy. We were able to take care of the lesion responsible for this with a technique known as ethanol ablation. This therapy, however was complicated by another condition known as heart block--a condition that required you to go to the intensive care unit. Because of the heart block, you had a very serious slow rhythm which required CPR. We were able to fix this seriously slow rhythm with a pacemaker. During this admission, you also were diagnosed with a urinary tract infection and started on antibiotics for this infection. The following changes have been made to your medications: START Aspirin 81mg daily INCREASE Atenolol from 50mg daily to 100mg daily Continue Macrobid (Nitrofurantoin) 100mg twice daily Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2116-8-26] at 2:00 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 ] FAMILY MEDICINE When: THURSDAY [2116-8-27] at 10:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 88538] Building: [Street Address(2) 3375] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: THURSDAY [2116-9-17] at 4:00 PM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2116-10-2] at 12:00 PM With: [Name6 (MD) ] [Name8 (MD) 163], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5990", "4280", "4240", "4019", "2859" ]
Admission Date: [2188-4-29] Discharge Date: [2188-5-23] Date of Birth: [2155-12-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: ESRD Major Surgical or Invasive Procedure: [2188-4-30] renal transplant [2188-5-7]: Kidney Biopsy [2188-5-19]: Kidney Biopsy History of Present Illness: 32 y.o. male with esrd secondary to chronic focal sclerosing glomerulonephritis s/[Name Initial (MD) ] failed CRT [2182-2-3] Past Medical History: ESRD on HD (M,W,F) ([1-18] glomerulonephritis) HTN Hypercholesterolemia * PSH: AVF - R radial-cephalic AVF - L aneurysm resection Tunneled L subclavian catheter Social History: denies tobacco, ETOH, drugs Family History: sister who is 26 also has ESRD on HD (?etiology) Physical Exam: VS: 98.7, 89 NSR, 164/109, 20, 97%RA Gen: NAD, A+Ox3, HEENT: slera anicteric Card: RRR, no M/R/G Lungs: CTA bilaterally Abd: Soft, NT, ND, +BS, well healed RLQ incision Extr: No C/C/E, R forearm AV fistula, well healed LUE AV fistula Neuro: CNII-XII intact Pertinent Results: On Admission: [2188-4-29] WBC-5.8 RBC-3.88* Hgb-10.5* Hct-32.3* MCV-83 MCH-27.1 MCHC-32.5 RDW-18.2* Plt Ct-157 PT-12.6 PTT-30.8 INR(PT)-1.1 Glucose-144* UreaN-74* Creat-14.6# Na-140 K-5.5 Cl-99 HCO3-23 AnGap-24* ALT-7 AST-7 AlkPhos-353* Amylase-204* TotBili-0.3 Albumin-4.2 Calcium-9.3 Phos-9.3* Mg-2.8* On Discharge: [2188-5-23] WBC-4.7 RBC-3.03* Hgb-8.3* Hct-25.3* MCV-84 MCH-27.3 MCHC-32.7 RDW-17.5* Plt Ct-134* Glucose-91 UreaN-49* Creat-4.7* Na-139 K-3.9 Cl-107 HCO3-21* AnGap-15 Calcium-8.9 Phos-4.3 Mg-2.1 FK506-10.1 Brief Hospital Course: He underwent cadaveric renal transplant into left iliac fossac on [2188-4-30] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please see operative report for details. He received standard induction immunosuppression consisting of solumedrol taper, ATG, and cellcept. His solumedrol was tapered. ATG was given for a total of 3 doses. Cellcept was well tolerated. Urine output was excellent with 200-300cc per hour. Creatinine trended down to 11.2 from 15.9 by pod 2. Diet was advanced without problems. [Name (NI) ] was ambulatory. The incision was clean, dry and intact. He experienced hypertension postop and labetolol was restarted and increased with improvement of BP. Creatinine trended down to nadir of 2.9 on POD 6 and then it began to rise again. Blood pressure was difficult to control and Nifedipine and Minoxidil were added back. The patient underwent a kidney biopsy on POD 7 which showed: Acute humoral rejection, Banff Type II, (capillaritis/thrombotic microangiopathy pattern) He was started on Plasmapheresis and IVIG, and also received an additional 4 doses of ATG 100 mg each. IVIG for the initial dosing was 90gms at completion of course.He also underwent a few treatments of hemodialysis, in general for volume as his urine output decreased to 300cc/day at the lowest point. Biopsy was repeated on [5-19] as well as repeat of antibody screen. This was reported as improved but not resolved. Pheresis was restarted, he received a dose of Rituximab on [2188-5-18] following the pheresis. In addition the IVIG was started with an additional 40 gms. Patient will complete pheresis/IVIG course as an outpatient with an additional 2 treatments scheduled. Creatinine fluctuates from 4.2-5.0 Urine output increased again to 1.5-2L daily. He has not received additional hemodialysis, last HD [5-13]. Medications on Admission: lisinopril 60', minoxidil 10', labetalol 800', nifedipine 60', sensipar 30', phoslo TT c meals Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 9. PredniSONE 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). 10. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO twice a day. 12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: esrd s/p kidney transplant htn Humoral Rejection Discharge Condition: good Discharge Instructions: Please call Transplant office [Telephone/Fax (1) 673] if fevers, chills, nausea, vomiting, inability to take medications, incision redness/bleeding/drainage, decreased urine output, weight gain of 3 pounds in a day. Call if you do not have any of your medication right away. Labs every Monday and Thursday for cbc, chem 7, calcium phos, ast, t.bili, albumin, urinalysis and trough prograf level. fax results to [Telephone/Fax (1) 697] Come for outpatient pheresis on Monday [5-26] and Weds [5-28] Followup Instructions: [Name6 (MD) ] [Last Name (NamePattern4) 11082], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2188-5-27] 10:10 PHERESIS,BED EIGHT PHERESIS ROOMS Date/Time:[2188-5-26] 8:00 PHERESIS,BED THREE PHERESIS ROOMS Date/Time:[2188-5-28] 8:15 Completed by:[2188-5-23]	[ "40391", "2720", "5849" ]
Admission Date: [2173-9-24] Discharge Date: [2173-10-2] Date of Birth: [2151-6-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: headache, neck pain, chills Major Surgical or Invasive Procedure: Lumbar puncture x 2 History of Present Illness: Mr. [Known lastname ] is a 22y/o M from [Country 11150] who presented to an OSH today with a 10 day history of persistent headache, neck pain, fevers, chills, nausea, vomiting, phonophobia, and generalized fatigue and malaise. The patient first noticed these symptoms ten days PTA with the insidious onset of headache and lethargy. The symptoms were initially accompanied by nausea and vomiting. The patient states that the symptoms went largely unchanged for most of the remainder of the time PTA, until roughly one day ago the nausea and vomiting went away and the headache began to get worse, accompanied by severe neck stiffness and pain with hip flexion. The patient began to notice that loud noises made his head hurt worse, and that moving his eyes exacerbated his pain. Throughout this period he continued to have fevers with shaking chills and sweats. He endorses decreased PO intake. He denies CP/SOB, dysuria, flank pain, cough, rash, itching, focal weakness, difficulty swallowing, numbness, tingling, abdominal pain, diarrhea, constipation, change in stool color or consistency. He denies sick contacts. [Name (NI) ] is unaware of PPD status or of having received BCG vaccine. He is currently a medical student in [Country 9362] and was scheduled to return there on [10-2]. On arrival to the ED in the OSH, the patient was given a LP and was started on Ceftriaxone 2g IV Q12h. The LP showed 357 WBC in tube #4 with 3 RBC, protein of 356, glucose of 39, and diff of 49 PMN, 50 lymphs, initial gram stain negative. Pt was noted to be in urinary retention, foley was inserted with 1.5L drainage, foley left in. Because the OSH had no available negative pressure rooms, the patient was transferred to [Hospital1 18] with direct admission to 12R. Past Medical History: Asthma Social History: The patient lives in [Country 11150], where he is a medical student. He has been visiting the USA over the past 2 months, and had spent most of the trip in [State 531] City. The patient denies sick contacts, environmental exposures, or unusual PO intake. The patient has not travelled outside the NY area while in the US. The patient has had no sexual contacts. [Name (NI) ] with friends while in NY. The patient does not use EtOH, tobacco, or illicits. His family lives in [Country 11150]. Family History: Noncontributory Physical Exam: VS: Tmax 102 \| Tcurrent 101.1 \| 116 \| 28 \| 98% RA . GEN: WDWN male in moderate distress, lying quietly in bed with covers pulled up, shivering. Answers questions appropriately, but frequently with delay. NEURO: Oriented to person, place, time, and situation. CN II-XII intact. Tenderness with evaluation of extraocular muscles. Moves all extremities spontaneously. Motor exam with [6-3] symmetric strength to flexion and extension in all major muscle groups. Sensory exam intact to light touch throughout. Gait not evaluated [3-3] pain. HEENT: PERRLA, EOMI, OP clear, MM dry. No palatal petichiae or tonsillar exudate. Anicteric sclerae. NECK: supple, no supraclavicular or cervical LAD. Exquisite tenderness to palpation in dorsal cervical midline. +Kernig sign. +Brudzinski sign. +pain with neck flexion. CHEST: CTA B COR: tachy, regular rhythm. Normal S1, S2. No M/R/G appreciated. ABD: soft, NT, ND, bowel sounds present. No masses or HSM. EXT: no edema. W/WP. Peripheral pulses intact and symmetric. SKIN: no rashes, no petichiae, palms and soles specifically evaluated. Pertinent Results: [2173-9-24] 08:59PM BLOOD WBC-15.4* RBC-5.38 Hgb-14.6 Hct-40.5 MCV-75* MCH-27.1 MCHC-36.0* RDW-11.9 Plt Ct-385 [2173-9-24] 08:59PM BLOOD Neuts-87.5* Lymphs-8.0* Monos-3.6 Eos-0 Baso-0.8 [2173-9-24] 08:59PM BLOOD PT-12.6 PTT-24.8 INR(PT)-1.1 [2173-9-24] 08:59PM BLOOD Fibrino-563* [2173-9-24] 08:59PM BLOOD ALT-17 AST-15 LD(LDH)-177 AlkPhos-74 TotBili-0.8 [2173-9-24] 08:59PM BLOOD Calcium-9.1 Phos-2.5* Mg-2.1 [2173-9-24] 08:59PM BLOOD Hapto-367* . CSF Results: LP #1: From OSH - CSF culture - no growth, Fungal cultures - preliminary no growth, AFB cultures pending Serologies - Lyme negative, Enterovirus negative . LP #2 [9-25]: Tube 1: WBC 273, RBC, polys 14, lymphs 84 mono 2 Tube 4: WBC 304, RBC 10, polys 18, lymphs 78, mono 4 protein 442 Glucose 13 . LP #3 [9-28]: Tube 1: WBC 408, RBC 1, polys 10, lymphs 90, mono 0 Tube 4: WBC 394, RBC 9, polys 10, lymphs 89, mono 1 protein 208 Glucose 32 . TB PCR pending x2 VDRL pending HSV [1-31] - negative . Blood Serology: Erlichia Antibody - pending Strongyloides Antibody - pending RPR - non reactive Lyme - negative . Microbiology: Urine culture [9-24] - no growth (final) Urine culture [9-27] - no growth (final) Blood cultures 8/26 - no growth (final) Blood cultures 8/27 - no growth to date Blood cultures 8/29 - no growth to date Blood cultures 8/30 - no growth to date . CSF [9-25]: gram stain negative, fluid culture negative, fungal cultures prelim negative, AFB culture pending, AFB smear negative, viral cultures pending, cryptococcal Ag negative . CSF [9-28]: gram stain negative; cultures negative todate, fungal culture pending, AFB pending Stool cultures - C. Diff negative, O&P pending, marcoscopic - no worms . Imaging: CXR [9-24]: No acute cardiopulmonary disease. _______________________________ CT HEAD [9-25]: IMPRESSION: No evidence of acute intra- or extra-axial hemorrhage, mass effect. No evidence of enhancing lesions, or meningeal enhancement. ______________________________ KUB [9-25]: The bowel gas pattern is nonspecific and nonobstructive with no evidence for free air, pneumatosis or ascites. ____________________________ MRI Head [9-26]: There is normal signal intensity throughout the brain parenchyma. The ventricles, sulci, and cisterns are unremarkable. There is no slow diffusion, susceptibility artifact, or areas of abnormal enhancement. Surrounding soft tissues are unremarkable. There is an isolated punctate focus of elevated T2/FLAIR signal in the periventricular white matter of the left parietal lobe, likely of little clinical significance. IMPRESSION: No evidence of acute infarction, an infectious process, or an enhancing mass lesion. ____________________________ MRI Lumbar Spine [9-27]: Vertebral body height, alignment, and signal intensity are normal. There is no paraspinal or epidural soft tissue enhancing masses. There is no spinal canal stenosis or neural foraminal stenosis. There is diffuse, marked leptomeningeal enhancement of the conus medullaris and the cauda equina nerve rootlets. No definite enhancing leptomeningeal nodules are appreciated. IMPRESSION: Leptomeningeal enhancement of the conus medullaris and cauda equina. This finding can be seen in diffuse meningeal infection as provided by history. Other differential diagnostic consideration would include metastatic disease. _________________________ MRI Thoracic Spine [9-27]: The study is technically limited due to extreme patient motion and is suboptimal for adequate evaluation of the thoracic spine. There is some suggestion of abnormal spinal cord enhancement along its surface, but this is difficult to fully characterize given the poor resolution due to motion degradation and the lack of axial images. Also, there is some suggestion of increased abnormal STIR signal intensity from the T6-T9 levels in the left paraspinal musculature with mild corresponding enhancement, but this evaluation too is limited due to lack of axial images or adequate resolution. Of note, vertebral body height and alignment appears normal. No definite paraspinal fluid collection is seen. IMPRESSION: Technically limited and suboptimal study for adequate evaluation of the thoracic spine. Possible abnormalities as described above need repeat imaging for adequate interpretation. ________________________ EKG [9-28]: Regular narrow complex tachycardia - may be sinus tachycardia but consider also atrial flutter with 2:1 response Modest nonspecific ST-T wave changes No previous tracing for comparison _______________________ ECHO [9-29]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. _______________________ CT OF THE ABDOMEN [9-29]: The imaged portions of the lung bases are clear with no opacities, effusions, or nodules identified. The liver appears normal with no focal lesions identified. The gallbladder, pancreas, and spleen all appear normal. The adrenals are normal. The kidneys enhance and excrete normally. There is no mesenteric lymphadenopathy. There is no retroperitoneal lymphadenopathy. There is no free fluid in the abdomen. The small bowel appears unremarkable. _____________________ CT OF THE PELVIS WITH CONTRAST [9-29]: The appendix is abnormally thick with a diameter up to 7.6 mm. In addition, the wall of the appendix abnormally enhances. However, there is no sign of any periappendiceal fat stranding or fluid. This may be consistent with a very early appendicitis. Though this may not correlate with the clinical history, careful clinical observation is recommended. The terminal ileum and cecum are unremarkable, which suggests no tuberculosis involvement. The large bowel is otherwise unremarkable. The distal ureters and bladder appear normal. A Foley tube and rectal tube are noted. There is no free fluid in the pelvis or lymphadenopathy. BONE WINDOWS: The osseous structures are unremarkable. IMPRESSION: Possible early appendicitis, careful clinical observation is recommended. No radiographic evidence of tuberculosis involvement in the abdomen. _____________________ Repeat CT Abdomen and Pelvis [9-30]: normal contrast filling the apendix, no acute change. ______________________ LENIs: no DVTs in lower extremities, bilaterally Brief Hospital Course: Mr. [Known lastname ] is a 22 man, native of [Country 11150], with no significant PMHx admitted with meningitis/encephalitis presumed to be Tuberculous meningitis. . The patient was initially admitted to the regular medical floor, vital sings were Tmax 102; Tc 98.8; P 62; RR 18; BP 94/56. Patient was continued on Ceftriaxone for bacterial meningitis. Patient then developed photophobia overnight and became increasingly lethargic, with waxing/[Doctor Last Name 688] mental status. Also, patient was noted to have new abdominal tenderness not noted on previous exams. Infectious Disease was consulted who recommended repeating the LP to obtain further specimen for TB PCR and other exams; they also recommended starting patient on Acyclovir pending HSV results and antibiotic coverage for suspected TB meningitis in conjunction with steroids. The patient was started on INH, pyrazinamide, pyridoxine, Rifampin, Ethambutol and Dexamethasone. . Given the patient's worsening mental status including increasing lethargy and new-onset photophobia without focal CNIII deficits, patient was transferred to the [Hospital Ward Name 332] ICU for further management. He was kept on respiratory precautions and with negative pressure isolation. . 1. Meningitis/Fever - Patient's history, physical exam, and LP results from the OSH and repeated at [Hospital1 18] were concerning for bacterial meningitis with very high opening pressures, although the time course was somewhat more prolonged than would be expected for a bacterial process. Gram staining was negative, but showed a relative preponderance of lymphocytes with high protein levels making a viral process or TB higher on the differential diagnosis. Initially, the patient was maintained on bacterial coverage with Ceftriaxone and Vancomycin which was added to cover resistant pneumococcus. Mr. [Known lastname ] continued to have photophobia with waxing/[Doctor Last Name 688] mental status although his WBC steadily trended downwards. He continued to show signs of increased intracranial pressure with CN VI palsy bilaterally, ?CN IV palsy and sluggish pupils. The patient continued to have headache, back pain and positive Kernig's sign. He was continued on treatment for TB meningitis with steroids. Ceftriaxone and Vancomycin were discontinued once CSF cultures from the OSH came back negative. Acyclovir was later discontinued as CSF HSV 1 and 2 came back negative. Repeat LP was performed as per ID recommendations which again showed a lymphocytic predominance with decreasing levels of protein and increasing glucose. With continued treatment the patient's mental status began to steadily improve. He became more alert and oriented and was able to respond quickly and appropriately to questioning. He continued to have a left sided CN VI palsy on lateral gave but his pupils were more reactive. Pt continued to have periods of severe headache, back pain and leg pain throughout his admission, treated with acetaminophen, oxycodone and IV morphine as needed. Droplet precautions and negative pressure isolation was discontinued as the patient has no signs or symptoms or active TB. MRI of the head was also performed which did not reveal any evidence of TB or other abnormalities. Patient had 1 value of temp of 101.1 during the last day of hospitalization. No source of infection was immediately apparent, so, since patient is at an increased risk for DVT (due to LE paraplegia), bilateral LENIs were ordered and were negative for DVT bilaterally. DDx for the fevers included atelectasis and incentive spirometer was placed at patient's bedside. 2. Lower Extremity Weakness - On admission to the ICU, the patient was acutely ill and remained in bed with altered mental status. With improving mental status the patient was found to have b/l lower extremity weakness. On admission, however, the patient had full strength bilaterally. Lower extremity strength was 2-3/5, upper extremity strength 5/5 b/l. In addition he had b/l up going toes, b/l clonus. Sensations remained intact throughout. There was at no time any saddle anesthesia or incontinence although the patient did have one episode of severe diarrhea as a result of aggressive bowel regimen for constipation. MRI of the thoracic and lumbar spine revealed leptomeningeal enhancement of the conus medullaris and cauda equina in the setting of diffuse meningeal irritation. There was question of a paraspinal soft tissue enhancement poorly seen on MR of the thoracic spine. These findings supported meningeal irritation of the cord as a cause for this patient's lower extremities weakness, with a combination of upper and lower motor neuron findings due to involvement of the conus medullaris. Neurology was consulted who suggested continued treatment of the underlying infection and continued steroids. CT of the abdomen/pelvis did not reveal any involvement of the paraspinal musculature or soft tissues. Patient received 6 days of steroids, patient should be given his last day of 6mg IV Dex q 6 today. ([2173-10-2]). Please refer to the enclosed taper of steroid doses to treat the patient appropriately. 3. Abdominal Pain - Initially the patient had one episode of abdominal pain with nausea/vomiting and decreased appetite. His abdomen remained soft, mildly tender, with no rebound or guarding. Abdominal x-ray did not reveal any free air or obstruction. LFTs were within normal limits. This resolved and the patient continued to have good PO intake without abdominal pain. On [9-28] the patient again began to complain of abdominal pain, diffuse in nature, constant and sharp in nature, rated [9-8]. He did not have an acute abdomen on physical examination. This was thought to be due to constipation as the patient had not had a bowel movement for several days. The patient was treated with an aggressive bowel regimen including PR lactulose which caused the patient to have a large quantity of loose stool. After this the patient continued to have an appetite with good PO intake but continued to complain of diffuse abdominal pain. A CT of the abdomen and pelvis was performed with oral and IV contrast which showed a filling defect in the appendix with a thickened wall suggestive of appendicitis. Surgery consult was placed who recommended repeat imaging of the abdomen due to the suboptimal quality of the first study which did not show filling of the cecum. The patient remained without an acute abdomen throughout, WBC count was steadily decreasing, fever curve decreasing. The suspicion for TB enteritis or lymphadenopathy causing appendiceal obstruction remained. Repeat CT abdomen/pelvis however showed a normal filling appendix, appendicitis was ruled out and surgery team signed off. 4. Urinary retention- At OSH, pt was found to have urinary retention, requiring a foley. Pt was tried on voiding trial here and failed, thus necessitating putting foley back in. Likely related to conus syndrome as above. Voiding trial was attempted once more, but the patient began to experience severe abdominal pain several hours after the foley was removed. Patient complained of inability to pass urine, the foley was placed back in and 750cc of urine came out while abdominal pain resolved. 5. Tachycardia - The patient was in sinus tachycardia beginning [9-27] which persisted and reached a maximum HR of 160s. This was thought to be due to his underlying infection with persistent low grade fevers. The patient was anxious and having at times severe headaches, back ache and leg pain. The patient responded appropriately to several fluid boluses of NS which caused his HR to come down to the 60s. Baseline fluids were maintained with intermitted NS boluses as needed. The patient continued to match his urine input and output and was able to tolerate aggressive fluids without any problems. In addition, he was treated with Ativan for anxiety, Percocet and Morphine for pain which also seemed to slow his heart rate. Notably, the patient's heart rate decreased during sleep and increased during the daytime, likely as a result of anxiety. On the last day, foley was clamped, patient had urge to void, so foley was d/c'ed. However, patient has a h/o of urinary retention while being in in the hospital, so he should be evaluated for urine output frequently. 6. Cerebral salt wasting: Initially the patient was thought to have SIADH with low serum sodium levels likely due to his underlying CNS infection. A trial of fluid restriction however failed to normalize the patient's sodium level. 24h urinary sodium secretion was above normal suggesting cerebral salt wasting as the cause for his low sodium. The patient was treated with NS at 150 cc/hr with one day of salt tablets with normalization of his sodium. Patient sodium normalized (135) being the last [Location (un) 1131], while taking in POs. 7. F/E/N: Maintained on a regular diet, NPO during the time he was suspected of having appendicitis. Serum electrolytes were monitored carefully. As mentioned above, serum sodium levels decreased to a low of 129 but increased to normal limits with normal saline and salt tabs. 8.Prophylaxis: Heparin SC, pneumo boots due to high risk of DVT with LE weakness. PPI, RISS due to steroids, PO intake. 9. Contact: [Name (NI) ] and [Name2 (NI) 62780] [Name (NI) ] (H)[Telephone/Fax (1) 62781], (C)[0-0-]. [Hospital3 13313]: [Telephone/Fax (1) 62782], Micro lab [Telephone/Fax (1) 62783]. Medications on Admission: None Discharge Medications: 1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 2. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:qs Capsule(s) Refills:2 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Ethambutol 400 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Morphine 2 mg/mL Syringe Sig: [1-31] Injection Q4H (every 4 hours) as needed. 15. Dexamethasone Taper 6 mg IV q6 hours - [Date range (1) 62784] 4.5 mg IV q6 hours- [Date range (3) 62785] 3 mg IV q6 hours- [Date range (1) 62786] 1.5 mg IV q6 hours- [Date range (3) 62787] 4 mg po (can divide doses) qday-[Date range (3) 62788] 3 mg po (can divide doses) qday-[Date range (1) 62789] 2 mg po (can divide doses) qday-[Date range (1) 62790] 1 mg po (can divide doses) qday-[Date range (3) 62791] OFF 16. Regular Insulin Sliding Scale Breakfast Dinner 0-150 0 0 151-200 2 units 2 units 201-250 4 units 4 units 251-300 6 units 6 units 301-350 8 units 8 units 351-400 10 units 10 units >401- [Name8 (MD) ] MD Discharge Disposition: Extended Care Facility: [Hospital3 13313] Discharge Diagnosis: Primary diagnosis: Meningitis most likely tuberculous Lower extremity weakness Abdominal pain NOS Discharge Condition: stable, afebrile, improved, regaining strength Discharge Instructions: -please continue all treatments as directed -please have PT work with the patient, especially strengthening exercises -please follow up all the CSF culture data. please call [Hospital1 18] at [Telephone/Fax (1) 4645] to finfd out any additional results from microbiology lab. Main number for [Hospital1 ] is [Telephone/Fax (1) 2756] -please continue all treatments as directed -please have PT work with the patient, especially strengthening exercises -please follow up all the CSF culture data. please call [Hospital1 18] at [Telephone/Fax (1) 4645] to finfd out any additional results from microbiology lab. Main number for [Hospital1 ] is [Telephone/Fax (1) 2756] -please involve Neurology and Infectious Disease specialists at your facility to care for the patient -Medication (including dexamethasone taper) per instructions Followup Instructions: -Will need to call [Hospital1 ] to follow up on CSF and culture data. -other as per discharge summary Completed by:[2173-10-2]	[ "2761" ]
