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5789,2851,2761,1809,193,4589,5296,7919,2822,2768,V8741,E9331

Admission Date: [**2161-10-5**] Discharge Date: [**2161-10-8**] Date of Birth: [**2106-11-20**] Sex: F Service: MEDICINE Allergies: Levetiracetam / Latex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Lower GI bleed, pelvic pain Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 54-year-old woman with a pmhx. significant for stage IIIA (T3, N0 Mx) high-grade cervical cancer, papillary thyroid cancer, seizure disorder, and atypical meningioma who is admitted from the ED with fever, lower GI bleed, and UTI. Patient has been undergoing active treatment for cervical cancer with Taxol/carboplatin with C4 on [**10-1**]. Ms. [**Known lastname **] has been having trouble with GI bleeding (in the setting of constipation and straining as per outpatient notes), and has been supported conservatively with blood transfusions. No history of EGD or colonsocopy in our system. Ms. [**Known lastname **] states the for the last weekshe has noticed increased blood in her stool. Also endorses fevers, chills, and abdominal pain. In the ED, initial vitals were: 102.0 109 105/65 16 100% ra. Hgb was 9.4 and u/a was consistent with UTI. Patient received 3L of NS and 1 gram of ceftriaxone. CT abdomen/pelvis showed: "thickening of the rectum and sigmoid colon with extension to possibly the mid-descending colon raise suspicion for a proctocolitis due to an infectious or inflammatory process. Heterogenous irregular cervical mass appears stable in size but there is more hypodense material endometrial canal suggesting either outlet obstruction by the mass or possibly involvement of the region by the mass. Left upper lobe nodule has decreased in size." Vitals on admission were: 98.3, 67, 92/55, 15, 100% ra. Past Medical History: 1. Atypical meningioma, s/p resection [**2159-3-30**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD) 2. Brief seizure disorder, given Keppra, developed rash. Not taking AED at this time. Purportedly to undergo radiation therapy, but did not undergo therapy. 3. Chronic eczematous process involving thighs, chronic hyperpigmented shins bilaterally, seen by dermatology in past. 4. G6P4 - 2 Ab 5. Cervical Cancer - Stage IIIa; dx [**2160-6-21**]-lung mets and progression in [**6-25**]- -cycle #1 [**Doctor Last Name **]-taxol [**2161-7-17**]. 6. Thyroid Cancer-no treatment Social History: She lives in the [**Location (un) 4398**] with her husband and works as a tailor. No tobacco or ETOh use. She is originially from [**Country 651**] and speaks Cantonese only. Family History: Father: lung cancer, smoker. Mother: no known medical issues. She has 5 sisters, 1 brother. She has 4 children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.3, 67, 92/55, 15, 100% RA GENERAL: Alert, oriented, pleasant no acute distress HEENT: Mucous membranes moist CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, no MRG ABDOMEN: +BS, slightly tender, non-distended EXTREMITIES: Dry skin, no edema bilaterally DISCHARGE EXAM: Tmax: 37.2 ??????C (99 ??????F), Tcurrent: 36.6 ??????C (97.9 ??????F), HR: 61 (60 - 93) bpm BP: 102/69(77) {93/53(65) - 126/93(98)} mmHg RR: 13 (11 - 22) insp/min SpO2: 99% GENERAL: Alert, oriented, NAD HEENT: MMM CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, S1 S2, no MRG ABDOMEN: +BS, soft, suprapubic mass is mildly tender, non-distended, hepatic edge palpable, no cvat EXTREMITIES: Dry skin, no edema bilaterally Pertinent Results: ADMISSION LABS: [**2161-10-5**] 12:20PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2161-10-5**] 12:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG [**2161-10-5**] 12:20PM URINE RBC-36* WBC->182* BACTERIA-MOD YEAST-NONE EPI-0 [**2161-10-5**] 12:20PM URINE MUCOUS-MOD [**2161-10-5**] 11:26AM TYPE-[**Last Name (un) **] COMMENTS-ADDED TO G [**2161-10-5**] 11:26AM LACTATE-1.7 [**2161-10-5**] 10:45AM GLUCOSE-183* UREA N-14 CREAT-0.5 SODIUM-132* POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-14 [**2161-10-5**] 10:45AM estGFR-Using this [**2161-10-5**] 10:45AM ALT(SGPT)-21 AST(SGOT)-19 LD(LDH)-170 ALK PHOS-113* TOT BILI-0.7 [**2161-10-5**] 10:45AM ALBUMIN-3.0* [**2161-10-5**] 10:45AM WBC-6.3 RBC-3.09* HGB-9.4* HCT-29.0* MCV-94 MCH-30.3 MCHC-32.3 RDW-16.1* [**2161-10-5**] 10:45AM NEUTS-92.7* LYMPHS-5.7* MONOS-1.4* EOS-0.1 BASOS-0.2 [**2161-10-5**] 10:45AM PLT COUNT-298 [**2161-10-5**] 10:45AM PT-10.5 PTT-30.7 INR(PT)-1.0 STUDIES: [**2161-10-5**] CT Chest Abd Pelvis IMPRESSION: 1. Proctocolitis, which may be due to an infectious or inflammatory process. 2. Heterogenous irregular cervical mass appears relatively similar, compatible with known carcinoma. Increased hypodense material in the endometrial canal with peripheral irregular enhancement is suggestive of increased endometrial fluid due to cervical obstruction by the mass with endometritis, but neoplastic involvement of the endometrium may also be present. Air within the cervix and vagina is unchanged from the prior studies; while no communication is seen between the vagina and rectum, if there is concern for a rectovaginal fistula, this can better be assessed with rectal contrast. 3. Interval decrease in size of the left upper lobe nodule. 4. Heterogeneous hypodense area within the right lobe of the thyroid gland, consistent with the patient's known thyroid carcinoma. 5. Mild dilatation of the ureters without frank hydronephrosis, likely due to mass effect upon the distal ureters by the cervical tumor. [**2161-10-6**] KUB FINDINGS: There is retained contrast within the large bowel. There is no dilated bowel. There is no free air or pneumatosis. IMPRESSION: No gas abnormality. MICROBIOLOGY [**2161-10-6**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2161-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2161-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2161-10-5**] URINE CULTURE-FINAL INPATIENT [**2161-10-5**] BLOOD CULTURE -PENDING [**2161-10-5**] BLOOD CULTURE- PENDING DISCHARGE LABS [**2161-10-8**] 03:59AM BLOOD WBC-2.4* RBC-3.43* Hgb-10.5* Hct-30.2* MCV-88 MCH-30.7 MCHC-34.9 RDW-16.9* Plt Ct-200 [**2161-10-8**] 03:59AM BLOOD Glucose-111* UreaN-10 Creat-0.5 Na-136 K-3.7 Cl-104 HCO3-23 AnGap-13 [**2161-10-8**] 03:59AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.3* [**2161-10-7**] 04:51AM BLOOD Lactate-1.3 Brief Hospital Course: This is a 54-year-old woman with a history of cervical cancer stage IIIA (T3, N0 Mx), papillary thyroid cancer, atypical meningioma, and anemia who is admitted with fever, lower GI bleed, and likely UTI. ACTIVE ISSUES: 1. LOWER GI BLEED: Patient received IVF and an active type, screen and crossmatch was maintained. She had a CT scan demonstrating colitis. Given recent chemotherapy, chemotherapy-induced colitis was high in our differential. We also considered infectious colitis and patient was started on antibiotics. She was afebrile in the ICU and not passing stool, so an infectious etiology was felt to be less likely and Zosyn was discontinued on [**10-7**]. Ischemic bowel was unlikely given lactate is within normal limits and patient does not appear systemically ill. On [**10-6**], patient received 2 units pRBC for a HCT of 21, with HCT increasing appropriately to 29 on the morning of [**10-7**]. While in the [**Hospital Unit Name 153**], patient passed small blood clots through her rectum but did not have frank hematochezia or melena. Patient was called out of the [**Hospital Unit Name 153**] on [**10-7**] but a floor bed was not available. On [**10-8**] she was stable for discharge home. 2. UTI: Patient with evidence of UTI on u/a on admission. Asymptomatic. She was initially treated with antibiotics. However, urine studies were felt to represent fecal contamination and her imaging was concerning for possible fistula. Antibiotics were discontinued on [**10-7**] and patient remained afebrile. 3. CERVICAL CANCER: Patient currently undergoing chemotherapy with taxol and carboplatin. Her outpatient oncologist was contact[**Name (NI) **] who felt colitis could be secondary to chemotherapy and chemotherapy was not given in house. Patient will follow up with oncology as outpatient. 4. HYPOTENSION: Patient was initially transferred to the [**Hospital Unit Name 153**] with an SBP in the 80's in spite of aggressive fluid resuscitation and concern for sepsis. Upon further investigation, patient's baseline outpatient SBP is 80's-100. She denied symptoms of orthostatic hypotension. CHRONIC ISSUES: 1. THYROID CANCER: No treatment at this time. 2. PAIN: Patient was continued on oxycodone and oxycontin. Ibuprofen was held in the setting of GI bleed. TRANSITIONAL ISSUES - Avoid NSAIDS - Determine future chemo regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO DAILY 2. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia Please hold for oversedation or RR <10. 3. Ondansetron 8 mg PO Q8H:PRN Nausea 4. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN Pain Please hold for oversedation or RR <10. 5. Oxycodone SR (OxyconTIN) 30 mg PO QAM Please hold for oversedation or RR <10. 6. Oxycodone SR (OxyconTIN) 20 mg PO QPM Please hold for oversedation or RR <10. 7. Prochlorperazine 10 mg PO Q8H:PRN Nausea 8. Docusate Sodium 100 mg PO BID 9. Senna 1 TAB PO BID:PRN Constipation 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 11. Ibuprofen 400 mg PO Q8H:PRN Pain Discharge Medications: 1. Dexamethasone 2 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia Please hold for oversedation or RR <10. 4. Ondansetron 8 mg PO Q8H:PRN Nausea 5. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN Pain Please hold for oversedation or RR <10. 6. Oxycodone SR (OxyconTIN) 30 mg PO QAM Please hold for oversedation or RR <10. 7. Oxycodone SR (OxyconTIN) 20 mg PO QPM Please hold for oversedation or RR <10. 8. Prochlorperazine 10 mg PO Q8H:PRN Nausea 9. Senna 1 TAB PO BID:PRN Constipation 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Hypotension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure caring for you at [**Hospital1 18**]. You were admitted for low blood pressure and blood in your stool. You had a blood transfusion which improved your blood pressure and your anemia. A CT scan showed inflammation of your colon which is most likely due to your chemotherapy. You also complained of tongue pain, which is also likely due to your chemotherapy. We have prescribed a lidocaine mouth rinse to help with the pain. In the future, please avoid over the counter non-steroidal anti-inflammatory medications (NSAIDs), as they may cause worse bleeding in your GI tract. This means you should NOT take ibuprofen (advil, motrin), aspirin, or naproxen. It is OK to take Tylenol. Please continue to follow up with your Oncologist for care of your cervical cancer. Followup Instructions: Dr. [**First Name (STitle) **] [**Hospital3 **] Thursday, [**2161-10-15**] 3pm Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2161-10-23**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19895**], MD [**Telephone/Fax (1) 4152**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MRI When: FRIDAY [**2161-10-16**] at 8:20 AM With: MRI [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: FRIDAY [**2161-10-9**] at 8:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

2252,6929,73819,45829

Admission Date: [**2159-3-30**] Discharge Date: [**2159-4-4**] Date of Birth: [**2106-11-20**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**2159-3-30**]: Left craniotomy/cranioplasty for excision of skull-based mass History of Present Illness: The patient was electively admitted for resection of a skull lesion. Past Medical History: unknown Social History: lives with husband; from [**Country 651**] and speaks Cantonese; works in a factory Family History: non-contributory Physical Exam: Exam upon discharge: Chinese speaking only, but able to follow commands with prompts. Pupils 4 to 3 mm bilaterally EOMI Face symetric No drift or droop Full strength with motor exam. Left sided cranial wound: C/D/I, closed with sutures. Pertinent Results: Head CT [**2159-3-30**]: Expected post-surgical changes after craniectomy and cranioplasty for a left frontoparietal calvarial lesion. MRI Head [**2159-3-31**]: Since the previous study, the patient has undergone resection of left parietal skull mass. There is no residual nodular enhancement seen. There remains a small left-sided subdural collection and meningeal enhancement. There is no midline shift or hydrocephalus. No acute infarct seen. IMPRESSION: Status post resection of left parietal skull mass. No residual nodular enhancement is seen. No acute infarct. Brief Hospital Course: The patient was electively admitted for resection of a skull-based lesion. She had a craniectomy and cranioplasty with mesh . The procedure went well and the patient was transferred to the ICU for monitoring overnight. The patient's post-operative MRI revealed complete resection of the lesion. She was neurologically stable and post-op imaging was consistent with total resection of the mass. The patient was transferred to the floor on [**2159-3-31**]. She worked with PT and OT but was slow to mobilize. She continued to work with PT and OT on [**4-1**] and [**4-2**]. She was re-evaluated on [**4-3**] and was deemed safe for discharge home on [**4-4**] with home services. The patient had lesions on her legs when she came into the OR. Dermatology was consulted and felt that she had chronic eczema for which she was discharged home with creams. She will follow-up with them in clinic. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: No driving while on this medication. Disp:*50 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 9 days: Continue for two weeks from the date of your surgery. Disp:*10 Tablet(s)* Refills:*0* 6. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 10 days. Disp:*1 tube* Refills:*0* 7. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical TID (3 times a day) for 10 days. Disp:*1 tube* Refills:*0* Discharge Disposition: Home With Service Facility: Carecentrix Discharge Diagnosis: Left skull-based mass - preliminary diagnosis is Meningioma Discharge Condition: Neurologically stable Mental Status: Clear and coherent (with interpreter) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance 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. - Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. -You may shower before this time using a shower cap to cover your head. -Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. -If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. -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 in the Brain [**Hospital 341**] Clinic. It is located on the [**Hospital Ward Name 5074**] on [**Hospital Ward Name 23**] 8. Call [**Telephone/Fax (1) 1844**]. Your appointment is [**4-16**] at 4 pm. Follow-up with dermatology in the clinic. Call [**Telephone/Fax (1) 1971**] to schedule an appointment within 2 weeks. Completed by:[**2159-4-4**]

42781,99601,42610,4580,4019,2724,25000,V5867,59970,32723,27800,7948,7904,42731,V5861,7823,41401,2449,3331,3659,V1582,V140

Admission Date: [**2125-6-9**] Discharge Date: [**2125-6-13**] Date of Birth: [**2043-12-6**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Attending Info 11308**] Chief Complaint: Transfer for pacemaker Major Surgical or Invasive Procedure: pacemaker placement History of Present Illness: Patient is an 81 yo M with history of HTN, HLD, IDDM, CAD s/p cardiac catherization in [**2118**], atrial fibrillation on Coumadin who was transferred to [**Hospital1 18**] from [**Hospital1 **] for pacemaker. Per medical history and patient account, he was in his USOH until he Friday [**2125-6-8**] morning when he felt lightheaded and dizzy while completing a crossword puzzle. Initially though it was hypoglycemia but his FS was 150. Patient then took his BP and found it to be 50/30 and his pulse was 28. He experienced orthostatic symptoms and felt dizzy while walking to bathroom and then fainted. At [**Hospital1 **] ED he was found to be hypotensive and with HRs in 20s, he was given Atropine in the ED which raised his BP to 30s. Patient was started on Dopamine and given another amp of Atropine and admitted to CCU. He was scheduled for a pacemaker but emergent interventions pushed his interventino back. Patient was transfered to [**Hospital1 18**] for planned pacemaker. 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, [**Known lastname **] stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations. In terms of his functional status, he used to be able to walk 3 miles without becoming SOB though in recent years he has been more limited. He is able to walk about a mile slowly without becoming short of breath and he denies CP with exertion though does report some calf pain occasionally. He also has chronic [**Location (un) **] for which he takes Lasix though the patient denies it is related to CHF and TTE/C.Cath with preseved LVEFs in the past. Past Medical History: - CAD - HTN - A.Fib: Rate controlled and anti-coagulated - Insulin Dependent Diabetes Mellitus: A1c 5.8% - OSA: uses CPAP - Hypothyroidism - Glaucoma PAST SURGICAL HISTORY: - Laparoscopic cholecystectomy [**2122-6-30**] - C.Cath [**2118**] - Laminectomy [**2124-7-5**] Social History: - Tobacco history: + smoking history though quit in [**2093**] <5 pack-yr - ETOH: Glass wine per month - Illicit drugs: Nont - Lives with wife in [**Name (NI) **], MA. Daughter lives in [**Name (NI) **], [**First Name3 (LF) **] has MR and lives in group housing in [**State 760**] Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - MI in Uncle in his 70s Physical Exam: VS: Afebrile, HR 40s, BPs 134/60, RR 12, 98%RA GENERAL: Pleasant, friendly, comfortable seated in bedside chair and 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 JVP of 10cm. CARDIAC: Bradycardic, S1S2 clear and of good quality, physiologic splite S2, no murmurs, rubs or gallops appreciated. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, distended abdomen but Soft and non-tender. No HSM, normoactive bowel sounds EXTREMITIES: Cold LE bilaterally, faintly palpable pulses, 1+ pitting [**Location (un) **] bilaterally to mid shin, chronic hyperpigmentation of LE bilaterally. Bilateral radial pulses 2+ and symmetric . Pertinent Results: Labs on Admission: [**2125-6-9**] 07:39PM BLOOD WBC-7.7 RBC-3.81* Hgb-12.5* Hct-37.6* MCV-99* MCH-32.9* MCHC-33.4# RDW-15.5 Plt Ct-112* [**2125-6-9**] 07:39PM BLOOD PT-22.0* PTT-43.5* INR(PT)-2.1* [**2125-6-9**] 07:39PM BLOOD Glucose-204* UreaN-41* Creat-1.5* Na-127* K-4.5 Cl-93* HCO3-21* AnGap-18 [**2125-6-9**] 07:39PM BLOOD ALT-33 AST-41* AlkPhos-231* TotBili-2.1* [**2125-6-9**] 07:39PM BLOOD CK-MB-3 cTropnT-0.01 [**2125-6-9**] 07:39PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1 [**2125-6-10**] 09:42AM BLOOD calTIBC-363 Ferritn-183 TRF-279 [**2125-6-9**] 07:39PM BLOOD TSH-0.52 Imaging: RUQ US 1. Suboptimal exam due to portable technique. The liver echotexture may be coarse. Hyperechoic lesions in the liver, may represent hemangiomas; however, HCC cannot be excluded in the setting of underlying liver disease. Further assessment with dedicated cross-sectional imaging is recommended. 2. Splenomegaly and ascites raising possibility of portal hypertension. 3. Right renal cyst. Chest X-ray: Left chest wall pacemaker is seen with leads in the right atrium and apex of the right ventricle. There is no pneumothorax. There is no focal consolidation or pleural effusion. Linear opacities at the bases are likely atelectasis. Cardiomediastinal silhouette is stable. IMPRESSION: Pacemaker leads in right atrium and apex of the right ventricle. No pneumothorax. Labs on Discharge: [**2125-6-13**] 06:08AM BLOOD WBC-4.6 RBC-3.20* Hgb-10.5* Hct-31.6* MCV-99* MCH-32.8* MCHC-33.1 RDW-15.5 Plt Ct-112* [**2125-6-13**] 06:08AM BLOOD PT-23.8* PTT-50.3* INR(PT)-2.3* [**2125-6-13**] 06:08AM BLOOD Glucose-134* UreaN-29* Creat-1.2 Na-138 K-4.5 Cl-104 HCO3-27 AnGap-12 [**2125-6-13**] 06:08AM BLOOD ALT-28 AST-36 LD(LDH)-173 AlkPhos-179* TotBili-1.6* [**2125-6-13**] 06:08AM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.6* Mg-2.0 [**2125-6-10**] 09:42AM BLOOD calTIBC-363 Ferritn-183 TRF-279 Brief Hospital Course: Mr. [**Known lastname 4887**] is an 81y/o gentleman with HTN, CAD, DM2 who presented initially to OSH with syncope and bradycardia, and was found to have sick sinus syndrome with junctional escape rhythm, transferred to [**Hospital1 18**] CCU for pacemaker implantation. # Bradycardia/tachycardia: Sick sinus syndrome, also with some His-Purkinje disease. His disease is likely due to age-related fibrotic replacement of his conduction system, though other etiologies were considered. Lyme negative DDI pacemaker (range 50-110). Per pacemaker interrogation [**6-12**], the RA lead seemed to not be capturing correctly and on CXR, was dislodged. Had revision of that lead [**6-12**]. Repeat chest x-ray confirmed lead was in place. Initially, all nodal agents were held. After pacemaker implantation, patient was stable on metoprolol. Discharged on metoprolol XL 25mg qd. Also, d/c on Keflex 500mg qid x7 days for prophylaxis (7 days because patient is at increased risk for ICD pocket infection as he had the pocket re-opened) Noted that patient had history of penicillin allergy (rash), so instructed patient to stop the Keflex and call his pcp if he develops a rash. . # CAD: stable.No recent episodes of chest pain, SOB or DOE though the patient reports his exercise capacity has been more limited in recent years though mainly due to hip pain. C.Cath in [**2118**] showing diffuse vessel disease though no intervenable lesions. D/c on metoprolol as above and home dose lisinopril. Not on aspirin because he is on coumadin. Continued pravastatin. . # LE edema : Stable. NO TTE in OMR but [**2118**] cath showed EF>55%. Continued home Lasix. . # Atrial Fibrillation: stable. Chronic, rate controlled with Labetalol at home, and on Coumadin. INR 1.9. Stopped labetalol while in house. Started metoprolol low dose as above. Continued coumadin. Will have INR checked as outpatient. . # HTN: Chronic, well controlled on Lisinopril and new metoprolol as above . # LFT abnormality: AST 34, ALT 34, AP 225, TBili 2.1 on [**6-10**]. Unclear etiology. He says he thinks this is baseline but he is not sure. No known h/o cirrhosis. RUQ U/S demonstrated ? coarse echotexture, but no clearly defined biliary abnl. Will likely need repeat exam s/p pacer placement. Albumin 4.3. Iron, ferritin and transferring nl. Informed PCP about this and [**Month/Day (4) **] report. . # Hematuria: patient with small amount of hematuria. UA negative for infection. Urine culture ngtd. . # Diabetes Mellitus: stable. Chronic, Insulin Dependent, Well controlled with recent A1c of 5.8% per patient report. Was on ISS. . # OSA: Chronic, on CPAP, continued in house. . # Hypothyroidism: Chronic, stable. TSH normal this admission. Continued Synthroid per home regimen. . # Glaucoma: chronic, stable. Continued home eye drop meds (except Timolol) . # Essential Tremor: stable . TRANSITIONAL ISSUES: - repeat UA; hematuria workup if still positive for RBCs - liver nodules on US and splenomegaly, small amount of ascites; will need f/u by PCP, [**Name10 (NameIs) **] report - will have INR checked as outpatient and results [**Name10 (NameIs) **] to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] complete 7 day course of keflex 500mg PO qid for prophylaxis for ICD infection Medications on Admission: HOME MEDICATIONS: - Pravastatin 40mg Daily - Lisinopril 40mg PO Daily - Labetalol 200mg PO BID - Furosemide 60mg Daily - Primidone 50mg DAily - Warfarin 2.5mg x2days/week 5mg x5days/week - Insulin - Levothyroxine 137mcg Daily (except Sat and Wed (274mcg)) - Allopurinol 300mg daily - Brimonidine Both eyes [**Hospital1 **] - Pilocarpine eye drops 2 drops both eyes - Timolol one drop both eyes - Bimatoprost 0.03% 1 drop right eye - Finasteride 5mg Daily . TRANSFER MEDICATIONS: - Dopamine 10mcg/kg/min IV drip Discharge Disposition: Home Discharge Diagnosis: Bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 4887**], You were transferred to [**Hospital1 69**] from [**Hospital6 4620**] for pacemaker placement because you were having episodes of very low heart rates. One of the wires of the device became dislodged so you had to go back for a second procedure to have it fixed. You tolerated the procedures well. We are discharging you on a 1 week course of antibiotic called Keflex to prevent infection around the pacemaker device. We know you have had a rash from penicillin in the past. There is an approximately 8% chance that you may develop a rash from this antibiotic, Keflex. We are prescribing this one because it is the best choice for preventing infection without causing adverse effects. If you do develop a rash or any swelling in the mouth or trouble breathing, please stop taking it and let your primary care doctor know so that you can be started on a different antibiotic instead. Again, the chance of you having an allergy to this medicine is small. We have made the following changes to your medications: -STOP taking Labetalol -START Metoprolol 25mg daily -START Keflex 500mg 4 times per day for 7 days (antibiotic to prevent infection) Please have your INR checked on Friday [**6-15**] and the results [**Month/Year (2) **] to Dr. [**Last Name (STitle) **] (prescription included below) On discharge, please follow up with your primary care doctor (please call to make an appointment) and in cardiology device clinic as scheduled below. Followup Instructions: Please call Dr. [**Last Name (STitle) **], your primary care doctor, to schedule an appointment in the next week Phone: [**Telephone/Fax (1) 64601**] Department: CARDIAC SERVICES When: MONDAY [**2125-6-25**] at 11:00 AM 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 [**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**] Completed by:[**2125-6-14**]

1510,5185,5533,53081,71690,53085,V1582

Admission Date: [**2124-6-21**] Discharge Date: [**2124-6-29**] Date of Birth: [**2060-4-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4679**] Chief Complaint: Esophageal Adenocarcinoma Major Surgical or Invasive Procedure: [**2124-6-21**] 1. [**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy. 2. Buttressing of intrathoracic anastomosis with pericardial fat. 3. Laparoscopic jejunostomy. 4. Esophagogastroduodenoscopy. History of Present Illness: Mr. [**Known lastname **] [**Known lastname **] is a 54-year-old male with an intramucosal adenocarcinoma of the esophagus seen while undergoing his routine 1 year endoscopy for surveillance of his gastric mucosa APC gene mutation. He was admitted for esophagectomy. Past Medical History: GERD Hiatal hernia Barretts APC gene mutation Colonic adenoma [**2122**] Social History: former smoker 40-50 ppy Family History: NC Physical Exam: VS: T: 98.9 HR: 72 SR BP: 128/80 Sats: 98% RA General: 64 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp; decreased breath sounds otherwise clear GI: bowel sounds positive abdomen soft non-tender/non-distended Extre: warm no edema Incision: Right VATs site clean, dry intact, well approximated. J--tube site clean dry intact Neuro: non-focal Pertinent Results: [**2124-6-21**] WBC-11.3* RBC-5.18 Hgb-16.1 Hct-45.4 MCV-88 MCH-31.1 MCHC-35.6* RDW-13.2 Plt Ct-201 [**2124-6-22**] 02:13AM BLOOD WBC-9.2 RBC-5.23 Hgb-15.5 Hct-46.4 MCV-89 MCH-29.6 MCHC-33.4 RDW-13.5 Plt Ct-206 [**2124-6-22**] 02:13AM BLOOD WBC-9.9 RBC-4.88 Hgb-15.2 Hct-44.0 MCV-90 MCH-31.2 MCHC-34.5 RDW-13.7 Plt Ct-221 [**2124-6-23**] 02:27AM BLOOD WBC-11.6* RBC-4.64 Hgb-14.2 Hct-41.3 MCV-89 MCH-30.7 MCHC-34.5 RDW-13.4 Plt Ct-205 [**2124-6-24**] 07:45AM BLOOD WBC-8.5 RBC-4.18* Hgb-12.9* Hct-38.1* MCV-91 MCH-30.9 MCHC-34.0 RDW-13.5 Plt Ct-159 [**2124-6-25**] 07:05AM BLOOD WBC-8.0 RBC-4.36* Hgb-13.5* Hct-39.9* MCV-92 MCH-31.0 MCHC-33.8 RDW-13.6 Plt Ct-190 [**2124-6-26**] 07:15AM BLOOD WBC-7.5 RBC-4.54* Hgb-14.5 Hct-41.0 MCV-90 MCH-31.9 MCHC-35.3* RDW-13.9 Plt Ct-216 [**2124-6-21**] 06:22PM BLOOD Glucose-174* UreaN-18 Creat-0.8 Na-138 K-3.9 Cl-103 HCO3-26 AnGap-13 [**2124-6-22**] 02:13AM BLOOD Glucose-160* UreaN-16 Creat-1.0 Na-133 K-8.0* Cl-103 HCO3-25 AnGap-13 [**2124-6-23**] 02:27AM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-138 K-4.3 Cl-102 HCO3-29 AnGap-11 [**2124-6-24**] 07:45AM BLOOD Glucose-119* UreaN-15 Creat-0.6 Na-139 K-3.5 Cl-100 HCO3-33* AnGap-10 [**2124-6-25**] 07:05AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-141 K-3.5 Cl-100 HCO3-33* AnGap-12 [**2124-6-26**] 07:15AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-139 K-3.9 Cl-100 HCO3-30 AnGap-13 [**2124-6-21**] 06:22PM BLOOD Calcium-8.0* Phos-4.0 Mg-1.7 [**2124-6-22**] 02:13AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.3 [**2124-6-22**] 02:13AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.2 [**2124-6-23**] 02:27AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.1 [**2124-6-24**] 07:45AM BLOOD Calcium-7.7* Phos-1.8* Mg-1.9 [**2124-6-25**] 07:05AM BLOOD Calcium-8.3* Phos-3.4# [**2124-6-26**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0 imaging: [**2124-6-21**] CXR Endotracheal tube, the tip projects roughly 7 cm above the carina. Normal course and position of the right-sided chest tube. No safe evidence of pneumothorax. No evidence of mediastinal widening. Moderate perihilar haze on the right, likely due to the post-operative situation. Mediastinal drains are in expected position. The lung bases show bilateral areas of atelectasis. Post-operative subcutaneous gas inclusions. Normal size of the cardiac silhouette. [**2124-6-22**] CXR Right apical chest tube remains in place. Nasogastric tube is in unchanged position with tip at the level of the hemidiaphragms. Enlarged cardiomediastinal silhouette is stable. There is no evident pneumothorax. Left lower lobe retrocardiac opacities have minimally increased, consistent with increasing atelectasis. Drain projects midline. [**2124-6-23**] CXR 1. Probably increased bilateral atelectasis or could be early pulmonary edema. 2. Stable mild cardiomegaly with likely new small bilateral pleural effusion. [**2124-6-25**] CXR Very small right apical pneumothorax with chest tube in place. Improving bibasilar atelectasis and persistent small pleural effusions [**2124-6-26**] CXR Small bilateral pleural effusions, including a right fissural component, have increased. Tiny right apical pneumothorax is stable. Moderate atelectasis at the lung base has worsened. Upper lungs clear. Heart size increased though normal. [**2124-6-27**] CXR Barium Swallow microbiology: none Brief Hospital Course: The patient was admitted to the Thoracic Surgical Service for elective esophagectomy for intramucosal adenocarcinoma of the esophagus. Patient tolerated the operation well. He arrived in the ICU NPO, on IV fluids and antibiotics (3 doses total), with a Foley catheter, JP drain, chest tube, epidural and PCA Dilaudid for pain control. Patient was extubated and re intubated shortly after secondary to the respiratory distress in the ICU. He was extubated once again shortly after, which he tolerated well. The patient was hemodynamically stable. Neuro: The patient received epidural and PCA Dilaudid with good effect and adequate pain control. On POD 6, after patient passed the barium swallow study, the epidural was removed and PCA was discontinued. When tolerating oral intake, the patient was transition ed to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: After the initial reintubation and successful re-extubation on POD 0 in the ICU, the patient remained stable from a pulmonary standpoint. The chest tube was placed in the operating room. It was initially placed to suction and on POD 1 to water seal. It remained to water seal, with no air leak, until POD 6, when it was taken out. The chest x-rays were obtained daily. Following the removal of the chest tube, there was tiny right apical pneumothorax seen on chest x-ray. Patient was stable and his oxygen saturation was > 92% on room air. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Tube feeds were started at 20 cc/hr on POD 1 as per pathway, and advanced by 20 cc/hr daily, up to a goal of 125 cc/hr. Patient tolerated the tube feeds well. The barium swallow study was obtained on POD 6. It demonstrated no leak. Subsequently, the diet was slowly advanced to full liquid. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and replete when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient remained afebrile throughout the hospital stay. He received 3 doses total of intra and perioperative antibiotics. Endocrine: No issues. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **] dyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled on oral pain medications. Patient was discharged with tube feeds at goal rate of 100 cc/hrs 12 hrs. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: OMEPRAZOLE 20 MG DAILY Discharge Medications: 1. Lansoprazole 30 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:*6* 2. Roxicet 5-325 mg/5 mL Solution Sig: [**5-15**] ml PO every six (6) hours as needed for pain. Disp:*500 ml* Refills:*0* 3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as needed for constipation: while on narcotics. 4. Tube feedings Replete full strength at 125 ml/hr via j-tube cycled over 18 hours each day for nutritional support, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12351**] [**Doctor Last Name **] esophagectomy. Flush feeding tube with 50 ml q 8 hr, and before and after use. Do not put any crushed meds down j-tube, only liquids. Pt will need feeding pump and tube feeding supplies. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Esophageal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fever 101 or greater -Increased shortness of breath, cough or sputum production -Chest pain -Difficult or painful swallowing. -Nausea, vomiting, diarrhea or abdominal pain -Chest tube site cover with a bandaid until healed -You may shower. No tub bathing or swimming -Call immediately [**Telephone/Fax (1) 2348**] if Feeding tube falls out. Please bring the feeding with you so it can be replaced promptly. -No driving while taking narcotics. Take stool softners with narcotics Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2124-7-11**] 10:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) **] radiology 30 minutes before your appointment. Completed by:[**2124-6-29**]

0389,78552,51881,5849,1977,1978,72973,9982,99592,4019,27541,V1046,E8700

Admission Date: [**2200-11-24**] Discharge Date: [**2200-11-26**] Date of Birth: [**2139-11-15**] Sex: M Service: SURGERY Allergies: Quinine Attending:[**First Name3 (LF) 3376**] Chief Complaint: Septic shock and pneumatosis coli. Major Surgical or Invasive Procedure: Exploratory laparotomy. History of Present Illness: The patient is a 61-year-old man with a personal history of prostate cancer and a diagnosis of pancreatic cancer with multifocal liver metastases on chemotherapy. He had an acute event and was transferred to our emergency room septic in shock. Resuscitation and intubation failed to improve his status and he was noted to have pneumatosis coli on a CT scan. Despite his poor prognosis from stage IV pancreatic cancer, his wife wished for all measures to be taken and he was taken to the operating room emergently for exploratory surgery with the presumptive diagnosis of ischemic bowel. Past Medical History: HTN PSH: LIHR, radical prostatectomy, L fibula steel plate insertion. Social History: Lives with his wife. Family History: NC Pertinent Results: Small bowel: Focal recent hemorrhage. No evidence of malignancy. Brief Hospital Course: [**11-24**] PT transferred to emergency room septic in shock. Resuscitation and intubation failed to improve his status and he was noted to have pneumatosis coli on a CT scan. Emergent exploratory surgery performed without evident cause of decompensation other than abdominal compartment syndrome without obvious causative factor. PT transferred to the ICU on mechanical intubation, pressors. BCx with GNR, started Cipro. DNR code statue per family meeting. Insulin GTT. [**11-25**] Episode relative hypotension with increased pressor requirements - SVV 14-17, gave fluid bolus. Continued intubation, full ICU support. [**11-26**] patient made CMO after family meeting with Dr [**Last Name (STitle) 35981**]. Pt expired 3:22 p.m. was pronounced dead roughly 45 minutes after made CMO. Family notified and offered autopsy. Family declined autopsy. Medications on Admission: Diltiazem, Tylenol, Milk of Magnesium. Discharge Medications: Does not apply Discharge Disposition: Expired Discharge Diagnosis: Death secondary to metastatic pancreatic cancer, sepsis, respritory failure. Discharge Condition: Death Discharge Instructions: Not applicable Followup Instructions: Not applicable SUMMARY NEITHER DICTATED NOR READ BY ME Completed by:[**2200-11-26**]

07030,570,5184,0389,99592,51881,78552,4846,5722,5849,1173,2869,07032,V641,2875,2512,4019

Admission Date: [**2135-5-1**] Discharge Date: [**2135-5-17**] Date of Birth: [**2084-1-15**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: [**2135-5-9**]: Cardiac catheterization History of Present Illness: 52 M cambodian native w/ h/o hep B treated w/ IFn-a and adefovir followed by entecovir. THe patient had been taking no medications for approximately 2 years. He was transferred from [**Hospital 794**] Hospital, RI, with N/V, weakness and abdominal pain with associated jaundice for ~2weeks. At the time of transfer, the patient had worsening LFTs to ALT 928, AST 624, Bili of 26.8 (direct 16.3), INR of 4.9 and Cr of 1.7. On arrival at [**Hospital1 18**] he had a MELD of 41 Past Medical History: PMH: Hep B, Tuberculosis, HTN, HL. PSH: Left lower lobectomy for TB, inner ear implant. Social History: No tob, rare etoh, no illicits. Lives at home w/ family Family History: Unknown Pertinent Results: Admission labs: [**Age over 90 **]|101|19 ----------<53 5.2|23|1.8 7.2>37.9<136 ALT 425 AST 321 AP 87 TBili 22.0 INR 4.6 PT 46.4 PTT54.2 Brief Hospital Course: Pt was admitted to [**Hospital1 18**] where he underwent a transplant workup by the hepatology and transplant surgery services. On [**5-5**] he was listed as a transplant candidate with a MELD of 41. On [**5-6**] he was transferred to the SICU in preparation for a possible iver transplant. Unfortunately the procedure was unable to proceed due to poor donor graft. He remained in the SICU under the managment of the transplant surgery service and the SICU team. On [**5-8**] he was once again prepared for a possible liver transplant but on the following morning he developed tachycardia with ST depressions on EKG. The transplant was cancelled and an urgent cardiology consult obtained. They recommended urgent heart catheterization, however his elevated INR required correction w/ 9U FFP prior to procedure. Cath identified 80% circumflex lesions that were deemed unstentable and cardiology recommended rate control. After receiving blood products the patient developed pulmonary edema requiring treatment with lasix and noninvasive ventilation (BiPAP). The following morning his respiratory status had improved and BiPAP d/c'd. He also received 2U PRBCs for Hcts 24 to maximize oxygen carrying capacity. On the afternoon of [**5-11**] he developed a rapid drop in blood pressure requiring urgent IV fluids, placement of a central line, intubation, and initiation of pressors. An echo obtained at this time demonstrated hyperdynamic left ventricle and he was presumed to be septic and antibiotics were started. His urine output on this day was minimal and his creatinine had risen to 3.3. Bladder pressure was 19 and the patient was not felt to have compartment syndrome. By [**5-12**] his blood pressure had improved sufficiently to discontinue pressors but he remained intubated due to his mental status. His INR remained elevated (7.3) and he received FFP for correction. He underwent bronchoscopy and one of the BAL samples grew mold which was eventually speciated to Aspergillis for which he was started on Voriconazole. His multisystem organ failure worsened over the next several days ([**2133-5-12**]): Despite several days without sedation his neurologic status worsened until he was no longer withdrawing to painful stimuli and his pupillary reflexes became nonexistent. His hemodynamic status worsened as evidenced by the progression from intermittent pressors to requiring increasing doses of levophed. His course was further complicated by oliguric renal failure with rising creatinine, which peaked at 8.4. His liver failure likewise worsened with Tbili's climing to 32 and coagulopathy marked by INRs > 7. In the setting of pulmonary aspergillosis, the patient was not a transplant candidate until he could receive at least two weeks of treatment and demonstrate clearing of the fungal infection. After consultation among the teams involved in the patient's care (transplant surgery, hepatology, SICU, infectious disease) consensus was reached that supporting the patient through multisystem organ failure for that amount of time was extremely unlikely. Several conversations were had with the family explaining that the patient's accumulated physiologic insults had made further treatment futile. The family agreed to withdrawal of care and within half an hour of extubation the patient died on [**5-17**]. Medications on Admission: Cipro 500 mg daily Losartan 50 mg daily Zofran 4 mg PRN Pravastatin 40 mg daily Vit D3 2000u daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Multisystem organ failure (liver failure, renal failure), pulmonary aspergillosis Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2135-5-18**]

42833,51881,5849,40390,1749,28521,49121,4280,4139,41400,5853,2720,28529,4240,28860,V4581,V4986,V5865,V462

Admission Date: [**2103-11-23**] Discharge Date: [**2103-11-30**] Date of Birth: [**2023-9-25**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2265**] Chief Complaint: dyspnea at rest Major Surgical or Invasive Procedure: none History of Present Illness: 80 year old female with COPD on home 2L, HTN, recurrent anemia, diastolic CHF who presents with progressive dyspnea. She was discharged from [**Hospital1 112**] 7 days PTA for COPD and CHF, where she was treated with blood transfusions, steroids and diuresis. Since discharge her dyspnea has progressively worsened. She states that it is exacerbated by activity and laying flat. Symptoms accompanied by cough with clear sputum for 1 day, palpitations, and chest pressure associated with some gas. No radiation to extremities or jaw, diaphoresis. Patient states that chest pressure was present for many hours on admission, consistent with her baseline chest discomfort she has experienced for years. Of note, the patient is on 2L home O2 at baseline, with home O2 sat ranging from 92-95%. . In the ED, initial VS were: 98.1, Pulse: 73, RR: 30, BP: 137/46. CXR revealed pulmonary edema. Foley was placed and the patient was given 40mg IV lasix, IV solumedrol, and levofloxacin. She was placed on a BIPAP. On arrival to the MICU, patient was satting 96% 40% BIPAP. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Diastolic CHF COPD, severe COLONIC ADENOMA CANCER - BREAST, INTRADUCTAL Anemia CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min Tobacco dependence INTESTINAL VASC INSUFFIC HISTORY CAROTID ENDARTERECTOMY DIVERTICULOSIS HYPERCHOLESTEROLEMIA CORONARY ARTERY DISEASE S/P CORONARY ARTERY BYPASS [**Doctor First Name 147**] HYPERTENSION - ESSENTIAL Social History: - Tobacco: 1 pack/day for 50 years, currently does not smoke - Alcohol: denies - Illicits: denies Family History: NC Physical Exam: Admission Physical Exam: Vitals:afebrile, 115/80, P-77, 95% face mask 40% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, poor air movement, no wheezes, bibasilar insp. rales, ronchi. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Rectal: brown, Guiac neg stool GU:foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Discharge Physical Exam: VS: 98.0 143-166/70-84 79-92 20 98%3L General: Pleasant woman; Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 8 mm H2O, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement bilaterally, scattered expiratory wheezing. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU:foley in place draining light colored urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2103-11-23**] 04:00PM BLOOD WBC-16.6* RBC-2.54* Hgb-7.3* Hct-21.7* MCV-86 MCH-28.9 MCHC-33.7 RDW-15.0 Plt Ct-240 [**2103-11-23**] 04:00PM BLOOD PT-13.3* PTT-25.4 INR(PT)-1.2* [**2103-11-23**] 04:00PM BLOOD Glucose-163* UreaN-47* Creat-2.2* Na-137 K-3.4 Cl-99 HCO3-25 AnGap-16 [**2103-11-23**] 11:38PM BLOOD Mg-2.1 Iron-75 [**2103-11-24**] 03:28PM BLOOD Type-[**Last Name (un) **] pO2-83* pCO2-72* pH-6.96* calTCO2-18* Base XS--17 . Discharge Labs: [**2103-11-30**] 06:30AM BLOOD WBC-13.0* RBC-3.30* Hgb-9.8* Hct-28.0* MCV-85 MCH-29.9 MCHC-35.2* RDW-15.0 Plt Ct-212 [**2103-11-30**] 06:30AM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1 [**2103-11-30**] 06:30AM BLOOD Glucose-112* UreaN-121* Creat-2.6* Na-139 K-4.0 Cl-90* HCO3-36* AnGap-17 [**2103-11-30**] 06:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9 . CXR [**2103-11-23**]: FINDINGS: Single AP upright portable view of the chest was obtained. Diffuse alveolar opacities throughout the lungs, right greater than left, which could represent asymmetric edema and/or infection. Slight blunting of the left costophrenic angle may be due to trace pleural effusion. The patient is status post median sternotomy. The cardiac silhouette is top normal. The aorta is calcified. . IMPRESSION: Diffuse bilateral, right much greater than left alveolar opacities could relate to asymmetric edema and/or infection. Correlate clinically and consider repeat after diuresis. Comparison with prior radiographs would be helpful. . ECHO [**2103-11-26**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe ([**12-21**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 80 year old female with COPD, HTN, recurrent anemia, diastolic CHF who was admitted for dyspnea and anemia. . #Dyspnea- The patient was admitted to the MICU with hypoxia to the 70%s on room air. She briefly required non-invasive ventilation. She was covered for a possible COPD exacerbation with nebs, prednisone and azithromycin (antibiotic course completed). She also was started on a lasix and nitro drip for acute on chronic diastolic CHF (EF 60%). Chest X-ray revealed bilateral pulmonary opacities with pulmonary edema. The patient diuresed well and dyspnea improved, making acute on chronic diastolic CHF the chief diagnosis. The patient underwent a transthoracic echo that showed moderate to severe MR worsened since [**9-/2103**], which may be contributing to CHF exacerbation. Cardiac enzymes were negative X3 for ischemic cause of heart failure exacerbation. Prior to transfer to the floor, lasix and nitro drips were discontinued. The patient was started on torsemide (in place of home lasix) and imdur. She continued to diurese well. Her oxygenation improved. At time of discharge, the patient was saturating well on 3L O2. She was discharged on torsemide for diuresis and a prednisone taper. . #Anemia- Patient has a history of significant anemia, with acute decrease in HCT on admission from 30 to 21. Stools guaiac negative. Patient was transfused 1 unit PRBCs. Hematocrit stabilized at 25 for the remainder of admission. Etiology of anemia likely multifactorial, secondary to CKD, repeated phlebotomy. Stools remained guaiac negative throughout admission. . #Acute on chronic kidney injury - Baseline creatinine is 1.5-2.0 over the past few months. With diuresis, creatinine increased to 2.4-2.6 daily. The patient should follow up regarding her creatinine within a week of discharge. . #Chronic Angina/CAD- Chronic angina has been controlled on ranolazine and isosorbide mononitrate. Stress test in [**10/2103**] revealed reversible inferior defect on nuclear imaging. Patient remained chest pain free throughout admission. The patient was continued on atorvastatin, ASA, hydralazine and imdur. Ranexa was discontinued due to acute kidney injury. The patient should follow up with her cardiologist about reinitiation of ranexa with improvement in renal function to baseline. . # Code:DNR/DNI ==================================================== TRANSITIONAL ISSUES: #The patient should follow up regarding her BUN/creatinine [**12-4**]. Results to be reported to Dr. [**Last Name (STitle) **]. #The patient should follow up with her cardiologist about reinitiation of ranexa with improvement in renal function to baseline. Medications on Admission: Prednisone 10 mg Oral Tablet Take 1 tablet in morning or as directed Atorvastatin 80 mg Oral Tablet Take one-half tablet (40mg) daily Folic Acid 1 mg Oral Tablet Take 1 tablet daily Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1 capsule 30 minutes before first meal of day Ranolazine 500 mg Oral Tablet Extended Release 12 hr one [**Hospital1 **] Ferrous Sulfate 325 mg (65 mg iron) Oral Tablet one qd Docusate Sodium (STOOL SOFTENER) 100 mg Oral Capsule one [**Hospital1 **] Furosemide 40 mg Oral Tablet Take 1 tablet daily Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg Inhalation Capsule, w/Inhalation Device One capsule (2 puffs) inhaled daily Prednisone 20 mg Oral Tablet 2 tablets daily for 3 days, then 1 tablet daily for 3 days, then [**11-19**] tab daily for 3 days. Isosorbide Mononitrate (IMDUR) 60 mg Oral Tablet Extended Release 24 hr 3 tablets = 180 mg once daily Metoprolol Tartrate 100 mg Oral Tablet Take 1 tablet twice daily Hydralazine 25 mg Oral Tablet one pill 3 x per day Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation HFA Aerosol Inhaler INHALE 2 PUFFS EVERY FOUR TO SIX HOURS AS NEEDED Fluticasone-Salmeterol (ADVAIR DISKUS) 500-50 mcg/dose Inhalation Disk with Device use 1 inhalation TWICE DAILY and rinse thoroughly afterward Amlodipine 10 mg Oral Tablet Take 1 tablet daily Montelukast (SINGULAIR) 10 mg Oral Tablet take one tablet once daily Aspirin 325 mg Oral Tablet, Delayed Release (E.C.) 1 tablet daily Alendronate 70 mg Oral Tablet TAKE 1 TABLET one day a week in the morning 30 minutes before food. do not lie down for at least 30 minutes Discharge Medications: 1. prednisone 10 mg Tablet Sig: as directed Tablet PO daily (): take 4 tablets x 1 day, then take 3 tablets x 2 days, then take 2 tablets x 2 days, then take 1 tablet daily (ongoing). Tablet(s) 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): take 30 min prior to first meal. 5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: Two (2) puffs Inhalation once a day. 9. Imdur 60 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) inh Inhalation twice a day: rinse thoroughly afterward. 13. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: take in AM 30 min prior to eating. Do not lie down for at least 30 min . 16. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 17. Outpatient Lab Work Please check BUN/creatinine [**12-4**]. Report results to: [**Last Name (LF) **],[**First Name3 (LF) 488**] M. Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 80426**] Fax: [**Telephone/Fax (1) 6808**] 18. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: Primary diagnosis: Acute on chronic systolic CHF Secondary diagnosis: COPD exacerbation, acute on chronic kidney disease, coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the intensive care unit with shortness of breath and found to have an acute worsening of your heart failure and a possible exacerbation of your COPD. In the ICU, you received medications IV to help remove the excess fluid from your body. You were also treated for worsening COPD with antibiotics and steroids. You will complete a steroid taper as an outpatient. You will also be discharged on torsemide to continue to remove the excess fluid form your body. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . MEDICATIONS CHANGED THIS ADMISSION: STOP lasix STOP ranexa. Please discuss reinitiation of this medication with your cardiologist START torsemide 80 mg by mouth daily Followup Instructions: Name: [**Last Name (LF) **], [**Name8 (MD) **] NP Location: [**Hospital1 641**]/CARDIOLOGY Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] When: [**Last Name (LF) 2974**], [**12-7**], 9:10 AM . DEPARTMENT: INTERNAL MEDICINE WITH: [**Last Name (LF) **],[**First Name3 (LF) 488**] M. When: [**2103-12-25**] 1:00PM Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 80426**] . Department: VASCULAR SURGERY When: TUESDAY [**2104-1-15**] at 10:00 AM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: VASCULAR SURGERY When: TUESDAY [**2104-1-15**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**]/ CARDIOLOGY Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] *Dr. [**Last Name (STitle) 80427**] office staff will contact you to schedule a follow up appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]

5789,2851,7840,53081,4019,2809,2724,32723,311,79029,V1204,V1582,V4586,V1082,V1272

Admission Date: [**2138-7-15**] Discharge Date: [**2138-7-18**] Date of Birth: [**2074-8-23**] Sex: F Service: MEDICINE Allergies: Percocet / Codeine / aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending:[**First Name3 (LF) 2763**] Chief Complaint: Dizziness, lightheadedness Major Surgical or Invasive Procedure: EGD [**2138-7-16**] History of Present Illness: 63 year old female with a past medical history of Roux en Y in [**2134**] who presented to the ED today with dizziness, lightheadedness, and black stools. She states that the black stools began about a week ago, initially resembling coffee grounds. She has had dark diarrhea since, and then had dark black stool today. For the past 2 days, she has also become increasingly lightheaded, dizzy, and short of breath, worse with standing. This morning, she had a syncopal episode during which she stood up, felt dizzy, fell to the floor, no head strike. Her husband also states that she looks pale. No chest pain, abdominal pain, nausea, or vomiting. Of note, she had a colonoscopy in [**2137-1-29**] which noted a sigmoid and ascending polyps, both found to be adenomas on pathology. There were no diverticuli noted. She took a two week course of [**Hospital1 **] ibuprofen in [**Month (only) **] when she had her upper teeth extracted. She also tapered off of her omeprazole and has not been currently taking this. She denies any recent symptoms of early satiety (more than normal), pain with eating, or pain after eating. She takes a baby aspirin daily. In the ED, initial HR in the 70s and SBPs in 110s-120s. Stools were guiac + black, Hct was 18.2 from baseline 37. She was type and crossed 2 units, however did not get the blood. She was also started on a protonix gtt. GI was notified. On arrival to the MICU, patient is comfortable, alert, in NAD. She notes a throbbing frontal headache, similar to prior but lasting longer. She denies any visual changes or neck pain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Laparoscopic Roux-en-Y gastric bypass with cholecystectomy on [**2135-4-6**] - GERD - Hypertension - Hyperlipidemia - Cholelithiasis - OSA on CPAP - Depression - Breast atypia s/p excisional breast biopsy via wire localization on [**2136-9-17**] - Melanoma s/p excision c/b MRSA infection in [**2123**] - Hysterectomy in [**2115**] Social History: She has been married for 14 years. She has one son. She is a former tobacco user and drinks approximately a cocktail with dinner. Activities remain the same. She participates in water aerobics and swimming and always wears a seatbelt. Family History: Mother died at 88. Father died at 62. She has no siblings. Physical Exam: On Admission: Vitals: 99.3 85 117/52 16 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended, no organomegaly GU: no foley Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: Labs on Admission: ====================== [**2138-7-15**] 12:48PM BLOOD WBC-8.6# RBC-2.11*# Hgb-5.9*# Hct-18.2*# MCV-86 MCH-27.7 MCHC-32.2 RDW-16.3* Plt Ct-298 [**2138-7-15**] 12:48PM BLOOD PT-11.4 PTT-26.3 INR(PT)-1.1 [**2138-7-15**] 12:48PM BLOOD Glucose-178* UreaN-31* Creat-0.7 Na-139 K-3.9 Cl-107 HCO3-23 AnGap-13 [**2138-7-16**] 05:38AM BLOOD ALT-13 AST-23 AlkPhos-31* TotBili-0.5 [**2138-7-16**] 05:38AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1 [**2138-7-15**] 12:48PM BLOOD %HbA1c-5.0 eAG-97 Labs Prior to Discharge: ========================== Brief Hospital Course: Assessment and Plan 63 year old female with a history of Roux en Y in [**2134**] presenting with melena and acute blood loss anemia. # Acute blood loss anemia: Initially an UGIB was suspected given melena and elevated BUN. However EGD this morning showed no source of bleeding. Bleeding may have stopped prior to endoscopy or it may be a small bowel or lower GI source. There was concern for anastomotic ulcers since patient has a gastric bypass and she is off omeprazole but nothing was seen at the GJ anastomotic site. The J-J anastomosis was not reached. Patient was using ibuprofen but no gastric ulcers seen. Metastatic melanoma is always a rare possibility in a patient with prior melanoma. Colonoscopy was negative. CTA abdomen pelvis showed no active bleeding. On discharge, she was HD stable with no sign of acutely active bleeding. Her aspirin was held and she was discharged on pantoprazole and misoprostol per GI and Bariatric surgery recs. She received a total of 4 units PRBCs. She will follow up with GI in two weeks. # Hypertension: Metoprolol initially held, then restarted on discharge. # HL: Continued simvastatin. # Depression: Continued sertraline. # OSA: continued CPAP Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. ALPRAZolam 0.25 mg PO BID:PRN anxiety 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. traZODONE 50 mg PO HS:PRN insomnia 6. Aspirin 81 mg PO DAILY 7. Vitamin B Complex 1 CAP PO DAILY 8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown 9. cod liver oil *NF* 1,250-135 unit Oral daily 10. Cyanocobalamin 1000 mcg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. ALPRAZolam 0.25 mg PO BID:PRN anxiety 2. Cyanocobalamin 1000 mcg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. traZODONE 50 mg PO HS:PRN insomnia 9. Vitamin B Complex 1 CAP PO DAILY 10. Vitamin E 400 UNIT PO DAILY 11. Misoprostol 100 mcg PO QID Give with meals, final dose at bedtime. RX *misoprostol 100 mcg 1 tablet(s) by mouth four times a day Disp #*20 Capsule Refills:*0 12. Calcium Carbonate 500 mg PO QD 13. cod liver oil *NF* 1,250-135 unit Oral daily 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - GI bleed - Acute Blood Loss Anemia - Iron deficiency Secondary: - Gastric Bypass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 12330**], it was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital because were dizzy and had dark stools. This was because you were anemic from bleeding in your digestive track. You had an upper endoscopy and a lower endoscopy (colonoscopy) which did not see any source of bleeding. However these studies are not able to visualize the areas in between. Your blood counts stabilized and there were no signs that you were still bleeding. It is VERY important that you avoid all NSAIDs, including aspirin, ibuprofen, aleve, and advil. Because your blood tests reveal an iron deficiency anemia, we gave you a dose of IV iron. You will continue to receive infusions of IV iron at the hematology clinic at the appointment listed below. Followup Instructions: IV Iron Transfusion, [**Hospital **] Clinic: Please call [**Telephone/Fax (1) 12331**] to schedule an appointment for IV iron next Thursday [**7-24**]. The infusion clinic is aware and should be contacting you as well. You will need to see Dr. [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) 12332**] in the gastroenterology clinic in 2 weeks. You should receive a call from his office by Monday to schedule an appointment, but just in case, the clinic number is [**Telephone/Fax (1) 9891**]. Department: BIDHC [**Location (un) **] When: WEDNESDAY [**2138-7-23**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**0-0-**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2138-8-1**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 12333**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: BARIATRIC SURGERY When: THURSDAY [**2138-8-14**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD [**Telephone/Fax (1) 305**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

5722,4589,7824,5712,2875,2767,30393,5723,27503,3004,7242,78650,2819

Admission Date: [**2191-8-3**] Discharge Date: [**2191-8-7**] Date of Birth: [**2140-1-6**] Sex: M Service: MEDICINE Allergies: Codeine / Morphine / Hydrocodone / Oxycodone / Ativan Attending:[**First Name3 (LF) 13256**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 51 year old man w/ hx of cirrhosis, reportedly secondary to alcohol and hemochromatosis, recently hospitalized [**Date range (1) 83051**] for hepatic encephalopathy, now re-presenting with altered mental status progressive over the last week. [**Name (NI) **] sister states that he has been at [**Location (un) 169**] nursing home since discharge from [**Location (un) **] facility, where she believes he is getting a decreased dose of lactulose from hospitalization and has not been having regular bowel movements. She reports that his mental status has been progressively worsening over the course of the last week, such that he was less and less interactive. He was only alert and oriented x1 today and was scheduled for an endocrinology appointment, so family brought him into the hospital. En route to hospital via EMS, patient admitted to chest pain. . . In the ED, initial vs were afebrile 93 135/95 18 100%RA. On arrival to ED, patient was unable to express any pain. He was reported to have scleral icterus and asterixis. He was able to open eyes to name but did not otherwise follow commands. ECG showed NSR rate 70, LAD, flattened T-waves throughout precordium, low voltages, similar to prior. CXR does not show clear infiltrate, though left hemidiaphragm border is obscured. A RUQ US was performed showing a patent portal vein, gallstone, and no ascites. He received 1 L of fluids. Transferred to the MICU for further management. . On arrival in the MICU the patient has VS 96.9 85/62 74 17 and 100%RA. He was responding able to state his name and sometimes respond yes to questions, though not clear to be appropriately responding. . Sister did state, over the phone, that patient has been in nursing home since last fall. She states that he was told he is not likely a candidate for liver transplant because he has not kept multiple appointments and because he is not independently functional at baseline, though she feels that all of the appointments missed were during hospitalizations here at [**Hospital1 18**]. She states that patient was much more independent with ADLs and IADLs, though living with her, prior to [**9-/2190**] at which time he was hospitalized for hepatic encephalopathy. In [**12/2190**], he had fallen in the shower at the nursing home. He fell twice since then in [**5-/2191**] when family took him out and 6/[**2191**]. Sister feels that his mental status has been worse since the initial fall. Sister feels that patient may have some depression with not likely qualifying for transplant, feeling like he may die soon. Per OMR notes, prior Head CT shows global cerebral atrophy, and there is some question from the transplant team of raising potential underlying dementia, which may be why he never seems to recover completely from his episodes of encephalopathy. Past Medical History: 1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given elevated iron levels (ferritin ~1500, TIBC ~200). Saw cardiology here in [**2191-4-15**], who performed an MRI and saw iron deposits in liver concerning for hemochromatosis. Mild CHF on last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis. 2. Recurrent cellulitis of left leg 3. DVT following trauma to left leg (MVA) Was on warfarin for 1 year. 4. Chronic low back pain 5. Depression 6. Anxiety Social History: No current tobacco use, former tobacco ~ 10 pack years (quit 3 years ago). Former alcohol and Klonopin abuse. Patient lives in [**Hospital 169**] Center, he does not work. He is separated from his wife. The patient's weekly exercise regimen consists of walking daily around the building. Patient usually tries to adhere to a sensible diet and manages ADLs well with assistance. He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31, 27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago. Family History: His father died of lung cancer and his mother has diabetes. He has 3 sisters and 1 brother who are healthy. His 3 children who are healthy. Physical Exam: Physcial Exam on Admission: Vitals: T: 96.9 BP: 85/62 P: 74 R: 17 O2: 100% RA General: Alert, oriented to self (stuttering when he says his name) but not able to answer any other questions, answers "yes" to some questions but not clearly appropriately, no acute distress HEENT: Scleral icterus, mildly dry mucous membranes, some asterixis of the tongue Neck: supple, difficult to assess JVP Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate, normal rhythm, soft heart sounds Abdomen: soft, obese, non-tender, non-distended, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses Physical Exam on Discharge: Vitals: T: 97.7 BP:109/65 P: 71 R:18 O2sat:100%RA General: alert, oriented to person, to some degree place, and on/off to time Neuro:CN II-XII intact, sitting up in bed and feeding himself Psych: able to answer questions appropriately and follow commands, alert Neuro: no asterixis Lungs: CTAB Ext: warm, well perfused, 2+ pitting edema Otherwise unchanged from admission Pertinent Results: Labs on Admission: [**2191-8-3**] 04:15PM BLOOD WBC-4.4 RBC-3.42* Hgb-12.8* Hct-37.1* MCV-109* MCH-37.3* MCHC-34.4 RDW-17.6* Plt Ct-55* [**2191-8-3**] 04:15PM BLOOD Neuts-62.8 Lymphs-23.5 Monos-10.4 Eos-2.7 Baso-0.6 [**2191-8-3**] 04:15PM BLOOD Plt Ct-55* [**2191-8-4**] 02:09AM BLOOD PT-18.6* PTT-41.7* INR(PT)-1.7* [**2191-8-3**] 04:15PM BLOOD Glucose-316* UreaN-10 Creat-0.9 Na-131* K-4.9 Cl-101 HCO3-21* AnGap-14 [**2191-8-3**] 04:15PM BLOOD ALT-27 AST-46* AlkPhos-139* TotBili-5.0* [**2191-8-3**] 04:15PM BLOOD Lipase-22 [**2191-8-3**] 04:15PM BLOOD cTropnT-<0.01 [**2191-8-3**] 08:36PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8 [**2191-8-4**] 02:09AM BLOOD Hapto-<5* [**2191-8-3**] 04:15PM BLOOD Ammonia-102* [**2191-8-4**] 02:09AM BLOOD TSH-1.7 [**2191-8-4**] 02:09AM BLOOD AFP-2.7 [**2191-8-3**] 08:42PM BLOOD pH-7.44 [**2191-8-3**] 08:42PM BLOOD freeCa-1.19 [**2191-8-4**] 02:09AM BLOOD T4, FREE, DIRECT DIALYSIS-PND Labs on Discharge: [**2191-8-7**] 06:21AM BLOOD WBC-4.6 RBC-3.09* Hgb-11.4* Hct-32.5* MCV-105* MCH-37.0* MCHC-35.1* RDW-17.0* Plt Ct-43* [**2191-8-7**] 06:21AM BLOOD PT-19.0* PTT-47.1* INR(PT)-1.7* [**2191-8-7**] 06:21AM BLOOD Glucose-158* UreaN-11 Creat-0.7 Na-138 K-4.4 Cl-110* HCO3-23 AnGap-9 [**2191-8-7**] 06:21AM BLOOD ALT-33 AST-60* TotBili-4.8* [**2191-8-7**] 06:21AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.4* Microbiology: [**2191-8-4**] 8:11 am URINE Source: Catheter. **FINAL REPORT [**2191-8-5**]** URINE CULTURE (Final [**2191-8-5**]): NO GROWTH. [**2191-8-4**] 8:44 am BLOOD CULTURE Source: Venipuncture #2. Blood Culture, Routine (Pending): Imaging: [**8-3**] RUQ U/S IMPRESSION: Extremely limited ultrasound demonstrating a patent periumbilical vein and splenomegaly. Cholelithiasis without cholecystitis. [**8-3**] CXR IMPRESSION: Limited exam. No gross consolidation or edema evident. [**8-3**] CT-PA IMPRESSION: There is no CT evidence of pulmonary embolism within the main, lobar and segmental pulmonary arteries. Due to suboptimal opacification of the subsegmental pulmonary arteries evaluation of subsegmental pulmonary embolism was limited. Cirrhotic liver with splenomegaly suggestive of portal hypertension Cholelithiasis and choledocholithiasis without bile duct dilatation, unchanged since [**2191-6-17**]. Brief Hospital Course: Primary Reason for Hospitalization: Mr. [**Known lastname **] is a 51 y/o male with alcoholic cirrhosis and possibly hemochromatosis who presented with one week of altered mental status from hepatic encephalopathy. . Acute Care: 1. Hepatic Encephalopathy: Patient presented with no response to sternal rub and was admitted to the MICU overnight. There was no evidence of bleed and patient's Hct was stable. Ultrasound showed patent portal veins and no ascites. It also showed cholelithiasis without cholecystitis. He was afebrile and had a normal WBC count, clean UA, and blood and urine cultures with no growth to date on discharge. In the MICU he receved lactulose enemas and laculose PO when he was able to take PO medication and his mental status improved. He was also continued on rifaximin. Given no history of recent falls and evident improvement with lactulose hepatic encephalopathy was diagnosed and head CT was deferred. He was transferred to the floor still only oriented to person but easily arousable and able to answer questions and call the nurse if needed. With continued standing lactulose administration on the floor patient became more alert and was able to speak more to staff. He was still only oriented to person on discharge, but knew that he had stayed in the hospital and could express complaints. He was discharged with instructions to titrate bowel movements to 3-5 per day with lactulose PO and to continue home rifaximin. . 2. Hyperbilirubinemia Patient noted to have TBili of 5.0 on presentation with mildly elevated alk phos. RUQ US had mention of gallstones, but no signs of ductal dilation. Patient was monitored with serial abdominal exams and had no RUQ pain and no changed on abdominal exam. He was discharged with his Tbili having decreased to 4.8. . 3. Chest Pain: Patient complained of chest pain en route to ED. ECG was unchanged from prior, NSR rate 70, LAD, flattened T-waves throughout precordium, low voltages. Troponins were negative x2 and patient ruled out for MI. . Chronic Care: 1. Chronic Hypotension- During his prior admission, the patient had significant hypotension with BPs in the ~90s systolic. This admission SBPs were 110-130s systolic and patient's midodrine was [**Known lastname **] but restarted once SBP dropped to 90's. With re-start, patient's BP again improved to 110's-130's systolic. During episode of hypotension/tachycardia patient received CT-PA for concern of PE which was negative for PE. . 2 Diabetes Mellitus: On presentation, patient had a glucose of 316. Patient was monitored with FSGS and treated with Insulin sliding scale with good glucose control. . 3. Cirrhosis/Transplant-The patient was worked up for potential transplant at [**Hospital1 18**]. Per last transplant note dated [**2191-7-29**] (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) the patient is a poor transplant candidate for a number of medical and psychosocial reasons. Has been instructed to follow with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**] for continued mgmt of end-stage liver disease. Patient was continued on lactulose and rifampin for hepatic encephalopathy and on midodrine for hypotension. . Transitional Care: Patient should follow-up with his primary care physician within one week of discharge. The final results of patient's blood and urine cultures were pending on discharge and should be followed-up by his primary care physician. [**Name10 (NameIs) **] should receive only lactulose to produce bowel movements and should be titrated to [**3-19**] bowel movements per day as prescribed. Medications on Admission: - rifaximin 550 mg Tablet PO BID - lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical to back and hip - tramadol 50 mg Tablet PO Q6H prn pain - testosterone 5 mg/24 hr Patch 24 hr Q24H - Calcium Citrate + D 315-200 mg-unit [**Hospital1 **] - folic acid 1 mg Tablet daily - thiamine HCl 100 mg Tablet daily - multivitamin daily - pyridoxine 25 mg Tablet daily - heparin (porcine) 5,000 unit/mL Solution TID - omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **] - ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (WE) for 3 weeks: to be completed [**2191-7-20**]. - nystatin 100,000 unit/g Powder Sig: powder to skin folds Topical twice a day as needed for rash. 14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: limit to 2g/24hrs. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for <3 BM's day prior. 17. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): see humalog sliding scale. 18. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Medications: 1. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 12 weeks: Please continue this medicine until 12 weeks from your original dose, then re-check vitamin D levels. 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<100. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 5. Novolog 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 6. Levemir 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 7. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H (every 4 hours): titrate to [**3-19**] bowel movements per day. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: 12 hours on 12 hours off to affected area. 9. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. nystatin 100,000 unit/g Powder Sig: One (1) application Topical twice a day as needed for rash. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 14. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**4-20**] hours as needed for pain: do not exceed 2gm/day. 16. Atrac-Tain [**4-24**] % Cream Sig: One (1) application Topical once a day: apply to lower extremities once daily. 17. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 18. Ensure Plus 0.05-1.5 gram-kcal/mL Liquid Sig: Two Hundred Forty (240) mL PO twice a day: mix with 60mL Propass. 19. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO three times a day. 20. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO twice a day as needed for if less than 3 bowel movements per day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 5344**] Discharge Diagnosis: 1)Hepatic Encephalopathy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted to our facility with altered mental status. You spent a day in the ICU where we were looking for causes of your altered mental status. We felt that your confusion was caused by your liver disease and we gave you medication for this condition. Your mental status improved. Please make the following changes to your medications: 1)START Lactulose 60ml by mouth every four hours and titrate to [**3-19**] bowel movements per day 2)STOP milk of magnesia and miralax for constipation treatment. If you are constipated take more laculose. Followup Instructions: Please make an appointment to see your primary care physician [**Name Initial (PRE) 176**] 1 week of discharge to arrange re-starting your full Lasix dosing. Department: LIVER CENTER When: WEDNESDAY [**2191-9-28**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2191-8-31**] at 4:30 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Admission Date: [**2191-6-15**] Discharge Date: [**2191-7-6**] Date of Birth: [**2140-1-6**] Sex: M Service: MEDICINE Allergies: Codeine / Morphine / Hydrocodone / Oxycodone / Ativan Attending:[**First Name3 (LF) 12174**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: none History of Present Illness: This is a 51 year old male with a history of cirrhosis secondary to alcohol use and possibly hemochromatosis who was admitted for unresponsiveness. Per his family, he was found by the nursing staff to be unresponsive on the morning of [**6-15**], they were unable to arouse him. Per his sister, the day prior they had seen him at the hospital after his elective EGD, and he was doing well, talking, at his baseline. She came to visit him today with the rest of the family and states that he was able to recognize them, but definitely far from his baseline. She states that this seems like prior episodes when "his ammonia is high." He has had prior episodes of encephalopathy, last at [**Hospital6 33**] from [**Date range (1) 83045**] because he "couldn't speak" per the family. After receiving lactulose, he returned back to his baseline. He has since had 2 falls in [**Month (only) 116**] - once on Mother's day where he tripped and broke his right hip. No intervention was done. He then fell again, which per the family he doesn't remember. He had head strikes during both falls (one requiring stitches to the forward), but per the family, he was no different mentally after those falls. . On [**6-14**], he underwent an EGD at [**Hospital 83046**] hospital for a hct that was trending down of unclear etiology. He has been getting blood transfusions for this downtrending Hct. Over this time his edema has been getting worse and a foley catheter was placed [**2-17**] days prior to admit as his scotal swelling prevented him from voiding effectively. Per his family he has been taking all of his medications as prescribed. . On admission yesterday, he was noted to be in the 90s systolic, afebrile. A RUQ US could not get great views of vasculature, but no ascites. A CXR was difficult to interpret but showed no obvious consolidation. He is guaiac negative and given a lactulose enema in the ED. In the MICU, he received 3 doses of 30ml lactulose, and 1 dose of PR enema with ~ 3 BM's. He was placed on Lasix 20mg IV bid and Spironolactone 100mg po daily. He is net negative 2L during his MICU stay. He seemed improved after lactulose enemas per the MICU team. . On the floor, he is arousable to voice, able to answer a few questions, states his name. Very poor attention. . ROS: Denies pain. Otherwise unable to obtain given pt's mental status. But, per the family, he was not having any pain, fever, or other complaints the day prior. Past Medical History: 1. Cirrhosis [**2-16**] alcohol and hemochromatosis complicated by encephalopathy 2. Recurrent cellulitis of left leg 3. DVT following trauma to left leg (MVA) Was on warfarin for 1 year. 4. Chronic low back pain 5. Depression 6. Anxiety Social History: No current tobacco use, former tobacco ~ 10 pack years (quit 3 years ago). Former alcohol and Klonopin abuse. Patient lives in [**Hospital 169**] Center, he does not work. He is separated from his wife. The patient's weekly exercise regimen consists of walking daily around the building. Patient usually tries to adhere to a sensible diet and manages ADLs well with assistance. He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31, 27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago. Family History: His father died of lung cancer and his mother has diabetes. He has 3 sisters and 1 brother who are healthy. His 3 children who are healthy. Physical Exam: ADMISSION: ON THE MEDICINE FLOORS, HOD#2 Vitals: T: 96.5 BP: 105/60 P: 79 R: 12 O2: 97%RA General: sleeping, arouses to voice, poor attention, appears very somnolent, able to only answer few questions with one word answers including stating his name and "no" to pain HEENT: NCAT, PERRL, ecchymoses over left eyelid, dry MM, unable to fully visualize oropharynx, no apparent tongue fasiculations Neck: supple, obese, JVP not elevated Lungs: no use of access mm, poor effort, no crackles or wheezes CV: RRR, nl S1 S2, no murmurs, rubs, gallops Abdomen: +NABS, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly, no fluid wave, no flank dullness GU: foley in place, dark yellow urine, diffusely edematous/tense scrotum Ext: warm, diffuse anasarca up to his abdomen Neuro: somnolent, poor attention, oriented only to self, able to follow limited commands, raise hands, unable to wiggle toes, 2+ DTR's in biceps & brachioradialis, downgoing toes, + asterixis DISCHARGE: Vitals: 98.4 98.2 92-115/46-66 70-101 18 100%RA BG 133-228 24H 1750/inc, BMx4 8H 540/inc, large BM General: awake, lying in bed, able to follow commands, tremulous, NAD, appears confused HEENT: NCAT, mildly icteric sclera, Dobhoff in place Neck: supple, obese, JVP not elevated Lungs: clear anteriorly without wheezes or crackles, no use of access mm CV: RRR, nl S1 S2, no murmurs, rubs, gallops Abdomen: +NABS, soft, non-distended, non-tender, no rebound tenderness or guarding, no fluid wave, no flank dullness GU: in adult diaper, no foley Ext: pitting edema to hip, left leg with 3+ edema in shin, stasis dermatitis, tender to palpation of shins bilaterally Neuro: oriented to person, states he does not know, says "[**2181**]" for the date, says "I'm confused," +asterixis **PT'S MENTAL STATUS FLUCTUATES THROUGHOUT THE DAY. Pt is always oriented to person, but occasionally not oriented to place or date. He seems to be better in the afternoon, frequently oriented to place and year but not exact date. Pertinent Results: ADMISSION LABS: [**2191-6-15**] 02:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2191-6-15**] 12:50PM GLUCOSE-123* UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-9 [**2191-6-15**] 12:50PM ALT(SGPT)-43* AST(SGOT)-88* ALK PHOS-143* TOT BILI-4.2* DIR BILI-0.9* INDIR BIL-3.3 [**2191-6-15**] 12:50PM LIPASE-26 [**2191-6-15**] 12:50PM cTropnT-<0.01 [**2191-6-15**] 12:50PM ALBUMIN-2.2* CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-1.7 IRON-187* [**2191-6-15**] 12:50PM calTIBC-213* FERRITIN-1494* TRF-164* [**2191-6-15**] 12:50PM AMMONIA-173* [**2191-6-15**] 12:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2191-6-15**] 12:50PM WBC-4.5 RBC-3.35* HGB-11.8* HCT-34.2* MCV-102* MCH-35.2* MCHC-34.4 RDW-19.9* [**2191-6-15**] 12:50PM NEUTS-78.4* LYMPHS-13.3* MONOS-5.8 EOS-2.1 BASOS-0.5 [**2191-6-15**] 12:50PM PLT COUNT-50* [**2191-6-15**] 12:50PM PT-16.9* PTT-32.7 INR(PT)-1.5* [**2191-6-15**] 12:48PM GLUCOSE-116* LACTATE-1.9 NA+-136 K+-4.4 CL--101 TCO2-29 [**2191-6-15**] 12:48PM HGB-12.0* calcHCT-36 [**2191-6-15**] 12:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2191-6-15**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-TR [**2191-6-15**] 12:40PM URINE RBC->182* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-<1 [**2191-6-15**] 12:40PM URINE MUCOUS-RARE DISCHARGE LABS: Na 136 K 5.4 Cl 99 HCO3 36 BUN 34 Cr 1.3 BG 182 WBC 3.2 Hgb 9.2 Hct 27.3 Plt 58 INR 1.5 ALT 14 AST 29 AP 90 Tbili 2.8 PERTINENT STUDIES: Urine hemosiderin: negative Ammonia: 35 IgG: 1323 QG6PD: 11.8 (normal) UPEP: no abnormalities SPEP: no abnormalities TSH: 2.4 FreeT4 1.2 Ret-Aut: 3.6 HFE gene: RESULT: NEGATIVE A1AT: 122 (range 83-199 mg/dL) Ceruloplasmin: 13 L (range 18-36 mg/dL) Copper: 34 (low) [**Doctor First Name **]: negative FSH: <1.0 LH: <1.0 Testost: 19 SHBG: 41 calcFT: 3.6 TSH:4.3 Free-T4:1.1 ACTH, PLASMA 12 ([**7-/2130**] pg/mL) cortisol, free Results Pending cortisol binding globulin (Transcortin) Results Pending STUDIES: CXR [**2191-6-15**]: FINDINGS: In comparison with the study of [**3-31**], there are lower lung volumes. Increased opacification in the retrocardiac region most likely represents pleural fluid and atelectasis. In the appropriate clinical setting, the possibility of supervening pneumonia would have to be considered. CT HEAD W/O [**2191-6-15**]: IMPRESSION: 1. No acute intracranial abnormality. 2. Global cerebral atrophy, disproportionate to the patient's age. 3. Diffuse sinus inflammatory disease. 4. Incidental note made of an arachnoid cyst in the left middle cranial fossa. LIVER U/S [**2191-6-15**]: FINDINGS: Evaluation is limited due to patient's body habitus and overlying bowel gas. Within the limitations the extremely limited portion of the liver that was imaged is unremarkable. The portal vein, common hepatic duct, spleen or pancreas could not be seen. A stone is noted in the gallbladder. The partially imaged gallbladder appears unremarkable. No ascitic fluid is noted. IMPRESSION: Gallstone noted. Severely limited study CXR [**2191-6-16**]: FINDINGS: As compared to the previous radiograph, the pre-existing left basal opacity has decreased in extent and severity. Otherwise, the radiograph is unchanged. No newly appeared focal parenchymal changes. CT ABD [**2191-6-17**]: could not fully visualize hepatic vv due to contrast timing IMPRESSION: 1. Patent portal vein, although direction of flow cannot be evaluated with this study. 2. Cirrhosis with evidence of portal hypertension, recanalized umbilical vein and splenorenal shunt. 3. Cholelithiasis and choledocholithiasis without evidence for inflammation. TTE [**2191-6-27**]: Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2191-4-5**], no change. RUQ U/S [**2191-6-28**]: FINDINGS: Note is made that this is a very limited ultrasound technically due to the patient's body habitus and his inability to hold his breath. No gross hepatic lesion is identified and no gross biliary dilatation is seen, although Visualization of the liver is very limited. Gallstones are again seen within the gallbladder. The spleen is enlarged measuring about 14.5 cm. No ascites is seen in the abdomen. DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained. Within the right portal vein, flow is noted to be reversed. Flow in the left portal vein is presumed to be patent and forward as there is a large patent umbilical vein. The main portal vein could not be identified. IMPRESSION: Extremely limited visualization of the anatomy due to the patient's body habitus. A large patent umbilical vein is identified. Shadowing gallstones are again seen within the gallbladder. Splenomegaly is also identified and there is no ascites seen. Visualization of the remainder of the structures is extremely poor. LENI left leg [**2191-7-3**]: No DVT in the left lower extremity. MICRO: URINE CX [**2191-6-15**]: NO GROWTH. BLOOD CX [**2191-6-15**]: NO GROWTH. STOOL CX, C DIFF [**2191-6-15**]: c. diff negative [**2191-6-16**] 7:39 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2191-6-19**]** FECAL CULTURE (Final [**2191-6-19**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2191-6-18**]): NO CAMPYLOBACTER FOUND. UA [**2191-6-23**]: RBC 17 WBC 146 Nitrite pos Leuks few Urine Cx [**2191-6-23**]: URINE CULTURE (Final [**2191-6-29**]): YEAST. 10,000-100,000 ORGANISMS/ML. Blood culture [**2191-6-23**], [**6-25**], [**6-26**], [**6-28**]: NO GROWTH. Brief Hospital Course: Pt is a 51 year old male with EtOH cirrhosis and possible hemochromatosis (still undergoing evaluation) who presented with increased confusion at home. He was initially taken to the ICU for close monitoring. He had no active s/s infection. He was treated with lactulose for hepatic encephalopathy and mildly improved. He was transferred to the medicine service where he continued to improve with lactulose. However, several days into his stay he appeared more confused. Infectious workup was resent, and pt was found to have a UTI, and was treated for 14 day course. Pt continued to be encephalopathic and was treated with Vancomycin for cellulitis of his left leg. Hospital course was complicated by hypotension, most likely due to diuresis and poor intravascular volume. He had mild renal insufficiency secondary to overiduresis. Tube feeds were started for nutrition. Eventually, pt was no longer able to be diuresed, and family meeting was [**Known lastname **], with the decision to be discharged to LTAC for further care and PT. He will follow-up with Hepatology on discharge. # Hepatic encephalopathy: On admission to the ICU, patient was arousable to pain and had asterixis, concerning for HE. There was no evidence of infection. Most likely precipitating factor was a medication effect from pain medicine and sedating medicine from the EGD (at OSH) or possibly medication noncompliance. RUQ U/S was performed to look for thrombus but inconclusive for PVT. CT scan showed patent portal vein but unable to fully visualize hepatic vein given contrast timing. Pt was transferred to the medicine liver service, where he continued to improve after increasing bowel movements with lactulose. However, as discussed below, course was complicated by complicated UTI, cellulitis, and hypotension, all likely contributing to continued encephalopathy. On discharge, he was more alert than on admission, but his mental status continued to fluctuate throughout the day. He was always oriented to person, able to state facts (such as President, current events), but occasionally not oriented to place or date and had poor attention. He had no other sources of infection and no further etiologies to treat to improve encephalopathy. # Cirrhosis: Alcoholic (last drink 4 years prior) and possible hemochromatosis suspected initially (based on elevated Ferritin and iron deposition on previous imaging). Multiple decompensations in the past with hepatic encephalopathy. On rifaximin (only once daily) and lactulose (only 60ml daily), and had been taking these as directed per the family and [**Hospital 4382**] facility. Prior to admission, had started evaluation for transplant, but had not yet completed it. His continued decompensation was concerning for secondary process in addition to alcoholic cirrhosis. Ferritin levels were elevated and previous imaging suggested possible hemochromatosis. Pt had no family history but has received blood transfusions in the past. HFE gene mutation analysis was negative. Additional studies for other etiologies for Cirrhosis were sent, including IGG, [**Doctor First Name **], A1AT, copper, ceruloplasmin. IGG was normal, [**Doctor First Name **] negative, A1AT negative, ceruloplasmin mildly low at 13, Copper was low at 34, 24hour urine copper showed normal levels. He was continued on spironolactone 100mg daily, and his lasix was uptitrated given anasarca (see below). However, given hypotension, further diuresis was limited and [**Known lastname **] for last several days prior to discharge. He was continued on Rifaxamin, increased to twice daily as it was recorded only as once daily at [**Hospital3 **] facility. Lactulose dose was uptitrated as well, and should maintain at least [**3-18**] bowel movements per day. **At [**Month/Day (3) **], he will need to have diuretics restarted and titrated as able. **Need to ensure [**3-18**] bowel movements per day. # Macrocytic anemia: DDx included hemolysis vs. hypersplenism vs. bleeding vs. ACD. Hct had been reportedly been drifting down at OSH, requiring blood transfusions, with EGD [**6-14**] without any bleeding and no varices seen, guaiac negative here on admission. Hapto <5 and elevated LDH concerning for hemolysis. However, given that he has cirrhosis, not unexpected that haptoglobin would be low, and LDH to be mildly elevated. SPEP and UPEP were negative. Hematolgoy was consulted, and reported that there were spherocytes in the peripheral smear, but no schistocytes. The DAT was negative, making differential for Coombs negative hemolysis hereditary spherocytosis (HS)/erythrocyte membrane defect (can also cause splenomegaly), G6PD, and paroxysmal nocturnal hemoglobinuria all possible. G6PD was normal. Urine hemosiderin showed was negative. He was transfused one unit PRBC's on [**2191-6-29**] with Hct at 25.7, mostly for improvement in intravascular volume (no active bleeding), with appropriate increase in Hct. He was found to have brown, guaiac positive stools the week prior to discharge, thought to be possibly due to gastritis seen on EGD at OSH. He had no melena or frank blood. His Hct remained stable at 27-28 for one week prior to discharge. On discharge he will follow-up with hematology. # Anasarca: Most likely [**2-16**] low albumin and cirrhosis with poor synthetic function. No protein seen in the urine. Pt was diuresed with IV lasix 40mg [**Hospital1 **], increased titration limited by SBP in 90s. He was continued on Spironolactone 100mg daily. However, pt became hypotensive, requiring decreased diuresis. Diuresis was attempted with albumin given back. However, pt had some mild ARF as well, and further diuresis was [**Known lastname **]. Nutrition was consulted and while he was eating well, he was started on TF's to try to improve nutrition. **On discharge, the physicians at rehab will restart and titrate diuresis as able (limitations will be renal insufficiency and hypotension). # Hypotension: DDx includes overdiuresis & dry intravascular volume, vs. SIRS physiology vs. adrenal inusfficiency. Diuretics stopped [**6-28**]. Midodrine uptitrated and given albumin. Consulted endocrine given low cortisol on testing, though confusing picture given Albumin only 2.1, therefore assay difficult to interpret. Pt was treated with appropriate antibiotics for UTI and cellulitis, and did not appear to be septic. Diuresis was [**Known lastname **] as above. He was started on Midodrine. Repeat RUQ u/s and CXR were unremarkable. Repeat Urine cultures showed yeast, and the foley was discontinued. Blood cultures on repeat showed no growth. Endocrine followed and did not think the picture was consistent with adrenal insufficiency. LH, FSH were low, in addition to low testosterone. He was restarted on testosterone patch. His BP remained stable in the systolic 90s-100s for 48hrs prior to discharge. He was discharged to continue Midodrine 10mg tid. # Acute renal failure: [**2-16**] pre-renal etiology given attempted diuresis, with Cr bump to 1.4. Diuresis was discontinued. His Creatinine was stable at 1.3 for 2 days prior to discharge. # Complicated UTI: Discovered on [**2191-6-23**] after pt appeared more confused, and infectious workup resent. He was treated with Ceftriaxone for 14 day course. Repeat urine culture showed yeast, but no bacterial growth. # Left leg erythema: Started on Vancomycin to cover for possible cellutlitis. Pt had already been on CTX for UTI, and therefore was getting adequate coveraged accept for MRSA. Completed a 7 day course with improvement. LENI was checked to ensure no DVT, which was negative. He had some mild erythema of bilateral legs on discharge, attributed to stasis dermatitis. # Depression: [**Known lastname **] home Abilify given concern for causing somnolence in addition to side effects of leukopenia in this patient who is already at risk. Recommend follow-up with PCP after discharge for further management. # Leukopenia: Most likely [**2-16**] hypersplenism, cirrhosis. No s/s infection. WBC remained stable. His WBC ranged from high 2s-3s consistently for the last 2 weeks prior to discharge. # Back pain: Chronic in nature. Continued lidocaine patch and tramadol for pain. # Recent avulsion fracture: Conservative management. PT was consulted and recommended acute rehab. Given tramadol for pain control. TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT: sister [**Name (NI) 83047**] (HCP) [**Telephone/Fax (1) 83048**] (c), [**Telephone/Fax (1) 83049**] (w); Brother [**Name (NI) **] [**Telephone/Fax (1) 83050**] 3. [**Name2 (NI) **]OW-UP: - Liver transplant - PCP after discharge - Hematology - Endocrinology 4. MEDICAL MANAGEMENT: - Stopped lasix, Abilify - Increased Lactulose, increased Rifaximin, start Miralax prn - Start Humalog sliding scale - Nutrition with tube feeds 5. OUTSTANDING TASKS: - tests: cortisol, free Results Pending , cortisol binding globulin (Transcortin) Results Pending. Pt will be seen by Endocrinology on follow-up. Medications on Admission: -atrac-tain 10% cream apply to both lower extremities daily -nystatin 100000units/gm apply to skin folds [**Hospital1 **] -abilify 10mg daily -lidoderm 5% patch 12 hours on lower back -tramadol 50mg q6hrs prn pain -lasix 20mg 2 tabs daily -androderm 5mg/24hr patch for 24hr -benadryl 25mg q6hrs prn agitation -calcium+d 600-400 twice daily -ergocalciferol 50,000 units cap weekly for 12 weeks (end date [**2191-7-1**]) -folic acid 1mg daily -lactulose 60ml daily -magnesium oxide 400mg po bid -MVI daily -omeprazole 20mg po bid -thiamine 100mg daily -vitamin b6 100mg daily -xifaxan 550mg daily Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to lower back and hip. 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). Disp:*2 Patch 24 hr(s)* Refills:*0* 5. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 12. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (WE) for 3 weeks: to be completed [**2191-7-20**]. 13. nystatin 100,000 unit/g Powder Sig: powder to skin folds Topical twice a day as needed for rash. 14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: limit to 2g/24hrs. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for <3 BM's day prior. 17. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): see humalog sliding scale. 18. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary diagnoses: 1. Hepatic encephalopathy 2. Anasarca 3. Hypotension 4. Macrocytic anemia 5. Complicated urinary tract infection 6. Cellulitis Secondary Diagnoses: 1. Depression 2. Chronic low back pain 4. Avulsion hip fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during this admission. You were admitted with unresponsiveness. You were initially cared for in the ICU. You were given lactulose, and you began to feel better. We sent off several tests to assess for your liver disease. However, we think the cirrhosis is mostly due to your previous alcohol use. You had a lot of swelling, and we had to increase the amount of diuretics you were getting. However, your blood pressure was a bit low, and we had to stop the diuretics. We had the endocrinologists see you to make sure there was [**Last Name **] problem with your adrenal glands. We restarted you on testosterone. Your blood sugars were high, and we had to start you on insulin. We found two infections during this admission, a urinary tract infection and cellulitis. We treated both of these with antibiotics. We had the nutritionists see you because your albumin was low. They recommended tube feeds, which we started you on to improve your nutrition. You continued to be confused. We discussed with you and your family that perhaps more intensive [**Last Name **] would be the best for you. The following medications were changed during this admission: - STOP Abilify **This medication can cause sleepiness and also lower your blood counts. Please discuss with your doctors whether there is a better medication for you. - STOP Benadryl, as this can cause confusion - STOP Magnesium oxide - STOP Lasix 20mg 2 tablets daily **The doctors [**First Name (Titles) **] [**Last Name (Titles) **] [**Name5 (PTitle) **] need to restart diuretics when you are there. - INCREASE the amount of lactulose you were taking from 60ml daily to 30ml four times daily to at least [**3-18**] bowel movements per day. - INCREASE the dose of Rixafamin from 550mg daily to twice daily - CHANGE the Pyridoxine dose from 100mg daily to 25mg daily - START Insulin per the sliding scale provided - START Midodrine 10mg by mouth three times daily - START Acetaminophen 325mg by mouth every 6 hours as needed for pain (do NOT exceed 2grams/day) - START Miralax 17g by mouth daily as needed for constipation Please continue the other medications you were taking prior to this admission. Followup Instructions: Please follow-up with the following appointments: Department: CARDIAC SERVICES When: TUESDAY [**2191-7-19**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2191-7-27**] at 4:30 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2191-7-29**] at 1 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV OF GI AND ENDOCRINE When: WEDNESDAY [**2191-8-3**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage **Your primary care doctor, Dr. [**Last Name (STitle) 5861**], [**First Name3 (LF) **] need to get prior authorization so that you can see the Endocrinologists before your appointment. Completed by:[**2191-7-6**]

0389,56723,51881,78552,5722,5724,28419,78959,5849,2869,99592,5712,30390,27503,311,30000,V1582,25000,V5867,V1251

Admission Date: [**2191-12-23**] Discharge Date: [**2191-12-23**] Date of Birth: [**2140-1-6**] Sex: M Service: MEDICINE Allergies: Codeine / Morphine / Hydrocodone / Oxycodone / Ativan Attending:[**First Name3 (LF) 594**] Chief Complaint: generalized weakness, diffuse abdominal pain, abnormal labs Major Surgical or Invasive Procedure: Intubation History of Present Illness: Patient is a 51 year old male with cirrhosis reportedly secondary to alcohol and hemochromatosis complicated by encephalopathy who presents to ED with concern for hyperkalemia noted on labs with outside provider. . In the ED, his potassium was noted to be normal though he appeared altered and reported generalized weakness and new diffuse abdominal pain without fever, chills, dysuria and headache. His physical exam was notable for SIRS criteria with heart rate of 110 and MAP of 50. Bedside TTE showed normal ejection fraction though showed collapsed IVC whose diameter improved with 2 liters of NS resuscitation and 150 g of albumin resuscitation though no response to his MAP with CVP 8 - 12 and SvCO2 of 97%. RIJ line was placed and levophed was started with concern for septic shock. He was given Vancomycin 1 gm IV x 1, ceftazidime 2 gm IV x 1 and flagyl 500 mg IV x 1 as empiric coverage and admitted to MICU for management of septic shock with likely nidus of infection being SBP. . Of note, FAST in the ED showed trace free fluid without any ascites though abomdinal ultrasound later confirmed moderate ascites. Labs notable for elevated creatinine to 3.9, lactate of 4.4, WBC of 3.8, elevated liver enzymes, INR of 2.09 and T.bili of 4.7. . CXR showed no acute cardiopulmonary process with satisfactory positioning of RIJ line. UA was WNL except for high specific gravity. EKG showed diffusely low voltage. He also has cellulitis. . Vitals prior to tranfer were 133/92 on levo gtt. . On arrival to the MICU, he was encephalopathic with somnolence but did arouse to voice and sternal rub. He answered questions with simple yes and no. He denied bloody bowel movements and vomiting blood although he had copious amounts of dried blood in his mouth. He was not making urine in the foley. Past Medical History: 1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given elevated iron levels (ferritin ~1500, TIBC ~200). Saw cardiology here in [**2191-4-15**], who performed an MRI and saw iron deposits in liver concerning for hemochromatosis. Mild CHF on last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis. 2. Recurrent cellulitis of left leg 3. DVT following trauma to left leg (MVA) Was on warfarin for 1 year. 4. Chronic low back pain 5. Depression 6. Anxiety Social History: No current tobacco use, former tobacco ~ 10 pack years (quit 3 years ago). Former alcohol and Klonopin abuse. Patient lives in [**Hospital 169**] Center, he does not work. He is separated from his wife. The patient's weekly exercise regimen consists of walking daily around the building. Patient usually tries to adhere to a sensible diet and manages ADLs well with assistance. He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31, 27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago. Family History: His father died of lung cancer and his mother has diabetes. He has 3 sisters and 1 brother who are healthy. His 3 children who are healthy. Physical Exam: Vitals: temperature 91.1, BP 80s/40s, HR 130s, RR 8-10, O2 sats 100% 5LNC General: somnolent, arouses to voice and sternal rub, answers "yes" to some questions but not clearly appropriately HEENT: Very mild scleral icterus, dried blood in the mouth Neck: supple, difficult to assess JVP Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate, normal rhythm, soft heart sounds Abdomen: firm, obese, diffusely tender with guarding, worse in the RUQ Ext: cold, left radial pulse 2+, right trace pulse, b/l DP trace Pertinent Results: [**2191-12-23**] 09:59AM BLOOD WBC-4.2 RBC-1.71* Hgb-6.4* Hct-21.0* MCV-123*# MCH-37.5* MCHC-30.5* RDW-16.9* Plt Ct-28* [**2191-12-23**] 09:29AM BLOOD WBC-4.4 RBC-1.95* Hgb-7.2* Hct-22.5* MCV-116* MCH-36.8* MCHC-31.8 RDW-17.1* Plt Ct-46* [**2191-12-23**] 05:01AM BLOOD WBC-4.2 RBC-2.26* Hgb-8.4* Hct-25.5* MCV-113* MCH-37.3* MCHC-33.1 RDW-17.0* Plt Ct-33* [**2191-12-22**] 09:40PM BLOOD WBC-3.8* RBC-2.52* Hgb-9.5* Hct-28.6* MCV-114*# MCH-37.7* MCHC-33.2 RDW-17.0* Plt Ct-24* [**2191-12-23**] 09:59AM BLOOD Plt Smr-VERY LOW Plt Ct-28* [**2191-12-23**] 09:59AM BLOOD PT-24.1* PTT-88.5* INR(PT)-2.3* [**2191-12-23**] 09:29AM BLOOD Plt Ct-46* [**2191-12-23**] 09:29AM BLOOD PT-21.9* PTT-53.7* INR(PT)-2.1* [**2191-12-23**] 05:01AM BLOOD Plt Ct-33* [**2191-12-23**] 05:01AM BLOOD PT-22.0* PTT-65.2* INR(PT)-2.1* [**2191-12-22**] 11:05PM BLOOD PT-22.0* PTT-150* INR(PT)-2.09* [**2191-12-23**] 09:59AM BLOOD Glucose-513* UreaN-48* Creat-3.3* Na-135 K-4.1 Cl-101 HCO3-17* AnGap-21* [**2191-12-23**] 09:29AM BLOOD Glucose-336* UreaN-48* Creat-3.3* Na-136 K-4.4 Cl-100 HCO3-17* AnGap-23* [**2191-12-23**] 05:01AM BLOOD Glucose-304* UreaN-54* Creat-3.5* Na-134 K-4.3 Cl-97 HCO3-23 AnGap-18 [**2191-12-22**] 09:40PM BLOOD Glucose-340* UreaN-57* Creat-3.9*# Na-134 K-5.0 Cl-98 HCO3-22 AnGap-19 [**2191-12-23**] 09:59AM BLOOD CK(CPK)-76 [**2191-12-23**] 05:01AM BLOOD ALT-73* AST-112* LD(LDH)-277* CK(CPK)-65 AlkPhos-241* TotBili-5.3* [**2191-12-22**] 09:40PM BLOOD ALT-83* AST-138* AlkPhos-282* TotBili-4.7* [**2191-12-23**] 09:59AM BLOOD Calcium-9.6 Phos-7.0* Mg-3.5* [**2191-12-23**] 09:29AM BLOOD Calcium-8.3* Phos-6.9* Mg-2.4 [**2191-12-23**] 05:01AM BLOOD Calcium-9.0 Phos-7.0*# Mg-2.7* [**2191-12-23**] 10:43AM BLOOD Lactate-8.1* [**2191-12-23**] 10:17AM BLOOD Lactate-7.9* [**2191-12-23**] 09:43AM BLOOD Lactate-5.4* [**2191-12-23**] 07:27AM BLOOD Lactate-4.1* [**2191-12-23**] 03:17AM BLOOD Lactate-3.5* [**2191-12-23**] 01:08AM BLOOD Lactate-3.7* [**2191-12-22**] 11:07PM BLOOD Lactate-4.4* Brief Hospital Course: Mr. [**Known lastname **] is a 51 year old male with a history of alcoholic cirrhosis and hepatic encephalopathy presented with new abdominal pain, altered mental status, and hypotension. . # Septic shock: Admitted to MICU with MAP 58 after 2L IVF. Etiology seemed to be SBP vs pneumonia, CXR was not c/w pneumonia. Cardiac causes less likely given normal bedside echo in ED w/ FAST negative for pericardial effusion. RUQ showed some ascites but did not characertize hepatic vasculature well. He was continued on pressors to maintain his MAP >65, and treated per standard MUST protocol. He was also started on vancomycin and zosyn in the ED. Despite aggressive goal-directed resuscitation and prompt antibiotic treatment, his septic physiology rapidly worsened and his lactate continued to rise and his blood pressure progressively fell. He subsequently went into PEA arrest as described below. . # Altered mental status: Most likely a combination of his baseline hepatic encephalopathy with infection and superimposed delirium. There is also concern that his MAP is not high enough to maintain cerebral perfusion pressure at this point since he has had low MAP for >3 hours and is also not making urine. We continued aggressive fluid resucication and pressors to maintain MAP. He was also continued on lactulose and rifaximin, but ultimately had to be intubated for declining mental status. . # Acute kidney injury: His creatinine is acutely elevated from baseline < 1. The possible etiologies include HRS versus ATN. We had planned to obtain renal consult in the morning. Patient had little to no urine output overnight, renal ultrasound in ED negative for obstruction or hydronephrosis. . # Coagulopathy: Patient with baseline coagulopathy and thrombocytopenia and presented with dried blood in his mouth. Anesthesia also found blood in the oropharynx. He was not known to have varicies. Given septic shock there was a concern for DIC as his condition worsened. . # Cirrhosis: Known to be alcoholic and suspected also hemochromatosis. His synthetic function is poor now with increasing INR and decreasing albumin. His known decompensations include hepatic encephalopathy and SBP. . # Cardiac arrest: Despite continued aggressive intervention with pressors, antibiotics, and fluid resuscitation, the patient's condition continued to decline with decreasing blood pressure, increasing lactate, and no clinical improvement. Bedside echo showed poor cardiac systolic function. He subsequently went into PEA cardiac arrest for which standard ACLS protocol was initiated. He briefly return of spontaneous circulation, and showed mildly improved systolic cardiac function on repeat bedside echo. Within one hour of ROSC his blood pressure started to trend downward, and family meeting was initiated at the bedside. During this meeting the family decided not to continue resuscitation of the patient given poor prognosis on maximal support (he was on four pressors at that time). His family and the medical team were all in agreement with this decision. Chaplain was called to the bedside, and supportive care was withdrawn. Patient subsequently expired. Medications on Admission: - rifaximin 550 mg Tablet PO BID - lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical to back and hip - tramadol 50 mg Tablet PO Q6H prn pain - testosterone 5 mg/24 hr Patch 24 hr Q24H - Calcium Citrate + D 315-200 mg-unit [**Hospital1 **] - folic acid 1 mg Tablet daily - thiamine HCl 100 mg Tablet daily - multivitamin daily - pyridoxine 25 mg Tablet daily - heparin (porcine) 5,000 unit/mL Solution TID - omeprazole 20 mg [**Hospital1 **] - nystatin 100,000 unit/g twice a day as needed for rash -lactulose 10 gram/15 mL 30 ML PO QID -acetaminophen 325 mg Q6H prn pain: limit to 2g/24hrs -polyethylene glycol 17 gram/dose PO DAILY -insulin lispro 100 unit/mL sliding scale. -midodrine 10 mg PO tid Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Septic shock Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2191-12-24**]

