notes_small.csv

PARSED
"Admission Date:  2130-4-14     Discharge Date:  2130-4-17
Date of Birth:   2082-12-11     Sex:  M
Service:  #58
HISTORY OF PRESENT ILLNESS:  Mr. Jefferson is a 47 year-old man
with extreme obesity with a body weight of 440 pounds who is
5'7"" tall and has a BMI of 69.  He has had numerous weight
loss programs in the past without significant long term
effect and also has significant venostasis ulcers in his
lower extremities.  He has no known drug allergies.
His only past medical history other then obesity is
osteoarthritis for which he takes Motrin and smoker's cough
secondary to smoking one pack per day for many years.  He has
used other narcotics, cocaine and marijuana, but has been
clean for about fourteen years.
He was admitted to the General Surgery Service status post
gastric bypass surgery on 2130-4-14.  The surgery was
uncomplicated, however, Mr. Jefferson was admitted to the Surgical
Intensive Care Unit after his gastric bypass secondary to
unable to extubate secondary to a respiratory acidosis.  The
patient had decreased urine output, but it picked up with
intravenous fluid hydration.  He was successfully extubated
on 4-15 in the evening and was transferred to the floor
on 2130-4-16 without difficulty.  He continued to have
slightly labored breathing and was requiring a face tent mask
to keep his saturations in the high 90s.  However, was
advanced according to schedule and tolerated a stage two diet
and was transferred to the appropriate pain management.  He
was out of bed without difficulty and on postoperative day
three he was advanced to a stage three diet and then slowly
was discontinued.  He continued to use a face tent overnight,
but this was discontinued during the day and he was advanced
to all of the usual changes for postoperative day three
gastric bypass patient.  He will be discharged home today
postoperative day three in stable condition status post
gastric bypass.
DISCHARGE MEDICATIONS:  Vitamin B-12 1 mg po q.d., times two
months, Zantac 150 mg po b.i.d. times two months, Actigall
300 mg po b.i.d. times six months and Roxicet elixir one to
two teaspoons q 4 hours prn and Albuterol Atrovent meter dose
inhaler one to two puffs q 4 to 6 hours prn.
He will follow up with Dr. Morrow in approximately two weeks as
well as with the Lowery Medical Center Clinic.
                          Kevin Gonzalez, M.D.  R35052373
Dictated By:Dotson
MEDQUIST36
D:  2130-4-17  08:29
T:  2130-4-18  08:31
JOB#:  Job Number 20340"
"Admission Date:  2107-11-13              Discharge Date:   2107-11-15

Date of Birth:  2078-9-5             Sex:   M

Service: EMERGENCY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:Annetta
Chief Complaint:
DKA

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. Abel is a 29 year old man with h/o Type I DM, 10 prior
admissions for DKA since 1-4, who presents with SOB/chest
discomfort, found to be in DKA.

The patient was at work today when he started feeling dyspnea on
exertion and substernal chest discomfort. CP worsened with deep
breaths. No difference with change in position. FS at that time
was 491, so the patient gave himself Humalog 7units. Repeat FS
369. He drove himself to the ED for further evaluation.

Of note, the patient was just admitted to Sprague Clinic 4 days prior in DKA, symptoms of N/V, discharged the
following day without any changes to his prior regimen. He had
been on insulin pump in the past, but was discontinued in 1-4.
Just restarted on insulin pump 10 days prior to this admission -
basal rate 0.75units/hr with bolus dosing at mealtime. Follows
with Dr. Rothwell as an outpatient, last seen on 2107-11-4 and
started on insulin pump at that time.

In the ED, initial vs were: 98.4 100 112/72 15 100% RA. Chest
discomfort resolved on arrival to the ED. Initial FS was >500,
with anion gap of 22, urine ketones 150. Patient was given IVF -
2LNS, 1L IVF with K, and started on 1L D5NS; started on insulin
gtt. Repeat lytes showed improved gap from 22 -> 18.

On the floor, the patient is currently comfortable. Only
complaint is that he is hungry. No fevers, chills, cough, sore
throat, N/V, abdominal pain, dysuria. SOB and CP are still
resolved.

Past Medical History:
- Type I DM, diagnosed 2096, frequent hospitalizations with DKA
- Diabetic cataract left eye s/p phacoemulsification with
posterior chamber lens implant 2098.
- Senile cataract right eye s/p phacoemulsification with
posterior chamber lens implant 2099.
- R shoulder subluxation

Social History:
- Tobacco: 10 cigarettes/day x 3 years
- Alcohol:  occasional
- Illicits:  none
The patient works as a line cook at House of Blues.


Family History:
Diabetes mellitus Type II in his father, paternal grandfather,
paternal aunts and uncles and maternal aunt; maternal GF/GM both
died of heart failure


Physical Exam:
Vitals: T: 96.8 BP: 120/66 P: 82 R: 13 O2: 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,
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
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities


Pertinent Results:
Admission labs:
2107-11-13 04:30PM   WBC-6.0 RBC-4.58* HGB-14.4 HCT-40.9 MCV-89
MCH-31.4 MCHC-35.1* RDW-11.7
2107-11-13 04:30PM   NEUTS-69.7 LYMPHS-26.3 MONOS-2.7 EOS-0.9
BASOS-0.4
2107-11-13 04:30PM   PLT COUNT-271#
2107-11-13 04:30PM   PT-10.6 PTT-22.1 INR(PT)-0.9
2107-11-13 04:37PM   PH-7.26*
2107-11-13 04:37PM   GLUCOSE-GREATER TH LACTATE-1.8 NA+-130*
K+-4.9 CL--96 TCO2-12*
2107-11-13 04:37PM   freeCa-1.19
2107-11-13 04:30PM   GLUCOSE-575* UREA N-23* CREAT-1.3*
2107-11-13 05:26PM URINE  COLOR-Straw APPEAR-Clear SP Tucker-1.021
2107-11-13 05:26PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG

EKG: NSR @ 80bpm, nl axis and intervals, diffuse STE, more
pronounced than prior in 9-4.

Discharge labs:
2107-11-15 05:54AM BLOOD WBC-7.2 RBC-4.72 Hgb-14.9 Hct-41.8 MCV-89
MCH-31.5 MCHC-35.6* RDW-11.9 Plt Ct-276
2107-11-15 05:54AM BLOOD Plt Ct-276
2107-11-15 05:54AM BLOOD Glucose-67* UreaN-17 Creat-0.9 Na-143
K-3.7 Cl-104 HCO3-26 AnGap-17
2107-11-15 05:54AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8

Brief Hospital Course:
Mr. Abel is a 29 year old man with h/o DM1, frequent
hospitalizations for DKA, recently restarted on insulin pump,
who was admitted in DKA.
.
#. DKA: Patient admitted for the 11th time this year with DKA.
Recently started on insulin pump, now with his second admission
in 10 days; insulin dosing did not appear to be adequate. No
signs or symptoms of infection as a trigger at this time, though
patient later had a persistent cough that was treated with
azithromycin.
On admission, patient was put on a regular insulin drip, and
started on D5 1/2NS when glucose came down <200. The next
morning, he was restarted on his insulin pump at a higher basal
dose.
The second day of admission, there was some confusion on two
levels. The patient misunderstood the calorie counts in the menu
and gave himself very low amounts of insulin based on his
calorie counting scale. His glucose meter was also poorly
calibrated and was giving finger stick readings about 150 lower
than actual. He was hyperglycemic to the 400s, but did not have
recurrent acidosis. His glucose levels subsequently improved.
The next day we spoke with his outpatient endocrinologist Dr.
Rothwell (114-594-2840), who said that he had only met the
patient once. He has few insulin pump patients, so the decision
was to have the patient return to Hughes for further follow-up.
He will see Dr. Ray the day after discharge to re-establish
care with him.
.
#. Cough: Patient had a productive cough. CXR negative. The
decision was made to treat him with azithromycin for a suspected
upper-respiratory tract infection.
.
#. ARF: Patient with Cr 1.3 on admission, baseline Cr 1.0.
Improved with fluid resuscitation.