Admission Date: [2184-8-7] Discharge Date: [2184-8-12] Date of Birth: [2129-9-14] Sex: F Service: MEDICINE Allergies: Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol / Erythromycin Attending:[First Name3 (LF) 477] Chief Complaint: Dyspnea, cough, nausea, emesis Major Surgical or Invasive Procedure: central catheter placement nasogastric tube placement History of Present Illness: 54 year old female with recurrent ovarian cancer, recently d/c'd on [8-3] with gastritis/esophagitis, who presented on [8-7] with increasing SOB, cough, nausea and vomiting x 3 days and acute onset bilateral edema. Per the patient, she had experienced no diarrhea with the nausea and emesis and instead noted decreased ostomy output. No BRB in ostomy output. Cough was nonproductive. She has baseline SOB due to asthma but she felt that this had worsened over the 1-2 weeks prior to admission, particularly with exertion. No orthopnea or PND, but worse when lying on her sides (either side). + sinus congestion in week preceding admission. No fevers, chills. Of note, she had received desensitization for carboplatin on [8-5] with a significant amount of IVF and her primary oncologist felt that she was fluid overloaded and she was sent in for diuresis and electrolyte monitoring. . In the ED course she had a leukocytosis, elevated lactate to 3.6, hypokalemia, and an elevated pro BNP. UA showed a UTI. CTA for PE was negative but demonstrated bilateral ground glass changes and nodular opacities consistnent with acute infection, with atypical vascular congestion being more unlikely. A central line was placed for concern of sepsis and she was given 3L given, cx sent, and vanc/cefepime/fluconzole/flagyl were started. . She was transferred to the MICU for concern of sepsis where broad spectrum antibiotics were continued. CT abd/pelvis showed SBO and NGT placed, bowel rest. Cefepime was changed to levofloxacin on [8-8] and vancomycin and flagyl were discontinued today ([8-9]) due to clinical improvement. Bilateral LE U/S performed for LE edema which showed no evidence of DVT. Due to nausea/emesis/abd pain/elevated bilirubin RUQ US obtained which showed contracted gallbladder completely filled with sludge and tiny [Known lastname ] and no evidence of cholecystitis. ECHO was performed to evaluate etiology of LE edema and showed hyperdynamic EF, small pericardial effusion, no significant change from prior. . Currently on the floor she has mild SOB with positional changes that responds to albuterol treatments. Continued cough, nonproductive, somewhat worse than admission. No hemoptysis. Nausea and vomiting has remarkably improved and she is tolerating clears without difficulty. Fatigued and worn out. . ROS negative for fevers, chills. +18lb weight loss in last 2 months d/t decreased appetite. No current sinus or nasal congestion. No sore throat. Mild dysphagia initially after removal of NGT this afternoon, now improved. No abdominal pain, dysuria. . Past Medical History: Asthma . Oncologic History: She was originally diagnosed in [2180-4-20] with stage III C adenocarcinoma of the ovary. Post operatively she received six cycles of carboplatin and Taxol chemotherapy, completing treatment [2180-8-23]. She then enrolled on the OvaRex study at the [Hospital 4415]. Right adnexal recurrence was noted by CT scan in [2182-9-21]. She received two cycles of Taxol and carboplatin, but had a severe platinum allergic reaction requiring a switch to Doxil and Taxol for several additional cycles of second line therapy. She then developed mucositis on this regimen and received 5 additional cycles of single [Doctor Last Name 360] Taxol. She developed a large bowel obstruction during her fifth cycle which required a diverting ileostomy performed on [2183-11-21]. She subsequently received four cycles of Halichondrin B as part of the 06-125 protocol, but had progressive disease and was taken off the protocol on [2184-4-1]. She then commenced gemcitabine at 600 mg/m2 and received three weekly doses followed by a week off. She received two cycles of gemcitabine but has progressed. She is now cycle 3 of carboplatin desensitization. Social History: She has one son who is 30 years old. She has worked as a freelance writer until recently. She lives in [Hospital1 ], MA with her son. She drinks alcohol occasionally and has quit smoking 20 yrs ago (15yr h/o of 1ppd). Family History: She had a maternal grandmother with heart disease who at the age of 83 developed colon cancer. There is no other cancer in her family. Her mother died of COPD. Her father had a gastric ulcer and died of renal artery stenosis. Physical Exam: VS: 95% on RA, 96.8, 18, 95, 112/55 GEN: comfortable, NAD, conversive, eating broth HEENT: PRRLA, EOMI, anicteric, MMM, OP clear Neck : supple, unable to assess JVD on right d/t line but flat on left, no [Doctor First Name ] CV: tachy, RR, no M/R/G PULM: Decreased BS bilaterally at bases, R>L, no wheezes, no crackles GI: soft, minor tenderness around umbilicus, no reboung or guarding, no tap tenderness, ileostomy in place and draining actively while in room EXT: 4+ edema b/l to thighs, pulses palpable, no cyanosis, clubbing NEURO: AAOx3. Cn II-XII grossly intact Pertinent Results: [2184-8-7] 01:30PM BLOOD WBC-16.3# RBC-3.69 Hgb-11.4* Hct-35.2* MCV-95 MCH-31.1 MCHC-32.6 RDW-21.6* Plt Ct-243# [2184-8-9] 04:00AM BLOOD WBC-7.0 RBC-2.85* Hgb-8.6* Hct-26.3* MCV-92 MCH-30.0 MCHC-32.5 RDW-22.0* Plt Ct-180 [2184-8-9] 04:00AM BLOOD PT-15.7* PTT-31.1 INR(PT)-1.4* [2184-8-9] 03:39PM BLOOD Glucose-95 UreaN-24* Creat-0.8 Na-138 K-2.9* Cl-107 HCO3-26 AnGap-8 [2184-8-9] 04:00AM BLOOD ALT-34 AST-36 LD(LDH)-307* AlkPhos-170* TotBili-1.1 [2184-8-7] 01:30PM BLOOD Lipase-16 [2184-8-7] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-2181* [2184-8-9] 03:39PM BLOOD Calcium-7.4* Phos-1.5* Mg-2.1 [2184-8-8] 03:28AM BLOOD Cortsol-24.3* [2184-8-8] 04:09AM BLOOD Cortsol-34.3* [2184-8-8] 05:11AM BLOOD Cortsol-39.7* [2184-8-7] 03:31PM BLOOD Lactate-3.6* [2184-8-7] 05:59PM BLOOD Lactate-2.3* [2184-8-8] 12:12AM BLOOD Lactate-1.6 . CT Abd/Pelvis [8-7]: 1. Limited study without contrast was designed primarily to evaluate for obstruction. This demonstrates small- bowel obstruction with transition point just proximal to the stoma site. . CTA chest: 1. No evidence of pulmonary embolism. 2. Bilateral ground glass change and nodular opacities likely represent acute infection. Consider opportunistic infection based on immune status. Aspiration considered given #3 below, however anterior upper lobe involvement difficult to reconcile. Atypical edema is a less likely cause for these findings. Mediastinal lymph nodes have progressed in size, though a component of this may be reactive. 3. Dilated fluid filled esophagus may represent more distal obstruction in the abdomen. 4. Stable right greater than left pleural effusions. 5. Evidence of metastatic disease within the abdomen incompletely evaluated. . LE U/S Bilat 8/20: No evidence of DVT . ECHO [8-9]: Hyperdynamic left ventricular function. Small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2183-11-24], the findings are similar. Brief Hospital Course: A/P: 54 year old female with recurrent ovarian ca who presented with SOB, cough, nausea, emesis, and edema who was found to have SBO and pneumonia. . #)SBO - Upon admission the patient was found on CT Abdomen to likely have a small bowel obstruction with transition point at the site of her ostomy. A nasogastric tube was placed and she was made placed on bowel rest. Her diet was slowly advanced until she was tolerating solids and liquids without difficulty. Complicating her course in the last several months has been chronic appetite loss as well as chronic nausea. . #) PNA - The inital concern was for aspiration pneumonia in the setting of nausea and vomiting. Sputum gram stain showed 1+GNR and GPC. She improved on levofloxacin (vanc and flagyl stopped) and this was continued for a full course. . #) Esophagitis - She was recently hospitalized for esophagitis, and fluconazole was continued throughout her stay for concern for [Female First Name (un) ] esophagitis. . #) LE edema - She had no evidence of systolic or diastolic dysfunction on ECHO. Also, she had no obvious pelvic or abdominal mass causing lymphatic obstruction/venous obstruction secondary to ovarian CA and mets. Most likely cause of edema is hypoalbuminemia in the setting of very poor nutritional status, which was exacerbated by fluid load from chemotherapy/ Medications on Admission: MEDS AT HOME: 1. Venlafaxine 125 QD 2. Zolpidem 10 HS prn 3. Metoclopramide 10 mg PO QIDACHS PRN (only takes occasionally 4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 5. Dronabinol 2.5 mg PO BID - just started one week ago 6. Oxycodone 10 mg Tablet Sustained Release [Hospital1 ] 7. Oxycodone 10 mg Tablet Q6H prn 8. Lorazepam 0.5 mg Tablet PO Q8H prn 9. Simethicone 80 mg Tablet PO QID prn 10. Loperamide 2 mg Capsule PO QID prn 11. Calcium Carbonate 500 mg Tablet PO QID prn heartburn . MEDS ON TRANSFER: Venlafaxine XR 150 PO DAILY (to start in a.m.) Levofloxacin 500 mg IV DAILY Albuterol [12-23] PUFF IH Q6H:PRN Lorazepam 0.5 mg IV Q4H:PRN Pantoprazole 40 mg IV Q12H Fluconazole 200 mg IV Q24H Ondansetron 8 mg IV Q8H:PRN [8-9] Acetaminophen 500 mg NG Q6H:PRN Magnesium Sulfate IV Sliding Scale Calcium Carbonate 500 mg PO QID:PRN Simethicone 80 mg PO QID:PRN OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Oxycodone SR (OxyconTIN) 10 mg PO Q12H Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN Zolpidem Tartrate 10 mg PO HS Docusate Sodium 100 mg PO BID Bisacodyl Loperamide Dronabinol Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day for 2 weeks. 2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 10. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO twice a day. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for nausea. 12. Loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a day as needed for diarrhea. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day: Take before meals. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 16. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [5-28] hours as needed for nausea. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: 1.) Small bowel obstruction 2.) Aspiration pneumonia 3.) Stage II ovarian cancer 4.) esophagitis Discharge Condition: afebrile, displaying normal vital signs, tolerating regular diet. Discharge Instructions: You were admitted to the hospital with cough, difficulty breathing, and worsening nausea and vomiting. You were treated with antibiotics, and a nasogastric tube was placed. This was removed and your diet was slowly advanced. . Upon discharge be sure to continue the full course of antibiotics and continue to keep all health care appointments as scheduled. . If you develop worsening cough, shortness of breath, fever, nausea + vomiting, abdominal pain or chest pain, or if your condition worsens in any way, seek immediate medical attention. Followup Instructions: You have the following follow-up appointments with Drs. [Last Name (STitle) 2244] and [Name5 (PTitle) ]. Continue to follow up with your physicians at [Hospital3 328] as previously scheduled. . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2184-8-19] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6198], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2184-8-19] 11:00 [Name6 (MD) ] [Name8 (MD) 490] MD, [MD Number(3) 491]	[ "0389", "5070", "5990", "49390" ]
Admission Date: [2180-5-22] Discharge Date: [2180-5-26] Date of Birth: [2129-4-20] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with a history of a myocardial infarction in [2166] and an angioplasty in [2167]. He did well for almost 10 years with medical treatment. Over the past year, he has had increasing shortness of breath with angina and left arm pain. To months ago he had a positive exercise tolerance test which led him to cardiac catheterization on [2180-4-13]. This revealed a left ventricular end-diastolic pressure of 22 as well as coronary artery disease consisting of left main 70 percent, left anterior descending 80 percent, obtuse marginal 90 percent, and posterior descending artery 90 percent, and proximal left ventricle 80 percent. No mitral regurgitation. No left ventriculography was done at that time. Prior to his surgery, he had ongoing symptoms of chest pressure and left arm pain with fatigue even with rest, occurring multiple times per day. PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Myocardial infarction in [2166]. 3. Percutaneous transluminal coronary angioplasty in [2167]. 4. Elevated cholesterol. 5. Psoriasis. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy in [2171]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: PHYSICAL EXAMINATION ON PRESENTATION: Right arm blood pressure was 108/57 and right arm blood pressure was 134/73, his heart rate was 70, height was 5 feet 6 inches tall, and weight of approximately 200 pounds. Cardiovascular examination revealed a rate and rhythm. Normal first heart sounds and second heart sounds. There was a 2/6 systolic murmur. The lungs were clear to auscultation. The abdomen was soft, round, nontender, and nondistended. There was no costovertebral angle tenderness. Neck revealed negative jugular venous distention and negative bruits. Extremities with some psoriasis on the bilateral elbows and knees. Warm and well perfused. Good CSM. Pulses were 2 plus right and left radial, 2 plus right and left femoral, 2 plus right and left dorsalis pedis, 1 plus right posterior tibialis, 2 plus at left dorsalis pedis. Neurologic examination revealed cranial nerves II through XII were grossly intact. Excellent strength in all four extremities. PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed Poor R wave progression, sinus rhythm at 66. A chest x-ray on [5-24] showed bibasilar patchy atelectasis; unchanged from a previous study with some mild thickening of the minor fissure, and no other changes. PERTINENT LABORATORY VALUES ON PRESENTATION: On [5-26], complete blood count revealed his white blood cell count was 9.2, his hematocrit was 28.2, and his platelets were 244. Sodium was 143, potassium was 4.4, chloride was 105, bicarbonate was 28, blood urea nitrogen was 19, creatinine was 0.8, and his blood glucose was 113. Magnesium was 2.1. SU[Last Name (STitle) 42242]OF HOSPITAL COURSE: The patient was admitted on [5-22] and underwent coronary artery bypass graft times four by Dr. [Last Name (Prefixes) ]. That evening, he had a brief episode of atrial fibrillation lasting less than one hour that resolved independently. His chest tubes were discontinued on [5-24], and his cardiac pacing wires on [5-26]. The patient was transferred to the Inpatient Floor on [5-25]. He was followed by the Physical Therapy Service and was found to safe for discharge to home on [5-24]. The remainder of his hospital course was uneventful. DISCHARGE DISPOSITION: To home on [5-26]. CONDITION ON DISCHARGE: Vital signs revealed a temperature maximum was 100.9, temperature current was 98.4, his heart rate was 88 to 96 (normal sinus rhythm), his blood pressure was 98 to 108/50s to 60s, his respiratory rate was 18, and his oxygen saturation was 94 percent on room air. Fingerstick blood sugars were within normal limits. Weight on discharge was 90.5 kilograms with a preoperative weight of 90.9 kilograms. He was alert, awake, and oriented times three. The sternal incision was open to air with Steri- Strips. Clean, dry, and intact with a stable sternum. He had an incision at the right knee and ankle which were both clean, dry, and intact with Steri-Strips. Respiratory examination revealed the lungs were clear to auscultation. Cardiovascular examination revealed a rate and rhythm. There were no murmurs, rubs, or gallops. No edema was noted. Gastrointestinal examination revealed there were positive bowel sounds in all four quadrants. The abdomen was rounds, soft, nontender, and nondistended. DISCHARGE STATUS: The patient was to be discharged home with Visiting Nurses Association. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass graft times four. 2. Elevated cholesterol. 3. Status post laparoscopic cholecystectomy. MEDICATIONS ON DISCHARGE: 1. Toprol-XL 25 mg by mouth once per day. 2. Lasix 20 mg by mouth once per day (for seven days). 3. Potassium chloride 20 mEq by mouth once per day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Aspirin 325 mg by mouth once per day. 7. Percocet 5/325-mg tablets one to two tablets by mouth q.4- 6h. as needed. 8. Crestor 10 mg by mouth once per day. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. The patient was instructed to follow up with Dr. [Last Name (STitle) 54731] in one to two weeks. 2. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1159] in one to two weeks. 3. The patient was instructed to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] in three to four weeks. 4. The patient was also to be seen in the [Hospital 409] Clinic for evaluation of his incisions in two weeks. 5. The patient will be followed by a visiting nurse briefly at home. [Doctor Last Name ] [Last Name (Prefixes) ], MD 2351 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2180-5-26] 13:26:56 T: [2180-5-26] 15:00:00 Job#: [Job Number 54732]	[ "41401", "5180", "42731", "2720" ]
Admission Date: [2113-12-31] Discharge Date: [2114-1-24] Date of Birth: [2050-9-6] Sex: F Service: Medicine, [Doctor Last Name ] Firm HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old female with multiple medical problems including chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis (on home oxygen), Takayasu's arteritis, diabetes, anxiety disorder, and chronic motor seizures. The patient had a recent admission from [12-12] to [2113-12-25] for chest pain and tachycardia. The patient is now admitted status post a fall with a hip fracture; scheduled for surgical repair on [2114-1-1]. The patient has had a history of falls. This morning, she fell after her right leg felt weak. She was also mildly short of breath, but she ran out of home oxygen. She denies any chest pain, loss of consciousness, or dizziness preceding the fall. She states that her right knee gave out on her. She denies any head trauma but may have had loss of consciousness after the fall. She denies any urinary or fecal incontinence. In the Emergency Department, the patient was found to have a T12 compression fracture on lumbosacral spine film and a right femoral neck fracture. A chest x-ray showed chronic changes with a question of a new pneumonia. A head computed tomography was negative but with prominent ventricles. The patient was given a total of 5 mg of intravenous morphine and 2 mg of Ativan, and two tablets of Percocet. Review of systems was negative for fevers, chills, dysuria, or any other constitutional symptoms. Due to her tachycardia and shortness of breath, the patient had a computed tomography angiogram which was negative for a pulmonary embolism even though the patient had just had a computed tomography angiogram performed only a few days prior to this admission. The Emergency Department staff felt that the patient's oxygen saturations were on the lower side, even though they were 94% on 4 liters. Given a negative computed tomography angiogram, it was thought the patient was mildly fluid overloaded and was given Lasix. Please refer to the excellent Discharge Summary done by Dr. [Last Name (STitle) ] from the previous hospitalization for further information. Of note, the patient frequently complains of shortness of breath and continued low back pain (which was alleviated with Percocet). She also has chronically low blood pressures in her arms secondary to subclavian stenosis from presumed Takayasu's arteritis. Consequently, blood pressures should only be checked in the patient's thighs as she is constantly admitted for similar workups for sepsis/adrenal insufficiency when blood pressures are checked in her arms. PAST MEDICAL HISTORY: 1. Takayasu's arteritis. 2. Idiopathic pulmonary fibrosis. 3. Chronic obstructive pulmonary disease. 4. Chronic motor focal seizures; recently diagnosed in [Month (only) ] to [2113-11-8]. 5. Hypothyroidism. 6. Type 2 diabetes mellitus. 7. Depression/anxiety. 8. Chronic low back pain. 9. History of pulmonary embolus in [2112-8-8]. MEDICATIONS ON ADMISSION: 1. Keppra 500 mg by mouth in the morning and 1000 mg by mouth at hour of sleep. 2. CellCept [Pager number ] mg by mouth twice per day. 3. Prednisone 5 mg by mouth once per day. 4. Synthroid 50 mcg by mouth once per day. 5. Flonase 100-mcg inhaler 2 puffs inhaled twice per day. 6. Salmeterol 50-mcg inhaler 2 puffs inhaled twice per day. 7. Ranitidine 150 mg by mouth twice per day. 8. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 9. Olanzapine 2.5 mg by mouth at hour of sleep. 10. Aspirin 325 mg by mouth once per day. 11. Colace. 12. Fluoxetine 50 mg by mouth once per day. 13. Albuterol nebulizers. 14. Calcium carbonate 500 mg by mouth three times per day. 15. Vitamin D 400 International Units by mouth every day.. 16. Metformin 500 mg by mouth twice per day. 17. Klonopin 1 mg to 2 mg by mouth twice per day. 18. Sarna lotion. 19. Benadryl 25 mg to 50 mg by mouth q.4-6h. as needed (for pruritus). ALLERGIES: SULFA and DILANTIN (which cause a rash). SOCIAL HISTORY: The patient lives alone. She has a past tobacco history times 10 years, but she no longer smokes. She denied any alcohol or intravenous drug use. Family members are minimally involved but are aware of her many issues. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 98 degrees Fahrenheit, her blood pressure was 194/55, her heart rate was 135, her respiratory rate was 22, and her oxygen saturation was 94% on 4 liters of oxygen. In general, the patient was an alert and oriented elderly female who appeared older than her stated age. The patient was mildly tachypneic, but she was in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The extraocular movements were intact. The mucous membranes were slightly dry. No jugular venous distention. The neck was supple and nontender. No lymphadenopathy. Cardiovascular examination revealed a regular rhythm with tachycardia. Normal first heart sounds and second heart sounds. A 3/6 systolic ejection murmur at the left sternal border. Pulmonary examination revealed bilateral fine crackles about half the way up. There were positive expiratory wheezes diffusely bilaterally. The abdomen was soft and nondistended. There were normal active bowel sounds. There was right lower quadrant tenderness over the iliac crest. There was positive ecchymosis in the right lower quadrant to the midline. No masses. Extremity examination revealed the right lower extremity was shorter and externally rotated. There was no thigh ecchymoses. Dorsalis pedis pulses were 2+ bilaterally. There were 2+ radial pulses present bilaterally. There was normal sensation to light touch. Neurologic examination revealed cranial nerves II through XII were intact bilaterally. The patient was unable to move the right leg secondary to pain. No obvious focal deficits, but the examination was limited. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed the patient's white blood cell count was 35.4 (with a differential of 89% neutrophils, 0% bands, 7% lymphocytes, 2% monocytes, and 1% eosinophils), her hematocrit was 29.8, and her platelets were 424. The patient's sodium was 137, potassium was 4, chloride was 98, bicarbonate was 25, blood urea nitrogen was 14, and her creatinine was 0.5. Her creatine kinase was 91. Troponin was less than 0.01. Her prothrombin time was 12.3, her partial thromboplastin time was 21, and her INR was 1. Urinalysis was negative for infection. Last thyroid-stimulating hormone was on [12-29] which was 0.58. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed sinus tachycardia, but no ST changes. The patient's last echocardiogram was in [2113-3-11] which showed a mildly dilated left atrium and left ventricular wall thickening. Cavity size and systolic function were normal with a left ventricular ejection fraction of 55%. Basilar and septal hypokinesis. Mild MS. There was 1+ mitral regurgitation. Mild pulmonary artery systolic hypertension. ASSESSMENT: The patient is a 53-year-old female with multiple medical problems here status post a fall with a right femoral neck fracture. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RIGHT FEMORAL NECK FRACTURE: The patient was evaluated by the Orthopaedic Service, and surgical repair of her right hip was performed on [2114-1-1]. Prior to her right hip repair, the patient was medically cleared with a stress MIBI which showed no perfusion defects and an ejection fraction of 70%. The patient had a right hip hemiarthroplasty performed without complications. She has since been working with Physical Therapy and is able to bear weight as tolerated. She occasionally had some complaints of right leg numbness which extended from her hip to her foot, but these would resolve after movement of her leg and were very nonspecific and infrequent. The patient is able to fully move her extremities and will need followup with the Orthopaedic Service in one week following her discharge. 2. TACHYCARDIA ISSUES: The patient's baseline heart rate from previous hospital admissions seemed to be in the 90s to low 100s. On admission, she was more tachycardic, but this was thought to be secondary to pain and dehydration. A computed tomography angiogram was initially negative for a pulmonary embolus. Prior to her surgery, the patient was placed on a beta blocker initially at a dose of 25 mg and titrated up rapidly, and the patient is currently on 50 mg by mouth twice per day of Lopressor. Her heart rate is currently in the low 90s and is stable. We did not chose to increase the beta blocker any further secondary to the patient's bronchospasm. 3. HYPERTENSION ISSUES: The patient has chronic subclavian stenosis from Takayasu's arteritis. Thus, blood pressures can only be adequately measured in the thigh which should be noted in future admissions. Her systolic blood pressures usually range in the 120s to 140s in her thigh. On admission, her blood pressure was quite elevated but this was again thought to be secondary to the patient's pain. Subsequently, after her pain was more adequately controlled and following postoperative, the patient's blood pressures remained in the normal range (in the 120s to 140s) when measured in her thigh. 4. PULMONARY/IDIOPATHIC PULMONARY FIBROSIS ISSUES: The patient was admitted on her chronic prednisone dose of 5 mg by mouth once per day for Takayasu's arteritis. The patient was maintained on this when she was admitted. It was thought that prior to surgery the patient should be given stress-dose steroids considering her poor pulmonary function and probable prophylaxis against adrenal insufficiency postoperatively. The patient was given two days of 100 mg intravenously of hydrocortisone q.8h., and then she was rapidly tapered off to 60 mg by mouth once per day times two days; then 40 mg by mouth every day times two days; etcetera. The patient's pulmonary status began to deteriorate several days postoperatively and continued for approximately one week. No clear etiology could be found for why the patient was more short of breath. She had been intubated during the operative procedure and took many hours to extubate, but the extubation proceeded without difficulties, and the patient was weaned off the ventilator without event. NOTE: A Discharge Summary Addendum will be added at this point to continue the hospital course. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 10397] MEDQUIST36 D: [2114-1-24] 12:28 T: [2114-1-24] 12:35 JOB#: [Job Number 97092]	[ "4280", "496" ]
Admission Date: [2199-10-21] Discharge Date: [2199-10-25] Date of Birth: [2141-3-24] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11304] Chief Complaint: right renal mass Major Surgical or Invasive Procedure: Right laparoscopic partial nephrectomy, laparoscopic cholecystectomy History of Present Illness: 58yF with 1.5 cm right posterior renal lesion and gallbladder polyp now s/p CCY (Dr [Last Name (STitle) ]/right partial Nx. Additionally, she does have a history of Factor [Doctor First Name 81] def (Dr [Last Name (STitle) 3060], [Hospital1 18]) and has rec'd 4FFP/Benadryl/Tylenol pre-op which has been used in the past for this. IVF: 2.0L + 8U FFP(!!) (plus 40IV lasix) EBL: 200cc Plan: Lap Partial Pathway No Toradol PACU labs Run light, may HLIV in AM given large fluid load q24 ptt and factor [Doctor First Name 81] levels Hematology (Fellow, Dr. [Last Name (STitle) ], [Numeric Identifier 101405]) following If bleed tonight, the on call hematologist aware, will give more FFP. Past Medical History: PMH: factor [Doctor First Name 81] deficiency, depression, recurrent genital herpes, Hx of iron deficiency anemia, hypertension, hypercholesterolemia, status post appendectomy , status post tonsillectomy, C-section, ex-smoker and she quit smoking in [2176]. Brief Hospital Course: Patient was admitted to Urology after undergoing laparoscopic right partial nephrectomy and cholecystectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the ICU given her history of factor [Doctor First Name 81] defiency and drowsiness. She was transferred to the floor on POD 1 in stable condition. On POD 0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. She recieved 8 units of FFP on POD 0. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. Hematology recommended 2 units of FFP that were given on POD 1. On POD2, JP and urethral catheter (foley) were removed without difficulty and diet was advanced as tolerated. Hematology recommended another 2 units of FFP that were given on POD 2. Her central line was removed on POD 2. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 3748] in 3 weeks. Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for break through pain only (score >4) . Disp:30 Tablet(s) Refills:0 2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn: over the counter. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking narcotics, over the counter. Disp:60 Capsule(s) Refills:0 4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 7. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). Discharge Disposition: Home Discharge Diagnosis: right renal mass Discharge Condition: stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofin) until you see your urologist in follow-up. -Call your Urologist's office today to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. Followup Instructions: 1-2 weeks Completed by:[2199-10-23]	[ "4019", "2720", "311" ]
Admission Date: [2127-7-8] Discharge Date: [2127-7-17] Date of Birth: [2056-7-8] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Bee Pollens Attending:[First Name3 (LF) 1267] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 4 on [2127-7-9] History of Present Illness: 70 y/o female without significant cardiac disease who was stung by a bee on saturday [2127-7-5]. Hand became swollen and pt went to the ED on Monday, [7-7]. She was given Keflex and Prednisone. At her second dose of Keflex she developed an anaphylactic reaction with throat tightness, SOB. She came back to the ED, now with chest pain. EKG showed ST depressions and was ruled in for NSTEMI. Transferred from OSH to [Hospital1 18] for cath with revealed 3vd and left main disease. Past Medical History: Hypertension Right Carotid Disease Social History: Lives alone with family close by. -ETOH/Tob Family History: Father MI at 65 Physical Exam: VS: VSS [5-13]" 91kg BSA 2.09 General: WDWN female in NAD HEENT: NC/AT, PERRLA, EOMI, oropharynx benign Neck: Supple, FROM, -lymphadenopathy Heart: RRR, +S1S2, -c/r/m/g Lungs: CTAB -w/r/r Abd: Soft, NT/ND, +BS -r/r/g Ext: -c/c/e, pulses: BRA 2+, BPT/BDP trace, LFA 1+ RFA IABP Neuro: Nonfocal, CN 2-12 intact Pertinent Results: [2127-7-8] 04:31PM BLOOD WBC-12.2* RBC-3.78* Hgb-11.8* Hct-35.8* MCV-95 MCH-31.3 MCHC-33.0 RDW-13.0 Plt Ct-310 [2127-7-15] 05:58AM BLOOD WBC-10.3 RBC-2.91* Hgb-9.2* Hct-28.0* MCV-96 MCH-31.8 MCHC-33.0 RDW-13.6 Plt Ct-332 [2127-7-8] 04:31PM BLOOD PT-12.3 PTT-35.3* INR(PT)-1.0 [2127-7-10] 02:59AM BLOOD PT-12.2 PTT-34.1 INR(PT)-1.0 [2127-7-8] 04:31PM BLOOD Glucose-169* UreaN-27* Creat-0.9 Na-138 K-3.3 Cl-103 HCO3-26 AnGap-12 [2127-7-11] 02:47AM BLOOD Glucose-146* UreaN-23* Creat-0.9 Na-134 K-4.5 Cl-99 HCO3-26 AnGap-14 [2127-7-15] 05:58AM BLOOD Glucose-104 UreaN-21* Creat-1.0 Na-135 K-4.7 Cl-102 HCO3-25 AnGap-13 [2127-7-8] 04:31PM BLOOD ALT-24 AST-59* AlkPhos-74 TotBili-0.7 [2127-7-8] 04:31PM BLOOD Albumin-3.6 Cholest-205* [2127-7-8] 04:31PM BLOOD %HbA1c-7.7* [Hgb]-DONE [A1c]-DONE [2127-7-8] 09:44PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.036* [2127-7-8] 09:44PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG Brief Hospital Course: AS mentioned in the HPI, pt had cardiac cath which revealed 3vd and left main disease. An IABP was placed and heparin continued. Pt was consented for bypass surgery and on [7-9] (HD#2) pt went to the OR and underwent a coronary artery bypass graft x 4. Pt tolerated the procedure well with CPB time of 92 minutes and XCT of 79 minutes. Please see op note for full surgical details. Pt. was A-paced at 88 and being titrated on Neo and propofol and was transferred to CSRU in stable condition. Early POD #1, pt was weaned fro sedation and extubated. She was awake, alert, MAE and following commands. Later on the same day IABP was removed. By POD #2 Neo was weaned off and both diuretics and b-blockade were intitiated. Pt.'s chest tubes were removed on POD #2 and he was transferred to step-down/telemetry floor. POD #3 pt's epicardial pacing wired were removed. Post-operatively [Last Name (un) ] was consulted for elevated sugar and A1C (newly diagnosed DM). Over the remaining hospital course pt slowly recovered. She was stable thoughout without post-op complications. All lab work remained stable. She slowly made it to level 5 and was discharged on POD #8. Medications on Admission: 1. Accupril 40mg qd 2. HCTZ 25mg qd 3. ASA 81mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. 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 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Hypertension Diabete Mellitus (newly diagnosed) Right Carotid Disease Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with water and mild soap. Do not bath or swim. Do not apply lotions, creams, ointments, or powders. Do not lift more than 10 pounds for 2 months Do not drive for 1 month. Take medications as prescribed. If you notice drainage from incisions, redness, or fever please contact office. Followup Instructions: Follow-up in [Hospital 409] Clinic ([Hospital Ward Name 121] 2) in 2 weeks Follow-up with Dr. [Last Name (STitle) ] in 4 weeks Follow-up with Dr. [Last Name (STitle) 3321] in [1-5] weeks Follow up with Dr. [Last Name (STitle) ] in 2 weeks Completed by:[2127-7-17]	[ "41071", "4240", "5180", "41401", "4019", "25000" ]