3962,42731,4168,5859,40390,2875,2724,29420,71590,V1051,V5861

Admission Date: [**2161-3-9**] Discharge Date: [**2161-3-14**] Date of Birth: [**2079-8-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: New chest discomfort Major Surgical or Invasive Procedure: Aortic valve replacement #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve History of Present Illness: 81 year old male with known aortic stenosis who is followed closely by Dr. [**Last Name (STitle) 11250**]. Recent cardiac catheterization confirmed severe aortic stenosis and showed only mild coronary artery disease. He has been referred to Dr. [**Last Name (STitle) **] for consideration of aortic valve replacement. His symptoms included chest discomfort on exertion and occasionally at rest. He also admited to exertional shortness of breath. He denied syncope, orthopnea, PND, and pedal edema. Also admitted to intermittent palpitations from his chronic atrial fibrillation, and described occasional lightheadedness. Despite above symptoms, he remains extremely active and performs routine ADL without difficulty. He denies unsteady gait and recent falls. He recently recovered from a pneumonia in [**Month (only) 956**] Past Medical History: Aortic Stenosis Mild to [**Month (only) 1192**] MR [**First Name (Titles) 151**] [**Last Name (Titles) **] TR Pulmonary Hypertension Chronic AF on Warfarin Renal Insufficiency Chronic Thrombocytopenia Dyslipidemia Hypertension History of Bladder Cancer s/p tumor removal(no chemo or rad) Recent Pneumonia Varicose Veins Arthritis, prior cortisone injections to left hip History of ETOH abuse, sober for over 3 years PSH: Bilateral Hernia Repairs, Hemorrhoidectomy, Bilateral Cataracts, Bladder tumor removal, Tonsillectomy Social History: Lives with:care giver Contact:[**Name (NI) **] [**Known lastname **](son) Occupation:retired saleman Cigarettes: Smoked no [] yes [x] last cigarette 15yr__ Hx: Other Tobacco use:n ETOH: < 1 drink/week [] [**1-20**] drinks/week [] >8 drinks/week [x]stopped 3 yrs Illicit drug use: None Family History: Family History:Premature coronary artery disease Physical Exam: Physical Exam Pulse: Resp:16 O2 sat: B/P Right:126/77 Left:110/70 Height:71" Weight:103kg General:WDWN, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade [**2-17**] ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds Extremities: Warm [x], well-perfused [x] Edema [n] _____ Varicosities: None [n]bilat LE varicosities Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [**Name (NI) 167**]:1 Left:1 Radial Right:1 Left:1 Carotid Bruit Right:n Left:n Discharge Exam: VS: T: 97.4 HR: 70-80's afib BP: 153/81 Sats: 94% RA Wt:101 kg (preop 103 kg) General: 81 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Card: irrgular. Resp: decreased breath sounds otherwise clear throughout GI: obese, benign Extr: warm with 1+ bilateral edema Wound: sternal incision clean, dry intact no erythema or discharge Neuro: awake, alert, oriented Pertinent Results: TEE [**3-10**]: Conclusions PRE-BYPASS: The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. [**Month/Year (2) **] to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. 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%). [Intrinsic right ventricular systolic function may be depressed given the [**Month/Year (2) 1192**] tricuspid regurgitation.] There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The three aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No ascending aortic aneurysm is seen. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. [**Month/Year (2) **] (2+) mitral regurgitation is seen. [**Month/Year (2) **] [2+] tricuspid regurgitation is seen. There is no pericardial effusion. POST-BYPASS: The aortic bioprosthesis is well seated and functioning well with a residual mean gradient of 10 mm of Hg across the valve. No peri valvular leaks seen. LVEF 50%. Mild to [**Month/Year (2) **] MR. Mild to [**Month/Year (2) **] TR. Dilated IVC like prebypass. RV function appears normal. Intact thoracic aorta. CXR: [**2161-3-11**]: All the lines with the exception of the right internal jugular sheath have been removed. There is no pneumothorax. Volume loss at the left lung base may be slightly worse. [**2161-3-14**] WBC-7.8 RBC-2.70* Hgb-8.9* Hct-26.8* MCV-99* MCH-32.9* MCHC-33.1 RDW-15.7* Plt Ct-92* [**2161-3-9**] WBC-8.9 RBC-3.59* Hgb-11.5* Hct-35.8* MCV-100* MCH-32.0 MCHC-32.1 RDW-15.0 Plt Ct-113* [**2161-3-14**] PT-13.5* PTT-28.1 INR(PT)-1.3* [**2161-3-13**] PT-13.3* INR(PT)-1.2* [**2161-3-12**] PT-12.1 INR(PT)-1.1 [**2161-3-14**] Glucose-82 UreaN-27* Creat-1.0 Na-138 K-4.1 Cl-103 HCO3-26 [**2161-3-9**] Glucose-178* UreaN-29* Creat-1.4* Na-140 K-3.8 Cl-105 HCO3-21 [**2161-3-9**] ALT-23 AST-24 LD(LDH)-182 AlkPhos-48 TotBili-0.5 [**2161-3-13**] Mg-2.3 [**2161-3-10**] MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2161-3-12**]): No MRSA isolated. Brief Hospital Course: Patient was admitted to the hospital on [**3-9**] from OSH long standing history of AS. On [**3-10**] he was brought to the operating room where the patient underwent aortic valve replacement. Please see intraoperative note for further details.` Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He initially required vasopressor and phenylephrine for blood pressure support. Slow to wean from ventilator but eventually weaned and extubated without difficulty. On POD#1 he was extubated and off pressors. He has long history of rate control atrial fibrillation. Low dose Lopressor, diuretics and ACE were initiated. His pre-operative dose of prednisone for thrombocytopenia was restarted. He was mildly confused post-operative and given his history of mild dementia his Aricept was started and his mental status improved. He transferred to the floor in POD#2. Pacing Wires and chest tube were removed per protocol. Anticoagulation therapy was started. He was evaluated by the physical therapy service for assistance with strength and mobility. He continued to make steady progress and was discharged to [**Location (un) 15739**] Manor in NH [**Telephone/Fax (1) 92122**] on [**2161-3-14**]. He will follow-up as an outpatient. Medications on Admission: Prednisone 10mg daily,Lisinopril 2.5mg daily,Donepezil 5mg daily,Folate 1mg daily,Coumadin 2.5mg daily(LD 5d),Metoprolol Succ 50mg daily,EcASA 81mg daily Discharge Medications: 1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2 times a day) for 4 days: last dose [**2161-3-15**]. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 13. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: INR Goal 2.0-3.0. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days: while take lasix. 15. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 15739**] Manor Discharge Diagnosis: Aortic Stenosis Mild to [**Location (un) 1192**] MR [**First Name (Titles) 151**] [**Last Name (Titles) **] TR Pulmonary Hypertension Chronic AF on Warfarin Renal Insufficiency Chronic Thrombocytopenia Dyslipidemia Hypertension History of Bladder Cancer s/p tumor removal(no chemo or rad) Recent Pneumonia Varicose Veins Arthritis, prior cortisone injections to left hip History of ETOH abuse, sober for over 3 years PSH: Bilateral Hernia Repairs, Hemorrhoidectomy, Bilateral Cataracts, Bladder tumor removal, Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Edema: 1+ edeam Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2161-4-22**] 1:15 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 92123**] in [**12-15**] weeks for a follow-up appointment. Cardiologist Dr.[**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] in [**12-15**] weeks for a follow-up appointment. Please call cardiac surgery if need arises for evaluation or readmission to hospital [**Telephone/Fax (1) 170**] Coumadin for Atrial Fibrillation: INR Goal 2.0-3.0 Coumadin follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24524**] as previous [**Telephone/Fax (1) 92123**] Completed by:[**2161-3-14**]

80111,3485,80121,319,3439,34590,81000,E8809

Admission Date: [**2157-10-30**] Discharge Date: [**2157-11-5**] Date of Birth: [**2119-1-21**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: status post fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a 38 year old female with history of [**First Name3 (LF) 91272**] palsy and mental retardation who is non verbal at baseline who was at her group home when she fell down some stairs striking the back of her head. The patient was brought to an outside hospital and received Zofran, 1 gram fosphenytoin, and Reglan. A Head CT was performed which was consistent with skull fracture and temporal contusions and the patient was transferred to this hospital for further treatment and evaluation. The patient presents to the ED alone. There is no one to relay the events of the fall. Information was taken from the chart to complete the history. The brother was called at home and he was able to describe the patient's baseline mental status as non verbal with minimal eye contact and minimal interaction with strangers. The patient uses gestures at times to communicate. She lives in a town house with three other residents with 24 hour supervision and attends a day school. Normally the patient ambulates around her home independently. Past Medical History: [**First Name3 (LF) 91272**] palsy, mental retardation. Social History: lives in a group home, she is able to do activities of normal living, she in nonverbal at baseline Family History: NC Physical Exam: On Admission: O: T:98.7 BP: 144/82 HR:84 R:16 O2Sats: 100% Gen: flicker eye opening to noxious, GCS 8 HEENT:Laceration occiput. No raccoon sign, No Battle Sign, No otorrhea, NO tympanum Pupils: 4.5-3 EOMs:pt unable to perform Neck: hard cervical collar Extrema: Warm and well-perfused. Neuro: Mental status: no commands, non verbal, no eye opening-(baseline MR [**First Name (Titles) **] [**Last Name (Titles) 91272**] palsy with inability to communicate) Orientation/Recall/Language: patient is non verbal Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4.5 to 3 mm bilaterally. Visual fields: patient is unable to cooperate with exam III, IV, VI,V, VII,VIII, IX, X,[**Doctor First Name 81**],XII: patient does not cooperate with exam Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Bilateral upper extremities spontaneous movement, bilateral lower extremities bends knees spontaneously. NO Commands. Pronator drift- pt does not cooperate with exam Sensation: pt does not cooperate with exam Toes downgoing bilaterally Coordination:pt does not cooperate Discharge exam: Eyes open to voice. Will follow commands intermittently. Moves all ext with good strength. Pertinent Results: CT HEAD W/O CONTRAST Study Date of [**2157-10-30**] 7:44 PM Left frontal and right parietal subarachnoid hemorrhage - small and stable. small left subdural hematoma as well. Contusions left frontal lobe/left temporal lobe with surrounding edema. Midline shift 3 mm to the right - unchanged.Non-displaced fracture involving the greater [**Doctor First Name 362**] of the sphenoid on the right extending posteriorly into the right parietal bone. Labs: WBC RBC Hgb Hct Plt Ct [**2157-10-30**] 19:15 12.5* 4.25 12.3 36.8 231 BASIC COAGULATION (PT, PTT,INR) [**2157-10-30**] 19:15 12.1 20.7* 1.0 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2157-10-30**] 19:15 160*1 12 0.7 137 3.8 102 20* 19 [**2157-10-30**] Pelvis AP Single AP view of the pelvis was obtained. No acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are not widened. There is a linear radiopaque structure measuring approximately 6 mm projecting over the soft tissue superior to the right greater trochanter. Recommend clinical correlation for whether this is external to the patient, artifact, versus embedded foreign body. CT head [**2157-10-31**]: No significant interval change in multicompartmental hemorrhage since [**2157-10-30**], including subarachnoid, subdural and parenchymal hemorrhage, with no evidence of expansion of the small right frontoparietal epidural hematoma. [**2157-10-31**] CT head In comparison with the study of [**10-30**], single view does not show the linear opacification suggested on the previous study. The prior finding presumably represented an artifact. [**2157-11-1**] MRI c-spine 1. No evidence of ligamentous injury. Normal alignment. Please note that a CT scan would be more sensitive for a subtle fracture, particularly in the posterior elements. 2. Global spinal canal narrowing from C3 through C6 due to congenitally short pedicles. This is exacerbated by degenerative disease, most notable at C3-C4 and C4-C5, where a moderate spinal canal narrowing with spinal cord deformity is present. However, spinal cord signal remains normal. 3. Moderate neural foraminal narrowing at several levels, as detailed above. [**2157-11-2**] R Clavicle X ray Non displaced R clavicular fracture Brief Hospital Course: Ms. [**Name13 (STitle) 91273**] was admitted to neurosurgery into the ICU for further management. She had a repeat CT head on [**10-30**] which demonstrated evolution of SDH with slight increase in edema. A repeat was performed on [**10-31**], which showed stable evolution of left frontal and temporal contusions. During the day, she had developed episodes of questionalble simple partial seizures of her right face. She had a therapeutic dilantin level, keppra was initiated. Neuromed was consulted and they recommended a 24 hour EEG and to hold keppra. Additionally, pt require a cervical hard collar during her admission and a cervical MRI was ordered but was cancelled due to foreign body in the right hip. A repeat pelvis xray demonstrated no harware, only artifact. She was cleared for MRI imaging of the cervical spine which did not demonstrate ligamentous injury. It did demonstrate some congenital anitomical varients which were insignificant. Her collar was removed in the afternoon of [**11-1**]. She was tolerating a soft/ground diet. She was more alert inthe afternoon. She was transfered to the floor. She had one epsidoe of self-limiting epistaxis. She was doing well with her altered diet. She had clavicle imaging with no further displacement. Orthopedics was called and they recommended a sling as needed for comfort and follow up with orthopedics in one week. She was seen by PT and required rehab. Dilantin was discontinued. The EEG showed showed no active seizure activity but she will remain on Keppra 1000mg [**Hospital1 **] for treatment of her seizures while in the hospital. Medications on Admission: Desogen 1 tab po qd, Levoxyl 50 mcg 1 tab po qd, lexapro 10 mg 1 tab po qd, multivitamin, MiraLax. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain headache. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for headace/pain. Discharge Disposition: Extended Care Facility: [**Hospital1 3894**] Nursing & Rehabilitation Center - [**Location (un) 5503**] Discharge Diagnosis: Seizure [**Location (un) **] Palsy Mental Retardation Aphasia Skull Fracture / non dispalced Subdural hemaotoma Intraerenchymal hemorrhage Subarachnoid hemorrhage subgaleal hematoma tahcycardia hypertension Right clavicel fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General 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. ?????? 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. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. This is to prevent seizures. You must take it for 3 months. ?????? 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 call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain with contrast. You need to see the orthopedics department for follow up on your right clavicle fracture. You have an appointment on Thursday [**11-10**] at 9:20 in the [**Hospital Ward Name 23**] Bld, [**Location (un) **], [**Hospital Ward Name **]. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2157-11-4**]

07044,452,51881,34839,1550,4254,5789,5849,2760,2851,5712,5728,4019,V4986,28860,30503

Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-23**] Date of Birth: [**2061-7-9**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: persistent encephalopathy Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Endoscopy (OSH) History of Present Illness: Mr. [**Known lastname 1349**] is a 60y/o gentleman with EtOH and HCV cirrhosis complicated by ascites, varices with bleeding in the past, HCC s/p TACE [**12/2121**] who presented to [**Hospital3 **] Hospital on [**2-18**] after being found unresponsive requring intubation and is transferred to the [**Hospital1 18**] MICU due to continued encephalopathy. . His wife reports that on the evening of [**2-17**] he was doing fine (oriented x3). Early on [**2-18**] at 2AM he felt nauseated and had dry heaves. Passed foul-smelling loose stools. Was lethargic and confused, not answering questions appropriately so his wife gave him an extra dose of Lactulose. Later that morning at 10AM she found him unresponsive with slow breathing. She called 911 and he was taken to [**Hospital3 **] Hospital. . There, he was hemodynamically stable, was intubated for airway protection. Head CT and CT abdomen/pelvis were unrevealing. He was noted to have maroon stools. His hospital course has been significant for GI bleed (Hct 32 but was noted to pass some blood clots per rectum so received a total of 3u pRBC, 2u FFP, vitamin K, and is on an IV PPI and Octreotide gtt), fever to 102 of unclear source being covered empirically with CTX/Flagyl then switched to Zosyn/Flagyl on [**2-19**] when he developed a leukocytosis, and shaking episodes yesterday and today (head tilting to right with head jerking movements - received Ativan yesterday). He was being sedated with a Versed drip @8/hr for ~36hrs, but then he was switched to Propofol. Despite QID Lactulose, his mental status is no more clear so he is transferred here for further workup/management. . On arrival to the MICU, he is intubated and sedated. Not responding to voice but withdrawing from pain. Past Medical History: Past Medical History: - EtOH and Hep C Cirrhosis, Hepatocellular CA, Ascites, ESLD - s/p [**2122-1-1**] TACE transarterial chemoembolization of HCC - 3 bands of grade 1 varices, last bleed [**2119**] ([**State 108**]) - failed treatment for HCV (IFN, IFN/Ribavirin 10 yesrs ago) - GI bleed from duodenal ulcer - Dilated cardiomyopathy with an ejection fraction of 55% - Hypertension - Hypogonadism - IBS . Past Surgical history: - Herniorrhaphy x 3 - Right wrist fracture s/p fixation - Left toe surgery - Knee arthroscopy x 4 Social History: -Home: Lives with wife [**Name (NI) **]. They have an adopted daughter. [**Name (NI) **] 4 children from a prior marriage. -Tobacco: None -EtOH: prior history of heavy use, quit 6 yrs ago but relapsed and now has been sober again for 6 months -Illicits: None Family History: No history of cancer or hepatitis. Physical Exam: Admission Vitals: T: 100.1 BP: 125/62 P: 117 O2sat 100% on PS 10/5, rate 20, FiO2 60% Gen: well-nourished gentleman appearing his stated age, intubated, sedated HEENT: Anicteric sclerae, MMM, normal oropharynx CVS: RRR, no MRG. Resp: CTAB, no rhonchi or crackles Abd: Obese but nondistended, no rebound or guarding Ext: Warm, 2+ DP and PT pulses bilaterally; no edema or cyanosis; right femoral CVL site with no erythema or hematoma Neuro: withdraws to pain, VOR intact, bracioradialis 2+ bilaterally, patellar reflexes 1+ bilaterally Discharge: Expired Pertinent Results: [**2122-2-18**] EGD (OSH) small esophageal varices without bleeding, no blood in the stomach, nodules in the gastric body, few gastric antral erosions . [**2122-2-18**] CT ABDOMEN/PELVIS W/O CONTRAST (OSH) 1. Abnormality of the right hemicolon with mural thickening may be secondary to portal hypertension although the possibility of colitis is difficult to exclude 2. Hepatic cirrhosis and new extensive abnormality in the right lobe of the liver suspicious for HCC 3. Abdominal ascites 4. Periportal lymphadenopathy 5. Gallstones 6. Right renal cyst unchanged and isodense nodule of right kidney also unchanged 7. Colonic diverticulosis without acute diverticulitis 8. Small right inguinal hernia containing fat 9. Bibasilar atelectasis and/or infiltrates . [**2122-2-18**] CT HEAD W/O CONTRAST (OSH) No evidence of acute intracranial abnormality. Mucous retention cysts in maxillary sinuses. . [**2122-2-21**] Liver U/S Limited examination showing unchanged thrombosis of the anterior right portal vein. Minimal/slow flow in the main portal vein noted, although this could be related to the limited examination. Patent hepatic artery. No significant ascitic fluid noted. . [**2122-2-21**] CTA Abd/Pelvis 1. Hyperdense material within the cecum and small bowel resection anastomosis. These regions are potential candidates for a bleed source. No active extravasation is seen. 2. New, likely bland thrombus within the main portal (nearly occlusive) and right portal veins (occlusive)and origin of left portla vein (nearly occlusive) since the [**2122-1-29**] MR examination. 3. Post-TACE changes and small hypodense nodules, representing tumor thrombi, in segment 5. No definite arterially enhancing hepatic lesions identified. 4. Varicose veins at the anterior abdominal hernia repair site and small bowel anastomosis. 5. Cholelithiasis. 6. Small amount of abdominal and pelvic ascites. Brief Hospital Course: Mr. [**Known lastname 1349**] is a 60y/o gentleman with EtOH and HCV cirrhosis complicated by ascites, varices, HCC s/p TACE [**12/2121**] who is transferred from an OSH with continued encephalopathy, GI bleed, and fevers. . #. Encephalopathy: likely multifactorial. Acute onset of depressed level of consciousness at home could represent hepatic encophalopathy. Has been taking Lactulose QID but no report of if he has been stooling. Precipitants could include upper GI bleed, medication effect (was on a Versed drip at OSH for ~36h), or infection (see "fevers" below). Doppler and CT Abdomen visualized portal vein thrombus which likely is contributing to current presentation of encephalopathy. Switched to bolus sedation and continued lactulose and rifaximin without improvement of mental status. Given his poor prognosis and absence of mental status, patient was terminally extubated on [**2-21**] and transitioned to CMO. . #. Bloody loose stools: lower GI bleed vs brisk upper GI bleed. Has history of bleeding ulcers as well as esophageal varices. At the OSH, he underwent EGD showing portal gastropathy and small gastric nodules which were not bleeding; had "diminutive varices." Patient had persistent Hct drops during this hospitalization along with persistently bloody bowel movements. Patient was transfused a total of 5units and CTA was obtained showing sources of bleeding in the cecum and at a prior small bowel anastomosis, likely ectopic varices. Initial plan was for colonoscopy but goals of care were discussed with family and as it was felt that this was a nonintervenable source of bleeding, supportive transfusions were discontinued and no further interventions were undertaken. PPI and octreotide drips were continued and patient was transitioned to CMO. . #. Fevers: Initially concerning for infection. Had leukocytosis and had bandemia at OSH. Sources could include PNA (especially concerning while intubated), UTI, SBP. Tap here was not suggestive of infection and CXR and urine were unremarkable. He was covered with Zosyn and Flagyl which were discontinued on HD #2 as there was no clear source of infection. . #. [**Last Name (un) **]: Prerenal with low urine Na and FeNa. Creatinine improved somewhat with fluids. . #. HCV and EtOH cirrhosis: No response to lactulose and rifaximin so these were discontinued. His lasix and spironolactone were held. . # Code Status: Given patient's persistent absence of mental status improvement, his poor prognosis given his underlying HCC and ongoing GI bleed, patient was made CMO on HD #2. Medications on Admission: - Spironolactone 200 mg daily - Furosemide 80 mg Tablet daily - Ursodiol 500 mg [**Hospital1 **] - Lactulose 10 gram/15 mL 15-30 MLs PO QID - Rifaximin 550 mg [**Hospital1 **] - Gabapentin 300 mg TID - Temazepam 30 mg QHS - Citalopram 10 mg daily - Sodium fluoride 1.1 % Gel [**Hospital1 **] - Pantoprazole 40 mg [**Hospital1 **] - B complex vitamins daily - Magnesium oxide 400 mg daily - Calcium 600 + D(3) 600 mg(1,500mg) -400 unit [**Hospital1 **] - Testosterone 1 %(50 mg/5 gram) Gel daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2122-2-23**]

3241,34830,51881,3229,5119,42832,4280,73027,2851,70715,42731,30500,79902,25000,79092,41400,2449,311,V5861,0414,04102,V4581,V454,3051,7821,32723

Admission Date: [**2171-7-8**] Discharge Date: [**2171-7-23**] Date of Birth: [**2115-2-1**] Sex: M Service: MEDICINE Allergies: Penicillins / morphine / IV Dye, Iodine Containing Contrast Media / Zestril / Glucocorticoids (Corticosteroids) / Lipitor / ceftazidime Attending:[**First Name3 (LF) 2751**] Chief Complaint: Back pain Respiratory distress Major Surgical or Invasive Procedure: - Endotracheal intubation - T6 & T7 laminectomy for evacuation of epidural hematoma. - L hallux amputation History of Present Illness: Mr. [**Known lastname 89225**] is a 56-year-old gentleman with a history of atrial fibrillation on coumadin, DM, CAD s/p 3-vessel CABG & chronic back pain s/p spinal surgery in [**2166**] who complained of worsening "flank pain" after having a root canal on [**2171-7-3**]. The next day he was unable to stand & the pain was described as being much worse than his chronic back pain. He initially presented to [**Hospital **] [**Hospital 1459**] Hospital on [**2171-7-7**] with back pain that was radiating to the top of his thights. He was discharged but returned later that day. On his second presentation, labs were drawn which revealed an INR 17 (the patient had been taken antibiotics in association with his root canal). The patient was started on ceftriaxone for a possible toe infections that was noted on exam. The patient was transferred to [**Hospital1 18**] for MRI (he has an allergy to contrast). A repeat INR was 4.5 s/p Vit K administration. In the ED, the patient was noted to be tachypneic & in respiratory distress s/p IV dilaudid & valium (for concern about possible EtOH withdrawal) administration; he was subsequently intubated. He was started on broad-spectrum antibiotics (cefepime & vanco), and was admitted to the MICU. In the ED, he was writhing in pain and was given Dilaudid. He drinks 3-4 drinks per day, but had not in the last 3 days. Given the posibility of withdrawal, he was given valium. He became hypoxic to the low 80s, tachypneic, and was intubated. A CT head was negative for an acute process. His INR here was 4.5. He was started on cefepime for a presumed L toe infection. He remained persistently tachycardic to high 120s/low 130s, even after intubation and sedation for which he was admitted to the ICU. Past Medical History: - CAD s/p CABG x3 in [**2163**], s/p stents - [**8-/2166**] bone graft - diabetes - carotid stenosis - anemia - atrial fibrillation - chronic back pain Social History: - Currently on disability from a job as a dispatcher - Previously worked as an critical care nurse - Denies tobacco use - Drinks approximately [**3-15**] drinks per day. He wife believes that he has had withdrawal symptoms in the past during previous hospital admissions, although he has never had seizures, nor has been been admitted for detoxication. - Lives with his wife. Family History: - Not-contributory Physical Exam: ADMISSION EXAM: Tmax: 37.2 ??????C HR: 130 BP: 115/86 RR: 22 SpO2: 96% GENERAL: Intubated, sedated HEENT: Sclera anicteric, PERRL, MMM COR: Tachycardic, regular. Normal S1S2, no m/g/r. PULM: Clear to auscultation bilaterally, no wheezes, rales, ronchi ABDOMEN: Obese, + NABS. Soft, non-tender, non-distended. No rebound or guarding, no organomegaly. GU: Foley in place EXT: Warm, well-perfused. 2+ pulses. Large ulcers in bilateral great toes. The left leg has a necrotic center with pus draining. DISCHARGE EXAM: T 98.3 HR 54 BP 126/76 RR 18 SP02 97% Gen: well-appearing, NAD HEENT: no lymphadenopathy, MMM, PERRL CV: Irregularly irregular, no murmurs Lungs: CTA b/l Abd: obese, +BS, soft, NT ND, no organomegaly Ext: WWP, no CCE, Left hallux amputed with clean dry dressing Back: well-healed midline scar over thoracic spine Pertinent Results: ON ADMISSION: [**2171-7-8**] WBC-15.0* RBC-4.63 Hgb-13.2* Hct-39.9* Plt Ct-168 Neuts-78* Bands-1 Lymphs-14* Monos-5 Eos-0 Baso-0 Atyps-2* PT-43.3* PTT-41.9* INR(PT)-4.5* Glucose-126* UreaN-33* Creat-0.9 Na-139 K-4.4 Cl-104 HCO3-22 AnGap-17 ALT-21 AST-27 AlkPhos-124 TotBili-0.8 cTropnT-<0.01 Art. Blood gas Rates-22/ Tidal V-550 PEEP-5 FiO2-100 pO2-386* pCO2-46* pH-7.34* calTCO2-26 CT Head IMPRESSION: No acute intracranial process. Specifically, there is no evidence of an acute hemorrhage CXR IMPRESSION: ET tube terminating 5.7 cm above the carina. Vascular crowding is seen in the setting of low lung volumes, however, no acute intrathoracic process is detected. Please note that the right costophrenic angle is completely excluded from the study. MR [**Name13 (STitle) **] IMPRESSION: 1. 5 cm x 13 mm x 9 mm left posterior epidural collection posterior to the T12 and L1 vertebral bodies is consistent with an epidural abscess with mild involvement of the left posterior paraspinal muscles. 2. Anterior displacement of the nerve roots of the cauda equina with mild thickening and clumping is most consistent with arachnoiditis. MR L spine [**2171-7-12**] IMPRESSION: Status post evacuation of epidural abscess. Except for tiny residual areas of fluid slightly above the level of the laminectomy site and also at T11-12 level majority of fluid seen within the epidural space is no longer visible. Some residual enhancement of the epidural soft tissues is noted with considerable decrease in mass effect on the thecal sac. No abnormal signal seen within the spinal cord. MR [**Name13 (STitle) 430**] [**2171-7-11**] FINDINGS: There is an area of slow diffusion in both occipital horns of the lateral ventricles. No corresponding abnormality is noted on the susceptibility T2 or T1-weighted images. No infarct, mass or mass effect is noted in the brain. There is no significant FLAIR hyperintensity within the brain parenchyma. The paranasal sinuses and mastoid air cells show mild fluid in the right maxillary and sphenoidal sinuses. IMPRESSION: Small areas of slow diffusion in both occipital horns concerning for pus within the ventricles. A small amount of blood is a less likely possibility. ECHO IMPRESSION: Very suboptimal image quality due to body habitus. Left ventricular systolic function is difficult to assess, ejection fraction is probably at least 45%. The right ventricle is not well seen. No significant valvular abnormality seen. ON DISCHARGE: [**2171-7-22**] 05:45AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.2* Hct-30.9* MCV-86 MCH-28.3 MCHC-33.0 RDW-17.1* Plt Ct-496* [**2171-7-23**] 05:48AM BLOOD PT-28.5* INR(PT)-2.8* [**2171-7-22**] 05:45AM BLOOD Glucose-107* UreaN-11 Creat-1.2 Na-136 K-3.6 Cl-100 HCO3-28 AnGap-12 Coags: [**7-20**] - INR 1.9 (warfarin 3.5mg) [**7-21**] - INR 2.9 (warfarin held) [**7-22**] - INR 3.2 (warfarin held) [**7-23**] - INR 2.8 (warfarin 3mg) Brief Hospital Course: 56 yo male w/ CAD s/p CABG & stents, Afib on coumadin and EtOH abuse here w/ acute on chronic back pain. Pt was admitted to the MICU after intubation in the ED for hypoxia. ACUTE DIAGNOSES: # Epidural Abscess & Hematoma: The patient was intubated on admission to the MICU. An MRI was obtained which showed an epidural fluid collection concerning for infection or hematoma. He was started on vancomycin and piperacillin-tazobactam. Neurosurgery was consulted and considered that the fluid was a hematoma consistent with his INR of 17 at presentation. His INR was partially corrected after FFP and Vit K to an INR of 4.5. On hospital day 2, a repeat MRI was ordered to help further identify the fluid collection. On hospital day 4, the patient had a brain MRI due to a concern for his mental status (given that he was not responding off of sedation). After his INR was corrected to 1.4 in preparation for surgery, he underwent a T5-T8 laminectomy and hematoma evacuation, during which purulent material was also found in the space. The culture from the epidural mass showed pan-sensitive E-coli as well as Group B strep. As per ID recs, the Pip-Tazo was changed to Ceftazadime, which was then changed to ciprofloxacin because of a drug rash presumed to be secondary to the ceftazidime. ID recommends continuance of the Vancomycin and Ciprofloxacin for a duration of 6 weeks (Vanc started on [**2171-7-8**], Cipro started on [**7-16**]). # Supratherapeutic INR: The patient presented to OSH with an INR of 17. His INR decreased to 4.5 after treatment with fresh frozen plasma & vitamin K. The patient states that he had recently been on a cephalosporin in preparation for his root canal procedure. His coumadin was resumed on [**2171-7-18**] after his podiatric surgery. Due to the ciprofloxacin, his coumadin was held for a few days with a slightly high INR. He was restarted at a lower dose of 3mg daily, but will need consistent monitoring while being treated with cipro. # ? Ventriculitis: The patient's MRI brain revealed "small areas of slow diffusion in both occipital horns concerning for pus within the ventricles. A small amount of blood is a less likely possibility." The patient will be on antibiotics for 6-8 weeks and neurosurgery did not feel that this finding required intervention. However, this radiographic finding will be followed up with a repeat head CT without contrast in [**6-19**] weeks. # Atrial fibrillation & Tachycardia: The patient had occasional tachycardia of unclear etiology. Possibilities included hypovolemia, atrial flutter, discomfort, or infection. After the MRI, the pt became agitated and developed Afib with RVR with a heart rate in 110's. Rate control was achieved with diltiazem 10 and 10 of metoprolol; the pt remained normotensive throughout. He had one further episode of rapid atrial fibrillation on the floor, which ultimately responded to 15 mg IV diltiazem. # Encephalopathy: Following his laminectomy, extubation, and weaning off sedation, the patient had episodes of aggression, cursing, and agitation. He appeared to be talking to people who were not present in the room. Psych was consulted, and it was felt that it was likely due to delirium. He was treated with seroquel and haldol, and his mental status steadily improved. While alcohol withdrawal remained a possibility, his lengthy hospitalization made the timeline for withdrawal unlikely. Upon transfer to the floor, the patient was alert & oriented to person, place, & time with a clear mental status. He had no further bouts of aggression or confusion # Congestive Heart Failure: The patient's volume status & I/O's were monitored throughout hospitalization. He occasionally required some diuresis with lasix while he was on the floor. His home spironolactone & metoprolol were held until the patient was able to take medications by mouth. #Foot ulcers: The patient was noted to have bilateral toe ulcers on admission; he had necrotization with purulent discharge of the left hallux. Podiatry was consulted and the patient underwent a left hallux amputation on [**2171-7-18**]. He will f/u with podiatry as an outpatient. CHRONIC DIAGNOSES: # Depression & Hypothyroidism: The patient was continued on his home levothyroxine & citalopram. # Diabetes: The patient's metformin was held during hospitalization and an insulin sliding scale was instituted. TRANSITIONAL ISSUES: # Follow-up: The patient has several follow-up appointments with neurosurgery, infectious disease, & podiatry. He will need a head CT without contrast in [**6-19**] weeks (prior to his outpatient neurosurgery appointment). # Lab Work: The patient will need weekly lab draws while he is on IV vancomycin. He will have services established upon discharge to arrange his weekly CBC, BUN/CR & vanco level checks. He will also need consistent INR monitoring while on cipro. Medications on Admission: - celexa 10mg daily - vitamin E 400 units daily - colace 100mg [**Hospital1 **] - levoxyl 250mcg daily - omeprazole 20mg daily - spironolactone 25mg daily - naprosyn 500mg daily PRN - metoprolol 100mg [**Hospital1 **] - coumadin - ASA 81mg - crestor 10mg daily - proair 90mcg 2 puffs Q6hrs - metformin 500mg [**Hospital1 **] - potassirum ER 20 mEq Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours) for 6 weeks. 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day. 11. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 13. naproxen 500 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 14. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 15. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 16. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a day for 6 weeks. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSES: - Spinal abscess - Left hallux infection - Atrial fibrillation SECONDARY DIAGNOSES: - CAD s/p CABG x3 in [**2163**], s/p stents - [**8-/2166**] bone graft - diabetes - carotid stenosis - anemia - atrial fibrillation - chronic back pain 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 89225**], it was a pleasure to participate in your care while you were at [**Hospital1 18**]. You came to the hospital because of back pain that worsened after some dental treatment. While you were here, you were admitted to the ICU. An MRI of your back showed that you had an area of infection with bleeding resting on your spine. You were taken to the operating room on [**2171-7-11**] to have this area of infection removed. You also had your left big toe amputated due to infection. The neurosurgeons & infectious disease doctors followed [**Name5 (PTitle) **] throughout your hospitalization. The infectious disease specialists recommended that you have 6-8 weeks of IV antibiotics to fight your infection. Medication Changes: - Medications ADDED: IV vancomycin 1250 mg twice a day for at least 6 weeks, oral ciprofloxacin 750 mg every 12 hours for at least 6 weeks - Medications CHANGED: Warfarin dose was lowered to 3mg daily, but will fluctuate with your INR - Medications STOPPED: None. Followup Instructions: Department: PODIATRY When: FRIDAY [**2171-8-2**] at 3:30 PM With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Name: MIDHA,SALIL [**Doctor Last Name 162**] Address: [**Last Name (un) **] [**Apartment Address(1) 82921**], [**Location (un) **],[**Numeric Identifier 28669**] Phone: [**Telephone/Fax (1) 40969**] When: Friday, [**8-9**], 2:30PM Department: INFECTIOUS DISEASE When: TUESDAY [**2171-8-6**] at 9:50 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2171-9-17**] at 10:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: WEDNESDAY [**2171-9-25**] at 8:30 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: WEDNESDAY [**2171-9-25**] at 9:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

41401,2762,4139,49120,27800,4019,V4582,V173,32723,29680,2724

Admission Date: [**2167-9-15**] Discharge Date: [**2167-9-22**] Date of Birth: [**2111-3-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: fatigue, weakness, dyspnea on exertion Major Surgical or Invasive Procedure: [**2167-9-15**] Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior left ventricular branch artery and the obtuse marginal artery History of Present Illness: 56 year old male with known coronary artery disease status post stents to right coronary artery and left anteriopr descending artery who now has complaints of fatigue and weakness. Several weeks ago he presented to [**Hospital **] Hospital with complaints of chest pain, ruled out for myocardial infarction, and was sent home for outpatient stress test which was abnormal. He presented on [**9-7**] for cardiac catheterization which revealed three vessel coronary artery disease. Now presents for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Cypher stents to RCA and LAD [**2164-5-31**], s/p LAD stent in [**2165**] Hypertension Hyperlipidemia COPD Chronic cough/bronchitis Bipolar disease Diverticulitis Recent "spot on liver"-found on imaging study for abdominal pain ***Episodes of epistaxis. Stopped ASA but continued plavix and epistaxis stopped. [**2137**] left ankle bullet wound injury, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] s/p tonsillectomy ear surgery as child Social History: Race: Caucasian Last Dental Exam: many years Lives with: wife Occupation: On disability Tobacco: 1ppd x45 years ETOH: Rare Recreational drugs: Marijuana daily Family History: Father died of MI age 59 Physical Exam: Pulse:83 Resp:16 O2 sat: 100%RA B/P Right:130/83 Left: 151/94 Height: 5'7" Weight:260 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema +2 Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: dressing Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left:0 Pertinent Results: [**9-15**] Echo: PRE BYPASS The left atrium is moderately dilated. The left atrium is elongated. Mild spontaneous echo contrast is seen in the body of the left atrium.. No thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). 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 moderate global left ventricular hypokinesis. In addition, the distal lateral, anterolateral, and anterior walls seem more hypokinetic than the other segments. The overall ejection fraction is about 35%. The right ventricle displays borderline normal free wall function. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POSTBYPASS The patient is atrially paced on a phenylephrine infusion. Global left ventricular function is now slightly improved (overall ejection fracture about 40-45%) although global left ventricular hypokinesis persists. The distal lateral, anterolateral, and anterior walls continue to be more hypokinetic than the other segments. Valvular function is essentially unchanged. Thoracic aorta is unchanged after decannulation. Brief Hospital Course: Mr. [**Known lastname 73256**] was a same day admit after undergoing his cardiac cath and pre-admission testing during previous hospital visit. On [**9-15**] he was brought directly to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed and he was transferred to the telemetry floor for further care. Beta blockers and diuretics were started and he was diuresed towards his pre-op weight. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing well and his pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Albuterol 90mcg inhaler-2 puffs PRN Plavix 75mg po daily Diltiazem 120mg po q12 hrs Advair Diskus 1 puff IH [**Hospital1 **] Furosemide 20mg po daily Atrovent 2 puffs IH four times a day Risperidone 2mg po qHS Sertraline 200mg po qHS Simvastatin 80mg po daily 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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. 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* 4. Zocor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 6. Zoloft 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* 7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1 puff Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 9. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puffs Inhalation four times a day. Disp:*1 MDI* Refills:*2* 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 11. Lasix 20 mg Tablet Sig: Take 2 tabs daily for 7 days, then decrease dose to 20mg daily. Tablet PO QAM: Take 2 tablets (40mg) daily with 20mEq potassium for 7 days, then decrease dose to 20mg daily without potassium supplement. Disp:*30 Tablet(s)* Refills:*2* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO QAM for 7 days: Take for 7 days with lasix and then stop. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 3 Past medical history: Hypertension Hyperlipidemia s/p Cypher stents to RCA and LAD [**2164-5-31**], s/p LAD stent in [**2165**] COPD Chronic cough/bronchitis Bipolar disease Diverticulitis Recent "spot on liver"-found on imaging study for abdominal pain ***Episodes of epistaxis. Stopped ASA but continued plavix and epistaxis stopped. [**2137**] left ankle bullet wound injury, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] s/p tonsillectomy ear surgery as child Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet prn Incisions: Sternal - healing well, no erythema or drainage. No instability. Leg Right/Left - healing well, no erythema or drainage. Edema 1+ bilaterally Discharge Instructions: 1. Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2. Please NO lotions, cream, powder, or ointments to incisions 3. Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4. No driving for approximately one month until follow up with surgeon 5. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 6. Take lasix 40mg (2 - 20mg tablets) once daily in the morning for 1 week, then decrease dose to 1 tablet (20mg) daily thereafter as per prior to surgery. You will take a potassium supplement 20mEq daily with your lasix dose of 40mg for for 1 week and then stop. 7. Please call with any questions or concerns. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on Wednesday [**2167-10-14**] at 1:00PM Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 73257**] [**Name (STitle) 19772**] in [**1-31**] weeks [**Telephone/Fax (1) 8506**] Cardiologist Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] in [**1-31**] 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:[**2167-9-22**]

486,34400,5119,2761,V6284,2930,80705,E8147,45829,27669,56400,2859,3090,V454,2724,3051,4019,V4986

Admission Date: [**2133-8-1**] Discharge Date: [**2133-8-6**] Date of Birth: [**2061-6-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 603**] Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 88733**] is a 72 year old gentleman who was discharged to [**Hospital 38**] rehab yesterday after admission for c3-t1 fusion following peds vs. MVA 1 wk ago leading to parapelgia, now presenting with confusion and respiratory distress. This morning at rehab he was noted to be in resp distress, with tachypnea and sats in low 90s, not aaox3. He was given O2 at the rehab and tachypnea resolved and sats improved to the high 90s. . In the [**Name (NI) **], pt was reportedly comfortable. Vitals on arrival were 97.8 (100.4 rectal) 72 145/77 16 97% 2L NC. CXR showed increasing bilateral pleural effusions with bibasilar consolidation ? atelectasis vs pneumonia. He was given vanc, cefepime and levofloxacin for treatment of HCAP. Blood and urine cultures were sent. He was admitted to the ICU because of concern for partial diaphramatic paralysis from his recent accident which could lead to respiratory distress. Vital signs on transfer were stable. . On the floor, pt is aaox0. Unable to answer any medical hx questions. Denies pain. States his breathing is a little difficult. Otherwise answers "no" to most questions. Past Medical History: -hyperlipidemia -tonsillectomy -maxillary surgery with likely screw placed for intractable nose bleed -MVA vs peds accident 1 wk PTA requiring multiple orthopedic procedures Social History: Prior to his accident, Mr [**Known lastname 88733**] was retired and lived in his home alone. Smokes 1 ppd, occ EtOH, no drug use. Family History: unknown Physical Exam: Admission: VS: Temp: BP: 164/95 HR:84 RR:21 O2sat 95% 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, [**Location (un) 2848**] J-collar in place CV: RR, S1 and S2 wnl, no m/r/g RESP: rhonchorous BS in L base, otherwise CTA b/l. Poor air movement, belly breathing, poor cough, minimal acccessory muscle use. ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: boots in place. R arm wrapped in gauze. 1+ edema in upper extremities, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], no CCE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx0. Cn II-XII intact. unable to follow commands. Moves arms and legs spontaneously but does not follow commands. Discharge: VS: Temp: 97.9 BP: 144/72 HR:56 RR:24 O2sat 97% 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, [**Location (un) 2848**] J-collar in place CV: RR, S1 and S2 wnl, no m/r/g RESP: mildly decreased breath sounds @ left lower lung base, otherwise CTA b/l. Moderate air movement, belly breathing, occasional difficulty with cough. ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: boots in place. R arm wrapped in gauze. 1+ edema in upper extremities, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], no CCE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. Conversant. Total paralysis of the lower extremity bilaterally. Limited ability to raise UE b/l to face, strength 3/5 in biceps, adduction 3-4/5. Pertinent Results: [**2133-7-31**] 06:19AM BLOOD WBC-8.3 RBC-2.74* Hgb-9.2* Hct-26.1* MCV-95 MCH-33.6* MCHC-35.4* RDW-13.1 Plt Ct-246 [**2133-8-1**] 02:12PM BLOOD Neuts-89.0* Lymphs-6.8* Monos-3.6 Eos-0.4 Baso-0.1 [**2133-8-1**] 02:12PM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.2* [**2133-8-1**] 02:12PM BLOOD Ret Aut-3.9* [**2133-7-31**] 06:19AM BLOOD Glucose-94 UreaN-14 Creat-0.4* Na-135 K-4.3 Cl-102 HCO3-28 AnGap-9 [**2133-8-1**] 02:12PM BLOOD ALT-25 AST-36 AlkPhos-101 TotBili-0.5 [**2133-8-1**] 02:12PM BLOOD Lipase-31 [**2133-8-1**] 02:12PM BLOOD proBNP-2173* [**2133-7-31**] 06:19AM BLOOD Calcium-7.4* Phos-2.6* Mg-2.0 [**2133-8-1**] 02:12PM BLOOD Albumin-2.6* Iron-35* [**2133-8-1**] 02:12PM BLOOD calTIBC-215* Ferritn-146 TRF-165* [**2133-8-2**] 11:09AM BLOOD Type-ART Temp-37.1 FiO2-40 pO2-94 pCO2-35 pH-7.46* calTCO2-26 Base XS-1 Intubat-NOT INTUBA [**2133-8-1**] 04:23PM BLOOD Lactate-0.9 [**2133-8-2**] 11:09AM BLOOD Lactate-0.8 REPORTS: CXR [**2133-8-1**] IMPRESSION: Increasing bilateral pleural effusions with bibasilar consolidation which may represent atelectasis and/or pneumonia. No pneumothorax. Left-sided rib fractures are again noted. LUE U/S [**2133-8-2**] INDICATION: Upper extremity swelling. COMPARISON: No relevant comparisons available. FINDINGS: Doppler and grayscale son[**Name (NI) 1417**] of the bilateral subclavian veins and the left internal jugular, axillary, basilic, brachial, and cephalic veins was performed. There is normal compressibility, flow and augmentation. IMPRESSION: No left upper extremity DVT. CLINICAL INFORMATION: A 72-year-old male status post motor vehicle collision, now paraplegic, question need for G-tube. VIDEO OROPHARYNGEAL SWALLOW [**2133-8-5**] COMPARISON: [**2133-7-30**]. TECHNIQUE: Barium containing foods of various consistencies were administered by the speech pathologist. FINDINGS: There is normal swallowing function. Mild-to-moderate vallecular pooling is noted, which is cleared with swallows of thin liquids. There is no laryngeal penetration or aspiration. IMPRESSION: No laryngeal penetration or aspiration. Please see the speech pathologists note for further details. The study and the report were reviewed by the staff radiologist. MICRO: [**2133-8-2**] URINE Legionella Urinary Antigen -PENDING INPATIENT [**2133-8-1**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2133-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2133-8-1**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2133-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Brief Hospital Course: 72 yo gentleman with recent hemiplegia s/p peds vs MVA, s/p c3-t1 fusion, now presenting from rehab with AMS and respiratory distress. Active Issues: #. Respiratory distress/Pneumonia: At rehab patient noted to be dyspneic. On presentation to the ED, the patient was reportedly comfortable with minimal O2 supplementation (2-3L NC) Admission CXR demonstrated bilateral increasing pleural effusions with bibasilar consolidations. Bibasilar considations thought secondary to aspiration vs hospital acquired pneumonia. Patient started on vanc/levoquin/cefepime which was eventually tailored to vanc/cefepime. Urine legionella negative. Patient respiratory status improved while on treatment. In regard to his aspiration risk, a swallow study was performed and advanced to a video swallow study, which demonstrated normal swallowing function without laryngeal penetration or aspiration. Pleural effusions were thought secondary to volume overload (patient was 14L up last admission) with possible parapneumonic contribtion. PNA was treated. In addition patient was actively diuresised with 5mg -10mg of IV lasix daily. Throughout his time on the medicine floor, the patient also received an evaluation and extensive chest PT. At time of discharge patient was saturating >92% on RA with improved aeration on exam. #. AMS: On admission, the patient was delerious, likely due to PNA, hypoxia. Although metabolic/electrolyte abnormalities were considered as a source of AMS, the minimal degree of the patient's hyponatremia (130) was deemed unlikely to cause AMS. While in the MICU, his mental status cleared upon abx, diuresis, and chest physical therapy, and his sensorium remained clear from his transfer to the medicine floor and onward. #. Hypotension: After the patient's initial diuresis in the MICU (20mg IV lasix), his SBP decreased to the to the 80s, which however was asymptomatic without change in MS, urine output, heart rate. BPs stabilized overtime on their own. Hypotension was thought to be secondary to intravascular volume depletion in setting of low albumin state vs autonomic dysreflexia. Blood pressures improved with stimulation and 25gm of albumin in 500cc. There were no sign of sepsis. On the medicine floor, his pressures remained stable, and he was diuresed on multiple occasions without his systolic blood pressure decreasing below the 100s. #. Hyponatremia: Thought to be [**3-4**] a combination of hypervolemia and diuresis with free H2O intake. Improved with fluid restriction and further diuresis with IV lasix. Also helpful was switching abx fluid from D5 to NS. At the time of discharge, the patient's serum sodium level had increased from 130 to 135. # Depression Shortly after the [**Hospital 228**] transfer to the floor, he became withdrawn and dysphoric, stating that he no longer wished to have any treatment. His wishes were respected, and antibiotics were briefly held, although he stated that he wished to continue receiving IV fluids. At this time, he also endorsed suicidal ideations and mentioned that he had made a suicide attempt approximately 30 years prior. He was subsequently placed on 1:1 precautions. A psychiatric evaluation was requested for a capacity evaluation. The psychiatry team felt that although dysphoric, he did not seem to be suffering from major depression, and was coherent and logical in his thought process. He was able to clearly articulate the risks associated with not treating his pneumonia, including that he might die. His desire to be left to die stemmed from the decline in the quality of his life since the accident, and not from depression, per se. The best course of action was being contemplated by all physicians, however the next morning, he stated that he had changed his mind. This change in sentiment resulted from several conversations with friends which had helped him decide that he would like to give life a shot. He had also been visited by PT, who helped him understand that there is a chance he will regain some function of his hands, and was given information regarding the psychiatric prognosis related to spinal cord injury - namely that most people are much more satisfied with their situation 6 months to a year after the accident. He accepted antibiotics after this point and was cooperative with further evaluations. He was not felt to be a suicide risk at present, per psychiatric evaluation, and he was also provided counseling by a social worker. The patient expressed a desire to speak with the psychiatrist again, and was amenable to doing so in the future. At the time of discharge, the patient stated that he was hopeful that he could recover a degree of independence, and his mood was considerably improved compared to his initial presentation on the medicine floor. He was also told that he may schedule a psychiatry outpatient appointment via his PCP. [**Name10 (NameIs) 2772**], [**Name Initial (NameIs) **] remaining issue is that he mentioned that he does possess a firearm in his home, and given his recent depression it is necessary to make sure that this issue is addressed as soon as is feasible. Patient should be re-evaluated by psychiatry or psychology at rehab to assess mood, social supports with plans to arrange family meetings, as well as ongoing discussion of end of life care. Of note patient does have loaded firearm at home and has expressed suidical ideation in the past but not at time of discharge from [**Hospital1 18**] . Chronic Issues: #. Anemia: Pt's H/H remained near his recent baseline throughout his hospitalization, with no clear source of bleed. This is consistent with losses from recent procedures and prior trauma. This issue remained remained stable throughout the period of hospitalization. # Hypertension: Initially, midodrine was held given his hypertension shortly after presentation. Thereafter, his BPs stabilized and this was restarted shortly after his admission to the floor. # Hyperlipidemia: Continued atorvastatin; this issue remained unchanged throughout the hospital course. # Tobacco use: Continued nicotine patch; this issue remained unchanged throughout the hospital course. Transitional issues # Med rec: Famotidine discontinued, no clear indication at this time. # s/p peds vs MVA Given the patient's multiple orthopedic injuries and paraplegic status, he continues to have little movement in UEs. He is to continue wearing his C-collar when out of bed. As mentioned above, the patient's disability remains a cause of deep distress, and much of his psychological improvement may be contingent on his continued involvement with social supports and measures designed improve his mobility and independence. # CODE: DNI/DNR at time of discharge; plan to continue having ongoing discussions regarding end of life care Medications on Admission: Meds on transfer (per dc summary [**2133-7-31**]): 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q 3 hrs as needed for pain. 11. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 14. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 5 days. DC [**2133-8-4**] Discharge Medications: 1. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 days: start date [**8-3**]; end date [**8-11**]. Disp:*11 soln* Refills:*0* 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. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal discomfort. 14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain/fever. 15. Zosyn 4.5 gram Recon Soln Sig: 4.5 gram Intravenous every six (6) hours for 6 days: end date [**8-11**]. Disp:*23 soln* Refills:*0* 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 17. 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. 18. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO TID (3 times a day) as needed for constipation. 19. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO ONCE (Once) as needed for bloating. 20. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**2-1**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Altered Mental Status secondary to Pneumonia 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 88733**], You were admitted to the hospital from your rehabilitation facility because you had become confused and were having difficulty breathing. You were admitted to the medical intensive care unit where you were monitored overnight, and a chest x-ray showed that you had a pneumonia which may have caused fluid to build up in your lungs which was making it difficult for you to breathe. You were treated with IV antibiotics, and you became more responsive. You were later transfered to the general medicine floor, where you were given medication to help you to get rid of some of the extra fluid you had. You responded well to the medication and the fluid cleared from your lungs. You were also given an evaluation of your ability to swallow to ensure that you will be able to take in adequate nutrition when you are at rehab. The test demonstrated that your ability to swallow is generally intact, and you should be able to handle progressively more difficult foods while you are in rehab. You were also seen by a psychiatrist during your time on the medicine floor because it was felt that you could use additional support to discuss how you were reacting to the accident. Toward the end of your hospital stay, you received a special type of IV line called a PICC line. This IV line will stay with you when you leave the hospital so that you can continue to receive your complete course of antibiotics while in rehabilitation. During your hospital stay, the following changes were made to your medications: To treat infection: start taking Abx with scheduled end date [**8-11**] ** Start Zosyn 4.5g IV every 6 hours (administered via your PICC) ** Start Vancomycin 1000 mg IV every 12 hours (via your PICC) These medications will be administered to you at your rehab facility. ** Stop famotidine 20mg one tablet twice a day. . To treat constipation and gas we added an aggressive bowel regimen as well as anti-emetics You will have a follow-up appointment with the orthopedic surgeons in a few weeks to evaluate your recovery and to talk about your long-term prognosis. You should contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 51794**] a meeting with a psychiatrist for 1-2 weeks from now. If you begin to feel faint, nauseated, or disoriented, please call your doctor or go to the nearest emergency room. It was a pleasure taking care of you. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] G Location: [**Hospital **] MEDICAL GROUP Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 34362**] Phone: [**Telephone/Fax (1) 35269**] **Please discuss with the staff at the facility a need for a follow up appointment with your PCP when you are ready for discharge. Also, please speak with your PCP about the need to be referred to Psychiatry within 1-2 weeks of your discharge from the hospital** Department: ORTHOPEDICS When: WEDNESDAY [**2133-8-19**] at 12:10 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SPINE CENTER When: WEDNESDAY [**2133-8-19**] at 12:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3736**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2133-8-11**]

80608,80705,86122,2761,78550,8600,E8147,3051,88101,2724,7224,45829

Admission Date: [**2133-7-23**] Discharge Date: [**2133-7-31**] Date of Birth: [**2061-6-30**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: pedestrian struck by MVC while crossing street Major Surgical or Invasive Procedure: [**2133-7-24**] 1. C3 bilateral hemilaminotomy. 2. Laminectomy, C4-C7. 3. Bilateral hemilaminotomy, T1. 4. Posterior spinal instrumentation, C3-T1. 5. Open treatment, cervical fracture/dislocation posterior. 6. Posterolateral fusion, C3-T1. 7. Application of local autograft for fusion. 8. Allograft for fusion. [**2133-7-27**] Right AC PICC History of Present Illness: 72M pedestrian struck by car on right side while crossing the street (?25mph). Denies LOC. Notes inability to move his legs after accident. Brought in by [**Location (un) **] to [**Hospital1 18**]. On imaging, patient has L sided [**9-11**] posterior rib fractures, small L pulmonary laceration and small pneumothorax, C5-C6 retrolisthesis and question of cord injury. Past Medical History: PMH: HLD PSH: tonsillectomy; maxillary surgery with likely screw placed for intractable nose bleed. Social History: Patient now retired, lives alone at home. Smokes 1ppd. Occasional EToH use. Family History: Non-contributory Physical Exam: Temp: 97.1 HR: 63 BP: 106/56 Resp: 23 O(2)Sat: 100 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: decreased BS at bases Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Extr/Back: No cyanosis, clubbing or edema, + pulses Skin: No rash, Warm and dry Pertinent Results: [**2133-7-23**] 01:35PM BLOOD WBC-14.9* RBC-4.00* Hgb-13.4* Hct-38.0* MCV-95 MCH-33.5* MCHC-35.2* RDW-13.0 Plt Ct-217 [**2133-7-30**] 04:38AM BLOOD WBC-8.6 RBC-2.86* Hgb-9.4* Hct-26.6* MCV-93 MCH-32.9* MCHC-35.4* RDW-13.1 Plt Ct-194 [**2133-7-30**] 04:38AM BLOOD Glucose-96 UreaN-13 Creat-0.5 Na-137 K-4.1 Cl-104 HCO3-25 AnGap-12 CT c-spine [**7-23**] 1. No fracture. 2. Grade 1 retrolishesis of C5 on C6 with widening of the C5/6 interspace anteriorly and a small amount of prevertebral fluid concerning for anterior ligament injury/disruption. 3. Posterior disc osteophyte complexes at C5-6 and C6-7 causing severe and moderate canal narrowing, respectively. 4. Calcified left thyroid nodule. Please correlate with exam findings. Thyroid ultrasound may be obtained nonemergently if indicated. CT Head [**7-23**] - no acute intra-cranial process CT Chest [**7-23**] - 1. Left posterior eighth through twelfth rib fractures, segmental from ninth through eleventh ribs, with small left pulmonary laceration and pneumothorax. 2. Left-sided calcified thyroid nodule. 3. No aortic dissection, vertebral fractures, or free pelvic fluid. No evidence of traumatic injuries to the abdomen or pelvis. Brief Hospital Course: The patient was admitted to the ICU upon admission. On [**7-24**], the patient went to the OR spine for decompression with C3-C7 laminectomy, C3-T1 fusion. Postoperatively the patient was hypotensive likely from cord injury, otherwise he was hemodynamically stable. He required intermittent pressor with neo gtt, and this was unable to be weaned until [**2133-7-27**]. On [**2133-7-25**], the patient was started on full liquid diet and transitioned to po pain medications. However, on [**2133-7-27**] patient was noted to have difficulty with swallowing and failed a speech and swallow study. He was kept on regular pureed solid diet. The patient's had a drain in place after his procedure, which was removed on [**7-26**]. His R arm laceration was closed with a penrorse drain on [**2133-7-26**]. He was started on ancef when the penrose drain was placed. On [**2133-7-28**], the patient was hemodynamically stable off pressors, his pain was well controlled, and he was afebrile with stable vital signs. He was transferred to the floor. Following transfer to the Surgical floor he was evaluated by the Physical Therapy and Occupational Therapy service for full evaluations. [**Hospital **] rehab was recommended to help in learning compensation techniques. He was also evaluated again by the Speech and swallow therapist and a video swallow was done which showed some aspiration of thin liquids and his diet currently remains pureed with nectar thick liquids. He underwent vigorous pulmonary toilet and has remained free on any pulmonary complications. His right elbow laceration is draining serous fluid but there is surrounding erythema and needs to be watched. The Penrose is out and Keflex will remain until [**2133-8-4**]. After an unfortunate accident he was transferred to rehab on [**2133-7-31**] with the hopes of returning home soon, able to compensate for his deficits. His upper extremities are improving daily but his lower extremities are without movement. Medications on Admission: atorvastatin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q 3 hrs as needed for pain. 11. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 14. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 5 days. DC [**2133-8-4**] Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: S/P MVC 1. Left posterior [**9-11**] rib fractures 2. Cervical spinal cord injury. 3. C5-C6 fracture-dislocation. 4. Cervical spinal stenosis. 5. Small left pulmonary laceration and pneumothorax 6. Large laceration ?avulsion R elbow (no obvious joint involvement) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital with multiple injuries after your motor vehicle accident including fractured ribs, a spinal cord injury and an elbow laceration. You have improved daily but need acute rehab to try to increase your mobility. * Wear your cervical collar when out of bed. * Continue to use your incentive spirometer, cough and deep breath to improve your lungs and prevent pneumonia. * Work hard with Physical and Occupational Therapy to get your muscles conditioned. * Continue to eat pureed foods and the Speech and Swallow therapist at rehab will re evaluate you to hopefully increase your diet. * Please call your doctor or return to the ED if you develop fever > 101.5, chills, nausea, vomiting, worsening pain not controlled by pain medications, decreased sensation/movement in any or extremities, chest pain, or SOB. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**4-3**] weeks. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 4 weeks. Completed by:[**2133-7-31**]

99661,51881,0388,2866,430,43411,570,99592,78552,5849,99811,1173,00845,449,44422,4260,45385,9971,78959,2851,7464,4200,6826,72972,E8788,42731,V1365,E8782,99662,37741,04104,V0980,72210

Admission Date: [**2125-11-1**] Discharge Date: [**2125-12-5**] Date of Birth: [**2083-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: endocarditis/ perivalvular abscess Major Surgical or Invasive Procedure: [**2125-11-9**]:Mediastinal exploration and chest closure/ CorMatrix patching of the pericardium. [**2125-11-5**]:Redo sternotomy and redo Bentall procedure and ascending aortic and hemi-arch replacement under deep hypothermic arrest with a 25 mm homograft and a 28 mm Gelweave tube graft. [**2125-11-6**]: L femoral thrombectomy/LLE fasciotomy [**2125-11-6**]: RLE fasciotomies [**2125-11-18**]: L leg debridement and VAC placement [**2125-11-25**]: L leg debridement [**2125-12-3**]: Exploratory lap History of Present Illness: 42 year old gentleman well known to the cardiac surgery service as he is s/p Bentall(29 StJude mech Ao valved graft) on [**2125-9-13**] with Dr.[**Last Name (STitle) **]. He was evaluated at [**Hospital6 17390**] on [**10-19**] for right facial numbness and concern for posiible TIA-however his symptoms resolved and he was not admitted at that time. He presented to [**Hospital6 2910**] on [**2125-10-30**] complaining of lower back pain, left hip pain and a low grade temp for which he was admitted for presumed endocarditis. At OSH a CT of abdomen and pelvis were done, as well as MRI which were unremarkable. His INR>6 and he was given 5mg Vitamin K. He spiked a temp to 103 and was cultured. He was empirically placed on Vancomycin and Rocephin. Cardiology was consulted and there was a question of perivalvular abscess.He was admitted for suspected endocarditis with perivalvular abscess and peripheral stigmata/recent suspected TIA on [**10-19**]/and supratherapeutic INR. [**Hospital1 18**] was contact[**Name (NI) **] and the pt was transferred for further workup and TEE. Past Medical History: Past Medical History: Bicuspid aortic valve Aortic insufficiency Dilated ascending aorta Hyperlipidemia Hypertension Past Surgical History: [**Last Name (un) 8509**] eye surgery [**2117**] Social History: Lives with: Wife Contact: Wife Phone # Occupation: HVAC Cigarettes: Smoked no [X] yes [] last cigarette Hx: Other Tobacco use: Denies ETOH: < 1 drink/week [] [**2-27**] drinks/week [] >8 drinks/week [X] - 2 drinks/day Illicit drug use: Denies Family History: Family History: Father with CAD and stent at age 60. GF underwent CABG. Mother and brother without issues. Physical Exam: Pulse:94 Resp:18 O2 sat: 97% R/A B/P 109/68 Height: 70" Weight: General: A&Ox3, appears uncomfortable lying flat 2' back pain Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT [X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: (R)basilar crackles [X] Heart: RRR [] Irregular [x] Murmur [] (+)Valvular click Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [X] U/LE splinter hemorrhages/osler nodes Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: Left: DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: Left: Radial Right: 2+ Left: 2+ Carotid Bruit: Right: - Left: - Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 3688**] [**Hospital1 18**] [**Numeric Identifier 112444**]Portable TEE (Complete) Done [**2125-11-2**] at 1:51:15 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 31496**] [**Last Name (LF) **], [**First Name3 (LF) **] C. [**Apartment Address(1) 112445**] [**Location (un) 86**], [**Numeric Identifier 8542**] Status: Inpatient DOB: [**2083-7-22**] Age (years): 42 M Hgt (in): 70 BP (mm Hg): 94/74 Wgt (lb): 175 HR (bpm): 101 BSA (m2): 1.97 m2 Indication: Endocarditis. ICD-9 Codes: 424.90 Test Information Date/Time: [**2125-11-2**] at 13:51 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Test Type: Portable TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: Doppler: Full Doppler and color Doppler Test Location: West Cath/EP Lab Contrast: None Tech Quality: Adequate Tape #: 2012W000-0:00 Machine: E9-1 Sedation: Versed: 4 mg Fentanyl: 50 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Abnormal ascending aorta tube graft. Normal descending aorta diameter. Normal abdominal aorta diameter. No thoracic aortic dissection. AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate ([**1-22**]+) MR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. Informed consent was obtained. 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) 69920**]e throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by benzocaine topical spray. The posterior pharynx was anesthetized with 2% viscous lidocaine. No glycopyrrolate was administered. No TEE related complications. Resting tachycardia (HR>100bpm). patient. Conclusions The ascending aorta tube graft appears abnormal. There is dehiscence of the proximal aortic graft/valve apparatus with the intervalvular fibrosa, with a false lumen in communication with the left ventricular outflow tract. Color doppler confirms flow in systole and diastole through the communication. The maximal diameter of the false lumen measures 1.6cm. The false lumen is bordered by the adjacent pulmonary artery and pericardium. No pericardial effusions seen elsewhere. The distal end of the false lumen could not be visualized. There are multiple lobulated structures at the proximal end of the false lumen, which may represent vegetations or thrombi. The distal anastomosis of the aortic graft appears normal. Mechanical valve appears well seated within the graft with no paravalvular leak within the graft. No evidence of masses/vegetations on aortic valve. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. A mechanical aortic valve prosthesis is present. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-22**]+) mitral regurgitation is seen. There is no pericardial effusion. There is no evidence of thoracic or descending aortic dissection. IMPRESSION: Dehiscence of the composite aortic root valved conduit with an extensive aortic root abscess, as described above. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2125-11-2**] at 1:40pm. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-11-2**] 17:22 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 3688**] [**Hospital1 18**] [**Numeric Identifier 112446**] (Complete) Done [**2125-11-9**] at 9:20:48 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 31496**] Status: Inpatient DOB: [**2083-7-22**] Age (years): 42 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. H/O cardiac surgery. ICD-9 Codes: 424.90 Test Information Date/Time: [**2125-11-9**] at 09:20 Interpret MD: [**Name6 (MD) 95342**] [**Name8 (MD) 95343**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 95343**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-3: Machine: IE33 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Stroke Volume: 60 ml/beat Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm Hg Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 14 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 7 mm Hg Aortic Valve - LVOT VTI: 19 Aortic Valve - LVOT diam: 2.0 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. No LV mass/thrombus. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV chamber size. Borderline normal RV systolic function. Mild global RV free wall hypokinesis. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Patient was brought to OR for chest closure. Repeat TEE was performed. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with borderline normal free wall function. There is invaginateion of the IAS into LA with a CVP of 24mmHg. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is a small probably vegetation on the anterior leaflet of the mitral valve. Not pedunculated, affecting the MV apparatus functionally. Surgeons aware. There is no pericardial effusion. Probe was placed and removed uneventfully and atraumatically I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 95342**] [**Name8 (MD) 95343**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-11-9**] 09:37 . [**2125-12-4**] Conclusions No atrial septal defect is seen by 2D or color Doppler. Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve appears to be a homograft. The aortic valve prosthesis appears well seated, with normal leaflet motion. No masses or vegetations are seen on the aortic valve. A large, extensive aortic annular abscess is seen, involving the entire extent of the anterior mitral continuity and full extention into the anterior fibrous skeleton. No aortic regurgitation is seen. There is a large vegetation involving the anterior mitral leaflet with leaflet abscess and mutliple areas of perforation (including one large perforation and partial flail). Severe (4+) mitral regurgitation is seen, with reversal of flow in the right superior pulmonary vein. The regurgitant jet is principally posteriorally directed through a large perforation of the anterior mitral valve leaflet, but additional regurgitation is seen through poor leaflet coaptation. The tricuspid valve leaflets are normal, with no masses or vegiations seen. There is mild to moderate ([**1-22**]+) tricuspid regugitation. IMPRESSION: Large vegetation/abscess involving the anterior mitral valve leaflet and extending throughout the anterior fibrous skeleton and aortic root. Extensive destruction of the anterior mitral valve leaflet with multiple sites of perforation and secondary severe, eccentric mitral regurgitation. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was notified in person of the results on[**2125-12-4**] at 1615. . [**2125-12-4**] CONCLUSION: 1. Normal-appearing liver without focal abnormalities. 2. Patent portal and hepatic venous system with pulsatile flow suggesting right heart failure or tricuspid insufficiency. 3. Bilateral pleural effusions, left greater than right. 4. Gallbladder sludge without evidence of cholecystitis. Brief Hospital Course: 42 year old male s/p Bentall(29 StJude mechanical Aortic valve graft) on [**2125-9-13**] with Dr.[**Last Name (STitle) **]. He presented to [**Hospital1 16549**] on [**2125-10-30**] complaining of lower back pain, left hip pain and a low grade temp. He was admitted for presumed endocarditis and transferred to the [**Hospital1 18**] for further workup. On his admission on [**11-1**], he was admitted to [**Hospital Ward Name 121**] 6,ID consulted,Empiric Vancomycin/Ceftriaxone were started,Blood CXs obtained, reversal of INR for TEE to evaluate paravalvular abscess/endocarditis with Cardiology and a CT torso was done. Pain service was consulted for his chronic lower back pain likely of multifactorial etiology: myofascial vs neuropathic vs infectious, however his chronic back pain is complicated by infectious processes on his aortic valve, high grade fevers, cerebral emboli hemorraghic and possibly septic. As such there was concern that his severe lower back pain could be a result of a disseminated infection to vertebral body or epidural space. MRI of the spine was done on [**11-3**], per Radiology showed: No evidence of spinal infection. Small midline L5-S1 disc protrusion. Neurosurgery and neurology was consulted and MRI/MRA of the brain performed. Per Radiology it showed: Multiple bilateral punctate infarctions, acute-to-subacute in chronicity,most compatible with embolic infarcts.Some of these infarcts are noted with small intraparenchymal hemorrhage,Small amount of subarachnoid hemorrhage in the adjacent sulci and No evidence of developing hydrocephalus or significant edema. MRA brain shows no vascular occlusion. During Mr.[**Known lastname 67977**] testing in the CT scanner his left antecubital fossa was infiltrated with 75cc of CT contrast. Hand surgery was consulted and found his arm had soft compartments without threatened overlying skin. Recommendations were appreciated. [**11-4**] Opthamology was consulted due to new blurry vision. His visual acuity and anterior exam were found to be normal. During intermittent episodes of extreme back pain, the pt was incontinent. Neurology was contact[**Name (NI) **] for evaluation of caudus equinus. Neuro felt it was narcotic induced. Due to Mr.[**Known lastname 67977**] worsening pain and mental status waxing and [**Doctor Last Name 688**], he was transferred to the CVICU to undergo a controlled intubation and intensive monitoring prior to surgery. [**Hospital1 18**] was informed on [**11-4**] by the OSH, the blood CXs from the outside institution grew Aspergillus. As previously stated, repeat imaging at the [**Hospital1 18**] was done on admission. It showed a dehiscence of the proximal suture line of the valve to the anulus with a contained pseudoaneurysm or abscess. He also suffered from multiple embolization. Dr.[**Last Name (STitle) **] discussed, numerous times, with Mr.[**Known lastname 30380**] and his family, that he is presenting for a very high risk undertaking of reoperative root most likely with the homograft in the setting of fresh embolic strokes seen on CT scan and an inadequately treated fungal infection. On [**2125-11-5**] Mr.[**Known lastname 30380**] was taken to the operating room and underwent Redo sternotomy and redo Bentall procedure and ascending aortic and hemi-arch replacement under deep hypothermic arrest with a 25 mm homograft and a 28 mm Gelweave tube graft. Please see operative report for further surgical details. He was transferred to the CVICU intubated, sedated, requiring multiple pressors and inotropic support to augment his cardiac function. He was received in the CVICU in very critical condition. Postoperative bleeding occurred and aggressive resuscitation with multiple blood products ensued. He was taken back to the operating room for exploration. Hemodynamic stability was obtained. At the completion of the rexploration, it was noted that Mr.[**Known lastname 67977**] left leg appeared mottled. He returned to the CVICU paralyzed with an open chest. Due to the extensive surgery, CRRT was initiated for [**Last Name (un) **] and volume removal. Renal was consulted. Postop night the left lower extremity became cool with no pulses distal to femoral artery. Vascular surgery reevaluated. On [**11-6**] he was taken to the angiosuite with vascular and underwent a left femoral common artery thrombectomy and lateral and medial left lower leg fasciotomies. Later that day it was noted that his right lower extremity was now cool and larger in appearance with associated elevated pressures. Vascular performed a fasciotomy on the right lower extremity, with wound vac placed. The following day his hemodynamics allowed for weaning off of inotropic support. Pressors were decreased as tolerated. On [**11-9**] Mr.[**Known lastname 30380**] returned to the operating room and Exploration of the mediastinum showed no active bleeding. There was no collection of fluid anywhere. All the surgical sites were free of any active bleeding. The heart size was small enough for chest closure to be accomplished. His fasciotomies were debrided. Postoperatively he developed persistent heart block with nonfunctional epicardial pacing wires after his redo Bentall/aortic homograft procedure. Despite his weaning off pressors with a stable heart rate in the 50s, his EKGs suggest an escape focus with alternating conduction down the anterior and posterior fascicles. EP was consulted and it was felt that he will eventually require a permanent pacemaker, but still being critically ill and actively being treated for fungemia, a pacemaker implantation would be premature at this time. EP therefore placed a temporary pacemaker with the use of a temporary screw-in lead. Due to the patients prolonged postop course, Physical Therapy was consulted while he was in the CVICU to evaluate his strength and mobility. It was noted that he moved all extremities to verbal commands except for his left lower extremity. Neurology reassesed.A repeat head Ct scan on [**11-13**] showed:Resolving right frontal subarachnoid hemorrhage/ No new hemorrhage/ Stable appearance of right frontal embolic infarct. Apparent new right cerebellar hemisphere infarct, likely also embolic. His Cultures returned positive for C-Difficile. Flagyl was added to his antibiotic regimen, ID continued to follow. Mr.[**Known lastname 67977**] left upper extremity was noted to be larger than his right. A LUE U/S was done: Acute deep vein thrombosis seen in the left subclavian vein with non-occlusive thrombus seen surrounding the vascular line in the left internal jugular vein. Hematology was consulted for recommendations. IV Heparin continued and his result was HIT negative. On [**2125-11-16**] Vascular intervened for Compartment syndrome of the right lower extremity. A Three-compartment fasciotomy of the right lower extremity was performed. Please see operative report for further surgical details. The following day he was taken to the operating room by Vascular surgery for Acute left lower extremity ischemia.He underwent Left lower extremity angiogram/ Femoral embolectomy/ Four-compartment fasciotomy of the lower leg. Please see operative report for further surgical details. He continued to have leukocytosis and he was cultured regularly. All lines were changed and he was given a line 'holiday'. On [**2125-11-19**] he was panscanned and found no obvious source of leukocytosis. A repeat bronch was performed and a BAL sent for culture. All lines were changed in IR. A repeat TEE was done which revealed: Interval development of cavitary space surrounding the bioprosthetic aortic root and aortic graft compared with post bypass images obtained intraoperatively. Severe thickening of the aortic root was noted. The following day he was taken back to the OR by vascular for a bilateral lower extremity debridement. On [**2125-11-21**] EP reevaluation felt that Mr.[**Known lastname 67977**] rhythm would recover. The temporary RV pacing lead was discontinued. He weaned to extubate. He remains anuric and CVVH continues. Her continued to improved and was advanced to a soft solid diet. He was found to have VRE in his leg and was started on Linezolid. He also complained of some vision loss in his R eye and was evaluated by opthamology and neurology. They was a dulling of the optic nerve on the R and could have been from his embolic issues. He had another leg debridement on [**11-27**] and had a tunnelled HD line and PICC placed on [**11-29**]. On [**12-2**] he became acutely short of breath and was reintubated. He became hypotensive and acidotic and was restarted on CVVH. He had a rising lactate and WBC up to 40,000. He had an abdominal and pelvic CT which was unremarkable. General surgery was consulted and he had a negative exploratory lap on [**2125-12-3**]. He continued to have an increased pressor requirement and remained acidotic. He also received large amounts of bicarb and volume. There was a family meeting on [**12-4**] to communicate the gravity of the situation to them. Echo on [**2125-12-4**] revealed 4+MR. After extensive thought, discussion and family meetings, it was decided that Mr. [**Known lastname 67977**] condition was not survivable. This was explained to the family in detail and they understand. The patient was made DNR, then CMO. Pressors were discontinued and ventillatory settings minimized. The patient died with his family at the bedside at 12:06pm. Medications on Admission: Ambien 5 (1)/HS prn, ASA 81(1), Diltiazem CD 120 (1),Chlorzoxazone 500 (3) prn, Warfarin daily, Deltasone 5 (1), Dilauded 2-4 mg q4h prn, Meds on TX from OSH: Ambien 5(1)HS prn, Ditiazem CD 120(1), Colchicine 0.6 mg qHS (pericarditis), Amiodarone 200 mg daily, Tylenol prn, Vanco 1250 q 12h, Ceftriaxone 2g q 24h, Prednisone 5 mg daily,Diazepam 10q6h prn, Protonix 40(1),Warfarin-4mg-held due to supratherapeutic INR Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: Procedure:[**2125-9-13**]: Bentall(29 StJude mech Ao valved graft)[**9-13**]-on Coumadin -postop AFib (on Coumadin) -postop pericarditis -Bicuspid aortic valve -recently seen at OSH for right facial numbness/ likely TIA on [**10-19**] -Aortic insufficiency -Dilated ascending aorta -Hyperlipidemia -Hypertension -Fungal endocarditis -bilat lower extremity compartment syndrome with VRE infection -respiratory failure with prolonged intubation -renal failure -hepatic failure -sepsis Discharge Condition: Expired Discharge Instructions: . Followup Instructions: . Completed by:[**2125-12-5**]

7464,4412,2859,4263,4019,2724

Admission Date: [**2125-9-13**] Discharge Date: [**2125-9-18**] Date of Birth: [**2083-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [**2125-9-13**]: Bental(29 StJude mech Ao valved graft)[**9-13**] History of Present Illness: 42 year old gentleman with a known bicuspid aortic valve and a dilated ascending aorta which has been followed by serial echocardiograms. His most recent echocardiogram showed mild to moderate aortic insufficiency however his CT scan showed his aortic root to measure 6.0cm. Given the size of his aorta, he has been referred for surgical evaluation. He denies any chest pain, dyspnea, palpitations, edema or syncope but does admit to mild fatigue. Past Medical History: Past Medical History: Bicuspid aortic valve Aortic insufficiency Dilated ascending aorta Hyperlipidemia Hypertension Past Surgical History: [**Last Name (un) 8509**] eye surgery [**2117**] Social History: Race: Caucasian Last Dental Exam: [**1-22**] yrs ago Lives with: Wife Contact: Wife Phone # Occupation: HVAC Cigarettes: Smoked no [X] yes [] last cigarette Hx: Other Tobacco use: Denies ETOH: < 1 drink/week [] [**2-27**] drinks/week [] >8 drinks/week [X] - 2 drinks/day Illicit drug use: Denies Family History: Family History: Father with CAD and stent at age 60. GF underwent CABG. Mother and brother without issues. Physical Exam: Physical Exam Pulse: 69 Resp: 16 O2 sat: 100% B/P Right: 116/69 Left: 136/70 Height: 70" Weight: 196 General: Well-developed male in no acute distress Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT [X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [**2-26**] sys/diastolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [X] Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: - Left: - Pertinent Results: [**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5* MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191 [**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5* [**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138 K-5.1 Cl-102 HCO3-28 AnGap-13 [**2125-9-17**] 03:46AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.3* Hct-29.4* MCV-87 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-148*# [**2125-9-17**] 03:46AM BLOOD Plt Ct-148*# [**2125-9-17**] 03:46AM BLOOD PT-18.2* PTT-34.3 INR(PT)-1.7* [**2125-9-17**] 03:46AM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-138 K-4.8 Cl-102 HCO3-29 AnGap-12 [**2125-9-17**] 03:46AM BLOOD Mg-2.0 [**2125-9-14**] 05:31AM BLOOD Glucose-108* K-4.4 TEE [**2125-9-13**] Conclusions Pre-Bypass: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta and arch are moderately dilated. The aortic valve is bicuspid. Moderate (2+) aortic regurgitation is seen. There is no aortic stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. Post-Bypass: The patient is in sinus ryhthm on a phenylephrine infusion. #29 St. [**Male First Name (un) 923**] Mechanical Aortic Valve graft appears well seated. There are no apparent peri-valvular leaks. Washing jets are present. Normal left ventricular function - EF50-55% Trace MR remains. Remainder of exam is unchanged. [**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5* MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191 [**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5* [**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138 K-5.1 Cl-102 HCO3-28 AnGap-13 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2125-9-13**] where the patient underwent Bental with #29 mechanical aortic valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was initially hypertensive and required a nicardipine gtt. He was started on lopressor and lasix. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. On POD#1 he transferred to the floor. Chest tubes and pacing wires were discontinued without complication. Post opertatively he was noted to have a new LBBB which has since resolved. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was started on anticoagulation therapy his goal INR 2.5-3.5. He was given the following Coumadin doses -5mg/7.5mg/7.5mg/7.5mg/5 mg with INR 2.5 at the time of discharge. By the time of discharge on POD# 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with visiting nurse services in good condition with appropriate follow up instructions. His first VNA INR draw is to be done [**2125-9-19**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Lisinopril 5 mg PO DAILY 2. LeVITRA *NF* (vardenafil) unknown Oral unknown 3. Clindamycin 150 mg PO Frequency is Unknown prn dental Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*100 Tablet Refills:*0 2. Furosemide 20 mg PO Q12H RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 3. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone 2 mg [**1-22**] tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 4. Metoprolol Tartrate 50 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 5. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 6. Warfarin MD to order daily dose PO DAILY mechanical AVR Take as directed for INR goal 2.5-3.5 for mechanical valve RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Milk of Magnesia 30 ml PO HS:PRN constipation Discharge Disposition: Home With Service Facility: amedisys Discharge Diagnosis: Bicuspid aortic valve Aortic insufficiency Dilated ascending aorta Hyperlipidemia Hypertension [**Last Name (un) 8509**] eye surgery [**2117**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema minimal Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions NO lotions, cream, powder, or ointments to incisions No driving for approximately one month and while taking narcotics No lifting more than 10 pounds for 10 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** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2125-9-27**] at 10:30a Surgeon Dr. [**Last Name (STitle) **] on [**2125-10-17**] at 1:00p Cardiologist: Dr. [**Last Name (STitle) 2912**] on [**2125-10-8**] at 1:45pm Please call to schedule the following: Primary Care Dr [**First Name (STitle) **] in [**4-26**] weeks Coumadin for Prosthetic Aortic Valve INR Goal: 2.5-3.5 Coumadin follow-up with Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 63696**] Confirmed fax [**Telephone/Fax (1) 112397**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Next INR Draw: [**2125-9-19**] **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:[**2125-9-18**]

80126,82021,2639,82123,8052,99731,340,2875,70703,2763,8020,20410,04112,2449,2724,4019,70721,E8849,2859,E8798,E8497

Admission Date: [**2122-10-7**] Discharge Date: [**2122-10-23**] Date of Birth: [**2050-5-14**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: polytrauma status post fall Major Surgical or Invasive Procedure: [**2122-10-8**]: 1. Open reduction internal fixation left distal femur fracture with [**Last Name (un) **] plate. 2. Open reduction internal fixation right distal femur with [**Last Name (un) **] plate. 3. Open reduction internal fixation right hip fracture with TFN devices, 11 x 170 x 130. 4. Hemiarthroplasty left hip with cemented [**Doctor Last Name 3389**] unipolar stem, 44 mm head, 0 mm neck, #8 cemented. 5. Closed treatment right proximal humerus fracture. [**2122-10-14**]: Insertion of inferior vena cava filter [**2122-10-14**]: Percutaneous tracheostomy; Percutaneous endoscopic gastrostomy tube. History of Present Illness: 72F with a history of MS [**First Name (Titles) **] [**Last Name (Titles) **] transferred from OSH after fall from wheelchair sustaining bilateral femoral head/neck fx as well as SAH/SDH. Reported mechanical fall, in wheelchair d/t MS. + headstrike and LOC. BPs dropped to 80s systolic, intubated electively w/etomidate and succinylcholine. Transfer via [**Location (un) **], recv'd fentanyl during xport. Rec'vd 1700cc and 4U PRBCs for hypotension w/BP in 120s on arrival to ED. Past Medical History: PMH: hypothyroid, hyperlipidemia, htn, MS, [**Location (un) **] PSH: unknown MEDS: tylenol, baclofen, amantadine, lasix, provigil, Copaxone, Lasix, Lexapro 40', ASA 81', Simvastatin Social History: Wheelchair bound pre-admission. Patient w no living relatives. Attorney as executor of estate. Taken care of by care giver, [**Doctor First Name **]. Tobacco/EtOH/Recreational drugs: denies Family History: Non-contributory Physical Exam: P/E on D/C: VS: 101.0 98 123/57 29 100% 0.5FM GEN: WD bedbound F in NAD HEENT: +large R frontal subgaleal hematoma; EOMI; PERRLA; +tracheostomy w no erythema/drainage CV: RRR PULM: coarse breath sounds b/l ABD: S/NT/ND; +PEG tube in LUQ w no erythema/drainage; +suprapubic catheter in place EXT: 2+ b/l lower extremity edema; b/l multipodus boots; L knee w staples at anterior incision; B/L lateral thigh incisions w staples in place; all incisions c/d/i w no erythema or drainage NEURO: A&Ox0; opens eyes spontaneously; does not track; does not follow commands; does not vocalize; B/L LE 0/5 strength; UE 1+/5 B/L Pertinent Results: LABORATORIES: Admit: [**2122-10-7**] 04:40PM BLOOD WBC-40.9* RBC-4.06* Hgb-12.8 Hct-36.2 MCV-89 MCH-31.5 MCHC-35.3* RDW-16.2* Plt Ct-105* [**2122-10-7**] 04:40PM BLOOD PT-13.7* PTT-22.0 INR(PT)-1.2* [**2122-10-7**] 04:40PM BLOOD Glucose-151* UreaN-21* Creat-0.6 Na-143 K-4.0 Cl-111* HCO3-20* AnGap-16 [**2122-10-7**] 04:40PM BLOOD ALT-36 AST-54* AlkPhos-85 TotBili-0.7 [**2122-10-7**] 08:00PM BLOOD CK-MB-8 cTropnT-<0.01 [**2122-10-7**] 04:40PM BLOOD Albumin-3.4* Calcium-7.4* Mg-1.8 Discharge: [**2122-10-20**] 01:42AM BLOOD WBC-17.4* RBC-2.26* Hgb-7.0* Hct-20.7* MCV-92 MCH-31.0 MCHC-33.8 RDW-16.1* Plt Ct-413 [**2122-10-20**] 01:42AM BLOOD Glucose-115* UreaN-53* Creat-1.0 Na-141 K-4.4 Cl-111* HCO3-23 AnGap-11 [**2122-10-20**] 01:42AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.3 [**2122-10-10**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE MICROBIOLOGY: [**2122-10-11**]: Mini-BAL: STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S [**2122-10-11**]: UCx: YEAST. >100,000 ORGANISMS/ML.. IMAGING: CT Pelvis [**10-7**]: 1. Complex fracture of the right femoral neck and intertrochanteric region. 2. Complex fracture of the left femoral neck. 3. Bilateral complex supracondylar fractures. 4. Bilateral hemarthrosis of the knees. 5. Subcutaneous soft tissue hematoma tracking along bilateral thigh. 6. Severe osteopenia. 7. Degenerative changes in the lower lumbar spine, SI and hip joints. 8. Suprapubic Foley catheter in the urinary bladder and air in the urinary bladder, presumably from catheter placement; correlate clinically. 9. Nonspecific fat stranding about the rectum; correlate clinically. CT Max/Sinus [**10-8**]: 1. Multiple maxillofacial fractures including the posterior sphenoid sinus, anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial wall of the right maxillary sinus and anterior wall of the left maxillary sinus and nasal bones . The bones are diffusely demineralized which makes identification of any additional fractures difficult to exclude. 2. Paranasal sinuses are filled with hyperdense material, likely blood. 3. Small foci of pneumocephalus posterior to the right frontal sinus. An underlying dural tear and CSF leak cannot be excluded. 4. Diffuse intracranial hemorrhage better characterized on concurrent head CT. CT Head [**10-8**]: 1. Slightly increased small extra-axial hematoma overlying the left frontal lobe convexity and possible small secondary frontal hematoma noted on the right. 2. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and temporal lobes and extending into the suprasellar, prepontine and interpeduncular cisterns with indentation on the pons. 3. Likely anterior maxillary and nasal bone fractures better evaluated on subsequent maxillofacial CT. Opacification of the paranasal sinuses likely related to blood. 4. Subgaleal hematoma overlying the right frontal bone. CT Head [**10-8**]: No significant change compared to study performed approximately 12 hours prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. Extensive facial fractures with blood in the paranasal sinuses was better characterized on prior dedicated facial bones CT. There is again no midline shift or evidence of central brain herniation. MRI C-spine [**10-9**]: 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel, multifactorial degenerative changes, with adequate assessment is significantly limited on the axial images, due to motion-related artifacts. Vague areas of cord signal intensity are noted, inadequately assessed on the present study. Areas of altered signal intensity in the thecal sac may relate to blood products/pulsation artifacts or a combination of both given the presence of subarachnoid and intraventricular hemorrhage on prior CT head study. CT T/L Spine [**10-9**]: 1. Acute compression fracture of the T3 vertebral body, with buckling of the posterior cortex, the inferior aspect of which is displaced posteriorly by approximately 3 mm. Suspected T2 vertebral body fracture (seen on concurrent cervical spine MRI) is not apparent by CT. 2. Compression deformities involving the T11, T12, and L1 vertebral bodies. While as detailed above these may be chronic, given the concurrent acute injury in the upper thoracic spine, it is difficult to exclude an acute component. MR T/L Spine [**10-10**]: 1. Areas of marrow edema in the T2 and T3 vertebral bodies, with mild contour irregularity of the posterior cortex of T3 which is seen to indent the ventral thecal sac and the ventral surface of the cord. Osseous details are better assessed on the prior CT. Mild diffuse disc bulge, with small-to-moderate sized disc extrusion, on the right side deforming the right side of the cord at T7/8. Small central protrusion at T6-T7 level indenting the ventral thecal sac and ventral cord. Moderate loss of height T12 vertebral body with Schmorl's nodes, likely chronic. Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's node with an acute component of marrow edema in the L1 vertebral body. Multilevel disc and facet degenerative changes in the lumbar spine with mild foraminal narrowing at L4 and L5 levels. 2. Diffusely altered signal intensity in the thecal sac, may relate to pulsation artifacts; however, blood products cannot be completely excluded given the presence of subarachnoid and intraventricular hemorrhage on the prior CT head study. 3. Vague areas of increased signal intensity in the thoracic cord, nature of which is uncertain. Assessment of cord lesions is limited due to artifacts. Attention on followup can be considered. 4. Diffuse hypointense signal of the marrow- correlate with hematology labs. 5. Bilateral pleural effusions and distended gall bladder -correlate with dedicated imaging. CT Head [**10-10**]: 1. Minimal increase of the intraventricular hemorrhage layering in the occipital horns. Otherwise, no change of the intraparenchymal, subarachnoid and subdural hemorrhage. 2. No shift of midline structures and no intracranial herniation. 3. Stable minimal dilatation of the ventricles. PATHOLOGY: [**2122-10-8**]: Bone, left femoral head, hemiarthroplasty: - Bone and cartilage with changes consistent with fracture site. - Bone marrow with an atypical lymphoid infiltrate, consistent with known history of chronic lymphocytic leukemia. Current labs: [**2122-10-23**] 04:27AM BLOOD WBC-21.4* RBC-2.94* Hgb-8.8* Hct-27.6* MCV-94 MCH-29.7 MCHC-31.7 RDW-16.1* Plt Ct-546* [**2122-10-22**] 04:45AM BLOOD WBC-20.1* RBC-2.89* Hgb-8.6* Hct-26.6* MCV-92 MCH-29.9 MCHC-32.5 RDW-16.6* Plt Ct-473* [**2122-10-23**] 04:27AM BLOOD Plt Ct-546* [**2122-10-22**] 04:45AM BLOOD Plt Ct-473* [**2122-10-23**] 04:27AM BLOOD Gran Ct-2573 [**2122-10-22**] 04:45AM BLOOD Gran Ct-3618 [**2122-10-23**] 04:27AM BLOOD Glucose-116* UreaN-46* Creat-0.9 Na-142 K-5.6* Cl-110* HCO3-23 AnGap-15 [**2122-10-22**] 01:38PM BLOOD Na-144 K-5.6* Cl-112* [**2122-10-22**] 04:45AM BLOOD Glucose-119* UreaN-47* Creat-0.9 Na-144 K-5.4* Cl-112* HCO3-21* AnGap-16 [**2122-10-21**] 12:51AM BLOOD Glucose-133* UreaN-51* Creat-1.0 Na-143 K-4.7 Cl-112* HCO3-20* AnGap-16 [**2122-10-23**] 04:27AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.5 [**2122-10-22**] 04:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.5 Brief Hospital Course: Patient was transferred from OSH via [**Location (un) **] intubated and sedated. STAT trauma protocol was initiated on arrival to [**Hospital1 18**] ED. Evaluation was carried out by ACS trauma team and ED trauma. Imaging was obtained as per above. Patient was tachycardic/hypotensive despite crystalloid fluid resuscitation. 4 units pRBC were given in trauma bay. Patient was then stabilized and admitted to the TSICU for further management. Neuro: At baseline patient is wheelchair bound secondary to MS. Cognitive baseline is described as mentally sharp with ability to do crossword puzzles. On arrival to [**Hospital1 18**] ED patient was not seen to be spontaneously moving extremities and not following commands. This mental status persisted throughout admission. CT head obtained on admission demonstrated traumatic brain injury (left frontal subdural hematoma and scattered frontotemporal subarachnoid hemorrhage). This was found to be grossly stable on interval imaging during admission. Seizure prophylaxis was administered per neurosurgical recommendation. Patient will follow up with neurosurgery with interval imaging per instructions. Throughout hospital course patient was given pain medication with good effect and adequate relief. Tylenol and narcotics initially administered via IV and then transition to enteral with good effect. CV: Patient demonstrated sinus tachycardia on admission to TSICU. This was minimally responsive to fluid resuscitation. Beta blockade was initiated following confirmation of adequate pain control and stable hematocrit. This was titrated up with good effect. At time of discharge patient is on stable dose of metoprolol with no cardiac issues. Vital signs were routinely monitored. Pulmonary: Patient was admitted intubated. Respiratory support was continued. [**10-11**] patient was febrile with desaturations. Bronchoscopy was performed that demonstrated thick secretions and treatment was initiated for VAP. Given inability to wean from ventilatory support a tracheostomy was placed [**10-14**]. Procedure was tolerated well and remains in good position at time of discharge. At time of discharge patient tolerating T-piece supplemental oxygen with persistent requirement for Q2-3 hour suctioning/pulmonary toilet. GI/GU: Patient was NPO with IVF at time of admission. Enteral feeding was initiated [**10-9**] with appropriate recommendations made by nutrition service. These were well tolerated and bowel regimen was given with good effect. Enteral access via PEG tube was obtained [**10-14**] given expectation for long term inability to tolerate po intake. This was noted to be in good position and functioning well. At time of discharge patient on stable enteral feeding regimen and passing flatus/BMs appropriately. Patient was admitted with suprapubic catheter in place related to MS. This was continued throughout admission. Following initial resuscitation lasix was utilized to assist in diuresis of massive volume previously required for cardiovascular support. At time of discharge patient with adequate urine output via pre-existing suprapubic catheter. Intake and output were closely monitored. MSK: Patient sustained bilateral proximal and distal fractures of the femur that were repaired by orthopedics as per above [**10-8**]. Patient is discharge with recommendation to be non-weight bearing at bilateral hips but may have full range of active/passive motion at knees. Multipodus boots used throughout admission per PT recommendations. Patient was seen early by physical therapy who continued to work with patient throughout admission. Patient was noted to have thoracic spine fractures as above. A [**Location (un) **] brace was recommended by ortho spine. This was obtained during admission. She should wear this at all times when not in bed. In bed patient may be without brace on logroll precautions. Facial fractures were evaluated by plastic surgery. Nasal bone fracture was reduced at the bedside [**10-8**]. Other fractures non-operative per plastic surgery with no need for plastics follow up. HEME: Patient has a history of [**Month/Year (2) **] which was demonstrated via WBC in 40s on admission. Patient was transfused 4 pRBC prior to arrival in TSICU related to refractory hypotension at OSH. [**10-8**] patient was further transfused 3 pRBC, 1 FFP and 1 platelets while in operating room with orthopedics. [**10-9**] hematocrit was persistently low without appropriate increases seen on prior day's transfusions. Three additional units of pRBC were transfused and patient's hematocrit remained stable in the low to mid 20s for remainder of admission. Hematology/oncology were consulted during this admission for considerations of [**Month/Year (2) **] in trauma patient. They recommended further workup of hematologic malignancy if patient manifested symptoms of hematologic dysfunction which she did not. An IVC filter was placed [**10-14**] given likelihood of protracted immobility and multiple orthopedic injuries. LENIs had been obtained prior to this ([**10-13**]) and these were negative. A HIT panel was sent for concern of low platelets during this admission and this was found to be negative. Heparin products were briefly held related to this but resumed when negative test was found. ID: Patient had recently completed a course of antibiotics for UTI at time of admission. Patient was febrile on [**10-11**] and pan cultures were obtained. Given desaturations and CXR findings at this time VAP protocol was initiated with triple antibiotic therapy (vancomycin, cefepime and cipro). BAL specimens demonstrated MRSA on [**10-11**] and [**10-16**]. Antibiotics were tailored appropriately. Cipro was discontinued [**10-14**] and fluconazole started for finding of yeast in BAL and UCx. Cefepime was discontinued [**10-15**]. At time of discharge patient is completing 14 day course of vancomycin and fluconazole and had been afebrile for over 72 hours. Vancomycin and fluconazole have been discontinued. Prophylaxis: See heme. Disposition: Patient was actively screened for appropriate post-hospital care and was accepted to facility. Regarding code status health care proxy has stated that patient is full code. Discussions prior to injury HCP states that patient never wanted to discuss things of this nature. At the time of discharge on [**2122-10-23**], the patient was doing well, afebrile with stable vital signs, tolerating enteral feeding, bedbound, voiding via suprapubic catheter, and pain was well controlled. Of note: borderline potassium of 5.6 reported on [**10-23**]. 15 gm Kayexalate given. Please repeat potassium [**10-23**] and [**10-24**] Patient was not started on home lasix dose while hospitalized because of borderline creatinine. Please resume 40 mg lasix daily ( records unclear as to home dose....40 mg daily or 40 mg [**Hospital1 **]) Continue to monitor lytes/creat.) Medications on Admission: [**Last Name (un) 1724**]: Copaxone, Lasix, Lexapro 40', ASA 81', Simvastatin Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 2. amantadine 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous daily (). 6. baclofen 10 mg Tablet Sig: One (1) Tablet PO Q AM (). 7. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 8. insulin regular human 100 unit/mL Solution Sig: One (1) per sliding scale Injection ASDIR (AS DIRECTED). 9. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) mg Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 10. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [**Hospital1 **] (2 times a day). 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): hold for systolic bp <110, hr <60. 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 16. dextrose 50% in water (D50W) Syringe Sig: 12.5 g Intravenous PRN (as needed) as needed for hypoglycemia protocol. 17. neutra-phos Sig: One (1) packet once a day: please continue to monitor phos. 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: 1. Traumatic brain injury (Left frontal subdural hematoma, scattered frontotemporal subarrachnoid hemorrhage) 2. Bilateral intertrochanteric fractures 3. Bilateral distal femur fractures 4. Multiple maxillofacial fractures including the posterior sphenoid sinus, anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial wall of the right maxillary sinus and anterior wall of the left maxillary sinus and nasal bones Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the acute care surgery service for management of polytrauma secondary to fall. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please also follow-up with your primary care physician within three weeks of discharge. Continue nursing care, enteral feeding, physical therapy per attached. Followup Instructions: Please follow up in [**Hospital 2536**] clinic in approximately two weeks. Call ([**Telephone/Fax (1) 2537**] at time of discharge to arrange appointment. Clinic located at [**Hospital1 18**] [**Hospital Ward Name 517**], [**Hospital 2577**] Medical Office Building, [**Location (un) 470**]. Please follow up with Dr. [**Last Name (STitle) 739**], neurosurgeon, in approximately one month. Call ([**Telephone/Fax (1) 88**] at the time of discharge to arrange an appointment to be seen and to have a non-contrast CT scan of the head on the day of your appointment. Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1005**], orthopedic surgeon, in two to four weeks. Call ([**Telephone/Fax (1) 2007**] at the time of discharge to arrange an appointment. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], orthopedic spine surgeon, in four weeks. Call ([**Telephone/Fax (1) 11061**] at time of discharge to arrange an appointment. Completed by:[**2122-10-23**]