Medications on Admission:
Insulin - on pump since 2107-11-4, basal rate 0.75units/hr, bolus
dosing for meals

Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Burke Industries Insulin Pump  Sig: One (1)   once a day.
3. One Touch Ultra Test     Strip Sig: One (1) strip
Miscellaneous four times a day.
4. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous four times a day: Use with insulin pump per
directions.
Discharge insulin pump settings:

Basal Rates:
  Midnight - midnight:  1.3 Units/Hr
Meal Bolus Rates:
  Breakfast = 1:8
  Lunch = 1:8
  Dinner = 1:8
  Snacks = 1:8
High Bolus:
  Correction Factor = 1:50
  Correct To mg/dL

Discharge Disposition:
Home

Discharge Diagnosis:
Diabetic ketoacidosis
Type I diabetes

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You were admitted with dangerously high blood sugar levels and
ketoacidosis. Your blood sugar levels improved with a continuous
insulin infusion and a lot of IV fluids. Your insulin pump was
restarted at a higher level, and you are now safe to go home.

You will need to follow your blood sugar very closely over the
next couple of days to make sure that your insulin pump is
properly titrated.

Your only medications are to continue using your insulin pump
and to take azithromycin for 2 more days.

Followup Instructions:
Please see Dr. Ray, at Hughes Diabetes Center, tomorrow,
11-15, at 3pm. You can call (250-886-7061 if you need
to make changes to that appointment.

Please follow-up with your primary care doctor, Dr Lareau,
within the next 2 weeks. You can call his office at
314-618-2706.


Completed by:2107-11-16"
"Admission Date:  2180-5-18              Discharge Date:   2180-5-25

Date of Birth:  2118-11-28             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:Joel
Chief Complaint:
confusion


Major Surgical or Invasive Procedure:
L Craniotomy for evacuation of L SDH


History of Present Illness:
This is a 61 year old woman without significant PMH who
presented to her PCP's office after becoming confused at work.
She remembers having a fall two weeks prior to presntation. An
MRI Brain was performed which revealed a large subacute left
SDH. She was sent to Reed Memorial Hospital ED and subsequently
transferred to Lorenzo Hospital. Neurosurgical consultation requested for
evaluation and treatment.
She states that she fell two weeks ago remembers hitting her
head
but does not recall which side. She does not think she is
confused but her co-workers believe that she is. She states that
her friends thought her walking was impaired. Otherwise she
reports no headache. She does say that she had trouble with her
right hand when writing. She denies seizure like
activity, LOC, fever, chills, Nausea, vomiting, chest pain or
pressure, sob, or weakness in other extremities.


Past Medical History:
rheumatoid arthritis, rectal bleeding, HTN, seasonal
allergies


Social History:
She works for the city of Lakeview, married, husband is currently
ill. Denies tobacco,etoh, drugs


Family History:
non-contributory


Physical Exam:
On Admission:
O: T:  BP: 130/60   HR: 92   R 18  O2Sats 99% 3L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to 2mm equal.  EOMs Intact no nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, cooperative with exam with mild
inattentiveness. Orientation: Oriented to person, place, and
date. 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, 4mm to 2
mm bilaterally. Visual fields perceived as full although
inattentive to task at times.
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.
Dr. Brown: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: tone increased b/l lower extremities. No abnormal
movements,
tremors. no drift noted. Motor impersistence.  Strength was full
with the following exceptions, has b/l tricep 4-25, IP's 5-/5 and
Hamstrigs 5-/5. The hands have significant pain and rheumatic
changes and finger extension and wrist extension were not tested
adequately.
Sensation: Intact to light touch bilaterally.
Reflexes: were grade 3 throughout.
Toes upgoing bilaterally

Gait: able to get up and out of bed with minimal assistance,
unsteady gait with swaying backward upon standing.

On Discharge: PERRLA, AAx O to person, hospital, Lakeview, time.
No word finding difficulties. Right pronator drift. LE's full
strength. RUE strength is 4- to 4-25 and LUE is 4 to 4+/5.

Pertinent Results:
CT HEAD W/O CONTRAST 2180-5-18
Evolving large left vertex subdural hematoma with rightward
subfalcine herniation and moderate effacement of the left
lateral ventricle.   Allowing for differences in technique, the
findings are little changed since the 14:11 MRI examination.

CT head 2180-5-19
1. Status post left craniotomy with evacuation of large subdural
hematoma.  Post-surgical changes with bilateral pneumocephalus,
left more than right with interval decrease of rightward shift
of normally midline structures.
2. No new focus of hemorrhage. Ventricles are stable in size.


CT head 2180-5-22
1. Increased size of a left vertex subdural hematoma with
increased
neighboring sulcal effacement and slight increase in rightward
subfalcine
herniation.
2. Increased hyperdense material subjacent to the craniotomy
site indicative of interval bleeding since 2180-5-19.
3. New minimal effacement of the quadrigeminal and suprasellar
cisterns.
4. Increased soft tissue swelling and subgaleal hematoma at the
craniotomy
site.
5. Evolving focal left frontal infarct at the subfalcine
herniation site.




Brief Hospital Course:
This is a 61 y/o woman who had a fall 2 weeks prior to admision,
striking her head. She presents to the ED with confusion. Head
CT revealed L SDH with significant midline shift. She was taken
to OR emergently for a L side craniotomy for evacuation of SDH.
Post operatively patient was transferred to ICU for recovery. On
5-19, post op head CT showed minimal improvement of midline
shift and pneumocephalus. On examination, patient was a&ox3, R
triceps 4-25, otherwise she was intact. She was transferred to
step down unit and PT/OT consulted.
On 5-21 the patient was neurologically stable and dilantin level
was therapeutic.
On 5-22 a repeat head CT was performed which revealed an increase
in MLS. Fluid and air was aspirated from the crani site at the
bedside and she was placed on 100%O2 for pneumocephalus. Her
exam improved and word finding difficulties resolved. She was
sorking with PT and OT and was being screened for rehab. Her BUN
elevated to 21 on 5-23 and IVF were restarted at 50cc/hr. Her Bun
stabilized to 20 and she was discharged to rehab on 5-25.


Medications on Admission:
Amlodipine Besy-Benxapril 11-9, plaquenil 1 tab Self Memorial Hospital (250mg),
naprosyn 500mg Self Memorial Hospital, prednisone 5mg daily


Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. prednisone 5 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 or fever: max 4g/24 hrs.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
11. heparin (porcine) 5,000 unit/mL Solution Sig: 14428 (14428)
units Injection TID (3 times a day).
12. benazepril 10 mg Tablet Sig: Two (2) Tablet PO Daily ():
Hold if SBP <105 or K> 4.5
.


Discharge Disposition:
Extended Care

Facility:
Duncan Medical Center Martinez Memorial Hospital Rehabilitation and Nursing Center - Eerie

Discharge Diagnosis:
L SDH with midline shift


Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - always.


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.
??????	You may wash your hair only after sutures and/or staples have
been removed. They should be removed on 5-27.
??????	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.
??????	You may resume taking prednisone
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking after post-op review
??????	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 311-654-8171.
??????	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

??????You may return to the office in 7-30 days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This can alos be done at rehab by 5-27.
??????Please call (505-473-5282 to schedule an appointment with Dr.
Wise, to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.


                             Ashley Jerald MD I17811034

Completed by:2180-5-25"
"Admission Date:  2177-10-2              Discharge Date:   2177-10-30

Date of Birth:  2120-8-4             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:Johnny
Chief Complaint:
Epigastric discomfort and lethargy

Major Surgical or Invasive Procedure:
2177-10-6 Five Vessel Coronary Artery Bypass Grafting(LIMA to
LAD, with vein grafts to first diagonal, second diagonal, obtuse
marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring),
with Insertion of an IABP.


History of Present Illness:
Mr. Gladys is a 57 year old male who presented to OSH in mid
September with shortness of breath, gastric discomfort and
fatigue. He ruled in for a ST elevation MI. Subsequent cardiac
catheterization revealed severe three vessel coronary artery
disease and an LVEF of 36%. Echocardiogram at that time was
notable for an LVEF of 40% with inferior wall akinesis and
moderate mitral regurgitation. Patient was declined for surgery
at Starr Clinic(secondary to poor distal targets) and
eventually transferred to the Wood Memorial Hospital for further evaluation and
treatment.

Past Medical History:
Ischemic Cardiomyopathy, Coronary Artery Disease with inferior
wall ST Elevation MI on 2177-9-30, Mitral Regurgitation,
Hypertension, Type II Diabetes Mellitus(poorly controlled),
Hyperlipidemia

Social History:
Denies tobacco and ETOH. He lives alone. He is a truck driver.

Family History:
Denies family history of premature coronary artery disease.

