tokens: Admission Date : 2017-09-03 Discharge Date : 2017-10-10 Date of Birth : 1946-12-27 Sex : M Service : MEDICINE Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Donald R Virgil , M.D. Chief Complaint : Shortness of Breath Major Surgical or Invasive Procedure : Endotracheal Intubation Central Venous Catheter and Swan Ganz catheter placement Arterial Line Placement Right sided thoracentesis History of Present Illness : 70 y/o male with h/o CAD s/p LAD PTCA 33 yrs ago , COPD , T2DM , and AICD pocket infection who presented to the Juan on 2017-09-03 with worsening SOB x 5 days and feeling " cloudy ." The patient was currently at Hubbard Regional Hospital and began to develop worsening SOB for the past 5 days . This AM while talking with his daughter on the phone , he was noted to desaturate into the high 80s and he was brought to the The Hospital for Orthopedics Juan for further evaluation . The patient states that he has felt " cloudy " of late which seems to relate to his worsening SOB . He is not ambulatory and is very deconditioned secondary to several complications within the past two months related to an AICD pocket infection . He denies any CP , N/V/D , abdominal pain , or HA . He states that he only uses one pillow to sleep but admits to sleeping at about 30 degrees at rehab . In the Juan , his VS were 97.8 150/80 88 12 89-94% 3L NC . He was given Percocet for back pain , Lasix 80 mg IV , and Combivent neb . For unclear reasons , he was placed on a NRB in the Juan . Upon arrival to the CCU , he was hemodynamically stable . He was quickly weaned to 3L O2 via NC , O2 sats 100% . Past Medical History : - AICD Pocket infection c/b MSSA bacteremia , pericardial effusion s/p mediastinal exploration , evacuation of pericardial effusion & hematoma ( 2017-07-24 ) - Ischemic colitis and ischemic liver 2017-06-22 ( post air embolism from post mediastinal exploration ) - CAD s/p LAD PTCA 33 years ago - T2DM c/b neuropathy and nephropathy - COPD - Hypothyroidism - CVA - s/p Bovine AVR 1999 - Hyperlipidemia - GERD - Chronic LBP - Lumbar sympathectomy Social History : The patient is a retired truck driver . He is currently married , has 10 children . No smoking for last 5 years . Prior to that smoked 2 packs a day . No EtOH or IVDU . Family History : Sister with diabetes . No other known family hx . Physical Exam : Vitals : 97.6 95/48 71 98% 4L NC General : Oriented to person and time . Slight confustion with place but oriented with some re-direction . HEENT : NC/AT . MM dry . OP clear . PERRLA . EOMI . Neck : JVD difficult to access 02-23 increased neck girth . CV : S1 , S2 with Grade II/VI SEM . +S3 . Pulm : Crackles halfway up lung fields B/L . Abd : Soft , NT/ND with normoactive BS . Ext : 2+ pitting edema to knees B/L . Pertinent Results : Admission Labs : 2017-09-03 PT - 13.8 * PTT - 33.1 INR ( PT )- 1.2 * 2017-09-03 PLT COUNT - 124 * 2017-09-03 HYPOCHROM - 2+ ANISOCYT - 1+ MACROCYT - 2+ 2017-09-03 NEUTS - 79.5 * LYMPHS - 9.9 * MONOS - 4.9 EOS - 5.4 * BASOS - 0.2 2017-09-03 WBC - 9.1 RBC - 2.77 * HGB - 8.8 * HCT - 27.2 * MCV - 99 * MCH - 31.9 MCHC - 32.4 RDW - 18.0 * 2017-09-03 CK - MB - Not Done proBNP - 2656 * 2017-09-03 CK ( CPK )- 16 * 2017-09-03 GLUCOSE - 206 * UREA N - 28 * CREAT - 1.8 * SODIUM - 135 POTASSIUM - 4.1 CHLORIDE - 85 * TOTAL CO2 - 42 * ANION GAP - 12 2017-09-03 CK - MB - Not Done cTropnT - 0.22 * 2017-09-03 CK ( CPK )- 38 Discharge Labs : 2017-10-10 : INR 3.5 , PT 32.5 , PTT 41 Imaging Studies : 1. CXR ( PA/Lateral ) 2017-09-03 Congestive heart failure with bilateral effusions ( R > L ) , with possible underlying consolidation in the RLL and to a lesser degree the RML and LLL . 2. CXR 2017-09-04 Compared to PA and lateral chest of the prior day . Right-sided PICC line with its tip in the distal SVC . The heart is markedly enlarged . There remains a large right and small left pleural effusion , not significantly changed . Patient remains in congestive heart failure , though it may be slightly improved compared to the prior study . Underlying infectious consolidation in the right lower lobe not excluded . 