Admission Date: [2174-7-22] Discharge Date: [2174-7-29] Date of Birth: [2132-3-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 42 yo with DM II and HTN who presents with 2 days of abdominal pain. THe patient reports that on Wednesday after eating a [Last Name (un) ] he developed abdominal pain, nausea, vomiting and diarrhea. He states that the abdominal pain is located predominantly in the LLQ, was mostly crampy and intermittently sharp in character, non-radiating. Over the next two days the pain got progressivley worsening abdominal pain. He was only able to take minimal po intake. Nothing appeared to make the pain worse or better. He does not recall any aspiration however he noted his breathing started to became more laboured on Thursday. He reports mild pleuritic chest pain associated with deep breaths, non positional. He also noted a fever for the first time on Friday as well as worsening respiratory secretions. Because of the worsening respiratory status and his abdominal pain he decided to go to the [Location (un) 620] [Hospital1 ] on Friday. There he was found to have an elevated WBC, Lipase and Amylase and a CT abdomen was consisted with pancreatitis. The patient was transfered to [Hospital1 18] for further care after receiving 2L NS, levofloxacin and Flagyl. . ED course: On arrival to the [Hospital1 18] ED the patient was tachycardic to 136, febrile to 101, normotensive to 129/79 with a RR of 19 and O2sat of 80RA. THe patient was started on O2 by nasal canula which was uptitrated over the next hours ultimately requiring a NRB. The patient was given a total of 5L of NS as fluid resuscitation. A CTA was done as well as a CT abdomen and pelvis which was negative for PE, but comfirmed a b/l lower lobe pneumonia and acute pancreatitis without necrosis. He was given Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for anxiety. . On admission to the ICU the patient complaint of LLQ pain, [4-7], non-radiating. He confirmed respiratory distress but rated that stable over the last several hours. He denied any nausea currently and did not have any further diarrhea. Pt denies any recent travel, excessive ETOH or yellow discoloration of skin. pt reports recent food excess during attendance of a symposium. . ROS: negative for rash, dysuria, changes in the color of the urine or stool. Past Medical History: Polycythemia Impaired fasting glucose-on metformin Obesity Depression Pre-hypertension Social History: ETOH: occ social, no recent binge drinking Tobacco: none Occupation: chemistry researcher working with Iridium Living situation: lives with wife and 2 children, age 16 and 4 [11-30] Family History: Father with valve replacement at age 72 Physical Exam: VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB Gen: NAD, AAOx3, talking in full sentences HEENT: NC/AT, PERRLA, mmm NECK: no LAD, no JVD COR: S1S2, regular rhythm, no m/r/g PULM: decreased breath sounds in b/l bases, positive egophony, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank, no rebound or guarding Skin: warm extremities, no rash EXT: 2+ DP, no edema/c/c, no CVA tenderness Neuro: moving all extremities, 5/5 strength, following commands, PERRLA, reflexes 2+ b/l Pertinent Results: EKG: SR, tachycardia, rate 120, NA, NI, no ST or TW changes . CTA/ CT abdomen: [2174-7-22] 1. No evidence of pulmonary embolism. 2. Bilateral lower lobe airspace consolidation, likely pneumonia, with small bilateral pleural effusions. 3. Acute pancreatitis, without evidence of acute complication. 4. Fatty liver. 5. Bilateral renal hypodensities, likely small cysts US liver - FINDINGS: The bedside ultrasound examination is markedly limited by patient body habitus, and inability to cooperate due to pain and respiratory distress. Limited images of the liver demonstrate increased echogenicity, likely representing fatty liver. Gallbladder was unable to be identified. IMPRESSION: Markedly limited portable study. Nonvisualization of the gallbladder. Echogenic liver. [2174-7-26] CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST Reason: Evaluate for pseudocyst formation, abscess, or interval [Doctor Last Name ] [Hospital 93] MEDICAL CONDITION: 42 year old man with pancreatitis and rising WBC, and SOB with tachycardia. REASON FOR THIS EXAMINATION: Evaluate for pseudocyst formation, abscess, or interval change in pancreatitis. R/o PE for persistent tachycardia and SOB. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 30-year-old man with pancreatitis and shortness of breath. Comparison is made to the CTA of the chest performed on [7-22], [2173]. TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to pubic symphysis. The CTA of the chest was performed based on pulmonary embolism protocol; nontheless, there is suboptimal contrast timing for assessing pulmonary embolism. The CT of the abdomen and pelvis portion is performed with CTE protocol. Two separate injections of contrast were administered, with the chest covered with both injections. CT OF CHEST WITH AND WITHOUT IV CONTRAST: The heart and great vessels appear unremarkable. No pathologically enlarged hilar, mediastinal or axillary nodes are noted. Severe degree of atelectatic changes is noted within the anterior [Doctor First Name ] segment of right lower lobe and base of the right middle lobe. Moderate degree of atelectasis is also noted at the left lung base. Given the presence of air bronchograms particularly at the left lower lobe, there is likely superimposed consolidation. Trace bilateral pleural effusion is seen, which is more prominent on the left side. Although the pulmonary artery contrast bolus appears suboptimal (probably due to patient habitus and slower injection rate due to IV size) on both scans of the chest, there is no evidence of pulmonary embolus within the limits of the study. CT OF THE ABDOMEN WITH IV CONTRAST: The pre-pancreatic fluid/phlegmon in the anterior pararenal space appears slightly larger, especially inferiorly-- there is increased fluid along the left lateroconal fascia. A small amount of fluid now tracks down the left anterior pararenal space to the pelvis. A trace of fluid is also seen within the right anterior pararenal space. The pancreas enhances homogeneously and there is no site of necrosis. No definite fluid collection is shown in the pancreas. No loculated pseudoaneurysm is visualized. No evidence of SMV or portal vein thrombosis. There is hepatic steatosis. A 1.8 cm hypodense structure is again noted within the dome of the liver, with fluid density likely representing a cyst. Small amount of ascitic fluid has developed adjacent to the liver and spleen. The gallbladder and intra- and extra- hepatic bile ducts are unremarkable. This spleen, adrenal glands and kidneys have normal appearance. No pathologically enlarged retroperitoneal or mesenteric node is noted. No free air is noted within the abdomen. CT OF THE PELVIS WITH IV CONTRAST: The rectum has a normal appearance. The sigmoid colon contains multiple diverticula, with no evidence of diverticulitis. The urinary bladder and distal ureters appear unremarkable. No pathologically enlarged pelvic or inguinal nodes are visualized. No free air is noted within the pelvis. As noted above, a small amount of fluid tracks into the pelvis. BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Overall similar appearance of peripancreatic inflammation; however, anterior pararenal fluid and phlegmon is minimally increased. No pancreatic necrosis, pseudocyst, or abscess is visualized. 2. No evidence of pulmonary embolism. 3. Atelectatic with superimposed consolidation at both lung bases. 4. Small amount of ascites is noted within the abdomen and pelvis. 5. Small hypodense lesion of the dome of the liver, which are too small to characterize, likely a cyst. CHEST (PORTABLE AP) [2174-7-26] 6:16 AM CHEST (PORTABLE AP) Reason: ? interval change [Hospital 93] MEDICAL CONDITION: 42 year old man with DM2 presents with acute pancreatitis and ? aspiration pneumonia, please assess for interval change REASON FOR THIS EXAMINATION: ? interval change CHEST HISTORY: Aspiration pneumonia. COMPARISON: [2174-7-24]. The patient has taken a poor inspiratory effort. Compared to the prior study there is increased pulmonary vascular re-distribution. There is blunting of both costophrenic angles left greater than right consistent with pleural effusions. There is persistent retrocardiac opacity. IMPRESSION: Bilateral pleural effusions and persistent left retrocardiac opacity. Increased pulmonary vascular re-distribution consistent with mild CHF. [2174-7-28] - CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The visualized portion of the lung bases demonstrates small left pleural effusion which is unchanged. Linear atelectatic changes/pulmonic infiltrate of the left lower lobe and right lower lobe appear unchanged. The heart and great vessels appear unremarkable. A small axial hiatal hernia is unchanged. The pancreas and peripancreatic inflammation are unchanged. No definite fluid collection is noted. No area of pancreatic necrosis is identified. No definite gas is noted within the peripancreatic tissue. The liver has faaty infiltration. The gallbladder, intra- and extrahepatic bile ducts, spleen, and adrenal glands appear unremarkable. The small hypodense lesion of the dome of the liver appears unchanged. The right kidney contains a small hypodense lesion which is too small to characterize and appears relatively unchanged compared to the prior study. The stomach, duodenum, and small bowel loops are unremarkable. There is ileus of the transverse colon adjacent to the site of inflammation. The remainder of the colon appear unremarkable. Small amount of ascites is noted within the abdomen. No free air is identified. No pathologically enlarged retroperitoneal or mesenteric nodes are noted. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, urinary bladder, and distal ureters are unremarkable. Small amount of ascites noted within the pelvis. No pathologically enlarged pelvic or inguinal nodes are noted. No free air is noted within the pelvis. BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Similar appearance of peripancreatic inflammation with no necrosis, pseudocyst or abscess formation. The anterior pararenal fluid and the phlegmon are stable. 2. Transverse colon ileus is unchanged compared to the prior study. 3. Unchanged appearance of small bilateral pleural effusion with atelectatic changes. Small ascites unchanged. 4. Stable appearance of a small hypodense lesion of the dome of the liver. 5. Fatty liver. Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal (for BSA) biventricular cavity sizes with preserved global and regional biventricular systolic function. [2174-7-29] 05:45AM BLOOD WBC-16.3* RBC-4.27* Hgb-13.2* Hct-37.9* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.1 Plt Ct-206 [2174-7-28] 06:00AM BLOOD WBC-17.1* RBC-4.48* Hgb-14.0 Hct-39.8* MCV-89 MCH-31.4 MCHC-35.3* RDW-14.5 Plt Ct-237 [2174-7-27] 05:55AM BLOOD WBC-19.4* RBC-4.70 Hgb-14.3 Hct-42.3 MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-212 [2174-7-22] 03:00PM BLOOD WBC-19.6# RBC-5.21 Hgb-16.3 Hct-45.5 MCV-87 MCH-31.3 MCHC-35.9 RDW-14.6 Plt Ct-188 [2174-7-26] 05:28AM BLOOD WBC-24.5* RBC-5.07 Hgb-15.7 Hct-45.2 MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-235 [2174-7-29] 05:45AM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-10 Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-3* Promyel-1* [2174-7-22] 03:00PM BLOOD Neuts-87.8* Lymphs-8.0* Monos-3.7 Eos-0.4 Baso-0.2 [2174-7-26] 05:28AM BLOOD Neuts-84* Bands-2 Lymphs-3* Monos-6 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1* Promyel-2* [2174-7-29] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2174-7-26] 05:28AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-1+ Tear Dr[Last Name (STitle) ]1+ [2174-7-23] 04:42AM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2* [2174-7-29] 05:45AM BLOOD UreaN-5* Creat-0.7 Na-134 K-3.9 Cl-95* HCO3-32 AnGap-11 [2174-7-22] 03:00PM BLOOD Glucose-284* UreaN-12 Creat-0.8 Na-137 K-4.0 Cl-105 HCO3-27 AnGap-9 [2174-7-28] 06:00AM BLOOD ALT-15 AST-19 AlkPhos-59 TotBili-0.5 [2174-7-22] 03:00PM BLOOD ALT-42* AST-24 CK(CPK)-54 AlkPhos-59 Amylase-141* TotBili-1.0 [2174-7-27] 05:55AM BLOOD Lipase-47 [2174-7-24] 04:16AM BLOOD Lipase-78* [2174-7-23] 04:42AM BLOOD Lipase-140* [2174-7-22] 03:00PM BLOOD Lipase-220* [2174-7-22] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2174-7-23] 04:42AM BLOOD Albumin-2.7* Calcium-7.3* Phos-1.2* Mg-1.8 [2174-7-29] 05:45AM BLOOD Mg-2.0 [2174-7-28] 06:00AM BLOOD Triglyc-318* [2174-7-22] 03:00PM BLOOD Triglyc-832* [2174-7-27] 05:55AM BLOOD Osmolal-287 [2174-7-26] 05:28AM BLOOD TSH-2.4 [2174-7-24] 01:51AM BLOOD Type-ART PEEP-8 FiO2-60 pO2-86 pCO2-43 pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA [2174-7-22] 03:14PM BLOOD Comment-GREEN TOP [2174-7-22] 03:14PM BLOOD Lactate-1.4 [2174-7-26] 08:02PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2174-7-26] 08:02PM URINE Blood-LGE Nitrite-NEG Protein-TR Glucose-100 Ketone-150 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG [2174-7-26] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [2174-7-26] 03:34AM URINE AmorphX-MOD [2174-7-22] 11:00PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]->1.035 [2174-7-26] 03:34AM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [2174-7-26] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [2174-7-26] 3:34 am URINE Site: CATHETER FINAL REPORT [2174-7-27] URINE CULTURE (Final [2174-7-27]): NO GROWTH. [2174-7-28] 6:27 am STOOL CONSISTENCY: LOOSE Source: Stool. FINAL REPORT [2174-7-28] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2174-7-28]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2174-7-25] 4:03 am BLOOD CULTURE Site: ARM AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [2174-7-22] 7:20 pm BLOOD CULTURE Site: ARM FINAL REPORT [2174-7-28] AEROBIC BOTTLE (Final [2174-7-28]): NO GROWTH. ANAEROBIC BOTTLE (Final [2174-7-28]): NO GROWTH. Brief Hospital Course: Acute pancreatitis - likely from hyperlipidemia/ hypertriglyceridemia. Started on niacin (pre Rx with EcASA). Pancreatitis treated with NPO, IVF, analgesics and bowel rest. Improved remarkably and tolerating low fat diet well at discharge. For a few days prior to discharge reported 'bloating' CT abdomen showed transverse colon ileus, likely from the pancreatitis in the neighbouring area. No colitis noted. GI consulted and hey did not recommend any neostigmine, decompression etc. Avoiding narcotics. The patient did not have much discomfort or pain and was eating well on the day of discharge. Advised to follow up with PCP. Hyperlipidemia - Niacin as above with EcASA. Dietary consulted to educate on a low fat diet. Patient advised weight loss as well as low fat diet. To get LFT, lipids checked next week with PCP. Bilateral pneumonia - treated initially with IV zosyn and improved with decreasing WBC. Was weaned off oxygen. Transitioned to levofloxacin and flagyl. To complete a 14 days course (total). CT chest neg for PE. Patient has symptoms of OSA. Again advised to follow up with PCP for arranging [Name Initial (PRE) ] pulmonary sleep study. Transverse colon ileus - as above Abnormal CBC differential - heme consulted and they saw toxic granulations of smear. Advised to get another CBC with diff with PCP after active infection issues resolve. Liver lesion on CT (incidental finding) - Advised to get a follow up US/CT in 6 months. I shall defer to PCP for arranging this. Abnormal UA - repeat testing should be done with PCP [Last Name (NamePattern4) ] [11-30] weeks and if blood persists, patient will need more testing and work-up. Will defer to PCP. Depression - meds continued. DM type 2 - metformin stopped and to be restarted at home (day after discharge) Medications on Admission: Metformin 500mg [Hospital1 ] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:30 Tablet, Chewable(s) Refills:0 3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:9 Tablet(s) Refills:0 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:27 Tablet(s) Refills:0 9. Niacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: take 30-60 mins before niacin. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute pancreatitis Bilateral pneumonia Transverse colon ileus Abnormal CBC differential Liver lesion on CT (incidental finding) Abnormal urinanalysis Hyperlipidemia / hypertriglyceridemia Hypertension Depression Discharge Condition: stable Discharge Instructions: Return to the hospital if you notice worsening abdominal pain, nausea, vomiting, fevers, chills or any other symptoms of concern to you. Keep your appointments. Take medicines as indicated. Complete the course of antibiotics. Avoid alcohol use; avoid use around niacin dose. Take the aspirin 30 - 60 mins prior to the niacin dose. See your doctor next week to check a blood tests. Strictly adhere to a low fat diet. Followup Instructions: [Last Name (LF) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 4775] on Friday [2174-8-5] at 1330 hours. Please go there 15 mins prior to the appointment. (Fax: 1-[Telephone/Fax (1) 4776]) Please follow up with your doctor for a repeat blood count (CBC, renal function, liver tests as well as a lipid panel, UA)	[ "486", "5119", "4280", "25000", "4019", "311" ]
Admission Date: [2119-8-3] Discharge Date: [2119-9-1] Date of Birth: [2057-11-21] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Prochlorperazine Attending:[First Name3 (LF) 78] Chief Complaint: Worst headache of Life [Last Name (un) ] eating dinner Major Surgical or Invasive Procedure: [8-4]: Cerebral angiogram with coiling of ACOMM Artery Aneurysm [8-8]: Cerebral angiogram with intra-arterial verapamil [8-9]: Cerebral angiogram with intra-arterial verapamil & nicardipine [8-21]: Trach and PEG [8-22]: Cerebral angiogram with additional coiling of ACOMM History of Present Illness: 61yoF, previously healthy, now transferred from [Hospital6 10443] with reported "worst headache of her life," found to have diffuse subarachnoid hemorrhage and left ACOM aneurysm. Reportedly, she was eating dinner at approximately 5:30pm when she complained of a severe headache, suddenly became somnolent and aphasic in association with acute onset of L-sided hemiparesis. No trauma or h/o previous symptoms. She reportedly proceeded to collapse and was brought to [Hospital6 5016], where she became intubated for airway protection after witnessed emesis. She received fentanyl and versed for sedation; no anti-epileptics were given. Reportedly she did not follow any commands and was observed to have decorticate posturing, left upper extremity and withdrawal to painful stimuli, lower extremities bilateral. At the OSH, she underwent a head CT which revealed a large, diffuse SAH and was subsequently Medflighted to [Hospital1 18] for neurosurgical management. Past Medical History: Osteoporosis Social History: Married, works as a hair dresser, three children Family History: NC Physical Exam: O: T: 98.0 BP:114/68 HR: 79 R: 15 O2Sats: 100% on vent Gen: NAD, intubated, sedated HEENT: Pupils: 3->2mm bilaterally, reactive Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated and sedated on arrival; does not follow commands. Orientation: n/a Recall: n/a Language: n/a Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm b/l III, IV, VI: not done V, VII: not done VIII: +gag IX, X: not done [Doctor First Name 81]: not done XII: not done Motor: decorticate posturing left upper extremity; unresponsive right upper extremity; withdrawal to painful stimuli lower extremities, bilaterally Toes downgoing bilaterally Upon discharge: Alert, does say some simple words, makes eye contact, smiles occasionally. Shows some slight finger movements to LUE. Withdraws to noxious with BLE. Localizes with RUE. PERRL. Pertinent Results: [2119-8-3] CTA head: IMPRESSION: Recently ruptured left anterior communicating artery aneurysm with extensive subarachnoid hemorrhage and intraventricular extension. No evidence of vasospasm, no other aneurysms. [8-4] CT head: IMPRESSION: 1. New right frontal-approach ventriculostomy catheter terminating in the third ventricle. 2. Slight decrease in size of right lateral ventricle, with bowing of the septum pellucidum into the right lateral ventricle and unchanged or slightly enlarged left lateral ventricle. 3. No increase in extensive subarachnoid blood. [8-7] Head CT: IMPRESSION: 1. Stable size of the ventricular system with right frontal approach ventriculostomy catheter stably terminating in the third ventricle. 2. Stable extensive subarachnoid hemorrhage. 3. Interval introduction of pneumocephalus seen within the right greater than left frontal horns and the right temporal ventricular [Doctor Last Name 534]. NOTE ADDED AT ATTENDING REVIEW: The patient is now status post coiling of an anterior cerebral artery aneurysm. There is no evidence of new hemorrhage. The left lateral ventricle is smaller than on the study of [2119-8-4]. The right frtonal [Doctor Last Name 534] is larger. There is a small focus of hypodensity in the right frontal lobe, adjacent to the hematoma and coil, new since the study of [2119-8-4], and likely reflecting infarction. [8-8] Head CT:IMPRESSION: 1. Unchanged appearance of subarachnoid hemorrhage, left frontal hematoma and right frontal infarct. 2. Small amount of subdural hemorrhage along the falx posteriorly to the left, potentially related to the decompression from the ventriculostomy placement. [8-9] Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with severe global hypokinesis c/w diffuse process (toxin, metabolic, etc. Multivessel CAD less likely, but cannot be fully excluded). Pulmonary artery systolic hypertension. Mild mitral regurgitation. [8-11]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2119-8-9], the left ventricular ejection fraction is higher. [8-13]: head CT: IMPRESSION: 1. No evidence of increase in subarachnoid hemorrhage. Previously noted subarachnoid hemorrhage is slightly evolved in the interval. 2. Normal ventricular size with the drain extending to the third ventricle. 3. Coiling in the region of anterior communicating artery with an adjacent hypodensity as before. [8-7]- pending EEG : This EEG telemetry from [Date range (1) 87361] showed persistent sleep or medication-related patterns with no major change in frequency or voltage over the time of the recording. There were no epileptiform features. [8-14] EEG This monitoring of cerebral function from [Date range (1) 10831]/[2118] showed a profoundly suppressed background at the beginning and throughout the recording. There was no major asymmetry in background voltages. There were no epileptiform features or electrographic seizures. [2119-8-15] CTA head 1. Multifocal narrowing in the proximal course of the anterior cerebral arteries bilaterally adjacent to the anterior communicating artery coiling suggestive of vasospasm. The remaining intracranial vasculature appears unremarkable. 2. Stable subarachnoid hemorrhage. 3. Air-fluid levels in the paranasal sinuses. 4. There is again artifact seen from the prior coiling in the region of the anterior communicating artery. There is stable appearance to the surrounding hypodensity, ischemic changes cannot be completely excluded, please correlate clinicallly. [2119-8-16] EEG This monitoring of cerebral function from [Date range (1) 61726]/[2118] showed a profoundly suppressed background throughout the recording. There was no major asymmetry in background voltages. There were no epileptiform features or electrographic seizures. [2119-8-18] EEG This EEG telemetry showed a slow and low voltage background throughout. This indicates a widespread encephalopathy. The record appeared unchanged from earlier recordings in the last several days. There were no epileptiform features or electrographic seizures. [2119-8-19] CT head Overall unchanged appearance of the ventricles. Other findings as described above. [2119-8-20] CT head 1. Status post removal of an external ventricular drain, without evidence of hemorrhage in the tube tract. 2. Stable changed appearance of the ventricles. No new intracranial hemorrhage [2119-8-22]: CT head 1. Slight enlargement of the third ventricle since [2119-8-19]. Close follow-up is recommended. 2. Persistent scattered foci of subarachnoid hemorrhage along the cerebral convexities with no evidence of new intracranial hemorrhage. [2119-8-28] MRI BRAIN: IMPRESSION: 1. Multiple acute infarcts in the watershed territory between the right anterior cerebral and middle cerebral arteries. 2. Chronic blood products in the anterior interhemispheric fissure, within the sulci of both hemispheres, and in the occipital horns of the lateral ventricles. 3. Apparent arachnoid cyst in the left medial cranial fossa. Review of prior studies suggests that there was prior hemorrhage into this lesion. [2119-8-29] UE Doppler: Occlusive thrombus seen within the left basilic vein. No DVT seen in the remainder of the veins of the left arm. ECG [2119-8-30]: Sinus rhythm and frequent atrial ectopy in a trigeminal pattern. Compared to the previous tracing of [2119-8-24] no diagnostic interim change. Brief Hospital Course: Ms. [Known lastname 87362] was admitted from the Emergency room to the Surgical ICU. She remained intubated for airway protection. An external ventricular drain was placed for hydrocephalus and shortly thereafter her exam improved tremendously to the point that she became arrousable and was following all comands and moving all four extremities. She was taken to Angio on [8-4] where she was found to have and left ACOMM artery aneurysm. This was succesfully coiled without complication but will require further coiling with a stent in the near future. Post procedure she was transferred to the SICU for close neurological monitoring including q1 neurochecks and strict blood pressure control to less than 140 systolic. Pt was extubated without difficulty following her procedure. On [8-5] her neurological exam was good therefore [Month/Year (2) 5041] was raised to 20. Continuous EEG monitoring was initiated per vasospasm protocol. Her neurological exam remained stable. On [8-6] [Month/Year (2) 5041] was clamped and she was started on SQH for DVT prophylaxsis. Pt noted to have increase heart rate into 150's and EKG showed atrial fibrilation. She was treated with lopressor 5mg IV x2 with good resolution. Cardiac enzymes were cycled and they were negative. [8-7] Pt [Name (NI) 5041] opened overnight as she had increased ICP's while clamped. The drain was left at 20cm above the tragus and she had no further episodes of increased ICP. Her episodes of atrial fibrilation did resolve and she had no further tachycardia and no further treatment. She was febrile on this day and blood, urine, sputum and CSF cultures were sent. [8-8] Upon examination she was noted to be more lethargic and oriented only to her self and not year or location. She was also not following commands with her lower extremities and not moving them spontaneously. A stat head ct showed no change from prior exam and no hydrocephalus or infarct. She was taken to the neuro interventional suite for cerebral angiogram. She did receive intra-arterial verapmil to the left ICA for treatment of her vasospasm. Her SBP goal was increased to 140-160 and this did improve her mental status somewhat and she was following commands with all extremities and oriented to year. On [8-9] The patient developed garbled speech and disorientation. She was again taken to angio and received verapamil and nicardipine for vasospasm. It was also noticed that there was coil migration into the parent artery. While in angio the patient became tachycardic and developed pulmonary edema requiring intubation. She progressed to cardiogenic shock and cardiology was consulted for assistance with managment and possible balloon pump. Over the next 24 hours the patient was very unstable requiring 3 pressors (max dose), esmolol and milrinone. The patient developed multiple arrythmias requiring cardioversion. She was then paralyzed and heavily sedated. [Date range (1) 87363] The patient remained paralyzed with pressors and medical management. On [8-12] a Head CT was performed and stable. On [8-13] head CT was again stable. paralytics were discontinued and pressors were weaned. On [8-14] Pt was only requiring 1 pressor. neurological exam was hindered by sedation. LFT's were very high and elevated INR is suspected secondary to the liver failure. It was decided at this time not to reverse the INR. On [8-15] Overnight, patient had an episode of seizure like activity of the lower extremities. Continous EEG revealed ****** exam still hindered. CSF was sent due to longevity of [Month/Year (2) 5041] catheter. On [8-19] [Month/Year (2) 5041] was discontinued and a final set of CSF was sent after a successful clamping trial. [8-21]: Bedside trach and Peg without complication. [8-22] Patient went back to the angio suite for coiling of the remainder portion of the ACOMM aneurysm. We consulted infectious disease for persistant fevers and nephrology for persistant respiratory alkalosis. On [8-22] she underwent a complete coiling of Acom aneurysm. She was on a heparin drip. [8-23] the heparin gtt was discontinued and the antibiotics were discontinued on [8-24] although she was still febrile. The thought was that her fever was possibly related to the Keppra. On [8-26] her nimodipine was discontinued, as she was past day 21. A rash was noted on her bilateral UE and chest. No known source was identified. Benadryl/Sarna lotion was initiated. on [8-29] patient was started on a heparin drip for stroke and a right upper extremity DVT. Coumadin was started on [8-30]. Dermatology was consulted who recommended Hydrocortisone cream which was started on [8-30]. On [8-30] she was noted to have some telemetry changes and cardiac enzymes were done which showed a Troponin of 0.02 which repeat Troponin was 0.08 then trended down [Date range (1) 43500]. ECG was unchanged. Coumadin was started for a goal INR of [12-27].5. [8-31] Coumadin was increased, Heparin gtt continued, PTT within range, INR not within goal. Speech eval done and PMV placed. [9-1] INR not within range. UA shows + UTI. Cipro started. Heparin gtt continued. Rehab bed offered and accepted. Patient was discharged. Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet [Month/Day (4) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 2. aspirin 325 mg Tablet [Month/Day (4) ]: One (1) Tablet PO DAILY (Daily). 3. camphor-menthol 0.5-0.5 % Lotion [Month/Day (4) ]: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash/itch. 4. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Hospital1 ]: 1350 (1350) units/hr Intravenous ASDIR (AS DIRECTED): PTT 60-80 Keep until INR goal obtained. Check PTT Q 6hrs. 5. miconazole nitrate 2 % Powder [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash. 6. 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. 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for CA < 8.4. 8. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [Hospital1 ]: One (1) PO DAILY (Daily). 9. ciprofloxacin 500 mg Tablet [Hospital1 ]: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 10. warfarin 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO Once Daily at 4 PM: GOAL INR 2-2.5. 11. cortisone 1 % Cream [Hospital1 ]: One (1) Appl Topical QID (4 times a day) as needed for Rash. 12. bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. diltiazem HCl 30 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 15. sodium chloride 1 gram Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 16. metoprolol tartrate 25 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO Q 8H (Every 8 Hours). 17. 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. 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Subarachnoid Hemorrhage Respiratory Failure Cardiac arrythmias Myocardial infarction Pulmonary edema Protien/Calorie malnutrition Coma Hydrocephalus-transient Drug rash Anemia requiring transfusion DYSPHAGIA LEFT HEMIPARESIE UTI Discharge Condition: Level of Consciousness: Alert but not interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: - Continue with medications as prescribed. - Continue with a bowel regimen. - There is no activity restrictions. [Month (only) 116] advance activity as tolerated. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 2102] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please follow-up with Cardiology within 2 weeks. Please call ([Telephone/Fax (1) 2037] to make this appointment. Completed by:[2119-9-1]	[ "51881", "42731" ]