Physical Exam:
Admission
HR 74 SR BP 126/62 RR 20 Sat 96% on 4L
Neuro Arousable, follows commands with encouragement. MAE,
strength 5/5 t/o. PERRL.
CV RRR no M.R.G
Lungs wheezes, crackles
Abdomen soft/NT
Extrem 1+ edema, warm 2+ pulses t/o
no carotid bruits
Discharge
T 99.6  HR 76SR  BP104/60  RR22  O2sat 96%RA
Neuro: Awake, moves rt side to command, left dense hemiparesis
CV: RRR, sternum stable
Pulm: course rhonchi
Abdm: soft, NT/+BS
Ext: left LE 3+ edema, Rt LE no edema

Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
2177-10-30 02:29AM    8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0*
281
Source: Line-CVL
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
2177-10-30 02:29AM        281
Source: Line-CVL
2177-10-30 02:29AM    20.5*1 65.6*   1.9*
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
2177-10-30 02:29AM    150* 25* 1.2 137 3.8 99 30 12

RADIOLOGY  Final Report
CHEST (PORTABLE AP)  2177-10-29 1:30 PM
CHEST (PORTABLE AP)
Reason: dobhoff placement
Choudhury Medical Center MEDICAL CONDITION:
57 year old man with s/p CABG
REASON FOR THIS EXAMINATION:
dobhoff placement
CHEST, SINGLE AP FILM
History of CABG.
Status post CABG. Distal end of feeding tube overlies body of
stomach. There is cardiomegaly and a left pleural effusion with
associated atelectasis in the visualized left lower lung. No
pneumothorax. The left subclavian CV line has tip located over
the proximal SVC.
IMPRESSION: No definite pneumothorax. Left pleural effusion and
associated atelectasis in left lower lobe, overall appearances
being essentially unchanged since prior study of 2177-10-28.

DR. Herbert Castaneda

2177-10-2 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4
MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273
2177-10-2 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4*
2177-10-2 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133
K-4.7 Cl-94* HCO3-27 AnGap-17
2177-10-2 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531*
AlkPhos-325* Amylase-35 TotBili-0.6
2177-10-2 10:30PM BLOOD Albumin-3.3* Mg-2.5
2177-10-2 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49*
calTCO2-28 Base XS-4
2177-10-2 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1
Cl-94*
2177-10-5 08:58PM BLOOD %HbA1c-12.4*
2177-10-3 Non Contrast Head CT Scan:
There is no evidence of intracranial hemorrhage, mass effect, or
shift of normally midline structures. Dr. Butler-white matter
differentiation is preserved. The ventricles are normal in size
and symmetric. There is no evidence of acute major vascular
territorial infarction. There are moderate cavernous carotid
calcifications. There is complete opacification of the right
maxillary sinus. The remaining paranasal sinuses and mastoid air
cells are clear.
2177-10-6 Intraoperative TEE:
PRE-BYPASS:
Pt requiring dobutamine infusion at 7.5
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild to moderate global left ventricular hypokinesis
(LVEF = 35-40 %), with basal to mid inferior and
inferior-lateral akinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.].
3. Right ventricular chamber size is normal. There is mild to
moderate global right ventricular free wall hypokinesis.
4. There are simple atheroma in the ascending aorta. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Trace aortic regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen, with noted centrally
directed regurgitant jet. The mitral regurgitation vena
contracta is >=0.7cm.
7.The tricuspid valve leaflets are mildly thickened; there is
mild to moderate (12-17+) tricuspid regurgitation.
POST-BYPASS:
Pt removed from cardiopulmonary bypass on vasopression,
milrinone, epinephrine and norephinephrine infusions and
placement of intra-aortic balloon pump.
1. Pt s/p mitral valve annuloplasty. There is no mitral
regurgitation.
2. Biventricular function is improved. Right ventricular is
normal sized and function has improved from moderate to mild
dysfunction. Left ventricular function remains globally
depressed; basal to mid inferior walls remain akinetic; there is
improvement of anterior wall function.
3. Aortic contours are intact post-decannulation. There is an
intra-aortic balloon noted in the proper position.
2177-10-15 Transthoracic ECHO:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
akinesis of the inferior and inferolateral walls. The remaining
segments contract normally (LVEF = 35-40 %). 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. A mitral valve annuloplasty ring
is present. The mitral annular ring appears well seated and is
not obstructing flow. No mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is a
very small pericardial effusion most prominent around the right
atrium.
2177-10-16 Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated native 3 vessel coronary artery disease. The LMCA
had
diffuse mild disease. The LAD was occluded in the mid vessel.
The LCX
was occluded proximally. The RCA was occluded proximally. The
SVG-PDA
was patent with slow flow into a small PDA. The SVG-D1 was
patent as was
SVG-D2, both with slow flow into small distal vessels. The
SVG-OM was
patent with slow flow as well. The LIMA-LAD was patent. The LAD
beyond
the LIMA was diffusely small with slow flow.
2. Limited resting hemodynamics were performed. The systemic
arterial pressures were borderline low measuring 86/63mmHg.
2177-10-20 Non contrast Head CT Scan:
There is no sign for the presence of an intracranial hemorrhage.
There is a question of a 1cm area of low density seen within the
region of the right uncus, which did not appear to be present on
the prior CT scan. If real, this finding could represent an area
of developing infarction. No other definite interval changes are
appreciated. There is no hydrocephalus or shift of normally
midline structures.
2177-10-21 MRA Brain:
Multiple areas of restricted diffusion bilaterally including
also the right cerebellar hemisphere as described above, areas
of subacute ischemic changes extending from the posterior limb
of the right internal capsule to the right, hippocampal area.
These December are suggestive of subacute infarcts likely from
an embolic source involving multiple vascular territories.




Brief Hospital Course:
Mr. Gladys was admitted to the cardiac surgical service. He
remained pain free on intravenous Heparin and Nitroglycerin. He
was initially evaluated by the Neurology service for an altered
mental status, experiencing periods of unresponiveness,
confusion and agitation/delirium. A head CT scan was
unremarkable and his altered mental status was attributed
metabolic encephalopathy. There was no evidence of stroke. Over
the next several days from a cardiac standpoint, he gradually
developed cardiogenic shock and required inotropic support.
Given his critical condition, he was urgently brought to the
operating room on 10-6 where Dr. Hess performed
coronary artery bypass grafting and mitral valve repair. Given
his low ejection fraction, an IABP was placed prior to weaning
from cardiopulmonary bypass. For additional surgical details,
please see seperate dictated operative note. Following the
operation, he was brought to the CVICU in critical condition.
His postoperative course will now be broken down into systems:

CARDIAC: Initially required multiple inotropes for poor
hemodynamics. Started on Amiodarone on postoperative day two for
atrial and ventricular arrhythmias. The IABP was slowly weaned
and eventually removed on postoperative day four without
complication. He remained pressor dependent at that time.
Cardioversion was performed on postoperative day six for
episodes of atrial fibrillation associated with a decrease in
SVO2. By postoperative seven, all inotropic support was weaned.
Despite Amiodarone, he continued to experience atrial and
ventricular arrhythmias. He went on to develop an episode of
sustained ventricular fibrillation/torsades on postoperative day
eight for which successfull defibrillation was performed.
Amiodarone was discontinued and switched to Lidocaine. A calcium
channel blocker was concomitantly initiated. The EP/cardiology
services were consulted and recommended EPS with potential VT
ablation. To rule out ischemia as the cause for ventricular
tachycardia, cardiac catheterization was performed on 10-16 which showed patent grafts. Given ventricular arrhythmias,
he was eventually started on Mexiletine.

PULMONARY: Given critical condition, required prolonged
mechanical ventilation. Eventually extubated on postoperative
day nine. He was electively re-intubated for cardiac
catheterization on 10-16, and re-extubated later that
night. Unfortunatly, he went on to develop acute respiratory
failure later that night and required reintubation. Bronchoscopy
was performed on 10-17 which found patent airways without
evidence of mucous plugs and only minimal scant secretions. A
left sided chest tube was placed for pleural effusion. The
effusion improved and the chest tube as removed.

NEURO: Given his critical condition, had a prolonged period of
sedation. Following his initial extubation, he awoke
neurologically intact. Following his second re-extubation on
postoperative day 14, he was noted to have new onset left
hemiparesis and left sided neglect. Neurology was consulted
while head CT scans and MR Donald Scrivens consistent with
embolic stroke(see result section). Heparin and coumadin were
started.

RENAL: Developed oliguric acute renal failure. Creatinine peaked
to 2.9 on postoperative day eight. The renal service was
consulted and attributed his renal insufficiency to pre-renal
etiology. Renal function gradually improved and he responded
nicely to diuretics.

ENDOCRINE: Initially maintained on Insulin drip. Transitioned to
lantus insulin.