42732,29181,496,5225,4254,V1254,4019,53081,32723,30391,3051

Admission Date: [**2190-11-11**] Discharge Date: [**2190-11-18**] Date of Birth: [**2125-8-17**] Sex: M Service: MEDICINE Allergies: Erythromycin Attending:[**First Name3 (LF) 613**] Chief Complaint: Atrial flutter, ETOH withdrawl Major Surgical or Invasive Procedure: Ablation of Atrial Flutter drainage of molar abscess History of Present Illness: Mr. [**Known lastname 11270**] is a 65M with a PMH s/f ETOH abuse and a tachyarrhythmia in the past that the patient cannot identify who is presenting with atrial flutter and ETOH withdrawl. The patient has been an alcoholic for 40 years off and on, where he intermittently consumes ~1 quart of vodka daily, of note he denies any prior history of withdrawl seizures. His last drink was on Monday at 8PM. On Tuesday he was at a dental appointment for a tooth extraction, where he was noted to be tremulous. The dentist took his pulse and noted him to be tachycardic. He was sent to [**Hospital1 **] ED. From there he was medically cleared to be transferred to [**Hospital1 **] for ETOH detox. At [**Hospital1 **] the patient was placed on an ativan sliding scale. At 8PM on [**11-11**], the on-call physician was called for a rapid HR to 144 despite three doses of ativan. He was otherwise hemodynamically stable. He was transferred to [**Hospital1 18**] for further evaluation. . In the emergency department initial vitals were 96.8, 142/107, 146, 18, 100% on 2L. CIWA score on arrival to the ED was 21 He recieved a total of 30mg IV diazepam. Vagal maneuvers were unsuccessful. After 18mg of IV adenosine (6mg followed by 12mg), his rate slowed down to 110s and revealed 3:1 atrial flutter. At that time he recieved a total of 3L of NS, and 3 10mg IV diltiazem doses. A diltiazem drip was started at 10mg/hr with minimal effect. He was transferred to the ICU for further monitoring. . ROS is negative for any changes in vision, headache, chest pain, palpitations, dyspnea, light-headedness, abdominal pain, or weakness. ROS is notable only for tremor and nausea Past Medical History: HTN GERD S/p multiple CVA's: last one seven months ago, where the patient presented with dysarthria Obstructive sleep apnea ETOH abuse: no history of withdrawl seizures Social History: 40 year history of ETOH abuse, off an on since his 20s. During active periods, he consumes ~8 drinks/day. He has been smoking 2 packs per day over the past 30 years. He denies any other substance abuse. Family History: Non contributory Physical Exam: T=98.6... BP=140s systolic... HR=140s... RR=13... O2=97% RA . . PHYSICAL EXAM GENERAL: Alert and oriented x3, tremulous, able to answer questions appropriately. NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry mucous membranes. OP clear. Neck Supple, No LAD, No thyromegaly. NECK: No carotid bruits CARDIAC: Regular rhythm, tachycardic, unable to auscultate any murmurs secondary to rapid rate LUNGS: Inspiratory and expiratory wheezes diffusely. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ================== ADMISSION LABS ================== WBC-7.6 RBC-3.98* Hgb-13.2* Hct-37.2* MCV-93 MCH-33.0* MCHC-35.4* RDW-13.8 Plt Ct-170 PT-13.1 PTT-26.3 INR(PT)-1.1 Glucose-114* UreaN-15 Creat-1.0 Na-140 K-4.1 Cl-107 HCO3-24 AnGap-13 CK(CPK)-72, cTropnT-<0.01, Calcium-8.3* Phos-3.4 Mg-1.3* ===================== TRANSTHORACIC ECHO ([**2190-11-12**]) ===================== The left atrium is mildly dilated. 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. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Impression: Mild spontaneous echo contrast in the left atrial appendage. No thrombus in the left atrial appendage. Normal left ventricular function. Mild mitral regurgitation. ============= CHEST X-RAY ============= The cardiomediastinal silhouette is within normal limits. There is no pneumothorax, consolidation, or pleural effusion. The pulmonary vasculature is normal. The osseous structures appear within normal limits. IMPRESSION: No acute cardiopulmonary process. ================== DISCHARGE LABS ================== WBC-6.7 RBC-3.82* Hgb-12.5* Hct-36.0* MCV-94 MCH-32.8* MCHC-34.8 RDW-14.1 Plt Ct-188 PT-13.9* INR(PT)-1.2* Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.6 Cl-107 HCO3-26 AnGap-11 Calcium-9.3 Phos-3.9 Mg-1.6 BLOOD TSH-1.4 Brief Hospital Course: Mr. [**Known lastname 11270**] is a 65M with a PMH s/f ETOH abuse and atrial flutter in the setting of alcohol withdrawal, status post ablation. Below is a problem based summary of this hospitalization: . #. Atrial flutter: Likely related to underlying un-diagnosed COPD given smoking history. Patient was placed on heparin drip and electrophysiology consultation was obtained. Patient was taken to radiofrequency ablation of atrial flutter which was found to be typical counter-clockwise at rate of 220 msecs. HV intervals and SA nodes were normal, and no atrial flutter was inducible after ablation. Patient will be anticoagulated for 4 weeks, with coumadin (INR goal [**3-7**]) with Lovenox bridge. On discharge, INR was 1.8 and he had been on 3 days of coumadin 5 mg daily. Patient will also be maintained on atenolol per pre-admission medications. This information was relayed to his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8049**] who will follow his INR. [**Hospital 197**] clinic appointment was also arranged for the patient. . #. ETOH withdrawal: Patient was closely monitored and maintained on Diazepam per CIWA scale > 10. Patient was also maintained on MVI, thiamine, folate. . # Dental abscess: Pt had abscess involving molar #19. He was seen by OMFS and underwent drainage of abscess. He was discharged on 7 days PO clindamycin and can follow-up with his outpatient dentist PRN. . #. History of CVA: We continued home ASA but discontinued his plavix as it was deemed no longer necessary. . #. HTN: Patient had good BP control on atenolol. . #. GERD: We continued home regimen of omeprazole . FEN: Patient tolerated a cardiac healthy diet PPX: -DVT ppx: On systemic anticoagulation -Bowel regimen: colace -Pain management: tylenol as needed. ACCESS: PIV's CODE STATUS: Patient remained FULL CODE during this admission. Medications on Admission: Plavix 75mg daily Atenolol 50mg daily Omeprazole 20mg daily ASA 325mg daily Lipitor 40mg daily MVI daily Thiamine 100mg daily Folic acid 1mg daily Ativan taper -Lorazepam 1mg [**Hospital1 **] on [**11-12**] -Lorazepam 1mg x1 on AM of [**11-13**] Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 weeks. Disp:*120 Tablet(s)* Refills:*0* 8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day) for 4 days. Disp:*8 syringe* Refills:*1* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 11. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Facility: [**Hospital3 8063**] - [**Location (un) **] Discharge Diagnosis: PRIMARY: ATRIAL FIBRILLATION ALCOHOL WITHDRAWAL dental abscess Discharge Condition: Hemodynamically stable, with sinus rhythm and with ongoing alcohol withdrawal symptoms. Discharge Instructions: You were admitted to the hospital with a rapid heart rate after you stopped alcohol intake. We helped to control your withdrawal and were able to perform a procedure to keep this type of fast heart rate from happening. You will need to continue anticoagulation for 4 weeks, with a medication called Coumadin. Dr. [**Last Name (STitle) 8049**] will check your coumadin level on Monday. You also had an abscess in your tooth which was removed by the oral surgeon. Please follow up with your dentist after this procedure. You should take an antibiotic called clindamycin for 7 days to prevent infection after your operation. Please keep all doctors [**Name5 (PTitle) 4314**] and take [**Name5 (PTitle) **] medications as prescribed. If you experience any nausea, vomiting, fevers, chest pain, palpitations, or any other symptoms that concern you, please seek medical attention immediately. Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Primary care: Please attend the appointment at Dr. [**Last Name (STitle) 79813**] office with Nurse, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79814**] on Monday [**11-22**] at 1:40PM for your coumadin level checked and coumadin teaching. . You also have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**] Phone: ([**Telephone/Fax (1) 79815**] Date/Time: Monday [**11-22**] at 2:45pm. . Please call to make an appointment with your regular dentists for follow-up. . Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] [**Last Name (NamePattern1) 51148**], [**Location (un) 551**] [**Location (un) 47**], [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 20259**] Date/time: Office will call you with an appt [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Admission Date: [**2170-4-9**] Discharge Date: [**2170-4-15**] Date of Birth: [**2109-1-4**] Sex: M Service: MEDICINE Allergies: Penicillins / Arterial Line in RIGHT RADIAL Attending:[**First Name3 (LF) 10593**] Chief Complaint: s/p failed gallstones removal c/b gallbladder perforation Major Surgical or Invasive Procedure: IR guided attempted removal of gallstones and fragmented cholecystostomy tube (failed attempt), complicated by perforation of the gallbladder. History of Present Illness: Mr. [**Known lastname 92497**] is a 61 y/o male with h/o HTN, COPD, chronic renal disease on HD, s/p AAA repair and cholecystitis who was admitted to the MICU after a failed attempt to remove stones/biliary dilation and removal of previous catheter fragment that was complicated by gallbladder/cystic duct perforation. The patient presented with acute cholecystitis on [**2169-10-17**] and underwent percutaneous cholecystostomy; at that time as based on his comorbidities he was not felt to be a good surgical candidate. Since then he has undergone ERCP x 2 with sphincterotomy as well as failed laparoscopic cholecystectomy because of adhesions on [**2170-2-8**]. His cholecystostomy tube came out accidentally and a new percutaneous tube was replaced on [**2170-3-9**]. Unfortunately this cholecystostomy tube was severed by VNA, leaving him with a cathetar fragment at his ostomy site. . Of note, all of his prior care has been at [**Hospital1 498**]. He was referred to IR (Dr. [**Last Name (STitle) 4686**] for a cholangiogram via his existing cholecystostomy tube +/- stone extraction, catheter fragment removal and sphincteroplasty. The procedure performed yesterday was unsuccessful in removing the gallbladder stones or the catheter fragment, and was also complicated by gallbaldder/cystic duct perforation. Pt was hemodynamically stable, complaining only of RUQ pain ([**5-8**]). . This morning pt had episodes of hypotension with SBP's to the 70's prior to dialysis. Pt was mentating well, Tmax of 100.1. Pt not currently complaining of abdominal pain. Pt was transferred to the MICU because of concern for sepsis following perforation. Past Medical History: -Hypertension -COPD on home oxygen (2L) -Chronic renal disease on HD (T,Th,Sat schedule. Last HD on Saturday [**2170-4-7**]) -Open AAA repair in [**2164**] c/b abdominal wall hernia repaired with mesh. -Thoracic aortic aneurysm, s/p endograft repair -S/p LUE AVF -Cholelithiasis -Sleep apnea -Hypercholesterolemia -CVA -recent (diagnosed via MRI) -Arthritis Social History: - Tobacco: 2-3packs/day x 40 years - Alcohol: very heavy drinker x 15 years - Illicits: none Family History: - No family history of gallstones - Kidney stones: brothers Physical Exam: Vitals: T:97.5 BP:90/50 P:79 R:12 O2:99% 2L General: Alert, interactive, oriented, no acute distress HEENT: Sclera anicteric, mucus membranes [**Doctor Last Name **], oropharynx clear, EOMI Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, GII systolic and diastolic murmer at RUSB, GII holosystolic and diastolic murmer at LSB, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, mild distension, ostomy site clean with bandage in place and cholecystostomy drain with serosanguinous drainage in bag, +BS Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MICU Admission Exam: Vitals: T: 99.5 BP: 83/48 P: 85 R:9 18 O2: 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mild tenderness to palpation in the RUQ, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission Labs: [**2170-4-9**] 09:40PM BLOOD WBC-11.1* RBC-3.57* Hgb-9.7* Hct-29.4* MCV-82 MCH-27.1 MCHC-32.9 RDW-16.0* Plt Ct-309 [**2170-4-10**] 10:40AM BLOOD Neuts-79* Bands-0 Lymphs-9* Monos-10 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2170-4-10**] 10:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2170-4-9**] 09:40PM BLOOD Glucose-102* UreaN-29* Creat-4.6* Na-138 K-4.0 Cl-102 HCO3-23 AnGap-17 [**2170-4-10**] 05:35AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.1 [**2170-4-10**] 05:35AM BLOOD ALT-5 AST-10 LD(LDH)-158 AlkPhos-65 TotBili-0.2 [**2170-4-9**] 09:40PM BLOOD PT-12.5 PTT-34.0 INR(PT)-1.2* [**2170-4-11**] 03:24AM BLOOD Cortsol-8.7 [**2170-4-11**] 03:24AM BLOOD Vanco-18.6 Micro: [**4-11**] BCx pending [**4-10**] BCx negative [**4-10**] UCx negative [**2170-4-11**] 9:58 am BILE BILE. **FINAL REPORT [**2170-4-15**]** GRAM STAIN (Final [**2170-4-11**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2170-4-15**]): ENTEROCOCCUS SP.. RARE GROWTH. ENTEROCOCCUS SP.. RARE GROWTH. SECOND MORPHOLOGY. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S 0.5 S PENICILLIN G---------- 4 S 2 S VANCOMYCIN------------ 1 S <=1 S ANAEROBIC CULTURE (Final [**2170-4-15**]): NO ANAEROBES ISOLATED. Imaging: CT Abd/Pelvis ([**2170-4-10**]): 1. Phlegmonous change within the gallbladder fossa with one intact pigtail catheter in place. There is also a fragment present laterally within No drainable collection identified. Adjacent inflammatory fat stranding and pericholecystic fluid. 2. Moderate duodenal diverticulum. 3. Simple cysts within both kidneys. 4. Multiple stable subcentimeter hepatic hypodensities which are too small to characterize. 4. Intrahepatic ductal dilation with enhancement of the intrahepatic duct suggestive of cholangitis. 5. Stable aneurysmal aorta and right common iliac artery. 6. Sigmoid and ascending colon diverticulosis, without evidence of acute diverticulitis. . TTE ([**2170-4-11**]): The left atrium is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . RUE Ultrasound ([**2170-4-12**]): No evidence of deep venous thrombosis in the right upper extremity. . CXR ([**2170-4-15**]): Normal size of the cardiac silhouette. No lung parenchymal disease. Brief Hospital Course: 61yoM with h/o HTN, COPD, chronic renal disease on HD, s/p AAA repair and cholecystitis who was admitted after failed attempts by IR to remove stones and previous catheter fragment, complicated by gallbladder/cystic duct perforation and sepsis. . # Hypotension/Perforated Gallbladder/Common Bile Duct: The patient was admitted on [**4-9**] following a failed IR attempt to remove gallstones and a cholecystostomy catheter fragment, which was complicated by gallbladder/cystic duct perforation with contrast seen extravasating from the gallbladder. Post procedure BPs were in the 90s from a baseline of 120-140 systolic, attributed to sedation with slow clearance in the setting of liver failure. He was covered with Ceftriaxone and Flagyl. However, he then became hypotensive with SBP 70's-80's the following morning on [**4-10**] with low grade fever and increasing white count, and he was broadened to Vanc/[**Last Name (un) **] for concern for early peritonitis and sepsis. Blood pressures did not respond to several boluses of IVF and he was transferred to the MICU, where he received 8L NS. His blood pressures stablilized and white count down-trended, fever resolved on Vanc/[**Last Name (un) **]. CT was concerning for cholangitis, but LFTs did not show a cholestatic picture. ERCP was consulted and did not have plans to intervene unless the patient developed a cholestatic hepatitis. Surgery was consulted and is planning to perform an open cholecystectomy when he becomes medically stable. GB was determined to be adequately decompressed with his cholecystostomy tube at this time, and LFTs were WNL. He was discharged with a plan to continue Vancomycin/Meropenem for a 2 week course. Bile culture grew enterococcus sensitive to Vancomycin. The patient was given Acetaminophen and Oxycodone was increased for pain control. Gemfibrozil was discontinued, as this can precipitate gallstone formation. The day of discharge, there was question of whether the patient's insurance would cover his Vancomycin and Meropenem as an outpatient, but the patient refused to remain in-house to wait for confirmation of insurance approval. He will follow-up with his PCP as an outpatient regarding this, as he was refusing to remain in-house for this issue, despite knowing the risks of leaving. The day after discharge, on [**4-16**], the patient was called and he confirmed that the VNA just finished giving him the IV antibiotics and confirmed that his insurance would cover enough antibiotics for 10 days, for a full course. . # Anemia: The patient had hct 29 on initial presentation that slowly down-trended to 24 post-op. Likely dilutional in the setting of missing HD due to hypotension vs slow blood loss from ostomy vs anemia of ESRD without EPO repletion given recent initiation of HD. He was transfused 2 units PRBC in the MICU with subsequent increased and stable HCTs. He will receive EPO with HD per renal. . # R Hand Ischemia: While in the MICU, the patient developed cyanosis of the right hand, which was attributed to A-line insertion in the setting of visualized small caliber vessel. Perfusion returned s/p removal of the line. Surgery/Hand consulted, felt there were no concerning findings. [**Doctor Last Name **]??????s test normal. . # HD dependent ESRD: The patient was initially on a T/Th/Sat hemodialysis schedule but while in the MICU, his schedule was switched to M/W/F. He received an extra dose of HD in-house after being called out to the floor, as he initially missed HD while in the MICU for sepsis. Continued sodium bicarb 650 mg tid, sevelamer 1600 mg tid with meals. Renal was following in-house. . # Hypertension: Patient was recently hypotensive in the setting of sepsis, and his home lisinopril and metoprolol were held until follow-up with his PCP. . # COPD on home oxygen (2L): Patient is currently asymptomatic, with no shortness of breath or wheezing. The patient is on 2L at home chronically but has been non-compliant with his oxygen use at home. He was intermittently on 2L NC in-house. His home regimen of tiotropium and albuterol were continued in-house. . #Hypercholesterolemia: Pt currently on Simvastatin 40mg daily, continued in-house. . #CVA: Recent (diagnosed via MRI). Continued home aspirin 81mg daily. . . # Code: Full code Transitions of Care: - Vancomycin, to be continued until [**2170-4-23**] - needs confirmation that insurance will cover outpatient medication - Meropenem to be continued until [**2170-4-23**] - needs confirmation that insurance will cover outpatient medication - f/u BP; re-start Lisinopril and Metoprolol as BP tolerated - Tamsulosin was STOPPED for hypotension; follow up PCP or nephrologist prior to re-starting this medication - Furosemide was STOPPED for hypotension; follow up with nephrologist prior to re-initiation - Percocet was INCREASED in frequency temporarily for pain control post-procedure - Gemfibrozil was STOPPED, as this can cause gallstones - Genasyme was HELD; follow up with nephrologist or PCP before [**Name9 (PRE) 18290**] Medications on Admission: -Aspirin 81mg daily -Flovent (1puff twice daily) -Furosemide 40mg [**Hospital1 **] -Genasyme -Lisinopril 20mg QD -Metoprolol 100mg [**Hospital1 **] -Gabapentin 100mg tab x 2 tabs TID -Ursodiol 300mg [**Hospital1 **] -Sevelemer 800mg TID -Meclizine 12.5mg [**Hospital1 **] -Darbepoetin injections on Thursday -Oxycodone/Acetaminophen PRN -Simvastatin 40mg dialy -Spiriva daily -Budesonide 2 puffs twice daily -Gemfibrizol 600mg [**Hospital1 **] -Tamsulosin -Sodium bicarbonate 325mg x 2 tabs three times daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO three times a day. 4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. darbepoetin alfa in polysorbat Injection 8. oxycodone-acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 7 days: You should not drive or do anything that requires alertness while taking this medication. You should AVOID drinking alcohol while taking this medication. . Disp:*20 Tablet(s)* Refills:*0* 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. budesonide 90 mcg/actuation Aerosol Powdr Breath Activated Sig: Two (2) puffs Inhalation twice a day. 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 13. sodium bicarbonate 325 mg Tablet Sig: Two (2) Tablet PO three times a day. 14. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon Soln Intravenous Q24H (every 24 hours) for 10 days: Last dose on [**2170-4-24**]. Disp:*5000 mg Recon Soln(s)* Refills:*0* 15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous HD PROTOCOL (HD Protochol) for 10 days: Last dose on [**2170-4-24**]. Disp:*5000 mg* Refills:*0* 16. Normal Saline Flush 0.9 % Syringe Sig: One (1) injection Injection twice a day: 10 cc of normal saline flush- before and after MEROPENEM INFUSION. Disp:*20 INJECTIONS* Refills:*0* Discharge Disposition: Home With Service Facility: Acclaim Discharge Diagnosis: Perforated gallbladder/common bile duct Sepsis Acute on chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were at [**Hospital1 18**]. You came to the hospital to have Interventional Radiology remove stones and a catheter fragment from your gallbladder. Unfortunately the procedure was very difficult and it was not possible to remove the stones nor the catheter fragment. During the procedure your gallbladder was perforated and you had to be admitted to the hospital for observation. While you were in the hospital, your blood pressure dropped most likely due to your body reacting to a bacteria in the blood. Your antibiotics were switched and you were in the intensive care unit until your blood pressure stabilized. You will be discharged on a course of antibiotics to be taken at home. You will have the VNA who will be doing the antibiotic infusion daily. The infusion company called [**Location (un) 511**] Home therapy will be calling you tomorrow in the morning to set up the delivery time of your antibiotic. However, we were not able to get it approved by your insurance today given it is [**Last Name (LF) 1017**], [**First Name3 (LF) **] we do not know the cost of your copay. We have recommended that you stay inpatient until this is cleared tomorrow morning, but you have refused. IT IS EXTREMELY IMPORTANT THAT YOU GET THE ANTIBIOTIC- MEROPENEM TOMORROW IN THE AFTERNOON. IF YOU HAVE ANY PROBLEMS PLEASE CALL OUR FLOOR AT [**Telephone/Fax (1) 3633**]. While in the hospital, your kidney function was found to be abnormal, likely due to ****dehydration**** and your kidney function improved after receiving intravenous fluids. Please call your dialysis unit on Monday morning at 06:00 AM to make sure if you will need to go on Monday or back to your regular schedule Tues/Thurs/Sat schedule. The following changes were made to your home medications: - Vancomycin was STARTED, to be continued until [**2170-4-23**] - Meropenem was STARTED, to be continued until [**2170-4-23**] - Nephrocaps was STARTED - Sevelamer was INCREASED - Percocet was INCREASED in frequency temporarily - Gemfibrozil was STOPPED, as this can cause gallstones - Tamsulosin was STOPPED; please follow up with your kidney specialist or your primary care physician before [**Name9 (PRE) 18290**] this medication - Furosemide was STOPPED; please follow up with your kidney specialist or your primary care physician before [**Name9 (PRE) 18290**] this medication - Genasyme was HELD; please follow up with your kidney specialist or your primary care physician before [**Name9 (PRE) 18290**] this medication -Lisinopril was STOPPED; please follow up with your kidney specialist or your primary care physician before [**Name9 (PRE) 18290**] this medication -Metoprolol was STOPPED; please follow up with your kidney specialist or your primary care physician before [**Name9 (PRE) 18290**] this medication Followup Instructions: Department: HEMODIALYSIS Please call your dialysis unit on Monday morning at 06:00 AM to make sure if you will need to go on Monday or back to your regular schedule. Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 92498**], and arrange to follow up with him within 5 days of discharge from the hospital. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the surgery department at [**Hospital1 18**] at ([**Telephone/Fax (1) 16915**] and arrange to follow up with him within [**3-2**] weeks after discharge to discuss removing your gallbladder.

41401,51852,4111,99859,5119,9975,7885,42731,4589,4240,7962,2859,79029,2724,30000,71690,32723,72400,3051,V173,E8782

Admission Date: [**2115-2-11**] Discharge Date: [**2115-2-19**] Date of Birth: [**2052-3-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2115-2-11**] Cardiac Cath [**2115-2-12**] Coronary bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to posterior descending artery and distal circumflex artery. History of Present Illness: 62 year old male reports about a two year history of intermittent chest pressure that has no exertional component. He describes his discomfort as a very mild mid sternal pressure that occurs randomly and at rest several times a week, lasting about five to ten minutes before resolving spontaneously. About three to four weeks ago he went for an appointment with his new PCP. [**Name10 (NameIs) **] did an EKG and compared it to one from a few years ago and told him that there were significant changes and evidence of a possible MI. He was then referred to Dr. [**Last Name (STitle) 7047**] for stress testing. Imaging revealed a large fixed inferior defect with mild to moderate peri-infarction ischemia and an LVEF of 31%. He was started on Aspirin, Lipitor and Coreg and is was referred for cardiac catheterization. He was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Borderline hypertension Dyslipidemia Mild glucose intolerance Arthritis/ Spinal stenosis Chronic back pain/leg numbness Possible sleep apnea (wife has witnessed periods of apnea) Anxiety s/p Hemorrhoid surgery Hx of remote back surgery Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:wife Contact:[**Name (NI) **] [**Name (NI) 46298**] (wife) [**Telephone/Fax (1) 92407**] Occupation:disabled from work Cigarettes: Smoked no [] yes [x]last cigarette [**2115-2-9**], quit 2 years ago and started smoking again 3 months ago, 1ppd x 20 years Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-26**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Brother died in his late 50's from complications of heart disease and diabetes Physical Exam: Pulse:86 Resp:18 O2 sat:98/RA B/P Right:179/88 Left:172/91 Height:5'7" Weight:234 lbs Temp: 99.9 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: (s/p cardiac cath, no bleed/hematoma) Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: [**2115-2-11**] Cath: 1. Selective coronary angiography of this right dominant system demonstrated severe three vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had an 80% proximal lesion. The LCx was occluded proximally. The RCA was occluded at mid-vessel with heavy calcification. 2. Limited resting hemodynamics revealed severe systemic systolic arterial hypertension with an SBP of 176mmHg. . Carotid U/S [**2115-2-11**]: 1. Less than 40% stenosis of the right internal carotid artery. 2. 50-69% stenosis of the left internal carotid artery. . Echo [**2115-2-12**]: PRE-CPB: 1. The left atrium is moderately dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. 4. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). The inferior wall is severely hypokinetic. 5. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 6. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 7. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. 8. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. 9. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of epi, phenylephrine briefly. A paced. Improved biventricular systolic function on inotropic support. LVEF = 45%. Inferior hypokinesis remains. MR remains 1+. The aortic contour is normal post decannulation. [**2115-2-18**] 04:45AM BLOOD WBC-11.3* RBC-4.00* Hgb-11.5* Hct-34.3* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 Plt Ct-311 [**2115-2-11**] 02:44PM BLOOD WBC-8.9 RBC-4.83 Hgb-14.0 Hct-41.7 MCV-86 MCH-29.0 MCHC-33.6 RDW-13.3 Plt Ct-183 [**2115-2-15**] 06:00AM BLOOD PT-13.0* PTT-30.9 INR(PT)-1.2* [**2115-2-11**] 07:25PM BLOOD PT-12.4 PTT-33.6 INR(PT)-1.1 [**2115-2-18**] 04:45AM BLOOD Glucose-124* UreaN-22* Creat-1.2 Na-135 K-4.3 Cl-96 HCO3-31 AnGap-12 [**2115-2-11**] 02:44PM BLOOD Glucose-105* UreaN-12 Creat-1.0 Na-135 K-4.0 Cl-100 HCO3-25 AnGap-14 Brief Hospital Course: Mr. [**Known lastname 46298**] was admitted following his cardiac cath which revealed severe three vessel coronary artery disease. He underwent surgical work-up and on [**2-12**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3 (left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to posterior descending artery and distal circumflex artery). CROSS-CLAMP TIME:61 minutes.PUMP TIME:74 minutes.Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He weaned off pressor support. Beta-blocker/Statin/Aspirin and diuresis was initiated. All lines and drains were discontinued per protocol. POD#1 he transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The following day he went into rapid atrial fibrillation which was treated with Amiodarone. He converted into normal sinus rhythm. Postoperatively serosanguinous drainage was evident from his sternal incision and IV ABX was started. Aggressive diuresis was continued. The remainder of his hospital course was essentially uneventful. His sternal drainage and edema improved and by POD# 7 only a scant amoune of sternal drainage was able to be expressed. His sternum remains stable with no [**Doctor Last Name **] or click. He was placed on oral ABX for a 10 day course upon discharge. He was cleared for discharge to home with VNA. Wound check will be done in 1 week following discharge. Mr.[**Known lastname 46298**] was advised of signs and symptoms of concern and advised to contact the cardiac surgery department if any of these changes occur. All follow up appointments were advised. Medications on Admission: ALPRAZOLAM 0.25 mg, 1-2 times a day as needed ATORVASTATIN 40 mg Daily CARVEDILOL 6.25 mg [**Hospital1 **] PERCOCET 1 Tablet every six hours as needed for back pain ASPIRIN 325 mg Daily ALEVE 220 mg Capsule - 2 Capsules a day as needed for pain Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day for 10 days: then decrease to 1 tab twice daily until reevaluated by MD. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO twice a day. [**Last Name (Titles) **]:*120 Tablet Extended Release(s)* Refills:*2* 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 7 days then decrease to 2 tabs (400 mg)once daily x 7 days, then decrease to 1 tab (200 mg) daily until MD advises differently. [**Last Name (Titles) **]:*120 Tablet(s)* Refills:*2* 10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. [**Last Name (Titles) **]:*40 Capsule(s)* Refills:*0* 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. [**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: Borderline hypertension Dyslipidemia Mild glucose intolerance Arthritis/ Spinal stenosis Chronic back pain/leg numbness Possible sleep apnea (wife has witnessed periods of apnea) Anxiety s/p Hemorrhoid surgery Hx of remote back surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema [**2-22**]+ 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) **] on [**2115-3-21**] at 1PM in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] Please call for a follow-up appointment in [**2-22**] weeks Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] in [**4-25**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2115-2-19**]

1911,3485,34839,99702,431,78093,E8788,37941,37854,4019,49390

Admission Date: [**2152-6-23**] Discharge Date: [**2152-7-7**] Date of Birth: [**2094-9-17**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: Stereotactic brain biopsy on [**2152-6-26**]. History of Present Illness: Per Mr. [**Known lastname 97022**] wife, Mr. [**Name13 (STitle) 97023**] has been acting "strangly" for the last month. He was staying at work all night or going into work early. He was unable to hold conversations or talking about things that did not make sense. Prior to that his wife denies any changes in his mental status. He has been seeing his primary physcian who sent him for a neurology consult at the [**Hospital1 **]. He was found to be hypotensive by the neurologist and told to stop his blood pressure meds. He continued to have low blood pressure and mental status changes, and his PCP recommended coming to the emergency room at [**Hospital1 1535**]. Past Medical History: Hypertension Asthma Incisional Hernia Social History: The patient drinks 3 to 5 beers weekly. He does not smoke cigarettes. He works at the [**Doctor Last Name 97024**]. Family History: He denies any family history of heart disease or cancer. Physical Exam: VITAL SIGNS: Temperature 98.3 F, blood pressure 82/58, pulse 80, respiration 20, and oxygen saturation 94% in room air. GENERAL: WD/WN, comfortable, NAD. HEENT: Pupils: [**1-24**] bilaterally EOMs full NECK: Supple. LUNGS: CTA bilaterally. CARDIOVASCULAR: RRR, S1/S2. ABDOMEN: Soft, NT, BS+ EXTREMITIES: Warm and well-perfused. NEUROLOGICAL EXAMINATION: Mental status: Awake and alert, cooperative with exam, flat affect. Orientation: Oriented to person, place, and had difficulty with date with time he was able to state [**2152-9-23**] than said [**6-23**]. Recall: [**12-28**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements or tremors. Strength full power [**3-28**] throughout. No pronator drift Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Toes downgoing bilaterally Coordination: Normal on finger-nose-finger Pertinent Results: MR HEAD W & W/O CONTRAST [**2152-6-23**]: FINDINGS: There is a large frontal lobe mass identified extending from corpus callosum to both frontal lobes with central area of low T1 and high T2 signal with areas of low signal on susceptibility images indicating small areas of chronic blood products. There is an extensive enhancement identified in the mass. The location and the appearance of the mass are suggestive of a glioma or less likely a lymphoma. Additionally, there is enhancement seen in the left frontal sulci as well as in the basal cisterns and internal auditory canals indicative of leptomeningeal spread of the neoplasm. There is mass effect on the anterior horns of both lateral ventricles. A prominent flow voids are identified adjacent to the inferior aspect of the neoplasm indicative of hypertrophic blood vessels or draining veins. IMPRESSION: Large bifrontal neoplasm extending through the corpus callosum likely a primary neoplasm such as glioma or lymphoma. Hypertrophic vessels are visualized in the inferior aspect of the tumor, indicating vascular supply and whatever the diagnosis of glioma. Leptomeningeal extension of the neoplasm is identified through the basal ganglia and internal auditory canal. CT Torso [**2152-6-24**]: FINDINGS: CHEST: There are no pathologically enlarged thoracic lymph nodes. There is no pericardial or pleural effusion. There is mild dilatation of the esophagus. Lung windows demonstrate no nodules or masses. The central airways are patent, without endobronchial lesions. There are no suspicious osseous lesions. ABDOMEN: The liver, spleen, kidneys, adrenal glands, pancreas, and gallbladder are normal. There are no pathologically enlarged lymph nodes. There is an umbilical hernia containing fat and small bowel, without evidence of obstruction. There is no free fluid in the abdomen. Delayed images demonstrate normal contrast excretion of the kidneys bilaterally. PELVIS: The bladder is decompressed with a Foley catheter. The pelvic bowel loops are unremarkable. There is no free fluid. There are no pathologically enlarged lymph nodes. Bone windows demonstrate a lytic lesion in the posterior left iliac bone with a thick sclerotic border. No other focal lesions are identified. There are minimal degenerative changes of the spine. IMPRESSION: 1. No evidence of mass in the chest, abdomen or pelvis. 2. Umbilical hernia containing fat and small bowel. 3. Nonaggressive-appearing lesion within the posterior left iliac bone, unlikely to represent a metastatic lesion. 4. Mild esophageal dilatation. CT HEAD W/O CONTRAST [**2152-6-25**]: FINDINGS: Again noted is extensive hypodensity involving both frontal lobes and the genu of the corpus callosum. There is persistent mass effect on the bilateral frontal horns. Allowing for differences in slice selection, there may be slight interval increase in the diameter of the lateral ventricles. The left lateral ventricle measures 14 mm compared to 10 mm previously and the right lateral ventricle measures 14 mm compared to 12 mm previously. There is no shift of normally midline structures or evidence of uncal or transtentorial herniation. The 3rd and 4th ventricles are preserved. There is no evidence of hemorrhagic conversion. The [**Doctor Last Name 352**]-white matter differentiation is otherwise preserved without evidence of infarction. The visualized portion of the paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. IMPRESSION: Extensive hypodense lesion in the bilateral frontal lobes with slight interval increase in the diameter of the lateral ventricles. Third and fourth ventricles remain patent and basilar cisterns preserved. Pathology Examination from steriotactic biopsy [**2152-6-26**]: DIAGNOSIS: 1. Brain, target point, stereotactic biopsy (A): Glioblastoma multiforme, (WHO Grade IV); See note. 2. Brain, -4, stereotactic biopsy (B): Glioblastoma multiforme, (WHO Grade IV); See note. 3. Brain -8, stereotactic biopsy (C): Glioblastoma multiforme, (WHO Grade IV); See note. 4. Brain, -12, stereotactic biopsy (D): White matter infiltrated by glioma. 5. Brain, -16, stereotactic biopsy (E): White matter with reactive gliosis and rare atypical cells. 6. Brain, -20, stereotactic biopsy (F): White matter with reactive gliosis and rare atypical cells. Note: The tumor displays hypercellularity, vascular proliferation, necrosis, and mitotic figures. Gross: The specimen is received in the O.R. in 11 parts, all labeled with the patient's name, "[**Known firstname 449**] [**Known lastname **]" and the medical record number. Each part consists of a 0.1 x 0.1 x 0.1 cm fragment of white soft tissue, except for the target point. Part 1 is additionally labeled "target point" and measures 0.6 cm x 0.1 cm and is red in color. It is entirely submitted in cassette A. Part 2 is additionally labeled "-2" and is consumed entirely by intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**] is: "Malignant glioma". Part 3 additionally labeled "-4", and is entirely submitted in cassette B. Part 4 is additionally labeled "-6", and is consumed entirely by intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**] is: "Malignant glioma". Part 5 additionally labeled "-8", and is entirely submitted in cassette C. Part 6 is additionally labeled "-10", and is consumed entirely by intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**] is: "Malignant glioma". Part 7 is additionally labeled "-12", and is entirely submitted in cassette D. Part 8 is additionally labeled "-14" and is consumed entirely by intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**] is: "White matter with reactive gliosis and rare atypical cells". Part 9 is additionally labeled "-16", and is entirely submitted in cassette E. Part 10 is additionally labeled "-18", and is consumed entirely by intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**] is: "Reactive gliosis with scattered atypical cells". Part 11 is additionally labeled "-20", and is entirely submitted in cassette F. CT Head without contrast post-op [**2152-6-26**]: FINDINGS: There is a new left frontal burr hole for stereotactic biopsy. There is a small focus of new hemorrhage along the biopsy path in the left frontal lobe (2:18). Extensive vasogenic edema is again seen in association with the known mass involving both frontal lobes and the genu of corpus callosum, with unchanged mass effect on the frontal horns of the lateral ventricles. Overall, the ventricles are stable in size. Mild rightward shift of the anterior falx is stable. There is a large mucus retention cyst in the right maxillary sinus and a possible polyp in the left nasal cavity, as before. IMPRESSION: Small amount of blood along the left frontal biopsy path. No change in mass effect from the bifrontal mass. MRI Head ([**2152-6-29**]) FINDINGS: Study is slightly limited due to patient motion during examination. Again demonstrated is a heterogeneous mass located within bilateral frontal lobes, and crossing the corpus callosum, compatible with biopsy proven glioblastoma multiforme. This mass measures grossly 6.5 cm x 4.6 cm, with central areas of susceptibility, particularly within the left frontal region, likely reflecting intratumoral hemorrhagic products from recent biopsy. The mass is situated in the expected location of the A2 segments of the anterior cerebral arteries, which are not clearly visualized. There is associated significant vasogenic edema of bilateral frontal lobes. Significant mass effect on the adjacent frontal horns of the lateral ventricles and a rightward shift of normally midline structures by approximately 7 mm are not significantly changed. Increased FLAIR signal and enhancement surrounding the left lateral ventricular ependymal surface is noted. Abnormal enhancement is also evident within the basal cisterns and in the region of the thalamus/tectal junction. These findings suggest subarachnoid spread of tumor with a differential diagnosis of infection, if clinically appropriate. No other foci of hemorrhage are identified. There is no infarct, without evidence of diffusion-weighted abnormality. Mucus-retention cyst in the right maxillary sinus with mucosal thickening of the ethmoid sinuses is noted. IMPRESSION: 1. Large butterfly glioma in the frontal lobes, compatible with known glioblastoma multiforme, with associated significant mass effect and vasogenic edema, unchanged. 2. Post-biopsy changes, including a small amount of intratumoral hemorrhage. 3. Abnormal enhancement of the left lateral ventricular ependymal surface, in the basal cisterns, and in the thalamo-tectal junction. These findings could indicate subarachnoid spread of tumor. However, a concomitant infection could have a similar appearance and needs clinical correlation . An MRI of the spine is recommended to assess for leptomeningeal involvement of the spinal axis. 4. Incomplete visualization of the A2 segments of the anterior cerebral arteries. A dedicated MRA or CTA is recommended to assess for vascular patency. CT head ([**2152-6-30**]) FINDINGS: Again demonstrated is a large bifrontal mass, compatible with biopsy-proven GBM, with significant mass effect on the adjacent frontal horns of the lateral ventricles and rightward shift of midline by approximately 7 mm. Surrounding low attenuation in bilateral frontal lobes is compatible with vasogenic edema, with a track of high density in the left frontal lobe compatible with post-biopsy hemorrhagic tract. These findings are not significantly changed from the prior study. The size of the ventricular system is stable, without evidence of new hydrocephalus. There are no other foci of intracranial hemorrhage. No major vascular territorial infarction is identified. Visualized paranasal sinuses and mastoid air cells are normally aerated. Osseous structures reveal biopsy burr hole in the left frontal bone. IMPRESSION: No significant change in large bifrontal mass, compatible with biopsy-proven GBM, and associated significant mass effect on the adjacent lateral ventricles and rightward shift of midline. Brief Hospital Course: The patient was admitted to the ICU for Q1 hour neuro checks after he was found to have a very large bifrontal brain mass. He had been given 1 dose of steroids at the outside hospital but they were not continued here in anticipation of a steriotactic brain biopsy. The patient had a CT torso that did not show evidence of metastatic disease. On [**2152-6-25**] his neurological examination changed and he was unable to speak. A stat head CT showed increased edema in the frontal region. At that time he was started on steroids due to his worsening examination and increased edema. Afterwards, he improved significantly and was oriented x 3 and following commands. On [**2152-6-26**], the patient had a steriotactic brain biopsy. The pathology revealed that the mass was a glioblastoma WHO Grade IV. Post-operatively the CT scan showed a new small hemorrhage at the surgical bed. He was transferred back to the ICU still intubated. The patient was started on mannitol. On [**2152-6-27**], the patient was extubated and his neurological examination was improved. His mannitol and steroids were weaned and he was transferred to the neuro step-down unit. He continued to be stable as the weaning of both mannitol and steroids continued and was transferred out of step-down to the floor on [**2152-6-28**]. In the afternoon of [**2152-6-29**] (after radiation planning appointment), he was found to have significant aniscoria (right greater than left) and sixth cranial nerve palsy. Head CT was repeated; and found to have significantly worsened edema. He was given a one time dose of mannitol 50 gm, re-loaded with Decadron 10 mg, and continued on Decadron 4 mg every 6 hours. Given his marked neurological decline, palliative care was again urgently consulted to assist with appropriate planning. At this time, the family changed his code status to include no cardiac compressions, defibrillation, or CPR; they agree to chemical code only. In subsequent hours, his neurological examination significantly improved to the point that he could possibly be discharged. In the setting of his progressive decline, and sensitivity to increasd steroids, emergent whole brain radiation was sought. Pursuant to this plan, he was transferred to the [**Hospital Ward Name 516**] 7 [**Hospital Ward Name 1950**] [**Hospital1 **] under the Neuro-Oncology Service on [**2152-7-2**] to make arrangements for this to occur. From [**2152-7-3**] to [**2152-7-7**], he received 5 of 22 total treatments of whole brain radiation. He also began temozolomide while in-house. He was started on Bactrim prophylaxis since he was on both radiation and temozolomide. His neurological examination remained stable during this time with mild right greater than left anisicoria (1 mm difference), with brisk pupillary reflexes. He remained oriented x 2 (difficulty with date) and with 1/3 recall after 5 minutes. He had poor attention and poor comprehension of his disease. He was discharged on Decadron 4 mg every 6 hours, with proton pump inhibitor, bowel regimen, and instructions to ambulate frequently in an attempt to prevent DVT. He was also discharged on [**Month/Day/Year 13401**]. He is scheduled for follow-up on [**2152-7-10**]. Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 puffs Q4 prn FLUTICASONE 50 mcg Spray 2 sprays each nostril QD Flovent 110 mcg 2 puffs [**Hospital1 **]; HCTZ Lisinopril 1 QD; Simivastatin; ASPIRIN - 81 mg QD Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*100 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. Disp:*1 month supply* Refills:*0* 11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 14. [**Hospital1 13401**] 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Visiting Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Glioblastoma multiforme Discharge Condition: Neurologically stable; R sided anisicoria, oriented x 2. Discharge Instructions: You were admitted to the hospital on [**2152-6-23**] with confusion. You were found to have a brain tumor. You had a brain biopsy on [**2152-6-26**]. The sutures have already been removed. You had 5 treatments of radiation so far and you have gotten 3 days of temozolomide chemotherapy. You can take zofran ODT as needed for nausea. You are being discharged on steroids because of the swelling in your brain. You must take omeprazole to avoid stomach irritation with steroids. You must take a bowel regimen to make sure you have a bowel movement everyday while you are on steroids. If you do not have a bowel movement in two days call your doctor. You must also be sure to walk around at least 5 times per day to avoid clots in your legs. You are also being discharged on [**Last Name (LF) 13401**], [**First Name3 (LF) **] anti-seizure medication, as you may be more prone to seizures now that you have a brain tumor. You are being discharged on Bactrim to prevent infection now that you are getting radiation and chemotherapy. DO NOT DRIVE. DO NOT DO ANY HEAVY LIFTING. YOU ARE AT AN INCREASED RISK FOR FALLING WITH YOUR BRAIN TUMOR AND CONFUSION. You are being sent home with a VNA for help with your medications and for a home safety evaluation. You will be contining your radiation and chemotherapy as an outpatient. General Instructions and Information: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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. ?????? You have been discharged on [**First Name3 (LF) 13401**] (Levetiracetam) as anti-seizure medication. ?????? You are being sent home on steroid medications, so make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? DO NOT DRIVE ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions You have an appointment in the Brain [**Hospital 341**] Clinic on [**2152-7-10**] at 9:30 a.m. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building on the [**Location (un) 858**]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. When you go to radiation treatment on Monday, please talk to the nurses about seeing a social worker so [**Name2 (NI) **] can be set up.

2752,29181,2651,78039,25000,496,2724,30391,3051,27541,2768,5589,53081,4019,29420,2875,2819,4439

Admission Date: [**2109-1-17**] Discharge Date: [**2109-1-23**] Date of Birth: [**2039-9-10**] Sex: F Service: MEDICINE Allergies: Penicillins / IV contrast dye Attending:[**First Name3 (LF) 603**] Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: In brief, this is a 69 yo F with a recent PMH significant for weight loss, anorexia, electrolyte abnormalities, who was sent in to the ED by her PCP for [**Name9 (PRE) 108827**] and tremor and had a tonic-clonic seizure in the ED likely related to alcohol withdrawal +/- electrolyte abnormalities. The patient had a head CT that was negative for acute intracranial process. The patient was seen by neurology who recommend continuing CIWA scale and attributed much of her confusion, confabulation, and ataxia to Wernickes Disease. The patient recieved IV folate, thiamine, as well as electrolyte repletion. . Prior to transfer, VS 98.7, 74, 141/86, 10, 95% RA. The patient was alert and oriented x [**12-28**], although she was extremely tangential with her thought process. She had poor attention and was easily distractable. She had no acute complaints, otherwise. . Review of systems: (+) Per HPI, complains of chronic diarrhea, some mild abdominal pain Past Medical History: Diabetes mellitus type 2, controlled Hypomagnesemia Collagenous colitis Diverticulitis Reflux Peripheral vascular disease COPD (chronic obstructive pulmonary disease) Tobacco abuse Thyroid nodule Hyperlipidemia LDL goal < 130 Lower extremity edema Fibrocystic disease of breast Obese Skin cancer Hypertension goal BP (blood pressure) < 130/80 Proteinuria Colon polyp Chest pain Transaminitis Chronic left shoulder pain Osteoporosis screening Vitamin D deficiency Sciatica Heart murmur Social History: - Tobacco: 1ppdX45 yrs - Alcohol: 2 drinks per day/unknown last drink. Likely underestimating the amount that she drinks - Illicits: denies Family History: Noncontributory Physical Exam: Vitals: T: 98.7 BP: 141/82 P: 74 R: 10 O2: 95% RA General: AOx2-3, tangential, distractable HEENT: dry skin, conjunctival pallor, coarse hair, tongue with some cuts on sides Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, bronchial breath sounds, prolonged expiratory phase CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no dullness to percussion, no shifting dullness Ext: dry, coarse skin, poor nail care Skin: palmar erythema, spider angiomas, no caput, coarse, dry skin Neuro: Poor at following commands, decreased sensation stocking and glove pattern, slowed rapid alternating movements, able to do months of the year backwards, 0/3 recall at 5minutes. Pertinent Results: ADMISSION LABS [**2109-1-17**] 02:10PM BLOOD WBC-6.8 RBC-3.52* Hgb-12.6 Hct-35.8* MCV-102* MCH-35.7* MCHC-35.1* RDW-12.8 Plt Ct-161 [**2109-1-17**] 02:10PM BLOOD Neuts-75.4* Lymphs-17.6* Monos-5.2 Eos-0.9 Baso-1.0 [**2109-1-17**] 05:34PM BLOOD PT-10.3 PTT-31.6 INR(PT)-0.9 [**2109-1-17**] 02:10PM BLOOD Glucose-103* UreaN-14 Creat-1.0 Na-143 K-3.6 Cl-106 HCO3-22.3 AnGap-18 [**2109-1-17**] 02:10PM BLOOD ALT-34 AST-43* AlkPhos-52 TotBili-0.6 [**2109-1-17**] 02:10PM BLOOD Albumin-3.9 Calcium-6.9* Phos-4.1 Mg-0.6* [**2109-1-17**] 10:12PM BLOOD 25VitD-6* [**2109-1-17**] 02:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2109-1-17**] 06:02PM BLOOD Ethanol-NEG CT head: NONCONTRAST HEAD CT: There is no evidence of hemorrhage, mass, mass effect, or infarction. There is no shift of the usually midline structures. Suprasellar and basilar cisterns are widely patent. Mild periventricular and deep white matter hypoattenuation is suggestive of chronic small vessel ischemic changes. Proportional enlargement of the ventricles and sulci is suggestive of age-related cortical atrophy. There is no scalp hematoma or acute skull fracture. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial process Liver US:Small simple hepatic cyst. Otherwise, normal-appearing liver. No ascites. Aneurysmal abdominal aorta, measuring up to 3.2 cm. Absent left kidney, possibly congenital versus post-surgical. Clinical correlation recommended. Tiny gallbladder polyps or adherent stones. [**2109-1-18**] 04:03AM BLOOD WBC-5.7 RBC-3.24* Hgb-11.7* Hct-32.9* MCV-102* MCH-36.2* MCHC-35.6* RDW-12.8 Plt Ct-150 [**2109-1-19**] 07:23AM BLOOD WBC-7.1 RBC-3.09* Hgb-11.5* Hct-31.3* MCV-101* MCH-37.3* MCHC-36.8* RDW-13.1 Plt Ct-153 [**2109-1-20**] 07:30AM BLOOD WBC-4.0 RBC-3.06* Hgb-11.1* Hct-31.3* MCV-102* MCH-36.4* MCHC-35.6* RDW-12.6 Plt Ct-123* [**2109-1-21**] 06:10AM BLOOD WBC-5.4 RBC-3.25* Hgb-11.7* Hct-32.6* MCV-100* MCH-35.8* MCHC-35.7* RDW-12.8 Plt Ct-153 [**2109-1-22**] 06:05AM BLOOD WBC-5.0 RBC-3.08* Hgb-11.1* Hct-31.0* MCV-101* MCH-36.2* MCHC-35.9* RDW-12.8 Plt Ct-149* [**2109-1-23**] 06:10AM BLOOD WBC-4.5 RBC-3.02* Hgb-10.7* Hct-31.0* MCV-103* MCH-35.6* MCHC-34.7 RDW-12.3 Plt Ct-175 [**2109-1-18**] 04:03AM BLOOD Glucose-313* UreaN-10 Creat-0.7 Na-133 K-7.1* Cl-103 HCO3-21* AnGap-16 [**2109-1-18**] 05:08AM BLOOD Glucose-148* UreaN-9 Creat-0.6 Na-137 K-4.2 Cl-105 HCO3-21* AnGap-15 [**2109-1-18**] 10:33AM BLOOD UreaN-9 Creat-0.7 Na-140 K-4.1 Cl-107 HCO3-20* AnGap-17 [**2109-1-18**] 06:50PM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-140 K-4.8 Cl-107 HCO3-23 AnGap-15 [**2109-1-19**] 07:23AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-138 K-5.0 Cl-108 HCO3-20* AnGap-15 [**2109-1-19**] 04:00PM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-137 K-4.7 Cl-103 HCO3-22 AnGap-17 [**2109-1-20**] 07:30AM BLOOD Glucose-123* UreaN-10 Creat-0.7 Na-139 K-4.1 Cl-106 HCO3-22 AnGap-15 [**2109-1-21**] 06:10AM BLOOD Glucose-127* UreaN-7 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-24 AnGap-14 [**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8 Cl-109* HCO3-25 AnGap-12 [**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8 Cl-109* HCO3-25 AnGap-12 [**2109-1-23**] 06:10AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-142 K-4.0 Cl-109* HCO3-24 AnGap-13 [**2109-1-18**] 04:03AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1 [**2109-1-18**] 05:08AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 [**2109-1-18**] 10:33AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 [**2109-1-18**] 06:50PM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 [**2109-1-19**] 07:23AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8 [**2109-1-19**] 04:00PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3 [**2109-1-20**] 07:30AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.6 [**2109-1-21**] 06:10AM BLOOD Calcium-9.2 Phos-4.9* Mg-1.3* [**2109-1-22**] 06:05AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.4* [**2109-1-23**] 06:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.5* [**2109-1-19**] 07:23AM BLOOD VitB12-268 [**2109-1-21**] 06:10AM BLOOD TSH-3.2 Brief Hospital Course: Ms. [**Known lastname **] is a 69F with PMH hypomagnesemia, collagenous colitis, T2DM, COPD, who presents with seizure, electrolyte abnormalities, and confusion. #Altered Mental Status--Per PCP, [**Name10 (NameIs) **] has had a slow decline over the past couple of months but previously very redirectable and making her outpatient appointments. Per friend [**Name (NI) **], patient has sensical conversations and is able to take care of herself. During admission, patient was intermittently nonsensical. CT head showed chronic small vessel ischemic changes and age related cortical atrophy. Patient has reportedly abused ETOH in the past and is currently confabulating, however history, exam, and labs are not convincing for withdrawal, wernicke's or korsikoffs dementia. Patient has not scored on CIWA and does not have evidence of cirrhosis on abd US. B12 was low-nml, on folate and thiamine supplementation. Electrolyte disturbances could be causing AMS (esp hypomagnesemia). Patient additionally was found on the ground on [**1-19**], without complaints, no focal signs of head trauma. Concern low for stroke (strong family history per patient), but no focal neuro abnormalities. Currently patient is refusing HIV test and MRI brain. TSH 3.2. RPR negative. Mental status continued to improve throughout admission and with additional input from her long-time partner that her mental status continued to improve. Based on this collateral information and [**Hospital 228**] medical stability, plan for discharge to rehab for further therapy. #Electrolyte abnormalities--Pt presents with hypomagnesemia 0.6 mg/dl on presentation, hypocalcemia (6.9), and hypokalemia (3.6-->3.2). Hypomagnesemia is ongoing, pt was prescribed PO magnesium supplementation 2 months ago, as Mg was 1.0 on [**2108-11-6**]. The patient was non-compliant with this therapy. Hypomagnesemia is likely due to chronic diarrhea from collagenous colitis, PPI use, EtOH, as well as poor nutrition. It does not seem as though she is having renal wasting of her electrolytes, given her FE of magnesium. After repletion with IV magnesium, she was transitioned to PO magnesim oxide. She initially got diarrhea as a result of the magnesium oxide which resolved with concurrent administration of immodium. Immodium should be minimized to avoid constipation and obstruction. # EtOH Abuse -- Pt states she usually has 1-2 drinks/night of vodka. Unclear about last drink. Pt has s/s of alcohol abuse and her seizure in the ED was likely due to withdrawal. Neurology agress with this assessement. The patient has skin manifestations of alcohol abuse including palmar erythema and telangectasias although palmar erythema may be dishydrotic eczema. However she had an Abd US that showed no evidence of chirrosis. She will continue supplementation with Thiamine and Folate. SW saw patient but evaluation was limited by patients confusion # Seizure -- Pt had a shaking episode in the ED that was thought to be a seizure, for which she received ativan. This was likely due to EtOH withdrawal and electrolyte abnormalities. The patient was monitored on CIWA but did not score making withdrawal unlikely. She did not require anti-epileptics and she had no further seizures during her stay. #Collagenous colitis--Diagnosed by colonic biopsy in 10/[**2108**]. Pt has ongoing diarrhea, improved from previously, only once per week according to PCP. [**Name10 (NameIs) **] is unable to provide detailed history. Home budesonide dose was continued. #GERD--PPI was d/c'd on [**1-16**] due to hypomagnesemia. No current complaints. If pt has symptoms, you should use H2 blocker. #HTN-- Her home HTN medications were continued (losartan 100mg daily and atenolol 50mg daily), However she continuned to have elevated BPs to 200s and had to be covered with Iv hydralazine and Labetolol. Amlodipine 5mg was added to her regimen and this improved her BPs. #COPD--~40 pack year smoking history. No O2 requirement or SOB at present. Ipratropium inhaler at home. #DM2--Diet controlled, HbA1c 5.3 in 1/[**2108**]. Diabetic diet TRANSITION OF CARE ISSUES -Added Amlodipine 5mg daily -Added Magnesium Oxide 400mg [**Hospital1 **] to be taken with immodium and meals -Methylmalonic acid level Pending -Added 50000U Vitamin D per week which she will need to continue for 7 weeks -She may need an MRI brain to asess for infarcts or other possible etiologies of her confusion, however, patient declined at this [**Doctor First Name **] -Health Care Proxy form signed after consistent statements that her long-time partner of 30 years be her HCP. She will need further home evaluation -Hypomagnesemia and electrolyte management should be closely monitored. Medications on Admission: -Budesonide (ENTOCORT EC) 3 mg Oral Capsule, Delayed & Ext.Release 2 tablets daily -Losartan 100 mg Oral Tablet Take 1 tablet daily -magnesium chloride (SLOW-MAG) 71.5 mg Oral Tablet, Delayed Release (E.C.) take 1 tablet 4 times per day -Potassium Chloride 20 mEq Oral Tablet, ER Particles/Crystals Take 1 tablet daily -Atenolol 50 mg Oral Tablet Take One Tablet Daily -Aspirin 81 mg Oral Tablet Take 1 tablet daily. -Ipratropium Bromide (ATROVENT HFA) 17 mcg/Actuation Inhalation HFA Aerosol Inhaler Discharge Medications: 1. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Two (2) Capsule, Delayed & Ext.Release PO DAILY (Daily). 2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation once a day. 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA) for 7 weeks. Disp:*7 Capsule(s)* Refills:*0* 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day: with morning magnesium oxide. 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Dementia Alcohol Withdrawal Seizures Hypomagnesemia Chronic Alcohol Abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with confusion, low magnesium, potassium, and calcium. In the ED, you had a seizure that was most likely due to your low electrolytes and also alcohol withdrawal. Your low electrolytes were attributed to your chronic diarrhea, alcohol use, and poor nutrition. A CT scan of your head did not show any acute problems. Our neurology colleagues saw you and recommended correction of your electrolytes and abstinence from alcohol. You were seen by PT, OT and social work who are concerned about your ability to care for yourself at home. You are being discharged to a rehab facility to help you regain your strength and ensure a safe return home. The following changes were made in your medications: START Magnesium Oxide 400 mg twice daily with breakfast and dinner START Amlodipine 5 mg by mouth daily START Folic Acid 1 mg daily START Thiamine 100 mg daily START Vitamin D 50,000 units weekly (on Saturdays) for 6 weeks DISCONTINUE Magnesium Chloride You may changed the Magnesium Oxide to Magnesium Chloride if you continue to have difficulties tolerating the medication. Followup Instructions: Please call to arrange an appointment with your primary care provider and gastroenterologist after discharge.

2767,99859,6826,25080,7823,04112,44023,70715,40390,5859,V4586,V1047

Admission Date: [**2107-9-24**] Discharge Date: [**2107-9-29**] Date of Birth: [**2041-4-11**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 2195**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 665**] is a 66 yo M with DM2, PVD, s/p surgical debridement of right thigh MRSA abscess sent to ED for evaluation when he was found to have elevated potassium at his PCP's office. He reports that he presented to his PCP's for a scheduled follow up visit but otherwise was without specific complaints. He does endorse weight gain of 21 pounds since his hospital discharge on [**9-11**]. Due to this he took some of his wifes water pills, the name he cant remember for three doses total. Otherwise he reports recent decrease in his total daily naproxen dose and slight increase in his tramadol dose. He has recently been taking Bactrim and Augmentin following surgical debridement Recent admission [**Date range (1) 27372**] to vascular surgery service for right groin mass c/w abscess on CTA without any evidence of communication with prior right CIA to SFA graft. He had ultrasound guided drainage which showed purulent material so he was taken to the OR for surgical debridement. He was discharged on bactrim and augmentin with a wound vac in place. In the ED, initial vs were: T 98 P 58 BP 118/46 R 18 O2 sat 100% RA. Potassium was checked in the ED and was noted to be 7.8. Patient was given calcium gluconate 1g IV x1, insulin 10 units x1, D50 x 1 amp, bicarb x1amp and kayexalate 30g po. He had an EKG which showed PR prolongation compared with baseline but no other changes. Following this therapy he became asymptomatically hypoglycemic with decrease in blood sugar to 56 from 114 on arrival and he was given a second amp of D50. Repeat glucose three hours later was persistently low at 40 and he was given a third amp of d50. He reports being asymptomatic with all of these levels. On the floor, he reports feeling at his baseline. His FSBG was 100 on arrival. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denied cough, he does endorse occasional dyspnea on exertion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: Past Medical History: DM2 - last A1C 5.9 [**1-/2106**] HTN severe DJD hyperlipidemia PVD testicular CA Anemia - unknown cause (bl HCT ~30) chronic renal insufficiency (bl creatinine ~1.5) . Surgical History: s/p right common iliac artery to SFA bypass s/p gastric bypass [**2101**] right groin dissection and XRT right cataract surgery appendectomy tonsillectomy multiple foot surgeries Social History: lives with wife, works as CEO of company and does a lot of travelling for work, remote smoking history of 1 PPD x12 years quit in [**2071**], denies ETOH or drug use. Family History: both parents died from aplastic anemia Physical Exam: Vitals: T: 98.1 BP: 177/48 P:76 R:19 O2: 100% RA General: Alert, oriented, no acute distress Skin: warm, scattered bruises over extremities HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, well healed surgical scars, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema of LE's bilaterally, atrophy of right lower leg muscles, clean bandage in placeover toes of letf foot. Pertinent Results: [**2107-9-23**] 02:45PM BLOOD WBC-6.1 RBC-3.07* Hgb-9.3* Hct-30.1* MCV-98 MCH-30.2 MCHC-30.8* RDW-14.8 Plt Ct-404# [**2107-9-23**] 02:45PM BLOOD Neuts-45.0* Lymphs-40.5 Monos-8.4 Eos-5.4* Baso-0.7 [**2107-9-23**] 11:00PM BLOOD PT-12.8 PTT-30.1 INR(PT)-1.1 [**2107-9-23**] 02:45PM BLOOD UreaN-14 Creat-1.6* Na-132* K-7.8* Cl-107 HCO3-21* AnGap-12 [**2107-9-23**] 11:00PM BLOOD ALT-18 AST-28 LD(LDH)-157 CK(CPK)-27* AlkPhos-136* TotBili-0.2 [**2107-9-23**] 11:00PM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.8 Mg-1.9 [**2107-9-23**] 02:45PM BLOOD VitB12-1824* [**2107-9-23**] 02:45PM BLOOD Triglyc-76 HDL-51 CHOL/HD-2.9 LDLcalc-80 [**2107-9-24**] 07:43AM BLOOD TSH-9.0* [**2107-9-24**] 07:43AM BLOOD Free T4-1.0 [**2107-9-24**] 02:09AM BLOOD Cortsol-6.5 [**2107-9-24**] 07:43AM BLOOD Cortsol-15.5 [**2107-9-29**] 06:55AM BLOOD WBC-5.9 RBC-3.06* Hgb-9.4* Hct-29.5* MCV-96 MCH-30.9 MCHC-32.1 RDW-14.0 Plt Ct-281 [**2107-9-29**] 01:10PM BLOOD UreaN-17 Creat-1.6* Na-134 K-4.8 Cl-97 HCO3-32 AnGap-10 [**2107-9-29**] 06:55AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.6 Brief Hospital Course: [**Hospital Unit Name 153**] course: #Hyperkalemia - Patient presented with severe hyperkalemia K of 7.8 with EKG changes of prolonged PR interval, it was 3.8 less than a month ago. Unclear etiology, but differential diagnoses include adrenal insufficiency given hyponatremia, hyperkalemia, and peripheral eosinophilia. However, he does not have hypotension. Morning cortisol was within normal limits. Other consideration would be hyperkalemia associated with metabolic acidosis, although ph normal on ABG. Another consideration was renal tubular acidosis given elevated potassium and low serum bicarbonate on admission. No evidence of tissue breakdown or hemolysis with normal CK. Hypoaldosteronism was also a possible cause, however he was not volume depleted on examination. Transtubular potassium gradient was 2.5, suggesting that patient's hyperkalemia was likely secondary to hypoaldosteronism. Renal was consulted who suggested that hyperkalemia was likely due to renal K secretion inhibition by multiple medications (benzapril, [**Last Name (un) **], triamtereme, nsaids, bactrim). All were discontinued. IV lasix was started to enhance K secretion and remove volume. On discussion with ID, patient's bactrim was replaced with linezolid. Pt's K currently corrected to 4.8, and he is being discharged on Lasix 10mg PO Daily. #MRSA abscess s/p surgical debridement with wound vac in place - Patient was evaluated by vascular surgery team in the ED, no acute issues. As bactrim may have played a role in patient's hyperkalemia, it was replaced with linezolid after discussing with ID. given the risk for serotonin syndrome, his Tramadol was discontinued. #DM2 - Diabetes was very well controlled per history with last A1c in our system of 5.9. Humalog sliding scale was continued, and NPH [**Hospital1 **] was held per patient's request. #Hypertension - Clonidine 0.3mg qam and 0.2mg qpm was continued while metoprolol and benicar were held in the setting of hyperkalemia. His blood pressures remained well-controlled. #PVD - Arterial insufficiency ulcers were seen on lower extremities bilaterally. Aspirin was continue during his stay in the hospital. Medications on Admission: Reconciled on [**2107-9-26**] [**Doctor Last Name **] Lotrel (Amlodipine/benazepril) 5/20 QD Benicar (olmesartan/hctz) 40/25 one tab [**Hospital1 **] Bactrim DS 160-800 mg One (1) Tablet PO BID x 4 weeks. Augmentin 875-125 mg one po tid (stopped [**9-22**]) Metoprolol Tartrate 50 [**Hospital1 **] Clonidine 0.3mg AM and 0.2mg PM Pantoprazole 40 mg [**Hospital1 **] Januvia (Sitagliptin) 100mg QD Aspirin-Coated 325 mg PO QD NPH 2 units [**Hospital1 **] Humulin R 10 units AM, 8 NOON, 9 PM Zetia 10mg [**Hospital1 **] Naproxen 220mg [**Hospital1 **] Tramadol 50mg qam and 100mg qpm Aspirin 325 mg PO DAILY Protonix Pantoprazole Sodium 40mg in the morning Ferrous Sulfate Ferrous Sulfate 325(65)mg 1 time per day Multivitamin Multivitamins 1 per day Vitamin C Ascorbic Acid 1000mg 1 per day Vitamin B-6 Pyridoxine Hcl 100mg twice a day Viactiv Ca Carbonate/vitamin D3/vit K 500-500-40 twice a day Vitamin B12 Cyanocobalamin 100mcg 1 time per day Vitamin E Vitamin E Acetate Super B Complex Vitamin B Complex 1 per day Glucagon Emergency Kit Glucagon 1mg as directed Folic Acid Folic Acid 0.4mg take 1 tablet (0.4MG) by ORAL route every day Chromium Picolinate Calcium Phosphate/[**First Name9 (NamePattern2) 27373**] [**Last Name (un) 27374**] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 4. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 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: Two (2) Tablet PO DAILY (Daily). 7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 8. Insulin Regular Human 100 unit/mL Solution Sig: As directed Injection ASDIR (AS DIRECTED). 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*20 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyperkalemia Discharge Condition: Improved Discharge Instructions: Please return to the hospital if you develop fevers, chills, nausea, vomiting, chest pain or shortness of breath. It is very important that you have your blood drawn tomorrow to make sure your potassium and creatinine are stable. Dr.[**Last Name (STitle) 5263**] will follow-up those results and help adjust your medications. You also need to follow-up in the [**Hospital 1944**] clinic to have your blood pressure checked since two of your blood pressure medicines have been stopped. Followup Instructions: Dr. [**Last Name (STitle) **], [**Location (un) **], Central Suite, [**Hospital **] Clinic: Monday [**10-3**] 8:30 [**Telephone/Fax (1) 250**] [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-10-19**] 11:00 [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-10-27**] 12:40 [**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **],MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 721**] Date/Time:[**2107-10-28**] 9:00

41401,4111,42731,4019,25000,2720,41072

Admission Date: [**2166-2-4**] Discharge Date: [**2166-2-8**] Date of Birth: [**2096-3-3**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABG X4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) [**2166-2-4**] History of Present Illness: 69 year old male with a history of coronary artery disease s/p remote MI, stent placement in the late [**2144**]'s and a positive stress test around 6 months ago. In [**2165-12-7**], he presented to the Emergency Room with crushing substernal chest pain at rest with associated nausea and diaphoresis. He ruled in for MI and underwent cardiac catheterization which revealed 3 vessel coronary artery disease. Cardiac surgery was consulted and preoperative evaluation was performed. The patient was discharged home to recover from his MI prior to surgical revascularization. He presents [**2-4**] for elective CABG. Past Medical History: Hypertension Dyslipidemia Coronary Artery Disease -- s/p multiple PCI -- ([**2143**]) s/p inferior MI no intervention -- ([**2151**]) mid and distal RCA stenting with three PS1530 -- ([**2152**]) Diag and multiple OM branch disease on cath -- ([**2152**]) rotational atherectomy of RCA after exertional angina Diabetes Mellitus Glaucoma Social History: Race:Caucasian Last Dental Exam:edentulous Lives with: sister Occupation:retired Tobacco:quit Friday [**2165-12-27**], smoked 1 pack per week for 50years ETOH:denies Family History: Brother with MI in his 50s, Mother had MI Physical Exam: Admission Physical Exam Pulse:56 Resp:16 O2 sat:98% RA B/P Right:140/62 Left: 160/67 Height:5'5" Weight:180 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] no Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], obese Extremities: Warm [x], well-perfused [x] [**1-9**]+ (B)LE edema; no Varicosities; 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 Pertinent Results: [**2166-2-4**] 03:00PM BLOOD WBC-6.9 RBC-1.85*# Hgb-5.9*# Hct-17.4*# MCV-94 MCH-32.2* MCHC-34.1 RDW-13.6 Plt Ct-48*# [**2166-2-4**] 04:50PM BLOOD WBC-8.9 RBC-2.43*# Hgb-7.9*# Hct-22.9*# MCV-94 MCH-32.7* MCHC-34.7 RDW-13.8 Plt Ct-74*# [**2166-2-4**] 08:59PM BLOOD WBC-10.6 RBC-3.05*# Hgb-9.8* Hct-27.9*# MCV-92 MCH-32.3* MCHC-35.3* RDW-13.9 Plt Ct-78* [**2166-2-5**] 12:58AM BLOOD WBC-8.5 RBC-3.04* Hgb-9.4* Hct-27.1* MCV-89 MCH-31.1 MCHC-34.8 RDW-14.0 Plt Ct-84* [**2166-2-6**] 04:40AM BLOOD WBC-6.0 RBC-3.02* Hgb-9.8* Hct-27.7* MCV-92 MCH-32.4* MCHC-35.2* RDW-14.1 Plt Ct-109* [**2166-2-7**] 04:30AM BLOOD WBC-6.1 RBC-3.01* Hgb-9.6* Hct-27.8* MCV-92 MCH-31.7 MCHC-34.4 RDW-13.8 Plt Ct-138* [**2166-2-4**] 03:00PM BLOOD PT-16.9* PTT-33.1 INR(PT)-1.5* [**2166-2-4**] 03:00PM BLOOD Plt Ct-48*# [**2166-2-4**] 04:50PM BLOOD Plt Ct-74*# [**2166-2-4**] 08:59PM BLOOD Plt Ct-78* [**2166-2-5**] 12:58AM BLOOD Plt Ct-84* [**2166-2-6**] 04:40AM BLOOD Plt Ct-109* [**2166-2-7**] 04:30AM BLOOD Plt Ct-138* [**2166-2-4**] 03:00PM BLOOD Fibrino-127* [**2166-2-4**] 04:50PM BLOOD UreaN-23* Creat-1.0 Na-141 K-5.4* Cl-116* HCO3-22 AnGap-8 [**2166-2-5**] 12:58AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-139 K-4.5 Cl-110* HCO3-23 AnGap-11 [**2166-2-6**] 04:40AM BLOOD Glucose-162* UreaN-23* Creat-1.3* Na-141 K-5.2* Cl-107 HCO3-27 AnGap-12 [**2166-2-7**] 04:30AM BLOOD Glucose-72 UreaN-29* Creat-1.1 Na-141 K-4.7 Cl-106 HCO3-28 AnGap-12 [**2166-2-8**] 04:35AM BLOOD UreaN-25* Creat-1.0 Na-137 K-4.2 Cl-100 Introp TEE [**2166-2-4**]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. 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 structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post Bypass The patient is now s/p 4 vessel CABG,on an Neosynephrine drip at 0.3mcg/kg/min and AV sequentially paced LV function and Ejection fraction are preserved with no new regional wall motion abnormalities There are no dissection flaps visible in the proximal ascending aorta There is persistent mild Mitral regurgitation. CXR [**2166-2-7**] FINDINGS: There is residual small right apical pneumothorax which is similar-appearing compared to most recent prior. Mild cardiomegaly is unchanged. There is minimal stable pulmonary vascular congestion. Small bilateral pleural effusions are seen. IMPRESSION: Unchanged small right apical pneumothorax. Brief Hospital Course: The patient was electively brought to the operating room on [**2166-2-4**] where the patient underwent CABG x4 LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA). Please see operative report for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Postoperatively, he received a total of 3 units of PRBCs for postoperative blood loss with a hct of 17. His hematocrit bumped appropriately to 27. 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. On POD 3, the patient had a brief burst of rapid atrial fibrillation and beta blockade was increased. 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 on [**2166-2-8**] in good condition with appropriate follow up instructions. Medications on Admission: crestor 20mg daily metoprolol xl 50mg daily glyburide/metformin 5/500 2 tab [**Hospital1 **] actos 30mg daily doxyzosin 2mg daily lisinopril 40mg daily fenofibrate 160mg daily aspirin travatan z 0.004% 1 drop QHS NTG sl (but does not use) Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 5 days. Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take stool softeners while taking narcotic pain medication. . 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Please do not drive or operate machinery while taking this medication. Take stool softeners to prevent constipation. Wean yourself off as tolerated. Disp:*40 Tablet(s)* Refills:*0* 6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): Per home regimen. 9. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. 10. doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Per home regimen. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 13. glyburide-metformin 5-500 mg Tablet Sig: Two (2) Tablet PO twice a day: Per home regimen. Do not restart Actos. Please log your blood sugars and f/u with PCP. . Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease Hypertension Hyperlipidemia Diabetes Mellitus Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage LE Edema: trace-1+ Discharge Instructions: DISCHARGE INSTRUCTIONS: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: You are scheduled for a wound check on [**Hospital Ward Name 121**] 6 with a midlevel provider on [**Name9 (PRE) 5929**] [**2166-2-13**] at 10am. Surgeon Dr.[**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2166-3-6**] 1:15 [**Telephone/Fax (1) 170**] PCP/Cardiologist Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2-20**] at 3:00pm **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:[**2166-2-8**]

185,5185,2851,5849,9975,7885,25000,4019,2449,32723

Admission Date: [**2109-2-1**] Discharge Date: [**2109-2-6**] Date of Birth: [**2051-5-25**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 19908**] Chief Complaint: prostate cancer Major Surgical or Invasive Procedure: radical prostatectomy History of Present Illness: 57 y/o male with T2DM, HTN, OSA, and prostate cancer (recent PSA 4.2, Gl 6+7 disease comprising up to 90% of the cores on the right, [**4-29**]; h/o colovesical fistula/repair. Got 10.0L EBL: 1.5L. Difficult intubation requiring fiber optic scope - took 15 minutes. Per anesthesia, would like monitoring overnight in unit before attempting extubation. ROS: Unable to obtain as patient is intubated and sedated Past Medical History: Diverticulitis s/p exploratory laparotomy, sigmoid and left colectomy with mobilization of the splenic flexure, repair of bladder, and primary anastomosis s/p repair of his bladder from a fistula [**2099**] Anti-platelet antibodies with chronic thrombocytopenia OSA s/p palatal surgery T2DM HTN Hypothyroidism Physical Exam: Vitals: T 101 BP: 100/65 HR: 107 GEN: No acute distress, intubated HEENT: Intubated, pupils small but reactive NECK: No JVD COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: rhonchorous throughout ABD: Soft, NT, JP drain in place draiing serosanguinous fluid EXT: no [**Location (un) **], 2+ DP pulses bilaterally NEURO: sedated SKIN: no rashes Pertinent Results: [**2109-2-1**] 07:06PM GLUCOSE-143* UREA N-13 CREAT-1.0 SODIUM-139 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13 [**2109-2-1**] 07:06PM CALCIUM-7.9* MAGNESIUM-1.5* [**2109-2-1**] 07:06PM WBC-13.7* RBC-3.67* HGB-11.4* HCT-32.5* MCV-89 MCH-31.1 MCHC-35.1* RDW-13.4 [**2109-2-1**] 10:57PM LACTATE-3.7* [**2109-2-1**] 02:34PM TYPE-ART TIDAL VOL-800 O2-100 PO2-227* PCO2-46* PH-7.30* TOTAL CO2-24 BASE XS--3 AADO2-440 REQ O2-76 INTUBATED-INTUBATED VENT-CONTROLLED [**2109-2-1**] 05:10PM TYPE-ART TEMP-35.3 RATES-10/ TIDAL VOL-1100 PEEP-5 O2-60 PO2-95 PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED [**2109-2-1**] 10:57PM TYPE-ART TEMP-37.6 RATES-/18 TIDAL VOL-865 PEEP-5 O2-100 PO2-153* PCO2-44 PH-7.32* TOTAL CO2-24 BASE XS--3 AADO2-516 REQ O2-86 INTUBATED-INTUBATED VENT-SPONTANEOU Imaging: CXR: No evidence of consolidation, ? blunting on CP angles bilaterally Brief Hospital Course: 57 yo M with prostate CA 2/p radical prostatectomy with difficult intubation requiring fiber optic scope. Admitted to ICU for monitoring now s/p extubation. # Difficult Intubation: Patient with fiber optic intubation, per anesthesia, needed monitoring overnight. Required increased fentanyl for sedation. Was sucessfully extubated [**11-1**] and was on CPAP overnight for OSA. This morning was satting well on RA. # Oliguria: The patient postoperatively had oliguria and was given LR boluses. This resolved with IVF. # Anemia: Hct decreased from 29.9 to 26.6 this am, on recheck was 26.3, likely secondary to dilution from IVF and intraoperative blood loss, EBL 1.5L. Recheck pm Hct, if continues to decrease would have a low threshold to scan his abdomen/pelvis with a CT to rule out RP bleed. # Lower extremity numbness: Patient had new onset numbness in her lower extremities b/l overnight which was improving this am. No motor deficits. Unclear cause, possible related to how he was laying for the operation (possible nerve compression?). # Positive UA: Patient had trace LE, pos nit, but >1000 RBC's. Has colovesicular fistula in past. Difficult to interpret UA in this setting. Was on cefazolin post surgically, wihch has some urine pathogen coverage. Per urology, expected to have dirty UA, no tx indicated at this time. # Fever: The patient spiked a fever to 101 on [**2-1**] and was cultured. Unclear source, could be post-op vs infectious, slighly tachy to 100's with the fever. WBC elevated at 14.9, but decreased to 11.9 today. Cx have been NGTD except for the dirty UA as above. No fever for the last day. # Tachycardia: Patient has been in the 90??????s to 100??????s; was on verapamil as an outpatient and this was held, so may be reflex tachycardia from this. Received IVF yesterday without much response. His home verapamil was added back and ****. # Prostate CA: T3N0M0, s/p radical prostatecomy. His JP tube continued to put out a large amount of serosanguinous fluid. # HTN: Patient is on verapamil and diovan as an outpatient. His pressures have been well-controlled, but he??????s been tachycardic. These medications were initally held perioperatively, however verapamil was restarted the day he left the MICU. #Hypothyroidism: The patient was continued on his home levthyroxine. He was admitted to Urology after undergoing radical prostatectomy. No concerning intraoperative events occurred; please see dictated operative note for details. He received ancef for perioperative prophylaxis. He was transferred to the ICU from the PACU in stable condition. On POD0 he remained intubated with large urine output from his JP. He was extubated on POD 1 and transferred to the floor on POD 2. His pain was well controlled on PCA , hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis. A physical therapy consult was obtained who recommended home with VNA. On POD3, he was restarted on his 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 regular diet with start of colace. JP removed POD5 without difficulty after drainage was <10 for the past 2 days. The remainder of the hospital course was relatively unremarkable. He was discharged in stable condition on POD1, ambulating independently, eating well, and with pain control on oral analgesics. On exam, his incision was clean, dry, and intact, with no evidence of hematoma collection or infection. He was given explicit instructions to follow-up in clinic with Dr. [**Last Name (STitle) 9125**] in 1 week, and that the urethral catheter (foley) would be removed during the follow-up appointment. He was instructed to start 3 day course of Ciprofloxacin on day prior to Foley removal. Medications on Admission: Diovan Verapamil SR 240 mg PO daily Metformin 500 mg PO BID Levothyroxine 0.225mg daily Discharge Medications: 1. 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* 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): use while taking narcotics. Disp:*60 Capsule(s)* Refills:*0* 4. Levothyroxine 200 mcg Tablet Oral 5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Start day before appointment. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: prostate cancer Discharge Condition: stable Discharge Instructions: -You may take motrin and narcotic together for pain control -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks. -Allow bandage strips to fall off over time, remove all remaining dressings in 2 days -No heavy lifting for 4 weeks (no more than 10 pounds) [**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath. -Follow up in 1 week for wound check/foley removal -Please do not drive or consume alcohol while taking pain medications. -Take first dose of Ciprofloxacin 1 day prior to foley catheter removal and for subsequent 2 days. - Wear Large foley bag for majority of time, leg bag is only for short-term when leaving house. Followup Instructions: 1-2 weeks Completed by:[**2109-2-6**]

43310,5990,43330,25000,4439,4280,42731,496,V4972,2859,78009

Admission Date: [**2142-2-16**] Discharge Date: [**2142-2-21**] Service: SURGERY Allergies: Morphine / Ativan Attending:[**First Name3 (LF) 4748**] Chief Complaint: Menatl status changes Major Surgical or Invasive Procedure: Left carotid endarterectmoy History of Present Illness: 86 F transfered from [**Location (un) **] ED s/p R toe amputation and Fem [**Doctor Last Name **] bypass in mid [**Month (only) **] who presents now with MS changes concerning for TIA. Pt has been recooperating in nursing home being treated for chronic infection. Today she developed acute episode of altered mental status- She was reported to be sitting in a chair and subsequently felt lightheaded. Pt was noted to have mom[**Name (NI) 12823**] garbled speech. Thought to be either delirium s/p infection vs mutiple TIAs. She was brought to the ED where she was noted to have elevated WBV, UTI. INR was subtherapeutic 1.6. Creatinin at 1.2 baseline <1. Pt was transfered to [**Hospital1 18**] for further evaluation. Past Medical History: -PVD s/p FEM [**Doctor Last Name **] bypass and toe amputation -DM2 -CHF -A-Fib -COPD -Bilateral carotid stenosis Social History: former tobacco use, no ETOH use, no drugs, lives with son and daughter in law. Recently d/c;d from rehab after fall with no major injuries Family History: N/C Physical Exam: VS: 98.4 79 121/52 20 96% RA Neck, left with incision intact, steri stripped RRR CTAB soft NT/ND, no pulsitile masses no LE edema, B/L feet warm RLE - 2+ Fem, MP PT, DP [**Name (NI) **] - 2+ Fem, MP PT, DP RLE: toes necrotic changes RLE wound on shin [**Name (NI) **]: blister like lesion on shin Pertinent Results: [**2142-2-21**] 06:30AM BLOOD WBC-9.4 RBC-3.08* Hgb-9.4* Hct-27.8* MCV-90 MCH-30.7 MCHC-33.9 RDW-16.0* Plt Ct-214 [**2142-2-21**] 06:30AM BLOOD Plt Ct-214 [**2142-2-21**] 06:30AM BLOOD Glucose-79 UreaN-15 Creat-1.1 Na-140 K-4.4 Cl-100 HCO3-33* AnGap-11 [**2142-2-20**] 02:46AM BLOOD Glucose-79 UreaN-12 Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-29 AnGap-10 Brief Hospital Course: [**2141-2-16**] Patient was transferred from OSH for mental status changes, admitted to vascular surgery/Dr. [**Last Name (STitle) 1391**] service. Concerning for TIAs in the setting of bilateral carotis stenosis. Head/brain CT was done-negative for ICH w/ severe narrowing of the common carotid artery bifurcation and proximal cervical internal carotid arteries, right more than left, started heparin drip. She was scheduled for L CEA on [**2142-2-19**], remained on Heparin drip over the weekend. She was pre-oped and consented for L CEA. [**2142-2-19**] Patient was taken to the OR and underwent L CEA, patient tolerated procedure well, transferred to PACU for recovery. In the PACU, patient became unresponsive, needing to be intubated and transferred to the ICU where she stayed intubated oevrnight. She was also placed on Neo drip to keep her SBP above 150 mmHg. Neurology consulted, Head CT repeated-no stroke. [**2142-2-20**] Patient was weaned and extubated, weaned off pressors, alert and oriented and neurologically intact. By the end of the day patient was transferred to floor. Patient recieved blood transfusion for HCT 21.4 <- from 27, also given Lasix. Physical therapy evaluated [**Hospital 84041**] rehab (which is patient's baseline). [**2-21**]/Overnight patient had episodes of wheezing, started Albuterol nebs prn. Resolved by morning. Patient is now stable, ambulating w/ assistance, eating and voiding. Discharged back to her rehab (LifeCare Center in [**Location (un) **]) in good condition. Will FU w/ Dr. [**Last Name (STitle) 1391**] in [**4-12**] weeks. Medications on Admission: Coumadin 2 mg po qd Celexa 10 mg po qd Lisinopril 2.5 mg po qd Verapamil 120 mg po qd Neurontin 100 mg po qd Metformin 500 mg po qd Lasix 40 mg po qd Amiodarone 200 mg po qd Lantus 100 unit/mL 16 units injection once daily Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Bilateral carotid stenosis with TIA's now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 84042**], [**First Name3 (LF) **] need RXEA in the near future Anemia-acute on chronic, Hct drop from 27->21+, transfused w/ 1 u PC History of: -PVD s/p FEM [**Doctor Last Name **] bypass and toe amputation -DM2 -CHF -A-Fib -COPD Past Surgical History: [**2142-1-9**] Right lower extremity diagnostic angiogram [**2142-1-11**] Right femoral-Below Knee popliteal bypass w/NRSVG [**2142-1-15**] Right 2nd toe amputation Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - needs assistance Discharge Instructions: Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions ACTIVITIES: - [**Month (only) 116**] shower, pat dry your incision, no tub baths - No driving till seen in FU by Dr. [**Last Name (STitle) 1391**] - No lifting heavy objects, suddent neck turns or excessive neck bending and rotating - Resume activities as tolerated, slowly incraese activiy as tolerated - Expect your activity level to return to normal slowly DIET: - Diet as tolerated, eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications WOUND: - You may have some swelling and feel a firm ridge along the incision, slightly red and raised - Keep your incision open to air - Keep wound dry and clean, call if noted to have redness, draining, or swelling, or if temp is greater than 101.5 WHEN TO CALL: - Call the office or go to ED if you experience severe headache that is not relieved by Tylenol, signs of TIA or stroke (weakness/paralysis of any or all extremities, difficulty of speech, facial drooping), difficulty of speaking, or swallowing. OTHERS: - You may have a sore throat and/or mild hoarseness - Try warm tea, throat lozenges or cool/cold beverages MEDICATIONS: - Continue all medications as instructed Followup Instructions: Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone: [**Telephone/Fax (1) 1393**] Completed by:[**2142-2-21**]

4413,41071,5609,5762,9974,5601,51881,56881,41402,486,5990,5849,5854,2761,496,E8782,2355,40390,412,41401,55321,78551,04104,2767,V4975,V1052,53081,2724

Admission Date: [**2166-10-14**] Discharge Date: [**2166-11-20**] Date of Birth: [**2096-2-28**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 7651**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Endovascular aneurysm repair with bilateral groin cutdowns [**2166-10-14**] History of Present Illness: 70 year old male presented with abdominal pain. The pain started the afternoon of [**10-14**] afternoon he laid down. Pt reported dizziness when he stood up. He had similar abdominal pain approximately 4 days prior, and at that time, he had a CT scan without IV contrast that demonstrated a non-leaking 4 cm abdominal aortic aneurysm. The patient was then sent to the [**Location 1268**] VA for admission and further evaluation. He reports he was discharged 2 days ago from the VA with a negative work-up for his abdominal pain. He had been pain free the day prior to admission but he also had nothing to eat until this afternoon. He denied fever, chills. No nausea or vomiting. No diarrhea. Blacked out at home and went to Caritas HC where a CT without contrast showed leaking aneurysm and creatinine up to 5.8 from baseline 1.8. He was hydrated and [**Last Name (un) **] Flighted to [**Hospital1 18**] to have emergent EVAR of AAA by Dr. [**Last Name (STitle) **]. Past Medical History: Past Medical History: Coronary artery disease s/p myocardial infarction, hypertension, hyperlipidemia, GERD, reflux esophagitis, constipation, cataract, blepharitis, cri, COPD, ventral hernia, renal cancer, low back pain, renal cell ca, pvd, elevated psa, . Past Surgical History: status post nephrectomy for renal cancer, Right femoral [**Doctor Last Name **] bypass in [**2161**] and s/p thrombolysis of his graft, Right below the knee amputation, CABG x 4 in 93, appendectomy, exploratory laparotomy with lysis of adhesions -internal hernia, biliary stenting [**2166-10-15**] EVAR for ruptured AAA Social History: Lives by himself. Ex-smoker and quit 8 years ago. He drinks about 3 alcoholic drinks per week. Family History: Non-contributory Physical Exam: VS: 98.3, 97.7, 91/47, 105, 20, 94%2L GEN: NAD, A&Ox3, NGT in place HEENT: anicteric sclera, neck supple, no LAD CV: RRR, nl S1 and S2 Lungs: Decreased BS B/L Abd: soft, distended, reducible large ventral hernia, diffusely tender to palpation, +tympany EXT: R BKA site well healed, L DP is 2+ palp B/L groin sites with slight erythema but no active drainage Pertinent Results: Please see OMR Brief Hospital Course: Pt was admitted on [**2166-10-14**] transferred from an OSH for ruptured abdominal aortic aneurysm. An urgent CAT scan with IV contrast performed at [**Hospital1 18**] demonstrated a contained, leaking abdominal aortic aneurysm. Due to prohibitive surgical risk, the pt underwent an endovascular aneurysm repair with bilateral groin cutdowns on emergent basis on [**2166-10-14**]. BP during the procedure was initially 90-100s over 40-50s (one value to 80/40) then 110/80s. Postoperatively, the pt was transferred to the CVICU intubated on pressors. He required fluid boluses and prbc as well as albumin. BP stabilized. He was extubated. Due to increase in creatinine from baseline of 1.8 to 5.0, nephrology was consulted on [**2166-10-15**]. ARF on CRF felt [**2-8**] to hypotension and poor perfusion. HD was not indicated. Avoidance of all nephrotoxins was advised as well as keeping MAP >65. On [**2166-10-16**], surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was consulted for concern for ischemic bowel as the patient had an episode of watery diarrhea. A flex sig was performed at the bedside which revealed no evidence of either mucosal slough or transmural ischemia. The colon was entirely normal up to 45 cm. No further episodes of diarrhea occured following the sigmoidoscopy. On [**10-19**],he was kept NPO, an NGT was placed for vomiting and a KUB was done to eval for free air. Urine was positive for pan sensitive enterobacter cloacae. Cipro was started. CT abdomen on [**10-21**] demonstrated findings consistent with ileus. Status post aortobifemoral graft with no interval change in the size of extensive right retroperitoneal hematoma. Cholelithiasis was noted. Of note, there were gas locules noted in the aneurysmal sac and in the retroperitoneal region likely post-surgical in nature. Although, there was concern for possible fistula. Hepatobiliary was reconsulted on [**10-22**]. On [**10-22**], hepatobiliary surgery was reconsulted for concerns for obstruction as he had abdominal pain and distention since [**2166-10-16**] without BM. The NGT output was 1L to 1.5L of gastric contents on a daily basis for the past 72 hours. After review of the MRI and CT scans from the VA, the pancreatic mass was felt to likely be either a primary pancreatic adenocarcinoma or potential renal cell carcinoma metastasis. Because the mass was obstructing the distal common bile duct, the patient underwent ERCP and stent placement. Brushings obtained during the ERCP were negative for malignancy, and biopsy obtained during a subsequent EUS of the mass was an insufficient sample and thus a proper diagnosis could not be made. GI was consulted on [**10-22**] for possible EGD. This was not felt to be indicated and recommendations to assess the pancreatic stent were recommended given elevated t.bili and alk phos (6.5 and 272). On [**10-23**], He was started on vanco, zosyn and flagyl for possible small perforation. Of note, patient's other current major issue is progressive renal dysfunction. ***NO SUMMARY FROM [**10-22**] - [**11-18**]. On [**11-18**], the patient was noted by nephrology to have altered mental status concerning for uremia, and so he received a tunnelled hemodialysis cathether. On [**11-19**] he was started on hemodialysis but became hypotensive to 40s and so dialysis was stopped early. On [**11-20**] AMS, hypoxic, transferred to SICU, intubated, became tachy/brady then asystolic, pulse returned w/ CPR found to have massive MI by echo put on pressors and taken to cath lab. Pt had stent placed in left main coronary and required IABP support, which was problem[**Name (NI) 115**] given recent AAA repair. Pt required 4 pressors and transient CPR. IABP was removed shortly due to distal skin mottling thought to be due to emboli from his aorta. He continued to deteriorate with pH on ABG of <7, and Potassium at 6.7. Pt's family was contact[**Name (NI) **] and decision was made to be DNR/DNR, and soon after CMO. Pt's medications were all stopped, including pressors and morphine drip started for comfort. Pt passed away within 30 minutes from cardiopulmonary arrest. Pt was warm, with no heart sounds or breath sounds. Negative gag reflex, neg corneal reflex and neg oculocephalic reflex. Pt's family was notified and appropriate death certificate and autopsy paperwork was filed. Primary cause of death: Cardiopulmonary arrest Secondary cause of death: NSTEMI Medications on Admission: Tylenol prn, Lisinopril 5', Senna 8.6", Omeprazole 20', Lubricating OPH ointment QHS, Carboxymethylcellulose 1% 0.4mL gtts"', Colace 100", Flunisolide 0.025%", Loratiadine 10', Lopressor 25", Simvastatin 80', Tamsulosin 0.4', Ketotifen 0.025 gtts ou prn: qd, Doxepin 50' Discharge Disposition: Expired Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Cardiopulmonary Arrest NSTEMI partial small bowel obstruction pancreatic mass Right lobe pneumonia Urinary tract infection. Acute on chronic renal failure. Abdominal aortic aneurysm ileus Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2166-11-21**]

4241,5849,9971,5990,27652,2724,42731,E8782,4019,25000,2749,2859,27800

Admission Date: [**2136-3-27**] Discharge Date: [**2136-4-3**] Date of Birth: [**2066-11-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [**2136-3-27**] cardiac cath [**2136-3-28**] aortic valve replacement (21mm St. [**Male First Name (un) 923**] Porcine) aortic root enlargement (pericardial patch) History of Present Illness: 69 yo male with hx of aortic stenosis followed by serial echos. Recent echo shows severe AS with [**Location (un) 109**] 0.54 cm2 and mild LVH. Known heart murmur for 10 years. Referred for pre-op cath and surgery. Past Medical History: gout obesity aortic stenosis non-insulin depenedent diabetes mellitus hypertension hypercholesterolemia benign left parotid mass nephrolithiasis Social History: works an an engineer never used tobacco occasional ETOH drink lives alone Family History: non-contrib. Physical Exam: HR 71 RR 12 145/60 5'3 [**12-9**]" 168# NAD, obese skin unremarkable large firm left parotid mass neck supple, full ROM CTAB RRR 4/6 SEM with radiation throughout precordium to carotids abd + BS warm,well-perfused, no peripheral edema or varicosities noted MAE [**4-10**] strengths, grossly intact 1+ bil. femorals 2+ bil. DP/PT/radials Pertinent Results: Cardiac Catheterization COMMENTS: 1. Coronary angiography of this right dominant system demonstrated no angiographically apparent flow-limiting coronary artery disease. The LMCA was a short vessel. The LAD had mild diffuse plaquing to 25% in the mid-vessel. The distal LAD wrapped around the apex. There was slight pulsatile flow. The high Diagonal-1 and the Diagonal-2 branches had mild plaquing. The LCX was patent and supplied small OM1 and OM2 branches and a major, slightly tortuous LPL and distal AV groove LCX. The RCA had minimal diffuse plaquing and bifurcated into large RPDA and RPL systems. 2. Resting hemodynamics revealed severe elevations in right and left sided filling pressures with a RVEDP of 24 mmHg and a LVEDP of 29 mmHg. There was mild pulmonary arterial hypertension with a PA pressure of 42/23 mmHg. There was mild systemic arterial systolic hypertension with a central aortic pressure of 158/76 mmHg. The mean gradient across the aortic valve was 50 mmHg. The calculated aortic valve area was 0.5 cm2. The cardiac index was 1.8 L/min/m2. FINAL DIAGNOSIS: 1. No angiographically apparent flow-limiting coronary artery disease. 2. Severe aortic stenosis. 3. Severe biventricular diastolic dysfunction. 4. Mild pulmonary arterial hypertension. 5. Mild systemic arterial systolic hypertension. ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] ECHO Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. 6. Trivial mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced. 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 16-22 mmHg). No aortic regurgitation is seen. 2. Aorta appears intact post decannulation 3. Biventricular function is normal. 4. MR appears slightly worse, No [**Male First Name (un) **] is seen. It is mild to moderate in severity Dr. [**First Name (STitle) **] was notified in person of the results. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81291**]Portable TTE (Complete) Done [**2136-4-3**] at 2:00:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] 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: [**2066-11-28**] Age (years): 69 M Hgt (in): 63 BP (mm Hg): 159/70 Wgt (lb): 191 HR (bpm): 84 BSA (m2): 1.90 m2 Indication: Evaluate for pericardial effusion. Recent aortic valve prosthesis. ICD-9 Codes: 423.9, 424.1 Test Information Date/Time: [**2136-4-3**] at 14:00 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2009W000-0:0 Machine: Vivid [**6-11**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *23 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 13 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 0.78 Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms TR Gradient (+ RA = PASP): 21 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.3 cm Findings This study was compared to the prior study of [**2136-2-27**]. LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated, normal leaflet/disc motion and transvalvular gradients. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR. PERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential. No RA or RV diastolic collapse. Sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation 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 small to moderate (1.3 cm) sized pericardial effusion. The effusion appears circumferential. No right atrial or right ventricular diastolic collapse is seen. There is accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. This may be secondary to etiologies other than pericardial tamponade (lung disease, etc..). Compared with the prior study (images reviewed) of [**2136-2-27**], an aortic valve bioprosthesis is now present. The aortic root appears thickened, consistent with aortic root enlargment. The pericardial effusion is new. The estimated pulmonary artery pressure is lower. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2136-4-3**] 17:10 Radiology Report CHEST (PA & LAT) Study Date of [**2136-4-3**] 1:34 PM Reason: assess for effusions Preliminary Report !! PFI !! 1. Enlargement of the cardiac silhouette relative to both the most recent prior and the pre-operative chest x-ray without evidence of CHF. These findings could represent interval development of a pericardial effusion and a cardiac echo may be obtained for further characterization. 2. Small bilateral pleural effusions and improved aeration of the left lung base. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**] [**2136-3-27**] 04:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2136-3-27**] 04:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-3-27**] 04:55PM URINE RBC-[**5-16**]* WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2136-3-27**] 03:32PM GLUCOSE-132* UREA N-23* CREAT-0.9 SODIUM-139 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17 [**2136-3-27**] 03:32PM ALT(SGPT)-30 AST(SGOT)-26 LD(LDH)-188 ALK PHOS-64 AMYLASE-57 TOT BILI-0.5 [**2136-3-27**] 03:32PM LIPASE-61* [**2136-3-27**] 03:32PM ALBUMIN-4.3 CALCIUM-9.4 MAGNESIUM-1.8 [**2136-3-27**] 03:32PM %HbA1c-6.6* [**2136-3-27**] 03:32PM WBC-15.6* RBC-4.65 HGB-13.6* HCT-38.8* MCV-83 MCH-29.2 MCHC-35.0 RDW-13. [**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3947**] [**Medical Record Number 81292**] M 69 [**2066-11-28**] [**2136-3-27**] 03:32PM PLT COUNT-452* [**2136-3-27**] 03:32PM PT-12.6 PTT-21.4* INR(PT)-1.1 [**2136-4-2**] 05:35AM BLOOD WBC-23.6* RBC-3.46* Hgb-10.1* Hct-29.2* MCV-84 MCH-29.3 MCHC-34.7 RDW-15.2 Plt Ct-446*# [**2136-4-2**] 05:35AM BLOOD Plt Ct-446*# [**2136-4-2**] 05:35AM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2* [**2136-4-2**] 05:35AM BLOOD Glucose-86 UreaN-24* Creat-1.2 Na-137 K-3.9 Cl-101 HCO3-25 AnGap-15 Brief Hospital Course: Admitted [**3-27**] and underwent cardiac cath. This did not reveal any significant coronary disease. Underwent surgery with Dr. [**First Name (STitle) **] on [**3-28**]. Transferred to the CVICU in stable condition on titrated insulin, phenylephrine, and propofol drips. Extubated later that day. Transferred to the floor on POD #2 to begin increasing his activity level. Rapid A Fib treated with amiodarone and metoprolol, converted to sinus rhythm. Low grade fever prompted UA which showed a UTI, Started on Cipro for a three day course. Chest tubes and pacing wires removed per protocol. Remainder of hospital stay uneventful. Cleared for discharge to home with VNA on POD 6. Medications on Admission: colchicine 0.6 mg [**Hospital1 **] colace 100 mg [**Hospital1 **] tenormin 50 mg daily glucophage XR 1000 mg [**Hospital1 **] diovan 320 mg daily HCTZ 25 mg daily zocor 20 mg daily glipizide 2.5 mg [**Hospital1 **] ASA 81 mg daily amlodipine 5 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg QD x7 days then 200mg QD. Disp:*35 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day: 20meq [**Hospital1 **] x 1 week then 20meq QD x 2 weeks. Disp:*60 Tablet Sustained Release(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 20mg [**Hospital1 **] x 1 week then 20mg QD x 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO twice a day: resume preop schedule. Tablet Sustained Release 24 hr(s) Discharge Disposition: Home With Service Facility: Home health and Hospice Discharge Diagnosis: aortic stenosis postop atrial fibrillation PMH: hypercholesterolemia hypertension non-insulin dependent diabetes mellitus h/o nephrolithiasis left parotid mass (benign) gout obesity 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, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) **],SUDARSHAN [**Telephone/Fax (1) 7660**] in 1 week Please call for appointments Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2136-4-3**]

V5811,1960,2536,1481,V1582,4019,V1046,53081

Admission Date: [**2197-5-30**] Discharge Date: [**2197-5-31**] Date of Birth: [**2136-3-17**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 3326**] Chief Complaint: chemotherapy with hypertomic saline administration Major Surgical or Invasive Procedure: None History of Present Illness: 61 y/o with Stage [**Doctor First Name 690**] Squamous cell carcinoma of the right piriform sinus presenting for C2D1 of TPF (Taxotere, cisplantin, 5-fluorouriacil). He originally presented with neck pain and in [**4-12**] underwent direct laryngoscopy with a biopsy of a pyriform sinus mass diagnostic of SSC. . Mr [**Known lastname 35716**] started Cycle 1 of TPF on [**2197-5-5**] on C1D13 he presented with NA of 120 and was hospitalized from [**5-17**] to [**5-19**]. He Na nadir was 118 and patient experienced decreased concentration at that time. He has a h/o chronic hyponatremia with Na 126 dating back to [**2188**]. Labs were consistent with SIADH, with the acute exacerbation thought to be a consequence of his platinum based chemotherapy. His sodium improved with 1L fluid restriction and NaCL tablets to 126 on discharge. He is followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], nephrology. . Given Mr [**Known lastname 35717**] hyponatremia with the last cycle chemotherapy admission for close Na monitoring and ppx hypertonic saline is planned. Past Medical History: Past Oncologic History: Mr. [**Known lastname 35716**] presented with a pain in his right neck after holding in a sneeze. A lump developed in the area and he was referred to Dr. [**Last Name (STitle) 1837**] and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a CT scan of the neck. The CT scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. Biopsy of the mass was positive for squamous cell carcinoma. On [**2197-4-13**] he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. Pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. He was HPV negative. Port was placed [**2197-5-5**]. He started C1D1 TPF on [**2197-5-5**]. . Other Past Medical History: - History of prostate cancer status post radical prostatectomy with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**], status post salvage radiation therapy and has since followed with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**]. - hypertension - acid reflux disease with hiatal hernia - hernia repair in [**2177**] - appendectomy in [**2149**] Social History: Social History: Lives in [**Location **]. The patient is married with five children, all local. He smoked half a pack per day for 10 years but quit smoking 30 years ago. He drank alcohol heavily in the past mostly associated with his job as a bar tender but has been sober for the last two and half years. He is retired navy and currently works as a doorman/security, which he enjoys. Family History: FAMILY HISTORY: His mother died of CHF. Father died of a heart attack. He has four siblings. His children are healthy. Physical Exam: Tmax=97.5=Tcurrent, HR=50s-60s, BP=100s-150s/60s-80s, RR=13-22, POx=93% General: Alert, NAD HEENT: NC/AT CV: RRR, No m/r/g appreciated Resp: CTA bilaterally Abd: S/NT/ND; BS present Ext: trace pitting edema in the LE??????s bilaterally Pertinent Results: [**2197-5-30**] 01:05PM GLUCOSE-86 UREA N-22* CREAT-0.7 SODIUM-123* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-23 ANION GAP-16 [**2197-5-30**] 01:05PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2197-5-30**] 01:05PM WBC-14.4*# RBC-3.52* HGB-11.0* HCT-31.6* MCV-90 MCH-31.2 MCHC-34.8 RDW-13.6 [**2197-5-30**] 01:05PM NEUTS-85.7* LYMPHS-7.1* MONOS-6.8 EOS-0.2 BASOS-0.2 [**2197-5-30**] 01:05PM PLT COUNT-480*# [**2197-5-30**] 01:05PM PT-12.3 PTT-21.7* INR(PT)-1.0 Brief Hospital Course: This is a 61 year old male with Stage IV squamous cell carcimona of the right pyriform sinus presenting for his second cycle of TPF requiring an elective ICU admission for hypertonic saline because his previous cycle was complicated by acute on chronic hyponatremia. . # Squamous cell carcinoma of right pyriform sinus: Pt was discharged on C2D2 of TPF (taxotere, cisplatin, 5-FU). He received Taxotere 75 mg/m2 and cisplatin 100 mg/m2 on admission. He was also set up with a 5-fluorouracil pump at 1000 mg/m2/24 hours X 96 hours via continuous infusion on the day of discharge. The patient says that he feels well after the chemo which he attributes to the cisplatin being infused over 8 hours instead of 5 hours like his previous treatment. He received hypertonic saline while the chemo was administered and his sodium remained above 123. He received the following antiemetics per oncology recommendations: Emend 125mg PO and zofran 8mg IV 1 hr prior to chemo on [**5-30**]. He also received Emend 80mg PO on [**5-31**] and was continued on zofran 8mg PO q8h standing. He also took dexamethasone 8mg prior to arrival and was continued on 8mg [**Hospital1 **] with a plan to take 4mg daily while getting the 5-FU infusion. Ativan and compazine were continued for breakthrough nausea. He will start cipro prophylaxis when his 5-FU infusion is complete. He will also use clotrimazole troches QID PRN mouth pain. . # Hyponatremia: He completed a regimen of normal saline and hypertonic saline per renal recs. Sodium was 127 on discharge and was never below 123. He will continue a 1 liter fluid restriction and start Lasix 20mg PO to keep his sodium up at home. . # Leukocytosis: Likely related to patient??????s recent steroid administration and improved on discharge. He did not spike a fever. . # HTN: His home atenolol was continued and his home enalapril was decreased to 5mg [**Hospital1 **] from 10mg. . # GERD: His home omeprazole was continued. Medications on Admission: Emend Dose pack (on hold) Atenolol 50mg daily dexamethasone 4-8mg as directed (has taken 8mg last two days) enalapril 10mg [**Hospital1 **] Hydrocodone- Acetaminophen 5/500mg [**2-4**] tab q6h prn (on hold) lidocaine - diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] mouthwash TID (on hold) lorazepam 0.5mg PO q6h prn (on hold) omeprazole 40mg PO daily Ondansetron 8mg q8h prn (on hold) Prochlorperazine 10mg q6h ( on hold) viagra 100mg PO prn tolvaptan 15mg PO dailyl (currently on hold, never started) multivitamin daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dexamethasone 4 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12 hours): take two tablets twice daily on [**5-31**] then reduce to one tablet once daily on [**5-31**] and [**6-3**] then stop. 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: take in the morning. Disp:*30 Tablet(s)* Refills:*2* 4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Clotrimazole 10 mg Troche Sig: One (1) troche Mucous membrane four times a day as needed for mouth pain. Disp:*100 troches* Refills:*0* 6. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: on [**5-31**] and [**6-1**], take every 8 hours. Then, can take every 8 hours as needed for nausea. 7. Emend 80 mg Capsule Sig: One (1) Capsule PO once a day: take on [**2197-6-1**]. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluorouracil 500 mg/10 mL Solution Sig: 1800 (1800) mg Intravenous continuous infusion: until [**2197-6-3**]. 13. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 14. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: Ten (10) ml Mucous membrane three times a day: as needed. Discharge Disposition: Home Discharge Diagnosis: Stage IV sqaumous cell carcinoma of the pyriform sinus Hyponatremia from SIADH . Secondary diagnoses: -Hypertension -GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for chemotherapy and concentrated saline administration. You tolerated the chemotherapy well and your sodium levels remained at your baseline. You are being discharged on a 5-FU chemotherapy pump. Be sure to continue to restrict your fluid intake to 1 liter a day. In addition try to eat salty foods. The following changes were made to your medication regimen: - Lasix was started to help keep your sodium level normal - Enalapril was decreased to 5mg twice a day. - Clotrimazole as needed for mouth pain - You should start cipro as directed on Saturday [**6-3**] when your 5-FU chemo pump is stopped Be sure to follow up with your doctors as listed below. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below: . Heme/onc: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-6-2**] 9:30 . Renal: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2197-6-20**] 4:30