Admission Date: [2113-2-9] Discharge Date: [2113-2-14] Date of Birth: [2055-8-26] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old man with no medical care in many years several months of exertional chest pain, no hest pain at rest. The patient was recently ruled out for an myocardial infarction and had a positive exercise tolerance test. An echocardiogram showed multiple areas of hypokinesis. Electrocardiogram showed left anterior vesicular block with questionable ischemia laterally. A catheterization done on [1-10] showed an EF of 60% and three vessel disease. PAST MEDICAL HISTORY: 1. Pancreatitis. 2. ETOH, marijuana and cocaine abuse. 3. Gastroesophageal reflux disease. 4. Urinary retention. 5. Benign prostatic hypertrophy. 6. Obesity. PAST SURGICAL HISTORY: Questionable pancrease surgery and other abdominal surgeries for fluid drainage as well as testicular surgery. SOCIAL HISTORY: The patient uses one to two bags of heroine several times per week, nasally. States no intravenous drug use. No alcohol use in 20 years. No cocaine or marijuana use at this time. PHYSICAL EXAMINATION AT THE TIME OF PREADMISSION TESTING: Heart rate 77. Blood pressure 160/74. Respiratory rate 18. O2 sat 98% on room air. Cardiac regular rate and rhythm. S1 and S2. No murmur. Lungs clear to auscultation bilaterally with faint expiratory wheezes. Abdomen is soft and guarded with tenderness in the right upper quadrant and the right lower quadrant. Also costovertebral angle tenderness. No hepatosplenomegaly. Active bowel sounds. Extremities are warm and well perfuse with no clubbing, cyanosis or edema. Neck is supple with no JVD or bruits. Pulses carotids are 1+ bilaterally, radial 2+ bilaterally, femoral 2+ bilaterally, dorsalis pedis pulses and posterior tibial pulses are both 2+ bilaterally. Neurological extraocular movements intact. Grossly nonfocal examination. Excellent strength in all extremities. REVIEW OF SYSTEMS: No claudication. No melena. No bleeding disorders. No CVAs or TIAs. ALLERGIES: Penicillin. MEDICATIONS PREOPERATIVELY: 1. Protonix. 2. Atenolol. 3. Aspirin. 4. Doxazosin. 5. Flomax. No known doses. LABORATORY DATA AT THE TIME OF PREADMISSION TESTING: White blood cell count 5.2, hematocrit 35.9, platelets 315, sodium 137, potassium 4.0, chloride 104, CO2 28, BUN 14, creatinine 0.6, glucose 88, ALT 23, alkaline phosphatase 95, total bilirubin 0.4, albumin 3.9, INR 1.1. HOSPITAL COURSE: As stated previously the patient is a direct admission for to the Operating Room. On [2-9] he underwent at that time coronary artery bypass grafting times four. Please see the Operating Room report for full details. In summary he had a coronary artery bypass graft times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the posterior descending coronary artery, saphenous vein graft to the diagonal and saphenous vein graft to the obtuse marginal. His bypass time was 117 minutes with a cross clamp time of 98 minutes. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient's mean arterial pressure was 83 with a CVP of 13. He was A paced at 80 beats per minute and he had neo-synephrine at 0.5 micrograms per kilogram per minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was successfully weaned from the ventilator and extubated. On postoperative day one the patient remained hemodynamically stable. He was weaned off all vaso active intravenous medications. He was started on oral beta blockers as well as diuretics. At that time he was seen by the acute pain service and he was transferred from the Intensive Care Unit to the Far 2 for continuing postoperative care and cardiac rehabilitation. On postoperative day two the patient remained hemodynamically stable. His chest tubes and temporary pacing wires were discontinued. With the assistance of the nursing staff and the physical therapy staff his activity level was gradually increased over the next several days. He had an uneventful postoperative course and on postoperative day five it was decided that the patient was stable and ready to be discharged to home. At the time of this dictation the patient's physical examination is vital signs temperature 98.6, heart rate 78 sinus rhythm, blood pressure 101/55, respiratory rate 18, O2 sat 96% on room air. Weight preoperatively 77.2 kilograms at discharge 82 kilograms. Laboratory data white blood cell count 11.5, hematocrit 28.2, platelets 247, sodium 142, potassium 3.9, chloride 107, CO2 30, BUN 17, creatinine 0.7, glucose 122. Examination alert and oriented times three, moves all extremities, follows commands, respirations clear to auscultation bilaterally. Cardiac regular rate and rhythm. S1 and S2. No murmur. Sternum is stable. Incision with Steri-Strips. Open to air clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfuse with no edema. Right saphenous vein graft site with Steri-Strips open to air clean and dry. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg b.i.d. 2. Pantoprazole 40 mg q.d. 3. Enteric coated aspirin 325 mg q.d. 4. Flomax 0.4 q.h.s. 5. Lasix 20 mg q.d. times seven days. 6. Potassium chloride 20 milliequivalents q.d. times seven days. 7. Dilaudid 2 to 8 mg q 4 to 6 hours prn as needed for pain. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the obtuse marginal, saphenous vein graft to posterior descending coronary artery and saphenous vein graft to diagonal. 2. History of pancreatis. 3. History of alcohol, marijuana, and heroine abuse. 4. Gastroesophageal reflux disease. 5. Urinary retention and benign prostatic hypertrophy. 6. Abdominal surgery. 7. Testicular surgery. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: He is discharged to home. FOLLOW UP: He is to have follow up in the [Hospital 409] Clinic in two weeks. He is to have follow up with his primary care physician in two to three weeks and follow up with Dr. [Last Name (STitle) 1537] in four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2113-2-14] 11:59 T: [2113-2-14] 12:20 JOB#: [Job Number 109443]	[ "41401", "53081" ]
Admission Date: [2130-8-13] Discharge Date: [2130-8-22] Date of Birth: [2064-4-19] Sex: M Service: MED Allergies: Bactrim Attending:[First Name3 (LF) 1881] Chief Complaint: Alcohol withdrawal, urinary tract infection Major Surgical or Invasive Procedure: None History of Present Illness: 66M with a history of longstanding alcohol abuse and withdrawal (three episodes in last month), relapsing remitting MS for 30 years, wheelchair-bound with a neurogenic bladder (self-catheterizes at home) and history of multi-drug resistance UTIs, anxiety; presents with tremulousness, hallucinations, and tachycardia likely secondary to ETOH withdrawal. Patient also complained of some bladder spasms consistent with his past episodes of urinary tract infections. Upon admission, patient was seen to have an episode of jerking, which was thought to be possible seizure activity (although patient states that he was awake the entire time and did not lose bowel or bladder continence). Past Medical History: 1. Progressive, relapsing, multiple sclerosis for the last 30 years. The patient is treated with monthly steroids, Solu-Medrol and Avonex. 2. Prostate cancer status post brachytherapy. 3. Depression with multiple admissions in the past and history of overdose of isopropyl alcohol. The patient's last admission was in [2130-1-5]. Please see discharge summary for more details. 4. Neurogenic bladder with recurrent urinary tract infections. The patient self-catheterizes. 5. History of multiple UTIs. MRSA urine infection in [Month (only) 404] [2130], also history of pansensitive Klebsiella recently in early [Month (only) 116] that was untreated. History of Pseudomonas UTI sensitive to Zosyn and enterococcal UTI sensitive to vancomycin in [2129]. Both of the [2129] urine cultures were resistant to levofloxacin. 6. History of recent right elbow bursitis with MRSA. 7. Hypertension. 8. Chronic lower back pain with cervical and lumbar spinal stenosis. 9. Osteoarthritis. 10. Impotence with penile prosthesis. 11. Chronic polyps. 12. History of peptic ulcer disease with upper GI bleed in the setting of chronic NSAIDs use. 13. History of alcohol abuse with history of generalized tonic clonic seizures in the setting of alcohol (see neuro note written in [2130-3-6]). 14. Coagulase negative staphylococcal bacteremia in [5-9]. Social History: Patient lives alone. Niece acts as attendant. EtOH abuse and withdrawal (per HPI). Family History: Non-contributory. Physical Exam: VS. T98.6F P74 BP 120/68 RR18 O2Sat98% RA HEENT: Normocephalic atraumatic. PERRL, EOMI, 4mm symmetric. No evidence of tongue or oral mucosa trauma. Neck: Supple, no JVD, no lymphadenopathy Cardiovascular: normal S1, S2. Regular, rate, and rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen: Bowel sounds present. Soft, nontender, nondistended, no rebound or guarding. GU: Light yellow purulent discharge, with caking under foreskin. No foreskin edema, no erythema or duskiness of glans. Extremities: Warm, no clubbing, cyanosis, or edema. Pertinent Results: [2130-8-13] 02:00PM GLUCOSE-144* UREA N-21* CREAT-1.1 SODIUM-141 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-18* ANION GAP-29* [2130-8-13] 02:00PM ALT(SGPT)-17 AST(SGOT)-27 ALK PHOS-94 TOT BILI-0.4 [2130-8-13] 02:00PM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-1.0# MAGNESIUM-1.6 [2130-8-13] 02:00PM TSH-0.78 [2130-8-13] 02:00PM URINE GR HOLD-HOLD [2130-8-13] 02:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2130-8-13] 02:00PM WBC-11.4 RBC-4.77 HGB-11.6* HCT-36.8* MCV-77* MCH-24.4* MCHC-31.6 RDW-18.6* [2130-8-13] 02:00PM NEUTS-80* BANDS-0 LYMPHS-5* MONOS-15* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2130-8-13] 02:00PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL TARGET-OCCASIONAL [2130-8-13] 02:00PM PLT COUNT-386# [2130-8-13] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.021 [2130-8-13] 02:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2130-8-13] 02:00PM URINE RBC-0-2 WBC-[11-25]* BACTERIA-FEW YEAST-NONE EPI-0-2 RENAL EPI-<1 [2130-8-13] 02:00PM URINE MUCOUS-FEW [2130-8-19] 10:43AM BLOOD WBC-7.2 RBC-4.03* Hgb-9.8* Hct-31.5* MCV-78* MCH-24.4* MCHC-31.2 RDW-18.8* Plt Ct-159 [2130-8-18] 06:44AM BLOOD WBC-6.8 RBC-4.12* Hgb-10.2* Hct-31.7* MCV-77* MCH-24.7* MCHC-32.0 RDW-20.0* Plt Ct-144* [2130-8-17] 10:25PM BLOOD WBC-7.5 RBC-4.19* Hgb-10.5* Hct-31.9* MCV-76* MCH-25.1* MCHC-33.0 RDW-19.8* Plt Ct-154 [2130-8-16] 06:35AM BLOOD WBC-8.6 RBC-4.63 Hgb-11.2* Hct-35.9* MCV-78* MCH-24.2* MCHC-31.2 RDW-18.5* Plt Ct-173# [2130-8-13] 02:00PM BLOOD WBC-11.4* RBC-4.77 Hgb-11.6* Hct-36.8* MCV-77* MCH-24.4* MCHC-31.6 RDW-18.6* Plt Ct-386# [2130-8-13] 02:00PM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-15* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2130-8-13] 02:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Target-OCCASIONAL [2130-8-19] 10:43AM BLOOD Plt Ct-159 [2130-8-18] 06:44AM BLOOD Plt Ct-144* [2130-8-17] 10:25PM BLOOD Plt Ct-154 [2130-8-16] 06:35AM BLOOD Plt Ct-173# [2130-8-13] 02:00PM BLOOD Plt Ct-386# [2130-8-20] 04:57AM BLOOD Glucose-87 UreaN-12 Creat-1.2 Na-142 K-3.9 Cl-107 HCO3-28 AnGap-11 [2130-8-19] 10:43AM BLOOD Glucose-95 UreaN-10 Creat-1.2 Na-143 K-4.3 Cl-108 HCO3-27 AnGap-12 [2130-8-18] 06:44AM BLOOD Glucose-92 UreaN-9 Creat-1.0 Na-142 K-4.5 Cl-108 HCO3-27 AnGap-12 [2130-8-17] 10:50AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-140 K-3.6 Cl-104 HCO3-26 AnGap-14 [2130-8-16] 09:10AM BLOOD Glucose-97 UreaN-6 Creat-0.9 Na-141 K-3.5 Cl-103 HCO3-26 AnGap-16 [2130-8-16] 06:35AM BLOOD K-3.4 [2130-8-15] 05:15PM BLOOD K-3.6 [2130-8-15] 06:40AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-138 K-5.7* Cl-101 HCO3-26 AnGap-17 [2130-8-14] 06:45PM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-142 K-3.8 Cl-104 HCO3-25 AnGap-17 [2130-8-14] 06:15AM BLOOD Glucose-123* UreaN-16 Creat-1.0 Na-140 K-3.2* Cl-100 HCO3-26 AnGap-17 [2130-8-13] 02:00PM BLOOD Glucose-144* UreaN-21* Creat-1.1 Na-141 K-4.7 Cl-99 HCO3-18* AnGap-29* [2130-8-14] 06:15AM BLOOD ALT-15 AST-22 AlkPhos-84 TotBili-0.7 [2130-8-13] 02:00PM BLOOD ALT-17 AST-27 AlkPhos-94 TotBili-0.4 [2130-8-20] 04:57AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 [2130-8-19] 10:43AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.7 [2130-8-18] 06:44AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2 [2130-8-17] 10:25PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.5* [2130-8-17] 06:50AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.3* [2130-8-16] 09:10AM BLOOD Calcium-8.6 Phos-3.0# Mg-1.6 [2130-8-16] 06:35AM BLOOD Phos-3.0# Mg-1.5* [2130-8-15] 06:40AM BLOOD Calcium-7.6* Phos-8.7# Mg-1.4 [2130-8-14] 06:45PM BLOOD Calcium-8.6 Phos-2.3* Mg-1.9 [2130-8-14] 06:15AM BLOOD Albumin-3.5 Calcium-9.1 Phos-1.2* Mg-1.5* [2130-8-13] 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-1.0# Mg-1.6 [2130-8-13] 02:00PM BLOOD TSH-0.78 [2130-8-18] 06:44AM BLOOD Ethanol-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2130-8-13] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2130-8-20] 04:57AM BLOOD EDTA Ho-HOLD [2130-8-17] 09:30PM BLOOD Type-ART pO2-71 pCO2-40 pH-7.46* calHCO3-29 Base XS-4 [2130-8-17] 09:30PM BLOOD Lactate-0.9 Brief Hospital Course: ALCOHOL WITHDRAWAL: Mr. [Known lastname 98193] is a 66 y.o. man with a history significant for longstanding etoh abuse with past episodes of DTs; relapsing MS x30 years, wheelchair-bound with a neurogenic bladder and history of multi-drug resistant urinary tract infections. More recently, Mr. [Known lastname 98193] has presented to the [Hospital1 ] ED three times in the past month, twice admitted for treatment of withdrawal via CIWA scale benzodiazepene administration. The most recent admission was on [7-24], and at that time he was evaluated by psychiatry who felt that his symptoms were also consistent with considerable anxiety. He was discharged home on [2130-7-31] with antibiotics for E. coli urinary tract infection. On [8-13] he presented again to the ED complaining of tremulousness, racing heartbeat, flushing, and diaphoresis. By report in the ED he also had some auditory hallucinations. He was given klonopin 1mg and valium 1mg. Subsequent tox screen was negative for etoh, positive for benzos only. CIWA scale was 30+. On admission to the floor he had two episodes of ??????shaking?????? described by the sitter. He remained conscious and oriented during these episodes, which the sitter described as general shaking of his arms and legs. These episodes were presumed to be seizures and treated with a total of 40mg of IV valium, 10 mg of po valium with a CIWA scale persistently >25. His exam has been otherwise benign on the floor, VSS without fevers, tachycardia ~100s. Patient transferred to [Hospital Unit Name 153] for continued monitoring. Patient did well and was returned to the floor and required no further benzodiazepines per CIWA score <10 by [2130-8-14]. He remained sleepy for several days due to the long half-life and large quantity of benzodiazepines administered to treat alcohol withdrawal. As patient's mental status improved, he strongly endorsed a desire for rehabilitation and interest in quitting drinking. He was very interested in seeking institutional rehabilitation. URINARY TRACT INFECTION: On [2130-8-13], patient complained of "bladder spasms" which he stated was consistent with previous episodes of urinary tract infections. Urinalysis at the time revealed bacteria and white cells in urine. Patient was treated with ceftriaxone and then switched to cephalexin PO in anticipation of discharge to continue treatment as outpatient. EPISODE OF UNRESPONSIVENESS: On hospital day 5, patient was found by nursing staff to be unresponsive, with "pinpoint pupils". Patient was given Narcan with good effect, and patient was roused for several minutes, but urine toxicology revealed no evidence of narcotics (only positive for benzodiazepines). Patient was transferred to the ICU for frequent neuro checks overnight, although patient had no loss of bowel continence and no evidence of mucous membrane or tongue trauma. Patient was deemed stable on hospital day 6 and returned to the floor. EEG revealed changes consistent with mild toxic-metabolic encephalopathy. Neuro consult did not feel that the episode was consistent with a seizure, as again, patient stated that he remembered the episode and was conscious for the entire duration of the event (but could not respond). Neuro will follow patient in ten days following discharge. PARAPHIMOSIS: On hospital day 7, patient was noted to have significant edema of the foreskin, consistent with paraphimosis without ischemia. The foreskin was easily reduced and edema was treated with compression and ice with good effect. However, on hospital day 9, patient was found to have purulent urethral discharge (negative urinalysis) and caking on the glans underneath the foreskin. Discharge was sent for gram stain and culture (including yeast and fungus), and will be followed up after discharge. Patient was restarted on Keflex for 7 days along with a miconazole topical powder for empiric treatment of the discharge. DISPOSITION: Patient was very interested in institutional alcoholic rehabilitation throughout his hospital stay and felt very strongly that he could not continue in this pattern of recurrent abuse and withdrawal. Patient was deemed to be stable for discharge on hospital day 9. Medications on Admission: Baclofen 5mg TID Protonix 40mg QD Nifedipine SR 60mg Thiamine 100mg QD Folic Acid 1mg QD MVI Colace 100mg [Hospital1 ] Olanzapine 5mg QD Naltrexone 50mg QD Keflex X 14 days Lexapro 10mg QD Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (once a day). 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: Hollywell - [Location (un) 5110] Discharge Diagnosis: Alcohol Withdrawal Alcohol Detoxification Urinary Tract Infection Multiple Sclerosis Discharge Condition: Good Discharge Instructions: Please continue taking your medications as directed. Please follow the recommendations of your rehabilitation institution for staying sober. Call your doctor or go to the emergency room if you have any problems with fever, chills, urethral discharge, urinary tract infection, loss of consciousness, or seizures. Followup Instructions: Please make an appointment to see Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] ([Telephone/Fax (1) 98194]) ten days after discharge. Please make an appointment to see Dr [Last Name (STitle) 665] within two weeks of discharge ([Telephone/Fax (1) 1247]). Urethral swab gram stain and culture for possible bacterial, yeast, or fungal infection. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883]	[ "5990", "2859" ]
Admission Date: [2173-3-9] Discharge Date: [2173-3-18] Date of Birth: [2114-6-13] Sex: M Service: MEDICINE Allergies: Iodine Containing Agents Classifier Attending:[First Name3 (LF) 134] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: ICD placement cardiac catheterization History of Present Illness: 58yo M s/p AVR ([2165]) on Coumadin, DM2, hyperlipidemia, presented to OSH s/p cardiac arrest at home. At OSH, found to be in CHB and is s/p temporary pacing wire placement. According to wife, patient has had progressive DOE over the past few weeks. He has also had increased LE edema recently. No known complaints of chest pain. He returned home after coaching a baseball game today and collapsed. He was found to be pulseless. A neighbor who is an [Name (NI) 9168] was called, and began administering CPR. EMS arrived ~15min later and found pt to be in VF. One shock was administered and he returned to sinus rhythm. He was nasally intubated in the field. En route, he was found to be progressively bradycardic, and his rhythm was c/w CHB. He was taken to [Hospital 487] Hospital and a temporary pacing wire was placed through the R IJ (apparently done under unsterile conditions). He was changed to oral intubation. He received IV metoprolol, NTG gtt, atropine, and Versed. Bedside TTE showed EF 30-35% with anterio AK, 2+ TR, 2+ MR. CK was 337 with negative troponin T. He was transferred to [Hospital1 18] for further management. . On presentation to the [Hospital1 18] ED, he was intubated and sedated, with the temporary pacer appropriately capturing. He was minimally responsive, on sedation, on admission. he was given gentamicin, metronidazole, and cefazolin for his unsterile pacer wire. Head CT was done to r/o bleed [1-14] fall and anticoagulation. He was admitted to the CCU for further monitoring. Past Medical History: 1. AVR: [2165], mechanical valve, on Coumadin, done at [Hospital1 18] 2. DM2: last HgA1C 7.5, on metformin 3. Hyperlipidemia 4. Hypertension: on atenolol Social History: teacher and coach, remote tobacco use, social EtOH use, no drug use Family History: 1 sister with HTN and DM2, other sister died at 49 of "infection", no sudden cardiac death in the family Physical Exam: vitals- T 99.1, HR 60 (paced), BP 154/89, RR 14, 99% on AC 700x14, PEEP of 5 and FiO2 of 100% General- sedated, intubated, minimally responsive to sternal rub HEENT- + dried blood in left nostril Neck- R IJ cordis, difficult to assess JVP, carotid pulses 2+ b/l, no carotid bruit Lungs- diffusely rhonchorous Heart- RRR, mechanical S2, 2/6 SEM at LUSB Abd- obese, hypoactive bowel sounds, slightly distended but soft, no palpable organomegaly Ext- 2+ pitting edema to knees b/l, DP/PT pulses 2+ b/l Pertinent Results: [2173-3-9] 11:00PM WBC-17.4# RBC-4.48 HGB-13.3* HCT-39.0* MCV-87 MCH-29.7 MCHC-34.2 RDW-13.9 [2173-3-9] 11:00PM NEUTS-90.1* BANDS-0 LYMPHS-4.5* MONOS-4.4 EOS-0.2 BASOS-0.9 [2173-3-9] 11:00PM PLT SMR-NORMAL PLT COUNT-360 [2173-3-9] 11:00PM PT-27.5* PTT-27.8 INR(PT)-2.8* [2173-3-9] 11:00PM CK-MB-6 [2173-3-9] 11:00PM cTropnT-0.17* [2173-3-9] 11:00PM CK(CPK)-293* [2173-3-9] 11:00PM GLUCOSE-226* UREA N-17 CREAT-0.9 SODIUM-143 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-18* ANION GAP-19 . OSH ECG: AV dissociation, RBBB, left axis deviation ECG s/p temp pacer: paced at 60bpm, native p waves not conducting, LBBB appearance to QRS . CXR: The tip of the right jugular temporary pacer is not clearly identified. There is mild congestive heart failure with cardiomegaly. Note is made of opacity in the left lower lobe indicating aspiration. There is no evidence of pneumothorax. . CT head: no ICH, ethmoid sinusitis, no fracture . TTE ([1-17]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is moderately dilated. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. The aortic prosthesis leaflets are not well seen. Mild to moderate valvular ([12-14]+) aortic regurgitation is seen. No paravalvular leak is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a physiologic pericardial effusion. . Cath ([2165]): 1. Normal coronary arteries. 2. Normal ventricular function. 3. Severe aortic stenosis. Brief Hospital Course: . # Cardiac arrest: On admission, it was reported that he had a VF arrest by EMS, and converted with 1 shock in the field. EP, however, felt his cardiac arrest was more likely secondary to polymorphic VT as a result of his prolonged QT and complete heart block. He had no CAD on cath so it was likely not ischemic in etiology. Despite the suspicion for polymorphic VT, EP felt primary VF could not be ruled out, so an ICD was placed on [3-12]. . # Complete heart block: He had a temporary pacing wire placed at the outside hospital, and was V-paced at 60bpm. His native heart rate was less than 30. The etiology of his complete heart block was thought to be secondary to degenerative conduction disease, as he seems to have had progressive conduction abnormalities per past EKGs. Viral myocarditis was also considered a possibility as his family gave a history of flu-like symptoms a few days before his cardiac arrest. His TSH was normal and his cath was clean. A dual chamber ICD was placed on [3-12]. He was maintained on a beta blocker for rate control as his rate was in the 90s after his dual chamber ICD was placed. He developed a hematoma from his ICD site, involving his left shoulder and inner arm. His heparin drip was discontinued, and his hematoma resolved into an ecchymosis that has been stable. He has an appointment in device clinic for interrogation of his ICD the day after discharge. He will follow up this and his other cardiac issues with his cardiologist, Dr. [Last Name (STitle) 120]. . # AVR: He is on Coumadin as an inpatient for his mechanical aortic valve. He received vitamin K 5mg po on [3-9] to reverse his INR in preparation for his ICD placement. IV heparin was restarted s/p ICD placement. His mechanical aortic valve was found to be functioning well on TTE. He was restarted on Coumadin, and his INR was therapeutic for a few days before admission. He was discharged on Coumadin 5mg po daily with the plan to get her INR checked 4 days after discharge. He will resume management of his anticoagulation with his PCP. . # Anoxic encephalopathy: According to the family, there was an approximate 5-minute lapse between his collapse at home and initiation of CPR. He was initially minimally responsive when intubated, even with lightening of sedation. His CT head showed no intracranial hemorrhage. Fortunately, he began to recover some cortical function within 48 hours of his cardiac arrest, and began to follow commands. Upon extubation and discontinuation of his sedation, he was disoriented and became agitated, responding well to olanzapine. He was maintained on olanzapine for a couple of days, and his agitation resolved. He also seemed to have some motor difficulty with impaired hand-eye coordination, as well as some short-term memory deficit. His cognitive and motor deficits are likely due to anoxic encephalopathy. He has experienced rapid improvement while in the hospital. He was evaluated by Occupational Therapy and Physical Therapy, and felt to be safe to be discharged home. He will follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of Behavioral Neurology in 6 weeks for reassessment. . # Respiratory status: He was initially intubated for airway protection during cardiac arrest. He had mild pulmonary edema on chest x-ray, for which he received IV Lasix for diuresis. He was weaned from the ventilator over the next couple of days, and was extubated on [3-13]. He had a possible infiltrate on chest x-ray and a leukocytosis, so he received a 7-day course of levofloxacin and vancomycin for empiric treatment of VAP. He was weaned off oxygen and had good sats with ambulation upon discharge. . # CAD: No CAD on cath. He was continued on aspirin and his outpatient dose of statin. . # CHF: He likely has diastolic dysfunction with his aortic stenosis and hypertension. His TTE showed an EF of 60%. His CHF symptoms were possibly due to progressive bradycardia and complete heart block. He was volume overloaded on admission. He diuresed well on IV Lasix, and was euvolemic for several days before discharge. He was maintained on a BB and ACE-inhibitor. . # DM2: His blood sugars were initially well-controlled on sliding scale insulin, but he had poor po intake. He was restarted on his metformin after he resumed his diet. . # Leukocytosis: His initial leukocytosis was felt to be secondary to a possible ventilator-associated pneumonia. He was initially treated with ceftriaxone and vancomycin. Ceftriaxone was discontinued for a possible drug rash. He was switched to levofloxacin and maintained on vancomycin, and completed a 7-day course of antibiotics. His leukocytosis resolved initially, but then recurred, while still on antibiotics. He had no localizing symptoms, a clear chest x-ray, and negative UA and culture. As the origin for the elevated WBC count could not be identified, his antibiotics were discontinued at the end of his 7-day course for VAP. He was discharged to PCP follow up, with a check of his WBC count in 4 days after discharge. . # FEN: After extubation, he had a video swallow evaluation that showed aspiration of a regular diet. He was found to tolerate ground solids and thin liquids with careful swallowing and strict aspiration precautions. He was discharged home on this diet. Speech and Swallow recommended repeat video swallow evaluation in 2 weeks to reassess his aspiration risk, and hopefully clear him for regular diet. . # Code status: FULL CODE. . Medications on Admission: Atenolol 100mg qd Coumadin Lipitor 20mg qd Metformin 1000mg [Hospital1 ] Tricor 48mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Outpatient Lab Work Please check PT/INR, WBC count, and creatinine on Monday, [2173-3-22] and speak to Dr. [Last Name (STitle) ] regarding the results. Discharge Disposition: Home Discharge Diagnosis: 1. Cardiac arrest 2. Complete heart block 3. Ventilator-associated pneumonia Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. Please have your INR, WBC count, and creatinine checked on Monday. Please follow instructions regarding aspiration precautions when eating. If you experience chest pain, palpitations, firing of your defibrillator, fever >101, or other concerning symptoms, please call your PCP or go directly to the ED. Followup Instructions: 1) Cardiology: Please call ([Telephone/Fax (1) 9169] to schedule a follow-up appointment with Dr. [Last Name (STitle) 120] within one month of discharge. Although you already have an appointment for [2173-12-28] at 2:30pm, you should see Dr. [Last Name (STitle) 120] sooner regarding this hospitalization. 2) ICD: Please follow up at Device clinic as scheduled on Friday [2173-3-19] on [Hospital Ward Name 23] 7, ([Telephone/Fax (1) 9170], [2173-3-19] 1:30pm. 3) PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [2173-3-31] 10:30, ([Telephone/Fax (1) 9171]. Please call Dr. [Last Name (STitle) ] on Monday regarding your lab results. 4) Neurology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], ([Telephone/Fax (1) 9172], [2173-5-3] 10:00, [Hospital Ward Name 860] Building Rm 253. Completed by:[2173-3-18]	[ "51881", "486", "5990", "V5861", "25000", "4019" ]