3. Echo 2017-09-04 The left atrium is mildly dilated . There is mild symmetric left ventricular hypertrophy . The left ventricular cavity size is normal . LV systolic function appears depressed . Resting regional wall motion abnormalities include inferior and inferolateral hypokinesis . Right ventricular chamber size is normal and free wall motion may be mildly impaired . The aortic root is mildly dilated . The ascending aorta is mildly dilated . The aortic valve leaflets are mildly thickened . A bioprosthetic aortic valve prosthesis is present . The aortic prosthesis leaflets appear to move normally . The transaortic gradient is normal for this prosthesis . The mitral valve leaflets are mildly thickened . The left ventricular inflow pattern suggests a restrictive filling abnormality , with elevated left atrial pressure . Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV ( severe ) left ventricular diastolic dysfunction . 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 2017-08-14 , ventricular function is now similar. EF 35-40% . 4. Echo 2017-09-14 The left atrium is mildly dilated . The left ventricular cavity size is normal . Overall left ventricular systolic function cannot be reliably assessed . 3l . The aortic valve leaflets are mildly thickened . The mitral valve leaflets are mildly thickened . There is no pericardial effusion . Compared with the prior study ( images reviewed ) of 2017-09-04 , there is probably no significant change . All cultures , including BCx , UCx , pleural fluid culture , and wound culture have been negative . 5. CT Chest 2017-09-16 : 1. Increasing large right-sided pleural effusion and pulmonary edema . Scattered parenchymal opacities in the left lower lobe represent superimposed infection vs atelectasis . There is no evidence of abscess . 6. 2017-09-28 Chest X Ray : SINGLE AP VIEW OF THE CHEST . There has been almost complete resolution of pulmonary edema . A small right pleural effusion has decreased in size . Mild cardiomegaly is stable . There is no pneumothorax . Right PIC catheter tip ends in the lower SVC . Patient is post median sternotomy . IMPRESSION : Almost complete resolution of pulmonary edema . 7. 2017-09-29 CT Head : FINDINGS : There is no evidence of intraaxial or extraaxial hemorrhage , mass effect , shift of normally midline structures , or acute major or minor vascular territorial infarction . The ventricles and sulci are mildly prominent , but stable in size and appearance . The gray-white matter differentiation is preserved . Again seen are subtle hypodensities within the periventricular white matter which is an indication of chronic microvascular ischemic changes , stable . Extensive carotid artery calcifications are identified . The visualized paranasal sinuses are clear . The surrounding osseous and soft tissue structures are unremarkable . IMPRESSION : No evidence of acute or chronic infarction . Stable microvascular ischemic changes in the periventricular white matter . 8. 2017-09-30 EEG : IMPRESSION : Abnormal EEG due to the moderately slow posterior background and occasional bursts of generalized slowing . These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures . Medications , metabolic disturbances , and infection are among the most common causes . No prominent focal abnormalities were evident , and there were no epileptiform features . The cardiac monitor showed occasional irregularities in a PACED rhythm . Brief Hospital Course : A/P : 70 y/o male with h/o CAD , T2DM , hyperlipidemia , and COPD who presented to the Juan on 2017-09-03 with worsening SOB x 5 days from Morton Hospital & Medical Center . Pt. was initially admitted to CCU on 