HEME: Mild postoperative anemia and was intermittently
transfused to maintain hematocrit near 30%.

ID: Remained afebrile with no evidence of infection.

GI: Bedside swallow on 10-22 recommended continuing NPO/tube
feeding as he was not consistently awake enough to safely
attempt anything by mouth. Tolerating tube feedings.

Skin: A hematoma formed at an ex-chest tube site on his left
flank and began bleeding with anticoagulation. It was sutured on
10-26 and subsequently improved.


Medications on Admission:
Intravenous Nitroglycerin
Docusate Sodium 100 Showalter Medical Center
Metoprolol 75 Showalter Medical Center
Pantoprazole 40 qd
Aspirin 325 qd
Lisinopril 2.5 qd
Simvastatin 40 qd
Glargine 20 units qhs
RISS

Discharge Medications:
1. Simvastatin 40 mg Tablet Showalter Medical Center: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Showalter Medical Center: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Showalter Medical Center: Two
(2) Puff Inhalation Q4H (every 4 hours).
4. Fluticasone 110 mcg/Actuation Aerosol Showalter Medical Center: Two (2) Puff
Inhalation Showalter Medical Center (2 times a day).
5. Docusate Sodium 50 mg/5 mL Liquid Showalter Medical Center: One (1)  PO BID (2
times a day).
6. Carvedilol 12.5 mg Tablet Showalter Medical Center: Two (2) Tablet PO BID (2 times
a day). Tablet(s)
7. Mexiletine 150 mg Capsule Showalter Medical Center: One (1) Capsule PO Q8H (every
8 hours).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR Kenison: One (1)
Tablet,Rapid Dissolve, DR Kenison DAILY (Daily).
9. Bisacodyl 10 mg Suppository Kenison: One (1) Suppository Rectal
DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray Kenison: 12-17 Sprays Nasal
QID (4 times a day) as needed.
11. Ipratropium Bromide 0.02 % Solution November: One (1)  Inhalation
Q6H (every 6 hours) as needed.
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
 Inhalation Q4H (every 4 hours) as needed.
13. Artificial Tear with Lanolin 0.1-0.1 % Ointment November: One (1)
Appl Ophthalmic PRN (as needed).
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
 Inhalation Q6H (every 6 hours) as needed.
15. Warfarin 1 mg Tablet November: as directed Tablet PO DAILY
(Daily): target INR 2-2.5
Pt to receive 7.5mg on 10-30.
16. Lisinopril 5 mg Tablet April: One (1) Tablet PO DAILY (Daily).

17. Furosemide 80 mg Tablet April: One (1) Tablet PO BID (2 times
a day).


Discharge Disposition:
Extended Care

Facility:
Blackwater Senior Care - Thomas Memorial Hospital

Discharge Diagnosis:
- Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction,
Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock
- s/p Urgent CABG and Mitral Valve Repair on IABP
- Postoperative Stroke
- Postoperative Acute Respiratory Failure
- Postoperative Acute Renal Failure
- Postoperative Atrial Fibrillation/Flutter
- Postoperative Ventricular Tachycardia
- Postoperative Bradycardia
- Postoperative Anemia
- Postoperative Pleural Effusion
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus


Discharge Condition:
Stable.


Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.

Dineenp Instructions:
Dr. Smith 4-5 weeks, please call for appt
Cardiology clinic-Dr Kenison (EP) in 2-16 weeks, please call
for appt



Completed by:2177-10-30"
"Name:  Kelli,Elizabeth                     Unit No:   66109

Admission Date:  2183-7-12              Discharge Date:   2183-7-27

Date of Birth:  2127-9-2             Sex:   F

Service: MED

Allergies:
Percocet / Codeine / Robaxin / Lomotil / Vancomycin And
Derivatives

Attending:Courtney
Chief Complaint:
Fatique, fever

Major Surgical or Invasive Procedure:
surgical removal of port.


Brief Hospital Course:
See prior addenda

Discharge Medications:
additional d/c medication, insulin:

Lantus(Glargine) - 13 Units q evening, Loftus Memorial Hospital.

Discharge Disposition:
Extended Care

Facility:
Blackwater House Nursing Home - Thundera

Discharge Diagnosis:
Line sepsis from infected Lt. port; MRSA bacteremia


Discharge Condition:
Good

                             John Sorrell MD J60211121

Completed by:2183-7-27"
"Admission Date:  2135-6-22       Discharge Date:  2135-7-2

Date of Birth:   2076-4-4       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 59-year-old
male with a history of metastatic melanoma to bowel and known
pulmonary and CNS metastases status post craniotomy with
resection of the brain metastases.  The patient presented
with a three day history of intermittent worsening and crampy
abdominal pain in the lower quadrants, worse on the right
than on the left.  The pain was described as severe.  The
patient had a bowel movement until the day prior to
admission.  KUB on arrival in the Emergency Department showed
dilated loops of small bowel with air fluid levels.  A CT
scan obtained shortly thereafter showed two large mesenteric
masses with erosion into small bowel and free perforation of
the more proximal segment of small bowel, as well as
mechanical mid small bowel obstruction.

PAST MEDICAL HISTORY:
1.  Metastatic melanoma with metastases to the lung, brain,
bowel, left flank

MEDICATIONS:
1.  Nexium 40 mg po qd
2.  Flomax
3.  Flonase
4.  Compazine
5.  Ambien 10 mg
6.  Quinine 260 mg
7.  Prednisone 10 mg po
8.  50 mcg fentanyl patch

The patient had recently been on his first week to Taxol
dexamethasone therapy and had also been through four cycles
of IL-2/temozolomide for his metastatic melanoma.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient had smoked one pack per day for
about 20 years, but quit 20 years ago.

PHYSICAL EXAM:
VITAL SIGNS:  Temperature 98.8??????, blood pressure 120/70, pulse
117, respiratory rate 20, O2 saturation 96% on room air.
GENERAL:  The patient was awake and comfortable and appeared
well nourished.
HEAD, EARS, EYES, NOSE AND THROAT:  No jugular venous
distention, no palpable nodes.  Oropharynx was clear.
NECK:  Supple.
HEART:  S1, S2, tachycardic with no murmurs, rubs or gallops.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Distended, nontender, no hepatosplenomegaly.  There
were decreased bowel sounds.  Abdomen was tense and was a 7
cm subcutaneous mass on the left flank.
EXTREMITIES:  There was no lower extremity edema, cyanosis or
clubbing.

LABS:  White cell count 9.8, hematocrit 13.8, platelets 947.
PT 12.8, PTT 21.5, INR 1.1.  Chem-7 - sodium 136, potassium
4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6,
glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2.

HOSPITAL COURSE:  The patient arrived in the hospital on the
evening of 6-22 and evaluation was initiated.  The patient
was taken to the Operating Room late in the night of 6-22
where, per the Operating Room note, tumors were discovered in
the ileum and jejunum with free perforation of both lesions.
The patient was then transferred to the Intensive Care Unit.
The patient was started on ampicillin, levofloxacin and
Flagyl.

On postoperative day #2, which was 2135-6-25, the patient was
started on TPN.  His antibiotics were continued.  On
postoperative day #3, the patient was noted to have a
slightly increased temperature to 100.2??????.  He was pan
cultured given the fact he had recently been on steroids.
His central line was also changed.  During the course of the
day, the patient was agitated at one point and pulled his
A-line.  Haldol was prescribed.

On postoperative day #4, the patient appeared to be less
confused.  He was transferred to the floor with a sitter.  By
postoperative day #5, while the patient was on the floor, he
was appearing much more lucid, communicating appropriately
and the sitter was discontinued.  The patient was continued
on total parenteral nutrition.  Because of continued increase
in white cell count from 14.3 on postoperative day #4 to 16.0
on postoperative day #5, the patient was sent for an
abdominal CT.  Although no abscess was identified that could
explain the patient's increase in white cell count, the
patient was noted to have developed mural thrombus in his
abdominal aorta and in the left iliac artery.  The patient
was also noted to develop some new bilateral pleural
effusions with some barium in the left lung base.  On being
notified of these findings, the surgical team immediately
consulted the patient's neuro-oncologist and oncologist team
for advice on the propriety of placing the patient on
anticoagulation.

The patient was seen by his neuro-oncologist on postoperative
day #6, which was the 4-29.  The patient's
neuro-oncologist requested head CT be obtained to rule out
any new brain metastases with bleeding because this would
determine the patient's suitably for anticoagulation.  The
head CTs were negative and per neuro-oncology, there was no
contraindication to anticoagulating the patient.  The patient
was seen by his oncologist team also on postoperative day #6.
Oncology was of the opinion of the patient, was unsuitable
for anticoagulation with Coumadin or heparin but that aspirin
could be initiated.  The patient was therefore started on
aspirin.