Admission Date: [2129-10-21] Discharge Date: [2129-11-4] Service: CSU HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 18719] is an 89-year-old, Russian-speaking woman with known CAD (coronary artery disease) who presented to an outside hospital emergency room on [10-19] with congestive heart failure and hypertension. She had elevated cardiac enzymes and troponins at that, along with ST elevations by EKG ruled in for non- STEMI and was transferred to [Hospital1 188] for cardiac catheterization. Catheterization done at [Hospital1 ] MC showed three-vessel coronary artery disease and cardiothoracic surgery was consulted for possible CABG (coronary artery bypass graft). As stated, the catheterization showed three-vessel disease, including 95 percent left main, 95 percent RCA (right coronary artery), 80 percent circumflex and 99 percent distal LAD (left anterior descending) with an EF (ejection fraction) of 40 percent. The patient's past medical history is significant for CAD, CHF (congestive heart failure), hypertension, osteoarthritis, BPV (benign positional vertigo) breast CA (carcinoma) status post lumpectomy. The patient has no known drug allergies. Her meds at home include nifedipine XL 90 q.day, Lipitor 40 q.day, Paxil 20 q.day, atenolol 25 q.day, Celebrex 200 q.day, meclizine 12.5 q.day, Imdur 120 in the a.m., 60 in the p.m., and Buspirone 10 b.i.d. SOCIAL HISTORY: She lives alone in [Location (un) 583], is very active doing volunteer work, uses a cane, does not drive, no tobacco or alcohol use. REVIEW OF SYMPTOMS: GENERAL: Sleeps poorly. SKIN: No lesions. HEENT: Positive headaches, with glasses, history of cataracts, status post removal. RESPIRATORY: No asthma, COPD (chronic obstructive pulmonary disease), positive CHF. CARDIOVASCULAR: Positive claudication, edema, palpitations, angina and CHF. GI: Nausea with angina. No GERD (gastroesophageal reflux disease) or melena. GU: No dysuria or hematuria. MUSCULOSKELETAL: Positive arthritis. ENDOCRINE: No diabetes or thyroid disease. HEME: No anemia NEUROLOGICALLY: No seizures, CVA's (cerebrovascular), TIAs (transient ischemic attacks), syncope. PHYSICAL EXAM: Height 5 feet, weight of 154 pounds. VITAL SIGNS: Heart rate 57 sinus rhythm, blood pressure 147/100, respiratory rate 22, O2 sat 99 percent on room air. GENERAL: Lying flat in bed, in no acute distress. Neurologically alert and oriented x3. Moves all extremities. Strength equal bilaterally. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops. GI: Soft, nontender, nondistended, normal active bowel sounds. No hepatosplenomegaly. EXTREMITIES: Warm, well-perfused with no to edema, no varicosities. Right groin cath site with dry sterile dressing. PULSES: Radial 2+ bilaterally. Dorsalis pedis 1+ bilaterally. Posterior tibial 1+ bilaterally. LABORATORY DATA: White count 5.8, hematocrit 31, platelets 317, PT 13.3, PTT 41.9, INR 1.1, sodium 139, potassium 3.5, chloride 105, CO2 27, BUN 13, creatinine 0.4, glucose 161, ALT 18, AST 26, alkaline phosphatase 95, amylase 17, total bilirubin 0.3. The patient was seen by cardiac surgery and accepted for coronary artery bypass grafting. She was followed by the medicine service and on [9-24] was brought to the operating room. Please see the OR report for full details and summary. She had a CABG x4 with the LIMA (left internal mammary artery) to the diagonal, saphenous vein graft to the LAD (left anterior descending), saphenous vein graft to OM (obtuse marginal) and saphenous vein graft to the PDA (posterior descending artery). Her bypass time was 71 minutes with a crossclamp time of 59 minutes. She tolerated the operation well was transferred from the operating to the cardiothoracic intensive care unit. At the time of transfer, the patient was A paced at 88 beats per minute with a mean arterial pressure of 71 and a CVP of 11. She had Neo- Synephrine 0.5 mics/ kilogram/minute and propofol at 25 mics/kilogram/minute. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator and successfully extubated on postoperative day 1. The patient continued to do well and it was felt that she was ready to transfer to the floor, but, given her age, it was decided that she would be transferred instead to a medical intensive care unit for close monitoring of her hemodynamic status. On postoperative day 2, the patient was transferred back to the cardiac surgery recovery unit, due to rapid atrial fibrillation with a ventricular response rate of 120 to 140. At that point, she was begun on an amiodarone drip and received IV beta blockade, following which the patient converted back to normal sinus rhythm. On postoperative day 3, the patient developed a fever of 102. Blood, as well as urine cultures, were sent and the patient was started on oral levofloxacin. Chest x-ray was also done at that time that showed no infiltrates and the patient stayed in the ICU at that point for close pulmonary monitoring. The following day, all cultures returned negative and patient's antibiotics were discontinued. She remained in the ICU for vigorous pulmonary toilet, given her relative hypoxia. By postoperative day 5, the patient's chest x-ray had shown improving lung fields and diaphragmatic excursion, and, at that time, she was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient showed slow progress in her activity level. She had no further of bouts of atrial fibrillation and, on postoperative day 9, it was decided that the following day the patient would be stable and ready to be discharged to rehabilitation. At the time of this dictation, the patient's physical exam is as follows. Temperature 97.9, heart rate 59 sinus rhythm, blood pressure 139/64, respiratory rate 18, O2 sat 96 percent on 3 liters. Weight preoperatively 69 kg, at discharge 66.6 kg. LABORATORY DATA: Sodium 144, potassium 3.9, chloride 105, CO2 31, BUN 32, creatinine 0.9, glucose 109, PT 14, PTT 31, INR 1.3, white count 10, hematocrit 36.4, platelets 366. PHYSICAL EXAM: NEURO: Alert and oriented x3. Moves all extremities. Follows commands. Nonfocal exam. PULMONARY: Breath sounds somewhat diminished in the bases bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1,S2. No murmur. Sternum is stable. Incision with staples and dry sterile dressing, no erythema or drainage. ABDOMEN: Is soft, nontender, nondistended with normal active bowel sounds. EXTREMITIES: Warm and well-perfused with no edema, bilateral leg incision from the saphenous vein harvest sites are clean and dry with Steri-Strips. MEDICATIONS AT THE TIME OF DISCHARGE: Include amiodarone 400 mg b.i.d., x7 days, then 400 mg q.day x7 days, then 200 mg q.day, aspirin 81 mg q.day, Colace 100 mg b.i.d., Lasix 40 mg b.i.d. x10 days then 40 mg q.day, metoprolol 50 mg b.i.d., potassium chloride 40 mEq b.i.d., x10 days and then q.day, Zantac 150 mg b.i.d., Paxil 20 mg q.day, Buspirone 10 mg b.i.d. The patient's condition at time of discharge is good. She is to be discharged to rehabilitation at the [Hospital3 1761] Center. She is to follow-up with Dr. [Last Name (STitle) 28413] in 2 to 3 weeks, follow-up with Dr. [Last Name (STitle) ] in 4 weeks and follow-up with Dr.[Last Name (STitle) 3357] after being discharged from rehabilitation. DISCHARGED DIAGNOSES: 1. CAD (coronary artery disease) status post coronary artery bypass grafting times 4, with LIMA (left internal mammary artery) to the diagonal, saphenous vein graft to the LAD (left anterior descending), saphenous vein graft to OM (obtuse marginal) and saphenous vein graft to PDA (posterior descending artery). 2. Hypertension. 3. Osteoarthritis. 4. Benign positional vertigo. 5. Breast cancer status post lumpectomy. 6. Congestive heart failure. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2129-11-3] 17:16:13 T: [2129-11-4] 03:41:42 Job#: [Job Number 93087]	[ "41071", "41401", "4280", "42731", "4019" ]
Admission Date: [2121-4-4] Discharge Date: [2121-4-21] Date of Birth: [2067-9-28] Sex: M Service: NEUROLOGY Allergies: IV Dye, Iodine Containing Attending:[First Name3 (LF) 618] Chief Complaint: R putaminal hemorrhage Major Surgical or Invasive Procedure: Endotracheal Intubation Tracheostomy History of Present Illness: Mr. [Known lastname 59501] is a 53 year old male with history of nephrolithiasis and ? pyelonephritis who presents with large R putaminal hemorrhage. The patient complained of feeling warm earlier today, and mild low back pain consistent with his history of kidney for percocet for the pain. The patient had entertained guests in his home this evening and was feeling well. He developed low back pain in the evening, took a percocet for the pain, went to his prayer room, and he was then found by his wife on the floor, vomiting and unable to get up. He was able to speak to her and asked that he be put in bed. He never complained of having any headache. His wife called EMS. The patient was intubated for airway protection en route to the OSH by EMS. At the [Hospital3 20284] Center the pt's head CT revealed a large right putaminal hemorrhage extending posteriorly and inferiorly in the right posterior midbrain with blood in the third ventricle. The patient was given phosphenytoin 1500mg, Ativan 2mg, Pancuronium, zofran and transferred to [Hospital1 18] for further care. At present the pt is unable to provide a ROS. His wife reports recent low back pain and perhaps fevers, but he did not take his temperature at home. Otherwise he has been feeling well recently without N/V/D. No recent wt loss. He does not have a history of headaches. Past Medical History: Nephrolithiasis- as above No known h/o hypertension Social History: Married, has two children, he works as a laotian translator at [Hospital3 1810] and also formerly at [Hospital1 18], he has also worked as a court transcriptionist. He smoked for many years, quit 2 years ago. He does not drink any alcohol. Wife reports that he has never used any illicit or IV drugs. Family History: pt's wife is unfamiliar with his FH, does not recall any h/o stroke, ICH or bleeding diasthesis. Physical Exam: PHYSICAL EXAM: Vitals: T 99, HR 60 (regular), BP 110/62, R 16, 97% on CMV Gen- critically ill, male on gurney, spontaneous extensor posturing of left hemibody, biting on ET tube. HEENT- NCAT, anicteric, OP clear, no oral trauma Neck- no carotid bruits bilat CV- RRR, 2/6 SEM heard best at apex PULM- CTA B Extrem- no CCE SKIN- multiple tattoos, R thigh, chest, patchy blanching erythematous reticular rash on anterior chest. NEUROLOGIC EXAM: MS- no response to voice, not following commands. He does not localize sternal rub. CN- right pupil dilated to 9mm unreactive to light, left pupil 3mm-->2mm, absent doll's eye reflex, intact corneal reflex bilaterally, brisk gag reflex. Motor- occasional fasciculation of left anterior quads. appears to withdraw with the RUE purposefully to noxious stimulation. Extensor posturing of LUE and LLE with noxious stimulation. Withdraws right leg to noxious. Sensation- intact to noxious throughout. Pt flexes R arm to noxious on left leg, but is unable to localize to sternal rub. Reflexes- 2+ on R [Hospital1 ], tri, brachioradialis and patellar, ankle. On the left there are 3+ reflexes in the [Hospital1 ], tri, brachioradialis. The left patellar reflex spreads to the left leg inducing clonus- 4+. left toe is upgoing. right toe is downgoing. Pertinent Results: Labs: Trop-T: <0.01 BUN 11, Cr 0.6 CK: 132 MB: 3 [Doctor First Name ]: 131 MCV 98 WBC 12.4, hgb 14.7, hct 45, Platelets 134 PT: 14.1 PTT: 31.3 INR: 1.2 At OSH: UA postive for RBC's, 3+ protein. PTT 28, INR 1.2 EKG (from OSH)- NSR with left atrial enlargement, RBBB. <br> Imaging: Head CT [2121-4-4]: FINDINGS: There is acute intraparenchymal hemorrhage in the right basal ganglia measuring roughly 4 x 3 cm, which extends inferiorly into the right pons and mid brain. There is a moderate amount of associated intraventricular blood seen within the lateral ventricles, greater on the right than on the left. Small amount of blood is seen within the third ventricle. There is slight effacement of the suprasellar cistern, suggesting early uncal herniation. There is minimal, 2 mm leftward subfalcine herniation. Edema surrounding the area of hemorrhage causes mild mass effect on adjacent sulci. There is no extra-axial hemorrhage. There is no evidence of infarction. There is no fracture. IMPRESSION: Acute intraparenchymal hemorrhage in the right basal ganglia, with extension into the right pons and mid brain. Moderate intraventricular extension into the lateral ventricles and third ventricle. Early uncal herniation. NOTE ADDED AT ATTENDING REVIEW: Although I agree with most of the above report, there is no evidence of uncal herniation associated with this globus pallidus hematoma. <br> Head CT [2121-4-5]: NON-CONTRAST HEAD CT: Since prior examination, there has been no significant change in the hemorrhage within the right globus pallidus extending into the midbrain. Although there is less blood in the frontal [Doctor Last Name 534] of the lateral ventricles, the extent of hemorrhage within the posterior [Doctor Last Name 534] of the lateral ventricles, third ventricle, and fourth ventricle is not appreciably changed. No new hemorrhage is identified. This is associated with mildly increased hydrocephalus. A 5 mm vague hyperdensity is seen within the inferior brainstem (series 2, image 4), which was retrospectively present on prior exam and may represent tiny focus of blood. Copious secretions are seen within the nasopharynx. The visualized paranasal sinuses and mastoid air cells remain normally aerated. IMPRESSION: 1. Stable hemorrhage within the right globus pallidus extending into the mid brain. 2. Minimally increased hydrocephalus. <br> CXR [2121-4-4]: FINDINGS: Single portable supine chest radiograph is reviewed without comparison. Endotracheal tube is in place, just below the thoracic inlet, 5.4 cm above the carina. Tube could be advanced for more optimal positioning. Cardiomediastinal contours are within normal limits allowing for portable supine technique. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: Endotracheal tube tip seen just below the thoracic inlet, 5.4 cm above the carina. <br> CXR [2121-4-6]: SINGLE FRONTAL VIEW OF THE CHEST: The nasogastric tube has been removed and Dobbhoff tube placed with tip terminating in similar location within the proximal stomach. An endotracheal tube tip terminates 3 cm from the carina. The cardiomediastinal silhouette is stable and unremarkable. The lungs are clear. There is no effusion. IMPRESSION: Standard Dobbhoff tube tip placement terminating over proximal stomach. <br> KUB [2121-4-9]: IMPRESSION: No evidence of ileus or obstruction <br> CT TORSO [2121-4-14]: FINDINGS: The lung volumes are low. The patient is status post tracheostomy. The airways are patent to the subsubsegmental level. The heart and great vessels are unremarkable. There are no pulmonary nodules. There is no mediastinal or axillary adenopathy. There are bilateral moderate, pleural effusions with adjacent atelectasis. CT ABDOMEN WITH IV CONTRAST: There is massive ascites. The right lobe of the liver is borderline small. The caudate lobe is somewhat prominent, as is the left lobe, consistent with cirrhosis. There is a hypoattenuating liver mass measuring 4.7 x 3.1 cm, in segment IV A of the liver, which encroaches on the IVC and the portal vein. There are other smaller liver lesions, which are too small to characterize. The gallbladder, pancreas, spleen, adrenals are normal. There is a cyst in the upper pole of the left kidney. The bowel shows generalized edema likely due to the patient's cirrhosis. The SMA, SMV, celiac artery, and [Female First Name (un) 899] are all opacified. There is no evidence of bowel obstruction or ischemia. There is no mesenteric or retroperitoneal adenopathy. CT PELVIS WITH IV CONTRAST: The free fluid tracks down into the pelvis. There is again bowel wall edema. The bladder is collapsed with a Foley in it. There is no pelvic or inguinal adenopathy. MUSCULOSKELETAL: No suspicious osseous lytic bony lesions. IMPRESSION: 1. No evidence of bowel obstruction. Patent SMA, SMV, celiac, and [Female First Name (un) 899], without evidence of bowel ischemia, although there is bowel wall edema, likely due to underlying cirrhosis. 2. New liver mass in segment IV A, which in the setting of the prominent left lobe, caudate lobe, and borderline small right lobe with massive ascites is concerning for a primary liver lesion, such as hepatocellular carcinoma, or less likely a cholangiocarcinoma. 3. Low lung volumes with bilateral pleural effusions and adjacent atelectasis. <br> PERITONEAL FLUID [2121-4-15]: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, neutrophils, histiocytes and lymphocytes. <br> ABDOMINAL ULTRASOUND [2121-4-16]: This study was done portably in the intensive care unit. Only portions of the liver could be imaged,and the left lobe and known left lobe mass could not be visualized due to the high position deep to the sternum. The right lobe was well imaged and showed no masses. The gallbladder was not overly distended, but the wall was thickened and edematous undoubtedly related to the underlying liver disease. There was marked ascites surrounding the liver, which had a somewhat coarse nodular texture. Color flow and pulse Doppler assessment was performed. The hepatic veins were well identified and fully patent with normal waveforms. Hepatic artery was also easily identified and patent as well as the inferior vena cava. However, no detectable flow could be identified within the right portal vein either by color flow or pulse Doppler. The imaged portion of the portal vein included only the right portal vein, but not the left or main portal, which were obscured or impossible to access. CONCLUSION: Cirrhotic liver with marked ascites. Limited views do not allow for visualization of the known left lobe mass. Doppler assessment shows patency of the hepatic artery and hepatic veins, but no flow could be detected in the right portal vein, even at low flow settings. This either indicates occlusion or extremely low velocity flow, less than 10 cm/sec. It is not possible to make distinction between these two possibilities on this portable study. Brief Hospital Course: Mr. [Known lastname 59501] was admitted to the Neuro ICU for close monitoring and blood pressure management after diagnosis of his putamenal hemorrhage in the ED. His blood pressure was controlled with a nicardipine gtt initially. He was kept euglycemic with insulin sliding scale, and Tylenol was administered for any temperature greater than 100.4F. It was presumed that the etiology was long-standing hypertension, with an acute hypertensive episode that likely led to the bleed perhaps precipitated by the pain due to his renal stones. To improve his intracranial pressure, he was hyperventilated and treated with mannitol; his head elevation was maintained greater than 30 degrees. Neurosurgery was consulted for possible EVD placement, but as there was no significant hydrocephalus and his 4th ventricle appeared patent, no drain was placed. Mr. [Known lastname 59501] was monitored with a repeat CT scan after 6 hours, which showed no change in the hemorrhage and only minimal increase in the hydrocephalus. Throughout his hospitalization, his neurologic status showed no improvement. He continued to have no pupillary reaction, minimal oculocephalic response, and decerebrate posturing. Despite his poor prognosis, his family wished to continue aggressive care. This was addressed with them in multiple family meetings, nearly daily for the first week of his hospitalization. Because no significant neurologic recovery was expected, a tracheostomy was performed at the end of his first week. A percutaneous enterogastrostomy (PEG) was planned as well, but before this could be performed, he developed significant ascites. To investigate the cause of this ascites, a CT torso was performed (lungs were evaluated for possible pneumonia, which was not seen). The CT of the abdomen and pelvis revealed massive ascites with one large liver mass and several smaller liver nodules, consistent with a primary hepatocellular carcinoma. At this point, the even poorer prognosis was discussed with the family, who still wanted to proceed with life-prolonging measures. The day after this CT, he underwent paracentesis for diagnostic and therapeutic measures. No malignant cells were seen in the ascitic fluid and there was no evidence of peritonitis. Following the paracentesis, he became hypotensive with systolic pressures in the 70s; he was given albumin to restore intravascular volume. Albumin needed to be given repeatedly over the next four days until his death to maintain blood pressure. At the same time, he began to develop a coagulopathy due to his failing liver. He received several units of fresh frozen plasma (FFP) and several doses of Vitamin K over the final 4 days of his life. Similarly, he began to develop renal failure due to hepatorenal syndrome. His creatinine climbed as high as 2.3. He was supported with the albumin in an effort to maintain intravascular volume. After several days of these heroic life-prolonging measures, a meeting was held with his providers (the Neurology and the ICU teams, including nursing), his family, social workers, and the Legal/Ethics Consult team. It was explained to his family that despite all the best medical care, there was no chance of his surviving. The Legal/Ethics consult determined that the hospital and the providers were under no obligation to provide treatment that could not produce the goal of survival, which his family identified as the goal of therapy (see separate note from Legal/Ethics consult on OMR). Therefore, it was agreed that care would be withdrawn. Mr. [Known lastname 59501] died within 48 hours, on [2121-4-21]. Medications on Admission: Meds: Percocet PRN- filled Rx a few days ago Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Hypertensive intracerebral hemorrhage, right putamen, with intraventricular and midbrain extension. 2. Hepatocellular carcinoma 3. Coagulopathy due to failed production of clotting factors 4. Hepatorenal syndrome Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2121-5-2]	[ "51881", "486" ]
Admission Date: [2113-11-9] Discharge Date: [2113-11-10] Date of Birth: [2089-11-21] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 338] Chief Complaint: hypotension & lethargy Major Surgical or Invasive Procedure: None History of Present Illness: 23 yo F brought to the ED from a correctional facility after reporting sexual assault 5 days ago by unknown assailant. She had been given unknown doses of clonidine, librium, and depakote for symptoms of withdrawal from heroin, cocaine, and benzo. . On arrival to the ED, 98.1, 66, 92/48, 12, 99% ra. Pt was lethargic but easily arrousable. Her BP trended down to 85/40 with HR=47. In total, she received 5L NS and received 1g of Ceftriaxone IV. Urine output was not measured. At the time of transfer to the MICU, her BP= 103/58 with HR=74. . Her initial labs were notable for a venous lactate of 1.1, bicarb of 33, mild transaminitis, positive benzo/opitae/cocaine, and positive UA. She did not receive "Rape Crisis Intervention Protocol" in the ED. . Currently, she is sleeping in bed apparently comfortable. She is arousable to voice and complains of abdominal cramping which she attributes to withdrawal--that said, she falls back asleep easily. . ROS negative for fevers, chills, sweats. She complains of mild dysuria, duration unclear. She last used IV heroin and inhaled cocaine 48 hours ago. She drinks daily & could not estimate her total intake but denies hx of ETOH withdrawal. . She does not know the HIV status or identity of her assailant. She denies trauma. Her menstrual cycle is regular and began two days ago. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: Hepatitis C Polysubstance abuse: cocaine, heroin, benzo, ETOH Bipolar disorder? Social History: Recently section 12, reasons unknown. Actively abusing heroin, cocaine (inhaled), ETOH and benzo. . Family History: Denied any family hx of serious illness Physical Exam: VS at discharge: 114/58, HR=82, afebrile, 95% room air GENERAL: NAD. Oriented x3. Mood, affect appropriate. Sleepy but very easily arousable to voice HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no appreciable JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2113-11-9] 02:00PM BLOOD WBC-5.2 RBC-3.56* Hgb-10.6* Hct-32.3* MCV-91 MCH-29.7 MCHC-32.8 RDW-14.1 Plt Ct-226 [2113-11-10] 09:32AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.7* Hct-31.2* MCV-89 MCH-30.3 MCHC-34.1 RDW-14.1 Plt Ct-214 [2113-11-9] 02:00PM BLOOD Neuts-40.1* Lymphs-51.7* Monos-4.6 Eos-3.1 Baso-0.5 [2113-11-9] 02:00PM BLOOD PT-13.6* PTT-37.6* INR(PT)-1.2* [2113-11-9] 02:00PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-33* AnGap-7* [2113-11-10] 09:32AM BLOOD Glucose-87 UreaN-4* Creat-0.6 Na-140 K-3.6 Cl-108 HCO3-26 AnGap-10 [2113-11-9] 02:00PM BLOOD ALT-57* AST-77* AlkPhos-93 TotBili-0.4 [2113-11-10] 09:32AM BLOOD ALT-64* AST-90* AlkPhos-160* TotBili-0.4 [2113-11-9] 02:00PM BLOOD Calcium-8.7 Phos-5.1* Mg-1.7 [2113-11-10] 09:32AM BLOOD Calcium-8.1* Phos-3.1# Mg-1.6 [2113-11-10] 09:32AM BLOOD HBsAg-PND HBsAb-PND IgM HBc-PND [2113-11-9] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2113-11-10] 09:36AM BLOOD Type-[Last Name (un) ] pO2-215* pCO2-39 pH-7.44 calTCO2-27 Base XS-2 Comment-GREEN TOP [2113-11-9] 03:53PM BLOOD Lactate-1.1 [2113-11-10] 09:36AM BLOOD Lactate-0.6 . BLOOD CULTURE, URINE CULTURE, HEPATITIS SEROLOGIES, HCV VIRAL LOAD PENDING AT THE TIME OF DISCHARGE. . ============================ CT ABDOMEN [11-9] TECHNIQUE: Multidetector CT images of the abdomen and pelvis after administration of IV contrast were submitted for interpretation. . ABDOMINAL CT WITH CONTRAST: The lung bases demonstrate interstitial thickening and mild posterior ground-glass opacities with intralobar and interlobar septal thickening. The heart is not enlarged. There is no pericardial effusion. There is a 2.2 x 0.7 cm nodule in the right cardiophrenic angle which may represent a lymph node. Perihepatic fluid is noted. Periportal edema is seen. The gallbladder demonstrates severe wall edema and surrounding fluid; however, appears relatively [Name2 (NI) 19973]. The spleen, adrenals, pancreas, kidneys are grossly unremarkable. Abdominal [Last Name (un) ] and iliac vessels demonstrate no evidence of aneurysmal dilatation. here is no bowel obstruction. Normal appendix is seen in the right lower quadrant. There is no bowel wall thickening. . PELVIC CT WITH CONTRAST: The uterus, adnexa, urinary bladder, and rectosigmoid colon are grossly unremarkable. A 1.6-cm area of hypodensity posterior and to the right of the uterus (2:75) likely represents small mount of free pelvic fluid. The right ureter appears slightly thickened and there is mild periurethral fat stranding. Evaluation for stones is limited due to IV contrast, however, there is no hydronephrosis or evidence of asymmetric renal enhancement. OSSEOUS STRUCTURES: There is a small Schmorl's node in the inferior endplate of T11 vertebral body.There is no fracture. IMPRESSION: 1. Interstitial thickening at the lung bases with interlobular and intralobular septal thickening. Differential diagnosis includes pulmonary edema and/or drug reaction. 2. Periportal edema, gallbladder wall edema, as well as perihepatic and pericholecystic fluid, may represent liver failure/acute hepatitis. Clinical correlation is recommended. The study and the report were reviewed by the staff radiologist. . ================================= CXR [11-9] Heart, mediastinal, hila are normal. Bilateral increased interstitial and reticular markings are present, especially in the lower lobes. There is no pneumothorax or pleural effusion. IMPRESSION: Bilateral interstitial opacities are most pronounced within the lower lobes and may be due to interstitial pulmonary edema or an atypical infection. Clinical Correlation is recommended. Brief Hospital Course: 23 yo F with polysubstance abuse s/p recent sexual assault admitted through the ED s/p recovery from transient hypotension/bradycardia which was likely medication related. . # Hypotension/bradycardia: Completely resolved at this point. Limited fluid responsivene in the ED; probably resolved with time. Clonidine dose and time given unknown. No EKG changes concerning cardiogenic source. Nothing on labs to suggest infxn. Avoid clonidine in the future. . # Lethargy: Reportedly with withdrawal symptoms at outside facility. No signs of ETOH or Benzo withdrawal currently. C/o of symptoms of heroin withdrwal, cramps, etc, but somnolent and appears comfortable despite complaints. Held all sedating medications including home seroquel and paxil. Can consider restarting these as lethargy resolves. . # Lung Findings: See attached report. Seems attributlable to chronic use of inhaled drugs. Pt requires f/u with a Pulmonologist in [12-23] weeks and a repeat CT of the chest in [2-24] months. Infectious process much less likely, but findings should be re-visited if pt turns out to be HIV positive. . # S/p sexual assault: 5 days out. No evidence of trauma. Denies Trauma. Currently menstruating, so does not require emergent contraception. Outside of 72h window and thus not a candidate for HIV ppx. Received flagyl 2000mg po x1, azithro 1000mg x1, CTX 250mg IM. Known HepC+, HepB serologies pending. Pt should have HIV checked now and again in 6 months. . # Transaminitis & peri-hepatic liver inflammation: AST>ALT but not in ETOH ratio. [Month (only) 116] be the consequence of Hep C. Please trend LFTs every other day until down-trending. HepC viral load pending, please call our lab in [2-23] business days at 617-667-LABS. She should establish care with a hepatologist within 2 weeks for further evaluation. . # Urinary Tract Infection: Uncomplicated. Prescribed 3 days of po Ciprofloxacin. Please repeat UA if symptoms recur. Culture is pending at the time of d/c and should be available at 617-667-LABS within a few days. . DISCARGE TO CORRECTIONAL FACILITY, PT SIGNED OUT TO MEDICAL STAFF THERE BY PHONE. Medications on Admission: Paxil Oral, dose uncertain Depakote Oral, dose uncertain Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. Disp:5 Tablet(s) Refills:0 2. Paxil Oral 3. Depakote Oral Discharge Disposition: Extended Care Facility: [Location (un) ] correctional fac Discharge Diagnosis: Medication induced hypotension and lethargy Uncomplicated Urinary Tract Infection Hepatitis C Poly-substance abuse Discharge Condition: Medically stable for discharge Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the Medical ICU at [Hospital1 ] from [Location (un) 47] after you reported a sexual assault. There was strong concern regarding your low blood pressure initially, but this seems to have been an effect of ssome of the medications you received prior to transfer, most likely clonidine. There are a few issues which you need to follow-up on: - Your abnormal Chest CT scan is likely the consequence of inhaled drug use. You should stop smoking and should establish care with a pulmonologist--this was communicated to the medical staff at [Location (un) 47] and they will make arrangements. Should you want to establish care with a pulmonologist at [Hospital1 18] you can do so by calling ([Telephone/Fax (1) 3554]. - Your liver is showing signs of injury on CT scan and blood tests. As you have Hepatitis C, you should see a hepatologist at least once per year. Your liver funtion tests (blood test) will be re-checked at [Location (un) 47] and they will make arrangements for you to be seen by a liver specialist. Should you want to establish care with a hepatologist at [Hospital1 18] you can do so by calling ([Telephone/Fax (1) 16687]. - You have received Antibiotics to protect you from contracting certain STDs. Unfortunately, since you presented 5 days after your attack, you would not benefit from medications to prevent HIV. The doctors [First Name8 (NamePattern2) ] [Last Name (Titles) 47] [Name5 (PTitle) ] test you for HIV now. You should be tested for HIV again in 6 months. - You need to take 3 days of oral ciprofloxacin for your urinary tract infection. Followup Instructions: To be arranged at [Location (un) 47] with Pulmonary and Hepatology within the next two weeks. Completed by:[2113-11-10]	[ "42789" ]