2017-09-03 , transferred to Pendleton on 2017-09-05 , triggered on 2017-09-10 for hypotension with BP 67/38 and transferred back to CCU on 2017-09-10 . He remained fluid overloaded and a swan catheter was placed . The following issues were addressed during this hospital admission : 1# Cardiac : Pump The patient was initially admitted for likely CHF exacerbation . He was started on a lasix gtt the night of admission with a good response . He continued to diurese and he was moved to the floor since he no longer required intensive level care . While on the floor , he continued to be diuresed . After several days , he became hypotensive and triggered for BPs 60s/30s . He was given IVF without an adequate response in his pressures . He was transferred back to the CCU and started on a dopamine gtt . He diuresed well on the dopamine gtt and his BP was supported . Gradually , the dopamine gtt was weaned . However , he still appeared volume overloaded with minimal improvement in his oxygen requirement . A swan was placed for a more accurate picture of his volume status and he was volume overloaded by swan numbers with an elevated PAD and elevated CVP without an obtainable wedge pressure . He also had a high CO and low SVR suggestive of sepsis , but he never had an elevated WBC and was afebrile during his entire hospital admission with negative blood , urine , wound , and pleural fluid cultures . The Lasix drip was eventually changed to IV Lasix boluses , with a net diuresis of over 36 liters for the hospital stay . He was then transitioned to oral Lasix for maintainence . The patient had an echo on 2017-09-04 with the results above in detail . It was unchanged in comparison to 2017-08-14 with similar ventricular function and inferior and inferolateral hypokinesis . The patient had another echo on 2017-09-14 with no new changes . At discharge the patient was thought to be euvolemic , satting well on room air and without peripheral edema . His dry weight is 70.4 kg . Ischemia The patient had an initial troponin bump on admission which was most likely secondary to CHF exacerbation . He was continued on Aspirin , Metoprolol and Lipitor with no further issues . Rhythm The patient is completely pacer-dependent , being epicardially paced at 70 . He is on Amiodarone for post-op afib and this was continued this entire admission . His underlying rhythm is atrial flutter ; it was unclear whether he had previously been cardioverted . Anti-coagulation was started with Warfarin 5 mg with a goal of 2-3 and a plan for cardioversion in 6 weeks . The patient 's INR became supratherapeutic and Coumadin was held . His coumadin was transitioned to 2 mg and then 1 mg . His INR continued to flucuate . He was discharged on 1 mg , but a stable regimen had not been achieved . His INR will have to be monitored closely unitl his levels are stable . His INR goal is 02-24 . 2# SOB on admission : Likely due to CHF exacerbation , with diuresis of over 36 L during his admission . He had 4 surgeries ( 3 cardiac surgeries ) earlier in the summer , so it is likely that he required copious IVF hydration surrounding these procedures which may have been the cause of his massive fluid overload . It appears that his diet was regulated at rehab but there is concern for medication non-compliance at rehab , per previous discharge summaries . On discharge , the patient was maintained on standing diuretics as well as PRN nebs and INH COPD meds . 3# Metabolic Alkalosis / Hypochloremia : Etiology most likely a combination of contraction alkalosis and / or post-hypercapnia . This acutely worsened on 2017-09-18 , when the patient was found to have mental status changes and an ABG revealed a CO2 of over 100 , likley due to a depressed respiratory drive secondary to sedatives given for agitation on top of a preexisting alkalosis . The patient was therefore intubated for ventilation , and continued to be diuresed . His CO2 improved and he was extubated after a few days . All sedating medications were held and serial ABGs were trended to follow the resolution of the metabolic alkalosis . 