The patient's steroids were also tapered beginning on
postoperative day #7.  His fluconazole was discontinued.  At
the suggestion of the patient's oncology team, the surgery
team also transfused the patient with 1 unit packed red blood
cells on postoperative day #8 for borderline low hematocrit
of 26.1.  On postoperative day #7, the patient's diet was
changed from NPO to sips.  The patient tolerated this well
and so on postoperative day #8, the patient was advanced to a
clear liquid diet and his TPN was discontinued.  By the
evening of postoperative day #8, the patient was able to
tolerate a regular diet and on the day of discharge, which
was 2135-7-2, the patient had a regular breakfast without any
problems.  Lindsey is to be discharged home with visiting nurse
assistant for wound care.  Mr. Jeannette continues to have an
open vertical incision in the midline of his abdomen that
would require wet to dry dressings twice a day.

DISCHARGE MEDICATIONS:
1.  Flomax
2.  Flonase
3.  Compazine
4.  Ambien
5.  Quinine
6.  Prednisone 10 mg po qd
7.  Protonix 40 mg po bid
8.  Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours
9.  Levofloxacin 500 mg po qd x5 more days

FOLLOW UP:  The patient is to follow up with oncology on 7-18.  The patient is to call Dr.Ervin office for
follow up appointment this coming week.




                            Barbara Sundberg, M.D.  W92784896


Dictated By:George
MEDQUIST36

D:  2135-7-2  10:51
T:  2135-7-2  11:14
JOB#:  Job Number 18599
"
"Admission Date:  2161-12-15     Discharge Date:  2161-12-22

Date of Birth:   2118-1-10     Sex:  F

Service:

DIAGNOSIS:
Tracheal bronchial malacia.

HISTORY OF PRESENT ILLNESS:  The patient is a delightful 43
year-old woman who was found to have tracheal bronchial
malacia and has suffered from years of dyspnea on exertion,
persistent tracheal bronchitis and recurrent infections. She
is therefore admitted to undergo a right thoracotomy and
tracheoplasty.

HOSPITAL COURSE:  The patient is admitted to the hospital and
underwent minimally invasive muscle sparring oscillatory
triangle thoracotomy with tracheal bronchoplasty on the day
of admission.  She did well and was discharged without
problems.






                          Diane Lewis, M.D.  C45888251

Dictated By:Vail

MEDQUIST36

D:  2162-4-5  05:00
T:  2162-4-7  09:38
JOB#:  Job Number 33135
"
"Admission Date:  2163-11-21              Discharge Date:   2163-12-1

Date of Birth:  2086-12-16             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:Flossie
Chief Complaint:
CHF, ARF, Mediastinal lymphadenopathy

Major Surgical or Invasive Procedure:
Bronchoscopy x 2
Mediastinoscopy with lymph node biopsy

History of Present Illness:
76M initially went to Davis Hospital hospital with L flank and sent
home with narcs.  Represented with DOE, weight gain and L flank
pain.  He reports that he has had intermittent DOE for year but
notice a sharp increase in his weight over a period of 10 days.
He gained 8-10lbs with associated LE swelling, but without
medication noncompliance, dietary changes, chest pain,
orthopnea, PND.  This happened at the beginning of July and
his Lasix was increased from 40 to 60 daily.  He also had a
holter revealing afib (rate 40-100), nuclear stress
(2163-11-1)without ischemia and normal ECHO on 2163-11-3 (mild AS,
mild MR).  Upon arrival to the ED he was found to be hypotensive
with hyperkalemia and ARF (Cr ~4 from basline of 1.2)  He was
sent to the floor, diuresed and then sent to the ICU after he
was hypotensive requiring dopamine and vasopressin.  He had a
Swan-Ganz catheter placed on 11-19 and had renally dosed
dopamine.  He was thought to be fluid overloaded and had a
transudative thoracentesis (amount removed unknown).  He was
aggressively diuresed with Lasix and renally dosed Dopamine. His
renal function improved prior to transfer.
Swan numbers:
RA: 25
RV: 55/20/10
PA: 55/25
PCW: 26
His L flank pain was evaluated with a CT Abdomen and he was
found to have L nephrolithiasis and an exophytic cyst on the
lower pole of the L kidney.  His pain has been controlled with
narcotics.
He had also been recieving  Zyvox for presumed pneumonia and
solumedrol 60 mg q6h for presumed COPD.
He was transferred for evaluation of his mediatinal LAD.  This
has been watched for seveal years and he has two non-FDG avid
PET CTs, most recently in 2163-6-26.  He denies any B symptoms.
He does have decreased appetite, but has been active with
outside hobbies including golf and curling.  The thoracics
service was contactTammy for this evaluation and it was suggested
that the patient be admitted to the MICU given his underlying
medical problems.


Past Medical History:
PAST MEDICAL HISTORY:
====================
AF, on coumadin at home
CRI Cr:1.6
Chronic Anemia
CHF EF
Bladder CIS s/p BCG washout in 10/2163
Colonic dysplastic lesions on bx
OSA- unable to tolerate CPAP
low grade NHL with diffuse stable LAD
AS
R popliteal artery endarterectomy
uretral stent
Gout
PVD
L CEA 2159
UGIB 2161
LLL lobectomy in 2135
Nephrolithiasis


Social History:
EtOH: 2 martinis daily
Tobacco: quit 1ppd 25 yrs ago
outside hobbies included golf and curling


Family History:
no history of malignancy

Physical Exam:
Tmax: 35.9 ??????C (96.6 ??????F)

Tcurrent: 35.9 ??????C (96.6 ??????F)

HR: 74 (67 - 75) bpm

BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg

RR: 20 (20 - 24) insp/min

SpO2: 96%

Heart rhythm: AF (Atrial Fibrillation)
Physical Examination

General Appearance: Well nourished, No acute distress

Eyes / Conjunctiva: PERRL

Head, Ears, Nose, Throat: Normocephalic, MMM

Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy

Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at
base

Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)

Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilateral bases)

Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present,
Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds

Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t)
Clubbing

Skin:  Not assessed

Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed


Pertinent Results:
2163-11-22 Echo: The left atrium is elongated. The right atrium is
markedly dilated. The right atrial pressure is indeterminate.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is mild to moderate aortic valve stenosis (area 1.2 cm2).
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.

2163-11-23 Pathology report
1.  Lymph nodes, 4L, biopsy (A-C):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in two of ten lymph nodes/lymph node fragments.
2.  Lymph nodes, 7, biopsy (D):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in three of four lymph nodes/lymph node
fragments. See note.
3. Lymph nodes, level 7, biopsy (E):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in one of two lymph nodes/lymph node fragments.
Note:
Immunohistochemical stains show the tumor cells are diffusely
positive for synaptophysin and chromogranin and are negative for
CK 7 and TTF-1.  Rare tumor cells are positive for CK20.
Despite the negative TTF-1, the tumor is compatible with a lung
primary.  Clinical correlation recommended.

FLOW CYTOMETRY 11-23:
FLOW CYTOMETRY IMMUNOPHENOTYPING:

The following tests (antibodies) were performed:  HLA-DR, FMC-7,
Kappa, Lambda and CD antigens:  2,3,5,7,19,20,23, and 45.



RESULTS:

Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.  B cells comprise 34% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens.  T cells comprise 50% of lymphoid gated
events, and express mature lineage antigens.

INTERPRETATION:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen.  Correlation with clinical findings and
morphology (see S08-85352) is recommended.  Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.

11-23 Bronchial Washings:
 Bronchial washing, left upper lobe:

  NEGATIVE FOR MALIGNANT CELLS.

  Reactive bronchial epithelial cells and alveolar
  macrophages.

ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL)
was
  reviewed and shows alveolar macrophages. No evidence of
  malignancy.

11-23 CXR:
FINDINGS: No pneumothorax. There is complete opacification of
the left lung, which is indicating collapse in the left upper
lung, likely due to mucus plug. There is overlapping
opacification, which was seen on the previous film, in the left
lower lung which might be postoperative, inflammatory, or
malignant and further evaluation is needed.

There is a small right pleural effusion, unchanged. There is no
consolidation in the right lung. The right jugular line was
removed.

2163-11-23 CXR Post-Bronch:

FINDINGS: As compared to the previous examination, the left lung
is slightly better aerated. There is no evidence of left-sided
pneumothorax. In the right lung, in the middle lobe, some subtle
areas of atelectasis are seen. No evidence of larger pleural
effusions.