5789,486,2536,79001,1960,4589,1481,V1046,4019,2800,53081,27652,V153,52801,E9331,2929,E9320

Admission Date: [**2197-6-16**] Discharge Date: [**2197-6-25**] Date of Birth: [**2136-3-17**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 3016**] Chief Complaint: Cough, confusion, hyponatremia --> Cycle 3 TPF Major Surgical or Invasive Procedure: Cycle 3 TPF (Taxotere, cisplantin, 5-fluorouriacil) chemotherapy History of Present Illness: The patient is a 61 yo M with h/o prostate cancer and currently undergoing treatment for piriform SCC who presents from home with non-productive cough and mental slowing. Pt reports a repeated sensation of abd cramping followed by coughing, only when supine. The cough is nonproductive and does not reaccure when sitting upright. Per the wife over the last few days Mr [**Name (NI) 35716**] has seemed slow with his thinking. He was not disoriented. No fevers, however 2 days ago he had rigors. No NS. No CP. + loose BM, no abd pain. NO dysuria. . In the ED, initial vs were: T 97 P72 BP 108/72 R16 O2 sat 100. BP droped to 89/64 but improved to 101/69 following resusitation with 3.5L NS. A chest xray showed a possible RLL PNA and crackles were heard in that area. Patient was given ceftriaxone, azithro and flagyl. His was admitted to the ICU given his transient hypotension. . On the floor, he is without complains other than pain at the finger tips from his chemo. Past Medical History: Oncologic history: # Head and neck cancer: - Mr. [**Known lastname 35716**] presented with a pain in his right neck. A lump developed in the area and he was referred to Dr. [**Last Name (STitle) 1837**] and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a CT scan of the neck. The CT scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. Biopsy of the mass was positive for squamous cell carcinoma. On [**2197-4-13**] he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. Pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. He was HPV negative. Port was placed [**2197-5-5**]. He started C1D1 of cisplatin, docetaxel, 5-FU on [**2197-5-5**]. # prostate cancer: status post radical prostatectomy with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**], status post salvage radiation therapy and has since followed with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**]. Non-oncologic history: - hypertension - acid reflux disease with hiatal hernia - hernia repair in [**2177**] - appendectomy in [**2149**] Social History: Lives in [**Location **]. The patient is married with five children, all local. He smoked half a pack per day for 10 years but quit smoking 30 years ago. He had extensive second hand smoke exposure working in a tavern. No alcohol use for the last 2 years. Previous drinking history. He is retired Navy and currently works as a doorman/security. . Family History: His mother died of CHF. Father died of a heart attack. He has four siblings. His children are healthy. . Physical Exam: General: Alert, orientedx 3, no acute distress. Slightly tangential and perseverating speech. HEENT: Sclera anicteric, pale conjuctiva, MMM, oropharynx clear (no visible mouth lesions) Neck: supple, JVP not elevated, no LAD Lungs: crackles RLL. No rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2197-6-16**] 05:46PM GLUCOSE-110* UREA N-16 CREAT-0.8 SODIUM-125* POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-26 ANION GAP-12 [**2197-6-16**] 05:46PM CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.9 [**2197-6-16**] 11:00AM URINE HOURS-RANDOM UREA N-454 CREAT-38 SODIUM-63 POTASSIUM-31 CHLORIDE-80 [**2197-6-16**] 11:00AM URINE OSMOLAL-386 [**2197-6-16**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2197-6-16**] 10:14AM HCT-22.2* [**2197-6-16**] 10:14AM FIBRINOGE-501* [**2197-6-16**] 10:14AM RET AUT-4.3* [**2197-6-16**] 08:05AM GLUCOSE-91 UREA N-24* CREAT-0.7 SODIUM-120* POTASSIUM-3.5 CHLORIDE-90* TOTAL CO2-26 ANION GAP-8 [**2197-6-16**] 08:05AM LD(LDH)-185 [**2197-6-16**] 08:05AM CALCIUM-7.1* PHOSPHATE-1.7* MAGNESIUM-1.5* URIC ACID-4.9 [**2197-6-16**] 08:05AM HAPTOGLOB-220* [**2197-6-16**] 08:05AM WBC-6.2 RBC-2.22*# HGB-7.2* HCT-19.8* MCV-89 MCH-32.5* MCHC-36.4* RDW-14.9 [**2197-6-16**] 08:05AM NEUTS-66 BANDS-2 LYMPHS-17* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-3* [**2197-6-16**] 08:05AM PLT SMR-NORMAL PLT COUNT-221 [**2197-6-16**] 03:53AM LACTATE-2.9* [**2197-6-16**] 03:40AM GLUCOSE-109* UREA N-28* CREAT-0.9 SODIUM-122* POTASSIUM-3.0* CHLORIDE-89* TOTAL CO2-26 ANION GAP-10 [**2197-6-16**] 02:16AM LACTATE-2.2* [**2197-6-15**] 11:45PM GLUCOSE-102* UREA N-33* CREAT-1.1 SODIUM-119* POTASSIUM-3.6 CHLORIDE-82* TOTAL CO2-31 ANION GAP-10 [**2197-6-15**] 11:45PM ALT(SGPT)-43* AST(SGOT)-30 CK(CPK)-117 ALK PHOS-112 TOT BILI-0.3 [**2197-6-15**] 11:45PM cTropnT-<0.01 [**2197-6-15**] 11:45PM WBC-7.4 RBC-2.98* HGB-9.6* HCT-26.4* MCV-89 MCH-32.3* MCHC-36.4* RDW-16.8* [**2197-6-15**] 11:45PM PLT COUNT-242 . CXR [**6-16**]: FINDINGS: In comparison with study of [**5-17**], there is little change in the appearance of the heart and lungs. There are some bilateral areas of opacification most likely representing atelectasis. In the appropriate clinical setting, the possibility of pneumonia would have to be considered. Continued mild cardiomegaly. The port-A-Cath remains in place. Definite vascular congestion. Central catheter. . EKG [**6-25**]: Sinus tachycardia. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2197-6-2**] heart rate has increased and Q-T interval prolongation is no longer seen. Brief Hospital Course: This is a 61 year old male with PMH of SCC of the pryiform sinus s/p C2 of TPF (taxotere, cisplatin, 5-FU) on [**5-30**] presenting with cough and confusion and found to have a possible RLL PNA on imaging, worsening of his known chronic SIADH hyponatremia, and anemia with a Hct=19.8. . # Pyriform sinus squamous cell carcinoma: # Stage [**Doctor First Name 690**] squamous cell carcinoma of the right piriform sinus: S/p Cycle 2 of TPF (taxotere, cisplatin, 5-FU) on [**5-30**]. Due to patient's hyponatremia, confusion and generally complex medical condition, he stayed in-house for his third cycle of TPF once his cough, confusion and anemia had improved. He required special preparations of his 5-FU with normal saline, not D5W given his hyponatremia. Discontinued dexamethasone 2 days early given steroid psychosis. He completed the cycle with no significant complications, although he did have some emotional lability with the steroids. The patient was discharged with antibiotic prophylaxis (Cipro) as well as Emend. . # Anemia: His hematocrit was down to 19.8 on [**6-16**] from 31.9 on [**6-13**]. He reports 2 days of BRBPR. He may have GI oozing secondary to mucositis or underlying diverticulosis which may be amplified by aggressive fluid repletion. His hematocrit was trended closely and he received 2 unit of pRBCs. . # Hyponatremia: The patient has a long history of hyponatremia which has been extensively evaluated by renal and found to be consistent with SIADH with unclear underlying cause, possibly due to his malignancy and worsened in the past (and this admission) with chemotherapy session. Cisplatinum chemo is also known to worsen hyponatremia and therefore the patient has been repeatedly admitted for hyponatremia. During his last admission, he was treated with lasix, salt tabs, and fluid restriction. On admission his sodium was 119 and he was last discharged with a Na=120. He was once again treated with Lasix, salt tabs, and fluid restriction (although patient occasionally found drinking fluids in the nutrition room with question of ability to comply). His sodium was trended closely and was quite labile. Renal followed the patient in-house. . # CXR Findings: He has a small infiltrate on imaging suggestive of RLL PNA vs. atelectasis. Given his recent chemotherapy, as well as current bandemia, chills, and cough with RLL crackles, he was given azithromycin, ceftriaxone, and flagyl in the ED. This regimen was changed to cefepime and azithromycin in the ICU. He does not have a history of chronic cough, but he claims to have "aspiration" due to cough with lying flat consistent with GERD. After monitoring the patient overnight, it was felt that pneumonia was very unlikely, and antibiotics were stopped. The patient remained stable from a pulmonary standpoint for the remainder of this hospital course. # Altered mental status: Likely multifactorial from hyponatremia and possibly toxicity from his chemotherapy may be contributing. He was near his recent baseline per his wife who has noted subtle memory changes since he started his chemo regimen. Recent MRI head imaging had not revealed a likely cause. It was later felt, also, once the patient started his next cycle of chemotherapy that the steroids (dexamethasone) made him emotionally labile, alternatively frustrated, anxious, tearful. The patient wandered off the floor once looking for coffee. This emotional lability improved once the steroids were discontinued. # GERD: He described abdominal cramping followed by a feeling of regurgitation and cough while supine which is consistent with GERD. He was started on a [**Hospital1 **] PPI with improvmenet in his symptoms. # HTN: His home atenolol was held given hypotension. As his pressures normalized, the patient's home beta blocker was resumed. It was felt that the patient has a tendency to develop vasovagal hypotension and bradycardia when his port site is accessed. The patient has had vagal episodes in the past during accessing his port. When the patient was prepared prior to port site access, it is well tolerated. Medications on Admission: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: Ten (10) mL Mucous membrane four times a day. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0 Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed for pain. Disp:*30 Troche(s)* Refills:*0* 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for insomnia, anxiety. Disp:*30 Tablet(s)* Refills:*0* 7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: [**2-4**] Capsules PO every six (6) hours. 14. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: Ten (10) mL Mucous membrane four times a day. 15. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 16. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 17. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Expired Discharge Diagnosis: Primary: Stage [**Doctor First Name 690**] squamous cell carcinoma of the right piriform sinus, hyponatremia, slow lower GI bleed, altered mental status Secondary: Hypertension, GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with mental slowing and cough. You were initially in the ICU because of concerns about your low sodium and a slow bleeding in your GI tract. You were treated briefly with antibiotics for possible pneumonia and closely monitored for the GI bleeding, which stopped. You also underwent your third cycle of chemotherapy, which you tolerated well. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> RESUME Atenolol 50mg daily --> INCREASE Lasix 20mg twice daily to 40mg twice daily --> DECREASE your Atenolol 50mg daily to 25mg daily --> CONTINUE Ciprofloxacin 500mg twice daily for 9 more days --> START taking Enalapril 10mg daily --> START Sodium Chloride (Salt) tablets 2mg three times daily --> START Clotrimazole troches 10mg four times daily -As we suspect you have bleeding in your intestinal tract, it is very important that you see a Gastroenterologist about getting a colonoscopy. This can be set up through your primary care doctor. The number of the Gastroenterologist office here is [**Telephone/Fax (1) 13246**]. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10351**] and Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **]. Their office will contact you with date/time of your appointments next week in Hematology/[**Hospital **] clinic. You also have an appointment with Dr. [**Last Name (STitle) **] (kidney doctor) to follow up with your low sodium level. That appointment will be on[**2197-6-20**] at 430pm. His office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical CEnter. It is very important that you go to this appointment. As we suspect you have bleeding in your intestinal tract, it is very important that you see a Gastroenterologist about getting a colonoscopy. This can be set up through your primary care doctor. The number of the Gastroenterologist office here is [**Telephone/Fax (1) 13246**]. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-6-28**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-8-5**] 10:30 [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

03812,48242,51881,5070,2866,5849,570,2762,2639,4271,2536,78551,1481,52800,28800,99592,78791,E9331,4019,42731

Admission Date: [**2197-7-3**] Discharge Date: [**2197-7-8**] Date of Birth: [**2136-3-17**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 5893**] Chief Complaint: Watery, nonbloody diarrhea Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Arterial Line Central Venous Line History of Present Illness: Mr. [**Known lastname 35716**] is a 61-year-old man with history of head and neck cancer. He is currently on docetaxel, cisplatin, and 5-FU who presented with diarrhea. The night before admission, he started having multiple bowel movements with watery, non-bloody diarrhea. Per his wife, he was also increasingly lethargic and nodding off while sitting on the toilet. He denies fevers, chills, or abdominal pain. In ED, T 98.1, HR 110, BP 116/92, RR 16, 99% RA. Exam revealed a macular rash on upper chest. WBC was 2.6 with 35% neutrophils, 21% lymphs, and 28% bandemia. Urinalysis was negative, and CXR was reported as unremarkable. (However, subsequent [**Location (un) 1131**] of CXR revealed LLL opacity.) He received empiric levofloxacin and metronidazole. REVIEW OF SYSTEMS: no recent weight change, fevers, chills, headache, visual changes, shortness of breath, cough, chest pain, abdominal pain, constipation, melena, BRBPR, hematuria, dysuria, weakness, numbness, tingling Past Medical History: Oncologic history: # Head and neck cancer: - Mr. [**Known lastname 35716**] presented with a pain in his right neck. A lump developed in the area and he was referred to Dr. [**Last Name (STitle) 1837**] and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a CT scan of the neck. The CT scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. Biopsy of the mass was positive for squamous cell carcinoma. On [**2197-4-13**] he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. Pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. He was HPV negative. Port was placed [**2197-5-5**]. He started C1D1 of cisplatin, docetaxel, 5-FU on [**2197-5-5**]. # prostate cancer: status post radical prostatectomy with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**], status post salvage radiation therapy and has since followed with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**]. Non-oncologic history: - hypertension - acid reflux disease with hiatal hernia - hernia repair in [**2177**] - appendectomy in [**2149**] Social History: Lives in [**Location **]. The patient is married with five children, all local. He smoked half a pack per day for 10 years but quit smoking 30 years ago. He had extensive second hand smoke exposure working in a tavern. No alcohol use for the last 2 years. Previous drinking history. He is retired Navy and currently works as a doorman/security. . Family History: His mother died of CHF. Father died of a heart attack. He has four siblings. His children are healthy. . Physical Exam: Vitals: T 97.3, BP 122/90, HR 125, RR 16, 98%RA Gen: Elderly Caucasian man in no acute distress, awake, alert, oriented x 3 but slightly confused about recent history, very talkative HEENT: EOMI, moist mucus membranes with punctate oral sores under tongue and on bilateral oral cavity, chocolate milk/boost on lips, ruddy complexion (unchanged from last admission) Neck: supple, no LAD, reticular/erythematous rash with clear margins on chest CV: Regular rate/rhythm, normal S1/S2, no murmur/gallops/rubs, port site c/d/i Lungs: CTAB, no wheezing/rhonchi/rales Abd: soft, nontender, nondistended, bowel sounds present, no hepatosplenomegaly Ext: no c/c/e - previous admissions' edema of bilateral lower extremiteis much improved Pertinent Results: [**2197-7-3**] 12:00AM PLT SMR-NORMAL PLT COUNT-254 [**2197-7-3**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2197-7-3**] 12:00AM NEUTS-35* BANDS-28* LYMPHS-21 MONOS-9 EOS-0 BASOS-0 ATYPS-2* METAS-3* MYELOS-2* NUC RBCS-1* [**2197-7-3**] 12:00AM WBC-2.6*# RBC-3.99* HGB-12.1* HCT-35.7* MCV-90 MCH-30.3 MCHC-33.8 RDW-17.4* [**2197-7-3**] 12:00AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.6 [**2197-7-3**] 12:00AM LIPASE-13 [**2197-7-3**] 12:00AM ALT(SGPT)-34 AST(SGOT)-16 ALK PHOS-135* TOT BILI-0.7 [**2197-7-3**] 12:00AM UREA N-24* CREAT-1.0 [**2197-7-3**] 12:05AM freeCa-1.07* [**2197-7-3**] 12:05AM GLUCOSE-125* LACTATE-2.6* NA+-131* K+-3.2* CL--94* TCO2-23 [**2197-7-3**] 12:05AM PH-7.42 COMMENTS-GREEN TOP [**2197-7-3**] 01:10AM URINE MUCOUS-RARE [**2197-7-3**] 01:10AM URINE HYALINE-[**4-7**]* [**2197-7-3**] 01:10AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2197-7-3**] 01:10AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5 LEUK-NEG [**2197-7-3**] 01:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 . = = = = = = = = ================================================================ MICRO DATA: [**2197-7-4**] Sputum from BAL _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . . [**2197-7-6**] Sputum: GRAM STAIN (Final [**2197-7-6**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Final [**2197-7-8**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 298-6523S [**2197-7-4**]. . . [**2197-7-7**] Sputum: [**2197-7-7**] 11:53 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2197-7-9**]** GRAM STAIN (Final [**2197-7-7**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2197-7-9**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. HEAVY GROWTH. . = = = = = = = = ================================================================ IMAGING CXR - 1. Focal opacity at the left lung base, could be focal consolidation; however, cannot exclude nodule in a patient with cancer history, although less likely. D/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Son [**Name (NI) **]. 2. Nonspecific bowel gas pattern, with a few scattered air-fluid levels in the right upper abdominal quadrant. . [**2197-7-4**]: Chest X ray IMPRESSION: Increase of the left lung opacity consistent with worsening pneumonia. . [**2197-7-5**] Chest X ray: FINDINGS: As compared to the previous radiograph, the endotracheal tube projects 4 cm above the carina with its tip. The course of the nasogastric tube is unchanged. Also unchanged is the course of the right pectoral Port-A-Cath. Newly appeared bilateral parenchymal opacities, notably in the perihilar areas, suggest pulmonary edema rather than pneumonia. Progressing retrocardiac atelectasis, the presence of a small left pleural effusion cannot be excluded. No other relevant changes. . [**2197-7-6**] Chest X ray: Comparison is made with multiple prior studies including all performed the day before. Cardiac size is top normal. Lines and tubes remain in place in standard position. There is no pneumothorax or enlarging pleural effusions. Extensive bilateral parenchymal opacities worse in the left lung have minimally improved in the right lower lobe. These are a combination of pulmonary edema and preexisting left lung pneumonia. . [**2197-7-7**] Chest X ray: IMPRESSION: Worsening multifocal consolidation and increased left lower lobe atelectasis. . [**2197-7-8**] Chest X ray: Diffuse bilateral extensive opacities have minimally improved in the left lower lobe. Cardiomediastinal contours are unchanged. Cardiac size is top normal. Lines and tubes remain in place in standard position. There is no evident pneumothorax or large pleural effusion. . [**2197-7-8**] Trans thoracic Echocardiogram: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The estimated cardiac index is depressed (<2.0L/min/m2). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is probably moderate pulmonary artery systolic hypertension. [RVSP 27 mmHg + RA pressure, with the latter almost certainly very elevated in the setting of significant tricuspid regurgitation]. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe left ventricular systolic dysfunction in the setting of rapid atrial fibrillation. Markedly dilated and severerly hypokinetic right ventricle with relative apical sparing, consistent with acute pulmonary hypertension with a chronically untrained RV (due to pulmonary embolism, hemorrhage, ARDS, etc.). Moderate to severe tricuspid regurgitation. At least moderate pulmonary hypertension. Brief Hospital Course: Mr. [**Known lastname 35716**] was a 61-year-old man with head and neck cancer who presented with diarrhea. He ultimately developed a pneumonia and passed due to complications of sepsis. Septic Shock: Mr. [**Known lastname 35716**] was admitted on [**7-3**]. He was initially started on levofloxacin for empiric coverage for a pulmonary infection. Later that day his antibiotic coverage was increased to vancomycin and cefepime. The following morning he became hypoxic after eating/drinking. A respiratory code was called. He was satting well on a non-rebreather. The decision was made to intubate on the floor to prevent further decompensation. After intubation, multiple secretions/food were suctioned from his airway. He was transferred to the ICU for further care. His antibiotic coverage was broadened to vancomycin and zosyn. The following day his blood pressures began to decrease. He was started on norepinephrine, phenylephrine, and vasopressin. He received several fluid boluses. On [**7-6**] micafungin was added for fungal coverage due to persistent fevers. MRSA grew from BAL sputum on [**7-4**] and on subsequent sputums on [**7-6**] and [**7-7**]. On [**7-7**] Zosyn was discontinued. Meropenem and linezolid were started based on ID recommendation. His primary source was felt to be from MRSA pneumonia. The infectious disease team followed his course and offered recommendations. Despite aggressive fluid resuscitation, multiple pressors, and appropriate antibiotic coverage, he had signs of end organ damage. An echo showed an EF of 15%, he had elevated LFT's, elevated lactate to 12.1, increasing coags and decreasing platelets indicating DIC, increasing WBC, and increasing creatinine. Multiple family discussion were held discussing Mr. [**Known lastname 35717**] poor prognosis. His family wanted an aggressive approach. He lost his pulse and a code was initiated. CPR was started, but his wife asked us the team to stop the code. Thrombocytopenia: Mr. [**Known lastname 35716**] was admitted with a platelet count of 254. This decreased to a low of 25. A HIT antibody test was sent and was negative. All heparin products were temporarily discontinued pending results of the test. His thrombocytopenia was ultimately thought to be due to his overwhelming infection and possible medication effects. Increased creatinine: Mr. [**Known lastname 35717**] kidney function remained intact for most of his ICU stay with a creatinine of 0.9. The day of his death his creatinine increased to 1.3 indicating renal failure from his sepsis. The renal team was consulted. There was no indication to for dialysis. His worsening renal function was attributable to overwhelming infection. Elevated LFT's: On [**7-7**] the patient's LFT's were significantly elevated. This was thought to be due mainly to hypoperfusion of the liver. Also in the differential was amiodarone toxicity as this was recently started prior to the increase in LFTs. The LFTs were monitored closely and continued to increase as we were unable to maintain adequate tissue perfusion. Head and neck cancer: No active treatment was given during this hospitalization. Atrial Fibrillation with RVR: Mr. [**Known lastname 35716**] [**Last Name (Titles) 35718**] went into atrial fibrillation with RVR. His heart rate was initially in the 200's. He was given metoprolol which slightly decreased his rate to the 150-160's. His blood pressures then decreased to systolics of 70-80's. He was cardioverted initially with 100 J, then 200 J. Each cardioversion resulted in a return to sinus rhythm. However, his heart rate went back into atrial fibrillation after a few minutes. He was then loaded with amiodarone. After a loading dose, an amiodarone gtt was started. He was then successfully cardioverted. He maintained this rate for several hours. However, throughout the next couple of days he again went into atrial fibrillation with RVR. Each time his blood pressure would drop. He was cardioverted multiple times throughout the next 2-3 days. However, each time he remained in sinus rhythm for a shorter period of time. His blood pressure rebounded less often. An esmolol gtt was briefly started, but this was discontinued for hypotension. Diarrhea: His episode of diarrhea was thought related to a chemotherapy side effect. C. diff and stool cultures were all negative. He was given intravenous fluids to maintain volume status. Medications on Admission: Atenolol 50 mg PO DAILY Omeprazole 40 mg PO DAILY Clotrimazole 10 mg Troche 4 times a day Ondansetron 4 mg PO Q8H as needed for nausea Lorazepam 0.5 mg PO Q6H as needed for nausea Prochlorperazine 10 mg PO Q6H as needed for nausea Multivitamin Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q6H as needed for pain Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash 10 mL four times a day Furosemide 20 mg PO BID * Had just completed 10 day course of Cipro ppx Discharge Disposition: Expired Discharge Diagnosis: Septic shock MRSA pneumonia/ARDS Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

20030,452,29281,7892,V6441,23871,2875,2800,V1582,E9379,2825

Admission Date: [**2168-8-30**] Discharge Date: [**2168-9-8**] Date of Birth: [**2086-9-30**] Sex: F Service: SURGERY Allergies: Bactrim Attending:[**First Name3 (LF) 1556**] Chief Complaint: splenic marginal zone lymphoma Major Surgical or Invasive Procedure: laparoscopic converted to open splenectomy History of Present Illness: 81-year-old woman who has been evaluated originally for abnormal blood smear. She was further worked up with a bone marrow biopsy and CAT scan and diagnosed with a low-grade lymphoma and thought most consistent with a splenic marginal zone lymphoma. In terms of symptoms, she has had right lower abdominal "pressure pain" which is more prominent at night when just prior to bed. Otherwise, she has had no symptoms, no nausea, vomiting, no exacerbating or alleviating symptoms. Past Medical History: PMH: 1. Headaches. 2. Thalassemia minor. 3. Degenerative joint disease. 4. Question of tuberculosis. PSH: 1. Total abdominal hysterectomy and bilateral salpingo- oophorectomy for bleeding. 2. Cataract surgery, left eye. 3. Cesarean section x1. 4. Bartholin cyst surgery. 5. Thumb surgery. Social History: She is a former smoker but quit years ago. She does not drink or use drugs. She is retired. She lives with her husband, daughter, and son. She has eight grandchildren. Family History: Family history is significant for her father having had kidney cancer. Her children have thalassemia, brother had thyroid cancer, another brother had [**Name2 (NI) 499**] and prostate cancer. Physical Exam: VS: 97.0, 76, 126/52, 20, 96% RA Gen: A&O, NAD CV: RRR no m/r/g Pulm: CTAB Abd: soft, TTP over incision site, non-distended, incision c/d/i with staples Ext: warm, 2+dp/pt, 1+LE edema Pertinent Results: [**2168-9-8**] 11:50AM BLOOD WBC-12.9* RBC-3.71* Hgb-9.1* Hct-29.2* MCV-79* MCH-24.6* MCHC-31.2 RDW-17.0* Plt Ct-840* [**2168-9-8**] 11:50AM BLOOD PT-34.2* PTT-35.2* INR(PT)-3.4* [**2168-9-8**] 11:50AM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-137 K-3.8 Cl-97 HCO3-32 AnGap-12 [**2168-9-6**] 07:20AM BLOOD ALT-34 AST-22 AlkPhos-74 TotBili-0.4 [**2168-9-8**] 11:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 Brief Hospital Course: Date of Admission: [**2168-8-30**] Date of Discharge: [**2168-9-8**] Procedures: laparoscopic converted to open splenectomy, Epidural placement x2 Imaging: CXR ([**2168-9-1**]): No acute infiltrate. Bilateral lower lobe atelectasis with small left pleural effusion. No cardiomegaly. No pulmonary edema. Abdominal U/S ([**2168-9-1**]): 1. Markedly abbreviated study due to poor patient noncompliance. 2. Limited findings are concerning for portal vein thrombus versus undetectable flow, but cannot be further clarified with ultrasound at the present time. A contrast enhanced liver CT is advised to further evaluate. CT Abd/Pelv ([**2168-9-1**]): occlusive PV thrombus in intrahepatic R and L branches of the PV. Non-occlusive thrombus in the main PV. Thrombus in splenic vein remnant. Colonic wall thickening, likely due to underdistention, but could represent colitis in the right clinical setting. Multiple hepatic and renal cysts. Bilateral pleural effusions, greater on the left than the right. CXR ([**2168-9-2**]): IJ is in proper position in the lower SVC. Otherwise, bilateral pancake atelectasis with small pleural effusions are unchanged. CXR ([**2168-9-7**]): Neg for PNA or effusions Pending labs: spleen for pathology Medication changes: none The patient was admitted for observation after laparoscopic splenectomy that was converted to open. An epidural was placed by the Acute Pains Service (APS) post-operatively for pain control which provided moderate pain relief. This was removed and was briefly started on a dilaudid PCA. However, she developed confusion and this was d/c'd and started on vicodin with IV morphine for breakthrough. APS was re-contact[**Name (NI) **] and another epidural was placed. POD#2 she developed low grade temperature with leukocytosis of 15,000 with a HCT drop from 29.6 to 26.8 and worsening abdominal pain. There was concern for possible venous thrombosis so an abdominal U/S was performed. However, this was suboptimal study limited views due to pain but did demonstrate lack of flow through the portal vein. A follow-up CT scan demonstrated an occlusive thrombus in the portal vein and non-occlusive thrombus in the splenic vein remnant. APS was paged and the epidural was removed and she was transferred to the SICU for observation and was started on Heparin drip. A right IJ CVL was placed for access. Her HCT continued to drop to 22.4 and she was transfused 2 units PRBCs, she responded appropriately with a HCT of 30. ID was consulted who recommend checking blood cultures and UA which were negative. She received pre-splenectomy vaccinations in [**Month (only) **]. Heme/Onc was consulted to assist with management and transfusion requirements in patient post-splenectomy with history of thalassemia minor. Their recommendations were to keep HCT greater than 21 and to follow up as an outpatient with her Oncologist and her scheduled f/u CT scan. POD#4 she was transferred to the floor and was started on coumadin. She was placed on regular diet and a morphine PCA for pain control. POD#5 the foley was removed and she was voiding without difficulty. She was transitioned to oxycodone and the PCA was stopped. PT was consulted who recommend [**Hospital 3058**] rehab upon discharge. POD#6 the heparin drip was stopped and she continued on coumadin. POD#7 her INR returned as 6.6 and all anticoagulation was held to allow her to drift back down. Her R IJ was removed and sent for culture which was negative. She continued to have mild O2 requirements via nasal cannula likely due to decreased ambulation. IS was continued to be encouraged and the O2 was then weaned. The oxycodone was stopped because she was overly sedated and she was placed on scheduled Tylenol and PRN tramadol of which she only needed 1 dose. POD#8 she did have temperature of 101.0, CXR was negative for infiltrate and UA was negative. She remained afebrile therafter, her WBC continued to trend down and her INR trended down to 3.4, and she developed post-splenectomy thrombocytosis with platelet count of 840 on discharge. She was ambulating, tolerating a regular diet, voiding, and having BM's. She was discharged to rehab with appropriate follow up appointments with Dr. [**Last Name (STitle) **] from surgery and her oncologist. She is going to receive 1mg coumadin tonight and should have her INR checked at rehab to titrate coumadin. Medications on Admission: prilosec 20', Ca-Vit D 600 mg-400'', MVI' Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 3. M-Vit 27-1 mg Tablet Oral 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 5. Coumadin. titrate to goal INR of [**3-3**]. Discharge Disposition: Extended Care Facility: [**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**] Discharge Diagnosis: splenic marginal zone lymphoma portal vein thrombosis splenic vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call the surgery clinic ([**Telephone/Fax (1) 3201**]) or go to the Emergency Department for the following: Temperature greater than 101.4; increasing redness, pain, swelling, or discharge from the incision sites; blood in your stool or black tarry stools; inability to tolerate food or drink; worsening abdominal pain; or any other concerns. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drink alcohol, drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**] Date/Time:[**2168-9-16**] 2:15 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-10-10**] 11:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2168-10-14**] 10:00 Completed by:[**2168-9-8**]

86113,51851,86402,03844,9584,4233,8621,86132,5849,99592,E9654,8605,00845,99859,6822,2761,2851,9582,99832,E8788,4019,25000,5715,V1253,42731,70709,70725,88013,30500,30550

Admission Date: [**2187-8-20**] Discharge Date: [**2187-9-14**] Date of Birth: [**2138-5-11**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Pt is a 49 yo male transferred via med flight from OSH [**Hospital3 **] s/p GSW. Pt was brought directly to the OR. Major Surgical or Invasive Procedure: OPERATION: 1.Median sternotomy, multiple cardiac repairs as dictated by Dr. [**Last Name (STitle) **], repair of right upper lobe parenchymal laceration, exploratory laparotomy,chromic suturing and Argon beam coagulation of 4 liver lacerations,abdominal packing, VAC closure of abdomen. 2. Emergency median sternotomy. 3. Evacuation cardiac tamponade. 4. Repair of bullet injury to the right ventricle free wall. 5. Tricuspid valve replacement with a size 29 [**Company 1543**] Mosaic tissue valve. 6. Repair of ventricular septal defect caused by the bullet with Dacron patch. 7. Left ventriculotomy to remove the bullet. 8. Laparotomy and repair liver lacerations and also lung parenchymal injury by Dr. [**Last Name (STitle) 16471**] as seen in her operation dictation note. 9. Mediastinal exploration and washout. 10. Mediastinal exploration and closure of the sternotomy. 11.Exploratory laparotomy/reopening of recent laparotomy, washout of the abdomen and closure, as well as exploration of the right arm wounds, debridement and packing 12.Exploratory laparotomy and abdominal washout. Abdominal wall debridement.Liver biopsy. Abdominal wall closure with retention sutures. History of Present Illness: This is a 49-year-old patient who sustained a gunshot injury to the right chest. He was apparently very unstable in the field with multiple arrests resuscitated successfully and on reaching the outside hospital at [**Hospital3 **] he was apparently reasonably stable. There, further investigations with x-rays revealed the bullet had traversed through the right hemithorax(chest tubed placed) across the heart and lodged itself into the left heart border and he was transferred emergently to the [**Hospital3 **] Hospital for further exploration and repair. On arrival to the [**Hospital3 **] Hospital, he was actively resuscitated to maintain reasonable hemodynamics and emergency surgery was carried out by [**Last Name (LF) **],[**First Name3 (LF) **] and the trauma surgeon, Dr. [**Last Name (STitle) 16471**], and initially explored by Dr. [**Last Name (STitle) **] as well. Past Medical History: +ETOH, DM, HTN, ? methadone user, s/p hit by train [**2180**] Social History: Heroin addict Family History: Non-contributory Physical Exam: Admission physical deferred- rushed emergently to O.R. Pertinent Results: TEE [**8-23**] Focused Study for Chest Closure and Ongoing Pressor Requirement: Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a muscular ventricular septal defect (VSD) just below the prosthetic tricuspid valve with left to right flow. This is approximately 1 cm superior to the VSD observed on [**2187-8-21**] that was repaired. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal.. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. A bioprosthetic valve is seen in the tricuspid position. There is a very small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2187-8-23**] at 0830. Following chest closure overall systolic function was unchanged from prior. [**2187-8-31**] Chest and ABD CT Scan: 1.Small apical right pneumothorax. 2.Small bilateral pleural effusions with overlying atelectasis; however, infection cannot be excluded, especially at the left lung base. Chest tube in appropriate position. 3.Small fluid collection inferior to the cecum with high density material concerning for extravasation of oral contrast. Associated focal wall thickening of the cecum which may be due to colitis: infections or inflammatory. 3. Wedge-shaped hypodense lesion within segment [**Doctor First Name 690**] of the liver, likely representing repaired liver laceration. Small amount of perihepatic free fluid. 4. Open anterior abdominal wall wound with a small amount of fluid or stranding inferiorly in the anterior abdominal wall. 5. Fractured left 1st and 2nd ribs. Discharge labs: [**2187-9-14**] 06:18AM BLOOD WBC-9.5 RBC-2.98* Hgb-8.4* Hct-27.0* MCV-91 MCH-28.3 MCHC-31.1 RDW-16.5* Plt Ct-381 [**2187-9-14**] 06:18AM BLOOD Glucose-68* UreaN-28* Creat-1.8* Na-126* K-4.8 Cl-93* HCO3-23 AnGap-15 [**2187-9-13**] 04:51AM BLOOD WBC-10.0 RBC-2.94* Hgb-8.4* Hct-26.8* MCV-91 MCH-28.4 MCHC-31.2 RDW-16.7* Plt Ct-401 [**2187-9-12**] 05:19AM BLOOD WBC-12.9* RBC-2.99* Hgb-8.6* Hct-26.8* MCV-90 MCH-28.8 MCHC-32.1 RDW-16.6* Plt Ct-431 [**2187-9-13**] 04:51AM BLOOD Plt Ct-401 [**2187-9-12**] 05:19AM BLOOD Plt Ct-431 [**2187-9-5**] 02:53AM BLOOD PT-15.0* PTT-42.0* INR(PT)-1.4* [**2187-9-13**] 04:51AM BLOOD Glucose-78 UreaN-30* Creat-2.1* Na-125* K-4.2 Cl-93* HCO3-25 AnGap-11 [**2187-9-12**] 05:19AM BLOOD Glucose-96 UreaN-34* Creat-2.2* Na-122* K-4.0 Cl-89* HCO3-23 AnGap-14 [**2187-9-7**] 05:50AM BLOOD ALT-72* AST-131* AlkPhos-108 Amylase-87 TotBili-1.9* [**2187-9-3**] 02:01AM BLOOD ALT-62* AST-170* LD(LDH)-378* AlkPhos-97 TBili-2.6* [**2187-9-7**] 05:50AM BLOOD Lipase-49 [**2187-9-1**] 02:07AM BLOOD Lipase-204* [**2187-9-13**] 04:51AM BLOOD Mg-2.2 [**2187-9-12**] 05:19AM BLOOD Mg-2.1 [**2187-9-5**] 10:58 am STOOL **FINAL REPORT [**2187-9-6**]** C. difficile DNA amplification assay (Final [**2187-9-6**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2187-8-30**] 9:52 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2187-8-31**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2187-9-2**]): RARE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 111925**] [**2187-8-25**]. [**2187-8-25**] 3:12 pm BLOOD CULTURE Source: Line-IJ 2 OF 2. Blood Culture, Routine (Final [**2187-8-28**]): SERRATIA MARCESCENS. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 353-3223V [**2187-8-27**]. Anaerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM NEGATIVE ROD(S). Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2187-9-9**] 2:54 PM Final Report: In comparison with study of [**9-7**], there has been placement of a left subclavian PICC line that extends to the lower portion of the SVC. Continued low lung volumes with bibasilar effusions and atelectasis. No definite pulmonary edema. Left apical pleural cap again is seen, representing a loculated, possibly extrapleural fluid collection related to the recent rib fracture. Brief Hospital Course: The patient was admitted from an outside hospital and went emergently to the OR after sustaining gunshot wound to the chest. He underwent extensive surgery to repair trauma sustained to chest. He was brought from the OR after undergoing Median sternotomy, TVR/VSD closure/RV repair by Dr. [**Last Name (STitle) **], repair of right upper lobe parenchymal laceration, exploratory laparotomy, chromic suturing and Argon beam coagulation of 4 liver lacerations,abdominal packing, VAC closure of abdomen .Please see multiple operative notes for further details. He arrived from OR intubated, sedated, paralyzed on Epi/Levo/vasopressin, open chest. He was bleeding from his chest tubes and required multiple blood products and returned to the OR for abd and chest washout, repair of diaphragmatic bleeder. Returned from OR continued to be hypotensive, elevated transaminases, chest and abd open and wound vac in place. He developed Rapid afib and received amiodarone with good effect. He returned to the OR on POD#2 for chest closure which he tolerated well. Abdominal wound remained open and packed. After chest closure pressors were weaned slowly over the course of several days. On pod# 4 his abd was closed. His sedation was weaned off, he remained neurologically intact and his c-spine was cleared by ACS. He spiked fevers and became bacteremic. He grew Serratia from his blood and STENOTROPHOMONAS and ENTEROBACTER from sputum on [**8-28**]. He was covered with broad coverage antibiotics, (vanc, fagyl, cefepime) ID were consulted and Bactrim was added. He developed drainage upper aspect of abd wound and was brought back to the OR by ACS. The abd was opened and packed. He returned a few days later for abd wound closure but the skin remained open. He was extubated on POD#7 but was reintubated 3hr later 2nd to resp distress. Left chest tube was placed for moderate to large effusion. He was again reextubated on POD#10. Due to his current drug history he was seen by the acute pain service for management of meds. He continued to progress slowly and was transitioned off tube feeds, seen by speech and swallow and cleared to eat regular diet. Appetite is poor and he is on supplements. His tranaminases have continued to improve. He developed acute renal failure peak creatinine 2.5. and was therefore gently diuresed. His creat continues to be above normal. He was noted to have developed a pressure sore to the back of his head for which he was seen by wound nurse and place in foam mattress. Chest tubes and PW were remove without incident. He eventually transitioned to the floor on POD#12. On the floor he continued to progress. He has remained very weak and deconditioned. He developed c-diff and was started on PO Vanco which he had completed. He became hyponatremic which has been slowly improving and was placed on fluid and free water restriction and meds were adjusted. He has remained afebrile and will continue on bactrim until [**9-14**]. The patient was evaluated by the physical therapy service for assistance with strength and mobility. At the time of discharge on POD 24 the patient was requiring max assist and was screened for rehab. He is able to sit and stand at the bedside he has a continued flat affect requiring encouragement to partake in physical therapy. All his wounds are healing well, his abdominal wound has several retention sutures and a vac in place to assist with wound healing. He was noted to be lethargic a few days prior to discharge and pain meds were adjusted, he has tolerated the adjustment and noted to be less lethargic. The patient was discharged to [**Location (un) 511**] Sianai in [**Location (un) 86**] in good condition with appropriate follow up instructions. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 10 mg PR HS:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. Furosemide 20 mg PO BID 7. Heparin 5000 UNIT SC TID 8. Metoprolol Tartrate 12.5 mg PO BID hold and call HO for SBP<90 HR<55 9. Milk of Magnesia 30 mL PO DAILY:PRN constipation 10. Nystatin Cream 1 Appl TP [**Hospital1 **] groin 11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 12. Oxycodone SR (OxyconTIN) 10 mg PO Q12H RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 13. Ranitidine 150 mg PO DAILY 14. Tizanidine 0.5 mg PO BID:PRN pain 15. Sodium Chloride 1 gm PO TID Discharge Disposition: Extended Care Facility: [**Hospital1 700**] at [**Hospital 3278**] Medical Center Discharge Diagnosis: 1)Gunshot wound to chest with resultant injuries to heart, diaphragm, lung and liver resulting in massive hemorrhage and pericardial tamponade. 2)Bleeding from diaphragm. 3)Fascial dehiscence and evisceration 4)Serratia bacteremia PMH: HTN, DM Discharge Condition: Alert and oriented x3 nonfocal Bed to chair with assist(per PT)full assist-lift(per nursing) pain managed with oral narcotics Extremities:warm well perfused-no edema Abd wound:with VAC, incision-clean Occiput: pressure ulcer-keep on sponge pillow Discharge Instructions: look at your incisions daily NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and in the evening take your temperature, these should be written down on the chart Vab dressing chnage to abdomin q 72hrs (last change [**2187-9-14**]) No driving for one month or while taking narcotics. Do not drive 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**] Followup Instructions: Recommended Follow-up: You are scheduled for the following appointments Surgeon: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2187-10-16**] 1:00 in the [**Hospital **] medical office building [**Hospital Unit Name **] Cardiologist:needs referral Please call to schedule appointments with your: Acute Care Surgery(ACS): call [**Telephone/Fax (1) 2537**] to schedule f/u appt in 2 weeks Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 66039**] in [**4-5**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2187-9-14**]

55221,9974,5601,6822,5680,27800,2440,V4586,32723,V1251,73300,4264,V4572,E8788

Admission Date: [**2134-1-27**] Discharge Date: [**2134-2-5**] Date of Birth: [**2073-8-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Admitted for repair of hernia. Major Surgical or Invasive Procedure: [**2134-1-27**] 1. Exploratory laparotomy with biopsy of mesenteric nodule. 2. Lysis of adhesions greater than 2 hours. [**2134-2-2**] PICC line placement History of Present Illness: Mr. [**Known lastname 29215**] has the history of multiple abdominal surgeries including hernia repairs with mesh. He presented with very large abdominal wall hernias with intermittent and recurrent obstruction. He was able to lose weight preoperatively with the aid of the Lap-Band procedure and now he required surgical repair of his hernias. Past Medical History: right bundle branch block ---Stress test in [**2124**] normal osteoporosis hypothyroidism s/p thyroid resection for thyroid nodule of undetermined significance sigmoid diverticulitis s/p Hartmann's with small bowel resection ([**2129-9-2**]) and takedown ([**2129-12-16**]) ventral hernia repaired with component separation ([**2131-5-2**]) Social History: The patient quit tobacco 20 years ago, does drink one glass of wine per night. No drugs. Works as mail carrier, lives with wife. Family History: Non-contributory -- as per HPI no h/o blood clots, coagulaopathies, or miscarriages Physical Exam: The BP is 116/74 and his pulse is 72 and regular. Resp is 14 and unlabored after walking down the hallway. The temp is 98.2 orally. There are no acute skin lesions. The hair and nails are normal for his age. The ear canals are clear with benign TMs. The sclera are anicteric and w/o pallor. PERRL and A. The oral mucosa has no lesions; dentition is in good repair. The neck is supple, and the thyroid is w/o enlargment or nodularity. The neck veins are flat when he is about 30 degrees from the fully supine position. The trachea is midline. There is no pain with percussion of the vertebral bodies or the CVAs. The thorax is resonant, and the BS are clear and symmetric in all lung fields, including the apices, RML and the lingula. The precordium is quiet and there is a soft and regular s1 and s2 and no murmurs, no s3 or s4 when he is upright and supine. There are no carotid bruits. No cardiac rubs. The abdomen has active BS. The liver is 9 cm in span by percussion and scratch. He has at least 2 very large ventral hernias. No abdominal masses. No peripheral edema, and no acute joint pathology. He is alert and orientated. Pertinent Results: [**2134-1-27**] 09:25PM BLOOD WBC-6.2 RBC-3.34* Hgb-11.2* Hct-33.6* MCV-101* MCH-33.7* MCHC-33.5 RDW-13.2 Plt Ct-302 [**2134-1-28**] 03:07AM BLOOD WBC-6.3 RBC-3.29* Hgb-10.6* Hct-32.6* MCV-99* MCH-32.4* MCHC-32.6 RDW-13.5 Plt Ct-277 [**2134-1-27**] 08:13PM BLOOD Glucose-183* UreaN-13 Creat-0.8 Na-140 K-4.4 Cl-107 HCO3-26 AnGap-11 [**2134-1-28**] 03:07AM BLOOD Glucose-144* UreaN-13 Creat-0.9 Na-139 K-4.4 Cl-107 HCO3-27 AnGap-9 [**2134-1-27**] 08:13PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.5* [**2134-1-28**] 03:07AM BLOOD Calcium-8.4 Phos-4.8* Brief Hospital Course: Pt underwent open heria repair on [**1-28**] with Dr. [**Last Name (STitle) **] and then Dr. [**First Name (STitle) **] from Plastics did the reconstruction. Procedure lasted over 10 hours and so pt was transfered to ICU after surgery. Three JP drains were placed. Pt did well, made good urine, vital signs were stable and so on [**1-28**] pt was transfered to the floor. On [**1-29**] foley was removed diet was advanced. Laboratory results and vital signs remained stable. JP drainage was reduced. Neuro - Patient's pain was well controlled with a dilaudid PCA until the patient was tolerating POs at which point he was transitioned to Percocet which offered good relief for his pain. CV - The patient's vital signs were monitored per routine on the floor after surgery. He was hemodynamically stable throughout the entirety of his hospital course. Pulm - After surgery the patient was encouraged to use his incentive spirometer 10 times/hour; the patient was compliant and had not postoperative complications with his pulmonary function. He maintained his oxygen saturations in the mid-90s on room air at the time of discharge. GI - The patient underwent an open hernia repair on [**1-28**] by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] (plastic surgery). His post-operative course was complicated by an ileus secondary to narcotics whichw as relieved by a suppository. Prior to discharge the patient was passing gas, defecating, and tolerating a Stage V diet without nausea or vomiting. Integumentary - The patient's incision was monitored for cellulitis on a daily basis and showed no signs of infection during his postoperative stay. He was kept on Ancef for prophylaxis while his JP drains were in. All JPs and the Ancef were discontinued on the day of discharge. Medications on Admission: 1. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H 2.Levothyroxine Sodium 150 mcg 3. Multivitamin Tablet Sig: One (1) Tablet PO once a day Discharge Medications: 1. Verapamil 40 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Ventral Hernia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-17**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call his office at [**Telephone/Fax (1) 3201**] to make an appointment. Please follow up with Dr. [**First Name (STitle) **], please call his office at [**Telephone/Fax (1) 6742**] to make an appointment. Please make an appointment with your primary care provider in the next month to review your current health status. Completed by:[**2134-2-8**]

5523,570,5722,5070,1124,51881,0380,99592,5845,5724,5185,78959,99931,6823,1122,2867,2760,5601,5579,57142,5715,78097,319,53081,5305,53789,04119,45182,E8798,28860,V0981,2766,78722,28529,V667,34690,2720

Admission Date: [**2116-5-21**] Discharge Date: [**2116-7-17**] Date of Birth: [**2064-4-13**] Sex: F Service: MEDICINE Allergies: Coconut Oil Attending:[**First Name3 (LF) 8388**] Chief Complaint: Altered mental status, hiatal hernia, hepatitis of unknown etiology Major Surgical or Invasive Procedure: 1. Several intubations for respiratory failure 2. [**2116-6-5**] laparoscopic reduction of hiatal hernia, repair of diaphragmatic defect with pledgeted sutures, pexy of stomach to diaphragm, and laparoscopic liver biopsy History of Present Illness: Ms. [**Known firstname **] [**Known lastname 85535**] is a 52 year old female with a history of mental retardation and migraine headaches who is transfered from [**Hospital 792**]Hospital for further management of hepatitis. She originally presented to [**Hospital **] Hospital on [**2116-4-28**] with an increase in the frequency of falls and confusion. Her sister and [**Name2 (NI) 802**] noted subtle changes in her behavior as far back as [**2115-10-13**] that became increasingly pronounced over the following months, viral hepatitis work-up was reportedly negative. At [**Hospital **] Hospital, the patient had a prolonged and complicated course with extensive evaluation of her elevated LFTs. She was noted to have hyperammonemia and was treated with lactulose for hepatic encephalopathy with some improvement in mental status. MRI abdomen was unremarkable. Ceruloplasmin, [**Doctor First Name **], AMA, [**Last Name (un) 15412**] were all normal. Viral hepatitis serologies were negative as was CMV PCR. Alpha-1 antitrypsin was elevated at 385. She underwent a liver biopsy on [**2116-4-5**] that showed "ongoing severe liver injury with extensive hepatocyte damage and resulting collapse. She underwent endoscopy that demonstrated a 10 cm hiatal hernia and gastric volvulus with edema and erythema of the stomach and an erosion at the GE junction. Colonoscopy showed grade IV internal hemorrhoids and 2 colonic ulcerations that were ischemic in nature and a 2 mm polyp that was resected. She required antibiotics (vancomycin and zosyn) to treat HAP and aspiration PNA. Her LFTs remained abnormal with AST of 146 and ALT 103. AP peaked at 457. She was transferred, at the request of her family, to [**Hospital1 18**] on [**2116-5-21**] for further evaluation as they were still seeking a diagnosis for her illness. The patient was admitted to the Medicine service on [**2116-5-21**] to evaluate her liver disease. While on the medicine service, her hospital course was complicated by ongoing aspiration events felt to be a result of her large hiatal hernia and esophageal dysmotility. On [**2116-5-28**], she was intubated and transferred to the MICU for increasing dyspnea and acute respiratory failure. She was extubated soon after on [**2116-5-29**] and was treated for HAP/aspiration pneumonia, but antibiotics were stopped on [**2116-6-1**]. On [**2116-6-5**], the patient was transferred to the thoracic surgery service and underwent laparascopic hiatal hernia reduction with percutaneous liver biospy. Past Medical History: - mental retardation of unknown etiology (some work-up at [**Hospital **] Hosp of [**Location (un) 86**] that was of unclear consequence) - history of migraine headaches that are associated with nausea and vomiting and can be debilitating. - hypercholesterolemia, was formerly on Lipitor. - history of self-mutilization characterized by picking at skin. - s/p right inner ear surgery x 2 with implant, [**2112**] and [**2107**] - ATN, AIN at [**Hospital **] hospital [**4-/2116**] Recent medical history during this hospitalization: - Recurrent aspiration pneumonia ([**5-28**] - 18 intubated for ARDS) - hiatal hernia s/p repair - gastric volvulus s/p repair - Right upper extremity phlebitis/cellulitis associated with PICC - NASH with Grade III-IV fibrosis - ARDS and intubation post operatively [**Date range (1) 85536**]/10 - ATN, CVVH with oliguric renal failure (Cr peaked at 3.5) - Coagulase negative staphylococcal bacteremia ([**6-16**]) - Persistent Leukocytosis of unclear etiology - Elevated alpha 1 antitrypsin Social History: She lives with her sister [**Name (NI) 17**], her [**Name (NI) 802**], and a Burmese mountain dog. She used to work at a daycare program where she did manual labor but then was switched to a group that manages dementia patients as it was thought she might be developing dementia. She has had diminished ability to perform her ADLs over the past few months. She has never smoked, no alcohol, and no drug use. Family History: - mother: breast CA at 76 - father: colorectal CA in his 60s, MI - 4 siblings: diabetes, hypertension, migraine headaches, vertigo/Meniere's disease Physical Exam: Vitals: T 99.1, BP 149/89, HR 80, RR 20, O2 sat 96% RA General: Morbidly obese, middle-aged, Caucasian female in NAD, voice is difficult to understand HEENT: dysmorphic facies, atraumatic, sclera anicteric, disconjugate gaze, unable to completely assess EOM d/t non-cooperation with exam, OP clear, MMM Neck: supple, no lymphadenopathy or thyromegaly Heart: RRR, normal s1 and s2, no murmurs Lungs: CTA anteriorly, laterally, and superiorly in the back. No w/r/r. Breathing comfortably without accessory muscle use. Abdomen: +BS, soft, obese, mild RUQ tenderness without rebound or guarding Extremities: 3+ edema in feet and ankles bilaterally. Neurological: Alert, oriented to self and family. Moves all 4 extremities. Difficult to assess due to lack of cooperation with exam. Pertinent Results: ADMISSION LABS: [**2116-5-21**] 09:32PM BLOOD WBC-14.5* RBC-3.89* Hgb-10.6* Hct-34.4* MCV-88 MCH-27.2 MCHC-30.9* RDW-15.8* Plt Ct-236 [**2116-5-22**] 05:53AM BLOOD Neuts-85.2* Lymphs-7.8* Monos-4.6 Eos-2.1 Baso-0.2 [**2116-5-21**] 09:32PM BLOOD PT-15.6* PTT-32.5 INR(PT)-1.4* [**2116-5-21**] 09:32PM BLOOD Glucose-101* UreaN-7 Creat-1.0 Na-140 K-3.9 Cl-108 HCO3-22 AnGap-14 [**2116-5-21**] 09:32PM BLOOD ALT-90* AST-145* LD(LDH)-229 AlkPhos-532* TotBili-0.8 [**2116-5-21**] 09:32PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.3 Mg-1.8 LABS ON TRANSFER TO MICU: [**2116-5-28**] 04:58AM BLOOD WBC-22.5* RBC-3.51* Hgb-10.0* Hct-31.6* MCV-90 MCH-28.5 MCHC-31.7 RDW-15.9* Plt Ct-288# [**2116-5-28**] 12:48PM BLOOD Neuts-91.5* Lymphs-5.0* Monos-2.9 Eos-0.2 Baso-0.4 [**2116-5-28**] 04:58AM BLOOD PT-16.2* PTT-30.6 INR(PT)-1.4* [**2116-5-28**] 04:58AM BLOOD Glucose-124* UreaN-15 Creat-1.5* Na-146* K-3.6 Cl-111* HCO3-21* AnGap-18 [**2116-5-28**] 04:58AM BLOOD ALT-94* AST-132* LD(LDH)-312* AlkPhos-505* TotBili-0.8 [**2116-5-28**] 04:58AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.9 Mg-1.9 [**2116-5-28**] 10:26AM BLOOD Type-ART pO2-65* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 [**2116-5-28**] 10:26AM BLOOD Lactate-3.4* BARIUM ESOPHAGRAM ([**2116-5-22**]): 1. Severe esophageal dysmotility and reflux. 2. Moderate hiatal hernia. LIVER BIOPSY, PATHOLOGY ([**2116-5-26**]): 1. Advanced fibrosis (stage 3-4) with extensive bridging, multifocal incomplete nodule formation (with a rare focus suggestive of complete nodule formation) and a prominent sinusoidal component. 2. Moderate lobular neutrophilic inflammation and mild portal mixed inflammation (score 2). 3. Foci of hepatocyte ballooning degeneration with associated intracytoplasmic hyalin (score 2). 4. Minimal steatosis (involving <5% of the core biopsy; score 0) 2D ECHO ([**2116-6-1**]): Mild regional left ventricular systolic dysfunction consistent with coronary artery disease. MRI ABDOMEN & PELVIS ([**2116-6-3**]): 1. No evidence of biliary obstruction. 2. Small amount of perihepatic ascites. 3. Significant dependent body wall edema indicative of "third-spacing". RENAL ULTRASOUND ([**2116-6-6**]): Essentially normal renal ultrasound. No evidence of hydronephrosis. DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US ([**2116-6-9**]): Major intrahepatic vasculature patent with normal direction of flow. Slightly coarsened and echogenic liver compatible with the history of autoimmune hepatitis. No intrahepatic or extrahepatic biliary ductal dilatation. CT CHEST/ABDOMEN/PELVIS ([**2116-6-14**]): 1. Improved aeration of lung parenchyma, with persistent predominantly basal consolidations and perihilar ground-glass opacities. 2. Small bilateral pleural effusions. 3. Diffuse body wall edema with mild abdominal and pelvic ascites without focal fluid collection. 4. Persistent geographic area of hypoattenuation involving the medial aspect of segment II and III of the liver of uncertain etiology. Edema or infarcts could be considered. When clinically appropriate, if the patient can have a contrast-enhanced CT or MR examination, depending patient factors, this appearance could be investigated further. Alternatively, a short-term follow-up with ultrasound might be able to provide some information and could provide a baseline for follow-up of the abnormality, if it is later visualized. Doppler features could also be reassessed in light of persistence of this abnormality. 5. Left PICC ends in the left brachiocephalic vein. 6. Thickening of the distal colon, involving the sigmoid and through the upper rectum, even allowing for underdistension. Differential considerations include colitis in the appropriate setting or sequelae of portal congestion. Since the upstream colon is mildly prominent, the fact that the distal is mild to moderately narrowed may be causing slight obstruction, although contrast passes entirely through the area. The whole segment was collapsed on the last examination, limiting assessment and comparison. Correlation with clinical factors is recommended. DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US ([**2116-6-16**]): 1. Patent hepatic vasculature 2. No focal liver lesion and no biliary dilatation seen. 3. Minimal ascites. CT ABD/PELVIS ([**2116-6-25**]): 1. No evidence of abscess. Moderate amount of ascites, which has increased since the previous study. 2. Small bilateral pleural effusions, which have decreased in size since the previous study. Adjacent bibasilar atelectasis in addition to diffuse ground-glass and patchy opacities at the bases have improved. 3. Small areas of hypoenhancement within segment II and III of the liver with slight decrease in size of these segments likely reflects evolving infarct and subsequent scarring corresponding with the area of hypodensity noted on the previous noncontrast CT studies. 4. Possible bowel wall thickening of the cecum, new since the previous study. While this may be due to underdistended bowel, focal colitis cannot be excluded. Previously described thickening of the distal colon is not seen on today's study and may have been due to underdistension on the previous study. MR HEAD W/ & W/O CONTRAST ([**2116-6-28**]): Non-specific, nonenhancing focus of high signal on FLAIR and T2 weighted images in the left parietal lobe. The differential considerations are demyleination, vasculitis or sequlae of small vessel disease. MICROBIOLOGY: [**5-27**] HD catheter - Coag neg staph [**6-26**] HD catheter - Coag neg staph [**6-28**] Blood cultures - VRE Multiple sputum and urine cultures showing undifferentiated yeast. Brief Hospital Course: HOSPICE CARE: Ms. [**Known lastname 85535**] was initially admitted to the hospital from [**State 792**]after being diagnosed with hepatitis that was found to be end stage liver disease (cirrhosis) from NASH. Briefly, her hospitalization course was complicated by intubation for aspiration pneumonia with subsequent respiratory arrest. She also underwent a hiatal hernia repair to help decrease the risk of aspiration, she was in the ICU for transient shock liver and renal dysfunction. She also developed VRE sepsis and was finally extubated several prior to her transition to the floor. Unfortunately her course continued to deteriorate, she was noted to again be in respiratory distress likely a combination of aspiration from secretions and a hypervolemic state. She was also not tolerating oral, NG tube feeds. Following the onset of NGT feeding her abdomen would become distended, she would have a fever. After a discussion with health care proxy and family members the decision was made for her to be comfort measures only. All non-essential, non-comforting medications were discontinued. Pt was started on oral Morphine for pain, oral Ativan for anxiety, Scopolamine patch to minimize secretions from the Morphine. - please continue with 5-10mg PO Morpine every 4 hours as needed for comfort, this may need to be increased pending her discomfort - please continue with 1mg Ativan PO every 4 hours for anxiety - please continue with 3 Scopolamine patches to the neck to decrease secretions - please continue with Bisacodyl 10mg PR as needed if the pt does not have a bowel movement for several days and seems uncomfortable from constipation - please continue with Acetaminophen PR as needed for any fevers PRIOR TO TRANSFER TO THORACIC SURGERY SERVICE/MICU: # Elevated liver enzymes: liver biopsy pathology slides were obtained from [**Hospital **] Hospital and reviewed by [**Hospital1 18**] pathology. Full findings are above. Pathology was consistent with stage 3-4 fibrosis thought to be secondary to NASH. # Dysphagia, hoarse voice: barium study evaluation revealed a large hiatal hernia, and OSH upper endoscopy showed possible gastric volvulus. Patient was continued on PPI [**Hospital1 **] and thoracic surgery was consulted. # Respiratory distress, aspiration pneumonia: a respiratory code was called when patient became increasingly dyspneic and hypoxic to 85% on the non-rebreather on [**5-28**]. Patient was then transferred to the MICU and started on HAP coverage with vancomycin and Zosyn. She was extubated on [**5-29**]. Bronchoscopy specimens only grew yeast. # Coag negative staph bacteremia: On [**5-29**] bottle grew GPCs which turned out to be coag negative staph. Surveilance cultures were negative, and this was felt to be likely a contaminant. Patient was initially covered with vancomycin, but this was stopped on [**6-2**]. # Candiduria: Patient grew [**Female First Name (un) **] from urine, as well as bronch specimen. Patient received fluconazole IV x 3 days, and foley catheter was changed. # Nutrition: After above mentioned aspiration event, patient was made NPO. Initial speech and swallow found esophageal dismotility on barium swallow, without coughing and patient was placed on diet of thin liquids and pureed solids. # Cellulitis: she presented to the hospital from [**Hospital **] Hospital with a right arm cellulitis at the site of her previous PICC. We completed her 7-day course of antibiotics. There were no further issues. FROM TRANSFER TO THORACIC SURGERY SERVICE/SICU ([**2116-6-5**]): KEY EVENTS: [**6-6**]: Hepatology rec likely volume down, supportive care. Renal recs likely ATN from hypotension. Renal US no source. TPN. Vanco inc 1gm q48. [**6-7**]: Placement of R subclavian CVL, started levo for sbp support, adequate UO, one dose of lasix 20 mg IV in am, improved liver function, rising creatinine [**6-9**]: continues with minimal UOP. Started albumin 25g TID and lasix drip with improvement in UOP, low dose levophed started to increase renal perfusion. Fever, sent u/a, ucx, blood cx, cxr. Ordered for RUQ ultrasound with doppler. [**6-10**] started CVVH, CT torso, placed HD line, bedside ECHO [**6-11**] CVVH at bedside, Cr / BUN / weight trending down, INR stable at 1.5. started vanco, [**Last Name (un) 2830**], fluc. [**6-12**] continues on CVVH. Now on PSV 10/10 with plan to extubate [**6-13**] [**6-13**] off CVVH since am, minimal urine production, improving past midnight, no vasopressors, febrile to 103.2 -> Blcx, UClx, sputum, on cpap. Sputum gram stain no organisms. [**6-14**]: Paracentesis done, 1.5 L of transudative fluid removed. RIGHT SC removed and new triple lumen placed in LEFT subclavian. CT torso without obvious etiology of fevers. Increasing stools overnight, c. diff sent. [**6-15**]: had HD performed at bedside with 1.5 L removed. SBT with 5/0 settings. Patient did well for ~45 minutes, then became tachypnic with desaturation. NO extubation. Became febrile to 104 and received ice packs and fan. [**6-16**]: HD was cancelled [**1-14**] fever, HD planned for [**6-17**], may not need renal recs albumin and lasix in interim; we gave lasix 40 mg once with adequate response, hepatology - f/u LFTs, no acute events, afebrile > 24 hours, d/c'ed RIJ HD line. Patient extubated. [**6-17**]: Vancomycin started for coag neg staph on RIGHT IJ HD catheter. UOP improving, lasix PRN. Overall, pt clinically improving. [**6-18**]: Urine output continues to improve. Received lasix with good output, however, afternoon lytes with hypernatremia (147). Evening lasix held. [**6-19**]: we D/Ced Fluconazole given completion of course for yeast cultures. She was cleared for thin liquids and pureed foods with swallow eval. [**6-22**]: repeat swallow study was performed demonstrating poor interest in intake, no aspiration or mechanical issue with deglutition. [**6-23**]: last dose of Vancomycin was given in the AM. Blood cultures were drawn x 2. FROM TRANSFER TO MICU ON [**6-26**]: # Respiratory failure: Pt was transferred to the MICU on [**6-26**] for hypoxic respiratory failure and was intubated. Multiple sputum cultures and a mini-BAL were negative except for undifferentiated yeast. Her respiratory failure was multifactorial, with contributions from her deconditioning after a long hospital stay, increased intraabdominal pressure from ileus and ascites, a component of ARDS during her immediate post-op period, and significant fluid overload from aggressive rehydration. She was initially >14L positive on arrival to the MICU. With aggressive diuresis with lasix and metolazone her respiratory status improved tremendously and she was extubated to face mask on [**7-11**] and transferred to the floor on [**7-15**] on nasal cannula. # Fevers and persistent leukocytosis: Patient had multiple infectious workups including repeat negative blood/sputum/urine/catheter tip cultures, negative CT chest/abdomen/pelvis, negative CT neck, cardiac echo negative for vegetations. She did have one positive blood culture for VRE early in her MICU stay. She received a long course of multiple broad-spectrum antibiotics, including vancomycin, meropenem, daptomycin, linezolid, flagyl and micafungin. It was noted that her fevers appeared related temporally to tube feeds and her fevers seemed to resolve when she was transitioned to tpn. # Renal failure: Patient's creatinine was 1.2 upon admission to the MICU and improved without intervention. # Constipation/ileus/abdominal distension: Patient had difficulty with high residuals and persistent fevers seemingly associated with tube feeds. She had intermittent increased abdominal distension which was evaluated on multiple abdominal KUBs, ultrasounds, CT scans which did not show acute abdominal processes. Diagnostic paracenteses x2 did not demonstrate SBP and ascites did not increase drastically during her MICU stay. Thought likely due to ileus and the distension improved with tpn (tube feeds held,) and erythromycin. Initially lactulose was effective but this was also held as it was given per NGT and was poorly absorbed. # AMS: Presumably hepatic encephalopathy was the cause of altered MS that led to pt's initial presentation to OSH in mid [**Month (only) 116**], when pt was found to have elevated LFTs for the first time. Apparently pt able to communicate with her sister at baseline, but level/sophistication of this communication unclear. [**Name2 (NI) **] had repeat negative head CTs and an MRI negative for acute abnormalities. Her mental status improved only slightly after extubation; however she never fully regained the ability to communicate at her reported baseline. # Anemia: First established at OSH, where EGD/[**Last Name (un) **] negative. Fe studies consistent with anemia of chronic disease. Did decrease once during her MICU stay requiring 1U PRBC but remained stable throughout the rest of her stay in the low/mid 20s. Had one episode of blood in ETT but no overt signs of significant hemorrhage. # Liver fibrosis/NASH: Transaminitis relatively stable during MICU course, [**Name (NI) 3539**] actually improved while in the MICU. Paracentesis on [**6-14**] and [**6-30**] negative for SBP. She was continued on ursodiol and rifaximin for hepatic encephalopathy. She was initially receiving lactulose, but this was discontinued due to high residuals in her tube feeds and concern for worsening abdominal distension. # Coagulopathy: INR generally 1.5-1.8 with peak 2.1. Platelet counts normal. Patient most likely had Vit K deficiency from chronic antibiotics, NPO status, and malabsorption/ileus. There was no need for reversal of anticoagulation during her MICU stay. Medications on Admission: MEDICATIONS (pre-admission): - propranolol 20mg qday - atorvastatin 20mg qday - fluoxetine 80 mg qday - nortriptyline 75mg qday - Ativan 1mg prn anxiety . MEDICATIONS (on transfer to MICU [**6-26**]) - Miconazole Powder 2% 1 Appl TP TID:PRN yeast - Nortriptyline 75 mg PO/NG HS - Acetaminophen 325-650 mg PO/NG Q6H:PRN pain or fever - Olanzapine (Disintegrating Tablet) 5 mg PO TID:PRN anxiety - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea - Ondansetron 4 mg IV Q8H:PRN nausea Order - Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing - Potassium Chloride 40 mEq / 500 ml D5W IV - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea - Polyethylene Glycol 17 g NG [**Hospital1 **] constipation - Bisacodyl 10 mg PR HS:PRN constipation - Propranolol 20 mg PO/NG DAILY - Docusate Sodium 100 mg PO BID - Fluoxetine 80 mg PO/NG DAILY - Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation - Heparin 5000 UNIT SC TID - Ursodiol 300 mg PO BID - traZODONE 50 mg PO/NG HS:PRN for sleep - Lactulose 30 mL PO/NG TID Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72 hr Sig: Three (3) Patch 72 hr Transdermal ONCE (Once): to thin secretions. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: please place rectal suppository if constipated for more than 3 days. 3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain/discomfort: Palliative Care. Disp:*500 mg* Refills:*0* 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: place under tongue. Disp:*30 Tablet(s)* Refills:*0* 5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for fever. Discharge Disposition: Extended Care Facility: [**Location (un) **] care and rehab Discharge Diagnosis: Hypoxemic Respiratory Failure VRE Sepsis Hiatal Hernia Cirrhosis NASH Mental Retardation Hyperlipidemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic, intermittently arousable. Activity Status: Bedbound. Discharge Instructions: You were initially transferred to the hospital for management for your hepatitis. After being transferred to the hospital we noted that your hepatitis was actually end stage liver disease called cirrhosis. You had a complicated hospitalization which included several intubations after you developed a lung infection after aspirating, you also had a severe infection called sepsis and you were in the intensive care unit for a prolonged time. After your breathing tube was removed you unfortunately still remained very sick with difficulty breathing. After talking with your family it was decided that you should be comfortable and you transferred to comfort measures only. Followup Instructions: Discharge to Hospice

8830,6824,E9687,30591,3004,3017

Admission Date: [**2184-4-5**] Discharge Date: [**2184-4-9**] Date of Birth: [**2158-11-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: Intubation at outside hospital Mechanical ventilation Extubation History of Present Illness: 25 year old male without any known medical problems but with possible depression/anxiety/bipolar disease who was called out from the ICU today after an extubation for violent and agitated behavior. He was involved in a violent altercation with his father two evenings ago, fueled a likely overdose of dextrmethorphan combined with alcohol. Per report, he had nearly strangled his father to unconsciousness, who required 30 stitches and now filed a restraining order. The [**Location (un) 7658**] police arrived at the scene, and were unable to subdue the patient with multiple taser shocks (3-5 times). He remained uncooperative. He was eventually brought to LGH, though had apparently some respiratory distress en route. Alcohol and marijuana were detected in the [**Location (un) **]. He was so agitated that he apparently required propofol/vecuronium sedation and was intubated. He was transferred to [**Hospital1 18**] thereafter. In the [**Hospital1 18**] ED, initial VS 97.3 100 140/80 18 100% unknown vent settings. He was found to have an abrasion over his left hand which was irrigated, and received amp/sulbactam. He was then admitted to the MICU for further management. In the MICU, he continued unasyn overnight and was extubated the following day. He was continued on CIWA due to an elevated ETOH level but he did not require additional benzos. A transition to PO augmentin yesterday was short-lived, as he spiked fevers to 101 last evening, 100.4 this morning. He was seen by hand surgery, who splinted the hand and recommended continued IV unasyn. Psychiatry and social work are both following. A warrant exists in [**Location (un) 7658**] for his arrest, and [**Location (un) 7658**] police will be providing a 1:1 sitter shortly. He has a long history of violent behavior, which prompted his "other than honorable discharge" from the marines several years ago. Per his mother, he tends to get violent when under the influence of drugs. Currently, he has a dry cough which has been present for about 24 hours. He denies shortness of breath. He denies malaise, fatigue, weakness, nausea, vomiting, dysuria, hematuria, loose stools. Past Medical History: - ADHD, not on meds - possible depression/anxiety - two psychiatric hospitalizations at [**Hospital3 **] in [**2183-5-17**] from [**2183-5-29**] to [**2183-6-2**] and in [**2183-6-17**] from [**2183-6-24**] to6/11/10. One hospitalization at least for suicide attempt. - polysubstance abuse- ETOH, marijuana, dextromethorphan - violent behavior Social History: Patient is unemployed since having a "other than honorable" discharge from the marines. He had been living with his parents recently. Smokes 1PPD cigarettes for 5 years. Denies alcohol or illicit drug use, though per family members, he has been abusing dextromethorphan and his admission tox screen positive for ETOH and marijuana. Family History: NC Physical Exam: Admission Exam: VS: 96.8 100 127/70 98% AC 550x20, 5, 0.4 Gen: Intubated, sedated HEENT: Pupils 2->1mm CV: Tachy S1+S2 Pulm: CTAB anteriorly Abd: S/NT/ND +bs, -hsm Ext: No c/c/e Neuro: Sedated. Pupils as above. Skin: 2 1 mm incision over left 4th finger consistent with tooth marks. Discharge Exam: VS: T96.5 (tm 98.4) BP118/78 P76 RR18 Sat97RA GENERAL: No acute distress HEENT: MMM, OP clear CARDS: tachy, normal S1 S2 no MRG PULM: Clear to auscultation, no rhonchi or crackles appreciated ABDOMEN: SNT ND +BS EXT: Less edema of the left hand today. sensation intact, suspended in stocking and splint. Pertinent Results: Admission Labs: [**2184-4-5**] 06:10AM URINE HOURS-RANDOM CREAT-84 SODIUM-173 POTASSIUM-62 CHLORIDE-200 [**2184-4-5**] 06:10AM URINE OSMOLAL-738 [**2184-4-5**] 06:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2184-4-5**] 06:10AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2184-4-5**] 05:41AM GLUCOSE-63* UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-20* ANION GAP-12 [**2184-4-5**] 05:41AM ALT(SGPT)-32 AST(SGOT)-30 LD(LDH)-235 CK(CPK)-251 ALK PHOS-33* TOT BILI-0.3 [**2184-4-5**] 05:41AM ALBUMIN-3.5 CALCIUM-7.4* PHOSPHATE-2.7 MAGNESIUM-1.7 [**2184-4-5**] 05:41AM WBC-11.4* RBC-4.05* HGB-13.1* HCT-36.5* MCV-90 MCH-32.4* MCHC-36.0* RDW-13.5 [**2184-4-5**] 05:41AM PLT COUNT-145* [**2184-4-5**] 01:29AM TYPE-ART RATES-0/18 TIDAL VOL-550 O2-100 PO2-484* PCO2-43 PH-7.32* TOTAL CO2-23 BASE XS--3 AADO2-212 REQ O2-42 -ASSIST/CON INTUBATED-INTUBATED [**2184-4-5**] 01:29AM O2 SAT-99 [**2184-4-5**] 12:55AM GLUCOSE-85 UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13 [**2184-4-5**] 12:55AM CK(CPK)-256 [**2184-4-5**] 12:55AM ASA-NEG ETHANOL-111* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2184-4-5**] 12:55AM URINE HOURS-RANDOM [**2184-4-5**] 12:55AM URINE HOURS-RANDOM [**2184-4-5**] 12:55AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2184-4-5**] 12:55AM WBC-12.1* RBC-4.48* HGB-14.8 HCT-40.7 MCV-91 MCH-32.9* MCHC-36.2* RDW-13.1 [**2184-4-5**] 12:55AM NEUTS-71.0* LYMPHS-23.2 MONOS-4.7 EOS-0.4 BASOS-0.7 [**2184-4-5**] 12:55AM PLT COUNT-175 Discharge Labs: [**2184-4-8**] 06:35AM [**Month/Day/Year 3143**] WBC-9.2 RBC-4.49* Hgb-14.4 Hct-41.0 MCV-91 MCH-32.0 MCHC-35.1* RDW-13.7 Plt Ct-182 [**2184-4-7**] 07:00AM [**Month/Day/Year 3143**] Glucose-95 UreaN-7 Creat-0.8 Na-141 K-4.4 Cl-105 HCO3-27 AnGap-13 [**2184-4-6**] 7:38 pm SWAB Source: L hand ring finger fight bite wound. GRAM STAIN (Final [**2184-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2184-4-8**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2184-4-5**] [**Month/Day/Year **] culture x 2: NTGD [**2184-4-5**] Urine Culture Negative EKG [**2184-4-5**]: Sinus rhythm with borderline sinus tachycardia. Prominent/modestly peaked T waves are non-specific and may be within normal limits. Cannot exclude possible hyperkalemia. Clinical correlation is suggested. No previous tracing available for comparison. CXR [**2184-4-5**]: The lungs are well expanded and show bibasilar atelectasis. The cardiac silhouette is top normal. The mediastinal silhouette, hilar contours and pleural surfaces are normal. An ET tube terminates 4.8 cm above the carina appropriately. An NG tube terminates in the stomach. IMPRESSION: Bibasilar atelectasis was much more pronounced on CT torso two hours earlier. LEFT HAND, 3 VIEWS [**2184-4-6**]: No specific localizing history is available. Allowing for this, no fracture or dislocation is detected about the left hand. No focal lytic or sclerotic lesion is identified. There is soft tissue swelling along the dorsum of the hand. No radiopaque foreign body or subcutaneous emphysema is detected. Brief Hospital Course: Mr. [**Known lastname **] is a 25 year old male with a nonspecific history of depression/anxiety/violence, polysubstance abuse, who was involved in a violent altercation requiring significant sedation and eventual intubation at an outside institution, who was transferred to [**Hospital1 18**] for further management of mechanical respiration and a left hand infected bite wound. ACTIVE PROBLEMS: 1. MECHANICAL VENTILATION: He was intubated at an OSH for agitation. CXR was clear without evidence of gas exchange impairment. Patient extubated without difficulty. SW and Psych evaluated the patient while in the ICU, with recommenadtion for prn haldol, ativan, and benadryl for further agitation. 2. AGITATION/VIOLENCE: Social work and psychiatry teams were immediately consulted for further management of his agitation. His mother revealed a dextromethorphan overdose pattern which causes euphoria and agitation, and the patient later confirmed this fact. Psych initially recommended benadryl/haldol/ativan for sedation, though was calm upon extubation and required no further chemical sedation. He did not physically or verbally abuse staff members. Psychiatry followed him throughout the hospitalization. Per psych attending discharge recommendations: Patient's history is suggestive of antisocial personality disorder, although there are some inconsistencies in the reported historical data (compare information from [**Hospital3 **] c info patient later reported to Dr. [**Last Name (STitle) 3756**], so it is difficult to say c certainy how accurate this diagnosis is. I don't appreciate persuasive evidence for a major mood or anxiety disorder, although patient does have some situational anxiety. At present, there is no psychiatric contraindication to patient's return to the legal system. Based on current data, I do not see an indication for a placement in a forensic psychiatric setting for acute risk; however, appreciating that risk assessment is dynamic, depending on the specific charges that patient is facing (e.g., level of severity, which we do not know at this time), his risk for impulsive self-harm might escalate in proportion to subjective sense of desperation & anxiety that is independent of a major mental illness. Patient is able to voice a clear understanding regarding his immediate future plans and an apparent acceptance of the situation. We rev'd how to access care within the justice system. 3. LEFT HAND BITE WOUND: He sustained a left 4th MCP fight bite which subsequently became infected. He developed fevers to 102 in the ICU with tachycardia. Received fluids and intravenous unasyn. The hand surgery team was consulted and cleaned the wound and splinted it. Swelling was intitially substantial, but improved with elevation in stockignette. He required no operative debridement. He continued 72 hours of intravenous unasyn and was discharged to complete 10 additional days of PO augmentin. He will follow up with the hand team in one week, at which point he will likely have an extensor tendon repair, which was partially torn in the fight. Will need daily dressing changes. Elevation no longer necessary. Tylenol and ibuprofen for pain. 4. ELECTRICAL INJURY: Patient received multiple electrical shocks from Taser, putting him at risk for arrythmia, rhabdomyolysis, and burns. CK stable without evidence of rhabdomylolysis. 5. POLYSUBSTANCE ABUSE: Patient with EtOH level of 200 at OSH with report of history of polysubstance abuse, particularly the dextromethorphan that triggered his acute agitation. Hyperstimulation and disassociation likely in setting of dextromethorphan. PCP and ketamine labs were pending at the time of discharge. 6. LEGAL: A warrant was issued for his arrest. Discharged into [**Location (un) 7658**] police custody. LABS PENDING AT DISCHARGE: - ketamine and PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] cultures x2 TRANSITIONAL CARE ISSUES: -follow up with hand surgery team in one week -outpatient psychiatric care Medications on Admission: none Discharge Medications: 1. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Cellulitis Left hand laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after being intubated. You were monitored in the intensive care unit, where you had your breathing tube removed. You were noted to have an injury to your hand, so you were seen by the hand surgeons. You were started on antibiotics to treat an infection of your hand. You did not need any surgery during this hospitalization, but you will need to follow up in hand clinic next week for an injury to one of your tendons. The following changes were made to your medications: #. START Augmentin 875mg by mouth every 12 hours for 10 days Followup Instructions: You have been scheduled the following appointment with the Hand doctors: Department: ORTHOPEDICS When: TUESDAY [**2184-4-13**] at 10:30 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

4829,51881,42821,34831,0312,5849,4160,4259,1120,V4282,4280,5859,79092,28749,E9331,28803,42731,4240,7245,33829,2449,5533

Admission Date: [**2191-4-12**] Discharge Date: [**2191-4-30**] Date of Birth: [**2115-8-27**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Epinephrine / Levofloxacin / Penicillins / Benadryl Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 75 yo W with recurrent/refractory multiple myeloma presenting with several days of increased shortness of breath and cough/chest congestion, transferred to the [**Hospital Unit Name 153**] for management of hypoxia. . She was recently admitted to the BMT service from [**Date range (1) 20565**] where she received a number of antimicrobials to treat fever, cough, and URI symptoms ultimately attributed to parainflenza virus III. The patient initially tested positive for parainfluenza on [**3-16**] and failed outpatient treatment with a Z-pack. During this last admission she also received IVIG and a video swallow study to evaluate chronic aspiration attributed to hiatal hernia. On [**2191-4-4**] she started Cytoxan/Velcade/Decadron with D8 of Velcade on [**2191-4-11**]. . According to the patient, she has not experienced any fevers, chills, or night sweats since discharge. She felt her symptoms had improved dramatically, but not entirely resolved. After receiving chemo her symptoms returned and are now worse than before. She endorses worsening sputum production, now pink and occasional episodes of frank blood. No sick contacts or significant outdoor exposures. Her dyspnea worsens with laying flat and is associated with L-sided pleuritic chest pain. She denies PND or LE swelling, hx of blood clots, hematuria, or rash. . She contact[**Name (NI) **] her Oncologist and was sent to the ED for evaluation of potential post-viral PNA. Her initial VS on presentation were: 98.8, 76, 136/86, 20, 88% on RA. She was placed on a NRB and her O2 sats rose to 98%. CXR revealed b/l pleural effusions and opacification of the bases. She received Vancomycin and Cefepime. They attempted to wean her supplemental O2 to 40% FiO2 on Venturi mask; however, her oxygen saturations again dropped to the 80s. Vitals prior to transfer were 141/94, 20, 99% NRB. . On admission to the [**Hospital Unit Name 153**], she appeared uncomfortable and tachypneic. She was tired, but willing to converse. She answered appropriately and expressed a need for pain medication to control her "rib pain." . . Review of sytems: (+) Per HPI, + N/V/D attributed to recent chemotherapy (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness. Denied chest pain or palpitations. Denied constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias or rash. Past Medical History: Past Medical History: - Vitiligo starting in [**2186**] - Diverticulosis- found in colonoscopy [**2186**]. Last had colonoscopy 6 months ago in [**Location (un) 47**]. - Atrial fibrillation - History of thyroidectomy - for benign cyst - History of radiation to her tonsils - History of radiation to a left clavicle plasmacytoma after a pathological fracture. - History of mitral valve prolapse - Allergies - since stem cell transplant - Chronic back pain - s/p 9 compression fractures related to multiple myeloma - Restless leg syndrome - 30 yrs - Auto. stem cell bone marrow transplant - Multiple myeloma diagnosed in [**2184**]. . Past Oncologic History: "She is most recently status post five cycles of bendamustine with her fifth cycle on [**2191-1-28**]. She was noted for increasing lower back and right hip pain and underwent an MRI of the thoracic and lumbar spine on [**2191-1-29**], which showed unchanged extensive myelomatous involvement of the thoracic vertebrae with no evidence of an epidural soft tissue mass. There were chronic deformities of T7 through T12 and myelomatous involvement of the lumbar spine, particularly the left anterior aspect of L4. Ms. [**Known lastname **] developed increasing numbness of her right lower leg from the anterior ankle and up the shin with some disruption of her balance and gait due to this numbness. She had no changes in bowel or bladder functioning. She was initiated on Decadron 4 mg four times per day on [**2191-2-4**], and began radiation therapy on [**2191-2-23**] to the lower back in hopes of improving her symptoms. Her Decadron has been decreased to 4 mg three times per day on [**2191-2-8**], 4 mg twice per day as of [**2191-2-16**], 4 mg once per day on [**2191-2-25**], and 2 mg daily as of [**2191-3-25**]. Radiation therapy completed on [**2191-3-19**]. She also received weekly Velcade while she was undergoing radiation therapy in order to continue to give her some systemic therapy during her treatment. She received a dose on [**2191-2-16**], [**2191-3-2**] and [**2191-3-9**]. She required periodic platelet transfusions during this time. Social History: Retired former administrator for GTE. Lives in [**Location 932**]. 4 children who live in the [**Location (un) 86**] area. She is a widow, now has male partner [**Name (NI) **] [**Name (NI) **], with whom she does not live. No tobacco history. Occasional social drinking. Family History: No known family history of myeloma or other blood disorders. Grandmother: breast cancer. Father: MI. Physical Exam: Admission Physical Exam: Vitals: 98.2, 114, 151/96, 16, 95% on 4L NC and high flow mask General: Alert, oriented, tachypneic, in no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rhonchi bilaterally CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge physical exam: AFVSS Gen: Well appearing, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, plasmacytoma noted on scalp Lungs: CTAB except for decreased BS in LLLF Heart: Regular, no m/r, +S3 Abd: soft, NT, ND, with BS, no HSM Ext: no c/c/e, WWP Pertinent Results: ADMISSION LABS [**2191-4-11**] -WBC-4.2 RBC-2.84* Hgb-9.1* Hct-27.8* MCV-98 MCH-32.1* MCHC-32.9 RDW-16.3* Plt Ct-24*# Neuts-92.8* Lymphs-2.5* Monos-3.7 Eos-0.2 Baso-0.8 [**2191-4-12**] -WBC-1.6*# RBC-2.50* Hgb-8.4* Hct-23.6* MCV-94 MCH-33.8* MCHC-35.8* RDW-17.0* Plt Ct-39* Neuts-91.1* Lymphs-5.6* Monos-2.9 Eos-0.3 Baso-0.1 [**2191-4-13**] -WBC-0.8* RBC-2.71* Hgb-8.9* Hct-26.1* MCV-96 MCH-32.8* MCHC-34.1 RDW-16.7* Plt Ct-36* Neuts-88* Bands-1 Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 . [**2191-4-12**] -PT-13.5* PTT-24.8 INR(PT)-1.2* -Glucose-146* UreaN-25* Creat-1.4* Na-141 K-3.7 Cl-105 HCO3-24 AnGap-16 -ALT-19 AST-33 LD(LDH)-357* CK(CPK)-31 AlkPhos-112* TotBili-0.3 . [**2191-4-13**] -Glucose-186* UreaN-27* Creat-1.5* Na-141 K-4.2 Cl-104 HCO3-24 AnGap-17 -Glucose-153* UreaN-29* Creat-1.6* Na-140 K-4.0 Cl-102 HCO3-28 AnGap-14 . [**2191-4-12**] CK-MB-4 cTropnT-0.09* [**2191-4-13**] CK-MB-5 cTropnT-0.27* proBNP-[**Numeric Identifier 20566**]* [**2191-4-12**] IgG-632* IMAGING [**4-13**] Final CT Chest 1. Multifocal consolidations throughout all lung lobes. While consolidations in the right and left lower lobes are more consistent with bacterial pneumonia, the other consolidations are concerning for fungal infection, specifically invasive aspergillosis. 2. Small bilateral pleural effusions, increased since CT of [**2191-3-21**]. 3. Prominent main pulmonary artery which may be seen with pulmonary hypertension. 4. Large hiatal hernia. CXR [**4-15**] IMPRESSION: AP chest compared to [**3-24**] and [**2191-4-12**]: Pulmonary vascular congestion and mild pulmonary edema have improved since [**4-12**]. Large area of consolidation at the right lung base and a smaller one at the left lateral to the large hiatus hernia have worsened, consistent with progressive pneumonia. Moderate-to-severe cardiomegaly is longstanding. Small bilateral pleural effusions are presumed. No pneumothorax. Right subclavian infusion port ends in the SVC. [**2191-4-16**] MR head IMPRESSION: No acute infarcts. Small vessel disease. Bony abnormalities in the skull and cervical vertebrae as well as the clivus indicative of multiple myeloma. No significant epidural disease is seen, although evaluation is limited without gadolinium administration. [**2191-4-19**] CT chest IMPRESSION: Improving bilateral bronchocentric ground-glass opacities, right pulmonary consolidation and bilateral pleural effusions, consistent with a responding multifocal consolidation, angioinvasive aspergillosis is considered a probable explanation for the appearance on the prior CT. [**4-20**] Cardiac MR Impression: 1. Moderately dilated left ventricle with global left ventricular systolic dysfunction. The LVEF was mildly depressed at 45%. The effective forward LVEF was moderately depressed at 35%. No CMR evidence of myocardial edema. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 57%. 3. Moderate mitral regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. Mild right atrial enlargement. 6. A note is made of bilateral pleural effusions and a hiatal hernia. MICROBIOLOGY RESPIRATORY VIRUS SCREEN [**4-28**] [**2191-4-28**] 4:00 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Final [**2191-4-29**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. MYCOLYTIC BLOOD CX [**2191-4-26**] 7:06 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-poc. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. BAL [**4-15**] [**2191-4-15**] 10:15 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. VIC WILL ALSO R/O CMV. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20567**] [**2191-4-15**] AT 1320. GRAM STAIN (Final [**2191-4-15**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2191-4-17**]): ~[**2180**]/ML Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [**2191-4-22**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2191-4-15**]): NO FUNGAL ELEMENTS SEEN. This is a low yield procedure based on our in-house studies. KOH PERFORMED PER [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6401**] [**2191-4-15**]. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-4-15**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2191-4-29**]): YEAST. ACID FAST SMEAR (Final [**2191-4-18**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2191-4-15**]): TEST CANCELLED, PATIENT CREDITED. PLEASE REFER TO VIRAL CULTURE FOR RESULT. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. SPUTUM CX [**4-13**] [**2191-4-13**] 12:25 pm SPUTUM Source: Induced. GRAM STAIN (Final [**2191-4-13**]): [**10-25**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2191-4-15**]): SPARSE GROWTH Commensal Respiratory Flora. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-4-13**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2191-4-29**]): YEAST. ACID FAST SMEAR (Final [**2191-4-14**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Reported to and read back by DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] AND [**Last Name (LF) 20568**],[**First Name3 (LF) 20569**] @ 15:30, [**2191-4-22**]. AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. SENT TO STATE LAB FOR FURTHER IDENTIFICATION [**2191-4-24**]. - per verbal report from state lab, probe of plated organism +[**Doctor First Name **] [**4-13**] Legionella negative [**4-13**] **FINAL REPORT [**2191-4-15**]** CMV IgG ANTIBODY (Final [**2191-4-15**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 35 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2191-4-15**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [**2-3**] weeks. Greatly elevated serum protein with IgG levels >[**2180**] mg/dl may cause interference with CMV IgM results. All Blood Cxs no growth/pending. DISCHARGE LABS COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2191-4-30**] 05:26 5.0 2.84* 9.2* 27.3* 96 32.3* 33.6 17.9* 23* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos NRBC [**2191-4-30**] 05:26 85* 0 4* 11 0 0 0 0 0 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2191-4-30**] 05:26 901 29* 1.7* 141 4.2 107 23 15 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2191-4-30**] 05:26 24 23 243 142* 0.5 Free kappa/lambda light chains pending Brief Hospital Course: 75 yo W with recurrent/refractory multiple myeloma, recent parainfluenza virus infection, presenting with increased dyspnea, transferred to [**Hospital Unit Name 153**] for management of hypoxia . # Dyspnea/Hypoxia: Likely multifactorial in etiology. Patient has an element of volume overload from acute congestive heart failure, supported by BNP of 33k, bilateral pleural effusions, and improvement with initial BiPAP and IV Lasix boluses. She also demonstrated multifocal opacities on CT chest, concerning for bacterial PNA (and potentially invasive Aspergillus). Given her immunocompromised state she was immediately started on broad antimicrobials (Vancomycin, Cefepime, and Azithromycin) and extensive studies for bacterial, viral, and fungal pathogens were sent. Respiratory culture was positive for Parainfluenza III. Sputum grew gram positive cocci from one induced culture that were further speciated to respiratory flora. A bronchoscopy was performed and revealed alveolar hemorrhage. Per infection control, pt needs to stay on droplet precautions until parainfluenza negative. . After stabilization, she was called out to the BMT floor. she received IVIG x1 for the paraflu, and we continued her abx for a 14 day course. She did well and her oxygenation improved to the point that her ambulatory saturation did not dip below 91. The patient then started to have AFB + cultures (x 3), and ID was consulted. She was empirically started on a brief course of linezolid, imipenem, and clarithromycin as she will likely require chemotherapy soon for her myeloma. However, the state lab probed her cx which was + for [**Doctor First Name **], and her regimen was changed to rifabutin, ethambutol, and clarithromycin. She will require a baseline eye exam as an outpatient, and she has close f/u with oncology and infectious disease. . # Acute Congestive Heart Failure: Patient presented with dyspnea and hypoxia (as above). CXR revealed b/l pleural effusions. BNP was elevated at 33k. Echocardiogram revealed EF of 30% with severe hypokinesis of the inferior wall and basal 2/3rds of the septum and anterior wall, which was new from her prior echo in [**6-10**]. Cardiac biomarkers did not support acute coronary syndrome. Cardiology was consulted and recommended starting low dose beta-blocker and uptitrating as needed to provide rate control and augment cardiac output. Initiation of ace-inhibitor was deferred until hemodynamic stability was assured. The etiology of her cardiomyopathy is unclear. Amyloid was considered (SPEP negative, UPEP was +), as well as [**2-2**] Parainfluenza virus, Velcade (very rare), or a missed ischemic cardiac event. . Out of concern that the echo showed coronary distribution hypokinesis, a cardiac MR was done which was c/w chemo induced cardiomyopathy, not a coronary issue. The repeat study showed an EF of ~ 45%. The CMR also did not show any signs of amyloid involvement. A cardiology c/s was recalled to assist with CM management, and metop was uptitrated to 37.5 POTID, and lisinopril was started and titrated to 5 mg PO daily, which she tolerated well. On discharge, her Metop was changed to long acting Toprol XL 100 mg PO daily. . # Multiple Myeloma: Diagnosed in [**2184**] and s/p Auto SCT in [**2184**]. Currently on C1D1 of Cytoxan/Velcade/Decadron on [**2191-4-4**]. Had increase of lytic lesions while on prior Bendamustine. ANC on admission was approaching neutropenia, so the patient was placed on neutropenic precautions. Hematolog/Oncology followed closely and provided daily recommendations. We transfused to maintain platlets >20 and Hct >25. She was continued on her prophylactic Acyclovir, inhaled Pentamidine (last dose 3/17), and current Dexamethasone. Per onc recs, her pentamidine was held. Her pain and other symptoms were controlled. Given the need for chemotherapy soon, she was placed on tx for MAC (see above). She has close f/u with oncology scheduled. . # Word finding difficulty: Pt endorsed word finding difficulty a few hours after bronchoscopy. Given concern for possible pulmonary/systemic fungal infection, aspergillosis or even mucor, vs acute embolic event, she was sent for MRI wo contrast. Neurological exam was negative for any focal findings. Preliminary read on MRI was negative for acute infarct, notable for chronic small vessel disease, mild atrophy, and skull deformities in L frontal/parietal/clivus/cervical vertebrae c/w known multiple myeloma. A neuro c/s was called, and as the patient improved, the thought was that this was [**2-2**] toxic/metabolic causes from acute infection. The word finding difficulty resolved over time, and she was set up for outpatient f/u appointment in Neurology. . # Chronic kidney injury: Related to multiple myeloma. Cr currently uptrending in the setting of diuresis. Baseline 1.4-1.8. Trended and was stble throughout stay. All medications were renally dosed. . # Prolonged PT: Likely secondary to nutritional deficiency and/or recent antibiotic use. She was given 1 dose of PO vitamin K 5 mg for repletion and INR improved. . # Paroxysmal Atrial Fibrillation: Held ASA 81 daily given low plts and monitored on telemetry. Pt was tachycardic and not on nodal blocking [**Doctor Last Name 360**] as outpatient. Last EKG shows ST with frequent PACs. Troponins peaked (othwer biomarkers flat), likely [**2-2**] heart failure/demand in setting of CKI. Per Cards, started low dose BB. Metoprolol 12.5 TID was started with subsequent improvement in rate and uptitrated to 25mg TID per cards rec. They attribute cardiomyopathy to chemotherapy and anticipate improvement w time. As above, these medications were continued to be titrated to metop succinate 100 po daily as well as lisinopril 5 mg for afterload reduction . # Hypothyroidism: Continued outpatient Levothyroxine 112mcg daily. . # Hiatal Hernia: Continued Ranitidine 150 mg daily (home dosage unknown), to restart home dose at discharge (25 mg effervescent tab). Medications on Admission: -Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day -EMLA 2.5 %-2.5 % Topical Cream Apply to POC site prior to blood draw -Caltrate 600+D Plus Minerals 600 mg-400 unit Tab 1 Tablet(s) by mouth once a day -Nystatin 100,000 unit/mL Oral Susp 5 cc(s) by mouth four times a day swish and spit as needed -Vitamin C 500 mg Tab 1 Tablet(s) by mouth once a day will hold during radiation treatment -Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected area twice per day Do not use on face. -Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth once a day -Acetaminophen 325 mg Tab 1 to 2 Tablet(s) by mouth every [**4-6**] hours as needed -Ativan 0.5 mg Tab [**1-2**] Tablet(s) by mouth q4-6 as needed for nausea, insomnia -Milk of Magnesia 400 mg/5 mL Oral Susp Suspension(s) by mouth as needed for constipation -Furosemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a day in the morning. presently on hold per patient -Alprazolam 0.5 mg Tab 2 Tablet(s) by mouth one hour before procedure. [**Month (only) 116**] take additional 0.5 mg tablet if needed. -Dexamethasone 4 mg Tab 0.5 (One half) Tablet(s) by mouth once a day ICD-9 code: 203.00 -Prochlorperazine Maleate 5 mg Tab [**1-2**] Tablet(s) by mouth every eight (8) hours as needed for nausea -Promethazine 12.5 mg Tab [**1-2**] Tablet(s) by mouth q 8 hours as needed for nausuea -Anti-Itch 0.5 %-0.5 % Lotion apply to affected areas three times a day as needed for itching -Colace 100 mg Cap 1 Capsule(s)(s) by mouth twice a day as needed for constipation Levothyroxine 112 mcg Tab 1 Tablet(s) by mouth once a day -Nebupent 300 mg Solution for Inhalation 300 mg(s) inhaled every month for 6 months Diluted in 6 ml sterile water administered via aerosol. Please administer 2 puffs of albuterol prior to treatment as needed. -OxyContin 10 mg 12 hr Tab 1 to 2 Tablet(s) by mouth every eight (8) hours -oxycodone 5 mg Cap 1 - 2 Capsule(s) by mouth every four (4) hours as needed for breakthrough pain -B Complex Cap one Capsule(s) by mouth daily -Acyclovir 400 mg Tab 1 Tablet(s) by mouth two times a day -Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day -ranitidine 25 mg Effervescent Tab -Ondansetron HCl 4 mg Tab 1 to 2 Tablet(s) by mouth every eight (8) hours as needed for nausea ICD-9 code: 203.00 -Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. rifabutin 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 2. ethambutol 400 mg Tablet Sig: Two (2) Tablet PO DAYS (MO,WE,FR). Disp:*24 Tablet(s)* Refills:*2* 3. clarithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. Caltrate 600 + D Oral 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four times a day as needed for thrush. 8. Vitamin C Oral 9. triamcinolone acetonide 0.1 % Cream Sig: One (1) appl Topical twice a day as needed for rash. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for nausea or anxiety. 12. Milk of Magnesia 400 mg/5 mL Suspension Oral 13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. EMLA Topical 15. alprazolam 0.5 mg Tablet Sig: Two (2) Tablet PO asdir as needed for before procedure: take 1 hr before procedure. 16. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 17. promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 18. Sarna Anti-Itch Topical 19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 20. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Nebupent 300 mg Recon Soln Inhalation 22. oxycodone 10 mg Tablet Extended Release 12 hr Sig: [**1-2**] Tablet Extended Release 12 hrs PO every eight (8) hours. 23. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 24. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 25. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. ranitidine HCl 25 mg Tablet, Effervescent Sig: One (1) Tablet, Effervescent PO once a day. 28. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 29. cetirizine 10 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Pneumonia Secondary Diagnoses Mycobacterium Avium Intracellulare Multiple Myeloma Parainfluenza Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your hospitalization. You were admitted to [**Hospital1 18**] with shortness of breath and were in the ICU because you needed to have assistance with your breathing. You were treated with antibiotics for 14 days for a bacterial pneumonia, and you were given IVIG because you were para-influenza positive. Finally, we found acid-fast bacilli in your sputum multiple times which required you to stay on precautions while here. Infectious Disease saw you while you were here and they felt you could be discharged with three drugs to treat MAC before your next round of chemo. We also had our cardiologists see you who added on medicine to keep your heart healthy. We also had our neurologists see you because of some word-finding difficulty, and they would like to see you in clinic. PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS - STOP TAKING LASIX - STOP taking ASPIRIN - DECREASE your ACYCLOVIR to 400 mg by mouth daily - START taking RIFABUTIN 150 mg by mouth daily - START taking ETHAMBUTOL 800 mg by mouth every MON, WED, FRI - START taking CLARITHROMYCIN 250 mg by mouth daily - START taking METOPROLOL SUCCINATE (TOPROL XL) 100 mg by mouth daily - START taking LISINOPRIL 5 mg by mouth daily Please follow up with you physicians as indicated below Followup Instructions: You will be contact[**Name (NI) **] by the [**Name (NI) **]/BMT department regarding an appointment on Monday with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. **You should also schedule an eye exam in the next week since you are on ETHAMBUTOL ** Otherwise, these are the appointments for your follow up: Department: [**Hospital3 249**] When: WEDNESDAY [**2191-5-4**] at 1:45 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20564**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2191-5-5**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: TUESDAY [**2191-5-17**] at 1:30 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 20570**] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2191-4-30**]

29181,85220,30301,E8881,3569,78321,28529,9100,9160,4019,7850

Admission Date: [**2189-2-14**] Discharge Date: [**2189-2-17**] Date of Birth: [**2134-7-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: tremulous Major Surgical or Invasive Procedure: none History of Present Illness: 54M with chronic alcohol use presenting with symptoms of withdrawal, his last drink was reported to be last night. Patient drinks approximately 1.75L of EtOH per day. He reports that he felt unable to walk today and had to sit down because his "legs were going to give out". Had a fall 2 days ago w/ apparenty head trauma. Apparently he had a similar problem last week and was admitted to [**Hospital1 2177**] for withdrawal. Patient states that his withdrawal usually manifests as shakiness, no history of withdrawal seizures. The patient has dried blood on face, unclear when trauma, ct head demonstrates miniscule SDH. . Patient's last drink was [**2-13**] afternoon. . Patient was admitted to the ICU because the patient will need frequent monitoring. . In the ED inital vitals were, 98.6 112 161/101 18 98% RA. Pt received Head CT - negative on initial read (? small SDH on attending read). Pt received Ativan per CIWA scale, pt received 6mg PO ativan (shaky). Pt received PO Thiamine, MVI, Folate. . On arrival to the ICU, afebrile, 110, 160/86, 96%RA. Patient tremulous, able to provide a reliable history. . Review of systems: (+) Per HPI: diarrhea, night sweats, 20lb weight loss in past 2 years, cough. (-) Denies fever, chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -EtOH abuse -neuropathy lower extremities (past month) -Hit head on curb 1 year ago --> residual L leg pain Social History: Has had alcohol abuse for many years. Many rehabs, many withdrawals. Pt does not smoke. Pt does not use illicit drugs currently -- had used IV drugs in 70s. Pt unemployed currently, used to be a wholesale representative. Lives near symphony, alone. Has a girlfriend. [**Name (NI) **] a son, daughter and one grandchild. Divorced. Family History: Father alcoholic. Died of lymphoma. Mother died of multiple myeloma. Brother with MS Brother w/ morbid obesity, alcohol abuse. Physical Exam: Admission Physical Exam: afebrile, 110, 160/86, 96%RA General: Alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema PE - tremulous, dried blood on face under L eye, tachycardic with small systolic ejection murmur, lungs CTA bilaterally, abd SNTND, 5/5 strength x 4 extremities. mildly decreased sensation to soft touch in lower extremities, b/l. Pertinent Results: Admission Labs: [**2189-2-14**] 02:15PM BLOOD WBC-5.9 RBC-3.80* Hgb-13.8* Hct-39.1* MCV-103* MCH-36.4* MCHC-35.3* RDW-13.3 Plt Ct-228 [**2189-2-14**] 02:15PM BLOOD Neuts-81.1* Lymphs-11.5* Monos-5.7 Eos-0.9 Baso-0.8 [**2189-2-14**] 06:30PM BLOOD PT-9.7 PTT-30.8 INR(PT)-0.9 [**2189-2-14**] 02:15PM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-141 K-4.7 Cl-96 HCO3-24 AnGap-26* [**2189-2-14**] 02:15PM BLOOD ALT-39 AST-61* AlkPhos-78 TotBili-0.5 [**2189-2-14**] 02:15PM BLOOD Lipase-67* [**2189-2-14**] 02:15PM BLOOD Albumin-4.6 Calcium-9.6 Phos-3.9 Mg-1.5* [**2189-2-14**] 02:15PM BLOOD ASA-NEG Ethanol-30* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: IMPRESSION: No acute intracranial process; mild left maxillary sinus disease. NOTE ON ATTENDING REVIEW: There is a small dense focus along the convexity in the right frontal/parietal regions likely representing a small acute subdural hemorrhage. A small venous tribuatry is noted adjacent and underneath. Small amount of scalp soft tissue swelling is noted overlying. ( se 601b, im43; se 2, im 15) No obvious fracture noted. Consider followup as clinically indicated. Prominent ventricles, sulci and extra-axial CSF spaces related to volume loss-correlate for risk factors. Brief Hospital Course: 54 yo M with chronic alcohol use presenting with EtOH withdrawal. . # Alcohol Withdrawal: Last drink was less than 24 hours prior to arrival. Very tremulous, requiring diazepam 10mg about every 2 hours for CIWA >10, fo total of 50mg in ICU. Received last 10mg dose Valium [**2189-2-16**] on medical [**Hospital1 **], and was started on 2 days of q6hr Librium to complete as outpatient as a natural benzo taper for anxiety and mild tremors despite CIWA < 10. Also received some ativan in the ED. Received multivitamin, thiamine and folate. He met with social work who gave him list of day programs. He plans on attending [**Hospital **] program because of convenient location to his home, and his son's family. . # SDH: Per radiology, very small frontal R SDH, likely from most recent fall. No symptoms and non-focal neurological exam. Neurosurgery recommended repeat head CT. Repeat was unchanged. . # Amemia: macrocytosis (103), Hct 39.1. Likely [**1-29**] chronic alcohol, marrow suppression, or B12. B12 level is normal, patient was given folic acid. . # Neuropathy: pt w/ peripheral neuropathy, complaining of it for a few months. Has worsened recently. Pt w/ full strength in extremities, mildly decreased sensation. Etiologies include EtOH neuropathy, B12 deficiency, DMII. A1C = 5.0%, B12 level is pending. He was empirically started on 100mcg B12 for 1 month. . # Weight Loss: 10-20lb over last 6 months, coincides with heavy drinking. He will seek support for abstinence, and was referred to primary care for further evaluation and health maintenance issues. CXR was normal. . # He was set up with PCP f/u apptmt at [**Company 191**] for [**2189-2-24**], and indicated he will keep appoitment. Medications on Admission: none Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 5. chlordiazepoxide HCl 25 mg Capsule Sig: One (1) Capsule PO four times a day for 2 days. Disp:*8 Capsule(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Alcohol dependency Mild anemia - likely alcohol related Peripheral Neurophathy - likely alcohol related 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 for alcohol withdrawal. You had a recent fall with abrasions to the face and knee. You indicated you have been driking 1-2liters vodka daily for past 6 months. You were admitted to ICU for monitoring, and then to the medical [**Hospital1 **]. You had 2 Head CTs which showed a stable, small subdural hematoma which does not need follow-up (per neurosurgical evaluation). You are tolerating a full diet. You were seen by physical therapy and deemed safe for home, to continue using your cane. B12, TSH, and HgbA1C were all normal. . You were started on Metoprolol for high heart rate and high blood pressure. You tolerated this well. . You indicated you have not been eating well because of the heavy drinking, and that you have lost weight. A Chest xray was normal. You indicated you did not wast to follow-up with your current [**Hospital1 2177**] primary care physician and have requested a referral to [**Hospital1 18**]. I recommend you see your PCP [**Last Name (NamePattern4) **] [**1-31**] weeks (new or old) for further evaluation of your overall health, including weight loss, age appropriate cancer screening and other preventive health measures. Please take the medications as prescribed. Vitamin B12 levels and evaluation for diabetes was normal. The neuropathy is likely from chronic alcohol use. Please follow up with your primary care physician for further evaluation. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2189-2-24**] at 1:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **Dr [**First Name (STitle) **] [**Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care.**