4# Pleural effusions : s/p right thoracentesis on 2017-09-06 , 1600 mL of serosanguinous fluid removed from right pleural space . Gram stain and cultures were negative , cytology was negative . The right pleural effusion slowly re-accumulated after tap but resolved after continued diuresis . Repeat CXR showed improvement of the effusion and on discharge he had been breathing well on room air without complications 5# T2DM : The patient was started on Glargine for tighter glycemic control and was covered with an insulin sliding scale . He was monitored with QID fingersticks . His blood sugars were in the 100s on discharge . 6# Hyperlipidemia : The patient was continued on his statin . 7# COPD : The patient was continued on nebs 8# MS changes : The patient has a history of baseline dementia which was confounded by delerium in the face of metabolic abnormalities . His mental status improved as his metabolic process was resolved as detailed above . Neurology was also consulted and a head CT showed old lacunar infarcts but no acute causes for a change in mental status . An EEG showed mild encephalopathy , but no other findings . His mental status did clear somewhat with the addition of standing lactulose ; he was discharged on this medication . 9# Hypothyroidism : The patient was continued on his outpatient dose of Levothyroxine . 10# ? UTI : The patient was started on levofloxacin at Newton-Wellesley Hospital for a question of UTI based on U/A positive for WBC . UCx during this hospitalization were negative and Levofloxacin was d/c 'd . 11# Chronic lower back pain : The patient was treated with a Lidocaine patch and Percocet prn . Stronger narcotics were avoided given somnolence and MS changes . 12# Wound Care : The patient has left chest wound and left gluteal pressure ulcer . Wound care was consulted on 2017-09-05 and they made several recommendations . For the left gluteal pressure ulcer , they recommended gentle cleansing with normal saline or commercial wound cleaner , thin layer of Duoderm gel , air dry , allevyn foam adhesive over the site , and change every 2 days or prn . For the left chest wound , they recommended cleansing with commercial wound cleanser , pat dry , pack aquacel AG rope and moisten with saline , cover with dry gauze and change daily . These recommendations were followed throughout the admission . 13# Voiding : Pt. failed multiple attempts to void on his own . Case was discussed with neurology . He was started on finsateride on the day prior to admission . He is scheduled to follow up with urology to address this issue . Until then , his foley should remain in place . 14# Code : The patient was full code during admission . Medications on Admission : Levothyroxine 100 mcg PO daily Duloxetine 20 mg PO QHS Ondansetron PRN Percocet 1 tab PRN Senna PRN Colace PRN Lasix 80 mg PO BID Lactulose PRN Lidocaine patch Nystatin powder Gabapentin 300 mg PO TID Alb nebs Fluticasone / Salmeterol Tiotropium Bromide Spironolactone 25 mg PO daily Epoetin 4000 units MWF RISS Amiodarone 200 mg PO daily Calcium Acetate 667 mg PO TID SubQ Heparin Pantoprazole 40 mg PO daily Simvastatin 40 mg PO QHS ASA 81 mg PO daily MVI Tylenol PRN Discharge Medications : 1. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO TID ( 3 times a day ) as needed for Constipation . Disp :* 90 Capsule ( s )* Refills :* 0 * 2. Levothyroxine 100 mcg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . Disp :* 30 Tablet ( s )* Refills :* 2 * 3. Duloxetine 20 mg Capsule , Delayed Release( E.C. ) Sig : One ( 1 ) Capsule , Delayed Release ( E.C. ) PO QHS ( once a day ( at bedtime ) ) . 4. Lactulose 10 g / 15 mL Syrup Sig : Thirty ( 30 ) ML PO BID ( 2 times a day ) . 