2163-11-24 CXR:
PORTABLE CHEST RADIOGRAPH: Compared to recent studies of
2163-11-23, there is improved aeration of the left upper lung,
without evidence of new
pneumothorax. There persists opacification of the left perihilar
and left
lower lung, likely representing combination of pleural effusion
and
atelectasis, although underlying consolidation cannot be
excluded. There is also improved aeration of the right lung
although small right pleural effusion persists.

2163-11-25 CXR:
REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy.

Since yesterday, diffuse opacification of the left lung is
overall unchanged, mostly in the perihilar and left lower lung
region, likely a combination of left pleural effusion and
atelectasis, possibly consolidation. Small right pleural
effusion is unchanged. The right lung is otherwise normal. There
is no other change.

2163-11-25 CT Scan Chest:

IMPRESSIONS:
1. Subcutaneous gas consistent with recent mediastinoscopy. A
small left
lower paratracheal collection containing fluid and gas could
represent post- procedural changes. Correlation with recent
procedure and clinical symptoms recommended. Multiple
mediastinal lymph nodes are noted. Larger soft tissue density in
the subcarinal region could represent lymphadenopathy or in the
right clinical context could also represent a hematoma.
Comparison with prior study if available could help
differentiate between the two.

2. Status post left lower lobectomy with fibrotic changes and
atelectasis
noted in the left lung. Fluid collection with thick enhancing
rind in the
left posterior sulcus is chronic and organized.

3. Nodule in the anterior left lung could represent rounded
atelectasis,
though in atypical location. Recurrent tumor cannot be excluded.


4. Moderate right dependent pleural effusion with associated
dependent
atelectasis of the left lower lobe.

5. Left adrenal mass. Dedicated imaging of the adrenal glands
recommended
for further evaluation. There is also suggestion of
lymphadenopathy in the
retroperitoneum that is incompletely imaged. Small ascites noted
along the
dome of the liver.

EKG 2163-11-27:
Normal sinus rhythm. Poor R wave progression, possibly related
to lead
placement. No other abnormality. No previous tracing available
for
comparison.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 0 88 912-120-18471

OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of 2163-11-29
Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE
NEOPLASM
Prelim findings c/w metastatic carcinoid, full report pending.

2163-11-21 07:32PM   GLUCOSE-130* UREA N-119* CREAT-2.2*
SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
2163-11-21 07:32PM   estGFR-Using this
2163-11-21 07:32PM   CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4
2163-11-21 07:32PM URINE  HOURS-RANDOM UREA N-828 CREAT-45
SODIUM-LESS THAN
2163-11-21 07:32PM URINE  OSMOLAL-427
2163-11-21 07:32PM   WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4*
MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1
2163-11-21 07:32PM   NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0
BASOS-0
2163-11-21 07:32PM   PLT COUNT-389
2163-11-21 07:32PM   PT-33.9* PTT-43.6* INR(PT)-3.6*
2163-11-21 07:32PM URINE  COLOR-Yellow APPEAR-Clear SP Gruwell-1.013
2163-11-21 07:32PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR

Other labs:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
2163-12-1 05:45AM    5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6
288
2163-11-30 08:05AM    5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7
277
2163-11-29 06:45AM    5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1
280
2163-11-28 07:00AM    6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4
242
2163-11-27 07:25AM    9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5
247

  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
2163-12-1 05:45AM    96 18 1.0 147* 4.0 105 37* 9
2163-11-30 08:05AM    81 20 0.9 145 4.0 108 34* 7*
2163-11-29 06:45AM    77 22* 0.9 1441 4.0 106 36* 6*
2163-11-28 07:00AM    79 27* 1.0 144 4.1 105 32 11
2163-11-27 07:25AM    95 30* 1.0 143 4.0 106 33* 8
2163-11-26 07:00AM    103 37* 0.9 143 4.2 107 33* 7*
2163-11-25 03:37PM    104 43* 1.0 147* 4.4 110* 33* 8
2163-11-25 02:07AM    168* 60* 1.0 146* 4.3 110* 31 9
2163-11-24 04:25AM    92 87* 1.2 150* 4.2 113* 31 10
2163-11-23 07:05AM    97 115* 1.7* 147* 4.5 108 31 13
2163-11-22 02:52PM      126* 2.0*
2163-11-22 05:34AM    122* 125* 2.1* 143 4.5 104 28 16
DIG ADDED 9:08AM
2163-11-21 07:32PM    130* 119* 2.2* 141 3.8 100 29 16

2163-11-27 07:25AM   BNP 7554*1


  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

2163-12-1 05:45AM          8.9 3.2 2.2
2163-11-30 08:05AM          9.0 3.4 2.3
2163-11-29 06:45AM          9.0 2.8 2.3
2163-11-28 07:00AM          8.6 2.7 2.2

HEMATOLOGIC calTIBC Ferritn TRF
2163-11-22 05:34AM    153* 270 118*
DIG ADDED 9:08AM
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
2163-11-22 05:34AM    NO SPECIFI1 1700-410-4771 NO MONOCLO2

  DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
2163-11-22 01:50PM    NEG NEG NEG NEG NEG NEG NEG 5.0 NEG
Source: Catheter
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
2163-11-22 01:50PM    3* 2 FEW NONE <1 <1
Source: Catheter
URINE CASTS CastHy
2163-11-22 01:50PM    9*
Source: Catheter

OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other

2163-11-24 08:13AM    01 01 71* 8* 6* 15* 02
BRONCHIAL LAVAGE


2163-11-25 3:37 pm SPUTUM      Source: Expectorated.

                            **FINAL REPORT 2163-11-27**

   GRAM STAIN (Final 2163-11-27):
      <10 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

2163-11-24 8:13 am BRONCHOALVEOLAR LAVAGE      BRONCHIAL LAVAGE.

                            **FINAL REPORT 2163-11-26**

   GRAM STAIN (Final 2163-11-24):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final 2163-11-26):    NO GROWTH, <1000
CFU/ml.

2163-11-23 7:10 pm TISSUE     Site: LYMPH NODE

   GRAM STAIN (Final 2163-11-23):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final 2163-11-26):    NO GROWTH.

   ANAEROBIC CULTURE (Final 2163-11-29):    NO GROWTH.

   ACID FAST SMEAR (Final 2163-11-24):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final 2163-11-24):
      NO FUNGAL ELEMENTS SEEN.

   LEGIONELLA CULTURE (Final 2163-11-30):    NO LEGIONELLA
ISOLATED.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      2163-11-24):    NEGATIVE for Pneumocystis jirovecii
(carinii)..


Brief Hospital Course:
76M initially admitted  to Davis Hospital hospital for CHF
exacerbation, and then transferred ICU-to-ICU for workup of
chronic mediastinal LAD.  Thoracic Surgery had been contactTammy
and was interested in seeing the patient and deemed that he
would be most appropriate for MICU given his ongoing ARF.  While
in the ICU his renal function improved with gentle intravascular
hydration. Echo was performed which revealed severe diastolic
dysfunction with ejection fraction of >70%.  His digoxin was
therefore discontinued.  He was discharged to the floor after
~24 hours of observation.

While on the medical service, the patient was brought to the OR
on 2163-11-23 for Flexible bronchoscopy with bronchoalveolar
lavage  of the left upper lobe, cervical mediastinoscopy and
bronchoscopy.  On post-op CXR there was noticeable whiteout of
the left lung field and the patient was kept in the PACU for
observation.  He was treated with Chest PT, IS and suctioning
for the thought of possible mucus plugging.  As per
documentation, the patient was doing well until the morning when
he had increasing oxygen requirements and more labored
breathing.  At 8am on 2163-11-24 the patient underwent
unremarkable bronchoscopy by IP.  Patient continued to have a
significant oxygen requirement, satting 93% on 40% facemask,
thus was transferred to the ICU for monitoring.

In ICU on 11-25, patient underwent upper airway suctioning,
along with albuterol, ipratropium, and mucinex treatment. He
utilized incentive spirometry as well. Serial chest x-rays
showed eventual clearing of his left lung. His oxygen saturation
improved to 100% on 4L.  He underwent a chest CT which showed a
large right pleural effusion and left airspace disease possibly
consistent with pneumonia.  he continued to produce increasing
amounts of airway mucous.  Though he did not spike a fever or
develop a leukocytosis, he was started on empiric coverage for
hospital acquired pneumonia with vancomycin and zosyn.  This was
continued for a total of 4 days, and then discontinued.  His
respiratory status continued to improve, and he was weaned down
to 2L NC O2, and often maintained O2 sats > 94% on room air at
rest.