6826,34982,2384,4011,V4987,7226,5718,33829,7892,78901,30000,42789,45829,E9426,E8497

Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-6**] Date of Birth: [**2112-2-27**] Sex: F Service: MEDICINE Allergies: aspirin / Penicillins / Ceclor / clindamycin / ibuprofen / Erythromycin Base / naproxen Attending:[**Doctor First Name 3298**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 82967**] is a 59-year-old female with a history of polycythemia [**Doctor First Name **], hypertension and chronic pain who is presenting with altered mental status. She was in her usual state of health the morning of admission when her wife left her at home. In the afternoon, the patient's wife found her confused, lethargic, and having vomited. Otherwise, the patient is unable to provide much history; however, she did have some pain with palpation of her right upper quadrant. Neither the patient nor her wife can remember any trauma to her left leg (though she had a recent fall with a fracture of her left humerus). In the ED, initial VS were: 102.9 108 189/81 16 98%. She was noted to have a large area of erythema and tenderness to palpation of the left lower extremity that was marked which involved a large portions of her calf as well as her distal thigh. She was given Tylenol 1g, Vancomycin 1g IV, levofloxacin, and Zofran. CT scan of her abdomen showed a small gallbladder, making cholecystitis unlikely although not completely excluded; with hyperdense contents which suggest stones or sludge. Fatty liver and splenomegaly: although splenomegaly is not specific, concern is raised for steatohepatitis or cirrhosis. Marked fatty replacement of pancreas. Large right adnexal cyst; ultrasound assessment recommended when appropriate. RUQ ultrasound was unable to be completed due to significant patient discomfort. . On arrival to the MICU, the patient was somewhat agitated. She became more calm in the presence of her wife, but still removed an IV and needed to be restrained. Vitals T 97.9 HR 109 BP 124/51 RR 16 97% on room air. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Hypertension 2. Degenerative disc disease 3. chronic pain 4. Polycythemia [**Doctor First Name **] followed by [**Last Name (LF) 1852**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Social History: Ms. [**Known lastname 82967**] lives with her wife in [**Location (un) 83264**], [**State 350**]. She is on disability. She has a cat, dog, and birds at home. Tobacco: Remote history of smoking for about five years at age 15. Alcohol: None. Illicits: None. Also no chemical or secondhand smoking exposure. Family History: Not known. The patient's mother and father are deceased. She has three brothers, six sisters and two daughters. She is estranged from all family members and does not know their medical history. Physical Exam: Admission to MICU exam: General: Oriented x 2 (person, place), agitated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not appreciated due to habitus, no LAD CV: S1, S2, 3/6 SEM heard best at upper sternal border Lungs: Clear to anterior auscultation bilaterally Abdomen: Soft, non-tender, obese, bowel sounds present, striae Ext: Warm, well perfused Skin: Left lower leg with significant erythem from just below the knee to foot, especially on medial side. Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities, sppech incoherent but intelligible Call out to Medicine Exam: GENERAL - Chronically ill appearing 59yo F who appears older than her stated age. She has an odd affect with tangential thinking. She is lethargic but arousable, oriented to person, place and time. Inattentive and unable to do months of the year in reverse HEENT - NC/AT, EOMI, sclerae anicteric, Adentulous, MMM, OP clear NECK - supple, no [**Doctor First Name **], no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilaterally, moving air well and symmetrically HEART - S1 S2 clear and of good quality, tachycardic, 3/6 SEM RUSB ABDOMEN - NABS, Obese, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs). Chronic venous stasis skin changed on bilateral LE. Left lower leg with significant erythema from knee to groing along medial aspect tracking in a linear pattern along medial aspect of thigh. Warm to touch. NEURO - Awake but lethargic, A&Ox3, Facial asymmetric but CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout. Speech slurred at times though adentulous may be contributing. Tangential thought processes Pertinent Results: Trends: [**2171-4-2**] 06:38PM BLOOD WBC-29.7* RBC-7.68*# Hgb-17.3* Hct-57.0* MCV-76* MCH-22.2* MCHC-29.3* RDW-18.7* Plt Ct-490* [**2171-4-4**] 05:18AM BLOOD WBC-21.5* RBC-7.26* Hgb-16.0 Hct-54.8* MCV-76* MCH-22.1* MCHC-29.2* RDW-19.0* Plt Ct-366 [**2171-4-2**] 06:38PM BLOOD Neuts-89.7* Lymphs-6.6* Monos-2.6 Eos-0.4 Baso-0.7 [**2171-4-4**] 05:18AM BLOOD PT-13.5* INR(PT)-1.3* [**2171-4-2**] 06:38PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-135 K-3.9 Cl-94* HCO3-27 AnGap-18 [**2171-4-4**] 05:18AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-137 K-3.8 Cl-97 HCO3-27 AnGap-17 [**2171-4-2**] 06:38PM BLOOD ALT-23 AST-43* AlkPhos-205* TotBili-1.2 [**2171-4-4**] 05:18AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2 [**2171-4-3**] 04:12PM BLOOD Lactate-2.8* [**2171-4-4**] 05:47AM BLOOD Lactate-1.8 [**2171-4-2**] 10:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2171-4-2**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG Discharge Labs: [**2171-4-5**] 08:20AM BLOOD WBC-17.3* RBC-7.24* Hgb-15.7 Hct-55.3* MCV-77* MCH-21.6* MCHC-28.3* RDW-19.1* Plt Ct-416 [**2171-4-5**] 08:20AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-4 Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2171-4-5**] 08:20AM BLOOD Glucose-152* UreaN-10 Creat-0.8 Na-139 K-4.1 Cl-99 HCO3-30 AnGap-14 [**2171-4-5**] 08:20AM BLOOD TSH-0.24* BCx pending: Imaging: CT abd/pelvis w/: IMPRESSION: 1. Mostly decompressed gallbladder which makes cholecystitis unlikely, although hyperdense contents could be seen with stones or sludge. 2. Fatty infiltration of the liver. 3. Marked fatty infiltration of the pancreas, which can be seen as a manifestation of chronic pancreatic inflammation, although other etiologies such as cystic fibrosis could generate such an appearance. 4. Mild-to-moderate splenomegaly including small infarcts. Splenomegaly in association with fatty liver may raise concern for steatohepatitis or cirrhosis with portal hypertension as the etiology for splenomegaly, although the appearance is not entirely specific. 5. Large right adnexal cyst. Although no complex features are apparent based on CT imaging, particularly based on size and the limitations of CT assessment, when clinically appropriate, evaluation with ultrasound is recommended. If the lesion is not accessible to visualization with ultrasound, then MR is recommended. 6. Mild left inguinal lymphadenopathy, likely reactive; correlation with physical findings involving the left lower extremity is recommended. LENI [**4-3**] IMPRESSION: No evidence of deep vein thrombosis either right or left lower extremity. CT LE [**4-2**]: IMPRESSION: 1. Findings above of subcutaneous edema and circumferential skin thickening, which in the right clinical setting may represent [**Month/Year (2) **]. 2. No focal fluid collections to suggest abscess. No subcutaneous emphysema. 3. Scattered degenerative changes of the left lower extremity. CXR [**4-3**]: FINDINGS: In comparison with the study of [**2168-8-25**], there is little change. Continued low lung volumes most likely account for the prominence of the cardiac silhouette. No pneumonia, vascular congestion, or pleural effusion. Brief Hospital Course: Ms. [**Known lastname 82967**] is a 59 y/o female with a history of polycythemia [**Doctor First Name **], hypertension and chronic pain who presented with altered mental status and [**Doctor First Name **]. Treated with IV antibiotics in the MICU with improvement in MS [**First Name (Titles) **] [**Last Name (Titles) **] and transferred to [**Hospital1 **] on HD2. # [**Hospital1 **]. Non-purulent, no necrosis on CT. Tx initially with Vancomycin/Levofloxacin given allergy profile (anaphylaxis to PCNs and Clindamycin). Levofloxacin d/ced on HD2 as pt. improved. LENI was negative for DVT. Although cephalosporin regimen would be most optimal, due to severe reaction type and potential crossreactivity, vancomycin was selected for treatment. In preparation for discharge antibiotics changed to Bactrim 2DS tabs PO BID to complete 5 more days for total 10 day course. # Altered mental status. Toxic-metabolic encephalopathy secondary to the patient's left leg [**Hospital1 **]. Head CT not suggestive of hemorrhage. UA negative. CT abdomen demonstrated no site of infection. Utox/Stox negative. Improved with treatment of [**Hospital1 **]. Initially held sedating medications but restarted prior to discharge with improvement in mental status. # LFTs: Isolated ALP elevation associated with slightly elevated T.Bili to 1.2 from 0.5. AST also elevated but ALT flat would suspect mitochondrial dysfunction. Tox screen only positive for Methadone so ingestion less likely especially while rising in MICU. In ED patient complained of RUQ pain and nausea consitent with cholecystitis. RUQ ultrasound incomplete/limited given patient agitation. CT scan could not definitely rule out cholecystitis. Patient has habitus and epidemiology for cholelithiasis but with improved mental status she has no RUQ pain or [**Doctor Last Name **] sign on exam with improvement in mental status so did not pursue a second RUQ US. Fever curve also improved on only Vancomycin without GNR or anaerobic coverage. # Tachycardia: Sinus tachycardia to 120s consistently in the MICU. Initially thought related to sepsis but did not improve with downtrend of fever curve or improvement in [**Doctor Last Name **]. Volume status euvolumic and patient with good urine output. Tachycardia did dip to 90s when wife is around and so there may be a psychologic component. Patient with chronic pain on Methadone so pain may be contributing as well. Outpatient HRs in 90s per record. Low likelihood for PE without hypoxia, tachypnea, chest pain and LENIs negative for DVT. Tachycardia resolved prior to discharge. # Hypertension: Chronic, Lisinopril recently restarted with resolution of sepsis but she remained hypertensive. Amlodipine started prior to discharge. Asymptomatic on floor. TSH checked and was low. Continued Lisinopril 40mg PO BID and added Amlodipine 5 mg PO/NG DAILY to augment BP control. Day of discharge she became hypotensive and orthostatic which, per patient's wife, usually happens when increasing BP meds. Amlodipine was discontinued, and lisinopril to 40mg po daily and patient discharged after BPs stabilized. # Anxiety: Continued home regimen of Ativan. # DJD/chronic pain: Continue methadone but tizanidine and gabapentin were initially held in setting of delirium but restarted prior to discharge # [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Stable. Plavix was continued. # Incidentalomas: Splenic infarcts likely PCV related in addition to splenomegaly. Large right adenexal cyst can be worked up as outpatient TRANSITIONAL ISSUES: - Follow up incidentalomas, patient should have adenexal cyst monitored as an outpatient - Better control of hypertension is essential in this patient - Careful with BP meds given profound orthostasis when starting CCB - CODE STATUS: Presumed Full - CONTACT: Wife and HCP [**Name (NI) 636**] [**Name (NI) 82967**] [**0-0-**] Medications on Admission: - lisinopril 40 mg PO BID - methadone 20 mg PO QID - methadone 10 mg PO Daily - tizanidine 4 mg PO TID - tizanidine 2 mg PO BID - gabapentin 600 mg PO Q4H - lorazepam 0.5 mgPO Q4H as needed for anxiety - Plavix 75 mg Tablet PO once a day - Colace 100 mg PO twice a day as needed for constipation Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 5. methadone 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 7. gabapentin 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 8. tizanidine 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Outpatient Lab Work Please check chemistry panel including sodium, potassium, creatinine on Mon [**4-8**] and fax results to Dr. [**Last Name (STitle) 70557**] [**Telephone/Fax (1) 83265**]. Discharge Disposition: Home Discharge Diagnosis: [**Telephone/Fax (1) **] Encephalopathy Polycythemia [**Doctor First Name **] Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 82967**], It was a pleasure treating you during this hospitalization. You were admitted to [**Hospital1 69**] because of confusion and an infection in the skin of your thigh. You were initially admitted to the ICU because of concern for sepsis and you were treated with IV antibiotics with improvement in mental status and skin infection. You were switched to by mouth medications with continued improvement in skin infection clearing. Your mental status also improved back to baseline. You should have a blood lab checked on Monday, which will be faxed to your doctor and discuss the results when you see Dr. [**Last Name (STitle) **] on Friday. Some of your medications may need to be adjusted further. The following changes to your medications were made: - START Bactrim 2 DS tablets twice daily until [**2171-4-11**] - DECREASE your lisinopril to 40mg tabs, 1 tab daily - No other changes were made, please continue taking your home medications as previously prescribed Followup Instructions: Name: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 83266**], MD Specialty: Primary Care When: Friday [**4-12**] at 11:30am Location: [**Hospital3 **] HEALTH CENTER Address: [**Street Address(2) 83267**], [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**0-0-**]

43331,3484,431,5070,5849,3314,25012,514,99731,51881,34200,43301,4019,2724,27669,37230,04119,E8798,78720

Admission Date: [**2142-4-2**] Discharge Date: [**2142-5-8**] Date of Birth: [**2099-7-23**] Sex: M Service: NEUROLOGY Allergies: Nifedipine Attending:[**First Name3 (LF) 2569**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: [**2142-4-4**] intubation suboccipital craniectomy and R venticulostomy - [**2142-4-6**] ventriculostomy - VP shunt- [**2142-4-16**] trach and PEG History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 2 minutes Time (and date) the patient was last known well: 12:30 on [**4-2**] NIH Stroke Scale Score: 10 t-[**MD Number(3) 6360**]: --- Yes Time t-PA was given ------:------ (24h clock) -X- No Reason t-PA was not given or considered: out of window I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score was 0: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 1 3. Visual fields: 0 4. Facial palsy: 2 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 2 7. Limb Ataxia: 0 8. Sensory: 2 9. Language: 0 10. Dysarthria: 2 11. Extinction and Neglect: 0 HPI: Mr. [**Known lastname 110219**] is a 42 yo Portuguese-speaking man with h/o DM2, HTN, HL who presents with L facial droop, R sided numbness, and slurred speech. History is somewhat limited due to language barrier and acute code stroke setting. The patient developed nausea/vomiting at 12:30 am today. Over the next several hours, he worsened, developing difficulty with balance and right sided numbness and weakness. At 4:00pm, wife noticed L facial droop. Patient was brought to [**Hospital 4199**] Hospital. NCHCT was interpreted as normal. [**Hospital1 2025**] neurology was consulted over the phone. NIHSS 8. Received IV labetalol 20 mg total, Zofran and ASA 325 mg. He was transferred to [**Hospital1 18**] without any thrombolysis (unclear if [**Name (NI) 2025**] on-call stroke line thought he was out of window). In [**Hospital1 18**], patient had NIHSS 9. BP was elevated at 254/125. He was started on nicardipine drip for BP control. According to patient's wife, he has been stable to slightly improving over past few hours. He was quite restless because he is bothered by the absence of sensation on his right side. He has no pain or headache. No nausea. No diplopia in primary gaze, and no vertigo. On limited ROS, no fever, cough, SOB, chest pain. Past Medical History: DM2 HTN HL Social History: married, no tobacco. Speaks Portuguese. Understands very limited English Family History: h/o CAD Physical Exam: ADMISSION EXAM Physical Exam: Vitals: T: afeb P:100 R: 16 BP:215/135 SaO2:96/ra General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Attentive and cooperative. Language is fluent with intact naming and comprehension. Speech was moderately dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: R pupil 6mm, L pupil 4mm, both briskly reactive both direct and consensual responses. VFF to confrontation with blink to threat. III, IV, VI: In primary gaze, L eye deviated inward. Complete L gaze palsy b/l. On R gaze there is horizontal nystagmus. Vertical gaze and convergence intact. V: Facial sensation intact to light touch. VII: Upper and lower facial musculature weakness. VIII: Hearing intact to voice grossly. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii. XII: Tongue protrudes in midline. -Motor: Normal bulk. Decreased tone in right side. R pronator drift present. No adventitious movements, such as tremor, 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 R 5 5 5 5 5 5 5 3 4- 4- 4 4- -Sensory: Decreased light touch and pinch on right upper and lower extremities (now intact on face though previously right face numb). No extinction to DSS. -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 flexor on left, extensor on right. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: deferred [**2142-5-1**] On transfer out of ICU: Spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L gaze palsy, R eye abducens weakness (R beating nystagmus when looking R). No blink to threat. No corneals. L upper/lower face weakness. +gag. +cough. LUE/LLE 4+ to 5/5 strength. RUE/RLE hemiplegia but R fingers/wrist/elbow extending/flexing now and R quad contracts (almost antigravity). Inconsistent with R side depending on exhaustion level. R toe up. DISCHARGE EXAM: Spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L gaze palsy, R eye abducens weakness (R beating nystagmus when looking R). L upper/lower face weakness. LUE/LLE 5/5 strength. RUE/RLE hemiplegia but R fingers/wrist/elbow extending/flexing now, can move R quad anti-gravity and dorsi/plantar flex foot with good strength. R toe upgoing. Pertinent Results: [**2142-4-2**] 07:15PM WBC-11.6* RBC-5.87 HGB-17.8 HCT-52.3* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.0 [**2142-4-2**] 07:15PM PLT COUNT-278 [**2142-4-2**] 07:15PM PT-9.8 PTT-26.9 INR(PT)-0.9 [**2142-4-2**] 07:15PM UREA N-16 [**2142-4-2**] 07:26PM GLUCOSE-353* NA+-141 K+-4.1 CL--100 TCO2-23 [**2142-4-2**] 08:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2142-4-2**] 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2142-4-2**] 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2142-4-2**] 10:58PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2142-4-2**] 10:58PM CK-MB-3 [**2142-4-2**] 10:58PM CK(CPK)-171 [**2142-4-2**] 10:58PM GLUCOSE-313* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [**2142-4-4**] 3:41 pm BRONCHOALVEOLAR LAVAGE LEFT LUNG. **FINAL REPORT [**2142-4-20**]** GRAM STAIN (Final [**2142-4-4**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [**2142-4-8**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110220**] FROM [**2142-4-4**]. FUNGAL CULTURE (Final [**2142-4-20**]): NO FUNGUS ISOLATED. [**2142-4-24**] 7:48 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2142-4-29**]** GRAM STAIN (Final [**2142-4-24**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2142-4-29**]): SPARSE GROWTH Commensal Respiratory Flora. GARDNERELLA VAGINALIS. MODERATE GROWTH. [**2142-4-24**] 10:01 pm Mini-BAL BRONCHIAL LAVAGE. **FINAL REPORT [**2142-4-27**]** GRAM STAIN (Final [**2142-4-24**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2142-4-27**]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. YEAST. 10,000-100,000 ORGANISMS/ML.. [**2142-4-25**] 2:16 pm Blood (Toxo) Source: Venipuncture. **FINAL REPORT [**2142-4-27**]** TOXOPLASMA IgG ANTIBODY (Final [**2142-4-27**]): POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 53 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [**2142-4-27**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with Toxoplasma once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [**2-16**] weeks. ECG [**4-2**] Normal sinus rhythm. Q waves in leads III and aVF consistent with prior inferior myocardial infarction. No previous tracing available for comparison. CTA Head/Neck [**4-2**] IMPRESSION: 1. Unremarkable head CT without evidence of infarct or hemorrhage. MRI is suggested if clinically warranted. 2. Hypoplastic right vertebral and small left vertebral arteries, likely developmental. Both vertebral arteries end as PICA with reconstitution of the right vertebral artery from the right superior cerebellar. [**4-3**] CXR IMPRESSION: 1. Unremarkable head CT without evidence of infarct or hemorrhage. MRI is suggested if clinically warranted. 2. Hypoplastic right vertebral and small left vertebral arteries, likely developmental. Both vertebral arteries end as PICA with reconstitution of the right vertebral artery from the right superior cerebellar. [**4-4**] CXR As compared to the previous radiograph, there is no relevant change. Minimal atelectasis at the right lung base. Borderline size of the cardiac silhouette. No pneumonia, no pulmonary edema. The nasogastric tube is in constant position. [**4-6**] MRI/A Brain FINDINGS: There is an acute infarct with hemorrhagic conversion identified in the left cerebellum in the region of posterior inferior and anterior inferior cerebellar arteries extending to the left side of the pons. There is mass effect on the fourth ventricle. There has been a craniectomy identified in the region for decompression. There is mild indentation of the lateral ventricles and there is presence of a right frontal approach ventricular drain with the tip in the region of left lateral ventricle. The temporal horns are mildly dilated indicating some degree of obstructive hydrocephalus. There is signal change within the anterior portion of corpus callosum related to the tract of the ventricular drain. The flow void of the distal left vertebral artery is not well visualized. On the MRA of the head no abnormalities are seen in the anterior circulation. Both vertebral arteries are not visualized beyond posterior arch of C1. Subtle flow signal is identified in the distal basilar artery but flow signal is not seen in the proximal basal artery nor the distal vertebral arteries. There are fluid levels within the left maxillary sinus which could be related to intubation. IMPRESSION: Postoperative changes for decompression secondary to hemorrhagic left cerebellar infarct. There remains mass effect on the fourth ventricle and some dilatation of the lateral ventricle. A ventricular drain is in position. Both vertebral arteries are not visualized distal to the posterior arch of C1 level. The proximal basal artery is not visualized as well. There abnormalities on the anterior circulation on MRA. [**4-7**] NCHCT IMPRESSION: 1. Known left cerebellar infarct with hemorrhage, with mass effect on the 4th ventricle and basal cisterns, stable in appearance since the earlier study of [**2142-4-6**]. 2. Stable positioning of the ventricular drain, coursing through the frontal [**Doctor Last Name 534**] of the left lateral ventricle, terminating at its lateral margin. Minimal interval increase in the ventricular size since [**2142-4-5**] CT study. [**4-8**] NCHCT IMPRESSION: 1. Interval repositioning of the right external ventricular drain with tip now projecting anterior to the frontal [**Doctor Last Name 534**] of the right lateral ventricle adjacent to the falx, outside the ventricular system. 2. Otherwise similar exam with left cerebellar infarct with hemorrhagic conversion, adjacent mass effect, and stable ventricular size. [**4-9**] NCHCT IMPRESSION: 1. Interval repositioning of right frontal external ventricular drain, now terminating in the left putamen or internal capsule. Ventricles have decreased in size since the prior exam. 2. Left cerebellar infarction with stable posterior fossa mass effect and hypodensity extending into the pons. [**4-10**] NCHCT IMPRESSION: 1. Significant interval decrease in size of left lateral ventricle is likely related to over shunting through the right frontal approach EVD, as there is no associated sulcal effacement or new edema. Correlate with catheter function and close f/u. Assessment of the position of the tip of the catheter is difficult due to the significant decompression of the ventricle- it is either outside the ventricular margin or within. Pl. review the images to decide on further management. 2. Left cerebellar infarct with stable posterior fossa mass effect and suboccipital craniectomy. [**4-13**] NCHCT IMPRESSION: 1. Right frontal approach EVD terminates in the left lateral ventricle. Left lateral ventricle has increased in size since the prior exam, with ventricles and sulci now similar in size and configuration to [**2142-4-2**]. 2. Status post suboccipital craniectomy with unchanged posterior low-density fluid collection. Left cerebellar infarction and pontine infarction are stable. Slight improvement in effacement of fourth ventricle. [**2142-4-15**] R Lower Ext - Doppler US: FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. There is normal compressibility, flow and augmentation. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. [**2142-4-16**] NCHCT IMPRESSION: 1. Repositioning of the EVD with the tip in the third ventricle. 2. Continued effacement of the fourth ventricle by mass effect in the left cerebellar hemisphere. Status post suboccipital craniectomy. [**2142-4-17**] Renal Son[**Name (NI) **]: RENAL SON[**Name (NI) **]: The right kidney measures 12.8 cm, and the left kidney measures 13.6 cm. There is no hydronephrosis, stones, or mass. Bladder is collapsed with a Foley in place. IMPRESSION: Normal renal son[**Name (NI) **]. [**2142-4-23**] TEE: Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest x 4 injections (central line x 2; peripheral line x 2). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch (clip [**Clip Number (Radiology) **]) and the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetation, intracardiac mass/thrombus seen. No evidence for an atrial septal defect or patent foramen ovale by color flow Doppler or saline injection at rest. Simple thoracic atheroma. Brief Hospital Course: 42yo M with h/o DM2, HTN who presented with L lower face weakness, dysarthria, R sided sensory loss and hemiparesis, nausea/emesis, found to have L vertebral and proximal basilar artery occlusion resulting in L cerebellar / L pontine infarct. . [] Acute Ischemic Stroke, Vertebrobasilar Occlusion - The patient was found to have a clinical syndrome consistent with a brainstem stroke and was found on imaging to have stenosis of both vertebral arteries and the proximal basilar artery. He arrived at the hospital outside the window for intravenous tPA or intra-arterial therapies. He has two fetal PCAs coming from his anterior circulation which would preclude him from being able to have a mechanical thrombectomy. He was started on a Heparin infusion with goal PTT 60-80 to aid the dissolution of the thrombus. After hemorrhagic conversion was found on a repeat MRI, this was switched to Aspirin 81 mg daily. A TTE was performed which was unrevealing for thrombus, wall motion abnormalities, or intracardiac shunt, but the suspicion for venous hypercoagulability causing paradoxical embolism remained high given the history of a brother of similar age with bilateral lower extremity DVTs. Hypercoagulability labs (except for genetic studies) were obtained and were normal. A TEE was obtained that failed to show an intracardiac shunt and showed only aortic arch simple atheroma. The patient will have genetic hypercoagulability studies as an outpatient. . He was transferred to the stroke step-down unit on [**2142-5-1**] and remained stable. His exam has continued to improve, as he is more alert and following commands well. He has begun to use a Passy-Muir valve to speak and is tolerating this well. His right hemiparesis is also improving, and he is currently able to lift his R arm over his head, can extend his leg anti-gravity, and dorsi/plantarflex his foot. . [] Increased Intracranial Pressure - On [**2142-4-4**], he transiently developed worsening neurologic deficits including losing his corneal, cough and gag reflexes. A repeat NCHCT showed worsening infarction of the left cerebellum and compression of the fourth ventricle. He was taken to the OR by Neurosurgery for emergent decompression/occipital craniectomy and placement of a ventriculostomy. The ventriculostomy was revised/replaced twice for improved placement. Due to mildly elevated ICP and CSF drainage, this was converted to a ventriculoperitoneal shunt on [**2142-4-16**]. He had no complications and no further signs of increased ICP after the procedure. . [] Pulmonary Edema/Volume Overload - In the setting of receiving IVF, he became net positive in his fluid balance, tachypneic, and hypoxic. Furosemide did not sufficiently improve his respiratory status. He was also noted to have worsening leukocytosis and extensive secretions concerning for infection. He subsequently was electively intubated to provide further respirator support. He was unable to wean from the ventilator and failed an extubation trial. An endotracheal tube was placed on [**2142-4-20**]. He succeeded in tolerating the trach mask for 36-48 hours on [**2142-5-1**] and was subsequently transferred to the stroke step-down unit. His secretions have improved with a scopolamine patch. He continues to have intermittent tachypnea of unclear etiology without desaturation or any compromise of his respiratory status. . [] Pneumonia - He had recurrent fevers shortly after admission. Cultures were obtained and revealed MSSA in the sputum. He was treated with IV antibiotics for 10 days for this. He also had proprionobacterium acnes in the blood. Later he again began having fevers and increased sputum production. He underwent bronchoscopy again on [**2142-4-24**] and was treated with VAP protocol (Cefepime, Cipro, and Vanc) from [**Date range (1) 92895**], during which time his fever curve and sputum improved. He had transient low grade fevers to 99.8 axillary on [**5-3**]; repeat infectious work-up including UA/UCx/Blood cultures/CXR as well as LENI's was negative. He subsequently remeained afebrile with no signs of infection. . [] Diabetes - His HgbA1c was 11.9, and his blood sugars were initially difficult to control. He was placed on an insulin GTT and then transferred to long acting insulin. Blood sugars remained well-controlled on this regimen. . [] Hyperlipidemia - Initial LDL was 109. He was restarted on statin therapy and this improved to 59. He will continue on atorvastatin 20mg daily for his hyperlipidemia. . [] Nutrition - He was maintained on tube feeds. Due to the likelihood of an inability to swallow based on the area of his stroke, a gastrostomy was placed on [**2142-4-20**]. Our speech/swallow team continue to follow for progress. His phos has been running a little high; please check a chem-10 in the next week to re-evaluate. . . TRANSITIONAL CARE ISSUES: [ ] He will need intensive PT, OT, and speech therapy. [ ] Please check chem-10 at least once in next week to re-evaluate his bun/creatinine and phos. [ ] Hypercoagulability - Prothrombin and Factor V Leiden gene mutation tests should be obtained as an outpatient. [ ] He has a follow-up appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in our stroke clinic on [**2142-6-26**]. He also has an appointment to establish care with a new PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on [**2142-5-18**]. Medications on Admission: asa 81 atenolol 50 mg daily chlorthalidone 10 mg daily HCTZ 25 mg daily lisinopril 40 mg daily amlodipine 10 mg daily pravastatin 40 mg daily metformin 1000 mg daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. erythromycin 5 mg/gram (0.5 %) Ointment Sig: see instructions Ophthalmic QID (4 times a day): apply to both eyes QID. 12. labetalol 100 mg Tablet Sig: Five (5) Tablet PO Q6H (every 6 hours). 13. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35) unit Subcutaneous twice a day: 35u with breakfast and dinner. 14. insulin aspart 100 unit/mL Solution Sig: as instructed Subcutaneous ACHS: Give ACHS as per insulin sliding scale. 15. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 17. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day): Left eye. 18. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day). 19. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q 3 DAYS (): for increased secretions. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Left cerebellar/pontine stroke Occlusion of the left vertebral and basilar arteries Hypertension Hyperlipidemia Diabetes type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 110219**], You were admitted to [**Hospital1 69**] on [**2142-4-2**] due to nausea/vomiting, right sided weakness, and a left facial droop. You were found to have a stroke in the left side of your cerebellum as well as part of your brainstem. This stroke likely resulted from a clot in your vertebral artery in your neck. This may be related to your high blood pressure, high cholesterol, and diabetes. You had tests to look at your heart as well as to look for any disorders of blood clotting and these were normal. You had tracheostomy and gastrostomy tubes placed while in the intensive care unit. You will need intensive physical therapy to help regain your strength. You were started on some new medications to better control your blood pressure and cholesterol. We made the following changes to your medications: Increased amlodipine to 20mg daily Started clonidine 0.3mg 3 times a day and labetalol 500mg 4 times a day to help control your bloood pressure Held atenolol 50mg daily and HCTZ 25mg daily Continued lisinopril 40mg daily Changed from pravastatin to atorvastatin 20mg daily to help control your cholesterol Changed from metformin to lantus 35mg twice a day in addition to insulin sliding scale injections to better control your diabetes If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: You have the following appointment scheduled with a new primary care physician at [**Hospital1 69**]: Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2142-5-18**] 2:15 You also have the following appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in stroke clinic: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2142-6-26**] 3:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

5780,43820,78791,7873,V441,7921,9916,29040,4370,43882,25040,40390,5853,V5867,41401,4264,2724,53081,33394,33182,29410,3331,V641

Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-25**] Date of Birth: [**2045-3-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 41957**] is an 81 yo Russian speaking male with dementia, h/o CVA previously on coumadin, left sided weakness, dysphyagia s/p Gtube, HTN, hyperlipidemia transferred from [**Hospital **] rehab with coffee ground emesis. Reportedly has had several days of diarrhea and abdominal distention and then developed acute vomiting of coffee ground emesis on the day of admission. He also has history of constipation with recent reports of hypoactive bowel sounds and abdominal distention. . In the ED T95.3 BP 130/80 HR 90 97% 2L RA. During EMS transport he was noted to have large amount of coffee ground emesis. On arrival in the ED he was given 3L NS, 16 gauge PIV placed and he was given protonix 40mg IV and a protonix gtt was started. NG lavage of G tube reportedly with coffee grounds with streaks of red blood. GI fellow was notified and tentative plan for scope in the morning unless concern for acute bleeding. Past Medical History: h/o CVA with left hemiparesis - previously on coumadin however d/c'd due to falls Dysphagia s/p G tube Vascular dementia Parkinson's Disease type 2 diabetes coronary artery disease stage III chronic kidney disease Left ankle decubitus ulcer hypertension hyperlipidemia GERD BPH essential tremor herpes zoster constipation Right Lung calcified granuloma Restless leg syndrome Pruritis Social History: lives at [**Hospital **] rehab facility Family History: n/c Physical Exam: On admission: VS:BP 133/48 HR 77 RR 20 93% on 3L NC Gen: sleeping quietly, awakens to voice, answers yes to russian interpreter on the phone but no other verbal communication, appears frightened HEENT: NC AT CV: regualr rate and rhythm, 2/6 systolic murmur Lungs: bibasilar crackles, right > left otherwise CTAB no wheezing Abd: distended, firm to palpation, gtube in place with coffee ground emesis on suction, hypoactive bowel sounds Rectal: Guaiac positive in ED Ext: warm, no pedal edema, DP's palpable bilaterally Neur: contracted, lying on right side, only verbalizes yes with the russian interpreter . On discharge: T99.1 HR65 - 92 BP109/46 - 182/107 RR 20 SpO2: 97% Gen: sleeping quietly, awakens to voice, HEENT: NC AT CV: regualr rate and rhythm, 2/6 systolic murmur Lungs: bibasilar crackles, right > left otherwise CTAB no wheezing Abd: ABD; soft, NT/ND, G-tube in place, no coffee grounds in or around G-tube, NABS Ext: warm, no pedal edema, DP's palpable bilaterally Neur: contracted, lying on right side, only verbalizes yes with the russian interpreter Pertinent Results: EKG: NSR at 85 bpm, normal axis, RBBB, st segment depressions in v2-v6 compared with prior from [**2125-7-12**] . [**2128-5-24**] 02:10AM BLOOD WBC-9.3 RBC-3.84* Hgb-12.0* Hct-36.3* MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-357 [**2128-5-24**] 06:39AM BLOOD WBC-6.3 RBC-3.40* Hgb-10.8* Hct-32.4* MCV-95 MCH-31.6 MCHC-33.3 RDW-13.9 Plt Ct-299 [**2128-5-24**] 12:28PM BLOOD Hct-31.0* [**2128-5-24**] 06:08PM BLOOD Hct-32.3* [**2128-5-25**] 12:56AM BLOOD Hct-30.8* [**2128-5-25**] 03:45AM BLOOD WBC-5.6 RBC-3.22* Hgb-10.5* Hct-30.7* MCV-96 MCH-32.5* MCHC-34.1 RDW-14.2 Plt Ct-296 [**2128-5-24**] 02:10AM BLOOD Glucose-144* UreaN-47* Creat-1.3* Na-142 K-4.5 Cl-103 HCO3-26 AnGap-18 [**2128-5-24**] 06:39AM BLOOD Glucose-114* UreaN-46* Creat-1.1 Na-141 K-4.5 Cl-109* HCO3-26 AnGap-11 [**2128-5-25**] 03:45AM BLOOD Glucose-101 UreaN-29* Creat-1.2 Na-147* K-4.0 Cl-114* HCO3-24 AnGap-13 [**2128-5-24**] 02:10AM BLOOD ALT-6 AST-14 CK(CPK)-39 AlkPhos-45 TotBili-0.4 [**2128-5-24**] 06:39AM BLOOD CK(CPK)-34* [**2128-5-24**] 06:08PM BLOOD CK(CPK)-32* [**2128-5-24**] 02:10AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2128-5-24**] 06:39AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2128-5-24**] 06:08PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2128-5-25**] 03:45AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2 Brief Hospital Course: Pt was admitted with concern for GIB given coffee ground material from G-tube. The patient was admitted to the ICU for monitoring, but remained hemodynamically stable throught his hospital stay. Initially, metoprolol, lisinopril and isosorbide were held, but metoprolol and lisinopril were restarted once the patient became slightly hypertensive. Isosorbide should be restarted in [**2-6**] days if his BP remains stable. His aspirin was also held and should be held for 7-10 days and can then be restarted on a baby aspirin (rather than 325mg). The patient was also placed on a pantoprozole drip and will need to be on the drip for 72 hrs, until the morning of [**2128-5-27**] per gasteroenterology consult. He can then be transitioned to a high dose PPI [**Hospital1 **] for a month. The patient did not receive an EGD as it was determined that the patient would require intubation and as he is DNR/DNI. The decision not to perform EGD was discussed with the patient's niece. On admission, the patient's HCT did come down from 36->32 with fluids, but then remained stable at 30-32. Medications on Admission: Glargine 18 units qhs simvastatin 20mg qhs acetaminophen 975mg TID citalopram 40mg daily famotidine 20mg qpm hydrocortisone cream gabapentin 200mg [**Hospital1 **] zinc oxide topical metoprolol 25mg [**Hospital1 **] terazosin 4mg qhs lisinopril 2.5mg daily aspirin 325mg daily bisacodyl suppository prn cetirizine 5mg daily isosorbide dinitrate 10mg TID lactulose 15 ml TID Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO three times a day. 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 6. Hydrocortisone 1 % Cream Sig: AS DIRECTED Topical AS NEEDED. 7. Gabapentin 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Zinc Oxide Lotion Sig: AS DIRECTED Topical AS NEEDED. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO at bedtime. 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 13. Cetirizine 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO three times a day. 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 16. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO three times a day. 17. Pantoprazole 8 mg/hr IV INFUSION until [**2128-5-27**] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 1. Coffee-ground emesis Discharge Condition: afebrile, vital signs stable, hematocrit stable. Discharge Instructions: You were admitted to [**Hospital1 69**] for bleeding in your G-tube, likely from your stomach. You were treated with IV medications, and your hematocrit dropped to the low 30s but remained stable. You did not require any blood transfusions. The GI specialists were consulted, who recommended medical management given the stable blood count. Your medications and tube-feeds are being restarted now. The following changes are being made to your medications: . 1. CHANGE Famotidine to Omeprazole 40mg [**Hospital1 **]. 1. HOLD Aspirin for 1 week before restarting. 2. HOLD Isosorbide mononitrate for 1-2 days before restarting, as tolerated by blood pressure. . You should follow-up with your primary care physician. [**Name10 (NameIs) **] there is further bleeding, you should call your doctor. You should also call your doctor or return to the Emergency Room for: * fevers, chills * chest pain, shortness of breath * abdominal pain, bloody stools or black tarry stools Followup Instructions: Primary Care Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] . Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2128-6-7**] 11:20

1550,0389,5762,99592,2762,5119,99811,2869,2930,2851,5990,78959,41401,412,4439,4019,2724,4414,3051,V1044,E8786,6930,E9479,27661,78551

Admission Date: [**2184-12-10**] Discharge Date: [**2184-12-30**] Date of Birth: [**2107-6-25**] Sex: F Service: SURGERY Allergies: Codeine / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 695**] Chief Complaint: Hepatocellular CA Major Surgical or Invasive Procedure: right hepatecomy [**2184-12-10**] History of Present Illness: 77-year-old female who was recently diagnosed with a right lobe hepatocellular carcinoma. This was initially diagnosed during routine imaging follow-up for renal cell carcinoma of her right kidney which is now status post RFA. She has had prior imaging from [**Hospital6 2561**] dating back to [**2182**] that showed a liver lesion of 2.3 cm. Most recently, a CT scan and PET scan both demonstrated enlargement of the liver lesion to greater than 9 cm. A biopsy demonstrated hepatocellular carcinoma. The kidney lesion has been noted to be stable. A CT scan of the chest demonstrated no evidence of pulmonary metastases. A triphasic CT scan demonstrated a large arterial and hyper-enhancing mass involving segments 5 and 6 of the liver consistent with a biopsy-proven HCC with no further concerning lesions being identified. Preoperative liver function tests included AST 66, alkaline phosphatase 116, total bilirubin 0.4, albumin 4.7, CEA 2.7, CA-125 9.3, CA19-9 6. She has undergone thorough preoperative evaluation of her cardiac and cerebrovascular vasculature and has been cleared for surgery. She has provided informed consent and is brought to the operating room for right hepatic lobectomy. Past Medical History: The patient has a history of coronary artery disease and had a heart attack in [**2165**]. Peripheral vascular disease s/p R external iliac stent and angioplasty. Hypertension, hyperlipidemia, depression, osteoarthritis, anemia, cataracts, 3 cm abdominal aortic aneurysm, vulvar cancer, R renal cell cancer s/p radiofrequency ablation. PSurgHx; R LE angioplasty, bilateral cataract surgery, vulvar cancer resection and bilateral inguinal lymph node biopsy, hip replacement x2, right knee replacement, and appendectomy as a child. Social History: She smokes one pack of cigarettes a day and has done so for 54 years. She denies alcohol or drug use. Family History: Mother died of SBO, father died of cerebral hemorrhage, sister died of leukemia, sister with bladder cancer, brother with prostate cancer Physical Exam: Post-op exam: T 98.3 HR 71, BP 119/51, RR 18, SpO2 98% gen: sedated, difficult to arouse, opens eyes to painful stimuli but not voice, intubated cardiac: RRR chest: CTAB, upper airway sounds abd: decreased breath sounds, mildly distended, clean dressings, sanguinous drainage in JP GU: Foley, urine concentrated ext: warm and well-perfused, decreased pedal pulses Pertinent Results: [**2184-12-10**] 11:52AM BLOOD WBC-3.1*# RBC-3.77* Hgb-9.9* Hct-30.1* MCV-80* MCH-26.2* MCHC-32.9 RDW-16.3* Plt Ct-120* [**2184-12-11**] 04:28AM BLOOD WBC-9.0# RBC-4.58 Hgb-12.8 Hct-37.2 MCV-81* MCH-28.0 MCHC-34.5 RDW-16.1* Plt Ct-92* [**2184-12-13**] 04:57AM BLOOD WBC-13.0* RBC-5.22 Hgb-14.3 Hct-43.5 MCV-83 MCH-27.4 MCHC-32.9 RDW-16.7* Plt Ct-76* [**2184-12-16**] 04:50AM BLOOD PT-17.3* INR(PT)-1.5* [**2184-12-16**] 04:50AM BLOOD Glucose-54* UreaN-24* Creat-0.8 Na-133 K-4.1 Cl-100 HCO3-26 AnGap-11 [**2184-12-10**] intraoperative liver U/S: Large right lobe liver mass which is lobulated in contour but appears to be solitary. [**2184-12-10**] pathology: pT1N0Mx G2 Greatest dimension: 11 cm. Additional dimensions: 10 cm x 7 cm. [**2184-12-11**] liver U/S: No large fluid collections are seen. Normal color flow and Doppler waveforms were noted in the main hepatic artery, hepatic vein, and portal vein. The common duct measures 3 mm. [**2184-12-17**] MRCP: Status post right hepatectomy. The liver demonstrates moderate dropout of signal intensity on out-of-phase imaging consistent with fatty infiltration. There is no evidence of other worrisome lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Small amount of perihepatic fluid is noted, without evidence of organized fluid collection. The portal vein is patent. The hepatic artery is patent. [**2184-12-20**] CT abdomen/pelvis: 1. Extensive perihepatic hematoma with mass effect upon the liver, portal vein and stomach. 2. Small bilateral pleural effusions, right greater than left. [**2184-12-20**] liver U/S: 1. Stable appearance of the resection bed hematoma (heterogeneous collection measuring 9.5 x 6.4 x 7.3 cm) as compared to the CT from [**2184-12-20**]. 2. Normal flow in the main portal vein, left hepatic vein, and hepatic artery. [**2184-12-23**] liver bx: 1. Severe hepatocellular and canalicular cholestasis, primarily involving zone 3 with prominent hepatocellular swelling. 2. Mild lobular and focal portal neutrophilic infiltration with neutrophilic aggregates and infiltration of bile ducts. No bile duct proliferation is seen. 3. Mild to focally moderate steatosis (not seen on previous resection). [**2184-12-24**] CXR: Interval increase in bilateral right greater than left small pleural effusions with associated atelectasis without evidence of pneumonia. [**2184-12-30**] CXR: As compared to the previous radiograph from [**12-25**], there is improvement with decrease in extent of the right-sided pleural effusion. The clips, the drains projecting over the liver and the monitoring and support devices are in unchanged position. No newly appeared focal parenchymal opacity suggesting pneumonia. No evidence of pneumothorax. [**2184-12-30**] liver U/S: 1. Resolving collection in the right hepatic surgical bed. 2. No biliary dilatation and appropriate vascular waveforms seen in the left lobe of the liver. 3. Right pleural effusion. [**2184-12-30**] LE U/S: No lower extremity deep venous thrombosis. Brief Hospital Course: On [**2184-12-10**], she underwent right hepatic lobectomy and cholecystectomy, with intraoperative ultrasound. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for complete details. Postop, patient was transferred intubated to the PACU due to episodes of apnea on CPAP accompanied by respiratory acidosis, likely related to the earlier administration of intrathecal morphine. Consequently, further opiate medication was limited. Patient was successfully extubated [**2184-12-11**] and transferred to the floor. On [**12-14**] was tolerating a regular diet and started on Lasix for weight gain and edema. Total bilirubin and alkaline phosphatase increased post-op: alk phos peaked at 614 on [**12-18**] and T bili at 23.4 on [**12-22**] before starting to decline. For this reason, an MRCP was obtained on [**2184-12-17**] that demonstrated no biliary obstruction. On [**2184-12-20**] WBC rose to 29.3 from 19.0 the day before. Patient was afebrile; cultures were obtained and were negative. Drain output had 10,000 WBCs but fluid culture was negative. She was empirically started on vancomycin, levofloxacin, and flagyl for the leukocytosis. Sanguinous output was noted from JP. Patient received 2u pRBC on [**12-20**] after a decline in HCT to 24.4 as well as 2 u FFP for an INR of 2.7. A Dobhoff was placed and tube feeds were started for poor oral intake. On [**12-23**] L blood was noted from JP drain with a decline in HCT to 28.9 from prior 32.8 and was taken to OR for hematoma evacuation. Hematoma was observed but no active bleeding was identified. Please refer to Dr.[**Name (NI) 1369**] operative note from [**12-23**] for further detail. Two JP drains were placed. Patient was kept in SICU following surgery for monitoring. She required albumin and a fluid bolus for hypotension/low UO, pRBCs for HCT 27.5, and 1 u plts for platelets of 66. She had an episode of delerium treated with Seroquel. Liver biopsy obtained intra-operatively demonstrated severe cholestasis. Cultures obtained from the hematoma intra-op grew sparse coag neg staph aureus. On [**12-25**] she was hemodynamically stable and was transferred to the floor, but still had confused mental status despite withholding of sedating medications. On [**12-27**] 1 FFP, 1 plt, and vitamin K were given for an INR of 2.1, but there was no evidence of bleeding from the JP drains, which had decreased output. On [**12-29**] dermatology was consulted for a worsening rash over her flanks and lower abdomen and suggested a drug reaction versus contact dermatitis. That afternoon, she was noted to have worsening mental status and complaint of shortness of breath for which albuterol nebs were given. Chest xray demonstrated right greater than left pleural effusion but mild vascular congestion. She was maintaining her saturations at 96% on 2L NC and appeared more awake and responsive by the late afternoon. The morning of [**12-30**] patient was transferred to the SICU for increased confusion and tachypnea with concern over airway protection. Ammonia level was 51. Patient was closely monitored in the ICU and was maintaining her airway until 17:15, when she was found to be in respiratory arrest and was subsequently intubated. At this time patient went into cardiac arrest and ACLS was initiated with pressor drip. Bleeding was noted from drains accompanied by abdominal distension, with drop in HCT from 41 to 20, rise in INR from 1.6 to >3, and platelets of 33. Massive transfusion protocol was initiated and patient underwent exploratory laparotomy at bedside by Dr. [**Last Name (STitle) **], but bleeding was unable to be controlled and patient required CPR and external pacing. Patient expired at 20:29 after discussion with daughter to withdraw care. For details, see death pronouncement note of [**2184-12-30**]. Medications on Admission: Atenolol 50 mg daily Omeprazole 20 mg [**Hospital1 **] Isosorbide Mononitrate 40 mg [**Hospital1 **] Lovastatin 40 mg daily Amitriptyline 125 qHS Ferrous Sulfate 325 mg [**Hospital1 **] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Hepatocellular CA s/p resection intra-abdominal hematoma s/p evacuation delirium respiratory depression cardiac arrest hemorrhage/coagulopathy Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

9654,2762,28249,27650,2769,2768,96909,9651,9800,311,2753,78701,7850,E9500,E9503,E9509

Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-10**] Date of Birth: [**2122-3-31**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 759**] Chief Complaint: tylenol PM and naproxen overdose Major Surgical or Invasive Procedure: none History of Present Illness: 20 yo F, with hx of depression w/ SI on Effexor, no previously established care here at [**Hospital1 18**], p/w tynenol / NASIADS overdose in setting of a suidical attempt. . Of note, night prior to admission pt heard from her boyfriend that his friends do not like her and don't want her around anymore. At 10pm, pt took 50 tylenol PM, 30 naproxen and an unknown amount of excedrin and a bottle of wine. Pt called the suicidal hotline and was sent to [**Hospital1 18**] by ambulance. . In the ED, initial VS were: Initial ASA 7.3 and tylenol 14 and EtOH 158. Two hours later, her ASA increased to 22.4, tylenol increased to 76. Toxicology was consulted and decided to admit to MICU for NAC protocol. . On arrival to the MICU, 98.6, 109, 109/48, 18, 98% on RA Past Medical History: History of SI attempt at age 15 per her mother, pt denies. Depression Social History: [**University/College 5130**] 3rd year student, digital arts major. History of SI attempt at age 15 per her mother, pt denies. Drinks alcohol [**11-26**] times per week, 3 drinks per time. Denies tobacco or drug use. Family History: Mother and aunts have depression Physical Exam: ADMISSION EXAM General: Lying in bed, breathing comfortably, interactive, stable. HEENT: PERRL, anicteric sclera, OP clear. CV: S1S2 RRR w/o m/r/g??????s. Lungs: CTA bilaterally w/o crackles or wheezing. Good air movement. Ab: Positive BS??????s, mild diffuse tenderness with deep palpation, non-distended, no HSM. Ext: No c/c/e. Neuro: Awake, alert, appropriately oriented, no focal motor deficits noted. No asterixis. DISCHARGE EXAM: VS: 97.3 103 110/80 20 99% RA GA: AOx3, NAD HEENT: PERRLA. MMM. no lymphadenopathy. neck supple. Cards: RRR, no murmurs/gallops/rubs. Pulm: CTAB, no crackles or wheezes Abd: soft, NT ND Extremities: wwp, no edema. Skin: warm and dry Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities with sensation intact. Pertinent Results: ADMISSION LABS [**2142-9-7**] 01:53AM BLOOD WBC-8.1 RBC-5.45* Hgb-11.7* Hct-34.6* MCV-63* MCH-21.4* MCHC-33.7 RDW-14.8 Plt Ct-308 [**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4 Baso-0.4 [**2142-9-7**] 01:53AM BLOOD PT-11.5 PTT-25.1 INR(PT)-1.0 [**2142-9-7**] 01:53AM BLOOD Glucose-113* UreaN-10 Creat-0.7 Na-139 K-3.1* Cl-105 HCO3-19* AnGap-18 [**2142-9-7**] 01:53AM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.2 [**2142-9-7**] 01:53AM BLOOD Albumin-5.0 Calcium-9.6 Phos-2.0* Mg-2.0 PERTINENT LABS [**2142-9-7**] 01:53AM BLOOD ASA-7.3 Ethanol-158* Acetmnp-14 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2142-9-7**] 04:24AM BLOOD ASA-22.4 Acetmnp-76* [**2142-9-7**] 07:05AM BLOOD ASA-22.4 Acetmnp-55* [**2142-9-7**] 09:50AM BLOOD ASA-18.4 Acetmnp-26 [**2142-9-7**] 12:20PM BLOOD ASA-16.0 Acetmnp-15 [**2142-9-7**] 03:01PM BLOOD ASA-11.9 Acetmnp-7* [**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG PERTINENT STUDIES CXR ([**9-7**]) Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. IMPRESSION: No evidence of acute cardiopulmonary abnormalities. [**2142-9-9**] 07:05AM BLOOD WBC-8.4 RBC-4.95 Hgb-10.6* Hct-31.4* MCV-63* MCH-21.4* MCHC-33.8 RDW-15.0 Plt Ct-244 [**2142-9-9**] 07:05AM BLOOD PT-11.7 PTT-24.2 INR(PT)-1.0 [**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4 Baso-0.4 [**2142-9-9**] 07:05AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-137 K-4.3 Cl-104 HCO3-27 AnGap-10 [**2142-9-9**] 07:05AM BLOOD ALT-14 AST-17 AlkPhos-43 TotBili-0.5 [**2142-9-9**] 07:05AM BLOOD Calcium-9.7 Phos-4.5# Mg-2.0 [**2142-9-7**] 09:50AM BLOOD calTIBC-321 Ferritn-58 TRF-247 [**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG Brief Hospital Course: 20 yo F with hx of depression and suicidal ideation, currently on Effexor, no previously established care here at [**Hospital1 18**], p/w tynenol / ASA overdose in setting of a suidical attempt. . ACTIVE ISSUES # Tylenol intoxication: Pt self-reported an overdose of large quantity of acetominophen (>25 gram). The low tylenol level and lack of elevation in LFT does not support overdose of such extent. However, the benadryl in Tylenol PM could potentially delay the absorption and administration of alcohol in the same time could be hepatic protective by competing with tylenol for cytochrome C. An N-acetylcysteine protocol was initiated at ED and continued initially in the MICU. Her Tylenol level was trended till non-detectable. . # ASA intoxication: The elevated ASA level is likely a result from Excedrin overdose. Pt was treated conservative with fluid hydration, and monitored closely on the rising ASA level. There was an anion gap initially, which was closed shortly after treatment. Her ASA level was trended till non-detectable. . # SI: Pt had a history of depression and suicidal ideation. She was evaluated by on-call psychiatrist in the ED. The psychiatrist at her college was notified. We restarted her effexor after her nausea resolved. Medically cleared for transfer to psychiatric facility. . CHRONIC ISSUES # Anemia: Pt has known anemia from thalassemia. No transfusion given. No evidence of iron deficiency. . Transitions of care: Outpatient management of anemia. Medications on Admission: Venlafaxine XR 225 mg PO altavera Discharge Medications: 1. venlafaxine 225 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 2. Altavera (28) 0.15-30 mg-mcg Tablet Sig: as directed previously Tablet PO Daily (). Discharge Disposition: Extended Care Facility: Four Winds Saratoga Discharge Diagnosis: Primary: tylenol / aspirin overdose Secondary: depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital for taking too much tylenol and aspirin. You were treated for this and improved and were deemed medically clear for transfer to a facility that specializes in psychiatric care. REGARDING YOUR MEDICATIONS... no changes were made to your medications Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Followup Instructions: Otherwise, please followup with your primary care physician [**Name Initial (PRE) 176**] 7-10 days regarding the course of this hospitalization. Completed by:[**2142-9-10**]

41401,4111,4142,2724,4019,32723,49390,3004,25060,3572,71941

Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-4**] Date of Birth: [**2123-1-29**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stent to left anterior descending artery and balloon angioplasty to Diagonal artery History of Present Illness: 43 year female with h/o DMT2, OSA, Asthma, and Dyslipidemia presents from OSH for ASA desensitization before PCI. Patient has had 6 month history of Left Chest Pain/Pressure that lasts for a couple of minutes and is a [**7-23**]. It radiates to the right chest. Associated with shortness of breath and recently some diaphoresis and nausea. She states she used to walk about 2 blocks before the CP starts, but it has been progressively getting worse as she must stop and rest quite a bit more with progressively shorter distances. She also states that this chest pain has begun to occur at rest. Prior to 6 months, she has never had this episode before. She went to her PCP who then referred her to get a Exercise Tolerance Test: she walked 6 minutes according to a standard [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her isotope study showed lateral ischemia. She was then admitted yesterday to [**Hospital 487**] Hospital for a cardiac cath performed today. ([**9-2**]) Her cath revealed a proximal 80% long lesion, totally occluded Cx, occluded diagnoal, mild RCA disease. LVEF reportedly 55%. Since the patient has an ASA allergy associated with rash/angioedema/and questionable wheezing (per patient), she was loaded with 600 mg of plavix, 50 mg of atenolol and transferred here for asa desensitization and further intervention. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes (complicated by peripheral neuropathy, + Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Obesity Asthma Obstructive Sleep Apnea: Recent Sleep Study shows indication for CPAP, although not currently using Anxiety/Depression Social History: SOCIAL HISTORY -Tobacco history: Never -ETOH: None -Illicit drugs: NOne Lives with family in [**Hospital1 487**] Family History: 2 aunts with "big heart", Father died of CVA, uncertain of age; sister has h/o tachycardia? Physical Exam: VS: T=97.6 BP=160/70 HR= 66RR=20 O2 sat= 97% 2LNC GENERAL: Well nourished obese female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of cm. Hepatojugular reflux 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, obese, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right Femoral sheeth in place; TTP in bilateral calves SKIN: Discoloration of BLE PULSES: Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2166-9-4**] 07:15AM BLOOD WBC-11.9* RBC-4.49 Hgb-12.9 Hct-37.7 MCV-84 MCH-28.7 MCHC-34.2 RDW-13.4 Plt Ct-288 [**2166-9-4**] 07:15AM BLOOD Glucose-189* UreaN-10 Creat-0.5 Na-138 K-4.4 Cl-104 HCO3-25 AnGap-13 [**2166-9-4**] 07:15AM BLOOD CK(CPK)-66 [**2166-9-3**] 09:55PM BLOOD CK(CPK)-71 [**2166-9-2**] 12:43PM BLOOD ALT-32 AST-20 AlkPhos-88 TotBili-0.4 [**2166-9-2**] 12:43PM BLOOD CK-MB-3 cTropnT-<0.01 [**2166-9-4**] 07:15AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2 [**2166-9-2**] 12:43PM BLOOD HDL-37 CHOL/HD-5.3 LDLmeas-130* . ECHO: [**2166-9-4**] The left atrium is 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). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. No pathologic valvular abnormality seen. . Cardiac catheterization [**2166-9-3**]: COMMENTS: 1- Limited selective coronary angiography confirmed the presence of a long mid LAD 80% stenosis with a totally and chronically occluded long diagonal branch (originates from the diseased LAD segment). The LMCA had mild plaquing and the LCX was chronically occluded in mid vessel with collaterals filling the OM2. The RCA was not engaged as it was found to be patent on earlier cath performed at OSH. 2- Limited resting hemodynamic assessment showed normal systemic arterial BP (130/70). 3- Successful PTCA of the chronically and totally occluded diagonal branch with 20% residual ostial stenosis, TIMI 3 flow and no dissection or distal emboli. 4- Successful PTCA and stenting of the mid LAD with a 2.5x23 mm Cypher DES, postdilated to 2.75 mm. Final angiography whosed no residual stenosis with TIMI 3 flow and no dissection or distal emboli. 5- Sucecssful closure of the LCFA with a perclose Proglide closure device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Sucecssful stenting of the mid LAD with a Cypher DES. 3. Successful POBA of the diagonal branch. 4. Sucecssful closure of the LCFA with a Perclose Proglide closure device. 5. Dual antiplatelet therapy (ASA and Plavix) for a minimum of 12 months then ASA indefinitely. . CXR: [**2166-9-2**] REASON FOR EXAMINATION: Chest pain after breast surgery. The portable AP chest radiograph was reviewed with no prior studies available for comparison. The study was obtained in lordotic projection. The heart size is mildly enlarged, which might be exaggerated by the lordotic projection of the study. The lungs are essentially clear. There is no pleural effusion or pneumothorax. Mediastinal position, contour and width are unremarkable. Impression: No acute cardiopulmonary findings. Brief Hospital Course: #ACS/CAD: Pt admitted for aspirin desensitization. No signs of wheezes, rash or pruritis with aspirin dose. S/P cath with Diffuse 3VD with DES to mid LAD and POBA to Diagonal. No further SOB during hospital stay, pt was able to ambulate in halls without difficuty prior to discharge. CK's flat, no evidence of prior MI or wall motion abnormality on ECHO. Started on clopodigrel, metoprolol, simvastatin and full dose ASA. Pt will need to take Aspirin and clopodigrel every day for at least one year because of her drug eluting stent. #Pump:No hx or symptoms of CHF. CXR clear, LS without crackles and no peripheral edema. ECHO [**Last Name (un) **] preserved EF. # Right Shoulder pain: Unclear precipitant. Developed after cardiac catheterization. No similar pain PTA, no obvious trauma or strain. Worse with movement and palpation at bicep area. Right shoulder somewhat diffusely swollen and tender but [**Male First Name (un) **] and pain decreased prior to discharge. Better with narcotics and ice. Right shoulder films showed no fracture. EKG and CK's stable, not thought to be cardiac related. Pt told to f/u with her PCP if right shoulder pain continues. # Dyslipidemia: Not on statin on admission, started on 80 mg Simvastatin. See lipid panel above. pt will need LFT's checked in 2 months and then at 6 months to assess for transaminitis. Low fat diet discussed with pt. She will need reinforcement. #Type 2 Diabetes :Glargine and Humalog cont, metformin held because of contrast load. Pt told to restart metformin on [**2166-9-6**]. No changes at d/c. #Asthma: Home medications of Singulair and Abluterol continued. No wheezes on exam or O2 requirement. No exacerbation with ASA. # OSA: Per pt, is being worked up as outpt. CPAP machine offered to pt but mask did not fit well and pt ref to use. Medications on Admission: Singulair 10 mg daily Flovent prn Prventil nebulized with albuterol 2 puffs QID Metformin 1000mg [**Hospital1 **] Risperdal 1 mg qhs Trazadone 50 mg qhs Omeprazole 20 mg [**Hospital1 **] Docusate 100 mg PRN Cialopram 40 mg daily Gabapentin 400 mg [**Hospital1 **] Novolog 10 units in AM Lantus 70 units qhs Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous once a day. 3. Insulin Lispro 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1-3 tablets Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain: Take 5 mintues apart. If still have chest pain after 3 tablets, call 911. Disp:*1 bottle* Refills:*1* 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain, discomfort: for right shoulder pain. 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Metformin Oral Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Diabetes Mellitus Type 2 Obstructive Sleep Apnea Asthma Depression/anxiety Discharge Condition: stable Discharge Instructions: You had a cardiac catheterization that showed blockages in multiple coronary arteries. A drug eluting stent that was placed in your left coronary artery and a balloon procedure was used to open a blockage in your diagonal artery. It is very important that you call your cardiologist, Dr. [**Last Name (STitle) 29070**], if you have any more chest pain or trouble breathing. You did not have a heart attack. You can now take aspirin safely but you need to take it every day for the rest of your life, don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. You also have to take clopodigrel (PLavix) every day for one year. Don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 29070**] tells you to. You may not drive for 48 hours. Please let Dr. [**Last Name (STitle) 29070**] know if you have any increased tenderness, bleeding, swelling or redness at your groin sites. No pools or baths for one week, you may shower. New Medicines: 1. Clopodigrel (Plavix): a blood thinner to keep the stent in your heart open 2. Aspirin: a blood thinner to keep the stent open 3. Metoprolol: a beta blocker medicine to prevent a heart attack 4. Lisinopril: an ACE inhibitor medicine to lower your blood pressure 5. Do not take your Metformin until Saturday 6. Your omeprazole was changed to Ranitidine 7. You were started on simvastatin for your cholesterol 8. You were given a prescription for nitroglycerin, to take if you had chest pain or trouble breathing again. Please refer to the spanish information on how to take nitroglycerin. . Please call Dr. [**Last Name (STitle) 29070**] for any chest pain, trouble breathing, dizziness or fainting, dark or bloody stools or any other concerning symptopms. . please come in to the walk in clinic on Monday [**9-8**] with your discharge papers, your doctor is on an extended leave of absence but you can be seen by another provider [**Name Initial (PRE) **]. Followup Instructions: Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 37284**] Date/time: [**9-30**] at 3:00pm at the [**Doctor First Name 5987**] office . Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63099**] Phone: [**Telephone/Fax (1) 63099**] Date/time: please go to the walk in clinic tomorrow.

5789,27651,2851,2112,56984,4550,2809,4019,311

Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-16**] Date of Birth: [**2083-1-19**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 2009**] Chief Complaint: GIB Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a 54y/o woman with a PMH of H. pylori and depression admitted with DOE and anemia with HCT of 19. The patient noted onset of DOE 2 days prior to presentation, with worsening so that she was unable to ambulate without significant difficultly over the past 24 hours. She noted black stools 24 hours prior to presentation. Denies previous recent history of bleeding. She underwent a routine screening colonoscopy in [**2134**] which demonstrated grade 1 internal hemorrhoids. She denies any other bleeding (urine, gums). She denies weight changes, fevers, chills, night sweats. She has nto had any bowel movements since admission. In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2 100% RA. On exam she was found to have dark, guaiac + stools. NG lavage negative. 2 18 guage PIV were placed. She was transfused 1U PRBC. On arrival to the MICU, the patient is resting comfortably, in NAD. Denies current CP/SOB. The GI performed an upper endoscopy on arrival to the MICU which demonstrated a large polyp with no evidence of current bleeding. Intervention was deferred overnight for planned excision and biopsy with EUS. She was transfused 3 units PRBC's with appropriate improvement in her hct and has been hemodynamically stable in the ICU. 10 point review of systems otherwise negative except as noted above. Past Medical History: Melanoma in-situ, lentigo maligna type - L cheeck [**2133**] Depression H. Pylori Social History: The patient is married and has one teenage son. She runs the Gift Shop at [**Hospital1 18**]. The patient denies tobacco, EtOH, IVDU. Denies over the counter herbal supplements. Family History: Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19839**] deficiency Physical Exam: VS: T 97.3 HR 59 BP 102/69 RR 18 Sat 99% RA Gen: wll appearing woman in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates, conjunctiva pink ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non tender, non distended, no heptosplenomegally, bowel sounds present Extremities: No cyanosis, clubbing, edema, joint swelling Neurological: Alert and oriented x3, CN II-XII intact, normal attention, sensation normal, asterixis absent, speech fluent, DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis bilaterally, babinski down-going bilaterally Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious Hematologic: no cervical or supraclavicular LAD Pertinent Results: [**2137-8-12**] 05:57PM COMMENTS-GREEN TOP [**2137-8-12**] 05:57PM HGB-7.8* calcHCT-23 [**2137-8-12**] 05:50PM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-141 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12 [**2137-8-12**] 05:50PM WBC-5.5 RBC-2.22* HGB-6.8* HCT-20.4* MCV-92 MCH-30.8 MCHC-33.4 RDW-14.0 [**2137-8-12**] 05:50PM NEUTS-68.4 LYMPHS-24.4 MONOS-5.5 EOS-1.4 BASOS-0.2 [**2137-8-12**] 05:50PM PLT COUNT-211 [**2137-8-12**] 05:50PM PT-11.3 PTT-21.8* INR(PT)-0.9 [**2137-8-12**] 01:46PM GLUCOSE-95 [**2137-8-12**] 01:46PM UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-29 ANION GAP-7* [**2137-8-12**] 01:46PM estGFR-Using this [**2137-8-12**] 01:46PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-57 TOT BILI-0.2 [**2137-8-12**] 01:46PM WBC-3.9* RBC-2.13*# HGB-6.4*# HCT-18.9*# MCV-92 MCH-30.0 MCHC-32.8 RDW-14.1 [**2137-8-12**] 01:46PM NEUTS-64.6 LYMPHS-24.2 MONOS-8.8 EOS-1.9 BASOS-0.5 [**2137-8-12**] 01:46PM PLT COUNT-177 [**2137-8-12**] 01:46PM PT-11.9 PTT-23.5 INR(PT)-1.0 [**2137-8-12**] 01:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2137-8-12**] 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG EGD [**2137-8-12**]: Impression: Polyp in the second part of the duodenum on wall opposite ampulla Otherwise normal EGD to third part of the duodenum Recommendations: Patient will require polypectomy of this polyp. We do not have the equipment to perform this as an emergency procedure. Can have clear liquids. give Protonix 40 mg twice daily. Colonoscopy [**2137-8-12**]: Impression: Grade 1 internal hemorrhoids Otherwise normal colonoscopy to cecum Brief Hospital Course: This is a 54y/o woman with a h/o H. pylori and depression with acute blood loss anemia, GIB, duodenal polyp. 1. Acute blood loss anemia due to GI bleeding: She presented with blood loss anemia, secondary to slow GI bleed. She had an emergent EGD which showed a duodenal polyp. She improved with transfusion of 3 units of blood with stable hematocrit. She will need to restart an [**Month/Day/Year **] supplement on discharge. . 2. Duodenal polyp: Underwent EUS on [**8-15**] for evaluation of polyp found on initial EGD. EUS showed 3 cm pedunculated polyp in the second part of the duodenum. The ampulla was identified and was separate from the mass. The ampulla appeared normal. On EUS, this lesion appeared as a pedunculated polyp. No extension of the lesion beyond the submucosa was noted. The muscularis was clearly identified and was intact. She went for removal on [**2137-8-16**]. During that EGD, EGD on she was found to have angioectasia in the stomach (treated with thermal therapy), a polyp in the second part of the duodenum (treated with polypectomy, endoclip, and otherwise normal EGD to third part of the duodenum. She was discharged home after the polypectomy, with advise to return in the event of pain, hematemesis, or worsening melena. She will have a CBC approximately 5 days post discharge, results to her PCP. . 3. Depression: continuee wellbutrin and celexa. . OUTSTANDING TESTS: Polyp, pathology pending Medications on Admission: On Admission: Bupropion HCl 200 mg Tablet SR daily Citalopram 20 mg Tablet daily Lorazepam 0.5 mg Tablet one half to one Tablet(s) by mouth @ hs no more than 3 nights per week Ferrous Sulfate 325 mg (65 mg [**Date Range **]) Tablet [**Hospital1 **] Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC) On transfer: BuPROPion (Sustained Release) 200 mg PO QAM Citalopram Hydrobromide 20 mg PO DAILY Pantoprazole 40 mg IV Q12H Discharge Medications: 1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. [**Hospital1 **] (Ferrous Sulfate) 325 mg (65 mg [**Hospital1 **]) Tablet Sig: One (1) Tablet PO once a day. 4. Outpatient Lab Work CBC, [**2137-8-21**]. Results to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] phone [**Telephone/Fax (1) 250**]. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Acute blood loss anemia Duodenal polyp Depression Discharge Condition: Stable, hematocrit 31.5, no active bleeding, ambulating without shortness of breath Discharge Instructions: You were admitted with anemia, due to blood loss. The most likely cause was the polyp in your duodenum, which was slowly oozing. You improved with transfusions with a stable blood count throughout your stay after the transfusion. You had the polyp removed on the day before discharge. . No aspirin, or NSAIDs. You do not need to take protonix. . Return to the ED if you get short of breath or dizzy. Your stool will probably turn black from the [**Last Name (LF) **], [**First Name3 (LF) **] that is expected. . Start eating solid food tonight. Stay well hydrated in the next few days. Followup Instructions: Call the GI department to make an appointment with [**Doctor First Name 4370**] [**Doctor Last Name **] in the next 2-3 weeks. The phone number is [**Telephone/Fax (1) 9557**]. They will give you the results of your polyp removal. . Provider: [**Name10 (NameIs) **] [**Name6 (MD) **] [**Name8 (MD) 19840**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-9-3**] 3:00 (resident working with Dr. [**Last Name (STitle) 5263**] . Blood count check next week.

41401,42831,4111,4280,4240,42769,2724,4552,34690,V173,3051,2982,E9352

Admission Date: [**2103-12-19**] Discharge Date: [**2103-12-24**] Date of Birth: [**2058-5-8**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: left & right heart catheterization, coronary angiogram [**2103-12-19**] Insertion of intraaortic balloon [**2103-12-19**] urgent Mitral valve repair (P2 triangular resection),ring annuloplasty(34mm [**Doctor Last Name **] Physio II annuloplasty ring, model number 5200,serial number [**Serial Number 92293**])/ Coronary artery bypass grafting times 3 LIMA-LAD,SVG-D1,SVG-OM1) [**2103-12-20**] History of Present Illness: This 45 year old white male began about one and a half months ago to notice chest discomfort "like indigestion", across the entire chest when exerting himself. He is avid walker and has noticed this discomfort when going up any type of incline and resolving with rest. He has not noticed this discomfort when walking on a level surface. It is easily reproducible. He underwent a stress echo which revealed mild LV enlargement with preserved LV function. The left atrium was moderately dilated. There was moderate mitral valve prolapse involving the posterior leaflet with severe mitral insuffiency and pulmonary vein flow reversal. Mild TR and borderline aortic root dilation were seen. He exercised 6 minutes and developed chest pain at peak exercise along with lateral ST depression. PVC's were noted. Echo imaging showed anteroseptal ischemia. He was referred for cardiac catheterization to further evaluate. He was found to have coronary artery disease upon cardiac catheterization and referred to cardiac surgery. He continued to complain of chest pain on a nitro drip and morphine. He had an intraaortic balloon placed with stabilization and was taken the following day to the Operating Room for an urgent operation. enzymes were flat. Past Medical History: Mitral prolapse/regurgitation Mild hyperlipidemia, recently started on statin Non sustained VT 13 years ago, on Atenolol since Hemorrhoids with occasional rectal bleeding Bone spurs s/p surgery Remote history of migraines Social History: Race:caucasian Last Dental Exam: Lives with:Wife and three kids Contact:[**Name (NI) **] [**Name (NI) 1024**] (Wife) #[**Telephone/Fax (1) 92294**] Occupation:works at a bank as a temporary worker doing booking Cigarettes: Smoked no [] yes [x] Hx:occasional cigarette/cigar (none in 2 months) Other Tobacco use:denies ETOH: 2 glasses of wine per day Illicit drug use:denies Family History: Adopted. Patient does not know his family history. Physical Exam: Height:6'2" Weight:228 lbs Unable to assess patient due to emergent nature of case. NO H&P in chart. Pertinent Results: [**2103-12-23**] 05:35AM BLOOD WBC-5.8 RBC-3.08* Hgb-9.1* Hct-27.0* MCV-88 MCH-29.4 MCHC-33.5 RDW-13.0 Plt Ct-138* [**2103-12-22**] 04:30AM BLOOD WBC-6.0 RBC-3.27* Hgb-10.2* Hct-28.9* MCV-88 MCH-31.1 MCHC-35.2* RDW-12.8 Plt Ct-133* [**2103-12-21**] 02:11AM BLOOD WBC-6.7 RBC-3.68* Hgb-11.2* Hct-32.0* MCV-87 MCH-30.3 MCHC-34.9 RDW-13.3 Plt Ct-148* [**2103-12-23**] 05:35AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 [**2103-12-22**] 04:30AM BLOOD Glucose-142* UreaN-10 Creat-0.9 Na-138 K-4.0 Cl-105 HCO3-25 AnGap-12 [**2103-12-21**] 02:11AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-137 K-3.8 Cl-110* HCO3-23 AnGap-8 [**2103-12-20**] 02:16PM BLOOD UreaN-14 Creat-1.0 Na-138 K-4.1 Cl-106 HCO3-24 AnGap-12 [**2103-12-20**] TTE Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *7.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: 0.45 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Stroke Volume: 113 ml/beat Left Ventricle - Cardiac Output: 8.48 L/min Left Ventricle - Cardiac Index: 3.69 >= 2.0 L/min/M2 Aorta - Annulus: 2.7 cm <= 3.0 cm Aorta - Sinus Level: *3.7 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - LVOT VTI: 25 Aortic Valve - LVOT diam: 2.4 cm LEFT ATRIUM: Dilated LA. LA not well visualized. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of the RA or RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Low normal LVEF. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. No atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Moderate to severe (3+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending aorta appears free from atherosclerotic plaque with some limitation in the study due to the presence of an intraaortic balloon pump. The distal tip of the IABP appears end prior to the subclavian artery takeoff. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate/severe posterior leaflet mitral valve prolapse. There is partial posterior (P2) mitral leaflet flail. Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. POSTBYPASS: The patient is in sinus tachycardia on low dose epinephrine & moderate dose phenylephrine infusions. The biventricular function is maintained. There is a well seated annuloplasty ring in the mitral position. There is trace MR. There are peak and mean gradients of 11 & 5mmHg, respectively. The remaining valves are unchanged. The aorta appears intact, though the descending aorta has suboptimal imaging due to the presence of an IABP. The IABP continues to remain with the distal tip in appropriate position. [**2103-12-24**] 04:40AM BLOOD WBC-6.0 RBC-3.00* Hgb-9.0* Hct-26.3* MCV-88 MCH-30.2 MCHC-34.4 RDW-12.9 Plt Ct-217# [**2103-12-24**] 04:40AM BLOOD Na-141 K-4.0 Cl-105 Brief Hospital Course: This is a 45-year-old male referred from Dr. [**Last Name (STitle) **] for consideration of coronary artery bypass grafting as well as mitral valve repair. The patient developed severe angina after his diagnostic cardiac cath which revealed moderate left main disease and high-grade LAD and diagonal stenoses. The patient was not responsive to nitroglycerin and therefore was brought to the Operating Room and an intra-aortic balloon pump inserted. This abated his chest pain. A stat echo in the Operating Room showed severe mitral regurgitation. It was felt that the patient should proceed with mitral valve repair or replacement and coronary artery bypass grafting the next morning. The patient had a stable night and did not rule in for a myocardial infarction by serial enzyme analysis. On [**2103-12-20**] he was taken to the Operating Room and underwent mitral repair and coronary artery bypass grafting times 3. CARDIOPULMONARY BYPASS TIME: 155 minutes CROSS-CLAMP TIME: 126 minutes. See operative note for full details. The operation went without complication and the patient was transferred to the CVICU in stable condition. He was initially hypoxic which improved with recruitment maneuvers. The intraaortic balloon pump was removed on the night of surgery and he remained hemodynamically stable off all vasoactive medications. He was started on Precedex and extubated on his post operative night. On POD1 beta blockers were started and he was gently diuresed with Lasix. Chest tubes were removed per cardiac surgery protocol and follow up CXR showed no pneumothorax. He was transferred to the step down unit in stable condition. Pacing wires were removed on POD3 per cardiac surgery protocol without difficulty. He was changed from Percocet to Ultram due to confusion and lethargy. He worked with Physical Therapy for strength and mobility. He was kept an extra day due to unsteadiness with ambulation. On POD 5 he was ambulating with assistance, tolerating a full oral diet and his incisions were healing well. It was felt that he was safe for discharge home with visiting nurse services. There was a tiny amount of serosanguinous drainage on the sternal dressing the morning of discharge, however, the sternum was stable, no further drainage could be expressed and he was afebrile with a normal white blood cell count. All follow up appointments were arranged. Medications on Admission: ATENOLOL 50 mg Tablet - 2 Tablets by mouth daily ATORVASTATIN 40 mg Tablet - 2 Tablets by mouth every evening ASPIRIN 81 mg Daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Severe mitral regurgitation Unstable angina with left main stenosis s/p insertion of intra aortic balloon s/p urgent mitral valve repair and coronary artery bypass grafts s/p left & right heart catheterization, coronary angiogram hyperlipidemia hemorrhoids Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right- healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2104-1-28**] at 1:45 pm Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]([**Telephone/Fax (1) 4475**]) [**2104-1-15**] at 1:30pm wound check at Cardiac Surgery office on [**1-1**]/ at 10:00am Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32651**] in [**3-6**] weeks ([**Telephone/Fax (1) **]) **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:[**2103-12-24**]

4241,7464,4260,4019,79319,2800

Admission Date: [**2162-4-16**] Discharge Date: [**2162-4-27**] Service: CARDIOTHORACIC Allergies: Vasotec Attending:[**First Name3 (LF) 1505**] Chief Complaint: Aortic Stenosis Major Surgical or Invasive Procedure: [**2162-4-19**] Aortic Valve Replacement (21 StJude porcine) History of Present Illness: 87 year old woman with hypertension presented to [**Hospital3 110856**] after awakening with chest discomfort on [**4-12**]. She had had several months of progressive DOE and fatigue. She lives alone and at baseline is self-sufficient. She had never had chest pain before. She denied any history of syncope. At LGH, she was found to have severe AS and was transferred to [**Hospital1 18**] On [**2162-4-16**] for AVR. Past Medical History: Aortic Stenosis Hypertension Status post cholecystectomy 40yrs ago Social History: Lives alone(5 sons near by, one in ajoining unit) Occupation:homemaker Cigarettes: never ETOH: less than 1 drink/week Illicit drug use none Family History: non-contributory Physical Exam: Pulse: Resp:14 O2 sat: 98% RA B/P Right:134/78 Left: Height:61" Weight:164 General:WDWN Skin: Dry [] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [x] grade _4/6 SEM -> neck Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [n] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:m Left:m Pertinent Results: [**2162-4-25**] WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3* MCV-95 MCH-29.5 MCHC-31.2 RDW-14.8 Plt Ct-196 [**2162-4-16**] WBC-4.1 RBC-3.59* Hgb-10.4* Hct-33.6* MCV-94 MCH-29.0 MCHC-31.0 RDW-14.2 Plt Ct-151 [**2162-4-25**] Glucose-183* UreaN-16 Creat-0.7 Na-139 K-4.5 Cl-96 HCO3-35 [**2162-4-16**] Glucose-176* UreaN-18 Creat-1.0 Na-141 K-4.3 Cl-104 HCO3-26 [**2162-4-16**] ALT-37 AST-55* LD(LDH)-233 AlkPhos-40 TotBili-0.3 [**2162-4-25**] Mg-1.9 MRSA SCREEN (Final [**2162-4-21**]): No MRSA isolated. CXR: [**2162-4-24**]: There is cardiomegaly which is stable. There are bilateral pleural effusions, right side worse than left as well as a left retrocardiac opacity. No overt pulmonary edema or pneumothoraces are seen. The tip of the right IJ Cordis is in the superior SVC. Echo: [**2162-4-19**] PRE-CPB: No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. The aortic valve is bicuspid with horizontal commissure. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-CPB: A bioprosthetic valve is seen in the aortic position. The valve appears well-seated with normally mobile leaflets. A tiny filamentous mass is seen in the LVOT side of the aortic valve, possibly debris from debridement or a suture. There are no paravalvular leaks, there is no AI. The peak gradient across the aortic valve is 21mmHg, the mean gradient is 9mmHg with CO of 3.5L/min. Biventricular systolic function remain normal. Other valvular function remain unchanged from pre-bypass. There is no evidence of aortic dissection. [**2162-4-26**] 05:40AM BLOOD WBC-5.4 RBC-3.33* Hgb-9.5* Hct-30.2* MCV-91 MCH-28.6 MCHC-31.5 RDW-14.3 Plt Ct-181 [**2162-4-25**] 09:30AM BLOOD WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3* MCV-95 MCH-29.5 MCHC-31.2 RDW-14.8 Plt Ct-196 [**2162-4-26**] 05:40AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-138 K-4.4 Cl-96 HCO3-36* AnGap-10 [**2162-4-25**] 09:30AM BLOOD Glucose-183* UreaN-16 Creat-0.7 Na-139 K-4.5 Cl-96 HCO3-35* AnGap-13 Brief Hospital Course: The patient was brought to the Operating Room on [**2162-4-19**] where the patient underwent Aortic valve replacement with a 21-mm Biocor tissue valve. 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. The patient was gently diuresed toward the preoperative weight. She exhibited a high degree AV block initially, which would show signs of recovery prior to discharge. EP was consulted and made recommendations. Beta blockade was attempted, however this compromised her normal sinus rhythm. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She will not be discharged on a beta blocker, and nodal agents should not be initiated in the future. By the time of discharge on POD 8 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital **] Rehab in good condition with appropriate follow up instructions. Medications on Admission: Lisinopril 40mg daily, Aldactone 25mg daily, nadolol 160mg daily Discharge Medications: 1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days. 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. 9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous membrane four times a day as needed for sore throat. Discharge Disposition: Extended Care Facility: [**Hospital **] Nursing and Rehab Center Discharge Diagnosis: Aortic Stenosis Hypertension status post cholecystectomy [**90**] yrs ago Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 1:15 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A Please call to schedule the following: Cardiologist Dr. [**Last Name (STitle) 5017**] Primary Care Dr. [**First Name4 (NamePattern1) 9097**] [**Last Name (NamePattern1) 110857**] [**Doctor Last Name 110858**] [**Telephone/Fax (1) 66039**] in [**4-15**] 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:[**2162-4-27**]

51881,5845,42832,49322,42732,2851,2762,515,4280,4019,42731,V5861,56210,2662,4168,2767,2753,E9478

Admission Date: [**2174-1-20**] Discharge Date: [**2174-1-22**] Date of Birth: [**2096-4-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypoxic respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 77 y.o. Male w/ h.o. diastolic dysfunction, A. fib/flutter s/p recent PVI, COPD, asthma, ?IPF, HTN, initially presented to [**Hospital1 **] [**Location (un) 620**] w/ [**1-8**] week h.o of lower extremity edema, shortness of breath. Intubated for hypercapneic respiratory distress. Transferred for further hypoxic work-up whether this is COPD exacerbation, PNA, CHF exacerbation. . On review of pt's outside medical records it appears he was initially admitted to [**Hospital1 18**] [**Location (un) 620**] on [**2173-1-18**] w/ a 2 week h.o. progressive lower extremity edema, several days of SOB. Day prior to admission pt was seen by his PCP who prescribed Steroid taper, Azithromycin for possible COPD exacerbation. Upon assessment in the ED it appears his oxygen saturation was 52% on RA, HR 120, RR 32, BP 157/99. His labs at that time were significant for a Leukocytosis of 22.0 (attributed to steroids). Pt was given IV diuresis 100mg with poor urine output response. A CXR was obtained which showed extesnive alveolar edema. Pt was given repetitive Furosemide doses with little to no response in urine output, pt was noted to have increase Creatinine, decreased urine output. His admission labs also showed +CK-MB, MBI, Troponins but negative CKS, am Echo which was obtained 3 days later, however, showed normal LV function, RV dilatation, no MR, trivial TR. Pul HTN 37. . During the evening of [**1-19**] pt was noted to become hypoxic to the 70% and was placed on a NRB where his O2 sat was ntoed to be 86-88%. He was titrated up to BiPAP with no reoslution in his hypoxia, he was noted to be more lethargic. ABG showed pH of 7.17, pO2 66, pCO2 82-101, HCO 30.6, pt was intubated. His initial ABG showed CO2 49, HCO3 30.4, pH 7.40. Sputum cx were sent which showed . He was also noted to be anemic in the low 20s on admission. Surgery and GI were consulted and he underwent a CT scan of his abdomen to check for an RP bld given his recent PVI which was negative. Stools were guaiac negative as were NG lavage. He was transfused 2 units with stable Hcts. Prior to him leaving [**Location (un) 620**] he received Cefepime, Levofloxacin, IV Solumedrol. A Femoral line was placed for central access. He was influenza neg, Sputum cx showed [**10-31**] PMNs, GPC chains, rare. GP bacili. . Of note pt was admitted to [**Hospital3 **] last year with similar presentation, was initially diuresed for ?CHF exacerbation and went into [**Last Name (un) **]. Eventually was diagnosed with Influenza A. He has been noted to have CT changes in his chest suggesting IPF though he has not seen a Pulmonologist. He was also admitted to [**Hospital **] in [**Month (only) 1096**] with new onset A. fib/flutter and underwent pulmonary vein isolation. He was discharged on Coumadin as well as a course of steroids. Per his wife he has been on a requirement of 5L n.c. over the past month or so. Over the past week he has been noted to desaturate to mid 80s on 5L n.c. with movement. . REVIEW OF SYSTEMS: Unable to obtain Past Medical History: 1. He has a chronic history of asthma and a possible COPD/chronic obstructive lung disease. 2. Possible pulmonary fibrosis that was diagnosed on a CT of the chest but per wife he never had any further evaluation of this fibrosis and never had any lung biopsies. 3. Atrial flutter status post ablation on [**2173-12-21**], and started on Coumadin. 4. History of anemia that required blood transfusion around 1 year ago. No clear origin for the anemia. Previous workup for retroperitoneal bleed. Guaiacs were all negative. 5. Hypertension. 6. Steroid-induced hyperglycemia. 7. Low vitamin B12. 8. Diastolic congestive heart failure, chronic lower limb edema with an EF of 65%. 9. Diverticulosis as noted above. 10. Previous admissions for ARDS, CHF, COPD exacerbation, Influenza A, A flutter. Social History: SOCIAL HISTORY: He lives at home. He is independent in his ADL, IADLs but over the last year he had a big decline in his functional status. He denies any drug abuse. No history of smoking. He has a history of alcohol intake three to four beers. Family History: non-contributory Physical Exam: GENERAL: Elderly Caucasian Male intubated laying down in bed HEENT: PERRLA, MMM. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM GROIN: Femoral central noted in rt groin with pulsatile wave form. EXTREMITIES: 2+ edema noted b/l LE to calf. SKIN: Multiple ecchymoses noted. NEURO: Intubated, sedated. Pertinent Results: [**2174-1-20**] 02:30PM PT-32.4* PTT-33.6 INR(PT)-3.3* [**2174-1-20**] 02:30PM PLT COUNT-264 [**2174-1-20**] 02:30PM WBC-16.7* RBC-2.72* HGB-8.0* HCT-25.4* MCV-93 MCH-29.4 MCHC-31.5 RDW-15.7* [**2174-1-20**] 02:30PM ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-7.4* MAGNESIUM-2.6 [**2174-1-20**] 02:30PM ALT(SGPT)-19 AST(SGOT)-34 LD(LDH)-592* ALK PHOS-53 TOT BILI-0.4 [**2174-1-20**] 02:30PM estGFR-Using this [**2174-1-20**] 02:30PM GLUCOSE-149* UREA N-80* CREAT-3.0* SODIUM-135 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 [**2174-1-20**] 02:40PM LACTATE-1.1 [**2174-1-20**] 02:40PM TYPE-ART PO2-147* PCO2-79* PH-7.17* TOTAL CO2-30 BASE XS--1 [**2174-1-20**] 04:12PM CK-MB-11* MB INDX-6.3* cTropnT-0.06* [**2174-1-20**] 04:12PM CK(CPK)-175 [**2174-1-20**] 04:34PM TYPE-ART TEMP-35.6 RATES-24/6 TIDAL VOL-400 PEEP-7 O2-70 PO2-74* PCO2-73* PH-7.20* TOTAL CO2-30 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED [**2174-1-20**] 04:55PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-97* LYMPHS-1* MONOS-1* OTHER-1* [**2174-1-20**] 05:25PM URINE MUCOUS-OCC [**2174-1-20**] 05:25PM URINE HYALINE-6* [**2174-1-20**] 05:25PM URINE RBC-70* WBC-8* BACTERIA-FEW YEAST-NONE EPI-0 [**2174-1-20**] 05:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2174-1-20**] 05:25PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2174-1-20**] 05:25PM URINE HOURS-RANDOM UREA N-380 CREAT-63 SODIUM-25 [**2174-1-20**] 11:35PM freeCa-1.12 [**2174-1-20**] 11:35PM GLUCOSE-117* K+-5.2 [**2174-1-20**] 11:35PM TYPE-ART PO2-83* PCO2-76* PH-7.21* TOTAL CO2-32* BASE XS-0 [**2174-1-21**] 12:00AM PT-21.5* PTT-31.5 INR(PT)-2.0* Original CXR: AP single view of the chest has been obtained with patient in supine position. The patient is intubated, the ETT is seen to terminate in the trachea some 3 cm above the level of the carina. Heart size is difficult to determine because of obscuring pulmonary abnormalities. There exist extensive bilateral pulmonary parenchymal densities occupying practically all lung fields in this single view examination. There exist undoubtedly some coinciding perivascular haze with blurred-out vascular contours. The pleural spaces on the other hand are grossly free and in particular the lateral pleural sinuses are not blunted. There is no pneumothorax identified, nor is there any chest wall emphysema. IMPRESSION: Not having any clinical history available, conclusive diagnosis cannot be established. Findings as presented here are compatible with acute left-sided heart failure and extensive pulmonary edema or ARDS. Severe pulmonary edema related to left-sided heart failure is a likelihood. Differential diagnosis must rely on clinical presentation. Comparison with possibly available previous examinations is essential TTE: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. 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 aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is mild functional mitral stenosis (mean gradient 3 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild right ventricular dilation. Diastolic dysfunction. Moderate pulmonary hypertension. Brief Hospital Course: ##. Hypoxic Respiratory Failure: Pt has had underlying hypoxia of unknown etiology over the past month with a requirement of 5L O2 particularly during activity. Pt noted to be hypoxic at outside hospital eventually requiring intubation. Etiology of hypoxic respiratory failure includes possible infection, cardiogenic pulmonary edema, COPD, IPF exacerbation. TTE was repeated and was significant for moderate diastolic dysfunction and pulmonary hypertension. Bronchoscopy and BAL was done, bacterial, viral, fungal and PCP were negative. [**Last Name (un) **] revealed bloody sputum and friable airway. Patient was initiated on empiric high dose steroids, broad spectrum antibiotics and nebulizers. Vent settings were maintained for ARDs-like picture, given high plateua pressures suggesting very poor compliance. Given [**Last Name (un) **] and worsening electrolytes, patient was also started on CVVH and diuresed aggressively. Patient continued to be acidotic and with no improvement in weaning off vent. He was made CMO on [**2174-1-22**] (see below). . ##. [**Last Name (un) **]: On admission pt noted to have a Creatinine of 1.8 which trended up to 3.0 in the setting of diuresis. Etiology was likely contrast induced. Cr continued to trend up, with worsening hyperkalemia, elevated calcium-phos product and evidence of volume overload. Patient was started on CVVH for dialysis and fluid removal. . ##. Femoral Line: Placed at OSH prior to transfer. Appears to be placed in artery as opposed to vein given blood gas draw from line and wave form when transduced. Pt has elevated INR of 3.3. Line was pulled after patient was given FFP. Pt was checked for femoral bruit, hematoma, and distal pulses q6 hours after line pulled. . ##. A. Flutter: Pt recently underwent PVI for new onset A. flutter, currently in sinus rhythm. INR was noted to be supratherapeutic, coumadin was held and pt given FFP. Continued on diltiazem. . ##. HL: Continued on home regimen of Simvastatin . [**2174-1-23**]: 16:00 pt??????s family verbalizing decision to make pt comfort care. CRRT stopped and pt switched from fentanyl and versed drip to morphine drip. Pt appearing very comfortable. Pt??????s ett remained in placed and pt remaining on vent titrated down to rm air by resp therapist. Morphine drip titrated to comfort. At 17:22 pt pulseless. Cyanotic. Dr. [**Last Name (STitle) **] pronounced pt at 5:27pm. Pt??????s wife [**Name (NI) **] requesting autopsy. Emotional support provided to family. Post mortem care provided. All lines left in for autopsy. Medications on Admission: MEDICATIONS ON TRANSFER: Propofol gtt Furosemide 60mg [**Hospital1 **] Albuterol/Ipratropium INH Esomeprazole 40mg IV qday ASA 81mg daily Clonidine 0.1mg [**Hospital1 **] Simvastatin 20mg qHS Levothyroxine 37.5mcg daily Methylprednisolone 80mg q8hrs Flunisolide 1 puff [**Hospital1 **] Diltiazem 180mg daily Monteluekast 10mg daily Colace Vancomycin 1gm Cefepime Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

41401,42823,5185,49322,9994,4280,99527,E9353,42731,E9478

Admission Date: [**2131-12-24**] Discharge Date: [**2131-12-27**] Date of Birth: [**2058-2-4**] Sex: M Service: MEDICINE Allergies: Aspirin / Ibuprofen Attending:[**Doctor First Name 1402**] Chief Complaint: ASA desensitization Major Surgical or Invasive Procedure: Cardiac catheterization ([**2131-12-24**]) Intubation ([**2131-12-25**]) History of Present Illness: The pt is a 73-yo man w/ severe COPD and recently-diagnosed cardiomyopathy with EF 30% who presented to OSH on [**2131-12-21**] with complaints of increasing SOB, DOE, orthopnea, PND, chest tightness, and wheezing. He denied any chest pain, palpitations, lightheadedness, syncope, lower extremity edema, fevers, chills, cough, or sputum production. He was treated as an acute on chronic CHF exacerbation with diuresis as well as a COPD exacerbation with steroids and nebulizers. He was seen by Cardiology and Pulmonology consults, and repeat TTE showed an LVEF of 20-25% with global LV hypokinesis and chamber dilatation, and the possibility of an apical thrombus could not be ruled out. He was started on weight-based heparin gtt and transferred to the [**Hospital1 18**] Cardiac Cath Lab for catheterization. Catheterization here showed diffuse 20-30% stenosis with mid-vessel 80% stenosis of the LAD and mild luminal irregularities with mid-vessel 60% eccentric stenosis of the LCx. Given his ASA allergy, he is admitted to the CCU for ASA desensitization and investigation of viability of the anteroapical wall in anticipation of probable PCI of the LAD lesion. . On arrival to the CCU: VS - Temp 97.6F, BP 125/93, HR 94, R 22, SaO2 97% 2L NC. He complains of mild left groin pain at the catheterization site. . ROS: He acknowledges a prior history of TIA but denies any history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. All of the other review of systems were negative. . Past Medical History: - severe COPD / bronchial asthma - cardiomyopathy w/ EF 30-35%, cause unknown - suspected TIA - h/o recent pneumonia - LBBB on ECG - nephrolithiasis - s/p cataract surgery - s/p hernia repair Social History: Lives with his wife, fairly independent until symptomatic w/ SOB. -Tobacco history: x15-20years, Quit smoking: [**2104**] -ETOH: Quit in [**2105**]. -Illicit drugs: None. Family History: Mother had a stroke, Father had CAD. No early CAD. Physical Exam: VS: T = 97.6 F, BP = 125/93, HR = 94, RR = 22, O2 sat = 97% 2L NC GENERAL: WA middle-aged man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL/EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10cm. No LAD or thyromegaly. CARDIAC: PMI located in 5th intercostal space, non-displaced. RRR w/ freq APCs and PVCs. Normal S1, S2. +[**2-1**] HSM at apex. No r/g, thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp mildly labored, tachypneic, no accessory muscle use. +Bibasilar crackles and scattered wheezes, prolonged expiratory phase. ABDOMEN: +BS, soft/NT/ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: WWP, no c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2131-12-24**] 08:26PM BLOOD WBC-8.2 RBC-4.02* Hgb-11.8* Hct-35.0* MCV-87 MCH-29.4 MCHC-33.8 RDW-15.0 Plt Ct-293 [**2131-12-24**] 08:26PM BLOOD Neuts-84.6* Lymphs-9.4* Monos-5.9 Eos-0.1 Baso-0 [**2131-12-24**] 08:26PM BLOOD PT-12.7 PTT-25.9 INR(PT)-1.1 [**2131-12-24**] 08:26PM BLOOD Glucose-106* UreaN-26* Creat-0.9 Na-141 K-4.7 Cl-103 HCO3-31 AnGap-12 [**2131-12-26**] 05:31AM BLOOD LD(LDH)-333* [**2131-12-26**] 05:31AM BLOOD cTropnT-0.08* [**2131-12-24**] 08:26PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3 . . ECG ([**2131-12-24**]): Sinus rhythm with atrial premature beats and possible first beat being a ventricular premature beat. Left bundle-branch block. No previous tracing available for comparison. . CARDIAC CATH ([**2131-12-24**]): 1. Selective coronary angiography of this left dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had diffuse 20-30% lesions throughout with a mid vessel 80% stenosis. The Lcx had mild luminal irregularities with a mid vessel 60% eccentric stenosis. The RCA was small and nondominant without any angiographically apparent stenosis. 2. Resting hemodynamics revealed elevated right sided filling pressures with an RVEDP of 17 mmHg. There was moderate pulmonary hypertension with a pulmonary artery pressure of 47/21 mmHg. There were moderately elevated left sided filling pressures with a PCWP mean of 24 mmHg. There was normal central aortic pressures of 126/77 mmHg. The cardiac index was normal at 2.9 L/min/m2. 3. Left vetriculography was deferred. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate pulmonary hypertension. 3. Moderate diastolic dysfunction. 4. Elevated RVEDP . CXR ([**2131-12-24**]): 1. Hazy opacity in the lingula and left lower lobe, concerning for early pneumonia versus asymmetric edema. 2. Cardiomegaly. Mild vascular congestion with interstitial edema. 3. Right retrocardiac density, atelectasis versus pneumonia. PA and lateral views are recommended for better assessment of this area. . TTE ([**2131-12-25**]): The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = [**10-9**] %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated left ventricular cavity with severe global hypokinesis. Preserved right ventricular cavity size and systolic function. Moderate mitral regurgitation. Mild pulmonary hypertension. . CT Abdomen/Pelvis ([**2131-12-26**]): 1. There is no evidence of a retroperitoneal hematoma. 2. Marked asymmetric enlargement of the proximal right thigh musculature, consistent with the patient's history of a known hematoma. 3. Small left greater than right pleural effusions with associated compressive atelectasis of the posterior lung bases. 4. Cholelithiasis. 5. Extensive colonic diverticulosis without evidence of diverticulitis. . Femoral Vascular U/S ([**2131-12-26**]): FINDINGS: There is no evidence of pseudoaneurysm or A-V fistula, as questioned. There is a large right groin/thigh hematoma as seen on CT, measuring at least 13.0 cm in greatest dimension. IMPRESSION: No evidence of pseudoaneurysm of AVF. Large right groin/thigh hematoma. . Brief Hospital Course: The patient is a 73-year-old man with severe COPD and recently-diagnosed cardiomyopathy with EF 30%, who presented to an OSH on [**2131-12-21**] with symptoms of acute on chronic systolic heart failure, transferred to [**Hospital1 18**] for cardiac catheterization to assess for ischemic cardiomyopathy, which showed LAD disease. He was admitted to the CCU for aspirin desensitization with plan for repeat cardiac catheterization and PCI. . #. Aspirin desensitization - The patient was admitted to the CCU overnight for aspirin desensitization. He completed the protocol overnight, but approximately 1 hour after completion he suffered from acute-onset of severe respiratory distress with chest tightness and wheezing, consistent with anaphylaxis. He was treated with steroids, H1- and H2-blockers, as well as treatments directed at his COPD, CHF, and anxiety, with no improvement, so he was intubated for respiratory failure. He was extubated later that day with significant improvement. He was seen by the Allergy consult service, who felt that this was consistent with anaphylaxis, and recommended repeat desensitization after a couple weeks if needed. He is stable for discharge. . #. Acute on chronic systolic CHF - The patient was recently diagnosed with a cardiomyopathy of unknown etiology, and was being treated for acute on chronic systolic heart failure prior to transfer. On transfer, he was still mildly fluid overloaded, so diuresis was continued with Lasix and spironolactone. Repeat TTE here revealed EF 15% with global LV dysfunction and no wall-motion-abnormalities to suggest ischemic cardiomyopathy. He is being discharged on Lasix and spironolactone, as well as a beta-blocker and an ACE-inhibitor. . #. Coronary artery disease - The patient underwent cardiac catheterization that showed a left-dominant system, an LAD with diffuse 20-30% lesions throughout and mid-vessel 80% stenosis, and a LCx with mild luminal irregularities and mid-vessel eccentric 60% stenosis. He was admitted for the aspirin desensitization protocol as above, but given his anaphylaxis he is not being discharged on aspirin. It was also suggested that he would need a viability study to assess for antero-apical myocardial viability in preparation for a potential PCI of his mid-LAD lesion, but his TTE showed no wall-motion-abnormalities to suggest ischemia as the reason for his cardiomyopathy, so there was felt to be no indication for viability study at this time. He is being discharged home on Plavix, beta-blocker, and lisinopril. . # ? Apical thrombus - The patient was transferred to [**Hospital1 18**] for evaluation for apical thrombus as the TTE done at OSH was unable to properly assess the apex. He was transferred on an IV heparin gtt, but TTE here showed no evidence of apical thrombus, so this was discontinued. He is being discharged off of anticoagulation. . # COPD - The patient has a history of severe COPD, with mild wheezes on exam on admission. This was significantly worsened after his intubation for anaphylaxis as above, so he was treated with IV Solu-Medrol and then quickly transitioned to Prednisone for a rapid taper. He was otherwise continued on Advair, Spiriva, and nebulizers as needed, and showed significant improvement by discharge. Medications on Admission: HOME MEDICATIONS: - Plavix 75mg PO daily - Nexium 40mg PO daily - Lisinopril 10mg PO daily - Toprol XL 37.5mg PO daily - Salmeterol 50mcg 1puff INH [**Hospital1 **] - Spironolactone 25mg PO daily - Tiotropium 18mcg 1puff INH daily - Docusate 100mg PO daily . . TRANSFER MEDICATIONS: - Plavix 75mg PO daily - Lisinopril 10mg PO daily - Advair Diskus 250/50 1puff INH [**Hospital1 **] - Guaifenesin syrup 200mg QID PRN - SL NTG PRN - Tylenol PRN - Nexium 40mg PO daily - Solu-Medrol 60mg IV daily - Tiotropium 18mcg 1puff INH daily - Spironolactone 25mg PO daily - Toprol XL 37.5mg PO daily - Lasix 20mg IV BID - Xopenex nebs PRN Discharge Medications: 1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation twice a day. Disp:*1 Diskus* Refills:*2* 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Puff Inhalation once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Digoxin 125 mcg Tablet Sig: ([**12-28**]) One-Half Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours. Disp:*1 Inhaler* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Aspirin allergy: anaphylaxis 2. Non-ischemic cardiomyopathy (EF 15%) 3. Coronary artery disease 4. Severe COPD 5. Atrial fibrillation Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were admitted to [**Hospital1 18**] for cardiac catheterization, and you were found to have a blockage in one of the arteries of your heart. Since you are allergic to Aspirin, you were admitted to the CCU for Aspirin desensitization. At the end of the desensitization you had an anaphylactic reaction that required intubation. You were extubated quickly and have done well since. You do have an exacerbation of your COPD (chronic lung disease) and are being treated for it with steroids. You will need to continue to take your medications as prescribed below. You also have atrial fibrillation but were not treated with blood thinners because you were not on this medication at home. You should discuss starting blood thinners (Coumadin) with your cardiologist at home. You should follow-up with your primary care doctor and your cardiologist within 1 week. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You should call your doctor or return to the Emergency Room for any concerning symptoms, including: - chest pain, shortness of breath, wheezing, palpitations - allergic reaction - leg swelling, feeling faint - fevers or chills - any other concerning symptoms. Followup Instructions: You should follow-up with your cardiologist at home within 1 week. You should follow-up wiht your PCP (Dr. [**Last Name (STitle) 77512**] within [**12-28**] weeks. You should discuss blood thinners with your cardiologist for your atrial fibrillation.