Admission Date: [2186-9-21] Discharge Date: [2186-9-22] Date of Birth: [2122-12-11] Sex: M Service: MEDICINE Allergies: Nitroglycerin Attending:[First Name3 (LF) 2387] Chief Complaint: Chest pain on exertion Major Surgical or Invasive Procedure: Cardiac catheterization, access through left brachial artery History of Present Illness: 63yo male with early onset CAD s/p CABG [2171] (LIMA-->LAD, SVG --> OM2 and LPLB), HTN, Hyperlipidemia who presented for elective heart catheterization with a history of stable angina. Pt reports chest pain with exertion for last several months, worse recently while mowing his lawn. Baseline two flights of stairs and develops CP. He denies any rest pain, PND or orthopnea. . Pt underwent heart catheterization complicated by multiple bilateral femoral sticks and required L brachial artery for access. Catheter was unable to advance to LIMA or SVG grafts to deliver stents due to severe vessel tortuosity. No stents were deployed. Pt became hypotensive after nitroglycerin gtt was started in the cath lab, required brief period on dopamine. . Pt arrived to CCU c/o [2-10] substernal chest pain consistent with prior anginal pain. SBP 190's on arrival. Low dose nitroglycerin gtt was started and patient became hypotensive to SBP 40's and tachycardic to 150's. IVF's, dopamine, atropine was given with return of SBP's 120's. Pt had HR 150's, SVT, adenosine given without effect. HR gradually returned to 100's. Metoprolol 5mg IV given and brought HR to 80's, 90's. The patient was monitored in the CCU overnight. Past Medical History: CABG- [2171] (LIMA-->LAD, SVG --> OM2 and LPLB) HTN Hyperlipidemia Social History: worked as manager of computer company, widowed, wife died of ovarian CA two years ago, now in a long term committed relationship with female sig other. Drinks 1-2 drinks once per week. 15py smoking history, quit 15 years ago. No Illicits. Remains independent of all ADL's prior to admission. Family History: Mother d.57 DM, CAD Maternal Aunts and uncles with multiple heart dx related premature deaths Brother CABG @ 51 Physical Exam: Vitals: BP 190/100, HR 70, R 16, Sat 94% 4LNC Ht: 6'5", Wt. 275lbs Gen: Pleasant, lying flat in bed, c/o [2-10] SS CP. HEENT: NCAT, PERRL, MMM CV: Nl S1 and S2, no MRG, JVP 7cm PULM: CTA B ABD: obese, soft, NT, no masses Extrem: no CCE, 2+ DP, PT pulses Groin- No hematoma, No Bruits Bilaterally, Good pedal pulses as above. Pertinent Results: [2186-9-21] 08:30PM WBC-11.7* RBC-4.69 HGB-15.8 HCT-44.2 MCV-94 MCH-33.8* MCHC-35.8* RDW-13.6 [2186-9-21] 08:30PM PLT COUNT-184 [2186-9-21] 08:30PM MAGNESIUM-2.2 [2186-9-21] 08:30PM CK-MB-NotDone cTropnT-0.06* [2186-9-21] 08:30PM CK(CPK)-73 [2186-9-21] 08:30PM CK(CPK)-73 [2186-9-22] 04:04AM BLOOD WBC-10.8 RBC-3.87* Hgb-13.0* Hct-37.4* MCV-97 MCH-33.6* MCHC-34.8 RDW-13.4 Plt Ct-154 [2186-9-22] 04:04AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139 K-3.7 Cl-107 HCO3-25 AnGap-11 . Cardiac Catheterization [2186-9-21] Preliminary Report 1) Coronary angiography revealed a right dominant system status post coronary artery bypass grafting with three vessel disease. The LMCA had no stenosis. The LAD gave off a single, large patent D1 branch prior to a 100% proximal segment stenosis. The LCx showed a 100% proximal segment stenosis. The RCA showed a 100% midsegment stenosis with right to left collaterals to the distal LCx system. Graft angiography revealed a stump occlusion of a graft which is likely the SVG-LPL branch. No other graft could be engaged or seen, suggesting likely occlusion of the SVG-OM2 graft. The LIMA-LAD graft revealed a patent LIMA graft with an 80% stenosis of the LAD immediately distal to the anastomosis site. 2) Hemodynamic studies demonstrated normal right atrial filling pressures of 3) Unsuccessful attempts at PCI of the LAD distal to the [Female First Name (un) 899] insertion was performed. The attempts were unsuccesful due to the poor guide support from the brachial access and the excessive tortuousity of the [Female First Name (un) 899]. Further attempts were aborted due to the concern over radiation and dye exposure. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Unsuccessful attempts at PCI of the LAD after the insertion of the [Female First Name (un) 899]. . ECHOCARDIOGRAM [2186-9-22]- PRELIMINARY [Location (un) ] ONLY The left atrium is dilated. The right atrium is moderately dilated. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed. Resting regional wall motion abnormalities include mid anteroseptal and inferior akinesis with hypokinesis elsewhere. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 63yo M with early onset CAD s/p CABG [2171] (LIMA-->LAD, SVG --> OM2 and LPLB), HTN, Hyperlipidemia. s/p heart cath complicated by difficult vascular access, tortuous coronary vascular supply impeding stent delivery, hypotension following administration of nitrates. . 1) Cardiac: Ischemia- The patient presented with stable angina. No stents were able to be delivered due to severely tortuous coronary vessels. Cardiac enzymes were cycled and negative post intervention. The patient was started on Metoprolol 12.5mg [Hospital1 ] for rate control given rate related LBBB. He was started on Aspirin 325mg daily, Clopidogrel 75mg daily, Lisinopril 5mg daily. Nitrates in any form were avoided due to episodes of hypotension. A strict contraindication to nitrates should be noted in all future patient records. . Rhythm- The patient remained in normal sinuse rhythm, he was noted to have a rate related LBBB as noted on prior exercise tolerance tests. Low dose Metoprolol 12.5mg was started while inpatient. . Pump- Preliminary read revealed moderate dilation, multi-regional hypokinesis/akinesis, severely depressed LVEF ~20%. The patient is well-compensated at present, no pulmonary edema, peripheral edema, orthonea/PND. However is at high risk of congestive failure. Given failure of percutaneous revascularization, strict compliance and optimization of medical therapy should continue as an outpatient. He was started on Lisinopril and Metoprolol while inpatient. . 2) Pulmonary- The patient had multiple apneic episodes overnight with bradycardia to 50's. Pt had sleep study 1yr ago but could not tolerate mask. Pt was informed of risks to his cardiac fx and is amenable for re-evaluation for trial of [Hospital1 ]/BiPAP. He should be scheduled for repeat Sleep/Pulmonary evaluation as an outpatient at the discretion of his primary care provider. [Name10 (NameIs) ] will likely improve his severely impaired cardiac parameters and he should be strongly encouraged to re-trial the device. . 3) Seizure disorder- No seizure activity was observed while during this hospitalization. We continued his home dosage of phenytoin during his inpatient stay. . 4) Renal- Creatinine clearance was stable following dye-load associated with catheterization and peri-procedure hypotension. He had excellent urine output without the aide of urinary catheter prior to discharge. . PCP: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Code: Full Contact: (fiance) [Name (NI) ] [Name (NI) 68776] [Telephone/Fax (1) 68777] Medications on Admission: Atorvastatin 80mg PO daily Phenytoin 300mg PO qam Phenytoin 200mg PO qpm Multivitamin 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Elective cardiac catheterization Coronary artery disease Secondary: Hypertension Hyperlipidemia Discharge Condition: Stable. The patient is currently chest pain free. Discharge Instructions: You came to the hospital for an elective cardiac catheterization which was complicated by difficulty accessing your arteries. In addition, your blood pressure dropped while on a nitroglycerin drip. No stents were placed. You are taking some new medications: Plavix, aspirin, lisinopril, and carvedilol. You will continue to take a multivitamin, atorvastatin, and dilantin as you were before. Please keep all outpatient appointments. If you begin to experience shortness of breath, chest pain, dizziness or lightheadedness or any other concerning symptom please call 911 or your physician right away. Followup Instructions: Please schedule the following appointments: 1. [Last Name (LF) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 2394] Appointment should be in [6-12] days 2. [Last Name (LF) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 48826] Call to schedule appointment	[ "41401", "4019", "2724", "42789", "412", "V4581" ]
Admission Date: [2183-11-6] Discharge Date: [2183-11-11] Date of Birth: [2109-7-26] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man who presented with chest pressure and an irregular heart rate for 14 days prior to admission that awoke him from a sound sleep. He was noted to have elevated cardiac enzymes and underwent an exercise tolerance test which was positive as well as a positive nuclear imaging study. The imaging study noted reversible inferior defect. The patient underwent a cardiac catheterization on [2183-10-23] that revealed three vessel coronary artery disease with significant left main stenosis, left main had a 90% stenosis at its origin. There was a 40% stenosis in the diagonal branch. There was a dominant RCA that had a 90% stenosis in its proximal segment and a 70% stenosis in its middle segment. Initial surgery was delayed secondary to a diffuse rash the patient had noted for approximately three weeks over his entire body. The patient was seen by dermatology and was placed on Clobetasol cream. Biopsies were consistent with psoriasis. The rash improved with treatment. The patient was taken to the operating room for CABG on [2183-11-6]. PAST MEDICAL HISTORY: Significant for bilateral carotid disease. He had a carotid ultrasound on [2183-10-24] which showed 40-60% right carotid stenosis and no left carotid stenosis. He also has history of claudication and the right lower extremity had a monophasic doppler tracing at all levels with an ABI of .79. On the left the patient had an ABI of .73. Arterial duplex consistent with significant bilateral superficial femoral artery and tibial disease. PAST SURGICAL HISTORY: Significant for fusion of his left foot in [2121] secondary to polio and revision in [2149]. The patient had a bilateral carotid endarterectomy and subclavian bypass in [2179], status post laparoscopic cholecystectomy in [2181]. MEDICATIONS: Prior to surgery include Isosorbide, Atorvastatin, Lisinopril, Lasix, Atenolol, Nitroglycerin, Co-enzyme Q, Diflucan, several herbal medications. ALLERGIES: Penicillin. There was noted to be an anaphylactic reaction. FAMILY HISTORY: Significant for his father deceased at age 53 secondary to an MI. HOSPITAL COURSE: The patient underwent cardiac surgery on [2183-11-6]. The patient underwent CABG times three with a LIMA to LAD, saphenous vein graft to OM, saphenous vein graft to PDA. The patient tolerated the procedure well and was transferred to the CSRU, not on any drips. The patient had an endovein harvest on the left thigh. Postoperatively the patient did well and was extubated successfully the evening of his surgery. On postoperative day #1 he was started on Lasix, Lopressor and Aspirin and was transferred to the floor. The patient received Vancomycin as perioperative antibiotic. The patient was noted on interoperative TEE to have an EF of 55-60%. The patient was seen by physical therapy and was noted to benefit from short term stay at rehab. The patient continued to do well but on the evening of postoperative day #1 was noted to be in atrial fibrillation with rapid ventricular response. This was controlled by IV Lopressor and patient was started on Amiodarone. The patient did convert to normal sinus rhythm, however, on the evening of postoperative day #2 he did have another second episode of atrial fibrillation that was converted to normal sinus rhythm after 10 mg of IV Lopressor. The patient, on postoperative day #3, had third episode of atrial fibrillation that converted spontaneously to normal sinus rhythm, however, at this point after three episodes of atrial fibrillation, it was decided to start the patient on Coumadin with a goal INR of 2.0. On discharge patient is doing well, he is afebrile, all vital signs stable, he is in normal sinus rhythm with heart rate in the high 50's to low 60's, his blood pressure is 140/80 and his O2 sats are 96% on room air. On exam patient is in no apparent distress, his heart is regular, his sternal wound is clean, dry and intact, his sternum is stable, his lungs are clear to auscultation bilaterally, his abdomen is soft, nontender, non distended, his extremities are warm and his incisions are clean, dry and intact. DISCHARGE MEDICATIONS: Include Amiodarone 400 mg po tid through [11-14], then Amiodarone 400 mg po bid from [11-14] through [11-21], then Amiodarone 400 mg po q d for one month, then Amiodarone 200 mg po q d. He is started on Coumadin 2 mg po q h.s. He will need to have his INR checked and his Coumadin dose adjusted for a goal INR of 2.0. He is on Lopressor 25 mg po bid, Lasix 20 mg po q d, Aspirin 81 mg po q d, Atorvastatin; he will be restarted on his preoperative dosage which is unavailable at this time. CONDITION ON DISCHARGE: The patient is being transferred to rehab in good condition. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 25727] MEDQUIST36 D: [2183-11-11] 09:30 T: [2183-11-11] 09:14 JOB#: [Job Number ]	[ "41401", "9971", "42731", "4241", "49390", "412" ]
Admission Date: [2126-3-1] Discharge Date: [2126-3-3] Date of Birth: [2079-4-2] Sex: M Service: MEDICINE Allergies: Lisinopril / Shellfish Derived Attending:[First Name3 (LF) 7333] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mr. [Known lastname ] is a 46 year old man w/hx of CAD s/p inferolateral MI [3-25] and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 to proximal LCx into OM1 who presented to the ED with chest pain. The patient reports [4-24] chest tightness which started while he was walking to work this morning. He works at [Hospital1 ] and continued to walk from [Location (un) 19903]to the ED. By the time he reached the ED, the chest tightness was [7-25], a band sensation across his chest. No radiation to arm, jaw, or back. He denies diaphoresis or nausea but does report associated SOB. He did not take NTG. He reports rare instances of chest pain since his MI [3-25] but did have an episode [4-23] for which he was evaluated in the ED and it was determined to be non-cardiac. He had an exercise tolerance test at that time which was normal. He does not take NTG at home and does not have any. Total time of chest pain prior to arrival to ED was 20 minutes. . In the ED, initial vitals were T99.2, BP175/86, HR99 RR18 O2 sat 99%. ECG showed ST elevations in II, III, AVF. He received aspirin 325mg x 1, Plavix 600mg x 1, Morphine 4mg IV x 1. NTG gtt, heparin gtt and integrillin gtt were started. A code STEMI was called and he was taken to the cath lab with door-to-balloon time of 40 minutes. . In the cath lab, his prior [Month/Year (2) ] in OM1 was occluded with an acute thrombus. An export wire extracted the clot and the patient became chest pain free. A balloon angioplasty was performed and IVUS showed the stent to be intact. He was given Prasugrel 60mg X 1 in the cath lab. . On arrival to the CCU, the patient feels well and denies chest pain, pressure or tightness, shortness of breath, nausea, vomiting, headache, abdominal pain, calf pain. Of note, he admits to missing several [Month/Year (2) 4319] of Plavix in the last few months. His aspirin dose was recently decreased from 325mg to 81mg daily. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He states that he has had a rash in his groin area recently. All of the other review of systems were negative. . Cardiac review of systems on admission is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD s/p inferolateral MI [3-25] with 2 overlapping Cypher stents to occluded LCx into OM1 prior RCA stenting [6-19] Angioedema after starting Lisinopril [3-25], resolved Pneumonectomy s/p MVA Social History: Social history is significant for the absence of current tobacco use, quit in [2121], 1ppd prior. There is no history of alcohol abuse. Lives with his wife and 2 children. Works in purchasing at [Hospital1 18]. Family History: There is family history of premature coronary artery disease in his father at age 41. Physical Exam: VS: T=97.8 BP=142/59 HR=84 RR=16 O2 sat= 99% 2L NC GENERAL: Alert and oriented x 3, NAD. Mood, affect appropriate. HEENT: NCAT. Slight reddened appearance to face and neck area. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No appreciable rash. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Right femoral cath site is clean, dry and intact with a small soft hematoma palpable. No femoral bruits. Pertinent Results: ADMISSION LABS: [2126-3-1] 07:59AM BLOOD WBC-8.5 RBC-4.72 Hgb-13.5* Hct-40.6 MCV-86 MCH-28.5 MCHC-33.2 RDW-14.4 Plt Ct-310 [2126-3-1] 07:59AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0 [2126-3-1] 07:59AM BLOOD Glucose-143* UreaN-12 Creat-1.1 Na-141 K-4.0 Cl-106 HCO3-21* AnGap-18 [2126-3-1] 07:59AM BLOOD CK(CPK)-212 [2126-3-1] 07:59AM BLOOD cTropnT-<0.01 ---------------- DISCHARGE LABS: ---------------- STUDIES: . EKGs: pre-cath: NSR at 7bpm. nl axis, nl intervals. 3mm ST elevations in II, III, AVF, V4-V6 with ST depression sin AVL, V1, V2, V3. Hyperdynamic T waves in V3, V4, V5. post-cath: resolving ST elevations which are not quite as pronounced. . Cardiac Cath [3-1]: COMMENTS: 1. Coronary angiography in this right dominant system demonstrated two vessel disease. The LMCA had no angiographically apparent disease. The LAD had an origin 30% stenosis. The LCx had a 30-40% origin stenosis and moderate thrombus within the mid stented segment. The RCA had widely patent stents and a 30-40% mid stenosis. 2. Limited resting hemodynamics revealed normaly systemic arterial blood pressure with SBP 103mmHg and DBP 69mmHg. 3. Successful thrombectomy and PTCA of the OM stent thrombus with a 3.5mm balloon. 4. Successful closure of the right femoral arteriotomy site with a 6F Perclose device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Thrombus within mid LCx stent successfully treated with thrombectomy and PTCA. . TTE [3-1]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. 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. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2124-4-14], no change. Brief Hospital Course: Mr. [Known lastname ] is a 46yo M with CAD s/p prior inferolateral MI and [Known lastname ] to OM1 [3-25] who presented to the ED with chest pain, was found to have a STEMI and taken to the cath lab were OM1 stent showed acute thrombus. . # STEMI: Patient presented with inferior STEMI, and door-to-balloon time was 40min. In the cath lab, patient was found to have thrombosis in the OM1 stent. An export wire extracted the clot and the patient became chest pain free. A balloon angioplasty was performed and IVUS showed the stent to be intact. This acute thrombosis in the stent may be due to missed Plavix dosing; however it is also possible that he has failured plavix. As a result, plavix was switched to Prasugrel. Pt was given 60mg loading dose in cath lab, and was kept on 10mg PO qday. Patient was also continued on aspirin 325mg daily, Metoprolol 25mg PO BID, Toprol XL 25mg daily and lipitor 80mg daily. Patient came back from the cath lab on nitro gtt which was promptly turned off, and he was chest pain free during the rest of his hospital stay. . # PUMP: No evidence of heart failure; prior echo [3-25] showed posterolateral hypokinesis with EF 50%. Repeat TTE was done on [3-2], which showed EF 50-55% and mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis, not significantly different compared to the one from approximately 2 years ago. . # RHYTHM: Patient was in sinus rhythm. Toprol 25mg daily was continued. . # FEN: Patient received cardiac, heart-healthy diet, and he tolerated POs well. # PPX: Patient was on SC Heparin for DVT prophylaxis. . # CODE: FULL, confirmed on admission. . # COMM: wife [Name (NI) 19904]: [0-0-] (cell); [Telephone/Fax (1) 19905] (home) Medications on Admission: Lipitor 80mg PO qday Plavix 75mg PO qday Toprol XL 25mg PO qday ASA 325mg PO qday Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Myocardial infarction - Coronary artery disease Discharge Condition: Afebrile, hemodynamically stable, chest pain free Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: It was a pleasure to be involved in your care, Mr. [Known lastname ]. You were admitted to [Hospital1 69] after having chest pain. You underwent a cardiac catheterization and a blood clot was removed from the stents supplying blood to your heart. Your Plavix was changed to Prasugrel 10mg by mouth once a day to help prevent a clot from reforming. It is very important that you take this medication, along with your aspirin, every day. Please do not miss [First Name (Titles) 691] [Last Name (Titles) 4319]. As Prasugrel was not available at your home pharmacy in [Location (un) 10059] today, a prescription was sent to CVS at [Location (un) 19906] in [Location (un) 86] that you can pick up when you are discharged. Your other medications have not been changed. Please continue to take lipitor, toprol XL, and full dose aspirin (325mg daily). Followup Instructions: You need to see Dr. [Last Name (STitle) ], your cardiologist, within the next two weeks. We will try to make an appointment for you this weekend, and please call the cardiology office at ([Telephone/Fax (1) 2037] on Monday to confirm your appointment. If for any reason there is no appointment made for you over the weekend, please make one with the receptionist at that time. Please see you primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ],[First Name3 (LF) ] V., within 1-2 weeks after discharge. Please call [Telephone/Fax (1) 4775] to make an appointment.	[ "41401", "412", "V4582" ]
Admission Date: [2182-2-13] Discharge Date: [2182-3-1] Service: CARDIOTHORACIC Allergies: Percocet / Percodan Attending:[First Name3 (LF) 14964] Chief Complaint: 80 year old white male with abdominal pain, nausea, vomitting, and diaphoresis over past few days. Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, , SVG->PDA, SVG->OM) [2182-2-14] History of Present Illness: This 80 year old white male without significant past medical history, complained of abdominal pain which was relieved with antacids 5 days prior to admission. The morning before admission, he had nausea, vomitting, and diaphoresis, and presented to [Hospital3 1443] Hospital. He was transferred to [Hospital1 18] because he had Q waves on his EKG, and had + troponin. Past Medical History: Smokes 1 pack per day HTN Social History: Lives alone. cigs: 1 ppd ETOH: none Family History: unremarkable Physical Exam: Elderly [Male First Name (un) 4746] in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Lungs: Clear to A+P CV: RRR without R/G/M, nl. S1, S2 Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+=bilat. Neuro: nonfocal Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2182-2-26] 06:35AM 10.2 4.35* 13.1* 37.7* 87 30.1 34.7 14.4 493* BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2182-2-26] 06:35AM 493* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2182-2-26] 06:35AM 96 21* 1.4* 138 4.5 104 26 13 THYROID T4 [2182-2-25] 08:05PM 7.0 INR 2.2 Brief Hospital Course: The pt. was admitted on [2181-2-12] and had a cardiac cath which revealed: 90% LMCA stenosis, 90% mid LAD stenosis, 90% LCX lesion with 90% OM2 stenosis, and dominant RCA with 99% serial lesions. An IABP was placed, and Dr. [Last Name (STitle) 70] was consulted. On [2182-2-14] the pt. underwent CABGx3 with LIMA->LAD, SVG->PDA and OM. Cross-clamp time was 43 minutes with a total bypass time of 74 minutes. He tolderated the procedure well, and was transferred to the CSRU in stable condition on Neo and Propofol. He was extubated on POD#1 and his IABP was d/c'd. He went into Afib on POD#2 and was started on Amio and anticoagulated with coumadin. He continued having multiple episodes of Afib. He developed disorientation which waxed and waned and complained of dizziness. He continued to progress and was transferred to the floor on POD#5. HIs epicardial pacing wires were d/c'd on POD#3. He was seen by neurology and they felt his dizziness was due to benign posteral vertigo, but they were concerned about his disorientation. He had a low B12 and was started on replacement, and had an MRI which revealed bilateral embolic CVAs in the parietal occipital region, with sl. hemorrhagic conversion. They wanted to continue coumadin, but keep his INR between 2-2.5 and monitor very carefully. He will be followed by Dr. [Last Name (STitle) ] from Neurology following discharge from rehab. He was discharged to rehab in stable condition on POD# 12. Medications on Admission: Aspirin PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a day: To start after 7 day [Hospital1 ] cycle complete. 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [2-3] Puffs Inhalation Q6H (every 6 hours). 7. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection DAILY (Daily) for 7 doses: Then give 1000mg IM once per week for 1 month, then 1000mg IM once a month. 8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO tonight: Dose for an INR goal of [3-6].5. Check INR qd for 2 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Coronary artery disease. S/P coronary artery bypass graft x 3. Hypertension. Benign postural vertigo. CVA Discharge Condition: Good Discharge Instructions: Shower daily and wash your incisions with soap and water. Rinse well. Do not apply any creams, lotions, ointments, or powders. No swimming or tub bathing. Do not lift anything heavier than 10 pounds. You may not drive for 4 weeks. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 70] in 6 weeks. Make an appointment with Dr. [Last Name (STitle) 5686] in [2-3] weeks. Make an appointment with Dr. [Last Name (STitle) ] from neurology following discharge from rehab. [Telephone/Fax (1) ] Completed by:[2182-2-26]	[ "41071", "41401", "9971", "42731", "4019", "3051" ]