He was transferred from the ICU to the medicine floor on 11-25,
where the below issues were addressed:

Hypoxia: Thought to be due to mucus plugging in setting of
procedure. Given the acuity of both the change and the reversal
it is likely that he experienced lung collapse and then
reaeration of expectorating mucus. Received 4 days of vanc/zosyn
for presumed HAP coverage in setting of hypoxia and increased
sputum production, this was d/c'd 11-28 with no additional fevers
and decreasing sputum.  He was continued on ipratropium nebs,
mucomyst nebs, guaifenesin, incentive spirometry.  During his
stay, his oxygen requirement was weaned, now requiring 2L NC
only intermittently. Will continue albuterol and ipratropium
nebs on a prn basis.
.
Hypernatremia: Na as high as 150, did decrease with IVF but
still mildly elevated on transfer to floor.  Improved to 147
with D5W.  IV hydration stopped at this time and POs encouraged
given risk of CHF. Free water deficit estimated at 2.3L on
transfer to floor.  Na remained stable in range of 143-147 when
taking more PO fluid.  Recommend continued intermittent
monitoring.

LAD: s/p mediastinoscopy.
His mediastinal lymph node biopsy results were consistent with
carcinoid.  The hematology/oncology service was consulted, and
they recommended getting an octreotide scan, the preliminary
read showed metastatic carcinoid.  These results were discussed
with the patient and his outpatient oncologist. The patient
requested to be followed by his oncologist in Lewis Memorial Hospital.
.
diastolic Congestive Heart Failure: ECHO with EF of 75%, has
severe dCHF. Cards consulted while in ICU.  Digoxin was
discontinued in setting of diastolic CHF.  Cardiology
recommended using either BB or verapamil to control HR, goal to
have <80. HR was well controlled without meds on transfer from
ICU.  Added Metoprolol 12.5 mg Meredith Medical Center on 11-26, though this was
d/c'd 11-27 for episodes of bradycardia to 30s. Added 12.5
Metoprolol SR 11-28, which he has tolerated well.  Also added
Candesartan at low-dose (4mg, home dose 16 mg) given h/o
diastolic CHF and goal of reducing afterload.  This can be
titrated up as his blood pressure allows.  He did have some
increased edema during his stay on the medical floor, and was
given TEDs stockings and encouraged to ambulate.  He also
received 40 mg IV lasix x 1 2163-11-28, and an additional dose of
40 mg po on 11-30 and 40mg IV on 12-1.  The long-term goal
remains to minimize diuretics, but use extreme caution with
fluids as pt is exquisitely volume sensitive due to severity of
dCHF.  Discharged with instructions to continue home lasix (40
mg) for 3 days with monitoring of daily weights and chemistries,
this may need to be reassessed and monitored.
.
RHYTHM: He has chronic afib.  His heparin was held after
surgery.  He was restarted on coumadin 1.25 mg daily on 11-26.
His INR rose to the therapeutic range, and was 2.5 on discharge.
 Recommend intermittent monitoring to tritrate necessary dosing
regimen.
.
ARF: Improved with hydration. Renal signed off prior to transfer
to floor.  Diuresis minimized on the floor, received 40 mg IV
lasix and 40mg PO lasix on two occasions with good diuresis, pt
maintained blood pressures.  The goal continues to be to
minimize diuresis to prevent excessive preload reduction.
.
CAD: He was continued on his statin, held ASA due to h/o GI
bleed





Medications on Admission:
PPI
Lipitor 10
Atacand 16 (confirmed with spouse)
Digoxin 0.125 mg qd
Aldactone 25 qd
Lasix 40 qd
Allopurinol 100 mg qd
Verapamil 180 qd
Coumadin 2.5 (MWF); 1.25 (TTSS)
Flomax 0.5


Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily ().
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.


Discharge Disposition:
Extended Care

Facility:
Lianes Medical Center - Thundera

Discharge Diagnosis:
Primary:
Mediastinal Lymphadenopathy
Metastatic Carcinoid
Acute renal failure

Secondary:
chronic diastolic congestive heart failure
anemia
atrial fibrillation
chronic renal insufficiency


Discharge Condition:
fair, tolerating PO, afebrile, VS wnl, O2 95-100% on
supplemental O2 2L Tomblin Hospital transfer to chair with assist


Discharge Instructions:
You were admitted to the hospital with mediastinal
lymphadenopathy.  You had a mediastinoscopy and bronchcoscopy.
The pathology reports showed this was consistent with carcinoid.
 You were seen by the oncologists, who recommended an Octreotide
scan; you indicated you would like to follow up with your
outpatient oncologist.

You were also noted to have an exacerbation of your heart
failure.  You were seen by the cardiologists, who recommended
you stop your digoxin.  You were given diuretics to remove
fluid.  You also had acute renal failure, which resolved during
your stay.
.
A CT scan showed a mass on your left adrenal gland, this should
be worked up as an outpatient, you should talk with your primary
care doctor about further evaluation.
.
The following changes were made to your medications:
Your digoxin, verapamil and aldactone were stopped
Your atacand dose was decreased to 4 mg
You were started on metoprolol
You were started on docusate, senna, and bisacodyl as needed for
constipation and albuterol and ipratropium nebs as needed for
SOB/wheezing
Your allopurinol and flomax were held, these can be restarted
during your rehab stay
Your coumadin was decreased to 1.25 mg daily, this can be
adjusted based on your INR
.
Please call your doctor or return to the ED for:
- fevers/chills
- shortness or breath or chest pain
- increasing sputum production
- weight gain > 3 lbs
- any other new or concerning symptoms

Followup Instructions:
Follow up with your primary care provider, Cooper. Audry Hall
(576-277-8956, within 1 week of leaving rehab.  On a CT scan,
you were noted to have a mass on your left adrenal gland, and
they recommended dedicated CT or MRI for better
characterization.  Dr. Mora should help you this setting this
up.

Follow up with your cardiologist  Dr. Morales Carol 118-669-6208,
fax 186-417-7342 within the next 2-3 weeks for reevaluation and
adjustment of heart failure meds as needed.

Oncology Dr. Gean 989-690-8790.  You have an appointment on
12-13 at 1:20 PM, call if you need to reschedule or be
seen sooner.



"
"Admission Date:  2139-2-27     Discharge Date:  2139-3-10


Service:

ADMITTING DIAGNOSIS:  Barrett's esophagus with high grade
dysplasia.

DISCHARGE DIAGNOSES:
1.  Barrett's esophagus with high grade dysplasia.
2.  Status post trans-hiatal esophagectomy.
3.  Aspiration.
4.  Myocardial infarction.
5.  Cardiogenic shock.
6.  Anoxic encephalopathy.
7.  Death.

HISTORY OF PRESENT ILLNESS:   The patient is an 84 year old
male who had a long standing history of gastroesophageal
reflux disease and Barrett's esophagus and had high grade
dysplasia diagnosed on recent endoscopy.  The patient elected
to have an esophagectomy performed.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Question renal insufficiency.
3.  Gastroesophageal reflux disease.

MEDICATIONS:
1.  Norvasc.
2.  Prilosec.
3.  Carafate.

PHYSICAL EXAMINATION:   On admission, the patient is an
elderly man in no acute distress.  Vital signs are stable.
Afebrile.  Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop.  Abdomen is soft, nontender, nondistended without
masses or organomegaly.  Extremities are warm, not cyanotic
and not edematous times four.  Neurological is grossly
intact.

HOSPITAL COURSE:   The patient was taken to the Operating
Room on 2139-2-27, where he underwent transhiatal
esophagectomy without significant complication.  In the
postoperative course, he was initially admitted under the
Intensive Care Unit care and kept in the Post Anesthesia Care
Unit overnight.  The patient was seen to have a low urine
output and both metabolic and respiratory acidosis and was
given approximately 8.5 liters of Crystalloid in the
perioperative period, including OR.

The patient was briefly agitated in the Post Anesthesia Care
Unit and discontinued his nasogastric tube.  On postoperative
day number one, the patient was doing well with a fairly
normalized blood gas of 7.35/43/94/25/minus 1 and was
transferred to the floor.

On postoperative day two, the patient was seen to have a
baseline oxygen requirement of 70% face mask in the morning
but was saturating well and otherwise seemed to be doing
relatively well.

The patient had a white count of 22.1 which prompted a chest
x-ray showing bilateral pleural effusion and patchy bibasilar
atelectasis but no focal infiltrates.  Over the course of the
day, the patient had deteriorating in his respiratory status
and became increasingly tachypneic with wheezing and coarse
breath sounds.