41401,42822,4139,4254,4280,49320,4263,V1251,V5861,V1254

Admission Date: [**2132-9-15**] Discharge Date: [**2132-9-21**] Date of Birth: [**2058-2-4**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Ibuprofen Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2132-9-16**] - Coronary artery bypass grafting x3 with left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the posterior descending artery and the marginal branch. History of Present Illness: 74 yo M with known 2vCAD who presents to clinic for evaluation for possible surgical revascularization. Pt was admitted to [**Hospital3 417**] Hospital on [**2131-12-21**] with increasing SOB and chest pain. He was treated for CHF as well as COPD flare. He was then transferred to [**Hospital1 18**] for ASA desensitization and cardiac cath. Pt developed anaphylactic reaction shortly after desensitization procedure complete and required short intubation for respiratory failure. Cath during that admission showed small, nondominant right coronary artery with 80% LAD lesion and 60% lesion in the circumflex. Of note, his chest discomfort has improved dramatically with the initiation of Imdur. Past Medical History: - severe COPD / bronchial asthma - cardiomyopathy w/ EF 30-35%, cause unknown - suspected TIA - h/o recent pneumonia - LBBB on ECG - nephrolithiasis - s/p cataract surgery - s/p hernia repair - chronic systolic heart failure Social History: Lives with his wife, fairly independent until symptomatic w/ SOB. -Tobacco history: x15-20years, Quit smoking: [**2104**] -ETOH: Quit in [**2105**]. -Illicit drugs: None. Family History: Mother had a stroke, Father had CAD. No early CAD. Physical Exam: Physical Exam: VS: T 97 HR:100 Resp:20 O2 sat:96% RA B/P Right: 137/60 Left: 134/56 Ht 64" Wt 59.6K General: Elderly gentleman in no acute distress Skin: Dry [x] intact [x] - well healed abd incision, mesh palpable from prior hernia operation HEENT: PERRLA [x] EOMI [x] anicteric, MMM, OP benign Neck: Supple [x] Full ROM [x] no Lymphadenopathy Chest: diffuse inspiratory and exp wheezing Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact, A&Ox3, MAE, follows commands Pulses: Femoral Right: 2+ Left: 2+ DP Right: decreased Left: decreased PT [**Name (NI) 167**]: decreased Left: decreased Radial Right: 2+ Left: 2+ Carotid Bruit Right: none appreciated Left: none appreciated ++ Femoral Bruits noted bilaterally Pertinent Results: [**2132-9-16**] ECHO Pre-bypass: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Right ventricular chamber size is normal. with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Mild to moderate ([**12-28**]+) mitral regurgitation is seen. There is no pericardial effusion. Post-bypass: The patient is AV-Paced and receiving 0.02 mcg/kg/min of epinephrine post-CPB. The LV - EF is approximately 30%. There is mild mitral regurgitation. All other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings communicated to [**Month/Day (2) 5059**]. [**2132-9-21**] 06:45AM BLOOD WBC-9.8 RBC-3.87* Hgb-11.3* Hct-35.0* MCV-90 MCH-29.2 MCHC-32.3 RDW-14.6 Plt Ct-294 [**2132-9-21**] 06:45AM BLOOD PT-14.4* INR(PT)-1.2* [**2132-9-21**] 06:45AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-139 K-3.9 Cl-99 HCO3-28 AnGap-16 Brief Hospital Course: Mr. [**Known lastname 1001**] was admitted to the [**Hospital1 18**] on [**2132-9-15**] for surgical management of his coronary artery disease. He was taken to the Operating Room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Within the next 24 hours, he awoke neurologically intact and was extubated. Hew as then transferred to the step down unit on postoperative day one. He was gently diuresed towards his preoperative weight. He was started on an ACE-I due to a low ejection fraction. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Chest tubes and pacing wires were removed per cardiac surgery protocol. His narcotics were discontinued due to visual hallucinations and he was using Ultram sparingly for pain control. His visual haalucinations abated. He benefited from vigorous pulmonary therapy. He has an allergy to ASA and therefore was not started on it. He is being anticoagulated with Plavix and Coumadin for a history of DVT. First INR draw to be done Mon [**9-22**] with results to be called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8725**] or faxed to [**Telephone/Fax (1) 8719**] for further instructions for coumadin dosing. Goal INR [**1-29**] for history of DVT. He was deemed safe for discharge home with services on POD#5. Medications on Admission: Plavix 75 mg daily Spiriva 18 mcg daily Lisinopril 10 mg daily Advair 500/50 ipuff [**Hospital1 **] PRN ALbuterol inh ii puffs daily PRN Xopenex neb 1.25mg Spironolactone 25 mg daily Lasix 40mg daily Digoxin 0.125mcg tablet daily Simvastatin 40mg daily Warfarin daily Metoprolol daily Imdur 30 daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:*30 * Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: dosing per the office of Dr. [**Last Name (STitle) **]. . Disp:*30 Tablet(s)* Refills:*2* 11. Outpatient Lab Work INR to be drawn on [**2132-9-22**] with results sent to the offie of Dr. [**Last Name (STitle) **]. Fax number ([**Telephone/Fax (1) 81642**] Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD s/p CABGx3 Aspirin Allergy Severe COPD, Lifelong Asthma Coronary Artery Disease, Ischemic Cardiomyopathy Hypertension Dyslipidemia History of TIA [**2130**] - no residual deficit History of DVT/significant groin hematoma(post-cath) - right lower extremity, on coumadin Left bundle branch block Nephrolithiasis Nasal polyposis Recurrent sinusitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) First INR/Potassium blood draw [**9-22**] with results to be faxed to [**Telephone/Fax (1) 8719**] or called to [**Telephone/Fax (1) 8725**] with instructions for coumadin dosing to be given-Goal INR [**1-29**] 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 81643**] [**Name (STitle) **] in [**1-29**] weeks ([**Telephone/Fax (1) 18658**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 10381**] Please call all providers for appointments. Completed by:[**2132-9-21**]

42823,51882,5849,3371,4280,41400,4148,V4581,V4582,V462,3320,V4986,7802,E8846,25050,36201,V5867,2724,40390,5859,43889,72989,V1582

Admission Date: [**2193-3-31**] Discharge Date: [**2193-4-7**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 6807**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 1968**] is an 88 year-old man with CAD s/p CABG in [**2162**] and PCI at [**Hospital1 2025**] in [**2192**], mild AS, Parkinsons with autonomic instability, CHF with EF 30% with multiple recent admissions for exacerbations ([**3-8**], [**1-31**], [**1-18**]) presents with acute onset dyspnea. . Patient reports acute onset tachypnea and chest pressure after having large BM this afternoon. Of note, he is DNR/DNI and the family has explicit wishes not to escalate care or have invasive procedures, including cardiac catheterization. The patient was previously discharged with palliative care and CHF nurse, with morphine and metolazone as rescue medications (which have not been used to date.) During his previous admission, he experianced significant orthostasis with SBPs in the 70s following potentiation of lasix with 5mg of metolazone. The patient's daughter considered using metolazone this afternoon, but was unable to communicate with his outpatient physcians and therefore elected to bring him to the ED instead. . In ED, initial VS: 96.8 72 160/51 20 and SaO2 70% on RA. Initial exam was notable for tachypnea and wet rales throughout lung fields. Labs notable for Cr of 1.8. EKG showed LBBB, unchanged from previous. CXR c/w pulmonary edema. Patient placed on CPAP, nitro gtt and given 80mg IV lasix with 420cc UOP with SaO2 rising to 100%. He was subsequently admitted to the CCU for further managment. . On initial evaluation in the CCU, he is wearing a BiPAP mask and appears comfortable. He is without addition complaint. . On review of systems, he denies deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: in [**2162**] -PERCUTANEOUS CORONARY INTERVENTIONS: stenting x in [**3-/2192**] 3. OTHER PAST MEDICAL HISTORY: - Parkinson's disease - Diabetic retinopathy - s/p Carotid endarterectomy - systolic CHF - mild Aortic stenosis - L CVA in [**2179**] with residual R sided weakness Social History: Widowed, has 3 adult children, lives with daughter who cares for him at baseline. He has a night aide from 8:00 pm until 8:00 am and goes to adult daycare. Needs walker + assistance for ambulation. He requires assistance with showering. He feeds himself. -Tobacco history: prior use, quit several years ago -ETOH: moderate use, many years ago, currently none -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: VS: T=99.4 BP=133/59 HR=82 RR=20 O2 sat=100% on BiPap 50% FiO2 with PEEP 5 PS 8 GENERAL: WDWN man 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 JVP of 12 cm. Marked kyphosis evedent on exam. CARDIAC: Well healed sternotomy notable on exam. Heart sounds are faint [**2-20**] to CPAP noise, no m/r/g. No thrills or lifts. LUNGS: Significant kyphosis. Crackles noted in BL lower lobes with minimal wheezes and no rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Discharge Exam: Gen: alert, oriented, NAD, joking with examiner HEENT: supple, difficult to assess JVD [**2-20**] upright position CV: RRR, [**Month (only) **] HS, no M/R/G RESP: [**Month (only) **] BS, no obvious crackles. ABD: soft, NT EXTR: no edema NEURO: A/O, weak [**2-20**] hospitalization but no obvious unilateral defects Extremeties: Pulses: palpable. Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Pertinent Results: Admission Labs: [**2193-4-1**] 04:35AM BLOOD WBC-8.5 RBC-3.56* Hgb-10.2* Hct-30.6* MCV-86 MCH-28.7 MCHC-33.4 RDW-16.1* Plt Ct-200 [**2193-4-1**] 04:35AM BLOOD Glucose-136* UreaN-47* Creat-1.6* Na-135 K-4.3 Cl-94* HCO3-31 AnGap-14 [**2193-3-31**] 07:59PM BLOOD Glucose-258* UreaN-49* Creat-1.8* Na-132* K-5.2* Cl-92* HCO3-24 AnGap-21* [**2193-4-1**] 04:35AM BLOOD CK(CPK)-47 [**2193-3-31**] 07:59PM BLOOD CK(CPK)-56 [**2193-4-1**] 04:35AM BLOOD CK-MB-3 cTropnT-0.02* [**2193-3-31**] 07:59PM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-5630* [**2193-4-1**] 04:35AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3 [**2193-3-31**] 07:59PM BLOOD Digoxin-0.3* [**2193-3-31**]: CXR: SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy. The cardiac silhouette is normal in size. Diffuse airspace opacities are noted, more pronounced on the right compared to the left, with vascular indistinctness compatible with moderate pulmonary edema. Bilateral pleural effusions are small. More focal opacities in the retrocardiac region and right lung base may reflect atelectasis. There is no pneumothorax. No acute osseous findings are seen. IMPRESSION: Moderate pulmonary edema with small bilateral pleural effusions and bibasilar atelectasis. Discharge Labs: [**2193-4-6**] 09:15AM BLOOD WBC-6.6 RBC-4.09* Hgb-11.5* Hct-34.9* MCV-86 MCH-28.1 MCHC-32.9 RDW-15.7* Plt Ct-261 [**2193-4-6**] 09:15AM BLOOD Glucose-168* UreaN-67* Creat-1.8* Na-135 K-4.0 Cl-89* HCO3-33* AnGap-17 [**2193-4-5**] 06:05AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.7* Brief Hospital Course: Patient is an 88 year-old man with CAD s/p CABG in [**2162**] and PCI at [**Hospital1 2025**] in [**2192**], mild AS, Parkinsons with autonomic instability, CHF with EF 30% with multiple recent admissions for exacerbations ([**3-8**], [**1-31**], [**1-18**]) who presented with acute on chronic systolic CHF. # PUMP: Patient has known brittle choronic systolic congesitive heart failure that has been exacerbated on numerous occasions over the past year. He presented with an acute exacerbation that appears to have been precipitated by the a straining episode while having a bowel movement. It is also possible that more strenous PT over the two days prior to admission contributed to his decompensation by transiently increasing his blood pressure. He had previously been feeling well and was well compensated. He responded well IV lasix and an attempt was made to transition him to lasix po on hospital day 2. However, he did not respond as expected to the oral lasix and he reaccumulated fluid and had to be given lasix 80 mg iv x2 plus a lasix gtt with BiPAP for a few hours for respiratory distress. This episode seemed to be triggered by being moved for nursing care further enforcing how brittle his heart failure is at this point. After recovering from this episode he was then transitioned to po torsemide and was discharged home on 20mg PO torsemide daily with instructions to increase torsemide if worsened SOB at home and PRN metolazone to be taken at home if more SOB. Pt [**Last Name (un) **] been stable for 2 days on current diuretic regimen at time of discharge. He was continued on his home dose of digoxin 0.125mg QOD. # Goals of Care: Due to severity of heart failure and how tenuous patient status appears to be, pt's daughters had multiple conversations with the palliative care service during the hospitalization. Palliative care had been consulted at the request of the palliative service who was aware of the patient. They followed during hospitalization and continued to give recs about care. They are currently working with daughters to develop a plan for possible outpatient hospice. For now, pt going home with palliative care NP home visits planned but not definitive hospice plans yet made. # Respiratory distress: Patient presented with hypoxia, likely in the setting of CHF exacerbation. He was appropriately diuressed in the ED with stabilization of his oxygenation on BiPAP. He was transitioned to nasal cannula on arrival to the CCU. He was continued on 2 L NC prn and patient has 2L home O2 requirment occasionally for comfort and sleep. On hospital day 2, he reaccumulated fluid on po lasix and was on BiPAP for a short time. After response to iv lasix (including lasix gtt), he was transitioned back to face mask and then nasal cannula when sats improved. At time of discharge pt was satting in mid 90s on RA and was comfortable. . # CORONARIES: Patient has known coronary disease s/p CABG and PCI on clopidigrel and ASA daily. He had no evidence of ACS on symptoms or CEs. His EKG was unchaged from 2/[**2193**]. He was continued on clopidigrel 75mg daily, Aspirin 81mg daily, Atrovastatin 20mg daily, Carvidolol 3.125mg [**Hospital1 **]. He was not started on an ACE-inhibitor as it was stopped during the last admission for orthostatic hypotension. . # RHYTHM: LBBB was known from prior admission with no significant change noted on EKG. He was monitored on telemetry with no rhythm changes noted. . # Type 2 diabetes: Well controlled on current regimen. He was continued on NPH 70/30 [**Hospital1 **] with humalog sliding scale. Some alterations were briefly made while pt not eating due to BiPAP but went back to home regimen when diet restarted. Blood sugars ranged from 80-200s on home regimen during hospitalization. . # Chronic renal insuficiency: Creatinine was initially elevated to 1.8 (recent baseline of 1.6). His creatinine came back down to 1.6 on hospital day two and remained stable in the 1.5-1.8 range while in the hospital. Cr was 1.8 on day before discharge. # Parkinson's disease: Stable. He was continued on home carbidopa, levodopa, entacapone, selegiline, home requip XL. Pt was having some groin pain thought [**2-20**] to cramping from Parkinson's and was started on tylenol to help with this while inpt. . Medications on Admission: - Home O2 1-2L continuous O2, pulse dose for portability. - pantoprazole 40 mg Tablet 0.5 tab q 24hrs. - entacapone 200 mg Tablet QID - selegiline HCl 5 mg Capsule [**Hospital1 **] - clopidogrel 75 mg Tablet DAILY - Requip XL 12 mg Tablet Extended Release 24 hr qam - carvedilol 3.125 mg Tablet [**Hospital1 **] - polyethylene glycol 3350 17 gram/dose Powder daily - docusate sodium 100 mg Capsule [**Hospital1 **] - donepezil 5 mg 2 tabs QHS - aspirin 81 mg Tablet daily - atorvastatin 20 mg Tablet QHS - calcium carbonate 200 mg (500 mg) Tablet, [**Hospital1 **] - cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **] - carbidopa-levodopa 25-100 mg Tablet 1.5 Tablets PO QID - Humulin 70/30 18U qam, 11U qpm (prior to dinner) - Lasix 80 mg Tablet daily - morphine 10 mg/5 mL Solution 2.5mg PO prn chest pain - metolazone 2.5 mg Tablet Sig: 0.5 Tablet PO prn SOB - digoxin 125mg QOD Discharge Medications: 1. Home equipment - [**Hospital 485**] hospital bed for CHF- medically necessary for body positioning for shortness of breath - commode - wheelchair - bedside table 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: 0.5 Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Requip XL 12 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO qam (). 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO twice a day. 9. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 16. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Eighteen (18) units Subcutaneous once a day: 11 units at night. 17. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO three times a day as needed for chest pain. 19. metolazone 2.5 mg Tablet Sig: 0.5 Tablet PO once a day as needed for shortness of breath or wheezing. 20. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Can increase to 2 pills twice daily if needed. 22. lactulose 10 gram/15 mL Solution Sig: Ten (10) grams PO twice a day as needed for constipation: Only take if you have not had a BM in [**2-21**] days. . Disp:*30 cups* Refills:*2* 23. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once as needed for shortness of breath or wheezing: Please call your cardiologist before taking this medication. You must be lying down in bed when you take this medication. . Disp:*10 tablets* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Parkinson's syndrome Coronary artery disease Diabetes mellitus type 2 Acute on chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had an acute exacerbation of your congestive heart failure and required diuretics to remove extra fluid. We have adjusted your medicines to minimize a drop in your blood pressure and to try to keep the fluid off. Weigh yourself every morning, call Dr. [**First Name (STitle) 2920**] if weight goes up more than 1 lbs in 1 day or 3 pounds in 3 days. This is very important to prevent episodes of congestive heart failure. You may also be asked to use metolazone or increase the dose of torsemide if additional diuresis is needed at home. Please also follow a low sodium diet. You also have morphine liquid to use at the first sign that you may be having difficulty breathing. Draw up 2.5 cc (a 5 mg dose) and take 1.25cc first (2.5mg). If your breathing does not improve in 10 minutes, you can take an additional 1.25cc. Please call Dr.[**Name (NI) 17793**] office right away if you take any morphine. You have nitroglycerin at home but don't use that unless Dr. [**First Name (STitle) 2920**] or other health provider tells you it is OK to do so. If you use the nitroglycerin, you should be laying in bed at home as your blood pressure may get lower after you take this medication. An appt was made with a PA who works with Dr. [**First Name (STitle) 2920**], please cancel this if you are unable to get there. A palliative care nurse practitioner will visit you at home and help you sort out decisions about further hospitalizations and care at home. . We made the following changes to your medicines: 1. Decrease the torsemide to 20 mg daily. Dr. [**First Name (STitle) 2920**] may tell you to take more if your weight rises or take additional metolazone at home. 2. STOP taking Carvedilol, take metoprolol instead to help your heart pump better. 3. Increase the colace to 200mg twice daily to prevent constipation 4. Increase the miralax to twice daily 5. Start senna one tablet twice daily, you can increase to 2 tablets twice daily if needed. 6. Start lactulose twice daily if all of the above fails to initiate a bowel movement in [**2-21**] days. 7. Nitroglycerin sub-lingual 0.3mg once if short of breath. Please call your cardiologist before using this medication and you must be lying in bed when you take this medication because your blood pressure may fall. Followup Instructions: Dr. [**First Name (STitle) 2920**]: Name: PA [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**] Location: [**Location (un) 2274**] [**University/College **] Address: [**University/College 88277**], [**Numeric Identifier **] Phone: [**Telephone/Fax (1) 72622**] Appointment: Wednesday [**2193-4-10**] 1:30pm

5789,5990,45829,5849,2762,E9452,04104,340,2724,2449,56409,92410,E9179

Admission Date: [**2129-7-4**] Discharge Date: [**2129-7-15**] Date of Birth: [**2069-7-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: weakness Major Surgical or Invasive Procedure: CVL placement History of Present Illness: The patient is a 60 year old female with a history of MS who presents with complaints of weakness. Patient has significant debilitation from her MS, with the use of a wheel chair at baseline. She is followed by Dr. [**Last Name (STitle) **] of neurology at [**Hospital1 18**], but hasn't been seen by her in over 3 years. 6 weeks prior, the patient developed shingles. Since that time, she has felt continued malaise and fatigue. She denies any weight loss, weight gain, fevers, chills, cough, chest pain, or shortness of breath. In the few days prior to presentation, the patient felt a dramatic increase in her fatigue, such that she couldn't transfer from bed to chair. She also felt confused, not recognizing her own kitchen. She denies any headahes, blurred vision, or worsening motor/sensory deficit. She was told by her care taker that her urine may be smelly. She called Dr. [**Last Name (STitle) **], who recommended evaluation in our ED. Of note, she has not noted any blood in her stools, and last scope was 2 years prior. In the ED, initial vs were: T 97.9 P 76 BP 85/50 R 19 O2 sat 99% on 2L NC. The patieng triggered on arrival for hypotention, although all remainin BP in ED was > 100 systolic over a 4.5hr time perior, and SBP on time of transfer was 145/71. With complaints of generalized weakness and foul smelling urine, the patient was given vanc/ceftaz/levo with concern of urosepsis. She was given 3L of NS. The patient was then found to be grossly guaic positive w/ reports of dark stool. She had a negative NG lavage. A FAST u/s was optained and was negative. She was given 40mg IV protonix, had a CVL placed for access, and was admitted to the MICU for further manegment. Past Medical History: Secondary Progressive MS [**First Name (Titles) 49099**] [**Last Name (Titles) 49100**] Rectal discomfort Hypothyroidism Social History: Patient is divorced and lives alone, with the assistance of a care taker. Ex-husband active in routine. Son would be HCP. Does not smoke or drink Family History: No family history of colon cancer or colonic polyps. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [**2129-7-4**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2129-7-4**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2129-7-4**] 05:33PM LACTATE-1.4 [**2129-7-4**] 05:21PM GLUCOSE-122* UREA N-45* CREAT-1.5* SODIUM-142 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [**2129-7-4**] 05:21PM ALT(SGPT)-21 AST(SGOT)-26 CK(CPK)-135 ALK PHOS-101 TOT BILI-0.3 [**2129-7-4**] 05:21PM LIPASE-31 [**2129-7-4**] 05:21PM cTropnT-0.03* [**2129-7-4**] 05:21PM CK-MB-6 [**2129-7-4**] 05:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2129-7-4**] 05:21PM WBC-10.7 RBC-3.27* HGB-10.3* HCT-30.5* MCV-93 MCH-31.7 MCHC-33.9 RDW-13.5 [**2129-7-4**] 05:21PM NEUTS-83.5* LYMPHS-12.1* MONOS-3.6 EOS-0.5 BASOS-0.2 [**2129-7-4**] 05:21PM PLT COUNT-277 [**2129-7-4**] 05:21PM PT-11.9 PTT-24.4 INR(PT)-1.0 Labs during admission: [**2129-7-7**] 04:14AM BLOOD CK-MB-5 cTropnT-0.01 [**2129-7-7**] 04:29PM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-7-8**] 01:10AM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-7-4**] 05:21PM BLOOD ALT-21 AST-26 CK(CPK)-135 AlkPhos-101 TotBili-0.3 [**2129-7-7**] 04:14AM BLOOD CK(CPK)-204* [**2129-7-7**] 04:29PM BLOOD CK(CPK)-140 [**2129-7-8**] 01:10AM BLOOD CK(CPK)-123 [**2129-7-4**] 05:21PM BLOOD cTropnT-0.03* [**2129-7-6**] 02:39AM BLOOD freeCa-1.20 [**2129-7-6**] 02:13AM BLOOD Free T4-1.2 [**2129-7-5**] 04:20AM BLOOD TSH-0.18* [**2129-7-5**] 04:20AM BLOOD calTIBC-280 Ferritn-72 TRF-215 [**2129-7-5**] 10:00AM BLOOD Hapto-173 [**2129-7-4**] 7:50 pm URINE Site: CATHETER **FINAL REPORT [**2129-7-7**]** ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. VIRIDANS STREPTOCOCCI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S Labs on discharge: [**2129-7-13**] 06:10AM BLOOD WBC-7.4 RBC-3.36* Hgb-10.6* Hct-30.8* MCV-92 MCH-31.6 MCHC-34.4 RDW-14.5 Plt Ct-379 [**2129-7-13**] 06:10AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-144 K-4.3 Cl-111* HCO3-24 AnGap-13 [**2129-7-13**] 06:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 STUDIES: CT ABD [**2129-7-5**]: 1. Inflammatory wall thickening in 12 cm loop of proximal transverse colon. Differential diagnosis includes inflammatory, infectious, or ischemic. No focal abscess or fluid collection. Although there are scattered colonic diverticula this does not appear to be the source of this problem. 2. Multiple liver cysts. . CXR [**2129-7-4**]: Overall findings are suggestive of mild/early CHF. Prominence of the left paratracheal stripe in the configuration of aortic arch suggests unfolding. If a dissection is suspected clinically, CT of the chest is warranted. . CXR [**2129-7-12**]: Since [**2129-7-5**], right internal jugular catheter was removed. Lungs are clear. The cardiomediastinal silhouette and hilar contours are normal. There is no pleural effusion. Brief Hospital Course: # [**Year (4 digits) **]: Her [**Year (4 digits) **] was likely due to a combination of urosepsis and tizanidine induced [**Year (4 digits) **]. There was initial concern for GI bleed given strongly guaiac positive BM in ED. However, pt with no further evidence of GI bleed and her lactate was normal. She was treated broadly for infection with Vanc/Zosyn given [**Year (4 digits) **] in setting of T>98 (considered fever in MS patients) and leukocytosis. Urine cultures grew out >100,000 pan-sensitive Enterococcus; also with 10,000-100,000 Strep viridans, and her antibiotics were narrowed to ampicillin. She was also started on on midodrine due to concern for autonomic dysfunction with MS. [**First Name (Titles) **] [**Last Name (Titles) 4246**] and midodrine was discontinued. Her blood cx and c diff were all negative. She was transferred to the medical floor and had episodes of [**Last Name (Titles) **] to the high 70s and low 80s which were responsive to fluid. It was discovered to be tizanidine (in combination with baclofen) induced [**Last Name (Titles) **] and her tizanidine was decreased in dose from 8mg and tapered down to 2mg. She was told not to take tizanidine within 2 hours of your baclofen or within one hour of lisinopril. Outpatient antihypertensives were held and then lisinopril was later restarted at a decreased dose of 5mg daily. Her HCTZ was not restarted prior to discharge. Her amitriptyline dose was decreased as well to prevent [**Last Name (Titles) **]. # GI Bleed: Per report, the patient had a BM in ED that was dark and strongly guaiac positive. That with the combination of [**Last Name (Titles) **] was concerning for significant bleed. Hct on presentation was 30. She reported a prior cscope 2 years prior w/o abnormalities. She had a negative NG lavage. In the ICU her SBP dropped to the 80s and she was transfused 1 unit. Hemolysis labs were negative. She was started on levophed. An A-line was placed. She was continued on IV PPI [**Hospital1 **]. GI was consulted and felt there was no need for emergent scope. Her Hct remained stable for the rest of the admission with no further bloody stools. She did have a with proximal transverse colon thickening that was thought to more consistent with ischemic rather than infectious or inflammatory processs. Initial hematochezia may have been secondary to mild bowel ischemia from [**Hospital1 **] in a pt with low reserve. She should have an outpatient colonoscopy. . # Weakness/confusion: Given her complicated neurologic history, her complaints of muscle weakness and confusion were likely due to both her MS, UTI, and transient [**Hospital1 **]. Her TSH was low but her T4 was normall. Provigil was held and her outpatient neurologist was contact[**Name (NI) **] and agreed. She should follow up with neurology as an outpatient. # MS: Patient was continued on baclofen, amitriptilene, copaxone, keppra, and tizanidine (at a decreased dose as detailed above). She was transiently on midodrine as detailed above. # Renal failure: She initially presented with ARF which was likely hypovolemic in the setting of [**Name (NI) **], UTI, and ?GI. Her creatinine [**Name (NI) 4246**] with transfusion and fluids. # Anion gap acidosis: She had a normal lactate with no evidence of uremia. Her anion gap acidosis was likely secondary to ketosis in setting of NPO status. This improved with IV fluids and diet restarted. # Hypothyroidism: TSH was low but T4 was normal. She was continued on Synthroid. # Hyperlipidemia: Continued Zocor. # Prophylaxis: continued on home famotidine and heparin sc. # Code: Full Code Medications on Admission: Baclofen 20mg qid Simvastatin 20mg daily HCTZ 50mg daily Famotidine 20mg [**Hospital1 **] Levothyroxine 25 mcg daily Lisinopril 10mg daily Provigil 100mg [**Hospital1 **] Tizanidine 8mg TID Colace 100mg ID Amitriptyline 10mg qhs Arginine 500mg daily MVI daily ASA 81mg daily Copaxone 20mg daily Keppra 500mg [**Hospital1 **] Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Glatiramer 20 mg Kit Sig: Twenty (20) mg injection Kit Subcutaneous daily (). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Amitriptyline 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for skin rash/fungal infection. Disp:*1 bottle* Refills:*0* 12. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Provigil 100 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: Urinary tract infection with question of resulting [**Hospital3 **] [**Hospital3 **] likely secondary to drug effect of combination of tizanidine and baclofen . Secondary Diagnosis: Secondary Progressive MS [**First Name (Titles) 49101**] [**Last Name (Titles) 49100**] Rectal discomfort Hypothyroidism Discharge Condition: Stable. Normotensive. Discharge Instructions: You were admitted with a urinary tract infection and decreased blood pressure. In the intensive care unit you required pressors to maintain your blood pressure. On the normal medical floor your blood pressure dropped several times and it responded to IV fluids. We think your blood pressure dropped due to a combination of tizanidine and baclofen. We spaced out these medications and we decreased your dose of tizanidine. You should not take tizanidine within 2 hours of your baclofen. Please do not take your lisinopril within 1 hour of your tizanidine. You were treated for a urinary track infection and you have completed your course of treatment. You also had a decreased hematocrit and we do not know whether you had a bleed in your GI tract but we do know that your hematocrit is stable now. You should have a colonoscopy as an outpatient. Please talk to your primary care doctor about arranging this. . The following medications were started: -miconazole powder for your rash . The following medications were stopped: -hydrochlorothiazide is being temporarily stopped to ensure you do not become hypotensive. Please discuss with your primary care doctor when to restart this. . The following medications were changed in dose: -Lisinopril was decreased to 5mg po daily to ensure you do not become hypotensive. Please discuss with your primary care doctor when to restart this. -amirtiptyline was decreased to 5mg po daily to ensure you do not become hypotensive. -tizanidine was decreased to 2mg po TID -aspirin was decreased to 81mg po daily . Please return to the hospital if you develop fatigue, dizziness, lighteheadedness, pain with urination, blood in your urine, diarrhea, blood in your stool, chest pain, shortness of breath, or any new concerning symptom. Followup Instructions: Appointment #1 MD: Dr [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 6707**] Specialty: Primary Care Date and time: [**7-28**] at 12pm Location: [**Street Address(2) **], [**Location (un) 5110**] Phone number: [**Telephone/Fax (1) 14214**] . Appointment #2 MD: Dr [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] Specialty: Neurology Location: [**Hospital Ward Name 23**] clinical Center Phone number: [**Telephone/Fax (1) 5434**] Scheduler will call you with appointment. Please call the above number if you do not hear by next Tuesday. Completed by:[**2129-10-19**]

25020,5849,42832,4280,2762,5855,40391,3572,2767,2761,25040,25050,25060,V5867,7801,3659,28521,36201,V1581

Admission Date: [**2181-8-6**] Discharge Date: [**2181-8-7**] Date of Birth: [**2128-1-18**] Sex: M Service: MEDICINE Allergies: Penicillins / simvastatin Attending:[**First Name3 (LF) 3326**] Chief Complaint: Hyperglycemia, confusion Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Mr. [**Known lastname **] is a 53 M with a history of type II diabetes on insulin, hypertension, chronic kidney disease, diastolic CHF who presents with malaise and confusion following a barbeque this afternoon. He reports feeling fine in the morning and attending a barbeque where he ate a significant amount of food and drank soda. Afterward, he became confused and reports hearing background noise "like voices on a radio." He reports that he took his QHS insulin last night, however he did not bring his insulin pen with him today to the barbeque. In the ED, initial vs were: T 98.8, HR 82, BP 179/83, RR 16, 100% on RA. His fingerstick on arrival was noted to be critically high and initial labs were notable for glucose > 1200 with anion gap of 15. He received 8 units of regular insulin SQ with improvement after two hours to glucose > 1000. He then received another 8 units SQ regular insulin. He also received 2L of IVF with NS. He was noted to have K elevated to 6.6 and did have some peaking of T waves on EKG, though no QRS widening. Given that he will receive additional insulin, no further intervention was taken to control his K, which came down to 5.0 on repeat BMP. He was transferred to the ICU for further management of hyperglycemia. Vitals on admission were T 97.2, BP 137/56, HR 80, RR 18, O2 sat 100% on RA. On the floor, he arrived on an insulin drip, was awake, alert and cooperative. He denied symptoms, endorsing only hunger and thirst. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Medical History: 1) CKD Grade 5, currently being evaluated for transplant 2) Diabetes. He says he has had this for 23 years and has been on insulin for seven years. He has a history of retinopathy and is status post laser surgery, and has some mild neuropathy. He says his sugars are relatively well controlled. 3) Hypertension. He has had this about five years. 4) High cholesterol. 5) History of small CVA in [**2174**]. He said it was characterized by tongue heaviness and he has no residual. 6) History of congestive heart failure requiring admission in [**2181-1-10**]. 7) History of latent TB by PPD that was treated 15 yrs ago and then again he was started on INH in [**2180-10-11**]. He says he has planned to take for six or seven months total at this time. 8) History of right Charcot joint surgery with hardware in place 9) Glaucoma Social History: Social History: Married, lives in [**Location 686**] with his wife and 2 sons, ages 17 and 6 who are both up-to-date on vaccinations. They have no pets. He presently works as a driver for a food-services company. In [**Country 2045**], he was the director of social services programs for the Ministry of Health, and spent a significant amount of time in the Health Department interfacing with numerous clients. Family History: Family History: His family history is significant for HTN secondary to DM; no CAD. Both parents passed away from what he feels were complications from DM. He has had a brother and sister both pass away in [**2174**] from DM related complciations. He has 2 other brothers and 2 other sisters who are alive. Physical Exam: Physical Exam on Admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Exam on Discharge: Pertinent Results: [**2181-8-5**] 11:15PM PLT COUNT-474* [**2181-8-5**] 11:15PM NEUTS-82.9* LYMPHS-10.6* MONOS-3.2 EOS-2.4 BASOS-1.0 [**2181-8-5**] 11:15PM WBC-11.7* RBC-3.26* HGB-9.4* HCT-29.5* MCV-91# MCH-28.9 MCHC-31.9 RDW-14.8 [**2181-8-5**] 11:15PM CK-MB-3 cTropnT-0.06* [**2181-8-5**] 11:15PM CK(CPK)-129 [**2181-8-5**] 11:15PM GLUCOSE-1267* UREA N-76* CREAT-5.3* SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION GAP-22* [**2181-8-5**] 11:20PM GLUCOSE->500 K+-5.7* [**2181-8-5**] 11:15PM GLUCOSE-1267* UREA N-76* CREAT-5.3* SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION GAP-22* [**2181-8-5**] 11:20PM GLUCOSE->500 K+-5.7* [**2181-8-5**] 11:30PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2181-8-5**] 11:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2181-8-5**] 11:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2181-8-6**] 01:50AM GLUCOSE-1004* UREA N-76* CREAT-5.0* SODIUM-120* POTASSIUM-5.0 CHLORIDE-85* TOTAL CO2-21* ANION GAP-19 [**2181-8-6**] 06:12AM PLT COUNT-505* [**2181-8-6**] 06:12AM WBC-12.1* RBC-3.28* HGB-9.6* HCT-26.6* MCV-81*# MCH-29.3 MCHC-36.1*# RDW-14.1 [**2181-8-6**] 09:57AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2181-8-7**] 04:00AM BLOOD Glucose-218* UreaN-64* Creat-4.5* Na-132* K-3.9 Cl-101 HCO3-20* AnGap-15 [**2181-8-5**] CXR UPRIGHT FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart size is normal. The hilar and mediastinal contours are within normal limits. The central pulmonary vessels are prominent, however, there is no overt edema. Mild bronchial wall thickening appears chronic. There is no pneumothorax, focal consolidation, or pleural effusion. IMPRESSION: No acute intrathoracic process. [**2181-8-5**] EKG Normal sinus rhythm. Marked peaking of T waves in leads V2-V4. No other diagnostic abnormality. Compared to the previous tracing of [**2181-1-31**] peaked T waves are new. Consider electrolyte abnormality (hyperkalemia). Brief Hospital Course: Hospital Summary: Mr. [**Known lastname **] was admitted [**8-5**] with confusion, hyperglycemia after a barbecue in which he took in a copious amount of food and [**Company 19015**]. He was started on an insulin gtt, progressed to a diabetic diet, SSI w/ Lantus qhs. Hospital course was complicated by, altered mental status and hyperkalemia. #Nonketotic Hyperosmolar Hypoglycemia. Pt. presented with a glucose of 1200 and an anion gap of 16 w/o ketonuria, and patient was started on an insulin gtt. Gap closed to 12 within 4 hours on gtt. On the first day of admission, BS dropped to 200's and the insulin gtt was discontinued. Mr. [**Known lastname **] was seen by the [**Last Name (un) **] diabetes service and they recommended the following changes to his sliding scale diabetic regimen: Range Meal QHS 0-70 juice 70-120 4 0 120-160 6 0 160-200 8 0 200-240 10 2 240-280 12 3 280-320 13 4 320-360 14 5 360-400 16 6 [**Last Name (un) **] also recommended 16 units lantus qhs. By [**8-7**], Mr. [**Known lastname 88088**] glucose had improved to 100's and [**Last Name (un) **] fellow agreed with discharge. Diabetes education is of major concern with Mr. [**Known lastname **] and the nursing staff spent ~30-45 minutes educating Mr. [**Known lastname **] and his wife. #Altered Mental Status. Upon presentation, Mr. [**Known lastname **] was confused and complaining of auditory hallucinations and was found to have waxing and [**Doctor Last Name 688**] of consciousness. Delirium and auditory hallucinations resolved upon normalization of glucose. #Mr. [**Known lastname **] initially experienced hyperkalemia to 6.6 on admission with an EKG demonstrating peaked T waves. Following insulin therapy, hyperkalemia resolved to 4.3 on the day of discharge [**8-7**]. Medications on Admission: Confirmed with PCP [**Name Initial (PRE) **] - 10mg qd CALCITRIOL - 0.25 mcg qd CALCIUM carbonate 200 mg PO BID CHLORTHALIDONE - 25 mg Tablet qd FUROSEMIDE - 80 mg [**Hospital1 **] INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - per sl sc INSULIN GLARGINE [LANTUS] - 16 units qhs Toprol XL - 200 mg qd Niacin PO daily Fish oil PO daily INH 300 mg PO daily B6 50 mg PO daily Discharge Medications: Confirmed with PCP [**Name Initial (PRE) **] - 10mg qd CALCITRIOL - 0.25 mcg qd CALCIUM carbonate 200 mg PO BID CHLORTHALIDONE - 25 mg Tablet qd FUROSEMIDE - 80 mg [**Hospital1 **] INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - per new sliding scale outlined in brief hospital course. INSULIN GLARGINE [LANTUS] - 16 units qhs Toprol XL - 200 mg qd Niacin PO daily Fish oil PO daily INH 300 mg PO daily B6 50 mg PO daily Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hyperosmolar Nonketotic Hyperglycemic Episode Acute on Chronic Renal Failure (stage 5) Secondary Diagnosis: Hypertension Diabetes Type II (Insulin Dependent) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital with high blood sugar levels. These levels were dangerously high. While you were in the hospital, you were given insulin and intravenous fluids to help control your blood sugars. It is very important to control your blood sugars at home. You should check your blood sugars several times per day. We made adjustments to your insulin sliding scale. Please check your blood sugar before meals and before bed and use the new scale to determine how much Novolog insulin to use. You should continue to take your glargine (Lantus) insulin 16 units before bed. Please take your other medications as prescribed. Please follow up with your primary care doctor as well as the endocrinology specialist as detailed below. Until you see your primary care doctor to review your case, you should not drive as these high blood sugars and confusion pose a serious risk to your health. Please keep a record of your blood sugar readings and bring it to your next appointments with your PCP and endocrinologist. You should also call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 86505**] tomorrow to report your blood sugar readings to make sure that your sugars stay well-controlled. Followup Instructions: We have scheduled the following appointments for you to follow up on your diabetes: Name: [**Last Name (STitle) **],SHANTHY Location: [**Location (un) 2274**] [**Location (un) **], Primary Care Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appt: [**8-16**] at 11am Name: [**Last Name (LF) 88089**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) 2274**]-[**Location (un) **], Endocrinology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 88090**] Appt: [**8-21**] at 10:30am You have the following appointments scheduled at [**Hospital1 18**]: Department: RADIOLOGY When: THURSDAY [**2181-8-23**] at 1:30 PM With: VASCULAR STUDY [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2181-8-23**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

25012,40391,5855,42832,5849,V5867,25062,3572,25052,36201,25042,2720,V1581,4280,V1254,79551,3659

Admission Date: [**2182-7-3**] Discharge Date: [**2182-7-8**] Date of Birth: [**2128-1-18**] Sex: M Service: MEDICINE Allergies: Penicillins / simvastatin Attending:[**First Name3 (LF) 1990**] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 54 year old male with PMH of type II diabetes on insulin(previous presentation for hyperglycemic, hyperosmolar state), hypertension, chronic kidney disease, and diastolic congestive heart failure presenting with hyperglycemia in the setting of not taking his insulin for 4 days. Patient states that he normally take 16 units insulin in the evening, but forgot the last few days. He glucometer broke and he got a new one that he did not know how to use. He says that over the last few days he has felt weak with poor po intake. Also on day prior to admission experienced abdominal pain and then n/v on morning of presentation. Patient denies fevers, cough, chest pain. He does report some nausea. He denies dysuria but does report urinary frequency and thirst. EMS initial blood sugar report was >600. . In the ED, initial vital signs were 98.0 83 165/76 16 100%. Glucose was noted to be >1000. Patient was noted to be drowsy, but arousable to voice. His lungs were clear to auscultation bilaterally. His abdomen was tender diffusely. Potassium was 4.4 with a creatinine of 5.9. Anion gap was noted to be 20. Chest X-ray was performed and showed no acute process. Urinalysis showed no evidence of infection, and no ketones. VBG was performed and showed 7.35/48/58/28 with a lactate of 1.7. Insulin 10 units IV were given and patient was started on an insulin gtt at 7 units per hour. He received 2 liters NS in the ED. Renal was consulted and requested urine electrolytes. . On arrival to the MICU, patient feels improved from presentation but still weak. Past Medical History: 1) CKD Grade 5, currently being evaluated for transplant 2) Diabetes. He says he has had this for 23 years and has been on insulin for several years. He has a history of retinopathy and is status post laser surgery, and has some mild neuropathy. 3) Hypertension. He has had this about five years. 4) High cholesterol. 5) History of small CVA in [**2174**]. He said it was characterized by tongue heaviness and he has no residual. 6) History of congestive heart failure requiring admission in [**2181-1-10**]. 7) History of latent TB by PPD that was treated 15 yrs ago and then again he was started on INH in [**2180-10-11**]. 8) History of right Charcot joint surgery with hardware in place 9) Glaucoma Social History: From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for meals on wheels. Denies tobacco, etoh, illicits. Family History: Family History: His family history is significant for HTN secondary to DM; no CAD. Both parents passed away from what he feels were complications from DM. He has had a brother and sister both pass away in [**2174**] from DM related complciations. He has 2 other brothers and 2 other sisters who are alive. Physical Exam: Physical Exam on Admission: Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation . Pertinent Results: Admission Labs: [**2182-7-3**] 06:00PM BLOOD WBC-14.7* RBC-3.77* Hgb-10.5* Hct-33.8*# MCV-90# MCH-27.8 MCHC-31.0# RDW-14.5 Plt Ct-455* [**2182-7-3**] 06:00PM BLOOD Neuts-92.2* Lymphs-5.0* Monos-2.1 Eos-0.3 Baso-0.4 [**2182-7-3**] 06:00PM BLOOD Glucose-1092* UreaN-68* Creat-5.9*# Na-121* K-4.4 Cl-81* HCO3-20* AnGap-24* [**2182-7-3**] 09:23PM BLOOD CK(CPK)-176 [**2182-7-3**] 09:23PM BLOOD CK-MB-2 cTropnT-0.04* [**2182-7-3**] 09:23PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.7* [**2182-7-3**] 06:35PM BLOOD Osmolal-349* [**2182-7-3**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-58* pCO2-48* pH-7.35 calTCO2-28 Base XS-0 Comment-GREEN [**2182-7-3**] 06:41PM BLOOD Lactate-1.4 . urine [**2182-7-3**] 07:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014 [**2182-7-3**] 07:40PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2182-7-3**] 07:40PM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE Epi-<1 [**2182-7-3**] 08:23PM URINE Hours-RANDOM UreaN-214 Creat-32 Na-30 K-16 Cl-24 [**2182-7-3**] 08:23PM URINE Osmolal-411 . micro: blood culture pending urine culture pending . IMAGING: Radiology Report CHEST (PA & LAT) Study Date of [**2182-7-3**] 7:20 PM IMPRESSION: No acute intrathoracic process . EKG: Sinus rhythm. LVH. TWI in I, II, avL, V4-V6 (new in II, V4-V6) Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 54yo male with PMH of T2DM, CHF, and CKD5 who presents with hyperglycemic, hyperosmolar state. He was admitted to the ICU on an insulin gtt and had correction of blood sugar with resolution of elevated anion gap overnight. He was transferred to the general medical floor. . # Non-ketotic hyperglycemic hyperosmolar state: Patient reports not having taken his insulin in the past 4 days. He experienced general malaise, abdominal pain, n/v and presented with blood sugar in the low 1000's. On admission, he was placed on an insulin drip and had blood sugars reduced to 100's overnight following admission. He receieved IVF resuscitation and D5 as FSBS fell. Lantus was overlapped with the drip and the drip was discontinued. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was obtained and recommended that his out pt insulin regimen be uptitrated to Glargine 30U at night and an insulin sliding scale with humalog. His dinner time sliding scale was made more aggressive due to his persistent elevated glucose levels after dinner. . # Altered mental status: Patient's mental status on admission was reported to be drousy but arousable, however upon reaching the floor mental status was much improved. This is likely explained by the non-ketotic hyperglycemic, hyperosmolar state, but also would consider toxic metabolic encephalopathy from infection given leukocytosis. His hyperglycemia was corrected and mental status remained normal. # Troponin elevation: Patient presented with ECG with TWI and troponin to 0.04 in the setting of CKD-5. Previous labs have shown troponin in the range of 0.03. Three sets of troponins were obtained and each was 0.04. The pt was asymptomatic and this was determined to not be ACS. . # Leukocytosis: Unclear etiology. Stress response vs. underlying infection. CXR clear and rest of infectious workup including UA, Blood and urine cultures were negative. The pt was afebrile during this hospitalization. His WBC trended down without treatment. . #T2DM: Patient has been non-adherent to insulin for four days prior to admission. He has had [**Last Name (un) **] consult on previous similar presentation. Will treat the hyperglycemia as above with additional education and aid of the [**Hospital **] clinic. . #Acute on CKD5: CKD [**3-14**] DM and HTN. Patient has a bump in his creatinine to 5.9 from last known baseline of around 5.0. Pre-renal etiology is most likely considering his kidney function improved with IVF administration. He was followed by renal during this hospitalization who did not recommend any changes to his current regimen. He had no acute indication for dialysis. . #Hypertension: - continued amlodipine - continued metoprolol 200mg daily - continued Lisinopril 20mg daily . #Chronic Diastolic CHF: The pt was not volume overloaded on exam even after volume resuscitation due to hyperglycemia. We continued his ACEi and Beta Blocker but initially held diurectics as pt was severely dehydrated due to hyperglycemia on admission. His diurectics were added back to his regimen at time of discharge. . #TRANSITIONAL: 1. F/U appointments were made with his primary care and nephrology Medications on Admission: AMLODIPINE - 10mg qd CALCITRIOL - 0.25 mcg qd CALCIUM carbonate 200 mg PO BID CHLORTHALIDONE - 25 mg Tablet qd FUROSEMIDE - 80 mg [**Hospital1 **] INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - per new sliding scale outlined in brief hospital course. INSULIN GLARGINE [LANTUS] - 16 units qhs Toprol XL - 200 mg qd Lisinopril 20 mg daily Niacin PO daily Fish oil PO daily Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 4. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. niacin 1,000 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 7. Fish Oil 1,000 mg Capsule Sig: Two (2) Capsule PO once a day. 8. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 9. Humalog 100 unit/mL Solution Subcutaneous Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperosmolar non ketotic hyperglycemia Secondary: Chronic kidney disease Diabetes Hypertension Hyperlipidemia Glaucoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with high blood sugar levels after not taking your insulin for several days. It is very important that you continue to take all of your medications everyday to keep your blood sugar under better control. You were seen by the [**Last Name (un) **] consultants, who approved the recommended insulin changes. The following changes have been made to your medications: CHANGE Insulin dosing; you should take 30 units of glargine every evening, and please see attached new insulin sliding scale DISCONTINUE your FUROSEMIDE and CHLORTHALIDONE; please discuss when to restart this medications with your regular doctors at your follow up appointments (see below for details). Please see below for follow up appointments that have been made on your behalf. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Name8 (MD) **],SHANTHY Location: [**Hospital1 641**] Department: Internal Medicine Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Tuesday [**2182-7-9**] 1:00pm Name: NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 26581**] Location: [**Hospital1 641**] Department: Nephrology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2263**] Appointment: Tuesday [**2182-7-9**] 2:30pm

185,51881,34982,1985,591,1628,5990,5849,514,5119,7994,4275,42731,41401,78097,40390,5859,2724,25000,28522,70703,70722,V5861,V1046,V446,V4986,V667

Admission Date: [**2113-6-4**] Discharge Date: [**2113-6-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8404**] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: central venous catheter placement cardiopulmonary resuscitation endotracheal intubation History of Present Illness: 86 yo M with history of metastatic prostate cancer with bilateral nephrostomy tube and recent diagnosis of malignancy in chest, initially presenting with altered mentatl status, who had an asystolic cardiac arrest in the ED, and is now transferred to MICU post-arrest. . The patient was diagnosed with a UTI 2 days ago, and was started on antibiotics (unclear what antibiotic). He took 2 doses of the antibiotic and presented this a.m. with confusion. He was following commands, but more confused that his baseline, which is A+Ox3. , In the ED, the patient was taken for CT head and CXR, and was noted to be non-responsive after the imaging studies. He was found to be in asystole, and received 2 minutes of CPR. During the resuscitation, he was given atropine 1 mg, epinephrine 1 mg, and amiodarone 300 mg. He was subsequently intubated, receiving etomidate and succinylcholine peri-intubation. He was started on peripheral dopamine, switched to levophed. A central line was placed ED prior to transfer to the MICU. The CXR that was done pre-arrest showed bilateral plerual effusions and interstitial edema. A bedside echo showed no RV strain. FAST scan negative. Only exam finding before code was mild abdominal pain. Vital signs on transfer pulse 59 BP 137/51 RR 18 100%/RA. . In MICU, the patient was initially non-responsive, with only corneal reflexes present. Subsequently, he withdrew to pain in all extremities. Past Medical History: - Metastatic prostate adenocarcinoma to bone with local extension to bladder and rectum also complicated by bilateral hydronephrosis s/p nephrostomy tubes. He has been treated with Casodex, Lupron, and most recently, Ketoconazole. He has declined chemotherapy. - Recently diagnosed extensive intrathoracic malignancy - Coronary artery disease - Atrial fibrillation (previously on coumadin) - Hyperlipidemia - Hypertension - Type 2 Diabetes - Pleural effusion s/p right thoracenteses x 2 in the past month Social History: Mr. [**Known lastname **] has 8 children who live nearby and are involved in his care. Previously worked at [**Hospital1 18**] as a transporter. Reports no smoking, ETOH, or illicits. He is a Jehovah's Witness and notes that his faith plays a central role in his life. Family History: His mother 'may' have had diabetes. Physical Exam: Vitals: T 98.2: BP 164/57: P 79: R 11: Sat: 100% O2: General: Intubated, not on sedation. Non-responsive. HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: Clear ventillated breath sounds bilaterally. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: bilateral nephrostomy tubes in place Ext: warm, well perfused, 1+ bilateral LE edema Neuro: Non-responsive to sternal rub or painful stimuli. Pupils 3 mm and non-reactive. Corneal reflex present bilaterally. Does not move any extremity initially. Subsequently withdrew to pain. Pertinent Results: Admission labs: [**2113-6-4**] 01:30PM BLOOD WBC-11.4* RBC-2.84* Hgb-6.6* Hct-20.3* MCV-72* MCH-23.3* MCHC-32.6 RDW-17.8* Plt Ct-232 [**2113-6-4**] 01:30PM BLOOD Neuts-83* Bands-0 Lymphs-8* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2113-6-4**] 01:30PM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2* [**2113-6-4**] 01:30PM BLOOD Glucose-163* UreaN-42* Creat-1.7* Na-125* K-5.7* Cl-88* HCO3-25 AnGap-18 [**2113-6-4**] 01:30PM BLOOD ALT-12 AST-28 AlkPhos-214* TotBili-0.3 [**2113-6-4**] 01:30PM BLOOD Lipase-27 [**2113-6-4**] 11:44PM BLOOD CK-MB-5 cTropnT-0.11* [**2113-6-4**] 01:30PM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.1 Mg-2.2 . CT head w/o contrast [**2113-6-4**]: 1. No acute intracranial process. 2. Opacification of the left mastoid air cells . Clinical correlation is recommended to assess for mastoiditis. . CXR (portable AP) [**2113-6-4**]: 1. Worsening bilateral pleural effusions. Increased opacity at the lung bases bilaterally may be a combination of pleural effusions and atelectasis. However, underlying pneumonia cannot be excluded. 2. Bilateral hilar lymphadenopathy. Stable right paratracheal mass. 3. Mild pulmonary edema. Brief Hospital Course: 86 yo M with metastatic prostate cancer and recent diagnosis of extensive intrathoracic malignancy, initially presenting with altered mental status, who had asystolic cardiac arrest in the emergency department. The pt arrived to the MICU intubated and on blood pressure support. However given his extensive comorbidity combined with grave prognosis and failure to respond to supportive measures, it was ultimately decided by the family to focus on comfort measures and the patient was terminally extubated and died on [**2113-6-13**]. Please see below for further details by problem. # Goals of care: Per recent OMR notes, the patient elected a hospice approach and was DNR/DNI. However, per family request, this was reversed in the ED and the patient was resuscitated and intubated. After discuss with family, patient was made full code but CPR not indicated. Family meeting on [**6-9**] demonstrated that they were not ready to withdraw life support and were hoping for a miracle. On [**6-11**], the family expressed some desires to not escalate care. On [**6-13**] family meeting, it was decided to withdraw care and focus on comfort. # s/p asystolic cardiac arrest: His initial rhythm was asystole in the ER with underlying etiology unclear. Patient's FAST exam was negative in the ER and blood cultures on admission were positive which suggests septic shock as possible cause of asystole. He was not cooled, and MRI the following day did not show any signs of anoxic brain injury. However, the EEG showed epileptiform activity and keppra was started. He had another episode on [**6-6**] when on pressure support on the vent and turning where is HR decreased, he desatted and his BPs dropped. He responded to atropine, and levophed was restarted. Family meeting established the CPR was not indicated. Neurology used EEG, clinical exam, and somatosensory evoked potentials to monitor the patient's neurologic status. The SSEP were present which did not change the overall poor neurologic status as he was not improving. . # Hypotension: Vital signs were normal on initial presentation but he became hypotensive requiring Levophed for blood pressure support s/p arrest. His hypotension could be related to cardiac stunning in setting of recent arrest but was more likely related to underlying sepsis. Echo was orderd in the ICU which showed focal regional left ventricular systolic dysfunction c/w CAD. Aneurysmal interatrial septum. Moderate pulmonary hypertension with at least moderate tricuspid regurgitation and mildly dilated right ventricle. Very small pericardial effusion. The patient continued to require norepinephrine for blood pressure support. With acute renal failure and poor urine output, and hypervolemia on exam, the patient was transitioned to low dose dopamine gtt with lasix boluses on [**2113-6-8**], which improved his blood pressures and his creatinine 1.8 --> 1.7 with good urine output (100cc/hr X2-3 hours with each bolus). Lasix gtt was started however his Cr rose and this was discontinued. # Respiratory failure: He was intubated in the ER and has been ventilating well on the ventilator. He did have a near arrest on CPAP and required reinitiation of full vent support. The patient was gradually transitioned back from Assist Control to PSV with thoughts that intermittent tachypnea due to central process and some discomfort that responded to Fentanyl 25mcg boluses. He was unable to be weaned from the vent and ultimately terminally extubated. # Altered mental status: Initially likely toxic-metabolic process in setting of medical illness/UTI. CT head was non-focal, and MRI after arrest without signs of hypoxic brain injury. His underlying toxic-metabolic encephalopathy is likely contributing as well. Neurology followed and recommended continuing EEG with somatosensory potential evaluation from [**6-4**] and [**6-7**] respectively. . # Urinary tract infection: U/A consistent with infection. He was broadly covered with vanc/zosyn, and urine culture was sent. Urostomy tubes bilaterally continued to put out purulent fluid although right urostomy tube output was persistently ~half that of left urostomy tube. Both tubes gradually had decreased output . # Bacteremia: Grew strep viridans from BCx. The patient was also CDiff negative. . # Extensive intrathoracic malignancy: Invades mediastinum and encases SVC, brachiocephalic, jugular, esophagus, and all major airways. Mechanical complications of this malignancy could underlie arrest, although echo in ED does not support this, and hypoxemia seems more likely given rapid return of spontaneous circulation. If patient improved, would have considered CT chest. . # Metastatic prostate cancer: Currently not on any treatment. . Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: hold for loose stools. Disp:*60 Tablet(s)* Refills:*0* 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. folic acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:*200 Tablet(s)* Refills:*2* 9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Home Oxygen Home Oxygen 2-3L Nasal Cannula Continuous Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**] Completed by:[**2113-6-21**]

42823,5990,2764,45829,42731,25000,40390,515,V4509,7295,V4581,412,4280,5852,2809,2449,4148,2724,53081,79902,56400,311,V5867,04104

Admission Date: [**2173-1-6**] Discharge Date: [**2173-1-19**] Date of Birth: [**2104-3-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: weakness Major Surgical or Invasive Procedure: PICC line placement DC cardioversion History of Present Illness: Mr. [**Known lastname **] is a 68 yo gentleman with hx CABG, MI x2, of stage IV heart failure, multiple admissions for CHF exacerbation who was transferred for further management of his heart failure. Pt states that most recently he has been in rehab and has been doing well with increased exercise tolerance, until approximately a week ago when he felt weak all over and slowly fell to the ground, no LOC. Since that time, pt states that he has been feeling progressively weak. While he denies worsening SOB, nursing noted labored breathing and low BPs to the 80s systolic for the last two days. Pt also denies CP, palpitations or worsening LE edema. He requested transfer to [**Hospital1 18**] for further management of his heart failure. His most recent hospitalization was in [**12-8**] for SOB. At that time, pressures were in the 80s/90s and pt was satting 89-95% on RA. He was treated with diuresis and ciprofloxacin for a UTI. At that time, pt was offered hospice but refused. He was transferred to rehab facility on discharge On review of systems, s/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. S/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 chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, recent syncope or presyncope. Pt does state that he had one episode of syncope over [**Holiday **], but none since. Also states that he has trouble lying flat but cannot articulate why. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: 1. Ischemic CMP, with an EF of 25%. s/p MI at age 37 and 52. s/p CABG in [**2146**] with LIMA to LAD, SVG to D1, SVG to OM, and SVG to PDA. s/p stent placement to the RCA graft in 08/00. 2. s/p BiV. ICD implant in [**5-/2167**] for primary prevention of SCD, in the setting of CAD, low EF, and inducible VT on EPS. Also had prolonged HV and bifascicular block (RBBB/LAHB). 3. Paroxysmal atrial fibrillation, s/p AV node ablation [**10-7**], now pacemaker dependent. At this time, he was taken off of quinidine, started on dofetilide which was subsequently dc'd as the pt reverted into A-fib, and the pt was dc'd on an increased dose of coreg. . 3. OTHER PAST MEDICAL HISTORY: - Diabetes mellitus type 2, on insulin - osteoarthritis - pulmonary fibrosis? - asthma - seasonal allergies - stage II CKD - htn - dyslipidemia - hx of multiple MIs, most recent episode [**8-6**], anginal equivalent is back pain . PSHx: cholecystectomy ([**2164**]), TURP, "benign tumor excision" Social History: He is married, and lives with his wife but has been in rehab for the past month. He is retired, former businessman. He is a former smoker and quit in [**2156**]. He denies alcohol or illicit drug use. Family History: Father with MI at 51, mother with MI age 84, sister with MI age 76, brother with MI age 79. Physical Exam: VS: T=96.0 BP=90/66 HR=79 RR=24 O2 sat=100% 3L GENERAL: chronically ill appear 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 JVD to the earlobe 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. Crackles bilaterally in bases approx 1/3 up the lung fields. ABDOMEN: Soft, NTND, +BS. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ LE edema to the knees. Cool UEs. 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: On Admission: [**2173-1-6**] 06:49PM BLOOD WBC-7.2 RBC-3.97* Hgb-9.2*# Hct-31.9*# MCV-80* MCH-23.3* MCHC-29.0* RDW-18.8* Plt Ct-145* [**2173-1-6**] 06:49PM BLOOD PT-29.9* PTT-50.4* INR(PT)-3.0* [**2173-1-6**] 06:49PM BLOOD Glucose-155* UreaN-54* Creat-1.7* Na-131* K-4.0 Cl-86* HCO3-39* AnGap-10 [**2173-1-6**] 06:49PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3 Iron-19* . On Discharge: [**2173-1-19**] 05:34AM BLOOD WBC-11.7* RBC-4.44* Hgb-10.8* Hct-34.3* MCV-77* MCH-24.3* MCHC-31.4 RDW-19.9* Plt Ct-168 [**2173-1-19**] 05:34AM BLOOD WBC-11.7* RBC-4.44* Hgb-10.8* Hct-34.3* MCV-77* MCH-24.3* MCHC-31.4 RDW-19.9* Plt Ct-168 [**2173-1-19**] 05:34AM BLOOD PT-31.6* PTT-45.2* INR(PT)-3.2* [**2173-1-18**] 08:30PM BLOOD Neuts-81.6* Lymphs-10.8* Monos-6.0 Eos-1.0 Baso-0.7 [**2173-1-18**] 08:30PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Spheroc-OCCASIONAL Ovalocy-1+ Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2173-1-19**] 05:34AM BLOOD Glucose-151* UreaN-45* Creat-1.8* Na-129* K-3.5 Cl-85* HCO3-32 AnGap-16 [**2173-1-19**] 05:34AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.5 . While inpatient: + WBCs and blood in urine, urine cx with ampicillin sensitive enterococci TSH 13 T4 5.3 TIBC 441 Ferritin 54 TRF 339 . [**1-6**] EKG: Ventricular paced rhythm with ventricular couplets. Atrial mechanism is uncertain. Since the previous tracing of [**2172-9-23**] atrial activity/question pacing is more difficult to assess. . [**1-6**] CXR: Mild cardiomegaly is stable. Left transvenous pacemaker leads terminating in standard position in the right atrium, right ventricle and through the coronary sinus. There is haziness of the perihilar regions minimally increased from prior study consistent with chronic CHF. There is no strong evidence of pneumonia. There is no pneumothorax. There is no large pleural effusion. Sternal wires are aligned. . [**2173-1-7**] TTE: The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. . IMPRESSION: Severely dilated and hypokinetic right and left ventricles with moderate to severe mitral and tricupsid regurgitation and mild pulmonary artery systolic hypertension. The inferior and inferior septum are severely hypokinetic akinetic with the other segments being moderately hypokinetic. . Compared with the prior study (images reviewed) of [**2172-7-9**], the function of the lateral wall is probably worse on the current study. The degrees of mitral and tricuspid regurgitation have increased. The estimated pulmonary artery systolic pressures are slightly lower but are probably UNDERestimated given the severity of tricuspid regurgitation. . [**1-12**] CXR Chronic CHF. The patient with biventricular pacing, but no significant interval change since next preceding portable chest examination of [**2173-1-6**]. . [**1-18**] CXR The pacemaker leads terminate in right atrium and right ventricle, unchanged in appearance. Cardiomediastinal silhouette is unchanged including severe cardiomegaly involving mostly the left ventricle. The left ventricular pacer is unchanged as well. The patient is in mild vascular engorgement as well as there is no change in bibasal interstitial abnormalities. Note is made that the lung apices were not included in the field of view. The broken third sternal wire is unchanged as well. Repeated radiograph is highly recommended including the lung apices for precise evaluation of the abnormalities. Brief Hospital Course: Mr. [**Known lastname **] is a 68 yo gentleman with hx CABG, MI x2, of stage IV heart failure, multiple admissions for CHF exacerbation (EF 20%) who was transferred for further management of his heart failure. Resp status initally improved since admission with diuresis, however required ICU transfer for hypotension and respiratory distress concerning for pulmonary edema. He was made DNR/DNI while in the ICU, transferred back to the floor in stable condition with request for no further escalation of care, medical management only. . # PUMP: Most recent ECHO showed LVEF of 15-20%. Mr [**Known lastname **] was treated with aggressive diuresis with a lasix gtt and metolazone while on the floor. Also received acetazolamide for treatment of elevated bicarb in the setting of aggressive diuresis. On transfer to the ICU, Mr [**Known lastname **] was below dry wt of 204 lbs however continued to have evidence of volume overload on exam with elevated JVP, crackles, LE edema. Pt required transfer to the ICU as he was unable to maintain pressures while on aggressive diuresis. He was treated with Milrinone and Lasix gtt while in the CCU with Phenylephrine for pressure support. He was diuresed several liters of fluid and approached euvolemia. Phenylephrine and Milrinone were weaned off, and the pt was switched to PO diuretic regimen of Torsemide 40mg PO daily and aldactone 25mg PO daily. Pt should have daily lytes checked and adequate repletion with potassium. BB and ACEI were held in the setting of hypotension and end of life care. . # CORONARIES: known 3 V disease based on [**6-1**] cardiac cath, however patent LIMA and SMG grafts, low concern for ACS at this time. The patient is on ASA and Plavix. BB, ACEi and statin held for hypotension and end of life care. If patient's pressures increase and his blood pressure tolerates, a low dose BB and/or ACEI would be indicated. . # RHYTHM: hx afib, previously on 2.5 mg/day of warfarin. Pt was cardioverted on previous admission in [**2172-8-29**] and started on warfarin at that time. On arrival, afib was not clearly identified on ECG, but evident on ECHO. He was loaded on amiodarone and cardioverted in attempt to restore atrial kick and improve forward flow. Digoxin was held [**3-2**] to high levels, and Metoprolol was held [**3-2**] to hypotension. The patient was rate controlled on Amiodarone - he will be discharged on a taper: 200mg PO BID x2 weeks (through [**1-25**]), 200mg PO daily thereafter. INR was supratherapeutic, up to 4.6. Warfarin has been discontinued as the patient had supratherapeutic INR on low dose of Warfarin, and the risks outweigh the benefits, as the patient is in the end stage of his heart disease. . # Hypotension: pt runs in the 80s-90s systolic at baseline, likely due to poor systolic function. While in the hospital he was asymptomatic until day 6 of his admission when pressures dropped to <80. At this time he had increasing difficulty with attention, some SOB, no CP, was transferred to the ICU given need for aggressive diuresis given his worsening respiratory status and volume overload. He was started on Phenylephrine for pressure support and weaned off. He maintained SBP >100 after diuresis. . # Hypoxia: improved with diuresis, but new cough developed on the day of transfer to the ICU possibly due to aspiration event. Pt also with ? underlying lung disease (COPD, pulm fibrosis) which may be contributing. The patient was not febrile in the CCU and maintained sats in mid-90s on 2LNC. . # CKD: Pt with history of stage II CKD, creatinine trended up to 2.1 with lasix, but improved to 1.9 prior to discharge. . # Anemia: no evidence of active bleed, however significantly decreased from baseline. Iron studies suggest iron deficiency anemia, pt started on iron supplementation. Haptoglobin WNL, guaiac negative. Crit stable for several days now. . # Leukocytosis: concerning for infection in the setting of amp sensitive enterococci in urine and worsening pulmononary exam. Pt was treated with ampicillin for UTI. Blood cxs were drawn and are NTD. Leukocytosis improved, pt remained afebrile. . # Metabolic alkaloisis: appears to be chronic, most likely due to contraction alkalosis in the setting of aggressive diuresis. Also likely a component of respiratory acidosis from CO2 retention in the setting of ?COPD/pulmonary fibrosis. . # Hypothyroidism: TSH elevated but levothyroxine recently increased as an outpatient. Pt was continued on levothyroxine, will hold on dose adjustment for now given recent increase. Thyroid function tests should be repeated as an outpatient. . # GERD: continue on ranitidine . # Diabetes: stable on Levemir as an outpatient. Sugars stable on glargine and ISS. . # Depressed mood: Pt was seen by SW and palliative care. Pt is aware that this is end-stage of his disease. . # Seasonal allergies: continued on fexofenadine, montelukast . # Constipation: BM uptitrated while on the floor. Regimen decreased in CCU as the patient had 2 episodes of bowel incontinence. Rectal tone was intact and there were no other neurologic deficits. . # GOALS OF CARE: The patient was seen by Social Work and Palliative Care during this hospitalization. It was decided that he would be maintained on the current medical therapy with minor changes if they would be helpful in the short-term. He understands that this is the end-stage of his heart disease. There is to be no escalation of care beyond the medications/treatments outlined in this discharge summary aside from minor changes if they would be helpful in the short-term. While in the ICU, decision was made not to re-hospitalize. The patient is DNR/DNI. If he decompensates on these medications, he should be transferred to hospice for end of life care. Medications on Admission: -Albuterol 0.083% Neb Soln -Ipratropium Bromide Neb -Artificial Tears -Levothyroxine Sodium 75 mcg PO/NG DAILY -Aspirin 325 mg PO/NG DAILY -Metoprolol XL 25 mg q day -Atorvastatin 40 mg PO/NG DAILY -Montelukast Sodium 10 mg PO DAILY -Clopidogrel 75 mg PO/NG DAILY -Mupirocin Cream 2% 1 Appl TP [**Hospital1 **] -Nitroglycerin SL 0.4 mg SL PRN cp -Digoxin 0.125 mg PO/NG DAILY -Potassium Chloride 20 mEq PO TID -Docusate Sodium 200 mg PO HS -Ranitidine 150 mg PO/NG DAILY -Fexofenadine 60 mg PO BID -Senna 2 TAB PO/NG HS -Furosemide 160 mg PO/NG DAILY -Gabapentin 100 mg PO/NG TID -Sodium Chloride Nasal -Tamsulosin 0.4 mg PO HS -TraMADOL (Ultram) 50 mg PO -Levemir 26 units at dinnertime Discharge Medications: 1. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day: Please take 200 mg twice a day through [**1-25**], then take one tab once a day. Disp:*30 Tablet(s)* Refills:*0* 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 sob, wheezing. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dryness. 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed for dry mucosa. 16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 17. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 20. Outpatient Lab Work Please check daily lytes and replete until a stable repletion regimen is determined. 21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 22. Levemir 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous at dinnertime. 23. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 25. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q4 hrs as needed for SOB/CP: Hold for oversedation, RR<12; 5mg should equal 0.25 mL. 26. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for 7 days. Discharge Disposition: Extended Care Facility: Life Care of [**Location (un) 2199**] Discharge Diagnosis: Primary: acute on chronic decompensated congestive heart failure atrial fibrillation microcytic anemia Secondary: coronary artery disease chronic kidney disease Discharge Condition: Activity Status:Out of Bed with assistance to chair or wheelchair Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Discharge Instructions: You were admitted to the hospital with fluid overload from worsening of your heart failure. Several liters of fluid were removed with intravenous Lasix. . You also had an abnormal heart rhythm called atrial fibrillation. Your heart was converted back into a normal rhythm. You are on medications to help control your heart rate and prevent it from going back into the abnormal rhythm. . We made several changes to your medication regimen. We changed the doses of your diuretic medications and stopped some of your nonessential medications including your metoprolol, warfarin, atorvostatin and digoxin. Followup Instructions: Please follow-up with your primary care physician after discharge from rehab.

74782,4010,3051,25000,V643

Admission Date: [**2146-1-6**] Discharge Date: [**2146-1-10**] Date of Birth: [**2095-11-27**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Spinal AVM Major Surgical or Invasive Procedure: [**1-6**]:Angiogram, partial embolization of Spinal AVM History of Present Illness: 50M with elective admission for embolization of spinal AVM Past Medical History: HTN / non-compliant with outpt regime, LE weakness Social History: Resides at home with wife +tobacco use Family History: non-contributory Physical Exam: On Discharge: AOx3, strength full except LE's [**5-1**] with exception of DF left 3-/5, right DF 4-/5. Rectal tone sl. diminished Pertinent Results: Labs on Admission: [**2146-1-6**] 08:00AM BLOOD WBC-5.1 RBC-5.36 Hgb-14.9 Hct-41.8 MCV-78* MCH-27.8 MCHC-35.7* RDW-13.3 Plt Ct-216 [**2146-1-6**] 08:00AM BLOOD PT-13.0 INR(PT)-1.1 [**2146-1-6**] 05:30PM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-143 K-3.1* Cl-111* HCO3-25 AnGap-10 [**2146-1-6**] 05:30PM BLOOD CK(CPK)-72 [**2146-1-6**] 05:30PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.3 Mg-1.9 UricAcd-5.6 [**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**] Radiology Report CARDIAC PERFUSION PERSANTINE Study Date of [**2146-1-10**] [**2146-1-10**] CARDIAC PERFUSION PERSANTINE Clip # [**Clip Number (Radiology) 81531**] Reason: 50YR OLD NEEDS CARDIAC CLEARANCE FOR OR. Final Report RADIOPHARMACEUTICAL DATA: 3.1 mCi Tl-201 Thallous Chloride ([**2146-1-10**]); 19.7 mCi Tc-[**Age over 90 **]m Tetrofosmin Stress ([**2146-1-10**]); HISTORY: 50 year-old male with history of NIDDM and HTN with abnormal ECG prior to surgery. SUMMARY FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. IMAGING METHOD: Resting perfusion images were obtained with Thallium. Tracer was injected approximately 30 minutes prior to obtaining the resting images. Following resting images and two minutes following intravenous dipyridamole, approximately three times the resting dose of Tc-[**Age over 90 **]m tetrofosmin was administered intravenously. Stress images were obtained approximately 30 minutes following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction (LVEF) is 51%. There is no prior for comparison. IMPRESSION: Normal myocardial perfusion study. LVEF is 51%. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **], M.D. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. Approved: MON [**2146-1-10**] 5:17 PM [**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**] Cardiology Report STRESS Study Date of [**2146-1-10**] EXERCISE RESULTS RESTING DATA EKG: SINUS, LAE, LVH WITH ST-T ABNLS, PRWP HEART RATE: 71 BLOOD PRESSURE: 146/108 PROTOCOL / STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 [**1-29**] 0.142MG/ KG/MIN 80 122/86 9760 TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 47 SYMPTOMS: ATYPICAL ST DEPRESSION: NONE INTERPRETATION: This 50 yo NIDDM man with a h/o hypertension was referred to the lab for the evaluation of an abnormal EKG prior to surgery. The patient was infused with 0.142 mg/kg/min of IV Dipyridamole over 4 minutes. Early post-infusion, the patient reported a nonprogressive [**5-6**] central "chest heaviness" which resolved quickly with administration of 125 mg IV Aminophylline. No significant ST segment changes were noted during the infusion or in recovery. The rhythm was sinus with no ectopy. Systolic and diastolic hypertension noted at rest (146/108mmHg) with an appropriate hemodynamic response to the infusion. IMPRESSION: Questionable persantine-induced symptoms with no significant ST segment changes. Atypical symptoms. Nuclear report sent separately. SIGNED: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81532**]TTE (Complete) Done [**2146-1-10**] at 9:53:13 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] J. [**Hospital1 18**] - Division of Neurosurger [**Hospital Unit Name 18400**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2095-11-27**] Age (years): 50 M Hgt (in): 68 BP (mm Hg): 130/90 Wgt (lb): 200 HR (bpm): 70 BSA (m2): 2.05 m2 Indication: Abnormal ECG. Hypertension. Preoperative assessment. Left ventricular function. ICD-9 Codes: 402.90, 427.89 Test Information Date/Time: [**2146-1-10**] at 09:53 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**] Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W058-0:20 Machine: Vivid [**8-3**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.8 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.5 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Stroke Volume: 103 ml/beat Left Ventricle - Cardiac Output: 7.21 L/min Left Ventricle - Cardiac Index: 3.52 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Sinus Level: *3.9 cm <= 3.6 cm Aorta - Arch: *3.6 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 2.7 cm Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 0.83 Mitral Valve - E Wave deceleration time: *303 ms 140-250 ms Findings LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50% decrease during respiration (estimated RA pressure (0-10mmHg). Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). Estimated cardiac index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting or Valsalva inducible LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-10mmHg. There is mild-moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic 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: Mild-moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Dilated thoracic aorta. CLINICAL IMPLICATIONS: Based on [**2144**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2146-1-10**] 11:45 [**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**] Radiology Report SPINAL ART Study Date of [**2146-1-6**] 2:39 PM [**Last Name (LF) 81533**],[**First Name7 (NamePattern1) 177**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 81534**] [**2146-1-6**] SCHED SPINAL ART Clip # [**Clip Number (Radiology) 81535**] Reason: spinal embolization of dural AVM., AVM seen on angiogram tod Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: dural spinal AVM, left lower extremity weakness REASON FOR THIS EXAMINATION: spinal embolization of dural AVM. AVM seen on angiogram today - plan embo today as well Preliminary Report Preliminary reports are not available for viewing. DR. [**First Name11 (Name Pattern1) 58372**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] PreliminaryApproved: MON [**2146-1-10**] 1:02 PM Imaging Lab Brief Hospital Course: Patient was electively admitted on [**1-6**] for embolization of spinal AVM. Post-operatively, in the PACU; he developed T-wave inversion in the setting of hypertension. Cardiology was consulted and made recommendations to start lisinopril, HCTZ, Norvasc. His cardiac work-up/EKG was negative for acute MI. Persantine stress test and Echo were done for cardiac clearance - he was deemed safe for d/c home per cards on medications previously recommended. He agrees with this plan and is to see his PCP [**Name Initial (PRE) 503**]. Dr [**First Name (STitle) **] will call pt tomorrow with a formal neurosurgical plan for the spinal avm. Medications on Admission: Hydralizine, HCTZ Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Spinal AVM Discharge Condition: Neurologically stable Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications 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 ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call [**Telephone/Fax (1) 1669**] to schedule follow-up with Dr. [**First Name (STitle) **] on [**1-11**] in the office. He will call you - if you don't hear from his office by 3pm - call them at the above number. You must also arrange for follow up with your PCP [**Name Initial (PRE) **]/ cardiology at [**Hospital1 69**] in the [**Hospital Ward Name 23**] building call [**Telephone/Fax (1) 70484**] for the managment of your HTN within the next 2 weeks. Completed by:[**2146-1-10**]

0389,51881,48242,78552,9972,45381,2764,99592,4414,53081,2720,7804,60000,2859,72887,56409,V1582,V1204

Admission Date: [**2153-4-13**] Discharge Date: [**2153-4-27**] Date of Birth: [**2068-9-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [**Known lastname 25816**] is an 84 year old patient of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25817**] who presented to the ED today after 2 episodes vomiting and diarrhea. Per his son, he lives independently and was doing well until he woke up this morning with nausea, a single episode of vomiting, a loose nonbloody stool, chills, and general malaise. He called his son who brought him to the [**Name (NI) **]. . In the waiting room, he had an episode of possible syncope. He felt SOB and looked ill, and his family noticed that he seemed confused. He was taken to the core area where he was found to have 80% on RA. EKG showed no ischemic changes. CXR was unremarkable. Labs notable for lactic acidosis with lactate 8. CT torso was done to rule out PE. This showed diffuse ground glass opacities in the lungs and AAA. Vascular Surgery service saw him. . In the ED waiting room, patient had a brief episode of near syncope during which he was feeling SOB and confused and "looked bad." He was tachycardic and tachypneic. O2 Sat was 80% on RA with venous pH 7.1, prompting intubation. Serial EKGs were without ischemic changes. He was noted to be acidotic with lactate 8. CT torso was done to rule out PE. No PE was demonstrated, but there were diffuse ground glass opacities concerning for multifocal pneumonia. He was given vancomycin, zosyn, levofloxacin. CT also showed 3.8 cm infrarenal AAA. Vascular Surgery service saw him in the ED. He was intubated and admitted to the MICU for further managemenet. Past Medical History: GERD Hyperlipidemia Vertigo BPH Social History: Lives with wife. [**Name (NI) **] is her primary care taker as she has suffered a recent stroke. Remote smoking history (30 pkyr). Occasional alcohol use. No history of illicit drug use. Family History: The patient has a mother who had HTN and father who had a stroke. Physical Exam: Admission exam: VS: T 100.0, HR 88, BP 130/70RR 32, O2 100% on PSV with 100% FiO2, [**6-20**] Gen: intubated, sedated, doesn't open eyes to voice or follow commands HEENT: NCAT. Sclera anicteric. EOMI. OP clear, no exudates or ulceration. Neck: JVP flat, RIJ in place CV: RRR, normal S1, S2. No m/r/g. Chest: diffuse crackles. Abd: Soft, NTND. No HSM or tenderness. Ext: no edema Skin: No stasis dermatitis, ulcers, scars. Neuro: PERRL, does not follow commands Pertinent Results: Admission labs: [**2153-4-13**] 01:30PM WBC-3.7* RBC-4.82 HGB-14.4 HCT-45.2 MCV-94 MCH-29.9 MCHC-31.9 RDW-13.0 [**2153-4-13**] 01:30PM NEUTS-47* BANDS-17* LYMPHS-26 MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-3* MYELOS-2* [**2153-4-13**] 01:30PM GLUCOSE-229* UREA N-26* CREAT-1.2 SODIUM-138 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-22* [**2153-4-13**] 01:30PM CALCIUM-9.3 PHOSPHATE-4.6*# MAGNESIUM-2.0 Brief Hospital Course: An 84 year-old man presents with likely sepsis secondary to pneumonia. . # Respiratory failure: patient was intubated in ED for hypoxemic respiratory failure, likely secondary to pneumonia. Due to initial aggressive fluid resuscitation, patient had to be diuresed over several days before extubation. During the course of intubation, patient intermittently hyperventilated regardless of ventilator settings and failed repeated SBTs. Benzodiazepenes and opiates briefly brought down respiratory rate. At one point, family considered making patient CMO and terminal extubation. However, patient was gradually more alert and once asked declined terminal extubation and agreed that if extubation was unsuccessful, re-intubation would be okay. Patient was successfully extubated on [**2153-4-24**] and called out to the medicine floor. Patient remained comfortable on 4L with improved breath sounds. . # MRSA pneumonia: Patient presented with bandemia and leukopenia, fevers, and CT with multilobar infiltrates diagnostic of severe pneumonia. Vancomycin, zosyn, and levofloxacin were started. He initially required levophed to maintain MAP >65. Sputum cultures grew MRSA. Antibiotics were narrowed to vancomycin. Levophed was weaned, and BP remained normal to hypertensive. However, a few days into his MICU course, he was again febrile and clinically tenuous, so antibiotic regimen was broadened back to include cefepime and ciprofloxacin in addition to the IV vancomycin. He finished his course of antibiotics on [**2153-4-24**] and he has been stable on 4L of O2 with gradually improving breath sounds. . # RUE edema/weakness - upper extremity ultrasound showed an age indeterminate midcephalic vein clot with signs of distal flow. Vascular surgery was consulted, recommended no anticoagulation. Warm packs, elevation, and NSAIDS were used. Head CT was performed with no signs of intracranial process to explain weakness. Patient will require physical rehabilitation of right arm. . # Hct drop: Hct fell from 35 on admission to 27, likely secondary to fluids, and was subsequently stable. . # Hyperlipidemia: Atorvastatin was continued. . # AAA: 3 cm, newly discovered. Patient was seen by vascular in ED who recommended repeat US in 6 months . CODE STATUS: Full code Medications on Admission: Aspirin 81 mg daily lipitor 20 mg daily omeprazole 20 mg daily Multivitamin Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day. 3. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) units Injection TID (3 times a day). 8. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 12. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] Discharge Diagnosis: Primary Diagnosis: MRSA pneumonia Secondary Diagnosis: GERD Hyperlipidemia Vertigo BPH 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 to [**Hospital1 69**] for respiratory distress. You were found to have a MRSA pneumonia, and you needed to be admitted to the ICU and required intubation to help with your breathing. You received a course of antibiotics to help clear your infection. You are being transferred to a rehabilitation facility to help you improve your breathing functions. Your medications have changed. Please take only the medications as listed below: Aspirin 81 mg daily Albuterol nebulizer every 6 hours as needed for shortness of breath or wheezing Atorvastatin 20 mg daily Docusate sodium 100 mg twice a day Heparin 5000 units injected under the skin three times a day Ipratropium nebulizer every 6 hours as needed for shortness of breath and wheezing Lansoprazole 30 mg daily Multivitamin 1 tablet daily Ibuprofen 400 mg every 8 hours as needed for pain Tylenol 325-650 mg every 6 hours as needed for pain, fever Quetiapine 25 mg three times a day If you experience chest pain, worsening shortness of breath, or any other worrisome symptoms please return to the emergency room Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] ([**Telephone/Fax (1) 10492**]), after discharge from the pulmonary rehabilitation facility [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

41401,34831,7801,4241,42731,78829,78009,4019,2724,25000,44020,V5867

Admission Date: [**2141-5-10**] Discharge Date: [**2141-5-18**] Date of Birth: [**2070-4-7**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain and dyspnea Major Surgical or Invasive Procedure: [**2141-5-12**] 1. Urgent coronary artery bypass graft x3 -- left internal mammary artery to the diagonal, vein graft to the distal left anterior descending artery, and vein graft to the right coronary artery. 2. Aortic valve replacement with a size 23 mm [**Doctor Last Name **] Magna Ease tissue valve. History of Present Illness: 71 y/o Hispanic male with PMH significant for PVD, DM, and hypertension who presented with fatigue after walking 2 to 3 blocks. Presented with chest discomfort in upper chest unrelated to activity. ECHO on [**2141-4-11**] showed mild concentric LVH with EF of 60-65%, sever AS with mean gradient of 53 mm HG and [**Location (un) 109**] of .63 cm2. Cardiac cath today showed severe AS with mean gradient of 54 mm Hg and [**Location (un) 109**] of .77 cm2, 50% ostial lesion of RCA, 70% D1 and diffuse disease of LCx. Transferred to [**Hospital1 18**] for further evaluation and treatment Past Medical History: Coronary artery disease IDDM hyperlipidemia moderate aortic valve stenosis with a valve area of [**12-4**].2 cm2 psoriasis Social History: The patient lives with his wife in an apartment complex. He is primarly Spanish speaking and denies tobacco, alcohol, or illicit drug use. Family History: N/C Physical Exam: General: NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []x Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade _3-4/6 SEM across precordium_____ Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds + [x] Extremities: Warm [], well-perfused [] Edema [] _____ Varicosities: None [][**12-5**]+ left pretibial edema with stasis dermatitis and amputation of rightsecond and third toes Neuro: Grossly intact [x] Pulses: Femoral Right: +1 Left:+1 DP Right:+1 Left:+1 PT [**Name (NI) 167**]: +1 Left:+1 Radial Right: +1 Left:+2 Carotid Bruit Right:murmur transmits to carotid Left:murmur transmits to carotid Pertinent Results: [**2141-5-11**] Carotid ultrasound Impression: Right ICA less than 40% stenosis. Left ICA less than 40% stenosis . [**2141-5-11**] CTA 1. No evidence of aortic aneurysm. No ascending aortic calcifications with calcifications seen only at the level of the aortic valve. 2. Extensive calcifications of the aortic valve itself consistent with known aortic valve stenosis. Extensive coronary calcifications. 3. Right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. Additional pulmonary nodules mentioned in the body of the report can be reassessed at the same time. [**2141-5-12**] ECHO PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results before surgical incision. POST-BYPASS: Preserved biventricular systolic functin. LVEF 55%. Intact thoracic aorta. The bioprosthetic valve in the native aortic position is well seated and moving well. The peak is 15 and mean is 5 mm of Hg. Trivial MR> . [**2141-5-13**] Head CT Arterial calcifications and signs of chronic sphenoid sinus inflammation, otherwise normal study. CXR [**5-17**]: Intact sternomy wires. Aortic valve prosthesis. Unchanged L hemidiaphragm elevation and atelectasis. [**2141-5-17**] 06:02AM BLOOD WBC-6.4 RBC-3.37* Hgb-9.3* Hct-29.7* MCV-88 MCH-27.7 MCHC-31.4 RDW-13.6 Plt Ct-113* [**2141-5-17**] 06:02AM BLOOD Plt Ct-113* [**2141-5-13**] 02:58AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4* [**2141-5-17**] 06:02AM BLOOD Glucose-148* UreaN-21* Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [**2141-5-12**] 04:30AM BLOOD ALT-117* AST-133* LD(LDH)-310* AlkPhos-130 TotBili-1.0 Brief Hospital Course: Mr. [**Known lastname 13621**] was transferred to the [**Hospital1 18**] on [**2141-5-10**] for surgical management of his aortic valve and coronary artery disease. He was worked-up in the usual preoperative manner. A carotid duplex ultrasound was obtained which showed less then a 40% bilateral internal carotid artery stenosis. A dental consult was obtained which found no contraindication for surgery after obtaining a Panorex x-ray of his teeth. A chest CT scan was performed which showed no significant aortic calcifications but did note a right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. Labs showed that he had elevated liver function studies. On [**2141-5-12**], Mr. [**Known lastname 13621**] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and replacement of his aortic valve with a tissue valve. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours he awoke and was extubated. He was noted to have some confusion, hallucinations and somnolence. A head CT scan was obtained which was negative. The stroke service was consulted who suspected a metabolic or possible infectious etiology to his confusion- no acute infection was detected. All narcotics were discontinued and his pain was managed with Tylenol only. Over the next day, his mental status cleared. Aspirin, beta blocker, statin therapy and diabetic management were continued. Mild confusion noted again on POD#4 and Ultram was discontinued.. Confusion improved. POD#5 he went into rapid a-fib and remained in it for several hours, was started on Amio and returned to SR for 24 hours prior to discharge. He failed first and second voiding trial, urology was consulted and it was determined that he would be discharged to home with the foley in place and will follow up with urology as an outpatient. After second foley placement his urine was noted to be cloudy. A UA C&S was sent and he was started on Cipro. Cultures were negative and Cipro was discontinued. He was noted to have some serosanguinous drainage from his mid sternal pole. He was afebrile, CXR showed intact wires, and WBC was normal. He was sent home on no antibiotics and will return for a wound check on [**5-23**]. He was seen by the physical therapy department and cleared for discharge. By time of discharge on POD #6 he was deemed safe for discharge to home. Follow-up appointments were advised. Medications on Admission: aspirin 81 mg QD, glipizide 5 mg QD, glucophage 1000 mg [**Hospital1 **], lisinopril 5 mg QD, metoprolol extended release 50 mg QD Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/fever RX *acetaminophen 325 mg q 6 hours Disp #*60 Tablet Refills:*0 2. Aspirin EC 81 mg PO DAILY RX *Adult Low Dose Aspirin 81 mg daily Disp #*30 Tablet Refills:*2 3. MetFORMIN (Glucophage) 1000 mg PO BID RX *Glucophage 1,000 mg twice daily Disp #*90 Tablet Refills:*0 4. Simvastatin 20 mg PO DAILY RX *simvastatin 20 mg daily Disp #*60 Tablet Refills:*2 5. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg bedtime Disp #*30 Tablet Refills:*0 6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days Hold for K+ > 4.5 RX *K-Tab 10 mEq twice daily Disp #*28 Tablet Refills:*0 7. Glargine 24 Units Bedtime 8. Amiodarone 400 mg PO BID for 6 more days starting [**5-18**] then 400mg daily for 1 week, then 200mg daily RX *amiodarone 200 mg twice a day Disp #*90 Tablet Refills:*2 9. GlipiZIDE XL 10 mg PO DAILY RX *glipizide 10 mg daily Disp #*60 Tablet Refills:*2 10. Metoprolol Tartrate 50 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *Lopressor 50 mg twice a day Disp #*90 Tablet Refills:*2 11. Furosemide 40 mg PO DAILY RX *furosemide 40 mg daily Disp #*7 Tablet Refills:*0 12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days Hold for K > RX *potassium chloride 20 mEq daily Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic Stenosis Coronary artery disease Diabetes Peripheral [**Location (un) 1106**] disease Hypertension post-op urinary retention Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol only Incisions: Sternal - Healing well, no erythema, no tenderness - minimal serosanginous drainage from mid sternal pole Leg Left - healing well, no erythema or drainage. Edema trace lower extremity edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] Keep your urine catheter in place until you are advised by the VNA or your primary care doctor to remove it. **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: The office will call you and schedule the following appointments your Surgeon: Dr. [**First Name (STitle) **]:[**2141-6-20**] at 2:15p Cardiologist: [**Doctor Last Name 29070**] [**2141-6-9**] at 8:45a Wound check: [**2141-5-23**] 10:45 [**Hospital 159**] Clinic for voiding trial: [**Last Name (LF) 5929**], [**5-25**] at 4:00 PM with [**Name6 (MD) **] Crohn, NP - Shipiro Building [**Location (un) 470**] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-9**] weeks ***Nodular opacity of CT scan seen on this admission - NEEDS FOLLOW UP CT SCAN IN 6 MONTHS*** Scheduled appointments: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2141-6-2**] 9:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2141-6-2**] 10:30 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2141-5-18**]

4241,2761,42731,41401,2724,53081,V153,V1582,V1021

Admission Date: [**2107-4-7**] Discharge Date: [**2107-4-11**] Date of Birth: [**2037-12-25**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] tissue) [**2107-4-7**] History of Present Illness: 69 year old male with no prior cardiac history who was recently treated for squamous cell carcinoma of the left vocal cord. Over the last several months, he has noted dyspnea on exertion and chest pain while walking. He noted this to his oncologist during a follow-up appointment who referred him to Dr. [**Last Name (STitle) 5310**]. An exercise tolerance test was done which was stopped due to near syncope. An echocardiogram showed severe aortic stenosis. In preparation for surgery, a cardiac catheterization was performed which showed mild non-obstuctive coronary artery disease. Currently he denies syncope, pre-syncope, orthopnea, PND and pedal edema. He had prviously never been told he had a heart mumrur. He presents for surgical evaluation. Past Medical History: Aortic Stenosis, s/p Aortic Valve Replacement PMH: mild coronary artery disease - squamous cell carcinoma of the left vocal cord, s/p chemotherapy/radiation - dyslipidemia - GERD Past Surgical History: - Tonsillectomy - Appendectomy - Repair of anal fissure - Feeding tube during chemo/radiation. This has been removed. Social History: Lives with: Wife in [**Name2 (NI) 3320**], MA Contact: Phone # Occupation: Retired Cigarettes: Smoked no [] yes [X] last cigarette 1.5 years ago Hx: [**12-20**] ppd for 50 years. Other Tobacco use: ETOH: < 1 drink/week [] [**1-25**] drinks/week [X] >8 drinks/week [] Illicit drug use Family History: Denies premature coronary artery disease. Mother died of aneurysm at age 74 Physical Exam: Vital Signs sheet entries for [**2107-3-16**]: BP: 152/79. Heart Rate: 73. Resp. Rate: 16. O2 Saturation%: 100. Height: 72" Weight: 170lb General: WDWNI in NAD. Voice is hoarse. Skin: Warm, Dry and intact HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Edentulous Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR [X] III/VI SEM, Nl S1-S2 Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit - Tranmitted murmur vs. bruit Pertinent Results: Intra-op TEE [**2107-4-7**] Conclusions Pre Bypass: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Phenylepherine. Patient is AV paced. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 19-20 mmHg). No aortic regurgitation is seen. Regional and global left ventricular systolic function are normal. Aortic contours intact. All findings discussed with surgeons at the time of the exam. [**2107-4-11**] 04:32AM BLOOD WBC-7.7 RBC-3.60* Hgb-11.2* Hct-33.6* MCV-93 MCH-31.2 MCHC-33.4 RDW-13.1 Plt Ct-190 [**2107-4-10**] 06:00AM BLOOD WBC-9.3 RBC-3.48* Hgb-11.1* Hct-32.5* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 Plt Ct-130* [**2107-4-9**] 04:50AM BLOOD WBC-12.5* RBC-3.38* Hgb-10.6* Hct-31.3* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.2 Plt Ct-107* [**2107-4-11**] 04:32AM BLOOD PT-12.3 INR(PT)-1.1 [**2107-4-8**] 01:45AM BLOOD PT-12.9* PTT-24.2* INR(PT)-1.2* [**2107-4-7**] 12:23PM BLOOD PT-13.5* PTT-26.7 INR(PT)-1.3* [**2107-4-7**] 10:48AM BLOOD PT-16.5* PTT-30.3 INR(PT)-1.6* [**2107-4-11**] 04:32AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-136 K-4.4 Cl-99 HCO3-27 AnGap-14 [**2107-4-10**] 06:00AM BLOOD Na-134 K-4.2 Cl-96 [**2107-4-9**] 04:50AM BLOOD Glucose-150* UreaN-14 Creat-0.8 Na-129* K-4.4 Cl-95* HCO3-27 AnGap-11 [**2107-4-8**] 01:45AM BLOOD Glucose-102* UreaN-7 Creat-0.7 Na-133 K-4.2 Cl-104 HCO3-21* AnGap-12 Brief Hospital Course: The patient was brought to the Operating Room on [**2107-4-7**] where the patient underwent Aortic Valve Replacement with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. 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. He demonstrated a few episodes of brief, rate-controlled atrial fibrillation. He converted to sinus rhythm with amiodarone and was in sinus rhythm at the time of discharge. Anti-coagulation was initiated with coumadin. He has received 3 mg on POD3 and was to receive 5 mg on [**2107-4-11**] for an INR of 1.1. INR to be checked on [**4-12**] by VNA. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1* 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*30 ML(s)* Refills:*0* 8. 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* 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. 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* 11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 400 mg daily x 1 week then 200 mg daily x 1 month. Disp:*80 Tablet(s)* Refills:*0* 12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed for INR goal 2.0-2.5. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Aortic Stenosis, s/p Aortic Valve Replacement PMH: mild coronary artery disease - squamous cell carcinoma of the left vocal cord, s/p chemotherapy/radiation - dyslipidemia - GERD Past Surgical History: - Tonsillectomy - Appendectomy - Repair of anal fissure - Feeding tube during chemo/radiation. This has been removed. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] at [**2107-4-19**] at 10:00a Cardiologist: Dr. [**Last Name (STitle) 5310**] [**2107-5-2**] at 12:00p Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] at [**2107-5-11**] at 1:30p Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 84368**] in [**3-24**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for Atrial fibrillation Goal INR 2.0-2.5 First draw day after discharge [**2107-4-12**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 5310**] [**Telephone/Fax (1) 5315**] Completed by:[**2107-4-11**]