5. Fluticasone - Salmeterol 100-50 mcg / Dose Disk with Device Sig : One ( 1 ) Disk with Device Inhalation BID ( 2 times a day ) . Disp :* qs Disk with Device ( s )* Refills :* 2 * 6. Tiotropium Bromide 18 mcg Capsule , w/ Inhalation Device Sig : One ( 1 ) Cap Inhalation DAILY ( Daily ) . Disp :* qs * Refills :* 2 * 7. Amiodarone 200 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . Disp :* 30 Tablet ( s )* Refills :* 2 * 8. Calcium Acetate 667 mg Capsule Sig : One ( 1 ) Capsule PO TID W/MEALS ( 3 TIMES A DAY WITH MEALS ) . Disp :* 90 Capsule ( s )* Refills :* 2 * 9. Oxycodone - Acetaminophen 5-325 mg Tablet Sig : 1-2 Tablets PO Q4-6H ( every 4 to 6 hours ) as needed for pain . Disp :* 30 Tablet ( s )* Refills :* 0 * 10. Multivitamin Capsule Sig : One ( 1 ) Cap PO DAILY ( Daily ) . Disp :* 30 tablets * Refills :* 2 * 11. Miconazole Nitrate 2 % Powder Sig : One ( 1 ) Appl Topical BID ( 2 times a day ) . 12. 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 * 13. Simvastatin 40 mg Tablet Sig : One ( 1 ) Tablet PO QHS ( once a day ( at bedtime ) ) . Disp :* 30 Tablet ( s )* Refills :* 2 * 14. Pantoprazole 40 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 * 15. Lidocaine 5 %( 700 mg / patch ) Adhesive Patch , Medicated Sig : Two ( 2 ) Adhesive Patch , Medicated Topical DAILY ( Daily ) . Disp :* qs Adhesive Patch , Medicated ( s )* Refills :* 2 * 16. Furosemide 40 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . Disp :* 60 Tablet ( s )* Refills :* 2 * 17. Ferrous Sulfate 325 ( 65 ) mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . Disp :* 30 Tablet ( s )* Refills :* 2 * 18. Epoetin Alfa 4,000 unit/mL Solution Sig : One ( 1 ) Injection QMOWEFR ( Monday - Wednesday - Friday ) . Disp :* qs * Refills :* 2 * 19. Spironolactone 25 mg Tablet Sig : Two ( 2 ) Tablet PO DAILY ( Daily ) . Disp :* 60 Tablet ( s )* Refills :* 2 * 20. Albuterol 90 mcg/Actuation Aerosol Sig : 4-6 Puffs Inhalation Q6H ( every 6 hours ) . Disp :* qs * Refills :* 2 * 21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig : One ( 1 ) Tablet Sustained Release 24HR PO DAILY ( Daily ) . 22. Finasteride 5 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . Disp :* 30 Tablet ( s )* Refills :* 2 * 23. Gabapentin 300 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) . Disp :* 60 Capsule ( s )* Refills :* 2 * 24. Warfarin 1 mg Tablet Sig : One ( 1 ) Tablet PO at bedtime : Please monitor INR with goal 02-24 . Discharge Disposition : Extended Care Discharge Diagnosis : Primary : Congestive Heart Failure exacerbation Secondary : Coronary Artery Disease Hypertension Type 2 Diabetes Mellitus Chronic Obstructive Pulmonary Disease Discharge Condition : The patient was discharged hemodynamicallly stable , afebrile with appropriate follow up . Discharge Instructions : During this admission you have been treated for a CHF exacerbation . Weigh yourself every morning , call MD if weight increases by > 3 lbs in 2 days . Adhere to 2 gm sodium diet Fluid Restriction : 1500 mL 1. Please take all medications as prescribed . 2. Please keep all follow up appointments . 3. Please call your PCP C. Lettinga or seek medical attention in the Juan if you experience worsening shortness of breath , chest pain , dizziness , passing out , or any other concerning symptom . Followup Instructions : Please follow up with your PCP C. Lettinga ( 572 8343 ) on 10-10 at 1:00 PM Please follow up with Dr. Parker in cardiology ( ( 216 ) 660-0019 ) on 10-17 at 4:45 PM Please follow up with Dr. Frye in cardiololgy ( ( 216 ) 660-0019 ) on 10-09 at 2:15 PM . Please follow up with Urology on 10-16 @ 1:50 PM on the 3rd floor of the Maricle Building , east campus of Lahey Clinic - North Shore Ronald Lyman MD 77-979 Completed by : Bristol MD 47-191 2017-10-10 @ 1058 Signed electronically by : DR. Ronald G. Elston on : WED 2017-10-11 5:03 PM ( End of Report )