Admission Date: [2187-11-18] Discharge Date: [2187-11-28] Date of Birth: [2117-7-13] Sex: F Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Nifedipine Er Attending:[First Name3 (LF) 922] Chief Complaint: Palpitations/Chest pain Major Surgical or Invasive Procedure: Cardiac Catherization [2187-11-19] s/p Coronary artery bypass graft x4 (Left internal mammary artery>left anterior descending, Saphenous vein graft > obtuse marginal, saphenous vein graft > RAMUS, saphenous vein graft > diagonal) MAZE, Left atrial appendage ligation [2187-11-23] History of Present Illness: 70yo Spanish speaking only F with h/o HTN, med-noncompliance, R carotid stent p/w chest pain/palpitations x 3 days. States has been having episode of chest pain lasting about 15 mins which are not related to exertion and resolve with drinking garlic water. Presented to emergency department for further evaluation. Past Medical History: HTN GERD carotid stenosis s/p R carotid stent Hyperlipidemia Osteoarthritis venous insufficiency Social History: Lives in [Location ] with daughter denies smoking, etoh Family History: mother and sisters with HTN. Uncle with MI Physical Exam: Vitals 97.5 BP 132/76 HR 70 RR 16 O2 94%RA . Gen: elderly female in nad HEENT: MMM, PERRL, EOMI, OP clear Neck: supple, JVP ~8CM Chest: CTAB, no crackles. Decreased BS at bases CVR: RRR, nl s1, s2, no r/m/g ABD: soft, nt, nd EXT: no edema Pertinent Results: [2187-11-28] 06:33AM BLOOD WBC-8.4 RBC-3.76* Hgb-11.2* Hct-32.5* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-264# [2187-11-28] 06:33AM BLOOD Plt Ct-264# [2187-11-23] 12:41PM BLOOD PT-17.3* PTT-45.2* INR(PT)-1.6* [2187-11-28] 06:33AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-137 K-3.8 Cl-99 HCO3-30 AnGap-12 [Known lastname 30941], [Known firstname 30942] [Hospital1 18] [Numeric Identifier 30943] (Complete) Done [2187-11-23] at 9:20:12 AM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2117-7-13] Age (years): 70 F Hgt (in): 60 BP (mm Hg): 135/78 Wgt (lb): 180 HR (bpm): 56 BSA (m2): 1.79 m2 Indication: Intraoperative TEE for CABG and MAZE procedure ICD-9 Codes: 786.05, 786.51, 440.0, 424.0 Test Information Date/Time: [2187-11-23] at 09:20 Interpret MD: [Name6 (MD) 1509] [Name8 (MD) 1510], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 1510], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2008AW1-: Machine: [Pager number 14694] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 1.7 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A ratio: 2.00 Findings LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([11-21]+) MR. TRICUSPID VALVE: Mild to moderate [[11-21]+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass 1. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2.Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.There are complex (>4mm) atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild to moderate ([11-21]+) mitral regurgitation is seen. Post Bypass 1. Patient is being A paced and receiving an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Aorta intact post decannulation. Brief Hospital Course: Admitted from ED ruling in for NSTEMI in atrial fibrillation. Underwent cardiac catherization that revealed coronary artery disease. She was treated with medications to control atrial fibrillation. Cardiac surgery was consulted for surgical evaluation. She underwent preoperative workup and [11-23] went to the operating room for coronary artery bypass graft, MAZE, and LAA ligation surgery. She received perioperative vancomycin as she was inpatient preoperatively. See operative report for further details. She was transferred to the ICU for hemodynamic monitoring. In the first 24 hours she was weaned from sedation, awoke neurologically intact, and was extubated. She was started on betablockers and diuretics. On post op day 2 she was transferred to the floor. Physical therapy worked with her for strength and mobility. She continued to make progress and was ready for discharge home with services on post operative day 5. Medications on Admission: Plavix 75 mg once daily Fenlodapine 10 mg daily Triamterene/HCTZ 50/25 Simvastatin 40 mg daily Prilosec 20 mg daily Discharge Medications: 1. 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 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p CABG Atrial Fibrillation s/p MAZE and LAA excision NSTEMI Hypertension Gastric esophageal reflux disease Carotid stenosis s/p right carotid stent Hyperlipidemia Osteoarthritis Venous insufficiency Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) ] in 2 weeks - please call for appointment Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2187-12-17] 4:00 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 9045] Date/Time:[2188-1-15] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1241] Date/Time:[2188-1-30] 1:00 Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Completed by:[2187-11-28]	[ "41071", "41401", "42731", "4019", "2724" ]
Admission Date: [2130-8-7] Discharge Date: [2130-8-17] Date of Birth: [2051-7-10] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 79-year-old male who developed a productive cough 3-4 weeks ago. The cough then became more dry and persistent. He saw his doctor a week before admission. Was given Robitussin and Flonase. Over the three days prior to admission, he noticed increasing dyspnea on exertion. Patient also reported some back pain along with pain around his right scapula. He denies fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or constipation. On admission to the ED, he was 89 percent on room air and was noted to be tachypneic. Respirations were in the 30s. Using his accessory muscles of breathing. He received ceftriaxone and azithromycin. A chest x-ray revealed a large partially loculated right pleural effusion. There is also a slight left pleural effusion. There is no pneumothorax. PAST MEDICAL HISTORY: Atrial fibrillation status post pacemaker placement and on Coumadin. Hypertension. Prostate cancer status post XRT. Osteoarthritis. History of rectal bleeding in [2128]. Mild dementia. Benign prostatic hypertrophy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aricept 5 mg p.o. q.d. 2. Cozaar. 3. Coumadin 1 mg p.o. q.d. 4. Amiodarone 200 mg p.o. q.d. 5. Atenolol 25 mg p.o. q.d. 6. Oxybutynin. 7. Flomax 0.4 mg p.o. q.d. 8. Robitussin. PHYSICAL EXAMINATION: General: He is an older gentleman in mild distress. Vital signs: Temperature is 98.4, heart rate 75, blood pressure 117/52, respirations 36 and labored. Oxygen saturation is 91-94 percent on 3 liters. Skin was diaphoretic. HEENT: He had a normocephalic, atraumatic head. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Sclerae were anicteric. Mucous membranes were dry. Neck was supple with no JVD. Trachea was midline. Cardiovascular: Regular, rate, and rhythm with S1, S2. Lungs had decreased breath sounds at the right base compared to the left. Abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, no rebound tenderness or guarding. Extremities: No cyanosis, no edema, warm with palpable pulses. Neurologic: He was alert and oriented times three. LABORATORIES ON ADMISSION: Chemistry: Sodium is 134, potassium 4.8, chloride is 100, bicarbonate is 21, BUN is 61, creatinine is 2.5. CBC: White blood cells 25.3, hemoglobin is 11.5, hematocrit is 34.5, platelets of 248. Chest x-ray: As above. Urinalysis was normal. Renal ultrasound showed no hydronephrosis and simple cysts in both kidneys. HOSPITAL COURSE: Patient was admitted on [2130-8-7] and taken to the operating room two days later for a right VATS thoracotomy with decortication. The patient tolerated the procedure well with 250 mL of blood loss. After the surgery, he was admitted to the CSRU, where he was extubated and sent to the floor on [2130-8-13]. Patient continued to do well on the floor, where he had adequate pain control and ambulated and voided appropriately. On [2130-8-14], his chest tube was removed without incident, and the following day, the second chest tube was converted to a drain. He was also changed from IV Unasyn to p.o. Augmentin. Patient was discharged on [2130-8-17] to an extended care facility in good condition. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q.d. 2. Tamsulosin 0.4 mg sustained release p.o. h.s. 3. Donepezil hydrochloride 5 mg p.o. q.h.s. 4. Levothyroxine sodium 5 mcg p.o. q.d. 5. Docusate sodium 100 mg p.o. b.i.d. 6. Senna 8.6 mg p.o. b.i.d. as needed. 7. Acetaminophen 325 mg 1-2 tablets p.o. q.[4-25]. prn pain. 8. Olanzapine 2.5 mg p.o. t.i.d. prn agitation. 9. Benzonatate 100 mg p.o. t.i.d. prn cough. 10. Pantoprazole sodium 40 mg sustained release p.o. q.24. 11. Oxycodone/acetaminophen 5/325 1-2 tablets p.o. q.4h. prn pain. 12. Polysaccharide iron complex 150 mg p.o. q.d. 13. Vitamin C 500 mg p.o. b.i.d. 14. Ibuprofen 600 mg p.o. q.6h. 15. Warfarin sodium 1 mg p.o. q.d. 16. Trazodone 25 mg p.o. q.h.s. prn sleep. 17. Metoprolol tartrate 50 mg p.o. b.i.d. 18. Amoxicillin/clavulanic acid 500/125 mg p.o. t.i.d. for 10 days. DISCHARGE PLANS: Patient was instructed to call for follow- up appointment in [1-20] weeks with Dr. [Last Name (STitle) ]. [Name6 (MD) 106489] [Name8 (MD) ], M.D. [MD Number(2) 39921] Dictated By:[Last Name (NamePattern1) 32536] MEDQUIST36 D: [2130-8-17] 11:48:42 T: [2130-8-17] 13:42:00 Job#: [Job Number ]	[ "5119", "5849", "42731", "V5861" ]
Admission Date: [2196-3-28] Discharge Date: [2196-4-2] Date of Birth: [2145-3-31] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 50 year old male with a history of pancreatic cancer status post Whipple procedure in [6-/2194], for ampullary cancer, who presented after demonstrating signs of jaundice, [Male First Name (un) 1658] colored stools PAST MEDICAL HISTORY: 1. Status post Whipple on [2194-7-14] for ampule of Vater cancer. 2. On [7-15], exploratory laparotomy for a postoperative hematoma. 3. Status post chemotherapy with two doses in [2193]. 5. Diabetes mellitus which was diagnosed two weeks prior to admission. MEDICATIONS ON ADMISSION: 1. Prilosec 20 mg p.o. q. day. 2. Celexa 40 mg p.o. q. day. 3. Alprazolam. 4. Glyburide 5. 5. Creon three times a day before meals. ALLERGIES: No known drug allergies. HOSPITAL COURSE: On [2196-3-28], the patient underwent an endoscopic retrograde cholangiopancreatography which was unable to reach to the choledochojejunostomy. An MRCP demonstrated dilated intrahepatic ducts and possible recurrent tumor at the site of the biliary enteric anastomosis and possible partial afferent limb obstruction. On [2196-3-29], the patient underwent percutaneous transhepatic cholangiography which led to a brief episode of transient hypotension and a fever of 100.6 F. The patient was then begun on Ampicillin, Gentamycin and Ceftriaxone immediately post procedure. The patient subsequently defervesced. The patient, throughout the hospital course, underwent a second PTC on [2196-3-31], the pathology of which demonstrated chronic inflammation but no tumor. The patient underwent a third PTC on [2196-4-1], which was a tube study demonstrating contrast exiting from the proximal hole. It was decided that the patient was stable and would return for further management. The tube was capped and the patient was afebrile, tolerating regular diet with stable vital signs on the 13th. The patient was discharged on his home medications, Prilosec, Celexa, Alprazolam, Glyburide and Creon three times a day, and also discharged on: 1. Ciprofloxacin 500 mg p.o. q. day for bacterial prophylaxis. DISCHARGE INSTRUCTIONS: 1. The patient is scheduled to follow-up with Dr. [Last Name (STitle) ] in one week with the capped biliary drain. 2. Dry sterile dressings for p.r.n. drain changes at home. [Known firstname ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 522] MEDQUIST36 D: [2196-4-7] 12:14 T: [2196-4-7] 18:57 JOB#: [Job Number 32054]	[ "25000" ]
Admission Date: [2113-11-3] Discharge Date: [2113-11-13] Date of Birth: [2113-11-3] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 10 day old female, ex-34 [5-12] week gestational age female admitted to the Neonatal Intensive Care Unit at [Hospital1 188] with primary complaints of respiratory distress and prenatally diagnosed neonatal alloimmune thrombocytopenia. The patient's mother is a 31 year old gravida IV, para III woman with past medical history notable for bipolar disorder being treated with Zoloft, Depakote and Risperidone. Prenatal screens as follows: O positive, antibody negative, hepatitis B antigen negative, RPR nonreactive, Rubella alloimmune, GBS status unknown. Estimated date of delivery was [2113-12-10]. The mother had been receiving IVIG since [27] weeks of pregnancy for prenatal diagnosis of neonatal alloimmune thrombocytopenia. There was no ultrasonographic evidence of fetal hemorrhage prenatally. Patient was born via repeat cesarean section under spinal anesthesia. Rupture of membranes at delivery yielding clear amniotic fluid. No intrapartum fever or clinical evidence of chorioamnionitis. Infant was born with good tone and spontaneous cry. Apgars were 8 and 9 at one and five minutes respectively. There was no evidence of cyanosis at birth. PHYSICAL EXAMINATION: On admission included birth weight of 2730 grams, OFC of 31.5 cm, length of 47.5 cm. Vitals as follows: Heart rate 170 beats per minute, respiratory 78 breaths were minute, temperature 98.9 degrees Fahrenheit, SAO2 92 percent on .3 FIO2 with C-PAP plus 6 cm of water. Blood pressure was 65/35 with a MAP of 47. General: Preterm female on radiant warmer in no apparent distress. Head, eyes, ears, nose and throat: AFOF, nondysmorphic, palate intact, OP clear, mild facial bruising, mild caput, nasal C-PAP in place. Respiratory: Clear to auscultation bilaterally, mild coarse breath sounds bilaterally, good air expansion bilaterally, no crackles, no retractions. Cardiac: Regular rate and rhythm, S1, S2 normal, no murmur, well perfused, femoral pulses 2 plus and brisk bilaterally. Abdomen: Soft, not distended, no hepatosplenomegaly, no masses, hypoactive bowel sounds, anus patent. Genitourinary: Normal female genitalia. Neurologic: Appropriate tone on examination, moving all extremities spontaneously. Moro/suck/palmar/plantar reflexes intact. Spine intact. No dimple. No hip click on examination. SUMMARY HOSPITAL COURSE BY SYSTEMS: Respiratory: Patient was placed on C-PAP plus six on FIO2 of room air for the first 48 hours of life. On day of life 3, [2113-11-6] patient was transitioned to room air without problems and remained on room air throughout her hospital course. Patient had no episodes of apnea or bradycardia throughout her hospital course. Cardiovascular: Patient cardiovascularly remained stable throughout hospital course with blood pressures all within normal range. She maintained good perfusion and strong pulses throughout her hospitalization. Fluid, electrolytes and nutrition: Patient was placed on intravenous fluids of 80 cc per kilo per day of D10W for the first 48 hours of life while she was not fed. On day of life 3, [2113-11-6], patient was started on Special Care Formula at 20 kilocals per ounce and tolerated initiation of feeds without problems. By day of life 4 patient was P.O. ad lib feeding up 150 cc per kilo per day with no signs of intolerance at full feeds. At time of discharge the patient was on the same formula of Special Care 20 kilocals per ounce at full feeds of 150 cc per kilo per day. At time of discharge patient's weight is 2620 grams. Gastrointestinal: Patient had hyperbilirubinemia at birth with initial bilirubin levels of 14.5 mg per dl at which time double photo therapy was initiated and continued until day of life 5, [2113-11-8] at which time her bilirubin had dropped to 8.0 mg per dl. Photo therapy was stopped with a rebound bilirubin level of 6.0 mg per dl on day of life 6, [2113-11-9]. Hematology: Patient has a prenatally diagnosis of neonatal alloimmune thrombocytopenia for which the mother had received intravenous infusions weekly since [27] weeks of pregnancy. The patient's platelet counts have been normal and stable throughout her hospital course here with her initial platelet count being 266 on [2113-11-6]. On day of life number five, [2112-11-7] her platelet count was 316. On [2113-11-10] her platelet count was 470. No further platelet counts have been checked. She is recommended to receive a follow up CBC one week after discharge. Neurology: The patient has been neurologically normal throughout her hospital course and did not receive a screening head ultrasound. Health Care Maintenance: Prior to discharge the patient did receive a hepatitis B vaccination. She also passed her hearing screening and her car seat test. State screening was sent on day of life number two. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: [Doctor First Name 56762] [Last Name (NamePattern5) 56763], MD [First Name8 (NamePattern2) ] [Last Name (Titles) 1411] Medical Office. CARE RECOMMENDATIONS: Feeds at discharge include Special Care 20 kilocals per ounce P.O. ad lib. No medications. Car seat positioning screening passed. State Newborn Screening sent. Immunizations received include hepatitis B vaccination. This patient does not quality for Synagis prophylaxis. Follow up appointments include follow up with pediatrician two days after discharge. DISCHARGE DIAGNOSES: 1. Respiratory distress. 2. Neonatal alloimmune thrombocytopenia. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) 56760] MEDQUIST36 D: [2113-11-13] 14:22:51 T: [2113-11-13] 15:04:02 Job#: [Job Number 56764]	[ "7742", "V053" ]
Admission Date: [2119-1-17] Discharge Date: [2119-3-31] Date of Birth: [2073-3-6] Sex: M Service: SURGERY Allergies: Penicillins / Zofran / Toradol / Phenobarbital / Trazodone / Compazine / Oxycodone Attending:[First Name3 (LF) 695] Chief Complaint: encephalopathy Major Surgical or Invasive Procedure: Blood transfusion Paracentesis x2 ([1-17], [1-23]) [2119-3-14] liver transplant History of Present Illness: 45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS done on [2119-1-5] who presented to the OSH yesterday with altered mental status. The patient was treated with lactulose at the OSH with some improvement in his encelpalopathy. There was concern that there was a problem with the TIPS and he was transferred to [Hospital1 18] for further workup. Denied chest pain, shortness of breath, fevers, chills. He reports abdominal pain slightly worse than his baseline. No melena or BRBPR. . Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5, Ammonia 330, Na 132. Past Medical History: # L4,L5,S1 fusion # Decompensated liver cirrhosis [1-28] to HCV, HBC, and alcohol c/b encephalopathy and ascites # Chronic pancreatitis # Non bleeding grade 2 esophageal varices in [4-3] # GERD-Barrett's esophagus # COPD # s/p incarcerated umbilical hernia repair [11-3], recent admission on [2118-12-26] to [2118-12-30] for concern for cellulitis around his surgical incision, started on clindamycin then vanc then bactrim for a total course of 7 days #OLT [2119-3-14] Social History: Married, but separated, has 3 children. Lives with roommates - limited support. Smokes a pack every 3 days. Quit cocaine and heroine in [2114]. Quit EtOH in [2101]. Family History: Family Hx: No known family history of hepatitis or liver disease Physical Exam: VS: 97.5 95/69 90 12 93%RA Gen: awake, oriented x 2 (able to state month and year, stated he was at B+W's) HEENT: NC/AT. PERRL, EOMI, MMM. OP clear. Neck: Supple, no LAD. CV: RRR, S1, S2 no m/r/g. Chest: CTAB no wheezes or crackles. ABD: Distended, + tense ascites, TTP diffusely Ext: WWP, no edema. + asterixis Pertinent Results: Upon admission, a CT of the abd/pelvis was done [2-1] demonstrating: 1. Large amount of ascites. Tiny amount of high-density fluid layers in the deep pelvis consistent with blood not changed from prior study at 2:13 a.m. today, [2119-2-1]. No subcapsular hepatic hematoma. 2. Small subcentimeter focus of arterial enhancement of hepatic segment VIII becomes isodense to liver parenchyma on the delayed phase. This is more conspicuous compared to [2118-12-27] and [2118-11-9]. Finding is non- specific but given cirrhosis a small focus of hepatocellular carcinoma cannot be excluded. Continued imaging surveillance is recommended. 3. Cirrhosis with splenomegaly indicating portal hypertension. 4. Patent TIPS. On [2-25] a ruq u/s was performed showing a patent TIPS with increased velocities, little changed. Head CT was negative and EEG was abnormal with findings consistent with moderate encephalopathy . There were no epileptiform features and no seizure activity. . [2-27] ct chest: 1. Abnormality in the right upper lobe demonstrates marked panlobular emphysematous changes. No evidence of pneumothorax. 2. Atelectasis within the right upper and bilateral lower lobes. No evidence of airspace consolidation. 3. Limited images through the upper abdomen show a large volume ascites, TIPS, and splenomegaly. Brief Hospital Course: Patient initially transfered from OSH with encephalopathy and concern for clotted TIPS. TIPS initially placed [2119-1-5]. Ultrasound showed patent TIPS and his mental status improved with lactulose and regular bowel movements. The patient was tapped for a large amount of ascites and it was negative for SBP. He continued to have waxing and [Doctor Last Name 688] encephalopathy, He required admission to the MICU twice for unresponsiveness, both times which he was intubated for airway protection, and given additional lactulose. His head CT on first MICU admission was negative for any acute process such as intracranial bleed. EEG findings were consistent with encephalopathy without seizure activity. An attempted Re-Do TIPS to divert blood through portal veins and not the TIPS was attempted, but technically unsuccessful and complicated by small hemoperitoneum that required transfusion but otherwise self-limited. He finally had successful TIPS revision on [2119-2-6]. He continued to receive therapeutic paracentesis. Ultrasound initially showed patent TIPS but subsequent ones showed increased velocities concerning for stenosis. He was restarted on diuretics because his sodium was improved from prior admissions, but these were held for worsening renal function. He was continued on 1500ml fluid restriction and Cipro for SBP prophylaxis. CVVHD was started. A CXR showed new right sided infiltrate and the patient had moderate growth of MRSA from his sputum with sparse growth of 2 colonies of GNR. He was treated with vancomycin and zosyn. On [3-14] he underwent Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct-common bile duct anastomosis with no T-tube, branch patch (recipient) to celiac patch (donor)hepatic artery anastomosis. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Please see operative report for further details. EBL was 2 liters replaced with PRBC, plt, FFP, cryo and cellsaver. Two JPs were placed. He was maintained on CVVHD during the case. He received HBIG intraop and on pod [12-31]. HBsAb titers were greater than 450. HBIG IM was given on pod 7 and 14. Entecavir was started immediately postop. This dose was renally dosed. Postop, he was transferred to the SICU per protocol. He was extubated on POD 2. CVVHD continue for ~ 2 days then lasix was started. He received prbc/plt/ffp on pod 0. Labs were monitored q 6 hours. US of the liver demonstrated difficulty detecting the expected hepatic arterial supply to the left lobe. Otherwise U/S was normal. LFTs trended down. The medial JP was removed on pod 5. The lateral JP continued to drain large amounts of ascites. Outputs were as high as 4.5liters per day. He received IV fluid replacements and albumin for JP outputs. Of note, creatinine started trending up off CVVHD as high as 4.3 from 2.7. Urine output averaged 1000-1200cc/day. Nephrology was consulted. It was felt that he had ATN on resolving hepatorenal syndrome. Fluconazole dose was renally dosed to 200mg qd as this was felt to increase the prograf level. Creatinine slowly trended down to 2.9. Hyperkalemia was a persistent problem that required treatment with insulin, dextrose, lasix and kayexalate. Hyperkalemia improved with improved renal function. A low potassium diet was ordered. The lateral JP was removed on [3-29] for outputs of 600cc. The transplant incision remained clean, dry and intact. His abdomen appeared a little distended PT evaluated him and initially recommended rehab, but he improved significant and it was felt that he would be safe for discharge to home. He was also started on insulin for hyperglycemia. Glargine and humalog sliding scale were given. Immunosuppression consisted of cellcept 1 gram [Hospital1 ], steroids were tapered to prednisone 20mg qd per protocol, and prograf was started on pod 1. Prograf was decreased to 2.5mg [Hospital1 ] per trough levels of [8-8].2. VNA services were arranged for home. Medications on Admission: 1. Morphine 30 mg SR [Hospital1 ] 2. Lactulose 30ML PO TID 3. Pantoprazole 40 mg Q24H 4. Folic Acid 1 mg DAILY 5. Oxycodone 5 mg Q6H as needed for Pain. 6. Colace 100 mg twice a day 7. Ciprofloxacin 250 mg Q24H 8. Entecavir 0.5 mg DAILY 9. Hexavitamin Daily --Of note, has been off diuretics since last admission [1-28] hyponatremia . Allergies: PCN, zofran, toradol, phenobarbital, trazadone Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY (Daily). Disp:50 ml Refills:2 11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:0 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 17. Insulin Syringes Low dose syringes for qid injections 25 guage needle supply: 1 box Refill: 1 Discharge Disposition: Home with Service Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: ESLD from HCV/HBV/ETOH cirrhosis Hepatic encephalopathy Hepatorenal syndrome ARF, improving malnutrition Chronic back pain Barrett's esophagus GERD COPD s/p incarcerated umbilical hernia repair Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take any of your medications, weight loss, jaundice, abdominal incision appears red, bleeds or has drainage. Labs every Monday and Thursday Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2119-4-5] 9:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2119-4-12] 9:40 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2119-4-12] 10:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2119-3-31]	[ "5845", "51881", "5070", "2761", "2767", "496", "40390", "5859", "53081", "2859", "311" ]
Admission Date: [2198-3-8] Discharge Date: [2198-3-23] Date of Birth: [2137-2-6] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2198-3-8]: OSH PCI: Prox LAD 95% occlusion, diffuse disease in Circumflex, 100% ProxRCA lesion, s/p POBA, complicated by dissection of the RCA, covered with BMS. [2198-3-19] 1. Urgent coronary artery bypass graft x5: Left internal mammary artery to left anterior descending artery; saphenous vein graft to diagonal obtuse marginal and a sequential saphenous vein grafting to posterior left ventricular branch and the posterior descending artery. 2. Endoscopic harvesting of the long saphenous vein. 3. Mitral valve repair with size #30 [Company 1543] CG Future Band. History of Present Illness: Mr. [Known lastname 59124] is a 61 y.o. male without a known past medical history who presented to [Hospital6 ] with intermittent persistent substernal chest pressure assocaited with epigastric pain, nausea/vomiting x 1 day. Patient was in his usual state of health when he began to notice these symptoms the evening prior to presentation. Initial ECG showed ST elevations in the inferior leads with ST depressions in V1-V4. He was started on a heparin gtt, brought emergently to the cath lab, loaded with prasugrel on the table. Intraprocedurally, was given infusion of bivalirudin. Noted to have prox LAD 95% occlusion, diffuse disease in Circumflex, 100% ProxRCA lesion, s/p POBA, complicated by dissection of the RCA, covered with BMS. IABP was placed. Right heart cath was performed, showing CI 2.4, SVR 1243, PCWP 17. Patient was transferred to [Hospital1 18] for evaluation for urgent CABG. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Coronary Artery Disease, s/p CABG and stent Diabetes Dyslipidemia Hypertension Social History: - Arrived in the U.S. one week ago. no ETOH or tobacco Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION . GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2198-3-23] 05:00AM BLOOD WBC-10.9 RBC-3.79* Hgb-11.2* Hct-31.6* MCV-83 MCH-29.4 MCHC-35.3* RDW-14.1 Plt Ct-201 [2198-3-22] 04:50AM BLOOD WBC-11.6* RBC-3.58* Hgb-10.6* Hct-29.7* MCV-83 MCH-29.7 MCHC-35.8* RDW-14.1 Plt Ct-143* [2198-3-23] 05:00AM BLOOD Glucose-99 UreaN-24* Creat-0.8 Na-138 K-4.3 Cl-99 HCO3-30 AnGap-13 [2198-3-22] 04:50AM BLOOD Glucose-98 UreaN-18 Creat-0.7 Na-136 K-4.1 Cl-99 HCO3-29 AnGap-12 ADMISSION EKG: Sinus rhythm. A-V conduction delay. Left axis deviation. Left atrial abnormality. Possible right atrial abnormality. Left ventricular hypertrophy. Inferior wall myocardial infarction with 1-2 millimeters of ST segment elevation in the inferior leads. One millimeter of sloping ST segment depression in high lateral leads. T wave inversions inferolateral leads. No previous tracing available for comparison. . OSH CATH [3-8]: prox LAD 95% occlusion, diffuse disease in Circumflex, 100% ProxRCA lesion, s/p POBA, complicated by dissection of the RCA, covered with BMS. IABP was placed. Right heart cath was performed, showing CI 2.4, SVR 1243, PCWP 17. . ECHO [3-8]: RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderately depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV chamber size. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild to moderate ([2-11]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %) secondary to severe inferior posterior hypokinesis/akinesis; apex is hypokinetic as well. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([2-11]+) mitral regurgitation is seen. There is no pericardial effusion. . CXR [2198-3-8]: Lungs clear without significant effusion or pneumothorax. Heart size and pulmonary vascularity is normal. Apparent RUL opacity is likely superposition of venous and osseous structures. A balloon pump marker is faintly seen superimposed over the T6 spinous process, pulled back roughly 4cm compared wtih prior, now at the level of the carina. Intra-op TEE Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is moderately depressed (LVEF= 30 - 35 %) with marked inferior and apical HK and moderate global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) central mitral regurgitation is seen. Mitral annulus is 4.1 cm. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on low-dose Epinephrine. Biventricular systolic fxn is mildly improved, with EF now 35 - 40%. There is a mitral ring repair with trace MR and no leak. Residual mean gradient is 4.5 mmHg and area is 2.8 sq cm. No AI. Aorta intact. Brief Hospital Course: Medical Course: 61 y/o Male with no known past medical history presenting with inferior STEMI s/p POBA to 100% prox RCA lesion, small dissection with BMS placed, prox LAD lesion, on IABP. . # STEMI: pt initially presenting to OSH with chest pain, found to have inferior STEMI. s/p POBA to 100% prox RCA lesion, small dissection with BMS placed, prox LAD lesion. He was placed on a balloon pump and tranferred to [Hospital1 18] for CABG eval and for repair of dissection. He was evaluated by CT surgery who planned for surgery on [3-16]. He remained stable on the balloon pump which was subsequently d/c'd on HD#2 given stable pressures. He was continued on ASA, plavix, atorva 80mg, and heparin ggt with metoprolol added in once after BPs remained stable. Of note, he had TTE which showed EF 30% with hypokinesis in the inferior posterior region, with 2+ MR. [Name14 (STitle) 67294] was followed and downtrended. . # Pump: Pt noted to have EF 30% on echo with severe inferior hypokinesis. Clinically patient euvolemic, normal cardiac index, slightly elevated wedge, and no evidence of cardiogenic shock. Urine output was appropriate both on and off the pump. . # RHYTHM: NSR OSH cath lab noted 2nd degree AV block, however no recording of this and pt remained stable on tele . # Social situations: Social work consult called. Multi-family members giving conflicting report of their relationship to patient. HPC now determined to be nephew. Cardiac Surgery Course: The patient was brought to the operating room on [2198-3-16] where the patient underwent CABG with Dr. [First Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: None Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for BMS. Disp:30 Tablet(s) Refills:2 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary Artery Disease, s/p CABG and stent Diabetes Dyslipidemia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ lower extremity edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Please come to [Hospital Ward Name 121] 6 for a wound check appointment on Thursday [2198-3-29] at 11am [Telephone/Fax (1) 3071] The following appointments have been made for you: Cardiac Surgeon: DR. [First Name8 (NamePattern2) ] [Name (STitle) ] [2198-4-23] 1:45 Phone:[Telephone/Fax (1) 170] Cardiologist: Dr. [Last Name (STitle) 4922], [Telephone/Fax (1) 2205] [2198-4-12], 12:30pm call [Telephone/Fax (1) 10676] to register prior to your appt. w Dr. [Last Name (STitle) 4922] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2198-3-23]	[ "51881", "41401", "4240", "4280", "25000", "2724", "4019" ]