45829,4532,2761,5723,4561,45621,5849,7455,E9394,5712,30393,V1582,5859

Admission Date: [**2201-2-23**] Discharge Date: [**2201-3-3**] Date of Birth: [**2146-10-4**] Sex: M Service: MEDICINE Allergies: OxyContin Attending:[**First Name3 (LF) 4393**] Chief Complaint: Hypotension in setting of ativan administration Major Surgical or Invasive Procedure: Diagnostic Paracentesis History of Present Illness: Mr. [**Known lastname 1124**] is a 54 year old gentlamen with EtOH cirrhosis complicated by ascites and encephalopathy admitted for transient hypotension. The patient was scheduled for outpatient MRI liver today, for which he was prescribed 0.5 mg po ativan taken 1 hour prior to arrival. While awaiting MRI in the waiting room, the patient became dizzy and states that he "couldn't see" and that he "lost focus." At that time, he lay down on the floor and was noted to have an SBP 70s from a baseline SBP 90-100s. He received 1L IVF, and was transferred to the ED for further evaluation. Of note, the patient reports that he last ate at 8 am this morning, with his meal consisting of a bowl of cereal. He does report that he had assocaited nausea, but denies any CP, f/c/s, HA, diaphoresis, palpitations, orthopnea, PND, LE swelling, pain in his legs. He does report chronic diarrhea since starting lactulose. Of note, the patient was admitted to [**Doctor Last Name **] County Hospital ([**Location (un) 50909**] RI) from [**Date range (1) 78183**] for hepatic encephalopathy, during which he was treated with lactulose and had a large volume paracentesis. In addition, the patient underwent RHC on [**2-10**] with [**Doctor First Name **] 21 mmHg. . In the [**Hospital1 18**] ED, initial VS 98.0 74 92/58 16 100%RA. He received 1 L NS, had a negative CXR, with labs notable for hyponatremia to 118 and creatinine 2.9, with only prior creatinine 2.6 on [**1-13**]. He had a diagnostic paracentesis that was negative for SBP, and was admitted to the MICU at the request of Liver. . Currently, the patient is resting comfortably. He does state on ROS that he has had worsening SOB over the past 3 days such that he is unable to walk 20 feet without feeling fatigued. Past Medical History: 1. EtOH cirrhosis complicated by diuretic refractory ascites and encephalopathy currently undergoing transplant eval. Reports having large volume paracentesis Q2Wks since [**11-21**]. 2. EtOH abuse 3. Acute kidney injury. 4. Hypertension. Social History: He denies a history of intravenous drug use. He has a 25- pack year history of tobacco use quitting 15 years ago. He has a history of extensive alcohol use in the past quitting 7 months ago (EtOH - last drink [**6-21**]). He is married and has 2 daughters ages 24 and 28. Family History: A grandparent had alcoholism. His mother died at age 75 and his father at age 77. There is a history of diabetes and colon cancer in the family. Physical Exam: On admission: VS - Temp 97.3F, 100/63 BP , 90HR , 18R , O2-sat 98% RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - Obese, no fluid waves, soft, NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: On admission: [**2201-2-23**] 08:00PM ASCITES GLUCOSE-125 LD(LDH)-37 ALBUMIN-LESS THAN [**2201-2-23**] 08:00PM ASCITES WBC-240* RBC-670* POLYS-10* LYMPHS-55* MONOS-28* EOS-1* MESOTHELI-1* MACROPHAG-5* [**2201-2-23**] 04:20PM GLUCOSE-99 UREA N-77* CREAT-2.9* SODIUM-118* POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-19* ANION GAP-14 [**2201-2-23**] 04:20PM ALT(SGPT)-83* AST(SGOT)-144* LD(LDH)-235 TOT BILI-2.0* [**2201-2-23**] 04:20PM LIPASE-182* [**2201-2-23**] 04:20PM ALBUMIN-1.8* [**2201-2-23**] 04:20PM WBC-8.4 RBC-3.09* HGB-11.1* HCT-31.9* MCV-103* MCH-35.9* MCHC-34.8 RDW-14.0 [**2201-2-23**] 04:20PM PLT COUNT-130* [**2201-2-23**] 04:20PM PLT COUNT-130* [**2201-2-23**] 03:04PM CREAT-2.9* [**2201-2-23**] 03:04PM estGFR-Using this . CXR: FINDINGS: Frontal and lateral views of the chest are obtained. Blunting of the right posterior costophrenic angles raises concern for small pleural effusion. Minimal left mid-to-lower lung atelectasis is noted. No discrete focal consolidation is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Small right pleural effusion. Mild left base atelectasis. . Echo: No atrial septal defect is seen by 2D or color Doppler but a patent foramen ovale is suggested with premature appearance of saline contrast in the left heart with cough. 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. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion around the right atrium. There is a prominent pleural effusion. IMPRESSION: Patent foramen ovale. Loculated pericardial effusion suggestive of a pericardial cyst. . Renal U/S: IMPRESSION: 1. Technically limited study, however patent bilateral main renal arteries and veins. 2. Large amount of ascites. . MRI/MRV: IMPRESSION: Non-obstructive infrarenal partial thrombus in IVC, without extension beyond the bifurcation. . LENIs: Negative for DVT . EGD: Esophagus: Protruding Lesions 1 cords of grade I varices were seen in the gastroesophageal junction. The varices were not bleeding. Stomach: Contents: Food was found in the stomach Mucosa: Diffuse erythema, congestion and mosaic appearance of the mucosa with no bleeding were noted in the stomach. These findings are compatible with portal gastropathy. . On discharge: [**2201-3-3**] 04:50AM BLOOD WBC-5.3 RBC-2.50* Hgb-9.1* Hct-25.9* MCV-104* MCH-36.2* MCHC-35.0 RDW-13.9 Plt Ct-112* [**2201-3-3**] 04:50AM BLOOD PT-17.1* PTT-97.3* INR(PT)-1.5* [**2201-3-3**] 04:50AM BLOOD Glucose-105* UreaN-58* Creat-2.4* Na-132* K-4.0 Cl-100 HCO3-21* AnGap-15 [**2201-3-3**] 04:50AM BLOOD ALT-28 AST-57* AlkPhos-241* TotBili-1.7* [**2201-2-23**] 08:00PM ASCITES WBC-240* RBC-670* Polys-10* Lymphs-55* Monos-28* Eos-1* Mesothe-1* Macroph-5* . MELD = 19 Brief Hospital Course: Mr. [**Known lastname 1124**] is a 54 year old gentleman with EtOH cirrhosis complicated by refractory ascites and encephalopathy admitted for transient hypotension. . # Hypotension: The patient became hypotensive after taking ativan prior to receiving his outpatient MRI for HCC screening. He was briefly dizzy but that felt normal within minutes. He was transported to the ED where he was given NS boluses. He was then admitted to the ICU overnight for observation. Blood pressures remained stable with SBP in the 80s-90s overnight. The patient was then transferred to the floor where orthostatics were neagative. The patient was asymptomatic with systolics in the 80s-90s. . # Hyponatremia: Na was 118 on admission. The patient reported having been drinking lots of fluid because he was told it would help his kidneys. He was placed on salt restriction and 1500 - 2L fluid restriction. His sodium gradually improved and was 132 on the day of discharge. He was taught about the importance of salt-restriction in his diet. Urine osm/Na showed perceived decreased effective circulating volume secondary to cirrhosis. . # Prolonged PR: New 1st degree AVB compared to prior ECG. He was kept briefly on telemetry without events. . # Acute on chronic renal failure: Creatinine was 2.9 on admission; past [**Hospital1 18**] labs revealed a Cr of 2.6 on [**2201-1-13**]. The patient reported having frequent large volume paracenteses without the administration of albumin. He also reported that he thought his creatinine was usually ~2. He was briefly treated for hepatorenal syndrome (with albumin, octreotide, and midodrine) without much improvement in his Creatinine. He had normal urine output. On discharge, Cr was 2.4. He was scheduled to see [**Hospital1 18**] nephrology for consultation for possible renal transplant in addition to liver transplant. . # EtOH Cirrhosis c/b portal hypertension with ascites and recent admission at OSH for hepatic encephalopathy: The patient's transplant evaluation was completed with Echo, MRI, and EGD. EGD showed grade I varices and portal hypertensive gastropathy. He was presented to the transplant committee and was listed for transplant. Unfortunately, the MRI showed an incidental IVC thrombus (see below). He was also scheduled for renal follow-up for possible renal transplant listing. Rifaximin and lactulose were continued on discharge. A diagnostic paracentesis on admission was negative for SBP. . # IVF thrombus: Infrarenal, non-occlusive thrombus was seen on MRI. Occupying 30% vessel. Likely a result of cirrhosis and decreased anticoagulant proteins. Heparin gtt was initially started and was continued for 3 days. Coumadin was started. INR was 1.5 on discharge with plans for repeat INR check in 2 days at PCP [**Name Initial (PRE) 3726**]. Goal INR 2-2.5 with anticoagulation for at least 6 weeks. . # EtOH abuse: Patient reports his last drink was in [**6-21**]. He was scheduled to begin substance relapse prevention program at Kodak shortly after discharge. . Transitional Issues: - sodium monitoring - renal function monitoring, possible listing for renal/liver transplant - anticoagulation for IVC thrombus - substance relapse prevention Medications on Admission: Rifaxamin 550 mg [**Hospital1 **] Dexilant 60 mg daily Ciprofloxacin 250 mg daily Vicodin prn Vitamin D 50,000 units weekly Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain or fever: Do not exceed 2g in 24 hours (caution: as vicodin contains acetaminophen). 2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 7. Dexilant 60 mg Cap, Delayed Rel., Multiphasic Sig: One (1) Cap, Delayed Rel., Multiphasic PO once a day. 8. Vicodin 5-500 mg Tablet Oral 9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: daily at 4pm; requires frequent monitoring of INR; goal INR 2-2.5. Disp:*150 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Please draw INR on [**2201-3-5**] and provide results to Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5456**] (ph: [**Telephone/Fax (1) 90437**]). Patient should have twice weekly INRs with goal 2-2.5. 11. lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO three times a day: Please titrate to [**1-15**] soft bowel movements per day. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension Inferior vena cava thrombus Cirrhosis - alcoholic Acute vs. chronic kidney disease . Secondary: GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted after you became hypotensive prior to your MRI. We completed your liver transplant evaluation and you were presented to the transplant committee. Dr. [**Last Name (STitle) **] would also like for you to see a transplant nephrologist to be evaluated for a possible kidney transplant as your kidney function is abnormal. We incidentally discovered a small thrombus in your inferior vena cava for which you will need to be anticoagulated for at least 6 weeks. Coumadin requires very close monitoring with twice weekly INRs - your goal INR is 2-2.5. . We made the following changes to your medications: We STARTED Coumadin (Warfarin) 5 mg per day; you will need to have your INR checked twice per week - first check this Thursday on [**2201-3-5**]. We CONTINUED lactulose, which you should use to titrate to [**1-15**] soft bowel movements per day . We called Dr.[**Name (NI) 56701**] office and he is willing to manage your coumadin. . Your follow-up information is listed below. Followup Instructions: Department: TRANSPLANT CENTER When: FRIDAY [**2201-3-6**] at 9:20 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ECHO LAB When: FRIDAY [**2201-3-6**] 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 Department: ENDO SUITES When: THURSDAY [**2201-3-19**] at 9:00 AM [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

5712,5856,5724,40391,9974,5601,30393,V1251,V5861,V1582,4580,27669,4168,E8780,E8497,2859,79902,78701

Admission Date: [**2201-5-15**] Discharge Date: [**2201-5-25**] Date of Birth: [**2146-10-4**] Sex: M Service: SURGERY Allergies: OxyContin Attending:[**First Name3 (LF) 668**] Chief Complaint: EtOH cirrhosis, ESRD Major Surgical or Invasive Procedure: liver transplant [**2201-5-16**] History of Present Illness: Mr. [**Known lastname 1124**] is a 54M with EtOH cirrhosis, ESRD not on HD, hx of IVC thrombus on coumadin presenting for liver and kidney transplantation. He was recently hospitalized for worsening renal function, however he continues to not require hemodialysis. The patient states that he continues to have baseline urine output and denies lower extremity swelling. He continues to require frequent therapeutic paracentesis; last performed 2 weeks ago at which time 14L were drained; planned on next tap in 1 week. Pt received 2 units of PRBC this past Tuesday. He states that he feels "great" and denies any specific symptoms or complaints. He denies nausea, vomiting, diarrhea, constipation, hematemesis, or melena. . Past Medical History: - EtOH cirrhosis complicated by diuretic refractory ascites and encephalopathy currently undergoing transplant evaluation. Frequent large volume paracentesis - EtOH abuse - Acute kidney injury recent baseline 3.0, multifactorial HTN and HRS - IVC thrombus, on coumadin Social History: He denies a history of intravenous drug use. He has a 25-pack-year history of tobacco use quitting 15 years ago. He has a history of extensive alcohol use in the past quitting [**6-21**]. He is married and has 2 daughters ages 24 and 28. Family History: A grandparent had alcoholism. His mother died at age 75 and his father at age 77. There is a history of diabetes and colon cancer in the family. Physical Exam: Vitals: 96.8, 68, 121/86, 16, 100% RA Wt: 88.1 kg General: Alert, oriented, no acute distress HEENT: NCAT, minimal scleral icterus, lateral nystagmus noted bilaterally; moderately dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, distended with ascites, bowel sounds present, no rebound tenderness or guarding Ext: warm, no clubbing, cyanosis or edema; eschar noted on R forearm, minimal ecchymosis . Labs: WBC-9.1 RBC-3.77* Hgb-12.7* Hct-37.8* MCV-100* MCH-33.8* MCHC-33.7 RDW-15.2 Plt Ct-162 PT-40.5* PTT-41.8* INR(PT)-4.2* Fibrino-230 ALT-45* AST-93* AlkPhos-419* TotBili-2.8* Albumin-3.6 Calcium-9.3 Phos-4.5 Mg-2.4 . URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 URINE CastHy-29* URINE Mucous-RARE . HEPATITIS HBsAg HBsAb HBcAb HAV Ab [**2201-5-15**] PND PND PND PND [**2201-4-29**] 05:10 NEGATIVE NEGATIVE NEGATIVE [**2201-1-13**] 12:55 NEGATIVE NEGATIVE NEGATIVE POSITIVE . HEPATITIS C SEROLOGY HCV Ab [**2201-5-15**] 16:45 PND [**2201-4-29**] 05:10 NEGATIVE [**2201-1-13**] 12:55 NEGATIVE . HIV SEROLOGY HIV Ab [**2201-5-15**] 16:45 PND [**2201-1-13**] 12:55 NEGATIVE . [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB ([**2201-1-15**]): POSITIVE [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB ([**2201-1-15**]):POSITIVE [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB ([**2201-1-15**]):NEGATIVE . TOXOPLASMA IgG ANTIBODY ([**2201-1-20**]): POSITIVE . CMV IgG ANTIBODY ([**2201-1-16**]): NEGATIVE CMV IgM ANTIBODY ([**2201-1-16**]): NEGATIVE . VARICELLA-ZOSTER IgG SEROLOGY ([**2201-1-16**]): POSITIVE . Rubella IgG/IgM Antibody ([**2201-1-14**]): POSITIVE . RAPID PLASMA REAGIN TEST ([**2201-1-14**]): NONREACTIVE . RUBEOLA ANTIBODY, IgG ([**2201-1-14**]): POSITIVE . EKG: NSR at 87, poor R wave progression; no ST-T changes, no TWI . CXR: pre-lim - Right pleural effusion, similar to [**2201-4-18**]. Trace/minimal left pleural effusion. No PTX or new findings compared to prior imaging. . [**2201-4-19**] Renal US: Echogenic kidneys suggestive of medical renal disease. No calculi or hydronephrosis noted. Splenomegaly with moderate amount of ascites. . [**2201-3-24**] Cardiac stress: No anginal symptoms or ischemic ST segment changes. Appropriate hemodynamic response to the Persantine infusion. Nuclear report sent separately. . [**2201-3-2**] ECHO: No atrial septal defect is seen by 2D or color Doppler but a patent foramen ovale is suggested with premature appearance of saline contrast in the left heart with cough. 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. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion around the right atrium. There is a prominent pleural effusion. IMPRESSION: Patent foramen ovale. Loculated pericardial effusion suggestive of a pericardial cyst. . [**2-27**] MRV ABD/PELVIS: Non-obstructive infrarenal partial thrombus in IVC, without extension beyond the bifurcation. . Pertinent Results: [**2201-5-25**] 05:22AM BLOOD WBC-5.3 RBC-3.17* Hgb-10.1* Hct-29.1* MCV-92 MCH-32.0 MCHC-34.9 RDW-16.2* Plt Ct-176 [**2201-5-25**] 05:22AM BLOOD PT-16.4* PTT-85.3* INR(PT)-1.4* [**2201-5-25**] 05:22AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-137 K-4.2 Cl-105 HCO3-23 AnGap-13 [**2201-5-25**] 05:22AM BLOOD ALT-26 AST-11 AlkPhos-107 TotBili-0.5 [**2201-5-25**] 05:22AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.8 Mg-1.7 [**2201-5-25**] 05:22AM BLOOD tacroFK-7.8 Brief Hospital Course: On [**2201-5-15**], he underwent kidney and liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. He was sent to the SICU for management. Postop duplex of liver and kidney demonstrated patent vasculature, no hydro or biliary ductal dilatation. He was hypotensive on postop day 1 and required IV hydration and blood products. Hct remained stable. LFTs and creatinine improved daily. Urine output was excellent. JP drainage was non-bilious. He developed an ileus. NG remained in place until [**5-22**] when ileus resolved. Diet was slowly advanced and tolerated. Pain medication was switched to oral Dilaudid. Lateral JP drain was removed on [**5-23**] and medial on [**5-25**]. Generalized anasarca improved daily and he only required only Lasix x1. Weight decreased to 85.8 (down 10 kg from admission wt). In fact, he developed orthostatic hypotension. Midodrine was started with improvement. Heparin drip was started for h/o IVC thrombus. A few days later, Coumadin was started a 1mg daily. Dose was increased to 2mg [**5-24**]. On [**5-25**], INR was 1.4. Dose was increased to 3mg and patient was instructed to get PT/INR done as an outpatient on [**5-27**] and [**5-30**]. PT worked with him and recommended home PT. VNA Care of [**Location (un) 4368**] was arranged. He was ambulating with a walker. He tolerated steroid taper to 20mg daily, cellcept [**Hospital1 **] and prograf dosing. Prograf levels increased to 15.2 on [**5-24**]. Dose was held and decreased to 1mg [**Hospital1 **]. He will go to stay at his sister's home in [**Location (un) 50909**] RI with f/u on [**5-28**]. Of note, a TTE was done when he was in SICU for hypotension. Mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the anterior septum and anterior walls, distal septum were noted with EF of 50%. Cardiology recommended ASA, BB and statin. Given orthostatic hypotension, metoprolol was stopped on [**5-22**]. ASA was on hold as patient was switched from IV heparin to Lovenox on day of discharge to home. A f/u cardiology appointment was scheduled for [**5-29**]. He will also f/u with hematology given h/o IVC thrombus. He was found to have 60% activity of antithrombin III. Recommendation was to continue anticoagulation and follow-up with Dr. [**Last Name (STitle) 6944**] to determine the optimal length of anticoagulation. See note from [**5-20**]. He was discharged to home in stable condition. Medications on Admission: CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth once a day DEXLANSOPRAZOLE [DEXILANT] - (Prescribed by Other Provider) - 60 mg Cap, Delayed Rel., Multiphasic - 1 Cap(s) by mouth daily ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s) by mouth qweek HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth as needed LACTULOSE - (Prescribed upon d/c) - 10 gram/15 mL Solution - 15-30 Solution(s) by mouth three times a day Please titrate to [**1-15**] soft bowel movements per day MIDODRINE - 7.5 mg by mouth three times a day RIFAXIMIN [XIFAXAN] - 550 mg by mouth twice a day WARFARIN - 5mg by mouth daily Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. sulfamethoxazole-trimethoprim 400-80 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. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (TU). 7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 8. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 10. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. Outpatient Lab Work Wednesday [**5-27**] then Every [**Month/Year (2) 766**] and Thursday 12. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day: Folow transplant clinic taper. 13. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 14. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous [**Hospital1 **] (2 times a day). 15. Outpatient Lab Work Wednesday [**5-27**] and Saturday [**5-30**] for stat PT/INR with results called to [**Telephone/Fax (1) 673**] attn: Transplant Coordinator 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: VNA Care [**Location (un) 511**] Discharge Diagnosis: ETOH cirrhosis s/p liver and kidney transplant [**2201-5-16**] ileus orthostatic hypotension h/o IVC thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the following: fever, chills, nausea, vomiting, jaundice, inability to take any of your medications, increased abdominal distension or pain, incision redness/bleeding/drainage, decreased urine output, weight gain of 3 pounds in a day or any concerns You will need to have blood drawn on Wednesday [**5-27**] at Quest then every [**Month/Year (2) 766**] and Thursday for labs No heavy lifting No driving if taking narcotic pain medications You may shower, no tub baths or swimming Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [**2201-5-28**] at 2:10 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT SOCIAL WORK When: THURSDAY [**2201-5-28**] at 3:00 PM With: TRANSPLANT SOCIAL WORKER [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: FRIDAY [**2201-5-29**] at 9:40 AM 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: TRANSPLANT CENTER When: [**Hospital Ward Name **] [**2201-6-8**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: Hematology When: WEDNESDAY [**2201-7-15**] at 2:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 6946**] Completed by:[**2201-5-25**]

25013,V5867,V1581,311,2720

Admission Date: [**2181-11-16**] Discharge Date: [**2181-11-18**] Date of Birth: [**2161-1-2**] Sex: F Service: MEDICINE Allergies: Radioactive Diagnostics, General Classif Attending:[**First Name3 (LF) 3853**] Chief Complaint: "Nausea." Major Surgical or Invasive Procedure: None History of Present Illness: 20F with DMI previously on insulin pump but now on HISS alone due to dislike of pump who is now admitted to [**Hospital Unit Name 153**] with DKA. She presented to ED due to nausea in the setting of being unable to find her insulin this am. Patient reports poorly controlled blood sugars 200s-400s since [**2181-5-9**] with no recent significant change who last took her insulin at her friend's house last night around 11pm per her usual sliding scale. This am, she awoke at home around 11am with slight nausea and could not find her insulin. She subsequently developed abdominal pain and had her father bring her to [**Name (NI) **]. She reports multiple recent stressors discussed below but denies sick contacts, CP, dysuria, urinary frequency, vomiting, cough, fever, chills, change in weight or recent illnesses. Her symptoms of nausea and abdominal pain were consistent with her previous DKA episodes. Last DKA was [**2181-5-9**] which occurred in the setting of her getting upset with her mother and breaking all of her insulin vials and refusing to take her insulin. In the ED inital vitals were, 98.2 84 127/82 16 100% RA. Labs remarkable for Glucose 600s, AG 23 and + urine ketones. UA otherwise negative and urine and blood cultures were sent. She was given 5 units of IV insulin and started on 5 unit/hr insulin drip which was decreased to 2 units/hr. She received 2L NS and 40 mEq of KCl in 1L of NS and was trasnferred to [**Hospital Unit Name 153**] On arrival to the ICU, she reports feeling much better and back to baseline. Denies further nausea or abdominal pain. FSBS 185. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Type I DM - diagnosed at age 3, last episode of DKA 6/[**2180**]. She has been prescribed insulin pump but doesn't like to use and has only been consistently using HISS at home - Hypercholesterolemia - History of seizures, none since [**2172**] and off meds - Depression and h/o cutting Social History: Works at [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] now living with her brother and his girlfriend in [**Name (NI) 392**] since lease recently up on Section 8 housing in [**Location (un) **] so had to move 1 week ago. Denies cigarettes or ETOH but used to smoke occasionally in past. Reports occasional marijuana use. recent stess related to being witness to her friend's stabbing. Sister lives in [**Name (NI) 108**] and was recently diagnosed with breast cancer. Family History: Grandmother had diabetes. Physical Exam: Admission Exam: Vitals: Afebrile HR 91 BP 107/72 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge exam VS: Tm: 98.3 Tc: 97.9 BP:120/86 HR:79 RR:18 O2 Sats 100% on RA . pain: none GEN: AAOX3 in NAD HEENT: CN 2-12 grossly intact, MMM NECK: no lad CV: RRR, no RMG RESP: CTAB, no WRR ABD: abdomen flat, active BS, no TTP, no HSM EXTR: WWP, 5/5 strength, sensation, pulses intact and equal DERM: no obvious rashes neuro: CN intact, strength, sensation wnl PSYCH: mood and affect wnl Pertinent Results: Admission labs: [**2181-11-16**] 03:00PM BLOOD WBC-11.6* RBC-4.46 Hgb-14.6 Hct-45.4 MCV-102*# MCH-32.7* MCHC-32.1 RDW-12.5 Plt Ct-379 [**2181-11-16**] 03:00PM BLOOD Neuts-82.0* Lymphs-14.8* Monos-2.4 Eos-0.5 Baso-0.4 [**2181-11-16**] 03:00PM BLOOD Plt Ct-379 [**2181-11-16**] 03:00PM BLOOD Glucose-625* UreaN-19 Creat-0.8 Na-127* K-5.0 Cl-85* HCO3-19* AnGap-28* [**2181-11-16**] 06:21PM BLOOD CK(CPK)-305* [**2181-11-16**] 06:21PM BLOOD CK-MB-2 cTropnT-<0.01 [**2181-11-17**] 05:51AM BLOOD CK-MB-1 cTropnT-<0.01 [**2181-11-16**] 06:21PM BLOOD Calcium-8.5 Phos-2.1* Mg-1.6 [**2181-11-16**] 06:21PM BLOOD VitB12-696 Folate-16.8 [**2181-11-16**] 03:00PM BLOOD %HbA1c-11.5* eAG-283* Brief Hospital Course: 20 y/o F with DMI presenting with DKA likely secondary to missed medications. # DKA- Patient has Type 1 DM and reports poorly controlled DM recently on HISS alone. HbA1C 11.5. She presents with symptoms of nausea and abdominal pain. DKA with AG>20 and ketonuria. DKA likely secondary to missed insulin on morning of admission. She denies symptoms of infection but has mildly elevated WBC 11.6 which resolved without antibiotics. She currently denies CP and cardiac enzymes negative. AG resolved with fluids and insulin drip, and patient transitioned to insulin SS + Lantus 15 units with [**Last Name (un) **] input. The patient was sent out on lantus 25 units QHS and humalog sliding scale. The patient will following up with a female provider at [**Name9 (PRE) **] in addition to her PCP. [**Name10 (NameIs) **] has means to call and make follow up appointments and can afford her medications. The patient said she had test strips and a glucometer at home and she was also written for insulin syringes. . # Social stress - Pt with h/o depression and multiple recent stressors but not depressed currently. Poorly controlled DM suggests poor insight into chronic disease process. SW consulted for poor coping and insight. . Transitional Issues: -Follow up at [**Hospital1 **] in [**12-10**] weeks -Follow up with PCP [**Last Name (NamePattern4) **] [**12-10**] weeks Medications on Admission: Humalog insulin sliding scale; not on any long acting medications. States she was told she should take lantus but was not given pescription last admission so has not been on Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime: Please take this dose of lantus unless otherwise instructed by a physician. [**Name Initial (NameIs) **]:*6 bottles (QS for 1 month supply)* Refills:*2* 2. Humalog 100 unit/mL Solution Sig: Variable per sliding scale Subcutaneous AC and HS: please dose humalog per sliding scale. [**Name Initial (NameIs) **]:*6 vials (QS for 1 month supply)* Refills:*2* 3. syringe (disposable) 1 mL Syringe Sig: One (1) syringe Miscellaneous fives times a day as needed for for injection of insulin. [**Name Initial (NameIs) **]:*120 syringes* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: diabetic ketoacidosis secondary to insulin non-compliance Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] with nausea. Your blood sugars were found to be very high and had laboratory values consistent with diabetic ketoacidosis. This was likely because you were not taking enough insulin at home. You were intially treated in the ICU and then transfered to the floor. You will be sent home on long acting insulin and short acting insulin. You should follow up closely with your PCP and [**Name9 (PRE) **]. Medication changes: latus 25 units before bedtime Humalog sliding scale (please see attached sheet) Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-80 mg/dL 3 Units 3 Units 3 Units 0 Units 81-130 mg/dL 5 Units 5 Units 5 Units 0 Units 131-180 mg/dL 6 Units 6 Units 6 Units 0 Units 181-230 mg/dL 7 Units 7 Units 7 Units 0 Units 231-280 mg/dL 8 Units 8 Units 8 Units 2 Units 281-330 mg/dL 9 Units 9 Units 9 Units 3 Units 331-380 mg/dL 10 Units 10 Units 10 Units 4 Units 381-400 mg/dL 12 Units 12 Units 12 Units 5 Units Followup Instructions: 1) Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73829**] within [**12-10**] weeks of discharge. Please call to make this appointment on Monday. Phone number is [**Telephone/Fax (1) 50305**] 2) Please follow up at [**Hospital6 **] in [**12-10**] weeks. You requested a women provider. [**Name10 (NameIs) **] suggestions are Dr. [**First Name8 (NamePattern2) 3692**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **]. Please call [**Hospital1 **] at [**Telephone/Fax (1) 3402**] to make an appointment Monday morning -You need to see one of the two physicians within a week of your discharge from the hospital

99859,56722,486,11289,5119,27900,75683,04104,E8786,V552,49390

Admission Date: [**2110-2-28**] Discharge Date: [**2110-3-6**] Date of Birth: [**2092-3-18**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: wound infection, intra-abdominal abscess Major Surgical or Invasive Procedure: CT guided drainage of abscess with pigtail drain placement History of Present Illness: 17 M s/p appendectomy at [**Hospital3 2737**] on [**2-17**] for perforated appendicitis. The patient recovered well and had an initial improvement in his symptoms and leukocytosis. On POD2 the patient started experiencing worsening abdominal pain, nausea and vomiting and was transferred to the OSH ICU where a CT was obtained showing postoperative changes and continued inflammation but no clear abscess. He was taken to the operating room for a exploratory laporotomy on [**2-21**] where, per report, an enterotomy or perforation was identified in the terminal ileum. An ileal resection was performed and an end ileostomy was placed, and the patient was taken to the ICU for further recovery. Following the procedure the patient continued to have abdominal pain and increasing leukocytosis up to [**Numeric Identifier 3301**]. His midline laparotomy wound was opened [**1-22**] wound infection. The patient had been receiving Zosyn and Flagyl and was then switched to Imipenem per ID recommendation. A repeat CT was obtained on [**2-27**] and demonstrated multiple fluid collections and the patient was transferred to [**Hospital1 18**] for further management. Past Medical History: PMH: Hypogammaglobulinemia PSH: Appendectomy [**2110-2-17**], ex-lap LOA, end ileostomy [**2110-2-21**] Social History: senior in high school, no ETOH, tobacco or drugs, active football player Family History: no immunodeficiencies, 2 siblings - one with ? diagnosis of SLE, other healthy Physical Exam: On Discharge: AVSS GEN: resting comfortably, NAD CV: RRR Lungs: CTAB ABD: Open midline abdominal wound with wet/dry dressing in place. Appropriately tender around the wound. Ostomy pink/viable. EXT: warm, well perfused Pertinent Results: [**2110-2-28**] 04:05AM BLOOD WBC-18.0* RBC-3.82* Hgb-11.3* Hct-34.3* MCV-90 MCH-29.7 MCHC-33.0 RDW-13.9 Plt Ct-543* [**2110-3-4**] 06:35AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.6* Hct-32.2* MCV-90 MCH-29.6 MCHC-33.0 RDW-13.9 Plt Ct-642* [**2110-2-28**] 04:05AM BLOOD Glucose-106 UreaN-11 Creat-0.9 Na-137 K-5.1 Cl-101 HCO3-27 AnGap-14 [**2110-3-4**] 06:35AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-139 K-4.8 Cl-102 HCO3-28 AnGap-14 CT abd/pel ([**3-5**]): IMPRESSION: 1. Two discrete collections are again visualized throughout the abdomen and pelvis. The previously aspirated, but not drained collection along the right paracolic gutter appears relatively unchanged with a focus of air consistent with prior instrumentation. The right lower quadrant collection with extension to pelvis which was aspirated and had a drain placed appears smaller with resolution of the lateral and superficial portion of the collection anterior to the right psoas muscle. 2. Moderate left pleural effusion, which is increased in size in comparison to prior study with adjacent atelectasis. Small right pleural effusion with adjacent atelectasis. Brief Hospital Course: Mr. [**Known lastname 89930**] was transferred to our trauma surgical intensive care unit from [**Hospital3 **] early in the AM of [**2110-2-28**]. He was seen by Dr [**Last Name (STitle) **] and his team, and based on the fluid collections seen on OSH CT scan, he was sent to IR for percutaneous drainage. The IR team aspirated the right paracolic gutter collection and left a drain in the pelvic collection. This fluid was sent for culture. The patient was initially tachycardic upon admission to the ICU, but was otherwise hemodynamically stable. He was transferred to the floor on HD4 in good condition. Neuro: His pain was initially well controlled on intermittent IV dilaudid. When tolerating po intake, the patient was switched to vicodin, which was well tolerated. CV: He arrived tachycardic with stable blood pressure. This improved quickly during his hospital stay, and he had no other issues. Resp: He had significant oxygen demand upon arrival and CXR showed bilateral effusions and atelectasis. Sputum cultures were drawn that were insufficient. Patient was concurrently being treated with vancomycin and meropenem for his intra-abdominal abscesses, which was determined to be sufficient for presumed pneumonia as well. The patient was also given intermittent lasix to improve his respiratory status as his lungs looked fluid overloaded. These effusions were followed with serial CXRs and improved throughout his stay. He was weaned off of oxygen on the floor and his breathing remained comfortable. GI/GU/FEN: The patient was initially NPO/IVF upon admission. His diet was advanced to regular by HD3 and this was well tolerated. Ostomy output was nearly 2 liters the first 24 hours of admission. The output remained high the first few days of his hospital stay, but then decreased on its own to an appropriate level without medical intervention. His electrolytes and fluid status were closely monitored and patient was repleted as needed. His open abdominal wound was treated with wet/dry dressing changes TID, and showed continued healing and improvement during his stay. ID: He was seen by our ID team upon arrival who recommended switching imipenem to meropenem. He was also started on vancomycin at arrival for presumed PNA. His abdominal wound was packed with wet to dry dressings. Abdominal fluid collections showed vanc sensitive enterococcus and [**Female First Name (un) **], so fluconazole was added as well. The patient was kept on this antibiotic regimen during his hospital stay. PICC line was placed on [**3-3**] to continue atbx as an outpatient. Repeat CT scan was performed on [**3-5**] that showed persistent abscesses in the pelvis and R pericolic gutter. However, after patient's drain was adequately flushed, the drain began to put out purulent material. Radiology felt the drain was in good position and did not need to be re-adjusted. The patient was sent home on meropenem, vancomycin, and fluconazole per ID's recommendations. Prophylaxis: Patient was started on SQH and encouraged to ambulate often. Dispo: Patient received ostomy teaching, Picc line teaching, and wound care teaching. He understood all of this and agreed with the plan. He was given discharge instructions and told to keep all follow up appointments as scheduled. Medications on Admission: zyrtec Discharge Medications: 1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. vancomycin 500 mg Recon Soln Sig: 1.5g Recon Solns Intravenous Q 8H (Every 8 Hours): Through [**3-8**]. Disp:*12 Grams* Refills:*0* 4. meropenem 500 mg Recon Soln Sig: 500mg Recon Solns Intravenous Q6H (every 6 hours): Through [**3-17**]. Disp:*23 grams* Refills:*0* 5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day: Through [**3-17**]. Disp:*22 Tablet(s)* Refills:*0* 6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Disp:*30 syringes* Refills:*0* 7. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection PRN as needed for drain or PICC line flush. Disp:*100 * Refills:*0* 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 9. loperamide 2 mg Capsule Sig: [**12-22**] Capsules PO With meals and at bedtime as needed for ostomy output greater than 1200cc/day. Disp:*30 Capsule(s)* Refills:*0* 10. Outpatient Lab Work LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] Discharge Disposition: Home With Service Facility: [**Telephone/Fax (1) 269**] of Southeastern Mass. Discharge Diagnosis: wound infection, intra-abdominal abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *New chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: *Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. *Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-29**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. *Avoid driving or operating heavy machinery while taking pain medications. *Please do not engage in any strenous activity until instructed to do so by your surgeon. . Wound Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the wound site. *No showering, tub baths, or swimming until cleared by Dr. [**Last Name (STitle) **] at your follow-up appointment. You may sponge bath until then. *Please perform wet-to-dry dressing changes three times daily. You will have a visiting nurse come to help assist you with dressing changes, and they will teach you how to perform these dressing changes yourself. . Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [**Last Name (STitle) 269**] nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output daily. *Keep the insertion site clean and dry otherwise. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . Monitoring ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *If ostomy output is greater than 1200mL in one day, please use Immodium to slow down the output: 2-4mg with meals and at bedtime, as needed. Do not exceed 16mg/24 hours. . PICC Line Care: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES. *Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. . Antibiotic Instructions: *You will be receiving IV antibiotic therapy through your PICC line. Per Infectious Disease recommendations, you will be on the following regimen: Vancomycin 1.5g IV every 8 hrs Start date: [**2110-2-28**] Stop date: [**2110-3-8**] Meropenem 500mg IV every 6 hrs Start date: [**2110-2-27**] Stop date: [**2110-3-17**] Fluconazole 400mg PO daily Start date: [**2110-2-27**] Stop date: [**2110-3-17**] Required laboratory monitoring while on IV antibiotics: LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP FREQUENCY: Weekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD in when clinic is closed. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-3-20**]. Please come to Dr.[**Name (NI) 1482**] clinic at 8:15am to receive the contrast for your scan. You will then have the CAT scan at 9:30am. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2110-3-20**] 10:45am. You will see Dr. [**Last Name (STitle) **] after your CAT scan to go over the results. 3. Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-3-25**] 9:30am Completed by:[**2110-3-7**]

43411,34830,34291,42731,71690,5859,E8809,V5883,V5861,9110,7802

Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-18**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a [**Age over 90 **] year-old right-handed Lithuanian only speaking woman with no significant PMH save for arthritis (per HCP who goes to [**Name (NI) 48924**] visits with her)who initially presented at around 11am after taking a fall at home at around 10:30. She was brought in by EMS and was felt to be neurologically intact when examined with a Lithuanian interpreter at around 2pm. She had said "Hospital" in english. She didn't initally know the date or time. The nurse caring for her did not feel that even with the interpreter that the patient could ever produce 5 consecutive words. At 2:20pm her BP was 204/60 and she was given 10mg IV labetolol. Her BP decreased to 180s/60s. She was then noted by the niece (who just arrived - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79715**] - 1-[**Telephone/Fax (1) 79716**]) at around 2:30 to be weak in the right hand and not paying attention to her right. Her verbal output was also diminished. The nurse was called and the ED physician [**Name9 (PRE) 31042**] calling [**Name Initial (PRE) **] code stroke at 2:39. Past Medical History: Arthritis. Per the HCP [**First Name5 (NamePattern1) **] [**Name (NI) 79717**] - 1-[**Telephone/Fax (1) 79718**]) the patient had a major medical workup 1 year ago that didn't reveal CAD (as was once thought in the ED.) He also denied HTN (also mentioned in the ED). In fact Mr. [**Name14 (STitle) 79717**] said she has low blood pressure. Social History: Lives in [**Location **] with Mr. [**Last Name (Titles) 79717**]. No ETOH, Drugs or tobacco. Family History: NC Physical Exam: On admission: Temp: 99.2; BP: 204/60 -> 183/61; HR: 70s; RR: [**10-26**]; SaO2:100%RA Gen: Alert, elder woman in C-collar. Sclerae anicteric. MMM. No meningismus. Lungs clear bilaterally. Heart regular in rate. Abd soft, nontender, nondistended. Bowel sounds heard throughout. Neuro: >>MS??????Alert. With niece translating could follow intermittent commands (looking l/r; lifting left arm; indicating whether she felt light touch). English speech limited to "ouch" and "yes". In Lithuanian, pt would repeat questions but not name or follow multi-step commands. >>CN??????PERRL. No threat blink on right. No ptosis. EOMI w/ smooth pursuit. Facial sensation and pterygoid strength intact. Facial mm intact. Tongue protrudes midline. >>Motor??????LEFT UE/LE [**5-13**] w/ nl tone. RIGHT UE postures to nox stim; no spontaneous movement; tone increased. RIGHT LE withdraws (MRC 3+) to nox stime; no spont movement; tone normal. >>Sensory??????withdraws/grimaces briskly to nox stim throughout. >>DTRs??????L/R: bic [**2-9**]+, br [**2-9**], tri [**2-9**]; pat [**2-9**], Ach 0/0. Right plantar extensor. >>Coord/Gait??????Not tested. NIHSS: At : 2:50 pm in the admission - performed with the Niece in Lithuanian. Total score 21-22 1a =2 1b =2 1c =2 2 =1 3 =[**1-9**] - unclear if complete or partial hemianopia with blink only. 4 =0 5a =4 5b =0 6a =3 6b =0 7 =0 8 =0 9 =3 10 =2 11 =1 Repeat NIHSS at 4pm. - performed with the Niece in Lithuanian. Total score 13-14 1a =2 1b =1 1c =0 2 =0 3 =[**1-9**] - unclear if complete or partial hemianopia with blink only. 4 =0 5a =4 5b =0 6a =3 6b =0 7 =0 8 =0 9 =2 10 =0 11 =0 Discharge physical exam: awake, interactive, following simple commands. Simple english naming is intact, answers appropriately. Dense right hemiplegia, sparing the face. Pertinent Results: [**2182-10-10**] 11:30AM BLOOD WBC-5.4 RBC-4.09* Hgb-12.8 Hct-36.9 MCV-90 MCH-31.3 MCHC-34.7 RDW-13.3 Plt Ct-343 [**2182-10-10**] 11:30AM BLOOD PT-13.9* PTT-26.2 INR(PT)-1.2* [**2182-10-11**] 02:59AM BLOOD Glucose-103 UreaN-23* Creat-1.1 Na-142 K-3.7 Cl-107 HCO3-26 AnGap-13 [**2182-10-11**] 12:05PM BLOOD ALT-14 AST-19 LD(LDH)-202 AlkPhos-73 Amylase-18 TotBili-0.5 [**2182-10-10**] 11:30AM BLOOD Lipase-11 [**2182-10-10**] 09:31PM BLOOD cTropnT-<0.01 [**2182-10-11**] 02:59AM BLOOD cTropnT-<0.01 [**2182-10-11**] 12:05PM BLOOD cTropnT-<0.01 [**2182-10-11**] 02:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.6 Cholest-184 [**2182-10-11**] 02:59AM BLOOD %HbA1c-6.5* [**2182-10-11**] 02:59AM BLOOD Triglyc-107 HDL-42 CHOL/HD-4.4 LDLcalc-121 [**2182-10-10**] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Relevant lab results for discharge: [**2182-10-15**] 06:35AM BLOOD WBC-7.5 RBC-3.61* Hgb-11.5* Hct-32.8* MCV-91 MCH-31.8 MCHC-35.0 RDW-13.7 Plt Ct-345 [**2182-10-15**] 06:35AM BLOOD Plt Ct-345 [**2182-10-15**] 06:35AM BLOOD PT-41.5* PTT-41.6* INR(PT)-4.5* [**2182-10-14**] 03:29AM BLOOD PT-23.5* PTT-63.9* INR(PT)-2.3* [**2182-10-13**] 05:13PM BLOOD PT-18.6* PTT-65.7* INR(PT)-1.7* [**2182-10-15**] 06:35AM BLOOD Glucose-98 UreaN-20 Creat-1.2* Na-139 K-4.3 Cl-106 HCO3-26 AnGap-11 [**2182-10-14**] 03:29AM BLOOD Glucose-143* UreaN-15 Creat-1.1 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 [**2182-10-13**] 05:13PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-142 K-3.5 Cl-112* HCO3-22 AnGap-12 [**2182-10-12**] 10:10AM BLOOD CK(CPK)-101 [**2182-10-15**] 06:35AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9 Trauma XRay: The examination is limited due to overlying spinal board and fixators. Within these limitations, there is no displaced rib fracture or pneumothorax. The lungs are clear. The cardiomediastinal silhouette appears unremarkable. Limited assesment due to spinal board. Degenerative changes are seen at the hip joints. There is no definite fracture identified. CTA/CTP [**10-10**]: CTA: Attenuationa nd markedly decreased caliber of the M1 segment of the left middle cerebral artery with attenuation and paucity of the M2 branches. CTP: Large area of elevated MTT in the left MCA territory with relatively well preserved blood volume in the periphery indicating ischemia. However, the abnormality extends beyond the area included on the present study. Area of low blood volume in the left parasagittal parenchyma in the higher slices is not adequately assessed as the abnormality is in the watershed zone. Acute infarcts in this location or in areas not included on the present study cannot be excluded. To consider MR head with DWI for better assessment. Echo: Suboptimal image quality - poor echo windows. The rhythm appears to be atrial fibrillation. The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Repeat CT of head [**10-12**]: Evolving left anterior cerebral artery territory infarction without evidence of hemorrhagic transformation. No new abnormalities identified. Brief Hospital Course: Ms. [**Known lastname 79719**] is a [**Age over 90 **]yo Lithuanian speaking RHW without significant PMH who presented with fall and transient right sided weakness with recrudescence of weakness noted ~4h later. It is unclear whether vessel occlusion/weakness prompted the fall. She was found to have a left ACA occlusion with some left MCA involvement. Her family declined intervention with IA tPA. She was admitted to the Neuro ICU initially with a heparin drip with PTT goal 50~70. She went into atrial fibrillation on HD #2 and thus was maintained on heparin and bridged to coumadin. There was no past documentation of Afib per history and there was no evidence of myocardial infarction per EKG or cardiac enzymes. On [**10-14**], INR was 2.3 and heparin drip was discontinued. She was started on Diltiazem 30mg [**Hospital1 **] for rate control since there was a question of severe bradycardia with metoprolol. She had sustained afib with elevated heart rate up to 160. Diltiazem was changed to extended release 120mg daily. She received a couple extra doses on [**10-17**] and had one 3.4sec pause on telemetry; she then flipped back into sinus rhythm. [**10-15**] INR = 4.5, [**10-16**] INR = 3.5, so coumadin was held; [**2182-10-17**] INR = 3, coumadin 2.5mg was restarted, but her most recent ([**2182-10-18**]) INR=3.7 and coumadin was again held. INR needs to be followed and coumadin adjusted in order to establish the correct dose of coumadin. Her right sided weakness remained unchanged during her hospitalization. Medications on Admission: ASA, meclizine, vicodin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Left ACA/MCA stroke Atrial fibrillation Discharge Condition: stable, however with dense hemiplegia over the right side (excluding the face), not walking Discharge Instructions: You were admitted to this hospital because you presented with weakness over the right side of your body. You had a brain MRI which showed signs of stroke at the left side of the brain. While in the hospital we noticed irregularity of your heart beat called atrial fibrillation, and this is a risk factor for stroke. To prevent further episodes of embolism and stroke you neeed to take coumadin and you need to have your blood checked every couple of days. Please return to the emergency department if you have new onset of weakness, mental status changes, loss of consciousness, dizziness, loss of balance, or any other concerning symptoms. Followup Instructions: You will need to call your primary care physician in [**Name9 (PRE) **] to set up a follow up appointment with Neurology after your discharge from Rehabilitation. We sent a copy of your Duscharge summary to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79720**] in [**Location (un) **]. Telephone # [**Telephone/Fax (1) 79721**] Fax# [**Telephone/Fax (1) 79722**]. While in [**Location (un) 86**] you can contact [**Name2 (NI) 79723**] office [**Telephone/Fax (1) 657**] for recommendations if necessary. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

486,1120,515,79902,4019,2720,53550,71690,311,V103

Admission Date: [**2128-5-11**] Discharge Date: [**2128-5-20**] Date of Birth: [**2062-9-6**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1943**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 65-yo woman with interstitial lung disease on chronic immunosuppression, and h/o left breast Ca s/p partial mastectomy + adjuvant chemo-XRT, who presented to the ED with dyspnea. Pt has been feeling unwell since Thursday of last week, when she initially developed symptoms of headache, dizziness, body aches, decreased appetite, and inability to get out of bed. These symptoms have continued since, and since Sunday she has had significant dyspnea as well. She has been using her home O2 continuously since Sunday (at baseline she only uses 2L NC as needed for dyspnea). She denies any associated cough or sputum production, but endorses mild wheeze, stating it feels like a bronchitis or pneumonia. Overnight last night she developed subjective chills and sweats, and this morning she found her temperature to be 101.7F, so she was brought to the ED for evaluation. In the ED, VS - Temp 98.0F, BP 128/57, HR 102, R 34, SaO2 78% on 2L NC. Labs were remarkable for an elevated WBC at 11.6 with 90% PMNs, and lactate 3.6, and negative UA. Blood Cx sent x2. CXR showed low lung volumes, increased interstitial markings c/w chronic fibrotic changes, and interstitial edema; an underlying atypical pneumonia cannot be ruled out. She was given Solumedrol 125mg IV x1, Levofloxacin 750mg IV x1, Vancomycin 1g IV x1, and 2L NS IVF for SBPs ~100. She seemed to improve and was changed from NRB to 3L NC, but desaturated to 85% on 3L so was restarted back on the NRB, with good response. CTA was done to r/o PE, which showed no PE or acute aortic syndrome; lung fibrotic changes, increased in left lung at site of radiation tx; and no underlying pneumonia. She is being admitted to the MICU for further care. On the floor, pt feels significantly improved. She has been on daily steroids and azathioprine for several months, with a recent decrease in her methylprednisolone dose and corresponding increase in her azathioprine dose on her last visit with Dr. [**Last Name (STitle) **] on [**2128-4-7**]. She also complains of mildly painful "pimples" on the sides of her tongue, which she relates to the increase in her azathioprine. She also endorses having stopped her Bactrim PCP [**Name9 (PRE) 5**], but was unsure as to when this was stopped. Past Medical History: - Interstitial lung disease, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], last seen [**4-/2128**], with increase in Azathioprine to 150mg daily and decrease in methylprednisolone to 16mg daily - Left breast carcinoma grade 3, T1c, N0, ER positive, PR negative, HER-2/neu negative, s/p partial mastectomy, sentinel node dissection, adjuvant chemotherapy and radiation therapy - Hypertension - Hypercholesterolemia - Depression - Gastritis - Arthritis - H/o low positive [**Doctor First Name **] Social History: Married, lives with husband and three children. Originally from El [**Country 19118**], Spanish-speaking only. No history of smoking or drinking. Family History: No family history of lung disease. No early CAD. Sister with breast cancer at 50. No other cancers in the family. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2128-5-11**] 12:00PM WBC-11.6* RBC-4.29 HGB-13.4 HCT-40.1 MCV-93 MCH-31.3 MCHC-33.6 RDW-15.2 [**2128-5-11**] 12:00PM NEUTS-90.3* LYMPHS-5.9* MONOS-3.2 EOS-0.4 BASOS-0.3 [**2128-5-11**] 12:00PM PLT COUNT-246 [**2128-5-11**] 12:00PM PT-12.5 PTT-20.6* INR(PT)-1.1 [**2128-5-11**] 12:00PM ALBUMIN-4.0 [**2128-5-11**] 12:00PM CK-MB-1 cTropnT-<0.01 [**2128-5-11**] 12:00PM LIPASE-50 [**2128-5-11**] 12:00PM ALT(SGPT)-23 AST(SGOT)-46* LD(LDH)-700* CK(CPK)-60 ALK PHOS-66 TOT BILI-0.6 [**2128-5-11**] 12:00PM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17 [**2128-5-11**] 12:11PM LACTATE-3.6* [**2128-5-11**] 09:35PM CK-MB-1 cTropnT-<0.01 [**2128-5-11**] 09:35PM LD(LDH)-292* CK(CPK)-26* [**2128-5-18**] Respiratory Viral Antigen Screen (Final [**2128-5-19**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. [**2128-5-18**] BAL Gram Stain: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. Studies: [**2128-5-11**] ECG: Normal sinus rhythm. Axis at 0 degrees. Poor R wave progression. Non-specific ST-T wave changes in leads V1-V3. Compared to the previous tracing of [**6-12**]-109 the Q-T interval prolongation is no longer present. The T wave inversions in leads V1-V3 persist unchanged. The prior T wave inversions in leads V4-V5 are no longer present. Otherwise, no diagnostic interval change. These T wave changes are non-specific. [**2128-5-11**] CXR: Low lung volumes with increased interstitial markings consistent with chronic fibrotic changes with some component of interstitial edema; an underlying atypical pneumonia cannot be ruled out, so repeat radiograph after diuresis is recommended. [**2128-5-11**] CT Chest: 1. No PE or acute aortic syndrome. 2. Chronic interstitial fibrotic changes in the lungs with increased fibrosis and bronchiectasis of the lingula with subpleural fat consistent with post-radiation changes. [**2128-5-13**] TTE: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild to moderate ([**12-6**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Preserved global and regional biventricular systolic function. Mild to moderate aortic regurgitation. Mild pulmonary artery systolic hypertension. Brief Hospital Course: 65-yo woman with ILD on chronic immunosuppression and PRN home O2 for symptoms of dyspnea, also with h/o left breast Ca s/p partial mastectomy and adjuvant chemo-XRT, admitted to the MICU with respiratory distress and hypoxia. #. Hypoxia, respiratory distress: Pt admitted with worsened hypoxia from baseline, somewhat acute and in setting of recent systemic symptoms. She was also febrile on admission. CXR and CTA had a faint suggestion of possible pneumonia, with diffuse faint ground glass opacities new compared to prior CTA from 1 year ago, making multifocal pneumonia a possibility. She continued to have O2 sats in the high-90s on 6L NC, but with desaturations to the 60s-70's even with small movements in bed. She was initially started on ceftriaxone and levofloxacin to cover for community acquired pneumonia, and was continued on levofloxacin for a total 5 day course. She was also placed on IV steroids (125mg IV methylprednisolone q6h) for three days and then given high-dose prednisone. She was also started on NAC and continued on her home azathioprine. Her respiratory status minimally improved with this treatment. She underwent bronchoscopy to rule out occult infection. At the time of discharge, her only positive culture was yeast in the fungal culture that hadn't been speciated. The pulmonary team planned to follow this culture and contact the rehab after discharge if an organism grew that needed treatment. It was not felt that this was likely to be aspergillus. Ultimately, it was felt that she likely had an infection on admission that caused a flare of her underlying ILD and her persistent hypoxia was a result of worsening of ILD. She was discharged still requiring 5L NC and on 40mg prednisone daily. #. Interstitial lung disease: She is followed closely by Dr. [**Last Name (STitle) **]. Her PFTs have declined considerably over time. She received steroids as above and was continued on azathioprine. It was felt that this presentation resulted from worsening of her ILD in the setting of acute infection. It was discussed with the patient that her degree of ILD is severe and her oxygenation is unlikely to substantially improve in the future. #. Left breast cancer: Grade 3, T1C, N0, ER positive, PR negative, HER-2/neu negative, s/p partial mastectomy with sentinel node dissection and adjuvant chemotherapy and radiation therapy. She was maintained on daily Tamoxifen. #. Hypertension: She was slightly hypertensive during her stay and is not on any antihypertensives at home. #. Gastritis: Continued home PPI #. Hypercholesterolemia: Continued on her home statin #. Depression: Continued on her home celexa #. Thrush: She was started on fluconazole for thrush for a total 14 day course. #. Code Status and Goals of Care: She was full code initially during this admission but she decided to change to DNR/DNI status during this admission. A long goals of care discussion was held and the patient was also interested in exploring any services that will help her to spend more time with her family. She is being discharged to a rehab facility with plans to possibly transition to hospice depending on her clinical course. Medications on Admission: - Azathioprine 150mg PO daily - Chlorpheniramine-Hydrocodone 10mg-8mg/5ml [**12-6**] tsp PO Q12hr PRN severe cough - Celexa [dosage uncertain] - Methylprednisolone 16mg PO daily - Omeprazole 20mg PO daily - Simvastatin 20mg PO daily - Sulfamethoxazole-Trimethoprim 800mg-160mg PO 3x/week - pt states this was stopped - Tamoxifen 20mg PO daily - Acetaminophen 500mg PO PRN - Ergocalciferol [Vitamin D2] - Loratadine Discharge Medications: 1. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 6. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 8. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO once a day. 9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Last day [**2128-5-30**]. 10. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale while on steroids Subcutaneous ASDIR (AS DIRECTED). 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred (600) mg Miscellaneous TID (3 times a day). 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Discharge Disposition: Extended Care Facility: Roscommon on the Parkway - [**Location 1268**] Discharge Diagnosis: Primary Diagnoses: - Interstitial lung disease - Community acquired pneumonia Secondary Diagnosis: - History of breast cancer - Left breast carcinoma - Hypertension - Hypercholesterolemia - Depression - Gastritis - Arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). O2 Sats: 93-97% on 5L NC, desats to 60's-70's with ambulation but recovers when rests. Needs oxygen supplementation at all times. Discharge Instructions: You were admitted to the hospital with shortness of breath and increasing oxygen requirements. You were treated for a pneumonia and for a worsening of your interstitial lung disease. You continued to require a large amount of oxygen supplementation and you are being discharged to a rehabilitation facility. Changes to your medications: ADDED fluconazole 100mg by mouth daily for 10 more days (last day [**2128-5-30**]) RESTARTED Bactrim 1 double strength tablet 3 times weekly INCREASED prednisone to 40mg by mouth daily ADDED trazodone 25mg by mouth at bedtime as needed for sleep INCREASED omeprazole to 20mg by mouth twice daily ADDED acetylcysteine 20% 600mg po by mouth three times daily ADDED guaifenesin 100mg/5mL syrup: 5-10ml by mouth every 6 hours as needed for cough Followup Instructions: You have the following appointments scheduled: Department: MEDICAL SPECIALTIES When: MONDAY [**2128-6-28**] at 2:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

42841,2761,4240,41401,4280,25000,4019,2859,5859,501,V1301,7231,73300

Admission Date: [**2200-10-24**] Discharge Date: [**2200-11-11**] Date of Birth: [**2119-12-23**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Vicodin Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath, exertional dyspnea Major Surgical or Invasive Procedure: [**2200-10-27**] Mitral Valve Replacement (33mm St. [**Male First Name (un) 923**] tissue)/ Coronary artery bypass grafts x 4 (LIMA-LAD, SVG-OM, SVG-Dg, SVG-PDA) [**2200-10-24**] Left and right heart catheterization, coronary angiography History of Present Illness: 80M with history of coaornary disease who was in usual health until two weeks ago when he noted progressively worsening dyspnea and orthopnea. His symptoms progressively worsened and he presented to [**Hospital3 3583**] on [**10-23**] and was found to be in heart failre with a BNP of 2351 and a borderline troponin of 0.15. An ECHO was performed and showed LVEF of 25%. He was diuresed with IV lasix and was oxygenating well on 2L NC but still had dyspnea. Of note, the patient's last stress test was in [**2199**] and was unremarkable with preserved LVEF. He received metformin and lovenox on morning of transfer and was not given plavix. He was transferred to [**Hospital1 18**] for catheterization. At cath, he was found to have severe three vessel coronary artery disease, moderate to severely elevated right and left sided filling pressures and depressed cardiac index and ejection fraction with diffusely hypokinetic left ventricle. He was referred for surgical revascularization. Past Medical History: osteoporosis spinal stenosis hx of asbestos exposure kidney stones- s/p lithotripsy colon polyps hyperlipidemia glaucoma peripheral vascular disease. diverticulosis colonic polyps Hypertension diabetes Social History: Quit smoking 44 years ago, previously had a 15 pack-year history. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Father died of CVA. No other known FH of CVD. Pertinent Results: [**2200-10-24**] Cardiac Cath: 1. Coronary angiography of this right dominant system revealed severe, calcific three vessel coronary artery disease. The LMCA did not have focal stenoses. The LAD had a 90% stenosis in the mid-vessel. The proximal portion of the major diagonal branch had a 70% stenosis. The LCx had a 99% stenosis at the origin, with left to left collaterals. The RCA was totally occluded proximally, with left to right collaterals. 2. Resting hemodynamics revealed moderate to severely elevated right and left sided filling pressures (RVEDP 19 mm Hg, LVEDP 25 mm Hg, respectively). The PCWP mean was elevated at 28 mm Hg. There was moderate pulmonary artery hypertension (PASP 59 mm Hg). The systemic arterial blood pressure was low-normal (SBP 105 mm Hg). The cardiac index was depressed at 1.7 L/min/m2. The systemic and pulmonary vascular resistances were mildly elevated at 1697 dynes-sec/cm5 and 315 dynes-sec/cm5, respectively. 3. Left ventriculography demonstrated a dilated left ventricle with global, severe hypokinesis to akinesis, with estimated ejection fraction of 25%. There was moderate to severe mitral regurgitation. [**2200-10-25**] ECHO: The left atrium is dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction with inferior/inferolateral and inferoseptal akinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] with borderline normal free wall function. 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. An eccentric, medially directed jet of at least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **] was found to have triple vessel disease on catheterization, with right heart pressure elevated and mitral regurgitation. He was taken to the operating room on [**10-27**] where coronary bypass grafting and mitral valve replacement were performed. See operative note for details. He weaned from bypass on Milrinone,epinephrine and neosynephrine. Postoperatively he was relatively stable and was extubated on [**Name (NI) 80108**]. His epinephrine was weaned and discontinued as was his neosynephrine by POD 2. The Milrinone was then slowly weaned and he remained stable. He was gently diuresed, however, he became hypotensive each time he received a Lasix bolus. A Lasix drip was instituted with a good diuresis and stable blood pressure. Consult was obtained from the CHF service-- we appreciate their recommendations. The patient was transitioned from the lasix gtt to bolus treatment, which he tolerated well. He made good progress with physical therapy before discharge. By the time of discharge, the patient was ambulating with assistance, the pain was controlled with oral analgesics, and the woundf was healing. He was discharged on POD 15 to The Rehab of [**Location (un) **] and Islands for further recovery. Medications on Admission: Prilosec 20 qd Altace 10 qd Metformin 1000 qam, 500 qpm Crestor 10 qd ASA 81 MVI Ca Vit D Actonel 35 qFriday Lasix Timolol 0.5% to L eye [**Hospital1 **] Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 5. Furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2 times a day). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 17. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: congestive heart failure coronary artery disease Diabetes Mellitus Dyslipidemia Hypertension peripheral vascular disease h/o nephrolithiasis chronic anemia spinal stenosis glaucoma osteoporosis diverticulosis colonic polyps Discharge Condition: good Discharge Instructions: No lifting more than 10 pounds for 10 weeks no driving for 4 weeks and off all narcotics report any temperature greater than 100.5 report any redness or drainage from incisions shower daily, no baths or swimming take all medications as directed no lotions, powders or creams to incisions Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58201**] in 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] in [**3-2**] weeks Completed by:[**2200-11-11**]

51881,5849,40391,5856,99812,5990,5839,2875,2859

Admission Date: [**2110-3-22**] Discharge Date: [**2110-4-2**] Date of Birth: [**2083-4-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3129**] Chief Complaint: Respiratory Failure, Acute Renal Failure, Emergent Dialysis Major Surgical or Invasive Procedure: HD catheter placement Femoral Line placement Hemodialysis x 6 History of Present Illness: This is a 26 yo Spanish speaking M, otherwise healthy, who presented initially to the [**Hospital3 15402**] ED with a history of couple of weeks of cough, more recently n/v, blurry vision in the last few days which then developed into acute dyspnea with pink frothy sputum. At [**Hospital3 15402**], he was found to have a low grade fever, and multiple electrolyte abnormalities, most notably a creatinine of 21.6, Hct 16, plts 88, and K 6.0. He was given blood, kayexalate, insulin, D50, amp bicarb x 1, protonix, and was sent to the [**Hospital1 18**] ED for further management. . On arrival here, he was tachypneic with lots of pink frothy sputum, and was satting 92% on a 100%nrb. His other vitals were AF 98.7 240/110 80's. On exam, he was diffusely rhonchorous and crackly on exam. He was started on a nitro gtt which quickly became maxed without benefit to either his blood pressure or his breathing. He was initially tried on CPAP but did not tolerate the mask [**3-17**] secretions and was intubated with etom/succ. 2 large bore IV's. Propofol gtt started. Bedside u/s showed hyperdynamic heart function, no effusion. He is undergoing a head CT for headache and elevated BP's and will be sent to the ICU for emergent dialysis and respiratory failure. Pressure 220's currently. . On arrival to the ICU, the patient is intubated and sedated, maxed on nitro gtt with BP's in the 170's, tachycardic. Past Medical History: none Social History: per OSH ED notes, no EtOH, tobacco or illicits. Has a brother/cousin who was with him there. Lives with a friend. Has a spot for ongoing hemodialysis treatments in [**Location (un) 5503**], Ma but needs to have his Essential Mass Health status upgraded to Limited, before they will accept him. They will not accept him with the "Limited" number still pending. Family History: per patient's brother, family is healthy, there are no renal or pulmonary problems and he denies bleeding dyscrasias, joint or heart disease. Physical Exam: Vitals: T: BP: 177/110 P: 114 Sat 100% A/C 500x14 Peep 10 FiO2 0.5 General: Intubated and sedated HEENT: PERRL, pupils pinpoint. Sclerae anicteric, MMM, oropharynx clear; nares with crusted blood. Unable to visualize discs at this time. Neck: supple, JVP to 9cm, no LAD Lungs: Rhonchorous diffusely with scattered rales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: +clonus at ankles Pertinent Results: [**2110-3-22**] 03:14AM WBC-10.7 RBC-2.45* HGB-7.5* HCT-21.0* MCV-86 MCH-30.6 MCHC-35.5* RDW-14.4 [**2110-3-22**] 03:14AM NEUTS-85.5* LYMPHS-9.5* MONOS-3.7 EOS-1.0 BASOS-0.3 [**2110-3-22**] 03:14AM GLUCOSE-146* UREA N-161* CREAT-21.3* SODIUM-148* POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION GAP-24* [**2110-3-22**] 03:14AM ALT(SGPT)-26 AST(SGOT)-24 CK(CPK)-543* ALK PHOS-75 TOT BILI-0.6 [**2110-3-22**] 03:14AM cTropnT-0.20* [**2110-3-22**] 05:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2110-3-22**] 05:35AM HCV Ab-NEGATIVE [**2110-3-22**] 05:35AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE [**2110-3-22**] 05:35AM [**Doctor First Name **]-NEGATIVE [**2110-3-22**] 05:35AM ANCA-NEGATIVE B [**2110-3-22**] 05:35AM C3-108 C4-27 [**2110-3-22**] 01:25PM dsDNA-NEGATIVE [**2110-3-22**] 01:25PM PTH-424* [**2110-3-22**] 01:25PM LD(LDH)-758* CK(CPK)-476* [**2110-3-22**] 01:25PM HAPTOGLOB-<20* [**2110-3-22**] 04:27PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Stipple-OCCASIONAL Bite-1+ Acantho-OCCASIONAL Fragmen-OCCASIONAL [**2110-3-22**] 04:27PM BLOOD Plt Ct-76* [**2110-3-31**] 07:45AM BLOOD Plt Ct-225 [**2110-3-22**] 01:25PM BLOOD PT-14.2* PTT-73.5* INR(PT)-1.2* [**2110-3-23**] 08:10AM BLOOD Ret Aut-2.0 [**2110-3-22**] 01:25PM BLOOD ACA IgG-2.5 ACA IgM-7.2 [**2110-3-22**] 03:14AM BLOOD Glucose-146* UreaN-161* Creat-21.3* Na-148* K-4.2 Cl-108 HCO3-20* AnGap-24* [**2110-3-31**] 07:45AM BLOOD Glucose-121* UreaN-102* Creat-13.8* Na-137 K-6.1* Cl-100 HCO3-15* AnGap-28* [**2110-3-22**] 05:35AM BLOOD LD(LDH)-788* TotBili-0.6 DirBili-0.2 IndBili-0.4 [**2110-3-23**] 06:45PM BLOOD LD(LDH)-595* TotBili-1.4 [**2110-3-22**] 03:14AM BLOOD cTropnT-0.20* [**2110-3-23**] 08:10AM BLOOD CK-MB-4 cTropnT-0.41* [**2110-3-22**] 03:14AM BLOOD Calcium-6.2* Phos-7.3* Mg-3.6* [**2110-3-31**] 07:45AM BLOOD Calcium-9.1 Phos-7.8* Mg-3.0* [**2110-3-23**] 06:45PM BLOOD Hapto-52 [**2110-3-28**] 08:55AM BLOOD HIV Ab-NEGATIVE [**2110-3-22**] 05:35AM BLOOD ANTI-GBM-Test - Test Result Reference Range/Units GBM AB 4 U/ML (High) <3 NEGATIVE >=3 POSITIVE Cardiology Report ECG Study Date of [**2110-3-22**] 3:10:36 AM Sinus tachycardia. Modest ST junctional depression which is non-diagnostic. No previous tracing available for comparison. TRACING #1 Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 121 108 82 318/424 71 -3 65 [**Last Name (LF) **],[**First Name3 (LF) **] A. EU [**2110-3-22**] 3:16 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80775**] Reason: r/o chf [**Hospital 93**] MEDICAL CONDITION: 26 year old man with desats, pink sputum with new ARFand low plt. REASON FOR THIS EXAMINATION: r/o chf Final Report INDICATION: 26-year-old male with desaturation, pink sputum, and new acute renal failure. Evaluate for CHF. Single AP chest radiograph demonstrates bilateral diffuse airspace opacity. Differential consideration include non-cardiogenic pulmonary edema, multifocal pneumonia or possibly diffuse hemorrhage. There is no pleural effusion or pneumothorax. The cardiomediastinal contour is normal. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**] Approved: SAT [**2110-3-22**] 11:25 AM [**Last Name (LF) **],[**First Name3 (LF) **] P. MED FA2 [**2110-3-31**] 5:22 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 80776**] Reason: patient with new tenderness in left flank s/p renal biopsy ? [**Hospital 93**] MEDICAL CONDITION: 26 year old man with IgA nepropathy in ESRD on HD, receiving dialysis. REASON FOR THIS EXAMINATION: patient with new tenderness in left flank s/p renal biopsy ? perinephric hematoma CONTRAINDICATIONS FOR IV CONTRAST: End stage renal disease;end stage renal disease Final Report STUDY: CT of the abdomen and pelvis. HISTORY: 26-year-old male with IGA nephropathy on hemodialysis. New tenderness of left flank. Assess for hematoma. TECHNIQUE: Non-contrast MDCT axial images of the abdomen and pelvis were acquired. Coronal and sagittal reformatted images were then obtained. CT OF THE ABDOMEN WITHOUT CONTRAST: The lung bases are clear. The liver, gallbladder, spleen, adrenal glands, stomach, pancreas, and abdominal portions of the large and small bowel appear unremarkable. The right kidney is normal in size and there is no perinephric stranding. There is a moderate sized left perinephric hematoma with heterogeneous internal density including a few areas of higher attenuation within the lower pole of the left kidney (2:22, 23, 300B:36). The largest dense area within the lower pole seen best on coronal images measures 2.8 x 2.4 cm (300B:36). The hematoma tracks along the capsule without evidence of large subcapsular component, and tracks within Gerota's fascia on the left, extending to the psoas medially. Along the inferior margin of the left kidney, the collection measures approximately 5.8 x 6.3 cm (300B:30). The right kidney is unremarkable. There is no free fluid or free air within the abdomen. CT OF THE PELVIS WITHOUT IV CONTRAST: The prostate, bladder, rectum, sigmoid colon, and intrapelvic loops of small bowel appear unremarkable. There is no free fluid within the pelvis. OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions. IMPRESSION: Moderate left perinephric hematoma, status post recent biopsy. Brief Hospital Course: 26 yo M with no PMH admitted with respiratory failure and marked acute renal failure of unknown etiology. # Respiratory Failure: Likely secondary to flash pulmonary edema in the setting of malignant hypertension. Mostly pink frothy sputum and not hemoptysis, but on admission, a pulmonary-renal syndrome was within the ddx. CXR showed diffuse infiltrates characteristic of pulmonary edema and BNP was very elevated. Mini BAL did not show evidence of eosinophilia. Due to unstable shortness of breath with decompensating O2 sats, the patient was intubated in the ER, started on a propafol drip and transfered to the MICU. Once dialyzed, the patient was weaned and extubated quickly with no further respiratory issues. Throughout the remainder of his stay he was kept on PRN Albuterol and Ipratropium, and never complained of shortness of breath, nor did he suffer and desaturation incidents. . # Acute Renal Failure: In the emergency department the patient's creatinine was elevated to 21.3 and a his BUN of 161. The patient met all but one of the indications for dialysis (acidosis, electrolyte derangements, overload and uremia) underwent emergent line placement and HD. Etiologies initially considered were TTP/HUS (although thrombocytopenia was not profound), vasculitic process including Wegener's, microscopic polyangiitis, Churg-[**Doctor Last Name 3532**] (but no eos on peripheral smear), HSP (no skin findings on exam), Cryoglobulinemia (but he is young for this dx), anti-GBM, and Goodpasture's. SLE was also on the differential initially. A broad work up was initiated, but UA with large blood and 500 protein without dyspmorphic red cells/red cell casts on sediment seemed to direct away from acute GN or vasculitis, and peripheral smear had relatively few schistocytes with normal bili, and with fairly high platelet count, so TTP also seemed unlikely. Renal u/s showed atrophic kidneys and elevated PTH, suggesting chronic renal failure. Anca, [**Doctor First Name **], dsDNA, hepatitis serologies were all negative, and C3 and C4 levels were wnl. Renal bx was done on [**2110-3-24**]. The patient had HIV, Hepatitis, and PPD tests that were negative. An anti GBM antibody study came back high at 4 (upper limit of 3) assumed a likely false positive given that biopsy results revealed IgA nephropathy with profoundly sclerosed glomeruli. The patient had a tunneled hemodialysis catheter placed and was started on dialysis. Over the course of his hospitalization, with dialysis treatments, his weight was reduced from 62.6 kg to 56.4 kg. His symptoms of nausea/vomiting abated early. 6 days post biopsy, the patient developed a 6cm x 6cm perinephric hematoma. The bleeding was contained and his pain treated. . # Hypertensive Emergency: on nitro gtt initially, but weaned off on arrival to MICU with fent/versed. Received HD for acute management. CT head without obvious bleed. BP between 140 and 170 systolic in unit. On floor managed with Amlodipine 10mg po daily until BP controlled only with HD. Final BP of 118/87. Had one episode of hypertension post dialysis on HD#5 treated with 10mg IV Hydralazine. Blurry vision and HA both resolved following first dialysis treatment. No evidence of ongoing end organ damage present. . # Anion Gap Metabolic Acidosis - AG was 20, and delta-delta was 1.6 on admission indicating a pure AG metabolic acidosis (although given the renal failure there is likely a component of NG acidosis as well). This was most likely due to uremia; the patients acidosis corrected with regular dialysis treatment. . # Elevated CE's: patient was very volume overloaded and with ARF so the likely etiology was significant strain; however, we considered myocarditis in the setting of vasculitis, specifically Wegener's. EKG had nonspecific findings but no evidence of acute ischemia. These trended downward over the course of admission without the patient complaining of chest pain or difficulty breathing. . # Anemia/Thrombocytopenia: Unclear why platelet count was low as this is not characteristic of uremia, but anemia initially considered to be secondary to malignant HTN. Hematology was consulted given the possibility of a TTP/HUS picture, though there were too few schistocytes, and primitive platelet forms on the peripheral smear to warrant this diagnosis. Following the renal biopsy, and the discovery of change more consistent with a chronic etiology to his renal failure, the anemia was believed to be secondary to poor epo output. On HD#7 he received 2 units of packed red blood cells prior to dialysis, however, his hematocrit continued to fall gradually. On HD#9 a 6 cm x 6 cm perinephric hematoma was discovered on CT. The patient's Hct was 32 and bleeding was well controlled upon discharge. His platelet count was within normal by time of discharge. . # UTI, on hospital day 7 the patient began spiking low grade fevers to the 100.4 range. Urinalysis revealed a pattern consistent with a UTI and the patient was started on 500mg of PO BID Ciprofloxacin for treatment. Given his hemodialysis this was considered to be safe. . # FEN: The patient was intubated at first and kept NPO while in the MICU, after transfer to the floor, he was placed on a renal diet. He did not enjoy the renal diet. Nutrition was consulted to provide him with an appropriate modification of his usual diet at home. . # Code: patient is full code Medications on Admission: None Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: IgA nephropathy Acute on Chronic renal failure. Discharge Condition: The patient was discharged hemodynamically stable, afebrile, and with appropriate follow up. Discharge Instructions: You were admitted to the hospital because of your shortness of breath, cough productive of pink frothy sputum, nausea, vomiting, inability to eat, and lab tests that suggested that you had acute kidney failure. Because of your pink frothy sputum you could not breathe and had to have a tube placed down your throat to help you. After you received your first dialysis treatment, this tube was removed. Afterward, you received an ultrasound of your kidneys which revealed them to be smaller than they should have been. You then had a CT scan that confirmed this. A biopsy was taken of your kidney that revealed the cause of your symptoms to be a condition called IgA nephropathy. This condition has likely been present for a very long time and has been damaging your kidneys during that time period without you even being aware of it. Because of your kidney failure, you had a hemodialysis catheter(tube for dialysis) placed in your chest, and began to receive hemodialysis treatments every other day. During your hospitalization you were treated with a number of medications: Amlodipine for your blood pressure, Albuterol and Iprotropium for your breathing, Sevelamer to remove phosphate from your blood, and pantoprazole to prevent the burning feeling in your stomach. On your 9th day of hospitalization, you experienced some left sided flank pain for which you were evaluated with a CT scan of your abdomen and pelvis. The CT scan showed that you had a small bleed to the side of your kidney where your biopsy had been taken. You were given medication for the pain. Please take the sevelamer medication, three pills, three times daily to prevent buildup of phosphate in your blood. Please continue to take the antibiotic Ciprofloxacin twice a day for 7 days. Please take the nephrocaps 1 pill once a day. You have been given some pills for pain, please take one or two every 6 hours for pain. You do not need to take Amlodipine. Please keep your follow up appointments as listed below. Should you experience further nausea, vomiting, headache with blurry vision, coughing up blood, or any other concerning symptoms, please return to the hospital at once. Followup Instructions: Please return to the hospital for dialysis treatment 11:30am [**Hospital Ward Name 121**] [**Location (un) 436**], every Monday, Wednesday, and Friday.

42833,486,41071,5781,2851,4240,5859,4280,41401,40390,725,42731,2749,2689,78791,V5865

Admission Date: [**2161-2-16**] Discharge Date: [**2161-2-21**] Service: MEDICINE Allergies: Demerol / Morphine / Hydrocodone / Codeine Attending:[**First Name3 (LF) 1711**] Chief Complaint: S/p Fall Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 85 yo F with HTN, polymyalgia rheumatica, transferred from [**Hospital1 18**] [**Location (un) 620**] for cardiac catheterization. The patient was in her usual state of health until Wednesday [**2-11**], when she developed black diarrhea, occuring 5 times daily. The patient attributes the black color to her iron supplements. Along with diarrhea, the patient also experienced 2 episodes of vomiting (clear, no blood or coffee grounds). The patient also had fever to as high as 100.6 on Friday [**2-13**] and Saturday [**2-14**]. On Sunday [**2-15**], the patient became lightheaded when getting up from the toilet and fell, hitting her head and right elbow. She presented to [**Hospital1 18**] [**Location (un) 620**], where head and c-spine CT were negative. She developed chest pain after admission, relieved with metoprolol and nitroglycerin. She received 1 unit of RBCs for Hct 27, and became short of breath. She was given 40mg IV lasix and diuresed 500cc. She ruled in for MI with third set of troponins peaking at 0.26. She was transferred to [**Hospital1 18**] for cardiac catheterization on 100% non-rebreather and a heparin gtt. Of note, pt was guaiac positive on admission. On arrival to [**Hospital1 18**], the patient was taken to the cardiac catherization lab, where she was found to have severe 3-vessel disease and an elevated LVEDP (see below for details). She was transferred to the CCU on a non-rebreather for further management. In the CCU, the patient was weaned to a non-rebreather. She reported that her breathing was improved and had no other complaints. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, cough, hemoptysis, or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She denies sore throat, sinus congestion, dysuria. She denies weakness, tingling, or numbness. All of the other review of systems were negative. Cardiac review of systems is notable for chest pain and lightheadedness as above and two pillow orthopnea. No syncope. The patient reports a recent decrease in exercise tolerance from 100 feet on a flat surface to 50 feet on a flat surface. Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Hypertension Diastolic CHF Chronic Kidney Disease (Baseline 1.5-1.7) Right BBB MRSA in nares Atrial Fibrillation Gout Cellulitus Polymyalgia Rheumatica Diverticulosis Depression and Anxiety S/p cholecystecomty/appendectomy S/p tonsillectomy S/p surgery for anal fissure Social History: Retired. Worked as secretary. Lives alone at [**Location (un) 582**]. -Tobacco history: quit 40 yrs ago; smoked 1 ppd x 30 years -ETOH: denies -Illicit drugs: denies Family History: Father with stroke at 68. Mother with MI at 65. Two brothers with HTN. Had 4 children (one died). Physical Exam: (Per Admitting Resident) VS: T=97.5 BP=129/54 HR=69 RR=18 O2 sat=96%/6L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. CARDIAC: RRR, 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. CTA anteriorly (could not sit up due to recent cath). ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, or xanthomas. PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [**2161-2-16**] 05:30PM BLOOD WBC-13.7* RBC-3.60* Hgb-9.7* Hct-29.4* MCV-82 MCH-27.0 MCHC-33.0 RDW-14.9 Plt Ct-311 [**2161-2-16**] 05:30PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.3 Baso-0 [**2161-2-16**] 11:01PM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0 [**2161-2-16**] 11:01PM BLOOD Glucose-174* UreaN-31* Creat-1.5* Na-141 K-3.3 Cl-105 HCO3-22 AnGap-17 [**2161-2-16**] 11:01PM BLOOD CK(CPK)-110 [**2161-2-16**] 11:01PM BLOOD CK-MB-3 cTropnT-0.14* [**2161-2-16**] 11:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9 [**2161-2-16**] 05:33PM BLOOD Type-ART O2 Flow-15 pO2-75* pCO2-34* pH-7.46* calTCO2-25 Base XS-0 Intubat-NOT INTUBA Discharge Labs [**2161-2-21**] 05:42AM BLOOD WBC-14.9* RBC-3.43* Hgb-9.8* Hct-29.3* MCV-86 MCH-28.4 MCHC-33.2 RDW-15.2 Plt Ct-360 [**2161-2-21**] 05:42AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.0 [**2161-2-21**] 05:42AM BLOOD Glucose-103* UreaN-36* Creat-1.4* Na-139 K-4.2 Cl-98 HCO3-32 AnGap-13 [**2161-2-21**] 05:42AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1 [**2161-2-18**] 04:05AM BLOOD %HbA1c-6.1* eAG-128* CXR ([**2161-2-18**]) - The size of the cardiac silhouette is at the upper range of normal, there is no evidence for overt pulmonary edema. In the right upper lobe as well as in the entire left lung, the interstitial markings are increased, there are patchy areas of opacities, that are ill-defined and distributed in a mainly peribronchial pattern. In addition, a small left basilar atelectasis and a small left pleural effusion is seen. Overall, the morphology and distribution of the changes suggests multifocal pneumonia rather than pulmonary edema. No evidence of right basal changes, no evidence of right-sided pleural effusion. CXR ([**2161-2-20**]) - In comparison with study of [**2-18**], there has been placement of left subclavian PICC line extends to the mid portion of the SVC. There has been some decrease in the bilateral patchy areas of opacification, most likely consistent with improving pneumonia. Cardiac Cath ([**2161-2-16**]) - 1. Coronary angiography in this right dominant system demonstrated severe three vessel CAD. The LCx was the least stenosed and there was no obvious single culprit stenosis. The LMCA had distal calcification with a hazy 30% stenosis. The LAD was heavily calcified with diffuse disease throughout with serial 60% stenoses just before a major D4 with a distal 85% stenosis and an 80% apical stenosis. There was a high D1, functionally a large septal branch which was patent. A large D2 and D4 were also patent. The LCx was tortuous proximally with slow flow and mild diffuse disease in the AV groove LCx. OM branch had a proximal 50% stenosis with a tortuous upper pole and mild diffuse disease in the lower pole. The distal AV groove LCx supplied collaterals to the distal RCA system. The RCA was heavily calcified with a 40% ostial stenosis without pressure dampening. There was proximal diffuse disease up to 75% and distal diffuse disease before the RPDA up to 45%. There was moderate diffuse disease throughout the RPDA with severe diffuse disease in the distal AV groove RCA supplying the RPLs with slow flow (? severe disease vs. competitive flow from collaterals). Septal collaterals from the LAD fill the RPDA. 2. Limited resting hemodynamics revealed mildly elevated RA pressure with a mean RAP of 9 mmHg. There was severely elevated left sided filling pressures with an LVEDP of 29 mmHg. There was moderate systemic arterial systolic hypertension with an SBP of 160 mmHg. No cardiac index could be calculated as unable to float PWP catheter beyond RA. 3. Modest hypoxemia (O2 sat 93% on 15L NRB mask) improved to 96% with the addition of 2L via nasal cannula arguing against significant shunt physiology. FINAL DIAGNOSIS: 1. Severe three vessel CAD. 2. Severe left ventricular diastolic dysfunction. Brief Hospital Course: 85 yo F with HTN, Afib, dCHF, CKD, h/o guaiac-positive stools, transferred from [**Hospital1 **] [**Location (un) 620**] for cardiac catheterization in the setting of elevated cardiac enzymes, new focal wall motion abnormalities, and worsened MR. [**Name13 (STitle) **] to have extensive 3-vessel disease. # Coronary Artery Disease: Pt noted to have a troponin leak at an OSH, with peak of 0.26. Was transferred to [**Hospital1 18**] for cardiac catheterization, which revealed three-vessel disease. Given this, pt is a poor candidate for PCI. After much discussion, pt decided that she would not want cardiac surgery. [**Hospital 49578**] medical management was pursued. During her hospitalization, she experienced episodes of chest discomfort, particularly at night. She did not exhibit any ECG changes during these episodes. Her metoprolol was uptitrated, and she was started on a long-acting nitrate for further antianginal activity. By the time of discharge, she had been free of chest pain for several days. # Acute on Chronic Diastolic HF / Worsened Ritral Regurgitation: Echo at OSH showing new focal wall motion abnormalities and worsened MR, likely of ischemic etiology. On presentation, she was thought to be hypervolemic. Metoprolol and amlodipine were tirated for optimum BP control / afterload reduction. The option of mitral valvular surgery was addressed, but the patient was not interested in cardiac surgery. She was diuresed with bolus IV lasix, which was converted to PO lasix prior to discharge. # Pneumonia: CXR performed on [**2161-2-18**] was suspicious for multifocal pneumonia. Pt was initially started on broad-spectrum coverage with vancomycin, cefepime, levofloxacin. She was noted to spike a fever on the night of [**2161-2-18**]; however, she remained afebrile after that. She did also have a leukocytosis throughout her hospitalization, which was improving at the time of discharge. On [**2161-2-20**], her antibiotics were narrowed to levofloxacin, as she had no positive cultures and appeared improved clinically. Of note, at the time of discharge, she did continue to have an oxygen requirement, which was likely multifactorial in etiology (see below). # GI Bleeding: The patient was noted to have guaiac positive stools during her hospitalization. She did have one episode of a hematocrit drop, for which she received a unit of PRBCs. Her hematocrit remained stable after that. She also complained of some episodes of dysphagia, with food getting "stuck" in her throat. She states that this has been occuring for some time. She was seen by GI for both of these issues. Further evaluation with a barium swallow was recommended as an outpatient. Further work-up of her GI bleeding should also be pursued as an outpatient. Of note, in the setting of this GI bleeding, her aspirin dose was decreased and her PPI dose was increased. Her iron was also discontinued. # Oxygen Requirment: Likely multifactorial in the setting of the patient's pneumonia and severe MR. Treatment as above. # Positive Blood Cx: One blood cx positive for GPR's. Likely a contaminant. Speciation pending and not further cultures positive at the time of d/c. # Pre-Diabets: Pt was noted to have elevated blood sugars in the CCU. A1C was 6.1, consistent with pre-diabetic state. This should be further followed as an outpatient. # Chronic Kidney Disease: Baseline creatinine 1.5 to 1.7. The patient remained at her baseline throughout the hospitalization. ACE inhibitors was held in the setting of her kidney disease. # Diarrhea: Pt presented with some recent diarrhea in the setting of recent fever and chills. Stool cultures were sent, including C.diff, and were negative. Her diarrhea improved. # Vitamin D Repletion: Pt's previous vitamin D regimen was not entirely clear. She is being discharged on 1000 units of Vitamin D3 daily. This may be adjusted as an outpatient if more significant vitamin supplementation is desired. # Polymyalgia Rheumatica: Continued on home prednisone dose. # Anxiety/Depression: Continued on nortriptyline and zyprexa at home dose. Medications on Admission: Ativan 0.5 mg daily PRN Tylenol 650 mg Q4H PRN Prochlorperidzine 10 mg Q6H PRN Lidoderm 5% patch apply to left hip for 12 hours on 12 hours off Norvasc 5 mg daily Prilosec 20 mg daily Nortriptyline 10 mg daily Metoprolol ER 100 mg daily Vitamin D 50,000 units weekly for 4 weeks, then monthy prednisone 10 mg daily Drisdol once a month ferrous sulfate 325 mg [**Hospital1 **] Tylenol 1000 mg PO BID Calcium carbonate 500 mg TID acidophilus 1 capsule [**Hospital1 **] Zyprexa 5 mg daily Trazodone 12.5 mg PO QHS Senna 1 tab [**Hospital1 **] 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). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea . 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: to right hip, 12 hrs on, 12 hrs off. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total dose = 225mg/day. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total dose = 225mg/day. 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 13. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. Acidophilus Capsule Sig: One (1) Capsule PO twice a day. 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 17. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual x3 as needed for CP : Up to three doses separated by 5 min. If not resolved after three, call physician. 19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: Start [**2-22**] am. 20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux. 21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 22. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Primary: Acute on chronic diastolic heart failure Pneumonia Coronary artery disease Secondary: Chronic kidney disease Guaiac positive stool Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance Discharge Instructions: You were admitted to [**Hospital1 18**] for a heart catheterization to evaluate for coronary disease. We found disease in all 3 blood vessels as well as a leaky mitral valve. You declined to have heart surgery to repair these problems. We removed extra fluid with medications called diuretics and treated you for a pneumonia. Please take all medications as prescribed. We have made the following medication changes: STOPPED: Lorazepam (Ativan) Ferrous sulfate (iron) CHANGED: Increased metoprolol succinate to 225mg daily Vitamin D to 1000 units daily STARTED: Atorvastatin for cholesterol Levofloxacin for 4 days (antibiotic for pneumonia) Isosorbide mononitrate for chest pain Aspirin for blood thinning Furosemide to prevent fluid buildup Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with the physician at your nursing facility. Please call [**Telephone/Fax (1) 62**] on Monday to set up a follow up appointment for 2-3 weeks with one of our cardiologists.

5770,5307,2763,5180,5990,0416,3441,V1251,78720,V441,30000,53081,2724,3019,43811,43882,79902,43813,43853,5758

Admission Date: [**2161-7-14**] Discharge Date: [**2161-7-21**] Date of Birth: [**2111-11-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2186**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 49 y.o male with pmhx of multiple CVAs, multiple dvts (s/p IVC filter), aphasia, G-tube for dysphagia presents with abdominal pain, nausea and vomiting. The abdominal pain started yesterday and was accompanied by nausea and vomiting (last episode yesterday) nonbloody bilious. Last BM was yesterday after he received ducolax and was brown, formed and nonbloody. He was also noted to have temperature up to 100, and WBC of 13 (from 8 yesterday) today at his care facility. . Of note per rehab notes: Yesterday dulc. supp given and patient had large BM with KUB revealing no ileus or obstruction. . Of note the patient had a G tube placed several months ago and a replacement inserted in [**2161-5-22**] due to leakage around the tube. . Initial ED vitals: 99.7 102 147/100 18 95% ra. Given 2mg Zofran IV and 5mg Morphine IV for pain and nausea.Because of increasing oxygen requirements in the ED transferred to the ICU, 92% on non-rebreather; and did abg which revealed resp alkalosis,CTA revealed no PE.Of note the patient recieved no IV fluid. . Prior to transfer vitals were: BP-147/104, HR 103, RR 13, 94% NRB . On arrival to the MICU, the patient denies dyspnea and is satting 96% on 4L NC, he also denies chest pain, back pain, confusion, vision changes,headache, recent vomiting. He does have persisting nausea and abdominal pain which is diffuse and not worse in any particular area. Review of systems: Obtained from patient (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Constipation Anxiety GERD Generalized pain HLD Insomnia Multiple CVA's [**Month (only) **] first in [**2152**] of the brain stem related to aneurysmal dilation of basilar artery w/ b/l hemiparesis especially right hand, b/l facial plegia, partial 6th nerve palsy, dysarthyria, and dysphagia. [**2152**] Basilar artery dissection several basilar artery aneurysyms (11mm) after was put on plavix, calcified mural thrombus suggestive of chronic dissection [**10-1**] ([**Last Name (un) 74591**] [**Hospital1 107**]) Back pain s/p lumbar disectomy L4-L5, L5-S1 [**2135**] Multiple DVT s/p IVC filter [**3-/2160**] Dysphagia s/p G tube being used for meds only + [**Doctor First Name **] [**2160-3-21**] Personality disorder- rapidly becomes verbally abusive periodically makes false accusations against staff Social History: Former professor, patient estranged from family who lives in [**State 8842**] . Currently living in [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] for Living LF Denies alcohol, tobacco and illicit drug abuse. Family History: NC Physical Exam: ADMISSION Vitals: T:99.0 BP: 140/90 P: 90 R:13 18 O2:98% 4L NC General: Alert, oriented X 3, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, distended, bowel sounds present though hypoactive in all quadrants, no organomegaly .G tube in place in epigastric area with no erythema or drainage around the site of the tube. Diffuse abdominal pain to palpation, neg [**Doctor Last Name **], and no rebound tenderness or guarding. GU: foley placed with dark amber urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact,EOMI, sym smile, can raise forehead sym, tongue midline, EOMI, pupils equal and reactive to light, [**3-26**] hand grip strength b/l, [**3-26**] UE extension, [**2-23**] UE flexion to only 40 degrees, cannot flex knees or pick up thighs off bed b/l, but has [**3-26**] plantarflexion b/l, downgoing babinski b/l, grossly normal sensation, cannot illicit achilles and patellar reflexes bilaterally, gait deferred. DISCHARGE Abdomen: soft, NT/ND,NABS x4. minimal diffuse TTP, no rebound/guarding Pertinent Results: ADMISSION LABS: [**2161-7-14**] 05:45PM BLOOD WBC-16.5* RBC-5.83 Hgb-18.1* Hct-51.1 MCV-88 MCH-31.1 MCHC-35.4* RDW-13.5 Plt Ct-255 [**2161-7-14**] 05:45PM BLOOD Neuts-89.5* Lymphs-4.1* Monos-6.0 Eos-0.3 Baso-0.2 [**2161-7-15**] 02:05AM BLOOD PT-30.9* PTT-39.0* INR(PT)-3.0* [**2161-7-14**] 05:45PM BLOOD Glucose-132* UreaN-22* Creat-0.8 Na-142 K-3.2* Cl-101 HCO3-29 AnGap-15 [**2161-7-14**] 05:45PM BLOOD ALT-23 AST-13 AlkPhos-62 TotBili-1.7* [**2161-7-14**] 05:45PM BLOOD Lipase-1576* [**2161-7-14**] 05:45PM BLOOD Albumin-4.9 Calcium-9.8 Phos-3.4 Mg-2.2 [**2161-7-14**] 05:45PM BLOOD Triglyc-67 [**2161-7-14**] 08:10PM BLOOD Type-ART pO2-363* pCO2-38 pH-7.50* calTCO2-31* Base XS-6 Intubat-NOT INTUBA [**2161-7-15**] 02:23AM BLOOD Type-[**Last Name (un) **] Temp-38.2 pO2-94 pCO2-42 pH-7.45 calTCO2-30 Base XS-4 Comment-AXILLARY T [**2161-7-14**] 05:47PM BLOOD Lactate-2.1* [**2161-7-15**] 02:23AM BLOOD Lactate-1.1 DISCHARGE [**2161-7-20**] 06:55AM BLOOD WBC-9.6 RBC-4.54* Hgb-13.8* Hct-40.0 MCV-88 MCH-30.5 MCHC-34.6 RDW-13.3 Plt Ct-283 [**2161-7-20**] 03:10PM BLOOD Hct-39.1* [**2161-7-20**] 06:55AM BLOOD PT-34.7* PTT-41.0* INR(PT)-3.4* [**2161-7-20**] 06:55AM BLOOD Glucose-96 UreaN-6 Creat-0.8 Na-143 K-3.3 Cl-107 HCO3-28 AnGap-11 [**2161-7-20**] 06:55AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.2 PERTINENT [**2161-7-15**] 02:05AM BLOOD PT-30.9* PTT-39.0* INR(PT)-3.0* [**2161-7-19**] 07:25AM BLOOD PT-38.3* PTT-37.8* INR(PT)-3.7* [**2161-7-20**] 06:55AM BLOOD PT-34.7* PTT-41.0* INR(PT)-3.4* [**2161-7-14**] 05:45PM BLOOD Lipase-1576* [**2161-7-15**] 02:05AM BLOOD Lipase-1196* [**2161-7-17**] 07:10AM BLOOD Lipase-50 [**2161-7-14**] 05:45PM BLOOD ALT-23 AST-13 AlkPhos-62 TotBili-1.7* [**2161-7-15**] 02:05AM BLOOD ALT-19 AST-9 LD(LDH)-163 AlkPhos-58 Amylase-1044* TotBili-1.8* [**2161-7-16**] 07:15AM BLOOD ALT-18 AST-12 LD(LDH)-224 AlkPhos-52 TotBili-2.0* DirBili-0.5* IndBili-1.5 [**2161-7-19**] 07:25AM BLOOD ALT-17 AST-10 LD(LDH)-210 AlkPhos-58 TotBili-1.1 DirBili-0.4* IndBili-0.7 IMAGING: RUQ U/S: Distended gallbladder containing a few sludge balls. No specific signs for acute cholecystitis. CXR: Low lung volumes with bibasilar atelectasis. CTA CHEST: 1. No pulmonary embolism. Bibasilar atelectasis. 2. Coronary artery atherosclerotic calcification, significant in this age group. Brief Hospital Course: 49 y.o male with pmhx of multiple CVAs, multiple dvts (currently has IVC filter), aphasia, s/p G-tube for dysphagia presents with abdominal pain, nausea and vomiting found to have elevated lipase concerning for pancreatitis. #Pancreatitis- Felt ultimately secondary to biliary obstruction, although ultrasound revealed only distended gallbladder with biliary sludge. Hypertriglyceridemia ruled out, and patient denied recent ETOH or trauma. Statin initially considered as potential etiology so held in this setting. His BISAP score was 1 with no significant uremia, clear mental status, very small left pleural effusion/atelectasis on imaging, and hemodynamically stable. calcium level normal. Lactate mildly elevated in ED so admitted to MICU. He was treated with IVF repletion and bowel rest with improvement. Upon initial reinitiation of fluids patient did not tolerate well and had episode of emesis leading to UGI bleed with coffee ground emesis ultimately suctioned from Gtube. Resumed bowel rest and patient improved and eventually tolerating regular diet w/o abdominal discomfort. #Hypoxemia- No ARDS or significant pleural effusion seen on imaging. No PE on CTA. The patient denied cough, chest pain, fevers, chills and recent dyspnea. He was euvolemic/hypovolemic on exam with no evidence of heart failure. Imaging only remarkable for mild bronchial wall thikening compatible with chronic airway disease. Per nursing facility Baseline oxygen sats 92-94 (<95). Patient likely w/ component of hypoventilation and atelectasis. Oxygen saturations remained w/in baseline throughout course. #Leukocytosis -Likely related to pancreatitis described above. The patient denies cough, dysuria, diarrhea. Blood cultures and urine cultures obtained which showed were negative. Resolved with management of pancreatitis. No antibiotics administered. #Past CVA- according to records due to basilar artery dissection and subsequent basilar artery aneurysyms, was on plavix which he was intolerant of for unknown reason at this time. Currently on Coumadin,current neurologic exam at baseline per records and patient denies any new numbness or paralysis. INR 3.0 on admission and uptrending although patient did not get any doses of warfarin during his inpatient courese. TRANSITION OF CARE - maintained full code status - studies pending at discharge: urine culture [**2161-7-20**] - patient to follow up with PCP, [**Name10 (NameIs) **], GI Medications on Admission: NaCl nasal spray Chlorhexidine Gluconate 0.12% mouthwash Qdaily Fluticasone 50mcg nasal spray [**Hospital1 **] Glucosamine Chondroitin 500-400mg daily Lotrimin AF 1% Topical cream daily Nystatin 100,000 unit/ml oral suspension Prevident 5000 1.1 % Cream apply on teeth and gum line senna 8.6mg tab Q daily Famotidine 20mg [**Hospital1 **] Tylenol 650mg/20.3 cc oral solution PRN Pain Pyridoxine 100mg daily Niacin 100mg daily Lorazepam 0.5mg p.o Q4H PRN anxiety Mag oxide 400mg Tab [**Hospital1 **] Trazodone 50mg [**12-22**] tab QHS Baclofen 10mg tab Q8H PRN spasm of the muscle Colace 100mg [**Hospital1 **] Vitamin D 3 TID Simvastatin 40mg daily Loratidine 10mg tab daily Baclofen 20mg [**Hospital1 **] Refresh Liquigel 1% eye drops each eye Q2H PRN eye dryness Dulcolax 10mg supp PRN Fish oil 1 cap daily Coumadin 4mg daily Compazine 5 mg Q4H PRN nausea Compro supp 25mg [**Hospital1 **] Senokot 218mg/5ml syrup 10ml Q dPRN Discharge Medications: 1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL DAILY 2. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 3. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP [**Hospital1 **] apply on teeth and gum line 4. Senna 1 TAB PO BID Constipation hold for loose stools 5. Famotidine 20 mg PO BID 6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 7. Pyridoxine 100 mg PO DAILY 8. Niacin 100 mg PO DAILY 9. Lorazepam 0.5 mg PO Q4H:PRN anxiety 10. Magnesium Oxide 400 mg PO BID 11. traZODONE 25 mg PO HS:PRN insomnia 12. Baclofen 10 mg PO Q8H:PRN spasm, hiccups 13. Docusate Sodium (Liquid) 100 mg PO BID 14. Vitamin D 400 UNIT PO TID 15. Loratadine *NF* 10 mg Oral daily 16. Baclofen 20 mg PO BID 17. Artificial Tears 1-2 DROP BOTH EYES PRN dry eye 18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 19. Fish Oil (Omega 3) 1000 mg PO DAILY 20. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 21. Prochlorperazine 5 mg PO Q6H:PRN nausea 22. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 23. THERAPY Please resume PT, OT, and speech therapy Discharge Disposition: Extended Care Facility: [**First Name9 (NamePattern2) 112207**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: PRIMARY acute pancreatitis upper gastrointestinal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname 112208**], You were admitted to the hospital for abdominal pain and found to have pancreatitis. You were treated conservatively with bowel rest and IV fluids and you improved. Your pancreatitis was probably caused by a very small gallstone, so it is important that you follow up with surgery because you will need your gallbladder removed. You did have an episode of nausea and vomiting that likely caused a small tear in the lining of your stomach and you had some bleeding in your stomach. However, this stopped on its own and your blood counts remained stable thereafter. MEDICATION CHANGES STOP simvasatin STOP warfarin START pantoprazole Please continue all other medications as previously prescribed. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: MONDAY [**2161-7-27**] at 11:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2161-8-6**] at 4:15 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2161-8-19**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

4321,3484,3485,78003,2760,25060,3572,99659,9982,E8708,4019

Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-19**] Date of Birth: [**2076-5-4**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: headache and unresponsive Major Surgical or Invasive Procedure: intubation by OSH prior to arrival. extubation with trach placement. History of Present Illness: Mr. [**Known lastname 89692**] is a 63 yo Haitian man with history of DM and HTN who presented with severe headache and vomiting to [**Hospital3 9683**]. The patient was at home with his wife, when he suddenly developed the worst headache of his life at 11pm. He had previously been in his normal state of health, and his daughter spoke to him at 8pm. The patient apparently did have headache 1 day prior to presentation, but had no other symptoms. When his headache became severe on the night of admission, he was taken to [**Hospital3 9683**]. Upon arrival he was vomiting and becoming increasingly somnolent, so was intubated for airway protection. This was a traumatic intubation causing some oral bleeding, most likely because the intubation had punctured the soft palate. NCHCT showed 19mm R SDH. Patient was transferred to [**Hospital1 18**] for surgical eval. On arrival to [**Hospital1 18**] ED, patient was intubated and on propofol. Head CT showed significant enlargement of R SDH to 21mm, with 19mm L midline shift and compression of the brainstem pushing the brainstem to the left c/w uncal herniation. Initial exam showed pupils fixed and dilated, no corneals, not responding to noxious stimuli. Neurosurgical consult did not feel that patient would benefit from surgery since pupils were fixed and there was no change in his neurological examination in particular in his pupillary reactions and cornealreflex after he had received a 100g Mannitol challenge. Pt continued to receive a high dose of mannitol, nicardipine gtt for HTN and Dilantin for seizure prophylaxis. Per patient's family, he had not been ill, no recent trauma or falls, no changes to medications. He takes ASA 81 mg daily but no other blood thinning medications. He has never had profuse bleeding with surgery/dental work/injuries/etc, and there is no family history of bleeding disorders. Past Medical History: HTN HL DM for decades c/b peripheral neuropathy Social History: lives with wife, no tobacco, EtOH or illicits. Family History: NC Physical Exam: At admission: VS: T afebrile HR 80s BP 130s/60s General: intubated, no responding to verbal commands or noxious stimuli even without sedating agents turned off. HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. NEURO: Off propfol approx 1 hour: Eyes closed. Eyes do not open to sternal rub, no response to noxious stimuli. No spontaneous limb movements. Pupils 8mm and nonreactive. No VORs, very sluggish right corneal reflex noted, no corneal reflex on the left; vestibulo-ocular reflex absent; +strong cough and gag. Tone decreased. Intermittently a decerebrate posturing in his UE with very severe noxious stimuli. DTR 2+ in bilateral [**Hospital1 **], tri, brachiorad, absent in LEs, toes mute. At discharge: deceased Pertinent Results: At admission: [**2139-7-14**] 01:50AM PT-13.2 PTT-22.4 INR(PT)-1.1 [**2139-7-14**] 01:50AM WBC-14.7* RBC-5.29 HGB-15.8 HCT-44.2 MCV-84 MCH-29.8 MCHC-35.7* RDW-13.5 [**2139-7-14**] 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2139-7-14**] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2139-7-14**] 01:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2139-7-14**] 01:50AM URINE RBC->182* WBC-8* BACTERIA-FEW YEAST-NONE EPI-0 [**7-14**] CTA with and without Recon IMPRESSION: 1. Right-sided subdural fluid collection with acute hemorrhage along with hypodense areas which may related to ongoing hemorrhage/coagulopathy. Maximum transverse dimension of 23 mm with mass effect on the right erebral hemisphere, lateral ventricles and shift of the midline structures to the left side by approximately 21.3 mm. Hypodense appearance of the cerebral hemispheres may relate to a component of cerebral edema. Right sided uncal herniation; brain stem compression and distortion with leftward shift. Assessment for osseous structures/fractures is limited on the present study. Please see the outside study for additional details. To correlate clinically, for trauma/coagulopathy and close followup as clinically necessary. 2. Patent major intra- and extra-cranial arteries as described above with decreased caliber of the Basilar artery, A1 and A2 segments of the anterior cerebral arteries on both sides, part of which may relate to mass effect/spasm from cerebral edema. 3. Small focus of enhancement in the right-sided subdural hemorrhagic collection may relate to contrast extravasation. No abnormally dilated vessels to suggest an obvious vascular malformation in this location. Recommended review of the images by neurosurgery to decide on further workup. 4. Multilevel degenerative changes in the cervical spine along with a focus of prominent posterior disc osteophyte complex at C5-6 resulting in moderate canal stenosis and varying degrees of foraminal narrowing. MR can be considered if not CI and if clinically necessary. [**2139-7-19**] Nuclear Brain Scan: INTERPRETATION: Following injection of tracer, SPECT images of the brain were obtained in multiple projections and show no evidence of perfusion to the cerebral cortex. IMPRESSION: The perfusion abnormalities are consistent with brain death. Findings discussed with Dr [**Last Name (STitle) **] via phone at [**Pager number **] on [**2139-7-19**]. Brief Hospital Course: The patient was admitted to the NeuroICU for subdural hematoma. Patient was intubated at OSH prior to transfer. Neurological exam showed patient to be nonresponsive, with pupils fixed and dilated 6mm bilaterally. Right corneal reflex could be elicited, but was very sluggish; no left cornealreflex; cough intact, and extensor posturing on applying severe noxious stimuli in the UE. CTA showed 23 mm mass effect on the right cerebral hemisphere, lateral ventricles and shift of the midline structures to the left side by approximately 21.3 mm, as well as right sided uncal herniation, brain stem compression and distortion with leftward shift. Neurosurgery saw the patient but did not feel there was any surgical intervention that they could offer that would be of benefit given the patient's presenting neuro exam, in particular his fixed pupils and the lack of any change in his neurological exam after he got a Mannitol challenge of 100g. Neuro: The patient was continued to be treated with mannitol after the initial Mannitol challenge to decrease cerebral edema and herniation. Administration was limited by checking for hypernatremia and serum hyperosmolality. He was continued on fosphenytoin for seizure prophylaxis. Neuro exam initially slight worsened, since he lost a cough and gag reflex and he did not breath over the vent anymore. He continue to have a very sluggish right corneal reflex and some extensor posturing to severe noxious stimuli in his UE. All other brainstem reflexes were absent. His neurological exam worsened on [**2139-7-19**]. He no longer had any brain stem reflexes on exam and no posturing to noxious stimuli. Given his hemodynamic instability, apnea test was forgoed for fear of worsening hemodymanics. Instead a nuclear brain scan was done to evaluate for brain death. The scan showed no activity and subsequently the patient was pronounced brain dead. Pulmonary: The patient arrived intubated from the OSH. It was discovered that the endotracheal tube was traversing the right tonsillar pillar and ENT was consulted. They evaluated the patient and then took the patient for trach in order to remove the endotracheal tube. The trach was placed without complication. The patient was started on Unasyn for empiric coverage given the tonsil perforation. Infectious disease: The patient was febrile throughout the majority of his stay. Initial culture data failed to show any infection. Sputum culture on [**7-16**] grew staph aureus coag positive and H. influnzae. Cardiovascular: The patient became hypotensive on HD 5 and required pressor support. Renal: The patient was maintained on IVF as well as free water through his NG tube to maintain hydration with care not to worsen ICP. GI: NG tube was placed and tube feeds were started [**7-16**]. Code: Multiple family meetings were had with the patient's wife and daughters who shared that based on previous, specific discussions they had held with him in the past, they felt that he would want all heroic measures done. The patient remained full code through out his hospital course. Medications on Admission: ASA 81 mg daily Metformin Sitagliptin Lisinopril Lantus Lispro Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: subdural hematoma with midline shift, uncal herniation and brainstem compression leading to brain death Discharge Condition: deceased Discharge Instructions: NA Followup Instructions: NA [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

3202,3240,7907,04109,3839,78039,7813,2858,79092,2724,25092,4019,41401,412,V1582

Admission Date: [**2157-2-20**] Discharge Date: [**2157-3-4**] Date of Birth: [**2089-2-1**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: OSH transfer for pneumococcal meningitis and cerebritis Major Surgical or Invasive Procedure: Stereotactic Burr hole drainage of subdural empyema. History of Present Illness: 68M with PMH of DM, HTN, HL, CAD s/p distant MI, who is transferred from [**Hospital **] Hospital, where he presented on [**2157-2-13**] with fever, cough, and sore throat. He was initially treated for pneumonia with ceftriaxone and azithromycin. On the afternoon of admission, he was noted to be acutely aphasic, with word finding difficulty. There was concern for acute stroke. Neurology was consulted, he was transferred to the ICU, and a stat head CT was performed. Given that he was also febrile with an elevated WBC count to 27 with 27% bands, an LP was performed. This revealed 7800 WBCs with 94% polys, a glucose of 5, and a protein of 447. He was initially covered with vanc/CTX/ampicillin/acyclovir. CSF and blood cultures from [**2-13**] grew strep pneumo. ID was consulted, and recommended PCN G and rifampin, which were started on [**2157-2-13**]. He was followed by neurology and ID. He steadily improved and was transferred out fo the ICU on [**2157-2-15**]. An MRI performed [**2157-2-16**] showed right cerebral meningeal enhancement c/w his h/o meningitis, as well as concern for mastoiditis (non-communicating with the meninges). There was no evidence of abscess or hemorrhage, but a small frontal hygroma vs. subdural empyema. Nsurg was consulted, and there was NTD per them. On [**2-19**], ENT performed a right myringotomy, and a copious amount of seromucoid purulent material was aspirated; tubes were placed. Per his report, later that day he developed tingling of both upper extremities and the LLE, as well as left hand weakness and general poor coordination. Neurology was re-consulted, and exam revealed left sided neglect and poor coordination without frank dysmetria. A repeat MRI was performed, the preliminary report of which showed evidence of cerebritis. Plans were initiated tranfer him to the [**Hospital1 18**] neuro ICU, but they refused. He was instead accepted by the MICU. Prior to transfer, rifampin was resumed, and keppra was begun for seizure ppx. His temp was 100.2 and he was hemodynamically stable. On arrival to the [**Hospital1 18**] MICU, he complained of nausea. He endorsed ongoing numbness in his hands and feet since yesterday's ear operation. Past Medical History: PMH: 1. CAD - s/p MI in [**2138**], [**2151**] tx with angioplasty 2. HTN - currently managed w/ toprol XL 200mg 3. DM2 - managed on glucophage 1000mg [**Hospital1 **], glyburide 3.75 4. Hyperlipidemia - on lipitor 40mg 5. S/p ORIF for R zygomatic fx, and orbital fx with 2 plate insertion 6. Atypical pneumonia in [**2144**], complicated by bronchocentric granulomatosis and cold agglutinins hemolytic anemia 7. Cystic pancreatic disease 8. BPH s/p TURP 9. Appendicitis s/p appendectomy 10. S/p bladder polypectomy Social History: Mr. [**Known lastname 410**] is a retired immunologist at the [**Hospital3 328**] whose research interest was in monoclonal antibodies. He and his wife live in [**Name (NI) 1439**], MA. He has at least one son and one daughter. Daughter is an OB/Gyn at [**Hospital1 18**]. Denies EtOH. Tob use: 20 pack year hx, d/c in [**2136**]. Family History: Non-contributory Physical Exam: Upon transfer to medical service: VS: 98.9 120/54 106 w/ PVCs 24 95RA Gen: Well-nourished elderly man, lying in bed, talking to son, not SOB, in pain, or otherwise distressed. HEENT: H: R eye palpabral fissure slightly smaller than L (9mm vs. 12mm), no signs of trauma. E: PERRLA 3mm->2mm, conjunctiva not pale, anicteric. E: Slightly tender to palpation. No drainage appreciated. N: No signs of epistaxis. T: Moist mucous membranes, no erythema or exudate. Neck: Soft, supple. No LAD at pre/post auricular, ant/post cervical, submandibular, supraclavicular nodes. No carotid bruits. No mastoid tenderness. CV: Tachycardic, reg rhythm with nl S1, S2. No m/r/g. Pulses 2+ in all 4 extremities (DP and PT on feet). No splinter hemorrhages. Lungs: Nl excursion on inspiration. No dullness to percussion. No tactile fremitus. Lungs clear to auscult, bilat and ant/post. No crackles, wheezes or rhonchi. Diaphragms symmetric. Abd: Soft, non-tender. Slightly distended, but not tympanic. Hypoactive bowel sounds. Liver percussed at 8cm. No renal bruits. Back: No spinal tenderness. No CVA tenderness. No paraspinal tenderness. Ext: No edema, erythema. WWP. Neuro: AAOx3. Gives identifiers without prompting. Able to name past 2 presidents only. Can multiply 6x7. Cannot subtract 17 from 81. Able to talk briefly about his research. Three word recall intact at 2min. Full strength (unable to break) in deltoids, biceps, triceps, IPs, and gastrocs, bilaterally. R does seem slightly stronger however. Able to hold pen in L hand, but trouble re-capping. Dysmetria w/ finger to nose on the L. CN II: Lower left quadrant cut bilaterally. III, IV, VI:EOMS intact. (son notes no ptosis as compared to baseline) V: Sensation intact to light touch. VII/VIII: Face symmetric aside from eyes as mentioned above. Hearing intact to snaps, not light rustle. IX/X: coughs. XII:SCM intact, trap intact. XII:tongue midline. Upon Discharge: c/o sl. HA controlled A&Ox3, PERRL, follows commands, 5/5 strength, wound C/D/I Pertinent Results: FROM OUTSIDE HOSPITAL PRIOR TO TRANSFER: MICRO: [**2-13**] CSF HSV PCR: negative [**2-13**] CSF gram stain: GPCs in P+C, culture neg [**2-13**] BCx + pansenstive strep PNA [**2-13**] UCx: <10,000 CFU, mixed flora No right ear fluid cultures sent from OR on [**2-19**] . OSH IMAGING: [**2-13**] CT-A: no evidence of PE. Calcified right costophrenic sulcus plaque with associated. . [**2-15**] Head CT without contrast new small amound of hypodense fluid in the right frontal subdural space/ While this may represent a subdural hygroma, given the patient's h/o bacterial meningitis, a subdural empyema should be considered. Complete opacification of the right mastoid air cells with fluid int he right middle ear, as seen previously. . [**2157-2-15**] Temporal Bone CT bilateral cerumen plugs, extensive opacifiaction of the right mastoid air cells, antrum, and middle ear suggesting otomastoiditis. No bony destruction. . [**2-16**] MRI Brain: extra-axial collection right cerebral hemisphere suggestive of meningeal enchancement c/w clinical hx of bacterial meningitis. No abscess or hemorrhage is seen.Non-aeration of mastoid air cells with fluid signal c/w mastoiditis. However, this does not appear to have broken through the subjacent meninges. Normal venous sinuses. . [**2-16**] B/L carotid U/S: < 20% ICA stenosis on both sides . [**2-16**] TTE LVEF 40-45%, with inferior and posterior akinesis. Normla RV. 2+ MR, 1+ TR. Negative bubble study. . [**2-17**] CXR fibrosis and scarring at the right base, small right pleural effusion. PICC line at jxn of SVC and RA. . [**2-21**] CT Head w/ and w/o contrast: "1. Right otomastoiditis. 2. Unchanged small right parietal subdural collection, concerning for a subdural empyema. 3. Persistent cortical swelling in the right parietal, posterior frontal, and temporal lobes, compatible with known cerebritis." . [**2-21**] CT Orbits, Sella w/ contrast: "Findings compatible with severe right otomastoiditis with possible coalescence of the mastoid septae. There is also thinning and demineralization of the tegmen tympani. Would recommend MRI with skull base protocol to assess for meningeal extension of infection. Additionally, there is a tiny subdural collection on the right, again recommend MRI for further evaluation and to exclude a subdural empyema." . [**2-22**] MR [**Name13 (STitle) 430**] w/ and w/o contrast, MRV Head: "1. Unchanged small right parietal subdural empyema. 2. Right cortical edema consistent with cerebritis is again seen. New mild slow diffusion suggests interval worsening. 3. Mild right-sided leptomeningeal enhancement, consistent with meningitis. 4. Right otomastoiditis again seen. 5. No evidence of venous sinus thrombosis. " . [**2-24**] CT Head: "No significant change from prior studies, with unchanged right- sided subdural collection, consistent with previously characterized subdural empyema. Persistent opacification of right mastoid air cells and middle ear cavity. " . [**2-26**] CT Head: "Stable examination demonstrating unchanged right subdural collection consistent with previously characterized subdural empyema. No interval change in opacification of right mastoid air cells and middle ear cavity. " . [**2-28**] MR [**Name13 (STitle) 430**]: "Stable appearance since [**2157-2-22**]. Evidence of right mastoiditis with adjacent subdural empyema, extensive dural enhancement, leptomeningeal enhancement, and no evidence of infarction or sinus thrombosis. " . CBC: [**2157-2-20**] 11:14PM WBC-14.5*# RBC-3.88* HGB-13.0*# HCT-35.7*# MCV-92 MCH-33.4* MCHC-36.3* RDW-13.1 [**2157-2-20**] 11:14PM NEUTS-87.7* LYMPHS-9.3* MONOS-1.9* EOS-1.0 BASOS-0 [**2157-2-20**] 11:14PM PLT COUNT-399# [**2157-3-3**] 04:50AM 7.9 4.12* 13.5* 37.6* 91 32.8* 36.0* 13.7 328 Coags: [**2157-2-20**] 11:14PM PT-15.2* PTT-33.9 INR(PT)-1.3* [**2157-3-3**] 04:50AM 16.2* 33.7 1.4* Chem 7: [**2157-2-20**] 11:14PM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-15 [**2157-3-3**] 04:50AM 128* 18 1.0 139 4.1 101 28 14 LFTs: [**2157-2-27**] 06:17AM 29 18 186 66 0.3 Head CT [**3-3**] There is a new posterior parietal burr hole, and pneumocephalus overlying the left posterior frontal and parietal lobes. Small low-density extra-axial collection layers dependently, and appears slightly more dense in comparison to [**2156-2-26**]. Effacement of the underlying sulci is unchanged. There is no hydrocephalus or shift of normally midline structures. No intracranial hemorrhage is identified. [**Doctor Last Name **]-white matter differentiation remains normally preserved. Complete opacification of the right mastoid air cells persist. Brief Hospital Course: 68M with PMH of DM, HTN, CAD s/p MI, who is transferred from an OSH with resolving pneumococcal meningitis and new neurological deficits, found to have mastoiditis, cerebritis, and subdural empyema. . # Meningitis: Mr. [**Known lastname 410**] was treated with IV Ceftriaxone 2mg IV q12, in addition to 50mg [**Hospital1 **] Metronidazole upon arrival. Metronidazole was replaced with Clindamycin following a seizure, but was changed back to metronidazole following the start of levetiracem. Since his transfer here, Mr. [**Known lastname 410**] has remained afebrile, with a WBC trending down. Clinically, Mr. [**Known lastname 410**] improved dramatically over the course of his stay to the point where no neurological deficits can be noted noted. He has no meningeal signs at present. . #Cerebritis - Empyema was followed serially by CT and MR imaging without any change over his stay. There was no involvement of the sinuses. The decision was made on [**2156-2-29**] by medicine, neurosurgery, and ID to surgically drain the fluid collection via stereotactic biopsy. . # Mastoiditis- Patient has ear tubes bilaterally that have drained minimally. He has remained afebrile since his arrival and w/o pain. Hearing remains sensitive to loud snaps only. He continues on Ciprofloxicin ear drops 0.3% Ophth Soln 4-10 drops to the right ear. . # Seizure - Patient had a single generalized, tonic clonic seizure in the MICU on [**2156-2-20**] while on Keppra 500mg. Metronidazole was stopped temporarily and the patient was loaded with additional Keppra. Pt has not seized since MICU stay. He remains on Keppra, now tritrated up to 1g for neurosurgical intervention. . # HTN - Mr. [**Known lastname 410**] was never hypotensive during his stay and his pressures largely ranged in the 130s sytolic. Metoprolol was started at 25 mg [**Hospital1 **] and titrated up to 50 mg tid, with the discharge goal of home dosing of 200mg qd. . #Diabetes - Mr. [**Known lastname 410**] was initially covered under a sliding scale. When full diet was resumed, his glucose values were in the high 200s. Medication was changed to pt's home PO metformin and glyburide, with modest effect. Hyperglycemia thought to be resultant of stress and illness. . #CAD, hx of MI - Stable, no events. Continued statin. Given possibility of intervention, ASA was held throughout the stay. . #Anemia - Pt was down from baseline of 47.7 in [**2155**] to 37.8. Because of history of cold agglutinin hemolysis, patient was worked up for anemia. Haptoglobin was within normal limits. Iron labs were consistent with anemia of inflammation, with normal MCV, lower transferrin, and lower TIBC. On [**3-2**] he was brought to the OR by Dr. [**Last Name (STitle) **] for a steriotactic burr hole placement and washout of subdural empyema. He tolerated the procedure and was transferred to the floor where he ambulated with nursing and tolerated a regular diet. He was then safe to be d/c'd home with services and follow up appointment Medications on Admission: Home Meds: Lipitor 40 mg ASA 650 mg daily Glucophage 1000mg [**Hospital1 **] Glyburide 3.75mg [**Hospital1 **] Toprol XL 200 mg MVI . Transfer Meds: Rifampin Keppra 250mg po bid ([**2-20**] - ) RISS Floxin otic gtt to right ear [**Hospital1 **] PCN G 4 million units q4h IV metformin 1000mg [**Hospital1 **] tylenol q4h prn prn metoprolol 25mg [**Hospital1 **] Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ciprofloxacin 0.3 % Drops Sig: 4-10 Drops Ophthalmic TID (3 times a day): Right ear only. Disp:*1 1* Refills:*2* 5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 13 days: Do not consume alcohol while taking this medication. Disp:*40 Tablet(s)* Refills:*0* 7. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for 13 days. Disp:*26 IV Piggyback* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: Please do not exceed 4 grams per day. . 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Headache: Please do not drink or drive while taking this medication. Disp:*50 Tablet(s)* Refills:*0* 12. PICC Line Care Saline flush 10cc SASH PRN Heparin flush 10u/ml 3cc SASH PRN Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary: Streptococcus pneumoniae meningitis, cerebritis, and mastoiditis. Secondary: Diabetes Mellitus, Type II, non-insulin dependent Coronary artery disease HTN Discharge Condition: Stable. Discharge Instructions: You were transferred from [**Hospital **] Hospital with an infection of your brain and your mastoid bone. While you were here, you received intravenous antibiotics, anti-seizure medication, and repeated imaging of your brain. The medicine, [**Hospital 1083**] disease, and neurosurgery teams decided that having surgical drainage of the [**Hospital 1083**] collection around your brain would best help clear the infection. You were started on the following NEW medications, all of which you will continue: 1. Ceftriaxone 2 g IV Q12H 2. Metronigazole (Flagyl) 500 mg PO Q8H 3. Ciprofloxicin Ear Drops 4. Levitracetam 1g PO BID The first medication will be given through the picc line in your arm. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] this. The flagyl will be an oral medication, in the same amount, to be taken three times a day. [**Last Name (Titles) **] disease will determine the length of your antibiotics. Because of the antibiotic ceftriaxone can interfere with your liver on rare occassion, you will need your liver enzymes tested once per week. Please have blood drawn and tested for CBCs, Chem 7, and LFTs each week and send the results to the [**Last Name (Titles) 1083**] disease clinic at ([**Telephone/Fax (1) 1353**]. If you should become febrile, confused, lose bowel or bladder function, have a strong headache, experience any loss in vision, or lose conciousness, please return to the emergency room immediately. You will need follow-up appointments with your PCP, [**Name10 (NameIs) **] Disease, Neurology, Neurosurgery, and ENT. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen etc. -You haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? 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. *******You may resume your Asprin on [**2157-3-12**]****** Followup Instructions: Please be sure to follow up with the following physicians: 1. [**Date Range **] Disease - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST (SB) [**2157-3-22**] 11:30am 2. Ear, Nose and Throat - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**] [**Apartment Address(1) 96381**], [**Location (un) 55**] [**3-8**] @ 10:15 am, Tuesday [**Telephone/Fax (1) 2349**] 4. PCP [**2157-3-8**] at 10am Dr [**First Name4 (NamePattern1) 449**] [**Known lastname 410**] [**Location (un) **], [**Location (un) **], MA. Because of the antibiotic ceftriaxone can interfere with your liver on rare occassion, you will need your liver enzymes tested once per week. Please have blood drawn and tested for LFTs each week and send the results to the [**Location (un) 1083**] disease clinic at FAX number [**Telephone/Fax (1) 11959**]. Neurosurgical Follow-Up Appointment Instructions ??????Please return to the office [**2157-3-11**] for removal of your sutures and 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. ??????You have an appointment with Dr. [**Last Name (STitle) **] on [**2157-3-15**] at 9a at [**Hospital Unit Name **], [**Hospital Unit Name **] If you have any questions please call ([**Telephone/Fax (1) 88**] ??????You are scheduled for an MRI of the brain with and without gadolinium contrast on [**3-15**] at 730 am in the [**Hospital Ward Name 517**] Basement. Completed by:[**2157-3-4**]

99811,2851,185,4019,49320

Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-16**] Date of Birth: [**2125-3-29**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1232**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 65 y/o male with [**Doctor Last Name **] 6 prostate cancer. He had a 26 core prostate needle biopsy this afternoon with Dr. [**Last Name (STitle) **]. He had rectal bleeding shortly after going home from the clinic this afternoon, and was brought to the ED by ambulance after feeling lightheaded with continuous rectal bleeding. He had a syncopal episode on admission to the ED. He denies nausea, vomiting, fevers, chills, chest pain, dyspnea, hematuria, urinary urgency, frequency. The patient had discontinued his aspirin one week prior to the biopsy as instructed. Past Medical History: HTN Hyperlipidemia Mild COPD/Asthma Colonic polyps Social History: Past tobacco use (quit 3-4 years ago), +EtOH use (approx 4 drinks per day) Family History: Father, mother: [**Name2 (NI) 499**] cancer Physical Exam: VS: Afebrile, HR 65, BP 139/49, R 16, 100%RA NAD, A&Ox3, lying in Trendelenburg RRR, No respiratory distress Abd: Soft, nondistended, nontender GU: No active rectal bleeding on initial exam. On DRE, pressure and surgicel were applied to the prostate, and there was no active bleeding or clots after pressure applied. Ext: No cyanosis/clubbing/edema. Pertinent Results: [**2191-7-15**] 02:41AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.1* Hct-26.6* MCV-91 MCH-31.2 MCHC-34.4 RDW-12.6 Plt Ct-226 [**2191-7-14**] 02:59AM BLOOD PT-15.9* PTT-23.5 INR(PT)-1.4* [**2191-7-14**] 02:59AM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-139 K-4.0 Cl-108 HCO3-26 AnGap-9 [**2191-7-15**] 02:41AM BLOOD CK-MB-5 cTropnT-<0.01 Brief Hospital Course: On [**2191-7-13**], the patient was admitted to Dr.[**Doctor Last Name **] Urology service/SICU from the ED with rectal bleeding and syncope after prostate needle biopsy. In the ED, surgicel and pressure were applied to the prostate and the acute bleeding stopped. The patient was placed in trendelenburg and serial Hct's were checked. GI consult was requested by the ICU team, and they recommended Vit K for elevated INR 1.5. Cardiac enzymes were negative. On HD 2, the patient had several bloody bowel movements and remained in the ICU for monitoring. Hematocrits were stable at 26-27 without transfusion on HD 2. On HD 3, the patient was seen by general surgery, who performed an anoscope. The anoscopy showed old clot, no active bleeding. Also on HD 3, the patient was transferred to the floor from the ICU in stable condition. Serial Hct's were monitored, which continued to be stable at 24-26. He received peri-operative antibiotic prophylaxis, and he remained afebrile throughout his hospital stay. At discharge, patient denied pain, was tolerating a regular diet, ambulating without assistance, and voiding without difficulty. He denied chest pain, dyspnea, abdominal pain at discharge. He was given explicit instructions to call Dr. [**Doctor Last Name 5752**] office to schedule follow-up appointment. Medications on Admission: Levoxyl 75mcg Fluoxetine 20mg Simvastatin 10mg Levaquin (perioperative) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Rectal bleeding status post ultrasound guided prostate needle biopsy Discharge Condition: Stable Discharge Instructions: -Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up appointment. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -If you have fevers > 101.5 F, abdominal pain, nausea or vomitting, bright red blood per rectum, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up appointment. Completed by:[**2191-7-16**]

4260,42789,7802,9100,4019,2724,53081,V1046,V1254,E8889

Admission Date: [**2191-8-23**] Discharge Date: [**2191-8-25**] Date of Birth: [**2114-2-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 1402**] Chief Complaint: CHIEF COMPLAINT: Syncope Major Surgical or Invasive Procedure: Dual Chamber pacemaker placement History of Present Illness: 77 y/o man with a PMH significant for prostate cancer (T2a, [**Doctor Last Name **] score 9), HTN and hyperlipidemia transferred from [**Hospital1 **] s/p syncopal episode this morning found to be in complete heart block with ventricular escape. By report, in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] he was asymptomatic with a SBP 110 and HR in the 30s. Transcutaneous pacing pads were placed with good capture at 50mA and a CT head was negative for mass/shift/bleed. He received 0.5mg atropine and was sent to [**Hospital1 18**] for further management. . In the ED, he was in complete heart block with a ventricular escape rhythm in the 20s. He was given 5mg IV glucagon [**3-2**] concern for Atenolol overdose in the setting of Cr 1.3 (baseline unknown). Labs were notable for trop <0.01. Cardiology was consulted and he was admitted to the CCU for temp pacer wire placement. . The pt states that he had been in his normal state of health this morning until rising from his car and walking towards a conveniece store. Approximately 2 seconds after rising from his car he fell, hit his head and briefly lost consciouness. There was no prodrome of lightheadedness, nausea, vomiting, diaphoresis, palpitations or changes in vision. He also denies ever experiencing CP/SOB and does not recall tripping or any mechanical aspect to the event. He has never had a seizure and was not post-ictal. He is followed by his PCP, [**Name10 (NameIs) 1023**] he last saw 1 month ago. His last EKG was 1 year ago, and there is a questionable history of pre-existing LBBB per family (pt unaware). He denies any cardiac history and has never been diagnosed with AS or other valvular or structural heart disease. . On review of systems, he endoses a stroke in [**2180**] with no residual neuro deficits. He denies 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. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema or palpitation. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: as per HPI - PACING/ICD: trans venous pacer in place 3. OTHER PAST MEDICAL HISTORY: 1. Prostate cancer 2. GERD 3. BPH 4. CVA ([**2180**]), no residual deficits Social History: The patient quit smoking 32 years ago. He does not drink excessively. He lives with his wife and his daughter who is a nurse. Family History: No FH of premature death, cardiac disease, early MI. Father died of colon cancer, mother died in her 80s of unknown cause. Physical Exam: Admission VS: T 96.3 BP 150/57 HR 60 (paced) RR 18 O2 Sat 98% RA Weight: 207.3. Height: 68.75. BMI: 30.8. GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, JVP difficult to asses [**3-2**] R IJ CARDIAC: PMI not palpable. 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: Superficial abrasion on the R scalp, hand and knee PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Discharge: General Appearance: Well nourished, No acute distress Head, Ears, Nose, Throat: Bandage on forehead intact. Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : Bilaterally) Abdominal: Soft, Non-tender Extremities: Right lower extremity edema: None, Left lower extremity edema: none Skin: Left chest dressing clean/dry/intact Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2191-8-25**] 05:14AM BLOOD WBC-9.0 RBC-4.11* Hgb-12.4* Hct-35.3* MCV-86 MCH-30.2 MCHC-35.2* RDW-15.5 Plt Ct-138* [**2191-8-23**] 10:30PM BLOOD WBC-11.0 RBC-4.17* Hgb-12.6* Hct-35.6* MCV-85 MCH-30.2 MCHC-35.5* RDW-15.3 Plt Ct-185 [**2191-8-23**] 10:30PM BLOOD Glucose-103* UreaN-21* Creat-1.3* Na-135 K-4.9 Cl-105 HCO3-21* AnGap-14 [**2191-8-25**] 05:14AM BLOOD Glucose-114* UreaN-22* Creat-1.3* Na-142 K-4.3 Cl-109* HCO3-27 AnGap-10 [**2191-8-23**] 10:30PM BLOOD cTropnT-<0.01 [**2191-8-24**] 06:10AM BLOOD CK-MB-3 cTropnT-0.03* [**2191-8-24**] 01:29PM BLOOD CK-MB-3 cTropnT-0.01 [**2191-8-24**] 06:10AM BLOOD TotProt-5.4* Albumin-3.9 Globuln-1.5* Calcium-8.8 Phos-3.4 Mg-2.0 EKG [**2191-8-23**] Sinus rhythm with slow idioventricular rhythm, complete heart block. No previous tracing available for comparison. [**2191-8-24**] Sinus rhythm with atrial sensed and ventricular paced rhythm and capture, newas compared to the previous tracing of [**2191-8-23**]. Echo [**2191-8-24**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No cardiac cause of syncope identified. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild tricuspid and mitral regurgitation. CXR [**2191-8-25**]: Cardiomediastinal contours are normal. Left transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. Thereis no pneumothorax. Left pleural effusion is small. Right lower lobe atelectasis has improved. Left lower lobe atelectasis is stable. LYME SEROLOGY (Final [**2191-8-25**]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in [**3-3**] weeks. Brief Hospital Course: # Bradycardia s/p Pacer placement: Patient presented with complete heart block and a slow idioventricular rhythm. His troponins peaked at 0.03 but were negative at discharge. His lyme serologies returned negative. He had successful placement of a St. [**Male First Name (un) 923**] dual chamber pacemaker. Follow up chest x-ray was unremarkable and EKG demonstrated atrial sensed and ventricular paced rhythm. Following pacemaker placement, atenolol and irbesartan were started. Patient tolerated the procedure well and was discharged without incident. # Syncopal episode with fall. Patient sustained abrasions on the top of his head which were bandaged and cared for. Head CT from outside hospital was negative. Patient was stable upon discharge. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - Dosage uncertain ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - Dosage uncertain FOLIC ACID - (Prescribed by Other Provider) - Dosage uncertain IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - Dosage uncertain TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE [CALTRATE 600] - (Prescribed by Other Provider) - Dosage uncertain L.ACIDOPH & SALI-B.BIF-S.THERM [ACIDOPHILUS] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN [MULTI-DAY] - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain . Chemotherapy/Anti-androgens: ([**2191-8-16**]) LUPRON 7.5mg IM ([**2191-8-16**]) CASODEX 50mg po daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily (). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* 8. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO once a day. Capsule, Ext Release 24 hr(s) 10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin C 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 12. lactobacillus acidophilus Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. Chemotherapy/Anti-androgens: ([**2191-8-16**]) LUPRON 7.5mg IM monthly ([**2191-8-16**]) CASODEX 50mg po daily Discharge Disposition: Home Discharge Diagnosis: 3rd Degree heart block Syncope [**3-2**] bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted to the hospital after a fall related to your heart rate going too slowly. We have given you a St. [**First Name8 (NamePattern2) 923**] [**Last Name (NamePattern1) 10661**] XL 5826 pacemaker which will keep the heart rate going at an acceptable rate. We would like you to please follow up with the electrophysiology clinic team to evaluate the pacemaker. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2191-8-31**] at 1 PM With: ONCOLOGY DIETITIAN [**Telephone/Fax (1) 3681**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2191-9-15**] at 11:00 AM With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] Location: [**Hospital **] MEDICAL ASSOCIATES, PC Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 70678**] Phone: [**Telephone/Fax (1) 60570**] Appointment: Friday [**2191-9-2**] 10:45am Department: CARDIAC SERVICES When: WEDNESDAY [**2191-8-31**] at 9:30 AM 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: CARDIAC SERVICES When: FRIDAY [**2191-9-30**] 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

00845,5849,5990,83500,27651,27652,E8889,32723,28860

Admission Date: [**2180-11-27**] Discharge Date: [**2180-12-1**] Date of Birth: [**2115-5-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: Hypotension, Diarrhea Major Surgical or Invasive Procedure: Placement of a central venous line History of Present Illness: This is a 65 year-old female with past medical history significant for R hip replacement post multiple disclocations and reductions and history of C. diff colitis in [**2177**] who presents with profuse watery diarrhea x1 week, hypotension and syncope. She was transfered from [**Hospital **] hospital after a syncopal event at home. Per records, she had been intermittently confused with decreased oxygen saturations. Of note, per report, the patient was started on dilaudid 4 mg prn at the time of her laminectomy and has apparently had several episodes of confusion and incoherent speech since starting this medication. The patient states she had been having significant diarrhea for over one week, and in fact took kayopectate which stopped the diarrhea for 2 days. It has been constant for the last week. She had been resting at home, and as she got up to stand last pm, she felt the room spinning and then had a syncopal episode. Her husband caught her before she fell. She then presented to [**Location (un) **] for evaluation. There, she had evidence of a right hip dislocation and hypotension and received around 9 L of NS as well as levoflox/flagyl. Given persisent hypotension, she was transfered here for further management. Of note, the patient has had multiple courses of antibiotics over the last 2 months, first for a UTI in [**Month (only) **], then at the time of her laminectomy, and most recently completed a course for pneumonia last week. In the ED, initial VS 99.2 101/50 87 18 98% on 4L. She received 1 gm ctx, 500 mg flagyl, ativan 1 mg IV and fentanyl (for hip reduction). A RIJ was placed given concern for shock, though no levophed was required. She rec'd 2 L NS in the ED. R hip was reduced by orthopedics and knee immobilzer placed prior to transfer to ICU. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. She does report decreased urine output over the last 24 hours prior to admission as well as abdominal discomfort that is new today. Past Medical History: Depression Anxiety Fibromyalgia Recent laminectomy in [**9-30**] at NEBMC R hip replacement in [**10-27**] RLS Sleep apnea Arthritis Social History: Quit smoking prior to surgery, smoked one pack per 3 days for many years prior, rare etoh, independent ADLS at home. Family History: No recent sick contacts, non-contributory Physical Exam: On Presentation: Vitals: T: 97.3 BP:101/50 HR:88 RR: 22 O2Sat:100% on 3L NC GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, mildly distended, tender diffusely to deep palpation only, no HSM, no masses EXT: No C/C/E, no palpable cords, knee immobilizer in place, R hip without ecchymoses NEURO: alert, oriented to person, place, and time. Poor historian Skin: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2180-11-26**] 09:30PM BLOOD WBC-17.2* RBC-3.25* Hgb-9.6* Hct-28.0* MCV-86 MCH-29.7 MCHC-34.4 RDW-15.5 Plt Ct-323 [**2180-11-27**] 04:41AM BLOOD WBC-16.9* RBC-3.25* Hgb-9.3* Hct-29.3* MCV-90 MCH-28.5 MCHC-31.6 RDW-15.4 Plt Ct-312 [**2180-11-27**] 04:41AM BLOOD Neuts-82.8* Lymphs-12.1* Monos-4.1 Eos-0.9 Baso-0.1 [**2180-11-27**] 04:41AM BLOOD PT-14.6* PTT-29.9 INR(PT)-1.3* [**2180-11-26**] 09:30PM BLOOD Glucose-94 UreaN-21* Creat-1.5* Na-140 K-3.5 Cl-118* HCO3-13* AnGap-13 [**2180-11-27**] 04:41AM BLOOD Glucose-88 UreaN-18 Creat-1.4* Na-140 K-3.4 Cl-117* HCO3-12* AnGap-14 [**2180-11-27**] 04:41AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.6 [**2180-11-26**] 09:46PM BLOOD Lactate-0.9 [**2180-11-27**] 04:56AM BLOOD Lactate-0.6 Brief Hospital Course: This is a 65 year old female with recent history of C. diff colitis (06') and recent mult abx use for UTI/PNA past couple months who presented after a syncopal episode in the setting of diarrhea/dehydration with c. diff colitis with a R hip dislocation as result of synocopal episode and also noted ARF (pre-renal). Tx from OSH for persistant hypotension - admitted to MICU - mgmt only with aggressive IVF resusitation (no pressors were required), tx with po vanc/IV flagyl. . # Leukocytosis: Pt presented with a leukocytosis of 17.2, most likely due to C. diff colitis given her diarrhea and clinical history. CXR at the OSH prior to admission in the [**Hospital Unit Name 153**] showed resolution of prior pna. Patient denied cough or fevers at home, though there was a report of hypoxia as noted above. Differential shows left shift without bandemia, no recent WBC for comparison. UA negative initially. Following onset of Flagly and Vancomycin regimen pt's leukocytosis started to trend down, however prior to transfer from the ICU to the medical floor her WBC increased to 19. Given her improving colitis signs as well as a clear pulmonary examination a U/A was sent and noted to be suspicious for infection. Pt was then started on a 3 day course of Ciprofloxacin by MICU. Importantly, pt's R IJ and foley were the day of transfer from the MICU. The patient's leukocystosis remained stable at 19K over the next 72 hours and given good clinical status and no significant documented fevers or symtoms while being observed in the hospital over that time, the patient was discharged to f/u with a repeat cbc the next week at her PCP office to monitor. . # C. diff colitis/Diarrhea: Vastly improved during her hospitalization. The patient was discharged to complete a prolonged course of po vanc and flagyl. . # OSA/OHA (sleep apnea): Restarted home CPAP here (patientused prior but then self d/c 1 mo prior but willing to re-try now). . # Hypotension/syncope: Likely due to profound dehydration from ongoing severe diarrhea. Patient had been unable to maintain hydration and had required upwards of 10 L of IVF since her admission to the OSH ED. Never required pressors. . # Syncope: Likely result of orthostatic hypotension secondary to her diarrhea from C. diff colitis. . # Hip dislocation: Status post reduction in the ED by ED staff and orthopedics. Hip had dislocated multiple times in the past, usually reduced in OR. Patient is currently in knee immbolizer, no plans for surgical intervention at this time. Pt was seen by Orthopaedics who recommended seeing her as an outpatient given that she was able to ambulate on her hip. . # Acute Renal Failure: On admission pt was noted to be in ARF with a reported elevated Creatinine of 2.17 at an OSH. During hospitalization course pt was given IV hyrdration (7 L in the ICU) and her creatinine was noted to trend down back to normal. Creatinine elevation most likely pre-renal secondary to her diarrhea. . # Depression/Anxiety - controlled with pt's home regime. Medications on Admission: Nexium 40 mg daily Prozac 40 mg daily ASA 81 mg daily Lunesta 2 mg QHS Celebrex 200 mg [**Hospital1 **] Oxazepam 10 mg TID Lisinopril 10 mg daily Buproprion 150 mg TID Requip 2 mg daily MVI Neurontin 600 mg QID Discharge Medications: 1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Celebrex 200 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO three times a day. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)): TAKE PRIOR HOME DOSE. 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Eszopiclone 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 20 days. Disp:*80 Capsule(s)* Refills:*0* 13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. Disp:*20 Lozenge(s)* Refills:*2* 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 20 days. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Clostridium Difficile Colitis Hypotension Syncope Leukocystosis, Persistent Discharge Condition: Vitals Signs Stable Discharge Instructions: Return to ED if having fevers, chills, worsening abdominal pain, worsening diarrhea, rigors, significant lethargy. You have a white blood cell count of 19,000 on day of discharge. This elevated white blood cell count has been stable over the past three days and has not worsened. Clinically, you are vastly improved. You should have your white blood cell count followed up next week by your PCP. Followup Instructions: Patient to f/u with her PCP and have her wbc checked and monitored next week. Patient to schedule appointment with her PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**].

42823,5849,4254,2763,4280,42731,78729,53081,V422,V5861,4168,56400,2768

Admission Date: [**2157-1-5**] Discharge Date: [**2157-1-12**] Date of Birth: [**2091-10-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: This is a 65 yo M who is 5 weeks s/p tricuspid valve replacement for severe nonischemic cardiomyopathy with h/o [**Hospital1 **]-V IVCD (lead causing wide open TR) and chronic afib on coumadin, who p/w one day history of worsening DOE and orthopnea. Pt has noted DOE with walking since his operation on [**2156-11-28**]. Three days ago his DOE increased. Two nights ago, he noted increased orthopnea and had 2 episodes of PND. He saw his cardiologist, Dr. [**First Name (STitle) 437**], for f/u yesterday, at which point he had no complaints. After the appointment he noted increased DOE, occurring after a few steps. All of these were acute changes from the past few weeks. No appreciable increase in edema. Denies prior PND. Denies CP. Has had nonproductive cough since leaving hospital on [**12-29**] for constipation. No f/c. No n/v/d. Came in today because of acute change in symptoms. . On [**Hospital1 1516**] this AM, pt received 100mg IV lasix. Went for RHC after which swan was placed. Now being admitted to CCU for milrinone +/- lasix gtt for fluid management. . On arrival to CCU, pt was comfortable without complaints. Past Medical History: s/p Tricuspid valve replacement for TR s/p biventricular pacer/ICD placement [**2155-8-10**] s/p removal of pacer/ICD s/p Left achilles tendon repair s/p Sinus Surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia Social History: Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**]. Never smoked. Denies illicits. Drank EtOH only rarely after diagnosed with CHF; quit in [**2156-4-9**]. Family History: Mother with renal failure. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION VS - HR 70 BP 89/59 97%RA GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, JVD 1/2 up neck @30 degrees LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted. Heart sounds distant. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 2+ bilateral pitting edema. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, grossly non-focal . DISCHARGE GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD appreciated LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no edema. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, grossly non-focal Pertinent Results: ADMISSION LABS [**2157-1-5**] 03:25PM BLOOD WBC-6.1 RBC-3.48* Hgb-11.2* Hct-33.6* MCV-96 MCH-32.3* MCHC-33.5 RDW-16.5* Plt Ct-145*# [**2157-1-5**] 03:25PM BLOOD Neuts-77.9* Lymphs-15.0* Monos-4.8 Eos-1.8 Baso-0.5 [**2157-1-5**] 03:25PM BLOOD PT-24.8* PTT-40.0* INR(PT)-2.4* [**2157-1-5**] 03:25PM BLOOD Glucose-90 UreaN-47* Creat-1.7* Na-138 K-4.7 Cl-94* HCO3-34* AnGap-15 [**2157-1-7**] 05:39AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2. . CARDIAC ENZYMES [**2157-1-5**] 03:25PM BLOOD cTropnT-0.03* [**2157-1-6**] 07:25AM BLOOD CK-MB-3 cTropnT-0.03* [**2157-1-6**] 07:25AM BLOOD CK(CPK)-33* . DISCHARGE LABS . PERTINENT LABS . PERTINENT STUDIES CXR [**2157-1-5**] FINDINGS: Frontal and lateral views of the chest were obtained. The patient is status post median sternotomy. There are small bilateral pleural effusions with overlying atelectasis. No overt pulmonary edema is seen. The cardiac silhouette remains top normal to mildly enlarged. IMPRESSION: Small bilateral pleural effusions with overlying atelectasis. . CARDIAC CATH [**2157-1-6**] COMMENTS: 1. Resting hemodynamics revealed right and left filling pressures with RVEDP of 20 mmHg and PCW 27 mmHg. There was moderate pulmonary artery systoic hypertension with PASP of 53 mmHg. The cardiac index was low at 1.9 L/min/m2. . FINAL DIAGNOSIS: 1. Biventricular elevated filling pressures. 2. Moderate pulmonary arterial hypertension. . ECHO [**2157-1-6**] Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. The left ventricular cavity is dilated. Systolic function of apical segments is relatively preserved. Overall left ventricular systolic function is severely depressed (LVEF= 15%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate to severe (3+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Biatrial enlargement. Dilated, severely hypokinetic left ventricle with relative preservation of the apical segments. Dilated, hypokinetic right ventricle. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Well-seated, normally functioning tricuspid annuloplasty ring. Mild pulmonary artery systolic pressure. . Compared with the prior study (images reviewed) of [**2156-12-20**], there is worsening left ventricular global and regional systolic function with a decrease in ejection fraction from 25% to 15%. The severity of mitral regurgitation has increased minimally. Mild pulmonary artery systolic hypertension is now appreciated; its presence could not be determined previously. [**2157-1-11**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 25 %). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. Compared with the findings of the prior study (images reviewed) of [**2157-1-6**], systolic function of both ventricles is improved. Brief Hospital Course: Mr. [**Known lastname 85439**] is a 65-year-old-man who is five weeks status post tricuspid valve replacement for severe tricuspid regurgitation, severe right ventricular enlargement, and severe right heart failure, with recent removal of defibrillator coil that revealed a massively dilated right atrium and right ventricle who is presenting with worsening dyspnea on exertion. . #. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC): patient is 5 weeks s/p tricuspid valve replacement, now with worsening right heart failure symptoms. TTE with worsening systolic function as well with depressed EF. Attempts were made with IV diuresis, but ultimately he required CCU admission for milrinone. Initially he was started on milrinone alone and his UOP was measured, and ultimately he required a lasix drip as well to maintain good UOP. His cardiac output doubled with milrinone therapy. Length of stay he was out approximately 9-10L net negative, his edema cleared, his lungs remained clear and his JVP was no longer elevated. Symptomatically, he felt much better, having improved exercise tolerance and a greatly increased appetite. Milrinone was on for approximately 3.5 days, after which it and the lasix were stopped. He had a repeat ECHO ~14 hours after cessation of his milrinone, showing improved global function. He was started back on his home torsemide without metolazone and maintained euvolemia. . #. AFIB/ectopy: patient therapeutic on warfarin with INR of 2.4. Also rate-controlled with home digoxin and metoprolol. These medications were continued throughout the admission. His afib was rate controlled well, never having a rapid ventricular rate. He did have a few episodes of ventricular ectopy with small runs of NSVT although these were likely related to hypokalemia and electrolyte shifts rather than the milrinone or other intrinsic cardiac etiology. . #. ACUTE KIDNEY INJURY: Creatinine at 1.7 from a baseline in late [**Month (only) **] of 1.0. Etiology is likely secondary to poor forward flow rather than overdiuresis as his diuretics had actually been decreased recently 1.5 weeks ago. His renal function quickly improved with milrinone and at the time of discharge was at his baseline. Medications on Admission: Omeprazole 20 mg EC PO BID Aspirin 81 mg PO daily Warfarin 5mg PO daily at 4pm Trazodone 50mg PO qHS PRN insomnia Polyethylene glycol 3350 17 gram/dose Powder one packet daily Senna 8.6 mg Tablet PO BID Docusate sodium 100 mg PO BID Digoxin 125 mcg PO daily Potassium chloride 10 mEq Tablet ER PO TID Metoprolol succinate 12.5 mg PO daily Torsemide 40mg PO daily Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. warfarin 5 mg Tablet Sig: 1-1.5 Tablets PO once a day. 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO three times a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 11. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute on chronic systolic heart failure Nonischemic cardiomyoapthy s/p ICD [**8-19**] later removed Chronic AF Chronic dysphagia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with shortness of breath and found to be in acute heart failure. You were given medication to take off the extra fluid and no longer appear to be fluid overloaded. In the future- please call Dr. [**First Name (STitle) 437**] or the heartline right away if you have symptoms of too much fluid: shortness of breath, swelling in your feet or ankles, weight gain. You should increase your Torsemide to 60mg daily. You will need to have your electrolytes repeated in 1 week (you can have it all done on Monday when you see Dr. [**Last Name (STitle) 4469**]. Your INR has been low. You should increase your Coumadin to 5mg alternating with 7.5mg daily. You should take 7.5mg tonight. You will need to have your INR checked on Monday [**2157-1-17**]. You should resume your Digoxin (seems like you may have been on and off this medication in the past). Medication changes: -INCREASE Coumadin to 7.5mg alternating with 5mg daily (take 7.5mg tonight) -INCREASE Torsemide to 60mg daily -ADD Losartan 12.5mg daily -RESUME Digoxin 125mcg daily For your heart failure diagnosis: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. Follow a low salt diet and a fluid restriction of 1500 ml/ day. Patient offered VNA services at home, declines the need for them at this time. Please let us know if you reconsider. Followup Instructions: Dr. [**Last Name (STitle) 4469**] ([**Telephone/Fax (1) 4475**]) Monday [**1-17**] 1:45pm *have your blood work repeated at this visit* Department: CARDIAC SERVICES When: TUESDAY [**2157-1-18**] at 1 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**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 [**2157-3-11**] at 2:40 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

42823,4254,2875,42731,3970,5303,4280,V5861,45829

Admission Date: [**2156-11-28**] Discharge Date: [**2156-12-8**] Date of Birth: [**2091-10-2**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Tricuspid regurgitation Major Surgical or Invasive Procedure: Tricuspid valve replacement(33mm St. [**Male First Name (un) 923**] tissue) [**2156-11-29**] History of Present Illness: This 65 year old white male has known nonischemic dilated cardiomyopathy for years. he has previously undergone biventricular pacemeker/ICD placement and has had progressive tricuspid regurgitation. The device was recently explanted due to concern for the lead interfering with the tricuspid valve. He has continued to have worsening symptoms and was referred for surgical intervention. Catheterization previously demonstarted no obstructive coronary disease, severely depressed LV function(15-20%) and elevated right heart pressures. Past Medical History: s/p biventricular pacer/ICD placement [**2155-8-10**] s/p removal of pacer/ICD s/p Left achilles tendon repair s/p Sinus Surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia Social History: Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**]. -Tobacco history: Never smoker -ETOH: Quit when diagnosed with heart failure -Illicit drugs: Denies Family History: Mother: Renal failure No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse 80 B/P 85/57 cuff 95/60 by Aline O2sat: 100% RA Resp: 18 Height: 71" Weight: 77.2 kgs General: NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] mild JVD Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] [**3-14**] holosystolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [X] Trace Varicosities: LLE Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2156-12-6**] 03:40AM BLOOD WBC-5.5 RBC-3.30* Hgb-10.5* Hct-31.6* MCV-96 MCH-31.8 MCHC-33.2 RDW-16.0* Plt Ct-131* [**2156-11-28**] 03:29PM BLOOD WBC-3.8* RBC-3.18* Hgb-10.5* Hct-31.1* MCV-98 MCH-33.0* MCHC-33.8 RDW-15.2 Plt Ct-113* [**2156-12-6**] 03:40AM BLOOD PT-17.3* PTT-33.6 INR(PT)-1.5* [**2156-12-5**] 03:59AM BLOOD PT-16.2* PTT-33.3 INR(PT)-1.4* [**2156-12-4**] 04:13AM BLOOD PT-15.0* PTT-33.1 INR(PT)-1.3* [**2156-12-3**] 01:26AM BLOOD PT-14.6* PTT-34.2 INR(PT)-1.3* [**2156-12-2**] 03:00AM BLOOD PT-14.8* PTT-36.5* INR(PT)-1.3* [**2156-11-28**] 03:29PM BLOOD Glucose-106* UreaN-29* Creat-1.5* Na-137 K-3.8 Cl-98 HCO3-30 AnGap-13 [**2156-11-29**] 01:49AM BLOOD ALT-19 AST-25 AlkPhos-76 TotBili-1.4 ECHO [**2156-12-3**] The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The prosthetic tricuspid leaflets appear normal. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2156-11-23**], the tricuspid valve has been replaced by a bioprosthesis. The right ventricle is no longer dilated. Trace-to-mild tricuspid regurgitation is present. Left ventricular function is improved due to reduction of right ventricular size, as well as reduction of ventricular interaction. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2156-12-3**] 16:10 Brief Hospital Course: He was admitted a day early for PA catheter placement and diuresis. Despite ultrasound visualization and an hour's time, the catheter could not be passed across the valve due to the regurgitant jet. Diuresis was undertaken. On [**11-29**] he went to the Operating Room where valve replacement was performed (see operative note for details). He weaned from bypass on Levophed and Milrinone. The PA catheter was placed at the end of the case, with great difficulty. He remained stable,and was extubated the day of surgery. Over the next few days the Milrinone was weaned off and he did well. He was diuresed toward his pre-operative weight and Coumadin was started for atrial fibrillation. Carvedilol was started for his cardiomyopathy and the Torsemide he was on at home resumed after stopping Lasix. Wires were removed as were CTs. He ambulated in the ICU and progressed well. Physical Therapy was consulted for strength as well. He was cleared for discharge to home on POD# 9 with VNA services, on medications as listed with appropriate follow up appointments. Coumadin will continue to be managed by Dr. [**Last Name (STitle) 4469**] his primary cardiologist. Medications on Admission: Losartan 25 mg daily 2. Metoprolol succinate 12.5 mg daily 3. omeprazole 20mg daily [**Hospital1 **] 4. Torsemide 20mg daily 5. Coumadin 5mg daily 6 days per week, 7.5mg on tuesday Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 6. Outpatient Lab Work INR/PT on [**2156-12-9**] and mon/wed and friday's until INR stable. Results to Dr. [**Last Name (STitle) 4469**] 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: indication afib- INR goal 2.0-2.5 . 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 10. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*80 Tablet(s)* Refills:*2* 11. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO DAILY (Daily). Disp:*120 Tablet Extended Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Tricuspid regurgitation s/p Tricuspid valve replacement nonischemic, dilated cardiomyopathy s/p Biventricular pacemaker/ICD placement s/p removal of Biventricular pacemaker/ICD chronic atrial fibrillation s/p Achilles Tendon repair chronic dysphagia Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2156-12-28**] at 1pm in the [**Hospital **] Medical office building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist:Dr. [**Last Name (STitle) 4469**] on [**2156-12-27**] at 1:30pm Heart failure: Dr [**First Name (STitle) 437**] [**2156-12-27**] 11:00am in [**Hospital Ward Name 23**] 7 Echocardiogram [**Telephone/Fax (1) 62**] Date/Time:[**2156-12-27**] 9:00 in [**Hospital Ward Name 23**] 7 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2.0-2.5 First draw [**2156-12-9**] then mon/wed/friday's until stable Results to Dr. [**Last Name (STitle) 4469**] phone:[**Telephone/Fax (1) 4475**] fax :[**Telephone/Fax (1) 23978**] Completed by:[**2156-12-9**]

42823,78551,4254,7994,5849,42731,4280,2875,59689,53081,56400,78720,V5861,V422,60001,78820

Admission Date: [**2157-2-16**] Discharge Date: [**2157-2-22**] Date of Birth: [**2091-10-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: right heart catheterization, PICC line placement History of Present Illness: Mr. [**Known lastname 85439**] is a 65 year old man with a PMHx s/f sCHF (EF 25%), and AF who initially presented to [**Hospital 20338**] Hospital in [**State 108**] on [**2157-2-7**] with five days of gradually worsening weakness, dyspnea on exertion, orthopnea, decreased appetite. He declines any dietary or medication nonadherance. Initially he declined any change in weight. Whilst in [**Location (un) 20338**], he was treated for a CHF exacerbation with diuresis and milrinone. Over the course of his first week, he became increasingly hypotensive requiring increasing doses of milrinone. On [**2-13**] following a fall with near syncope while walking, Mr. [**Known lastname 85439**] was found to be hypotensive to SBPs in the 50s requiring transfer to the CCU. Note his only injury suffered with this fall was an excoriation of his left knee. He was maintained on dopamine and milrinone early in his ICU course, but this was able to be weaned on [**2-14**]. LE US demonstrated no DVT. Throughout his course, when BP would allow he was gently diuresed with IV boluses of bumex (2mg) and torsemide (10-20mg), but given his low BP this occurred only every other day. Troponin I peaked at 0.27 on [**2-14**].12 on transfer. MB remained flat throughout his admission. Ischemic etiology was not entertained. Echo was performed on [**2157-2-10**] demonstrated EF 22%, severe RV dysfunction, dilated LA, moderate to severe MR. Initial CXR demonstrated RML and LLL pneumonia with bilateral pleural effusions, but CT at the OSH demonstrated large b/l pleural effusions, several rib fractures on the right, with no evidence of pneumonia. Of note, he was afebrile throughout his admission without leukocytosis. Labs on day of transfer: Na 128, K 3.5, Cl 86, Bicarb 30, BUN 62, Cr 1.9. MG 2.3, Ca 8.6, PT 16.3, INR 1.7. Also of note, Mr. [**Known lastname 85439**] was initiated on megace for poor appetite and cachexia. Past Medical History: CHF (EF 25% in [**1-/2157**]) s/p Tricuspid valve replacement for TR s/p biventricular pacer/ICD placement [**2155-8-10**] s/p removal of pacer/ICD s/p Left achilles tendon repair s/p Sinus Surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia Social History: Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**]. Never smoked. Denies illicits. Drank EtOH only rarely after diagnosed with CHF; quit in [**2156-4-9**]. Family History: Mother with renal failure. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Physical Exam on Admission: GENERAL - cachectic elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, JVD 1/2 up neck @30 degrees LUNGS - rales in RLB, otherwise CTAB good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted. Heart sounds distant. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 2+ bilateral pitting edema up to thighs. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, grossly non-focal Physical Exam on Discharge: GENERAL - cachectic elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. JVP much improved at 12. NECK - supple, no thyromegaly, JVD at level of the mandible at 60 degrees LUNGS ?????? faint bibasilar crackles R>L, improved from prior, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2, no murmurs. Heart sounds distant. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ bilateral pitting edema up to knees and in dependent aspect of thighs Pertinent Results: Admission Labs: [**2157-2-16**] 06:45PM BLOOD WBC-7.1 RBC-3.83* Hgb-11.9* Hct-36.1* MCV-94 MCH-31.0 MCHC-32.8 RDW-15.7* Plt Ct-163 [**2157-2-16**] 06:45PM BLOOD Neuts-73.8* Lymphs-17.4* Monos-6.5 Eos-1.4 Baso-0.8 [**2157-2-16**] 06:45PM BLOOD PT-13.9* PTT-34.3 INR(PT)-1.3* [**2157-2-16**] 06:45PM BLOOD Glucose-106* UreaN-42* Creat-1.3* Na-131* K-3.8 Cl-91* HCO3-35* AnGap-9 [**2157-2-16**] 06:45PM BLOOD Calcium-9.3 Phos-2.3* Mg-2.0 [**2157-2-16**] 06:45PM BLOOD Digoxin-0.8* [**2157-2-18**] 04:11AM BLOOD Hgb-11.1* calcHCT-33 O2 Sat-69 Pertinent Studies: Echo The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2157-1-11**], LV systolic function appears slightly less vigorous. Cardiac Catheterization [**2-17**]: 1. Hemodynamic catheterization in this patient demonstrates decreased cardiac output at baseline with moderately elevated left ventricular filling pressures. Following milrinone infusion the cardiac index signficantly increased from 2.1 to 2.5 L/min/m2 without a change in left ventricular filling pressures. FINAL DIAGNOSIS: 1. Severe systolic and diastolic ventricular dysfunction. 2. Significant improvement in hemodynamic parameters following milrinone infusion. TTE [**2-18**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Labs on Discharge: [**2157-2-22**] 03:32AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.3* Hct-31.1* MCV-93 MCH-31.0 MCHC-33.2 RDW-16.1* Plt Ct-132* [**2157-2-22**] 03:32AM BLOOD PT-22.1* PTT-35.2 INR(PT)-2.1* [**2157-2-22**] 03:32AM BLOOD Glucose-110* UreaN-37* Creat-1.5* Na-133 K-3.5 Cl-86* HCO3-34* AnGap-17 [**2157-2-22**] 03:32AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 Brief Hospital Course: Mr. [**Known lastname 85439**] is a 65 year old man with a past medical history significant for non-ischemic cardiomyopathy with an EF of 25% who presented with a CHF exacerbation and was initiated on homegoing dopamine. Active Diagnoses: #. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC):Mr. [**Known lastname 85439**] was initially managed in [**Location (un) 20338**], FL for a CHF exacerbation with milrinone and dopamine. Diuresis was deferred due to hypotension. Weight on admission of 158 was above discharge weight from [**1-/2157**] of 138. Heart failure is primarily driven by dilated RV in the setting of long term wide open TR which had only been repaired 6 weeks earlier. RHC demonstrated improvement in CO with milrinone (3.8 to 4.2), but to a less extent than would be inferred by his improvement in clinical status during his last admission. On his second day of admission, support with Milrinone only was attempted, but was aborted due to persistent hypotension (MAPs of 55). Dopamine was attempted at 6 mcg/kg/hr with improvement in BP with MAPs > 60, and improvement in CO 5.8 and CI 3.0. A PICC was placed for home dopamine infusions. However, diuresis was tapering off even though patient was on lasix 20 and dopamine 10. Patient was not maintaining good O2 sats and felt cold in his peripheries and short of breath when talking. A decision was made to transfer him to [**Hospital 3278**] Medical Center for heart transplant evaluation. Upon discharge, he was 10.8L negative. His discharge weight was . #. AFIB: Patient is anticoagulated for Afib, goal [**2-11**]. INR 2.1 today. Patient was continued on warfarin 7.5mg daily. . #. ACUTE KIDNEY INJURY: Baseline Cr 1.0, Cr at OSH is 1.9 likely secondary to decompensated CHF. With continued diuresis, Cr initially came downt o 1.2, but then bumped up to 1.5 on transfer. Despite further increases in dopamine and lasix drips, his urine output continued to taper off. Patient had diuresed -800cc since midnight of the day of transfer. . # Thrombocyteopenia: Plts slowly downtrending to 132 from 163 on admission. DDx includes malnutrition, marrow suppression, drug effect. HIT was thought to be less likely, as there was a less than 50% fall, no evidence of thrombosis. . #.SKIN DISCOLORATION: patient noted to have yellowish skin discoloration on [**2157-2-22**], initially concerning for congestive hepatopathy. However, LFTs were normal. Most likely etiology is pyridium use (started for bladder spasm). Pyridium was discontinued. . #. GERD: Patient was continued on home lansoprazole. . #. CONSTIPATION: Patient was maintained on an aggressive bowel regimen with senna, colace, miralax. At one point, patient had not had bowel movement in 3 days, so was given lactulose and fleet enema, to which he responded with a bowel movement. . #. DYSPHAGIA: Patient has a history of dysphagea and cannot swallow while supine. He tolerated a regular diet, but was willing to consider a soft diet if he was unable to swallow regular food. . # BPH: Patient had low UOP one day and bladder scan confirmed urinary retention. Prostate exam revealed enlarged bladder, and patient is known to have hx of BPH. He was started on phenazopyridine and tamsulosin. Transitional Issues: Patient was transferred to [**Hospital 3278**] Medical Center for heart transplant evaluation. He will be sent with this discharge summary, several recent TTE and RHC reports, and several of his outpatient cardiology appointment notes. At [**Hospital1 18**], he was evaluated for a LifeVest, and most of the paperwork was filled out, but this was deemed no longer necessary upon transfer. If patient is deemed at [**Hospital1 3278**] to still need LifeVest, can contact [**Name (NI) 13764**] Case Manager at [**Hospital1 18**] for additional details. Medications on Admission: DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth once a day LOSARTAN - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider: [**Name Initial (NameIs) 4469**]) - 25 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) by mouth once a day OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17 gram/dose Powder - 1 by mouth daily POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Extended Release - 1 Capsule(s) by mouth at breakfast, lunch & supper TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 3 Tablet(s) by mouth once a day WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 5 mg Tablet - 1-2 tablets as directed. Tablet(s) by mouth take as directed ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for constipation Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) solution Injection TID (3 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 10. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 16. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Discharge Diagnosis: Congestive Heart Failure Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 85439**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for diuresis for your heart failure. While you were here, we started you on two pressors (milrinone and dopamine) and a lasix drip to help you with urine output. While you were here, you diuresed 10.8L. We ultimately decided to transfer you to [**Hospital1 3278**] for cardiac transplant evaluation because you were not maintaining adequate urine output despite high doses of dopamine and lasix drip. Followup Instructions: Please follow-up with your outpatient cardiologist, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], when you are discharged from [**Hospital1 3278**].

41001,5849,41401,60001,2724,4019,V4582,78820

Admission Date: [**2193-4-26**] Discharge Date: [**2193-4-29**] Date of Birth: [**2114-9-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1899**] Chief Complaint: transfer for c. cath/STEMI Major Surgical or Invasive Procedure: Cardiac catheterization with drug-eluting stent placed in the left anterior descending artery History of Present Illness: 79-year-old male with history of CAD and prior PCI with DES to OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**2192-2-8**] chest pain. The night prior to presentation he experienced indigestion. He then awoke with a "rope-like" non-radiating chest discomfort with no associated symptoms except perhaps chills that resolving except the portion "over the heart." He continued to have this discomfort. His wife called his PCP and told him to report to the nearest ER. EKG on presentation showed ST elevation in leads V3,4, and 5. Troponin was 12.483. He was given 81 mg ASA x 4, 4500 units heparin bolus with drip at 1800 units/hr and 5 mg IV lopressor. He was given plavix 600 mg PO x 1 prior to transfer to [**Hospital1 18**] for c. cath. He was chest pain free prior to transfer. Vitals at transfer were BP 145/87 HR 63 SR pOx 100 % on 3 L O2 and RR 20. He was taken to the c. cath lab showing subtotally occluded LAD with successful PTCA/stenting with 2.5 x 18 promus stent. LCx and RCA were patent. On the floor, patient in NAD without any complaints. Of note, he was recently hospitalized at [**Name (NI) 75328**] [**Hospital 18806**] Medical [**Name2 (NI) **] in early [**Name (NI) 547**] for sepsis from a urinary source secondary to BPH. He completed a course of levofloxacin, was placed on flomax, and is scheduled to follow-up with urology. . 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 exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. + palpitations two days before the event . Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD s/p prior PCI - PERCUTANEOUS CORONARY INTERVENTIONS: [**Hospital1 2025**] ([**2185**]): Has stent placed to OM2 with ? MI in setting of shoulder pain. At that time, he was placed on ASA/plavix. 3. OTHER PAST MEDICAL HISTORY: - BPH with urinary retention - History of HL - History of UTI - Esophageal Dilitation Social History: He lives with his wife. - Tobacco history: none - ETOH: [**1-6**] glasses of wine/week - Illicit drugs: none Family History: - Brother died of MI at age 60 (sudden death) while shoveling snow. - Mother: unknown cancer at age [**Age over 90 **] - Father: COPD at age 85 Physical Exam: Tmax: 35.9 ??????C (96.6 ??????F) Tcurrent: 35.9 ??????C (96.6 ??????F) HR: 69 (69 - 69) bpm BP: 125/73(82) {125/73(82) - 125/73(82)} mmHg RR: 21 (21 - 21) insp/min SpO2: 98% Heart rhythm: SR (Sinus Rhythm) General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): AAOx2 (not to date fully), Movement: Not assessed, Tone: Not assessed Pertinent Results: I. Cardiology A. Cath ([**2193-4-26**]) ** PRELIM REPORT ** BRIEF HISTORY: 78 M presented to OSH with chest pain and [**Hospital **] transferred to [**Hospital1 18**] for emergent cardiac catheterization. INDICATIONS FOR CATHETERIZATION: Coronary artery disease, STEMI transfer PROCEDURE: Coronary angiography Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. **PTCA RESULTS LAD PTCA COMMENTS: Initial angiography reveald a mid LAD 95% subacute thrombus. We planned to treat this thrombus with aspiration thrombectomy/PTCA/stenting and heparin/integrilin given prophylactically. An XB LAD 4.0 guiding catheter provided good support for the procedure and a Prowater wire was advanced into the distal LAD with moderate difficulty. We then proceed with an Export AP aspiration thrombectomy but unable to deliver device distal to subacute thrombus. We then predilated the mid LAD thrombus with an Apex OTW 2.0x8 mm balloon inflated at 8 atm. We then noted an acute cut-off in the distal LAD after flow was re-established and proceeded with cautious dotting of the cut-off area with the balloon and distal delivery of NTG via balloon with minimal improvement of distal LAD flow. We then stented the mid LAD with a Promus Rx 2.5x18 mm drug-eluting stent (DES) post-dilated with an NC Quantum Apex MR 2.75x12 mm balloon inflated at 20 atm for 20 sec. Final angiography revealed normal TIMI 3 flow in the vessel, no angiographically apparent dissection and 0% residual stenosis in the newly deployed stent but acute cut-off in distal LAD showed diffusely diseased small apical vesswel that remained unchanged despite mechanical dottering and distal NTG delivery via balloon. The R 6Fr femoral artery sheath was removed post limited groin angiography and an Angioseal closure device was deployed without complications with distal pulses confirmed post deployment. The patient left the cath lab angina-free and in hemodynamically stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 59 minutes. Arterial time = 56 minutes. Fluoro time = 15.2 minutes. IRP dose = 733 mGy. Contrast injected: Omnipaque 175 cc total contrast during procedure Anesthesia: 1% Lidocaine SC, fentanyl 25 mcg IV, versed 0.5 mg IV total Anticoagulation: Heparin [**2182**] units, integrilin bolus and infusion COMMENTS: 1. Emergent coronary angiography revealed a right dominant systemt. The LMCA, LCx and RCA were all patent. The LAD revealed a mid 95% occlusion with thrombus. 2. Limited resting hemodynamics revealed a SBP of 142 mmHg and a DBP of 80 mmHg. 3. Successful aspiration thrombectomy/PTCA/stenting of the mid LAD with a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm balloon. Final angiography revealed normal TIMI 3 flow, no angiographically apparent dissection and 0% residual stenosis in the newly deployed stent with an abrupt cut-off in the distal LAD unchagned despite mechanical balloon dottering and distal NTG delivery via balloon. (see PTCA comments) 4. R 6Fr femoral artery Angioseal closure device deployed without complicatons (see PTCA comments) FINAL DIAGNOSIS: 1. Severe coronary artery disease with subtotally occluded mid LAD: see comments section. 2. Successful aspiration thrombectomy/PTCA/stenting of the mid LAD with a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm balloon. (see PTCA comments) 3. R 6Fr femoral artery Angioseal closure device deployed without complications (see PTCA comments) 4. ASA indefinitely; plavix (clopidogrel) 75 mg daily for at least 12 months for DES 5. Integrilin gtt for 18 hours post PCI for thrombus and abrupt cut-off of distal small vessel apical LAD unchanged despite mechanical balloon dottering and distal NTG delivery via balloon B. TTE ([**2193-4-26**]) Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid lateral hypokinesis and distal septal/distal anterior and apical septal hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. C. ECG No prior ECG available for comparison. OSH ECG dated [**2193-4-26**] at 9:01 showing ?ectopic atrial rhythm, NI, leftward axis. STE in V3, V4, and V5. II. Labs A. Admission [**2193-4-26**] 03:15PM BLOOD WBC-7.5 RBC-4.21* Hgb-13.6* Hct-38.9* MCV-92 MCH-32.3* MCHC-34.9 RDW-12.7 Plt Ct-253 [**2193-4-26**] 03:15PM BLOOD PT-13.4 PTT-27.0 INR(PT)-1.1 [**2193-4-26**] 03:15PM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-139 K-4.2 Cl-103 HCO3-28 AnGap-12 [**2193-4-26**] 03:15PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 Cholest-204* B. Cardiac [**2193-4-27**] 05:57AM BLOOD CK(CPK)-426* [**2193-4-26**] 11:13PM BLOOD CK(CPK)-675* [**2193-4-27**] 05:57AM BLOOD CK-MB-22* MB Indx-5.2 cTropnT-1.36* [**2193-4-26**] 11:13PM BLOOD CK-MB-41* MB Indx-6.1* [**2193-4-26**] 03:15PM BLOOD CK-MB-96* MB Indx-9.2* cTropnT-3.21* C. Misc [**2193-4-26**] 03:15PM BLOOD %HbA1c-6.0* eAG-126* [**2193-4-26**] 03:15PM BLOOD Triglyc-135 HDL-44 CHOL/HD-4.6 LDLcalc-133* D. Discharge WBC 4.5 Hgb 11.2 Plt 181 INR 1.2 Na 141 K 4.4 Cl 108 HCO3 29 BUN 20 Cr 1.4 Ca 9.1 Ph 3.2 Mg 2.1 Brief Hospital Course: 79-year-old male with history of CAD and prior PCI with DES to OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**Hospital **] transferred to [**Hospital1 18**], and now s/p successful PTCA/stenting with DES for LAD lesion. # STEMI Patient has known history of CAD given prior stent placement in OM2. It is uncertain why the patient is not on any cardiac medications for risk reduction. He presented with chest discomfort. OSH ECG notable for ectopic atrial rhythm and ST elevations in V3, V4, and V5 and initial troponin 12.483 (unknown if I or T) and CK-MB 68.5. Cardiac biomarkers indicated CK-MB 22 and cTrop 1.36. He was transferred to [**Hospital1 18**] for c. cath with successful PTCA/stenting with DES for 95 % subacute mid-LAD thrombus. Final angiography revealed normal TIMI 3 flow and no angiographically apparent dissection. See cardiac cath report for full details. Cardiac biomarkers indicated CK-MB 22 and cTrop 1.36. Post-MI ECHO indicated LVEF 35-40 % withmild to moderate regional left ventricular systolic dysfunction with basal to mid lateral hypokinesis and distal septal/distal anterior and apical septal hypokinesis. This may be suggestive of another MI given that these wall motion abnormalities do not necessarily correspond to his LAD lesion. He was continued on an integrilin infusion for 18 hours post PCI for thrombus and abrupt cut-off of distal small vessel apical LAD unchanged despite mechanical balloon dottering and distal NTG delivery via balloon. He was placed on aspirin 325 mg PO qD indefinitely, clopidogrel 75 PO qD for at least 12 months for DES. He was started on crestor given concern for myalgias. He was also started on metoprolol and lisinopril. # Hyperlipidemia Patient was not on lipid-lowering therapy on admission. Cholesterol panel showing total cholesterol 204, TG 135, HDL 44, and LDL 133. He was started on statin as above and advised to initiate lifestyle modifications. A1c was 6 suggestive of pre-diabetic state. # RHYTHM: Patient remained in NSR during hospitalization with telemetry showing bradycardia to low 40s during sleep. # BPH with urinary retention Patient was recently hospitalized at [**Name (NI) 75328**] Brothers in the state of [**Name (NI) 531**] for sepsis from a urinary source in the setting of urinary retention per provided records from family. He was continued on flomax during hospitalization and will follow-up with urology after hospitalization. CODE: Full COMM: patient, wife [**Name (NI) **] [**Telephone/Fax (1) 88873**] (H) [**Telephone/Fax (1) 88874**] (C) Medications on Admission: - flomax 0.4 mg PO qD - Multivitamin Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 6. Outpatient Lab Work Please check Chem-7 and CBC on [**4-1**] at Dr.[**Name (NI) **] office. 7. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Disp:*25 tablets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ST elevation myocardial infarction Coronary Artery Disease Acute Kidney Injury . Secondary Diagnosis: Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 26762**], It was a pleasure taking part in your care at [**Hospital1 18**]. You were transferred here after it was determined that you had suffered a heart attack prior to arriving at hospital. You underwent a cardiac catheterization procedure where a drug eluting stent was placed in one your heart arteries and you did very well after this. You will need to take a number of medications to keep your heart healthy and make sure the stent stays open. We have made the following changes to your medications: START taking aspirin 325 mg and Plavix daily. These medicines work together to prevent the stent from clotting off. YOu will need to take these medicines daily for the next year and possibly longer. Do not stop taking aspirin and Plavix unless Dr. [**Last Name (STitle) **] says that it is OK. START taking Rosuvastatin (Crestor) to lower your cholesterol. YOu will need to have your liver function tested with blood tests on a regular hasis on this medicine. If you develop muscle cramps on this medicine, please call Dr. [**Last Name (STitle) **]. START taking Lisinopril to lower your blood pressure and help your heart recover from the heart attack. START taking Metoprolol to lower your heart rate and help your heart recover from the heart attack. START taking nitroglycerin if you have chest pain at home. Take one tablet under your tongue, sit down and wait 5 minutes. You can take another tablet if you still have chest pain but please call Dr. [**Last Name (STitle) **] if you take any nitroglycerin. Continue to take Flomax as before. Followup Instructions: D'[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 22235**] Appointment already made on [**2193-5-2**] at 11:00 AM . Name: [**Last Name (LF) 7526**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] BLDG Address: 131 ORNAC, [**Apartment Address(1) 88875**], [**Location (un) **],[**Numeric Identifier 17125**] Phone: [**Telephone/Fax (1) 88876**] Appt: [**5-16**] at 3:30pm [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]

0389,51881,48241,4870,78552,V4281,99592,2449,2724,2859,53081,V1072,23871

Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-12**] Date of Birth: [**2127-4-8**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**First Name3 (LF) 1936**] Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Pt's a 53-year-old male patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is here for evaluation of fever. The patient states fever began two days ago along with a mild dry cough, fever was low-grade at that time. Day of admission, pt noticed to be 101.8 has some chills as well. No shortness of breath, no chest pain. Denies any headache, ear aches, and some scratchy throat. The patient denied any change in stools, ab pain, urinary sx, has some mild nausea on [**1-27**] but thought it more due to fever. No arthralgias or myalgias or rashes. The patient says cough is nonproductive. He did recently have URI symptoms beginning of the month which abated shortely . He then came on the 22nd for routine medical examination and was found to be in pretty good health and stated remains until these last two days. Of important note - pts kids had been sick earlier this week (both) - similiar sx - lasting just 3 days. Pt reports having the flu shot earlier this week. Noted poor po intake past few days. <br> Review of systems: <br> Constitutional: No weight loss/gain, fatigue, malaise, + fevers, +chills, NO rigors, night sweats, or anorexia. HEENT: No blurry vision, diplopia, loss of vision, photophobia. No dry motuh, oral ulcers, bleeding nose or [**Male First Name (un) **], tinnitus, sinus pain. Cardiac: No chest pain, palpitations, LE edema, orthopnea, PND, DOE. Respiratory: No SOB, pleuritic pain, hemoptysis, does have mild DRY-cough as above. GI: + mild nausea but NO vomiting, abdominal pain, abdominal swelling, diarrhea, constiatpion, hematemesis, hematochezia, or melena. Heme: No bleeding, bruising. Lymph: No lymphadenopathy. GU: No incontinence, urinary retention, dysuria, hematuria. Skin: No rashes, pruritius. Endocrine: No change in skin or hair (has chronic hair loss), no heat or cold intolerance (noted thyroid meds recently adjusted). MS: No myalgias, arthralgias, or back or nec pain. Neuro: No numbness, weakness or parasthesias. No dizziness, lightheadedness, vertigo. No confusion or headache. Psychiatric: No depression, anxiety. Allergy: No seasonal or medication allergies. Past Medical History: -splenectomy -pericarditis -Hodgkin's disease, and bone marrow transplant in [**2164**], Hodgkin's treatment was in [**2157**] Social History: No tob, etoh, or drugs. Lives with wife and 2 kids, - employment - real estate developer. Family History: Mother with Breast CA/Uterine CA Physical Exam: Vitals: 99.5 138/80 95 18 96%RA Pain: denies Access: RUE PICC Gen: nad, thin man HEENT: anicteric, mmm CV: RRR, no m Resp: CTAB, improved L sided crackles, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal Skin: no changes psych: appropriate Pertinent Results: WBC 20-->15.4-->12.4 (peak 26 [**2-6**]) Hgb [**7-4**]-->8.8 stable s/p 1U [**2-9**] plt 800s INR 1.3 retic 4.7 Chem panel unremarkable BUN 11/creat 0.9 LFTs normalized except alk phos 214, downtrending (peak 385 on [**2-2**], normal prior), albumin 2.8 . . Influenza swab +B Ag Sputum cx MSSA X2 Blood cx all NTD Urine Cx NTD Stool Cx NTD . . Imaging/results: CXR [**2-8**]: LUL consolidation, mod pulm edema, R PICC . . RUQ US [**2-4**]: 1. Unchanged appearance of mildly distended gallbladder containing layering sludge, without evidence of acute cholecystitis. 2. No focal liver lesions or biliary ductal dilatation. 3. Right pleural effusion. . [**2-4**] CT Chest: 1. Interval decrease in right-sided pleural effusion. Left- sided pleural effusion is unchanged. 2. Persistent multifocal pneumonia with interval worsening consolidation in the lingula and left upper lobe. 3. Nonspecific soft tissue stranding in the left upper quadrant, new from prior study but difficult to assess without oral contrast. Consider CT of the abdomen for more complete assessment, if warranted clinically. . . [**2-2**] Echo: EF 55%, mod pulm HTN. [**1-28**] CTA, no PE . . Brief Hospital Course: 53-year-old male patient with h/o of hodgkins lymphoma in BMT '[**64**], h/o splenectomy, h/o pericarditis, hypothyroidism was initially admitted for fever in setting +sick contacts. In ER, confirmed Influenza B + (Rx with Tamiflu X7days). Pt initially did well first night, but then had rapidly worsened hypoxia am of [**2181-1-28**] with CT chest showing new multilobar consolidations. Developed septic shock and ARDS, started broad Abx (vanc/cefepime/azithromycin), transfered to MICU, was intubated for hypoxemic resp failure [**1-28**]. Resp cultures grew MSSA and Abx changed to nafcillin to complete 3week course per ID (until [**2-18**] via R PICC). Was finally extubated [**2-7**] and transfered to Gen Med on [**2-9**]. On Gen Med, continued with rapid improvement, weaned off O2. There was some concern initially with persistant leukocytosis in 20s with fevers and imaging with pleural effusions that raised concern for parapneumonic efffuisons or empyema. However, WBC did start to trend down so [**Female First Name (un) 576**] was deferred. He will have ID f/u after Abx and needs repeat imaging. Still having low grade fevers and imaging with L>R infiltrates but clinically much better. Other infectious w/u negative. Of note, during hospitalization, pt had some LFT elevation with US/CT showing sludge but no evidence of cholecystitis and this was likely [**1-29**] acute illness and possible TPN which he recieved for few days (improving by time of discharge). Also developed Anemia 12-->8 w/o gross evidence of bleeding or hemolysis, s/p 1U prbc [**2-9**] with hgb stable 9s thereafter. this can be followed up as outpt. . . See progress note below for details according to each problem: 53 year-old male with a history of hodgkin's s/p BMT in 93, s/p splenectomy, h/o pericarditis, hypothyroidism, anemia, admitted [**1-27**] with influenza B (received antiviral treatment in ICU) complciated by severe MSSA bacterial superinfection-->ARDS/intubation, extubated [**2-7**], t/f to floor [**2-9**], doing very well, ambulating, tolerating PO, plan to d/c home today . . MSSA CAP, superinfection (Influenza B): ARDS, extubated [**2-7**]. Doing well, off oxygen. Some concern initially with persistant leukocytosis/fevers and CT with persistant L>>R pleural effusions concerning for parapneumonic effusions but white count finally down. Pt has been afebrile (low grade temps) - continue Nafcillin 2 gm IV q 4hr through [**2-18**] for total of 3 weeks per ID (confirmed plan) -since downtrending wbc, can hold off on [**Female First Name (un) 576**], but needs repeat imaging to ensure resolved effusions, f/u [**Hospital **] clinic in [**2181-3-6**] - continue incentive spirometry - guiafenisin prn, duonebs -note, pt is post splenectomy, asked to confirm pneumovax and meningitis vaccine, but none here while PNA . . Leukocytosis: as above, 20s for several days, today down to 12, as above, concern for parapneumonic effusions but holding [**Female First Name (un) 576**] as above with repeat CXR in 1week. Currently with low grade temps, no fevers. As for other sources, LIJ tip not sent, PICC site looks good, no urinary complaints, no diarrhea. note, baseline elevated wbc partly due to post-splenectomy. . . Anemia and thrombocytosis: baseline hgb 12s, here 9-->7s s/p 1U prbc [**2-9**], now 9s. No obvious bleeding or hemolysis but was acutely ill. -Fe studies will be unreliable since got blood t/f, hold supp since Fe load with transfusion -will need to be followed as outpt -as for thrombocytosis, likely reactive (anemia, illness) and post-splenectomy . . Hodgkins disease s/p BMT'[**64**], no issues . . Hypothyroidism: cont levothyroxine 88mcg . . GERD: protonix 40-->prilosec at home . . Dyslipidemia; resume lipitor 10 . . Elevated Alk phos: RUQ [**2-4**] with sludge, no dilation, bili normal, no RUQ pain -slow trend down, monitor, follow as outpt . Medications on Admission: ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE [PRILOSEC] - 10 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. PICC care per protocol 2. Nafcillin 2 gram Piggyback Sig: Two (2) Intravenous every four (4) hours for 6 days: total 4g. continue until [**2-18**]. Disp:*qs doses* Refills:*0* 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**12-29**] MLs PO Q6H (every 6 hours) as needed for cough. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Influenza type B Severe MSSA multilobar pneumonia as superinfection causing ARDS Anemia s/p blood transfusion Discharge Condition: GOOD Discharge Instructions: You were admitted with influeza with superimposed severe bilateral pneumonia due to staph. YOu will need to complete IV antibiotics until [**2-18**]. If you have worsening of fevers/cough/shortness of breath, call your doctor or come to ER. Your PICC line will be removed after the antibiotics are complete. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**3-6**] as scheduled so that she can make sure you are stable, you will need repeat Chest xray as well. Confirm with your primary doctor that you are up to date with your vaccination since you have your spleen removed. Your medications are otherwise kept the same. You had anemia during this hospitalization likely from your severe illness, please follow this with your doctor to make sure this is getting better. You recieved 1 unit of blood for this. You can take daily Fe supplement to help with this. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2181-3-6**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2181-5-29**] 10:45 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 5647**], M.D. Date/Time:[**2182-1-24**] 10:40

56211,0389,5570,5849,99592,56081,78959,5538,7885,40291,4280,71947,5644,25000,V0254,E8788,27651

Admission Date: [**2184-12-24**] Discharge Date: [**2185-1-5**] Date of Birth: [**2137-4-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Recurrent diverticulitis Major Surgical or Invasive Procedure: [**2184-12-24**]: Laparoscopic sigmoid colectomy, splenic flexure takedown, rigid sigmoidoscopy. . [**2184-12-28**]: Exploratory laparotomy, lysis of adhesions, omentectomy, washout of abdomen, drain placement and abdominal closure. History of Present Illness: Mr. [**Known lastname **] is a 47-year-old gentleman with a history of diverticulitis in [**2177**] and again in [**2184-9-9**]. His last episode required a seven day hospital stay on intravenous antibiotics. Subsequently, his symptoms resolved and he was discharged on an oral regimen. He had a colonoscopy after his first attack of [**2177**]. He has no colonoscopies within our system. He feels well now and has no further symptoms. He was admitted for prophylactic operation to prevent recurrence. Past Medical History: PMHx: Type II DM, HTN, Diverticulitis . PSHx: Negative Social History: He lives in [**Location 4628**]. He is in a same sex marriage. Rarely drinks alcohol. Smokes very rarely and at that time smoked four to five cigarettes per day. He is a registered nurse [**First Name (Titles) **] [**Last Name (Titles) 3278**]. Family History: Family history is significant for grandmother with lung cancer, grandfather with strokes, and other family members with hypertension and diabetes. Physical Exam: Pre-Admission Examination: On physical exam, he is afebrile. Vital signs are normal. Sclerae are nonicteric. Chest is clear. Heart is regular. Abdomen is soft without rebound or guarding. There is nofullness. Testicles are symmetric and descended. He is circumcised. Extremities are warm without edema. Rectal exam is heme negative, normal tone. . At Discharge: AVSS/afebrile GEN: Well appearing male in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B) COR: RRR; no m/c/r. ABD: Midline incision with staples c/d/i. BSx4. Appropriately tender along incision, otherwise soft/NT/ND. EXTREM: No c/c/e NEURO: A+Ox3. Comfortable. Non-focal/grossly intact. Pertinent Results: On Admission: [**2184-12-24**] 07:28PM POTASSIUM-4.1 [**2184-12-24**] 07:28PM MAGNESIUM-1.9 [**2184-12-24**] 07:28PM HCT-39.6* . IMAGING: [**2184-12-27**] CXR: Aside from several regions of subsegmental atelectasis at the right base, lungs are clear, though low in volume. There is no pleural effusion or evidence of central adenopathy. Severe gastrointestinal gaseous distension present in the upper abdomen raises concern for small-bowel obstruction. . [**2184-12-31**] AP CXR: In the interval there has been improvement in the degree of vascular engorgement with the lungs appearing clear. Nasogastric tube has been removed. Right-sided jugular central venous catheter is in unchanged position. . [**2185-1-1**] HEEL (AXIAL & LATERAL) LEFT: There is a large dorsal calcaneal enthesophyte. No discrete fracture is identified. There is mild fragmentation within the enthesophyte but there appears to be cortication in the fragment. . MICROBIOLOGY: [**2185-1-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- NEGATIVE. [**2185-1-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- NEGATIVE. [**2184-12-28**] URINE URINE CULTURE- NO GROWTH. [**2184-12-28**] BLOOD CULTURE: No GROWTH. [**2184-12-28**] BLOOD CULTURE NOT PROCESSED. [**2184-12-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS). [**2184-12-27**] BLOOD CULTURE: NO GROWTH. [**2184-12-27**] BLOOD CULTURE: NO GROWTH. [**2184-12-27**] URINE URINE CULTURE- <10,000 organisms/ml. [**2184-12-27**] BLOOD CULTURE: NO GROWTH. [**2184-12-27**] BLOOD CULTURE: NO GROWTH. Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2184-12-24**] for prophylactic operation to prevent recurrence of diverticulitis. The patient underwent laparoscopic sigmoid colectomy, splenic flexure takedown, rigid sigmoidoscopy, which initially went well (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO on IV fluids, with a foley catheter in place, and a Dialudid PCA and Toradol IV for pain control. The patient was hemodynamically stable. . Postoperatively, initially he did well, but he began spiking fevers. His white blood cell count dropped, his urine output dropped, and he began to have a septic etiology. He was pan-cultured, started on empiric antibiotic therapy, and given aggressive IV fluid rescusitation. Concern for an anastomotic leak was raised. A chest x-ray showed evidence of pneumoperitoneum. The patient was [**Last Name (un) 4662**] back to the Operating Room on [**2184-12-28**] and underwent exploratory laparotomy, lysis of adhesions, omentectomy, washout of abdomen, drain placement and abdominal closure, which went well without complication (see Operative Note). After a prolonged PACU stay where he was extubated, he was transferred to the TICU. He arrived NPO with an NG tube, on IV fluids and IV Zosyn and Vancomycin, a foley catheter and 2 JP drains to bulb suction were in place, and he recived Fentanyl for pain control with good effect. Post-operative fluid overload and associated hypertension was treated with IV Lasix for diuresis as well as Metoprolol and Hydralazine with good effect. He was transitioned back to home Labetolol and Clonidine was started. The NG tube was removed. While in the TICU, he began to notice some (L) ankle pain. . On [**2184-12-31**], the patient was transferred back to [**Hospital Ward Name 121**] 9. Pain was initially well controlled with a Dilaudid PCA, which was converted to oral pain medication when tolerating clear liquids. The patient was started on sips of clears upon transfer, which was progressively advanced as tolerated to a low fat, heart healthy regular diet by [**2185-1-3**] with good tolerability. The foley catheter was discontinued the morning of [**1-2**]. The patient subsequently voided without problem. IV antibiotics were discontinued on [**2185-1-1**]. Both JP drains were discontinued on [**1-4**] as their output was low. The incision with staples remained clean and intact. He was transitioned back to his home anti-hypertensive medications with good BP control. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. By discharge, he was started back on home Metformin for diabetes. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged home wihtout services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Viagra 50 mg 1 tab PO as directed for ED. Discharge Medications: 1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: Over-the-counter. 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. 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* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety/insomnia. Disp:*30 Tablet(s)* Refills:*0* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Recurrent diverticulitis. 2. Sepsis with acute abdomen and internal hernia secondary to infarcted omentum with small bowel obstruction. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-18**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment with Dr. [**First Name (STitle) 2819**] (Surgery) in 2 weeks. . Please call ([**Telephone/Fax (1) 1577**] to arrange a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP) in [**1-12**] weeks. Completed by:[**2185-1-5**]

9999,56881,5772,2851,5849,5799,72992,53081,4019,2721,5699,3004

Admission Date: [**2144-7-25**] Discharge Date: [**2144-7-28**] Date of Birth: [**2078-10-17**] Sex: F Service: MEDICINE Allergies: Bactrim / Norvasc / Lipitor / Cortisone Attending:[**First Name3 (LF) 2751**] Chief Complaint: Chief Complaint: anemia . Reason for MICU transfer: retroperitoneal bleed Major Surgical or Invasive Procedure: Coiling of superior gluteal artery History of Present Illness: Ms. [**Known lastname 91180**] is a 65 YOF with history of GERD, HTN, and hypertriglyceridemia who was recently admitted from [**7-9**] to [**7-22**] after being transferred from an OSH for intractable diarrhea. This hospital course was complicated by PEA arrest in the setting of pH 6.98 and she was intubated and had a right femoral CVL placed and was started on a bicarb drip. She was diagnosed with postviral autoimmune enteropathy and was treated with TPN and eventually discharged on budesonide and methylprednisolone with improvement in her diarrhea. Notably her hospital course was complicated by hypertensive urgency with SBP above 200, volume overload in the setting of steroids, and an enterococcus UTI. She was discharged to rehab 4 days ago. . The following day, she developed some mild pain in her medial knee up her thigh to the groin. This was in the setting of increased mobility - as she had previously been limited by rectal tube during her admission. She had a f/u appointment with her gastroenterologist the following day and when she returned to rehab she complained of the pain and had LENIs that were negative for DVT. The following morning (today) she was turing and had increased pain in her right hip and flank. She films and checked a Hct that was 14 (down from 27 on [**7-22**]). She denied dizziness, chest pain, or dyspnea. She denied history of trauma and was only on heparin subq for DVT prophylaxis but otherwise no anticoagulation. She was sent to the ED for further eval. . In the ED, VS 97.9 88 85/39 18 99% 3L. She was given fentanyl for pain and hydrocortisone 100 mg (stress doese). She had guiac + brown stool, NG lavage was negative. CT scan showed large RP hematoma. IR rec CTA - which showed a small focus at right psoas muscle, concerning for active bleed. She was given 2 units uncrossmatched blood for the hypotension, followed by a unit of cross matched blood and a L of NS. BP remained 100-110 over several hours. . The patient went straight to IR where no active extravasation was seen, but there was an irregular smaller branch that was embolized with 2 small coils. A second arteriogram revealed no more bleeding Past Medical History: Anxiety GERD Hypertension Anemia of chornic disease malnutrition euthyroid sick s/p hysterectomy Social History: Patient used to work part-time as a secretary. She is married and has one son. Denies tobacco, etoh, or other drug use. Family History: Mother died at 78, father at 71 from MI. Physical Exam: Admission Exam: Vitals: T: 97.6 BP: 133/61 P: 65 R: 18 O2: 95% General: Alert, oriented, no acute distress HEENT: slightly pale, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, no murmurs Abdomen: multiple echymosis from heparin shots, firmness to palpatio over the right abdomen, mild tenderness to palpation in that region, no guarding, + BS Ext: warm, well perfused, 2+ pulses, no edema Pertinent Results: Admission Labs: [**2144-7-25**] 02:04PM BLOOD WBC-21.4*# RBC-1.35*# Hgb-4.7*# Hct-12.9*# MCV-95 MCH-34.5* MCHC-36.4* RDW-16.3* Plt Ct-188 [**2144-7-25**] 02:04PM BLOOD Neuts-84.9* Lymphs-9.1* Monos-5.0 Eos-0.7 Baso-0.3 [**2144-7-25**] 02:04PM BLOOD PT-12.9 PTT-43.9* INR(PT)-1.1 [**2144-7-25**] 02:04PM BLOOD Glucose-206* UreaN-56* Creat-1.2* Na-136 K-4.9 Cl-105 HCO3-22 AnGap-14 [**2144-7-25**] 02:04PM BLOOD ALT-32 AST-20 AlkPhos-55 TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2144-7-25**] 02:04PM BLOOD Albumin-2.0* Calcium-7.1* Phos-6.0*# Mg-1.8 [**2144-7-25**] 02:04PM BLOOD Hapto-160 [**2144-7-25**] 02:04PM BLOOD D-Dimer-664* . CXR [**2144-7-25**] 1. Minimal right basilar atelectasis. Otherwise, no acute intrathoracic process. 2. Small bilateral pleural effusions as seen on subsequent CT. . CT AP [**2144-7-25**] 1. Large right iliopsoas intramuscular hematoma with associated retroperitoneal hematoma. Further evaluation with CTA is recommended to assess for active bleeding. 2. Diverticulosis without evidence of diverticulitis. . CTA AP [**2144-7-25**] 1. Tiny focus of active arterial extravasation within the right psoas muscle (2:124). Overall stable size of large right retroperitoneal hematoma. 2. Hypodense 3-mm lesion in the body of the pancreas, more fully characterized on the MRCP dated [**2144-7-11**]. Brief Hospital Course: Ms. [**Known lastname 91180**] is a 65 YOF with recent diagnosis of postviral autoimmune enteropathy requiring prolonged hospitalization complicated by acidosis and PEA arrest who represented from rehab with acute Hct drop and was found to have a retroperitoneal bleed, now s/p coiling by IR with stable Hct. # Retroperitoneal bleed: Unclear etiology. Pt was instrumented 3 weeks ag during PEA arrest with right femoral line, however, likely not related to bleed as pt was noted to have a stable hct 3 prior to admission (27) and femoral lines do not typically travel far enough to cause a psoas bleed. Possible pt had heparin shot into a vessel which caused bleeding? Symptoms began wednesday night and she was not symptomatic despite her profound anemia, making a slow bleed most likely. S/p IR coiling of small artery though unclear if it was actually bleeding. Hct stable after the procedure around 27. Lasix and valsartan were held in setting of IV contrast load during IR procedure. Coreg was also held to monitor for tachycardia as sign of re-bleed. Blood pressure medications were slowly restarted as blood pressure and blood counts stabilized. # Autoimmune enteropathy: Continued budesonide and methylprednisolone taper and monitored fingersticks. Should continue methylprednisolone 15 mg [**Hospital1 **] x 1 day, 12.5 mg [**Hospital1 **] x 3 days, 10 mg [**Hospital1 **] x 3 days, 7.5 mg [**Hospital1 **] x 3 days, 5 mg [**Hospital1 **] x 3 days, then off. Should follow up with GI as scheduled. # Hypertension: Has history of poorly controlled BP. Pt was hypotensive in ED in setting of anemia and had one episode of BP 80s overnight the night of admission, but was otherwise was normotensive. Her home isosorbide mononitrate was continued with holding parameters; and clonidine patch replaced to prevent withdrawal. Held valsartan, lasix, and coreg initially as above which were slowly restarted. # GERD: Omeprazole instead of esomeprazole while inpatient. # Depression/anxiety: Continued citalopram and Ativan during hospitalization. Restarted both on discharge. # 4-mm pancreatic cystic lesion: Found within the neck / body of the pancreas during previous hospitalization. Concern for IPMN (intrapapillary mucinous neoplasm) of pancreas. Will need follow up with MRI as outpatient. # Hypoxia: Likely atelectatis, but may have a component of pleural effusion from hypoalbuminemia. CHF possible, but no history of echo in our system. Echo done this admission showed normal systolic function and mild pulmonary artery hypertension. Incentive spirometer use encouraged. Transitional Issues: - monitor O2 status - monitor Hct daily for 2 days, then again on [**Hospital1 2974**] [**2144-7-31**] to ensure stable - monitor BPs - outpatient MRI - continue methylprednisolone taper as above FULL CODE during this admission. Medications on Admission: [**Last Name (un) **] 5000 TID Trazodone 25 mg HS Valsartan 320 mg Q day Conjugated estrogen 0.625 Q day Esmompreazole 40 mg Q day Lorazepam 0.5 mg Q 8 PRN Citalopram 40 mg Q day Vitamin D 400 units Q day Acetaminophen 650 mh Q 6 PRN Folic acid 1 mg Q day Tiamine 100 mg Q day Budesonide 9 mg Q day Gemfibrozil 600 mg Q day clonidine 0.2 mg patch Q thursday furosemide 40 mg Q day Carvedilol 25 mg [**Hospital1 **] isosorbide mononitrate 30 mg Q day Lidocaine patch Q day methylprednisolone 17.5 mg [**Hospital1 **] until [**7-27**] --> 15 mg [**Hospital1 **] x 3 days --> 12.5 mg [**Hospital1 **] x 3 days --> 10 mg [**Hospital1 **] x 3 days --> 7.5 mg [**Hospital1 **] x 3 days --> 5 mg [**Hospital1 **] x 3 days Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 2. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Three (3) Capsule, Delayed & Ext.Release PO DAILY (Daily). 10. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week: change on Thursday. 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. methylprednisolone 8 mg Tablet Sig: One (1) taper PO BID (2 times a day) for 13 days: taper as below: 15mg [**Hospital1 **] x 1 days 12.5mg [**Hospital1 **] x 3 days 10mg [**Hospital1 **] x 3 days 7.5 mg [**Hospital1 **] x 3 days 5 mg [**Hospital1 **] x 3 days . 15. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily). 16. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 18. insulin lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED): follow insulin sliding scale enclosed. 19. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 20. dextrose 50% in water (D50W) Syringe Sig: One (1) syringe Intravenous PRN (as needed) as needed for hypoglycemia protocol. 21. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 22. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 23. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 5481**] Skilled Nursing Center Discharge Diagnosis: Retroperitoneal bleed Autoimmune enteropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 91180**], You were admitted to [**Hospital1 18**] for a bleed in your right lower abdomen/back, called a retroperitoneal bleed. It is not clear why this has happened, but it may have been spontaneous (for no apparent reason). You were transfused with blood products to improve your blood counts. Interventional radiology doctors placed a [**Name5 (PTitle) 91181**] in the blood vessel that appeared to be bleeding and you did not have any subsequent problems. You were restarted on your most of your home blood pressure medications after the bleeding was felt to be stable. For your diarrhea and autoimmune enteropathy we continued your steroid regimen which will be tapered down as planned by the gastroenterology doctors. We also discontinued your foley catheter. The following changes were made to your medications: STARTED Atovaquone to prevent fungal pneumonia while you are on steroids STARTED calcium supplement INCREASED vitamin D supplement CONTINUE methylprednisolone taper for additional 15 days as follows: - 15 mg [**Hospital1 **] x 1 days - 12.5 mg [**Hospital1 **] x 3 days - 10 mg [**Hospital1 **] x 3 days - 7.5 mg [**Hospital1 **] x 3 days - 5 mg [**Hospital1 **] x 3 days Your blood pressure medications were initially stopped when you came in because you were bleeding significantly, but after your blood pressure and your blood counts were stable, we slowly restarted your blood pressure medications. Please be sure to discuss with your primary care doctor the possibility of again trying to very slowly taper down your conjugated estrogens because of potential risks of being on these medications. Please be sure to keep your followup appointment with your GI doctor as below. Followup Instructions: Department: DIVISION OF GI When: [**Hospital1 **] [**2144-8-7**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Please follow up with your primary care doctor once you are discharged from [**Hospital **] rehab. They can assist you with this function once you are ready for discharge to home.

4414,42833,99812,2851,4241,25000,99811,9961,E8798,2724,V4581,4280,V103,V1582,V5861,4400,41401

Admission Date: [**2147-2-8**] Discharge Date: [**2147-2-11**] Service: SURGERY Allergies: Zantac Attending:[**First Name3 (LF) 6088**] Chief Complaint: Abdominal Aortic Aneurysm Major Surgical or Invasive Procedure: [**2147-2-8**]: groin cutdown with mass excision and endovascular repair of an aortic aneurysm History of Present Illness: Ms. [**Known lastname **] is an 88-year-old female who is currently being evaluated for percutaneous aortic valve replacement due to severe aortic stenosis. She has a known infrarenal aortic aneurysm. This was in the 4-5 cm range when it was first discovered approximately eight years ago. In [**Month (only) **] of this past year, she was evaluated at the [**Hospital3 2358**] and was judged not to be an endovascular candidate. For that reason, repair was deferred. She was recently hospitalized in [**Month (only) 956**] of this year for flash pulmonary edema and back pain related to vertebral compression fracture. CAT at that time demonstrated a 7.5-cm infrarenal aortic aneurysm. She presents for elective endovascular repair. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: CAD Diabetes Dyslipidemia Hypertension CABG afib on coumadin dCHF (EF 60%) severe AS breast cancer s/p right partial mastectomy s/p hysterectomy Social History: Remote smoking history (quit 30 years ago). lives in [**Hospital 4382**] with her husband. walks with a walker. has four children, one died from MI. no etoh use. no illicit drug use Family History: one child died from MI as above, two brother died of MI in 40s, one sister died of cancer, one sister of heart disease, father died of heart problems, mother died of breast cancer Physical Exam: Physical Exam: Alert and oriented x 3 VS:BP 138/58 HR 72 Carotids: 2+, no bruits or JVD Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left Femoral palp , DP dop ,PT dop Right Femoral palp , DP dop ,PT dop Bilateral groin Dressing clean dry and intact. Soft, no hematoma or ecchymosis. Pertinent Results: [**2147-2-10**] 02:05AM BLOOD WBC-6.4 RBC-2.99* Hgb-8.9* Hct-28.1* MCV-94 MCH-29.8 MCHC-31.7 RDW-18.0* Plt Ct-124* [**2147-2-10**] 02:05AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.5 Brief Hospital Course: The patient was brought to the operating room on [**2147-2-8**] and underwent a right groin cutdown and mass excision and EVAR. The procedure was without complications. She was closely monitored in the PACU and then transferred to the floor where she remained hemodynamically stable. Her diet was gradually advanced. She is ambulatory with ad lib. She was discharged to home on POD # 2 in stable condition. Follow-up has been arranged with Dr. [**Last Name (STitle) **] with surveillance CTA in one month. Medications on Admission: Metoprolol 50', Lasix 40', Simvastatin 20', Lisinopril 10', Amiodarone 200', Coumadin 2.5'(on hold), Magnesium 120', MVI, Ca/Vitamin D Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: as per PCP. 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. magnesium 120 mg daily 10.calcium/vit d Discharge Disposition: Home Discharge Diagnosis: Abdominal Aortic Aneurysm Aortic Stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after an endovascular repair of an abdominal aortic aneurym. Please restart your coumadin at your home dose of 2.5 mg starting tonight. Have your INR checked at your PCPs office on [**2-13**]. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**12-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications Followup Instructions: Department: RADIOLOGY When: THURSDAY [**2147-3-16**] at 11:45 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: VASCULAR SURGERY When: THURSDAY [**2147-3-16**] at 1:30 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2147-2-11**]

75612,7861,4019,25000,4139

Admission Date: [**2117-12-30**] Discharge Date: [**2118-1-4**] Date of Birth: [**2054-1-6**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2724**] Chief Complaint: Neurogenic claudication Major Surgical or Invasive Procedure: [**2117-12-30**] PLIF L4-5 History of Present Illness: 63-year-old woman who complains of bilateral lower extremity symptoms that are exacerbated by walking. She receives some amelioration with rest. She denies difficulty with bowel or bladder function. Past Medical History: HTN Diabetes Angina Social History: NC Family History: NC Physical Exam: Pre-Op on clinic visit: On examination, her motor strength was [**3-30**] in hip flexion, extension, quadriceps, hamstrings, dorsiflexion, and plantar flexion bilaterally. Her sensory examination was intact with respect to the modality of light touch. Her reflexes were normal and symmetric in the patellar and absent in the Achilles bilaterally. Her pulses were palpable bilaterally. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] sign was positive on the left and not on the right, but weekly so. Upon Discharge: A&OX3 PERRL EOMs: intact Motor: IP [**Initials (NamePattern5) 12643**] [**Last Name (NamePattern5) **] AT [**Last Name (un) 938**] R 5 5 5 5 4 4 L 5 5 5 5 5 5 Incision: c/d/i- STAPLES Pertinent Results: CT L-SPINE W/O CONTRAST [**2118-1-1**] 1. Postoperative changes in the lumbar spine including posterior fusion of L4-L5. Grade 1 anterolisthesis of L4 on L5. 2. Drain is identified within the postoperative bed. No evidence of immediate hardware complication. LUMBO-SACRAL SPINE (AP & LAT) [**2118-1-1**] Status post L4-L5 stabilization. The stabilization material is in correct position. No evidence of complications. Brief Hospital Course: [**2117-12-30**] s/p PLIF L4-5 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]. Surgery was uneventful and immediately post-operatively she remained stable. POD 1 [**12-31**] she had an episode of stridor and feeling like she could not breath, desat to 84-86% - she received an albuterol and racemic neb with good effect, CXR was negative. Later that morning she experienced a second episode of stridor and feeling like she could not breath but OS sat was 100% and was transferred to the ICU for observation. Etiology is unclear but appeared to be upper respiratory. SQ Heparin was started on [**2117-12-31**]. On [**1-1**] she was transferred to the floor and her JP drain was discontinued. On [**1-3**], patient complained of pain in her back that radiated down both legs. Her R IP and [**Last Name (un) 938**] were both [**2-28**] on exam. She was started on neurontin and a medrol dose pack to help alleviate pain. PT is working with patient to determine if she needs to go to a rehab facility. On [**1-4**], patient reported that her pain was much more controlled. Her exam is improved with her R IP [**3-30**], but [**Last Name (un) 938**] is [**2-28**]. Patient will be discharged to [**Location (un) 86**] Center for rehabilitation. Medications on Admission: Atenolol Metformin Lisinopril Nortriptyline Hydroxychloroquine [Plaquenil] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever > 100.4, pain. 2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain. 6. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO breakfast/lunch/dinner () for 1 days. 15. Methylprednisolone 8 mg Tablet Sig: Two (2) Tablet PO bedtime () for 1 days. 16. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 days: start on [**2118-1-5**]. 17. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 days: start on [**2118-1-6**]. 18. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days: start on [**2118-1-7**]. 19. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO QD () for 1 days: start on [**2118-1-8**]. 20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 22. Magnesium Citrate 1.745 g/30mL Solution Sig: Three Hundred (300) ML PO ONCE (Once) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center - [**Location (un) 2312**] Discharge Diagnosis: Lumbar Spondylolisthesis 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: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ begin daily showers [**2118-1-3**] ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? 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: PLEASE RETURN TO THE OFFICE IN [**6-4**] DAYS FOR REMOVAL OF YOUR STAPLES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT Completed by:[**2118-1-4**]