Admission Date: [2177-9-14] Discharge Date: [2177-9-18] Date of Birth: [2100-1-30] Sex: M Service: [Hospital Unit Name 196] Allergies: Pollen Extracts / Carvedilol Attending:[First Name3 (LF) 2704] Chief Complaint: Left Sided Substernal Chest Pain radiating to arm and jaw. Major Surgical or Invasive Procedure: Per-cutaneous Cardiac Catheterization with Drug-Eluting Stent of Mid Left Anterior Descending Artery. History of Present Illness: Pt is a 77 yo M with a h/o dilated cardiomyopathy (EF 20%), Afib on coumadin, s/p BiV PCM secondary to complete heart block, DM, CRI (baseline 1.4-1.7), PVD s/p superficial femoral artery stent transferred from OSH for ST elevation MI. Pt awoke this am with Left sided substernal chest pain raditating to his arm and neck lasting 4 hours. Sub-lingual NTG was given by EMS and reduced his pain from [11-23] to [5-24]. His ECG at [Hospital1 ] demonstrated ST elevation in leads V2-V4, on a background of biventricular pacing. He was hemodynamically-stable, but had exam findings of heart failure. He was transferred to [Hospital1 18] for emergency catheterization for acute anterior [Hospital1 ]. Past Medical History: Dilated Cardiomyopathy (EF 20%), Afib (coumadin), s/p BiVentricular PCM secondary to Complete Heart Block, DM, CRI (1.4-1.7), PVD s/p Superficial Femoral Artery stent, HTN, h/o TIA, COPD, Right Internal Carotid Artery w/ 60-69% stenosis, hypercholesterolemia Social History: The patient lives alone. He is a retired Biochem teacher. He is a former cigarette smoker. He does not drink alcohol. Family History: Father died secondary to a cerebrovascular accident. Physical Exam: 158/68 HR 76 Wt 88 kg Gen: NAD HEENT: MMM. Anicteric. PERRL. Neck: JVD to mid ear at 0 degrees Lungs: CTAB ant/lat CV: RRR. Nl S1S2. No M/R/G. No S3S4 Abd: obese. soft. NT/ND. +BS Ext: no palpable DP pulses b/l. L LE w/ 3+ pitting edema, R LE w/ 1+ pitting edema Pertinent Results: [2177-9-14] 08:18PM CK(CPK)-4051* CK-MB-346* MB INDX-8.5* GLUCOSE-314* UREA N-25* CREAT-1.5* SODIUM-137 POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 [2177-9-14] 01:46PM CK(CPK)-4132CK-MB-348 MB INDX-8.4* cTropnT-14.11* CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.9 CHOLEST-88 TRIGLYCER-83 HDL CHOL-36 CHOL/HDL-2.4 LDL(CALC)-35 WBC-12.2* RBC-4.60 HGB-13.4* HCT-38.6* MCV-84 MCH-29.0 MCHC-34.7 RDW-14.3 PLT COUNT-292 * [2177-9-15] Echo: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (ejection fraction 20 percent) secondary to severe global hypokinesis with some relative preservation of the basal and midventricular segments of the inferior and posterior walls. There is no ventricular septal defect. The right ventricular cavity is dilated. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic valve leaflets (3) are mildly thickened but not stenotic. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. * CT HEAD W/O CONTRAST [2177-9-15] 12:28 PM 1. No evidence of acute intracranial hemorrhage. 2. Evidence of previous infarcts in the posterior right temporal and left occipital lobes, as well as chronic small vessel ischemic changes. 3. There is no evidence of acute territorial infarct. * Cath [2177-9-14] 1. Two vessel CAD. 2. Acute anterior myocardial infarction, terminated by primary PCI. 3. Markedly elevated filling pressures and pulmonary artery hypertension. 4. Congestive heart failure. * CXR Portable [2177-9-14] Congestive heart failure with interstitial pulmonary edema. Brief Hospital Course: Pt is a 77 yo M with a h/o dilated cardiomyopathy (EF 20%), Afib on coumadin, s/p BiV PCM secondary to complete heart block, DM, CRI (baseline 1.4-1.7), PVD s/p superficial femoral artery stent transferred from OSH for [Month/Day/Year ]. 1. [Name (NI) ] - Pt underwent a cardiac cathederization on [2177-9-14] revealing a totally occluded LAD after a small first diagonal branch. Two drug-eluting stents were placed in the proximal LAD with residual distal occlusion. Pt was started on Integrelin gtt, Plavix, [Date Range ] 325, and Lipitor 40. Ace-Inh was restarted and titrated to lisinopril 10 [Hospital1 ]. His B-Blocker was restarted on the day of discharge. BP meds were weaned back given his recent likely CVA (described below) and goal was for SBP>130. 2. CHF - DCM w/ PCWP 40 at cardiac catherization. History of bivent pacer with EF of 15%. TTE 2 days post revascularization showed EF 20% w/ severe global hypokinesis. He was diuresed with Natrecor x24 hours and remained euvolemic off of the drip for >72 hours prior to discharge. He will continue lasix at rehab/home on a prn basis. 3. Probable CVA - on HD#2 patient developed acute onset of mental status changes, primarily involving word finding difficulties and slow/slurred speech. He was evaluated by the stroke team who also noted mild weaknees in right UE. Lysis was considered, however, given his recent cath and elevated PT from anticoaggulation for Afib, this was felt not to be an option. He had two negative CT of the Head. An MRI was contraindicated given his pacemaker. He will need to have a CTA of the brain sometime in the futuer as an outpatient. He mental status gradually improved during the hospitalization, but never returned to baseline. He was seen by speech and swallow and felt to have no acute needs. Cartoid U/S was not repeated given examination in [1-16]. Although not definitive, it was felt that he had a minor ischemic CVA as a complication of his MI. 4. Afib- Heparin started HD#2, turned off after MS changes but restarted once CT Head w/o evidence of bleed. Overlapped with Coumadin with Goal INR 2.0-3.0. His INR was 3.3 on date of discharge and he was instructed to hold coumadin until INR <3.0. 5. ARF on CRF - creat bumped from 1.5 -> 2.1 with diuresis. Once stopped, creat normalized at 1.6 (baseline). 6. COPD - stable on MDIs. Likely partially responsible for elevated pulmonary pressures at catherization. 7. Dispo - PT worked with patient on at least one occasion and felt he was not safe for home. He was stubborn and initially refused rehab, but eventually was agreeable. He will be d/c'd to [Hospital1 ] TICU where his Cardiologist will be able to participate in his care. Medications on Admission: Coumadin, Dig 0.25 qd, lisinopril 10 mg po [Last Name (LF) ], [First Name3 (LF) ] 81 mg po qd, lipitor 10 mg po qd, glipizide 10 mg po qd, zyrtec, coreg 3.125 mg pi [Hospital1 ], albuterol IH prn Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day) for 300 days. Disp:300 Tablet(s) Refills:0 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO Please take if your weight increases by 2 lbs in one day. Disp:30 Tablet(s) Refills:2 11. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please hold on evening of [9-18] and recheck in am. Goal INR [3-18]. . Discharge Disposition: Extended Care Facility: [Hospital1 ] - [Location (un) 47] Discharge Diagnosis: Myocardial Infarction with Stent of Left Anterior Descending Artery. Discharge Condition: Fair. Discharge Instructions: Please call your primary care physician or return to the hospital if your chest pain recurs or any other problems arise. Followup Instructions: 1. Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] Where: [Name12 (NameIs) ] [Name12 (NameIs) 3628] Date/Time:[2177-10-2] 9:00 2. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2177-10-2] 10: 3. Follow up appointment with Dr. [Last Name (STitle) 5051]. [2177-10-10] at 4:30 PM. 4. Thurs [2177-10-2] at 1:30 PM for Nuclear Stress Test at [Hospital ] Hospital. Please do not eat or drink 4 hours prior to the test. Please do not have caffeine 24 hrs prior to the test. Please call [Telephone/Fax (1) 6256] with questions.	[ "42731", "496", "4280", "5849", "40391" ]
Admission Date: [2129-6-5] Discharge Date: [2129-6-6] Date of Birth: [2059-2-5] Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 618] Chief Complaint: IPH. Major Surgical or Invasive Procedure: extubated History of Present Illness: Mr. [Known lastname 69580] is intubated and sedated; history obtained from family. Mr. [Known lastname 69580] is a 70 y/o man with PMH significant for "small strokes" per the family (for which is is on Aggrenox) and HTN, who was transferred from OSH for IPH. He awoke this morning and noted his left hand was swollen, but was otherwise in his usual state of health. Around 3PM this afternoon, he was eating dinner with his family, when he coughed and suddenly developed left sided weakness with slurred speech. He was brought to OSH ([Hospital3 ]), and found to have 8.6 x 5.8 cm right basal ganglia hemorrhage with intraventricular extenstion. He was intubated and tranported to [Hospital1 18] for further care. In the ED, he was started on Nicardipine gtt for HTN as well as Propfol gtt. He was assessed by Neurosurgery, who thought that the hemorrhage was already too devastating that any intervention would be futile. Past Medical History: -"small strokes" per family -HTN Social History: Unable to obtain from patient as he is intubated Family History: Unable to obtain from patient as he is intubated Physical Exam: At admission: Vitals: P: 75 BP: 178/84 vent CMV mode General: intubated, sedated HEENT: ET tube in place Pulmonary: anterior lung fields cta b/l Cardiac: RRR, S1S2 Abdomen: nondistended Extremities: warm, well perfused Examined off sedation x 3 min. Neurologic Exam: No eye opening. No commands. No response to nasal tickle. Right pupil 4 mm and nonreactive. Left pupil 2 mm and nonreactive. No Doll's eyes. Right corneal is present. Left corneal is absent. Does not blink to threat. + cough/gag. No spontaneous movement. Extensor posturing in UE b/l to nailbed pressure. He withdraws LLE to nailbed pressure. Triple flexion of RLE to nailbed pressure. Left patellar reflex is 2+; unable to elicit remainder of reflexes. Extensor plantar response L>R. At discharge: deceased Pertinent Results: [2129-6-5] 06:04PM BLOOD WBC-13.2* RBC-4.07* Hgb-12.8* Hct-37.5* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.0 Plt Ct-261 [2129-6-5] 06:04PM BLOOD PT-11.6 PTT-25.7 INR(PT)-1.1 [2129-6-5] 06:04PM BLOOD Fibrino-303 [2129-6-5] 06:04PM BLOOD UreaN-20 Creat-0.9 [2129-6-5] 06:04PM BLOOD Lipase-40 [2129-6-5] 06:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2129-6-5] 06:54PM BLOOD Type-ART Temp-35.9 Rates-14/ Tidal V-550 FiO2-50 pO2-137* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2129-6-5] 06:04PM BLOOD Glucose-180* Na-132* K-5.2* Cl-100 calHCO3-23 [2129-6-5] 06:04PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.019 [2129-6-5] 06:04PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2129-6-5] 06:04PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 [2129-6-5] 06:04PM URINE CastHy-11* [2129-6-5] 06:04PM URINE Mucous-OCC [2129-6-5] 06:04PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CXR: IMPRESSION: ET and NG tubes positioned appropriately. Opacity at the left lung base likely reflects atelectasis, aspiration, and effusion. NCHCT: IMPRESSION: 1. Massive right cerebral hematoma with 17 mm of leftward shift with subfalcine and early downward transtentorial herniation. Obstructive hydrocephalus and occipital [Doctor Last Name 534] entrapment. Further correlation should be made once prior study is uploaded for comparison. 2. Paranasal sinus disease and oropharyngeal and nasopharyngeal aerosolized material, likely related to recent intubation. Brief Hospital Course: The patient was transferred here from [Hospital6 3105] for evaluation of IPH with intraventricular spread. He had been intubated prior to transfer. A family meeting was held with his wife and children. Given that this was a devastating hemorrhage, the family came to the decision to extubate and focus care on comfort measure. He was extubated at approximately 11pm [2129-6-5]. He passed away at 12:10 pm on [2129-6-6] with his wife and children at bedside. His wife declined an autopsy. The medical examiner waived an autopsy as well. Medications on Admission: -Vicodin 5mg-500mg prn -Lisinopril 2.5 mg daily -Celexa 10 mg daily -Aggrenox 200mg-25 mg [Hospital1 ] -Valium 5 mg prn -Vytorin 10mg-40mg daily -Celebrex 200 mg daily -Tramadol 50 mg prn -Lovaza 2 grams [Hospital1 ] -Percocet 5mg-325 mg prn -Avodart 0.5 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "4019" ]
Admission Date: [2164-8-20] Discharge Date: [2164-8-23] Date of Birth: [2119-8-26] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1283] Chief Complaint: atypical chest pain and palpitations with exertion Major Surgical or Invasive Procedure: [2164-8-20] Minimally Invasive Mitral Valve Repair History of Present Illness: 46 yo female with know history of MR since [2147], followed by serial echos. She has atypical chest pain and palpitations with exertion and is referred for surgical evaluation by Dr. [Last Name (STitle) 1290]. Echo in [4-12] showed mild LVH, 4+MR, trace TR and LVEF 76%. ETT done in [4-12] showed no evidence of ischemia at stress level and EF 65-75%. Past Medical History: migraines [Month/Day (1) ] s/p breast lumpectomy for benign mass mitral regurgitation Social History: lives with husband and 2 kids, homemaker, rare use of ETOH, and has never smoked Family History: non-contrib. Physical Exam: 133/78 R, 134/80 L, 72 SR, 5'6", 133 # pre-op exam: NAD, benign nevi HEENT in remarkable, and teeth in good repair neck supple with no bruits RRR grade [2-10]/ 6 SEM with diastolic rumble lungs CTAB abd soft, NT, ND with + BS extrems warm, no c/c/e with 2+ bilat fem, DP/PT pulses, and no varicosities neuro grossly intact without focal deficits Pertinent Results: [2164-8-22] 07:00AM BLOOD WBC-8.6 RBC-2.76* Hgb-8.6* Hct-24.7* MCV-90 MCH-31.0 MCHC-34.7 RDW-13.4 Plt Ct-128* [2164-8-22] 12:55PM BLOOD Hct-25.4* [2164-8-22] 07:00AM BLOOD Plt Ct-128* [2164-8-21] 03:44AM BLOOD Fibrino-210# [2164-8-22] 07:00AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.0 Cl-110* HCO3-26 AnGap-8 [2164-8-21] 03:44AM BLOOD Calcium-7.6* Mg-1.4* [2164-8-21] 04:15AM BLOOD freeCa-1.21 cath [7-13]: MVP with 4+ MR, dil LA, normal cors Brief Hospital Course: Admitted [8-20] and underwent a minimally invasive mitral valve repair with a 26 mm annulplasty band by Dr. [Last Name (STitle) 1290]. Transferred to the CSRU in stable condition on neo, epinephrine and propofol drips. Extubated later that evening in SR, alert and oriented, off all drips the following morning. Chest tubes removed, and transferred to floor. Started aspirin therapy. Some ecchymosis present in area of right thoracot. incision, but continued to do well on the floor, immediately increasing her level of activity and ambulation. Restarted topamax and using toradol for pain management. On day of discharge, POD #3, 107/59, SR 74, RR20, sat 96% RA, incisions clean, dry and intact, wt. 64.4 kg. Discharged home with VNA services in stable condition. Medications on Admission: topamax 25 mg [Hospital1 ] maxalt 10 prn clindamycin prn dental procedures Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. 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 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:30 Tablet(s) Refills:2 7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: MR [First Name (Titles) ] [Last Name (Titles) 61640] headaches R Breast Lumpectomy s/p min. inv. mitral valve repair Discharge Condition: Good. Discharge Instructions: Shower, wash incision with soap and water and pat dry. No baths, lotions, creams or powders. No lifting more than 10 pounds or driving until follow up with surgeon. Call for fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [Last Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 61641] 2 weeks Completed by:[2164-9-5]	[ "4240" ]
Admission Date: [2183-1-15] Discharge Date: [2183-2-10] Date of Birth: [2137-5-17] Sex: M Service: MEDICINE Allergies: Zoloft Attending:[First Name3 (LF) 10293] Chief Complaint: Hypotension in the setting of decompensated liver disease Major Surgical or Invasive Procedure: Arterial line placement [2183-1-15] Right internal jugalar line [2183-1-16] History of Present Illness: 45M h/o EtOH cirrhosis c/b massive ascites, EtOH cardiomyopathy s/p AICD placement, and PUD c/b GIB s/p EGD is transferred from an OSH with hypotension in the setting of decompensated liver disease. Briefly, after undergoing scheduled large volume paracentesis (6L), he was admitted to [Hospital3 ] on [2183-1-10] with confusion accompanied by ammonia of 64, with some improvement in mental status following lactulose administration. In light of elevated Cr to 2-2.4 on admission, up from 1-1.2 at baseline, diuretics were held. Hospital course was also complicated by persistent hyponatremia. When he developed SBP to 70s accompanied by low-grade fever, shortness of breath, progressive abdominal pain/distention, lethargy, and bandemia earlier today, he was transferred to the OSH MICU, where he received 500 cc IVNS and albumin 12.5 g x2, with improvement in SBP to 80s without pressor requirement. Empiric ceftriaxone 1g x1 and vancomycin 1g x1 were administered prior to diagnostic paracentesis, which revealed 43 wbc. On arrival to the MICU, he was minimally conversant, but somnolent and unable to provide detailed history. He endorses minimal shortness of breath coupled with nonproductive cough, as well as non-bloody emesis just prior to arrival. He denies pain in his abdomen or elsewhere or bloody/tarry stools. Past Medical History: EtOH cirrhosis c/b diuretic-resistant ascites requiring weekly large volume paracentesis EtOH cardiomyopathy (EF 30% on TTE in [11-28]) s/p AICD placement PUD c/b GIB, now s/p EGD Gastic Bypass Social History: - Tobacco: Endorses previous tobacco use; now quit. - Alcohol: Per OSH notes, last drink on [2183-8-28]. Family History: Unknown. Physical Exam: Physical Exam on admission: Vitals: 95 80 78/47 16 100% on 5LNC General: Alert, oriented x3, somnolent in no acute distress HEENT: Sclera anicteric, MM dry, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, distant heart sounds Lungs: Rhonchi/wheeze in anterior fields bilaterally Abdomen: Non-tender, tensely distended, +fluid wave Ext: Thready pulses throughout, no clubbing, cyanosis or edema, positive asterixis Neuro: AOx3, somnolent, but minimally conversant and following commands, weak UE grip bilaterally MSK: UE proximal muscle wasting bilaterally Skin: Few scattered spider angiomata, multiple scattered excoriations overlying U/LE bilaterally, minimal palmar erythema, no abdominal caput Physical Exam on discharge: 98.5 103/74 88 18 98%RA BS: 199, 169, 201 GENERAL: cachectic appearing man, AOx3, no asterixis HEENT: Sclera anicteric. PERRL, EOMI. CARDIAC: RRR no m/r/g PULM: CTAB. ABDOMEN: Distended and tense, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ [Location (un) ] bilaterally to knees. NEURO: difficulty with concentration, CNII-XII grossly intact no apparent focal lesions, no asterixis, intermittently combative Pertinent Results: Labs on admission: [2183-1-15] 08:31PM BLOOD WBC-3.8* RBC-3.93* Hgb-11.0* Hct-32.5* MCV-83 MCH-28.0 MCHC-33.9 RDW-15.5 Plt Ct-114* [2183-1-15] 08:31PM BLOOD Neuts-72.2* Bands-0 Lymphs-21.6 Monos-5.1 Eos-0.7 Baso-0.3 [2183-1-16] 02:10AM BLOOD PT-21.0* PTT-60.2* INR(PT)-2.0* [2183-1-15] 08:31PM BLOOD Glucose-163* UreaN-40* Creat-3.0* Na-125* K-5.0 Cl-97 HCO3-17* AnGap-16 [2183-1-15] 08:31PM BLOOD ALT-33 AST-35 LD(LDH)-251* CK(CPK)-39* AlkPhos-109 TotBili-0.3 [2183-1-15] 08:31PM BLOOD CK-MB-6 cTropnT-0.06* [2183-1-16] 02:10AM BLOOD CK-MB-5 cTropnT-0.04* [2183-1-15] 08:31PM BLOOD Albumin-2.6* Calcium-8.0* Phos-5.4* Mg-1.7 [2183-1-18] 05:50AM BLOOD Vanco-25.9* [2183-1-15] 09:32PM BLOOD Type-ART pO2-32* pCO2-42 pH-7.24* calTCO2-19* Base XS--9 Intubat-NOT INTUBA [2183-1-15] 08:43PM BLOOD Lactate-3.0* [2183-1-15] 11:44PM BLOOD freeCa-1.08* [2183-1-16] 02:10AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2183-1-16] 02:10AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2183-1-16] 02:10AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [2183-1-16] 02:10AM URINE CastHy-25* [2183-1-16] 02:10AM URINE Mucous-OCC [2183-1-16] 02:10AM URINE Hours-RANDOM UreaN-395 Creat-225 Na-<10 K-22 Cl-<10 Microbiology: C diff [1-17]: negative Blood cx [1-16]: No growth Urine cx [1-16]: negative Imaging: Chest x-ray [12/2099]: Cardiomediastinal contours are normal. Left transvenous pacemaker leads are in a standard position with tips in the right atrium and right ventricle. There are low lung volumes. There are faint ill-defined opacities in the left perihilar region. This could be due to atelectasis, but developing infection cannot be excluded. There is no pneumothorax or pleural effusion. There is dilatation of small bowel loops in the upper abdomen Chest x-ray [1-18]: CHEST, SINGLE AP VIEW: Low lung volumes. Compared with [2183-1-17], there is increased opacity in the left upper and mid zones, which could represent worsening asymmetric CHF. The possibility of a left-sided pneumonic infiltrate cannot be entirely excluded, but is considered less likely. No effusions. A left-sided dual-lead pacemaker is present with lead tips over right atrium and right ventricle. An NG tube is present -- the tip is obscured in the lower mediastinum due to overlying soft tissues and cannot be definitively identified. A right IJ central line is present, tip over distal SVC. IMPRESSION: Worsening asymmetric opacity, likely worsening CHF. Echo [1-16]: 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 mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Limited study as patient could not cooperate. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not probably normal. No significant valvular abnormality CT abdomen and pelvis without contrast [1-16]: IMPRESSION: 1. Large amount of non-hemorrhagic ascites throughout the abdomen. No evidence of intra-abdominal hemorrhage. 2. Intact Roux-en-Y anastomosis. 3. Cirrhotic liver. Gas-distended loops of bowel with decrease of caliber just distal to the J-J anastomosis. While this could represent post-operative changes from gastric bypass, early partially small bowel obstruction cannot be excluded. 4. Minimal-to-mild colonic wall edema, likely secondary to patient's end-stage liver disease. Fecal loading in the rectum. RUQ US with dopplers [1-17]: IMPRESSION: 1. Large amount of intra-abdominal ascites. 2. No concerning focal liver lesion identified. 3. Somewhat limited Doppler evaluation of the left hepatic lobe, however, no evidence of portal venous thrombosis. Brief Hospital Course: Mr. [Known lastname ] is a 45 year old man with EtOH cirrhosis c/b massive ascites and cardiomyopathy s/p AICD placement who was transferred from an OSH with hypotension in the setting of decompensated liver disease. His course was complicated by hepatorenal syndrome necessitating dialysis as well as encephalopathy. . #[Last Name (un) ] (Hepatorenal Syndrome): Elevated Cr at 3.0 on admisison, reportedly up from 1-1.2 at baseline. Urine sodium of less than 10 narrowed differential to pre-renal dehydration vs. HRS. Pt was given albumin challenge for the first two days as well as boluses of NS. Creatinine did not respond to resuscitation over the first few days, ruling in favor of HRS. Pt was also started on midodrine/octeotide for presumed HRS. Renal US was negative for post-renal obstruction. Pt was started on dialysis once he was transferred back to the MICU with the hope of bridging him until he is a candidate for liver transplant. . #Liver Tranpslantation Eligibility: To become a liver transplant candidiate, Mr. [Known lastname ] will need to have been sober out of the hospital for approximately 3 months. Per the liver transplant committee, he must demonstrate that he is comitted to sobriety by engaging in an intesive outpatient alcohol treatment program. Sobriety within the hospital or an inpatient rehabilition center does not count towards transplant eligibility. . #Alcoholic Cirrhosis: MELD is 22 upon discharge. Last drink was [2182-8-28] but in context of hospitalization/physical rehab. Not a transplant candidate as abstinence occurred in healthcare setting as explained above. Lactulose/rifaximin were continued for encephalopathy. Folate and thiamine were continued. . #Altered mental status: On admission he was somnolent, but conversant. Likely secondary to hepatic encephalopathy and sepsis from HCAP. Altered mental status initially improved after copious lactulose infusion, but worsened as Mr. [Known lastname ] became progressively uremic. Following initiation of dialysis and aggressive lactulose infusion, Mr. [Known lastname ] was back at his baseline mental status. Patient is discharged on 1mg PO Haldol [Hospital1 ]. . #Aspiration: Mr. [Known lastname ] was noted to aspirate on beside swallowing study, and had several episodes of desaturation which were thought to be potentially secondary to aspiration (as noted above). Per last Video Swallow evaluation, Mr. [Known lastname ] had experienced a bit of relief from his dysphagia with biofeedback swallowing training, and progressed from strict NPO to ground solids and nectar thick liquids. . # Hypoxemia: Upon admission, Mr. [Known lastname ] was treated for a HCAP with 8 days of vanc/zosyn/levofloxacin. Initially Mr. [Known lastname ] had an oxygen requirement which improved with treatment of his pneumonia. He experienced hypoxemia on [1-20] following completion of antibiotics which improved spontaneously several hours later and was likely secondary to a mucous plugging episode. A similar event occurred on [2-3] and improved with aggressive pulmonary toilet. A component of aspiration is also likely as Mr. [Known lastname ] has known microaspiration/penetration on videoswallow evaluation. He had no further desaturations after being made NPO. . #Hypotension: On admission SBP was persistently in the 70s-80s with improvement following IVF administration. This likely represented sepsis [12-19] HCAP given fever, chills and bandemia seen at the OSH. Although no e/o SBP on the basis of OSH diagnostic paracentesis, systemic infection with possible intrabdominal source could not be excluded. He was therefore started on Vanc/Cefepime from empiric coverage of HCAP. Pt's goal map of 65 was maintained prior to transfer to the floor. On the floor BP's remained stable and he was disconrtinued from antibiotics on [1-23]. Midodrine was continued thereafter with SBP ranging from 80-90. Medications on Admission: Vancomycin 1000 mg IV x1 Ceftriaxone 1g IV x1 Folate 1 mg PO qd Lactobacillus 1 tab PO qd Omeprazole 20 mg PO qd Sertraline 50 mg PO qd VitD 800 IU PO qd Zinc sulfate 220 mg PO qd Gabapentin 100 mg PO tid Lactulose 30 ml PO tid Ascorbic acid 500 mg PO bid Ondansetron 4 mg IV q6-8h prn Discharge Medications: 1. folic acid 1 mg Tablet [Month/Day (4) ]: One (1) Tablet PO DAILY (Daily). 2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 3. lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO QID (4 times a day). 4. rifaximin 550 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 5. B complex-vitamin C-folic acid 1 mg Capsule [Last Name (STitle) ]: One (1) Cap PO DAILY (Daily). 6. midodrine 5 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO TID (3 times a day). 7. trazodone 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. thiamine HCl 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 10. zinc sulfate 220 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath. 12. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours). 13. miconazole nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 14. haloperidol 0.5 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day). 15. fluoxetine 10 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Primary diagnosis: Alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [Known lastname ], It was a pleasure caring for you at [Hospital1 18]. You were initially transferred from another hospital to our intensive care unit. You were quite sick and developed kidney failure due to your worsening liver disease. Dialysis was initiated due to this kidney failure. You continued to be very confused after dialysis was started and required medications to help this. Upon discussions with you and your family, we have decided not to pursue aggressive measures like resuscitation (chest compressions and shocks) and intubation (breathing tube) should your heart stop pumping or you stop breathing. Your "code status" has been changed to DNR/DNI to reflect this wish. You will continue on dialysis outside of the hospital at your rehabilitation facility. Remember that any further alcohol intake could kill you and you should avoid this at all costs. Further information about possible liver transplant will be provided to you once you have maintained sobriety for at least 3 months once you return home from the rehabilitation facility. You will be discharged with a feeding tube in place because your swallowing muscles are weak and you are at risk of aspirating foods and liquids which can cause a dangerous pneumonia. Once the medical staff determines that you are safe to swallow, the tube can come out. You will receive your medications through the tube as well. We have made the following changes to your medications: STOP spironolactone, sucralfate, metoprolol, omeprazole, and gabapentin, furosemide START lansoprazole instead of omeprazole while you have your feeding tube START midodrine 15mg three times a day to keep your blood pressure up for dialysis START lactulose and rifaximin to prevent your episodes of confusion from returning START folic acid and thiamine for your nutrition START trazadone as needed for sleep START nephrocaps for nutrition while on dialysis START Vitamin D START Zinc START Albuterol and ipratropium as needed for shortness of breath Followup Instructions: Once you are discharged from the rehabilitation facility, you should call [Hospital3 ] to schedule an appointment with Dr. [First Name8 (NamePattern2) 7568] [Last Name (NamePattern1) 12130] at ([Telephone/Fax (1) 30825]. . With: Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 7033] When: Wednesday, [3-12] Department: LIVER CENTER Location: [Hospital1 ] Phone: [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "0389", "5070", "486", "5849", "2761", "2762", "4280" ]

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