An EKG was performed which showed atrial fibrillation but no
ischemic changes.  A baseline arterial blood gas was obtained
at that point which was 7.37/47/86/28/zero, again on 70% face
mask.

Intravenous fluids were then stopped and the patient was
begun on 20 mg of intravenous Lasix and albuterol nebulizers.
The patient was transferred to another floor for Telemetry
purposes and cycled for myocardial infarction.  His
respiratory status during transfer seemed somewhat improved.
Upon arrival to the other floor, the patient stopped
respiring briefly and went bradycardic.  Upon stimulation, he
was tachycardic to the 110s with a blood pressure 130/70.

Immediately subsequent to that the patient went pulseless and
into respiratory and cardiac arrest and was down for
approximately two to three minutes.  CPR was begun and the
patient intubated and 15 to 20 cc. of brownish fluid was
suctioned from the endotracheal tube post intubation.

The patient regained pulse and cardiac activity and was
transferred to the Intensive Care Unit.

Cardiac consultation at that time recommended aspirin,
cycling enzymes and agreed with probable aspiration event.
They suggested a heparin drip but not is surgically
contraindicated.  A heparin drip was not started.  The
patient ruled in for myocardial infarction with a troponin of
26.5.

In the patient's Intensive Care Unit stay, he was supported
with a dopamine drip and diuresed for fluid overload.
Pressors were weaned off on postoperative day number eight.
Respiratory function was supported throughout his Intensive
Care Unit course appropriately with mechanical ventilation.

The patient was noted to be unresponsive after the aspiration
event, with some slow return of responsiveness over the next
several days, but no purposeful movement.  To evaluate
possible neurologic injury, a CT scan was obtained after the
patient was felt to be stable enough to be transferred.

On postoperative day six, the CT scan showed no acute
intracranial event but was consistent with chronic
microvascular infarction.  EEG was also obtained which
revealed diffuse widespread encephalopathy.  There was a
question of possible seizure activity involving the left
upper extremity and phenytoin was begun empirically.

A repeat EEG was obtained on postoperative day number 10 and
again showed moderately severe diffuse encephalopathy with no
seizure focus.

A Neurology consultation was obtained and assessed the
patient to have minimal chance for a meaningful recovery.

In accordance with the patient's living will, the family's
wishes and discussion with the surgical attending, the
patient was made comfort measures only and expired on
postoperative day number 11.


                          Joshua Guttmann, M.D.  P39287153

Dictated By:Branch

MEDQUIST36

D:  2139-3-24  10:08
T:  2139-3-28  16:18
JOB#:  Job Number 48824
"
"Admission Date:                   Discharge Date:

Date of Birth:                    Sex:  M

Service:  UROLOGY
HISTORY OF PRESENT ILLNESS:  Mr. Stephen is a 53-year-old
gentleman who presented on 2121-6-28 for cystectomy and
neobladder diversion.  He had grade 3 of 3 TCC.

PAST MEDICAL HISTORY:
2.  Myocardial infarction in '09
3.  Hypertension
4.  Left internal capsule cerebrovascular accident in '18
5.  Hypothyroidism
6.  Gastroesophageal reflux disease
7.  Hypercholesterolemia
8.  Depression
PAST SURGICAL HISTORY:
1.  TURBT's in '13 and '15

ALLERGIES:  He has no known drug allergies.

HOME MEDICATIONS:
1.  Aspirin 250 mg q.d. which was held
2.  Metoprolol 25 mg b.i.d.
3.  Levoxyl 300 mcg once a day
4.  Paxil 40 mg once a day
5.  Lipitor 20 once a day

ADMISSION LABS:  CBC of 9.3, 43.6, 252.  Chem-7 of 135, 4.4,
97, 23, 16, 0.8, 252.  PT 12.8, PTT 24.4, INR 1.1.  Liver
enzymes:  ALT 23, AST 18, alkaline phosphatase 101, albumin
3.8, total protein 7.4.

IMAGING:  Preoperative electrocardiogram showed left atrial
abnormalities with Q-waves in 2, 4, AVF, V5, V6.  Thallium
stress test done preoperatively showed normal heart rate,
normal blood pressure, normal respirations, no acute
electrocardiogram changes, some portal V-function from an old
infarction prior myocardial infarction, however it was clear
for the operation.  His chest films revealed no acute
cardiopulmonary process.

The inital surgery resulted in creation of a neobladder from
ileum. Postoperatively, the patient remained intubated with a
septic picture that deteriorated, requiring pressor agents.
 The patient returned to the Operating Room on
2121-7-8 for an exploratory laparotomy and excision of an
infarcted neobladder and resection of a nonviable segment of
small bowel x2, creation of a jejunal conduit.  His postop
course was equally stormy with spiking fevers, renal failure,
and BP instability
A third surgical exploration was necessary on 7-26.  At this time,
the patient
More ischemic bowel was removed where perforations had occurred
resulting in peritonitis.  The jejunal loop was excised and the
right ureter ligated. A left cutaneous ureterostomy was created.
Postop he had bilateral nephrostomies inserted and continued to
have an extended stormy ICU course.  A tracheostomy was
necessary because of hi need for prolonged ventilator support.
He also developed extensive DVT requiring anticoagulation.
Bowel function gradually returned allowing for tube feedings.
Multiple courses of antibiotic therapy were given during his
hospital stay.

NEUROLOGICALLY:  By system, neurologically the patient is
status post a left internal capsule infarct with residual
right sided weakness.  His history of depression leaves on
Paxil and he was started on such.  Radiologically, the
patient had a CT done of the head done during his admission.
Showed a stable appearance, considering no definitive
evidence of any type of abscess.  Neurologically, the patient
is being discharged home and is stable.  He is alert, however
he is unable to move secondary to his wasting and being in
bed for so long without assistance.  The patient is able to
get out of bed to chair.  Neurologically, the patient has no
acute issues upon discharge.

CARDIOVASCULAR:  The patient is status post myocardial
infarction in 2109 and he did not have a myocardial
infarction during the course of his stay in-house at the
hospital and he was ruled out by enzymes with no acute
electrocardiogram changes.  The patient has no acute
cardiovascular issues.  The patient is not on clonidine, nor
is he on Lopressor currently and his pressure is tolerating,
basically being on nothing.  The patient had been on pressors
immediately because of sepsis which was weaned off slowly
during the course of his stay.  He has not been on pressors
for the previous month.

RESPIRATORY:  The patient had poor respiratory failure and
required full respiratory support.  He is postoperative his
three operations and has been slowly weaned down to a
pressure support of 40 with a CPAP pressure support with 405
FIO2 with a PEEP of 5 and a pressure support of 5 with tidal
volumes ranging from 550 to 650.   The patient
was also bronched on 8-22 and mucous plugs were removed from
the patient.  A CT done on this patient in the last two weeks
in the middle of January showed that he had no acute
pulmonary process with possible left lower lobe pneumonia.
At that point, he had also been on antibiotics with this
course.  Upon discharge, the patient has no acute pulmonary
process and his lungs are sounding remarkably clearer.

GASTROINTESTINAL:  The patient is not able to eat on his own
and has a left Dobbhoff tube and is suffering from short--gut
syndrome requiring B12 injections.  The patient is currently
tolerating his tube feeds of Impact at goal rate of 90 cc an
hour and is having some stool output.  Clostridium difficile
sent on the patient recently as of 9-15 came back negative.
The patient is receiving all his feeds through tube feeds and
is not a candidate for a PEG given his previous abdominal
surgery.  The patient's other gastrointestinal issues are
obviously evolving around the reception as previously stated
of massive portions of his small bowel, as well as the large
bowel and appendix.  Upon discharge, there are no acute
discharge issues for this patient.

GENITOURINARY:  The pathology report from the original
surgery showed a high grade invasive TCC involving the
bladder neck, prostate, urethral margin and regional
nodes.  His right ureter is tied off secondary to
the leak and he has a right nephrostomy tube which was
changed on 9-16 as well as his left nephrostomy tube.  His
ureterostomy tube on the left side was changed on 9-18.  All
this was done in response to his febrile episode he had which
will be outlined later which was felt to be urosepsis.  On
discharge, it was found that his nephrostomies were positive
for yeast, most likely colonized.  The patient was not on any
type of antimicrobial for that.  The patient has been showing
yeast growing from the left side nephrostomy and
ureterostomies almost to his Intensive Care Unit stay, but no
evidence of acutely febrile as a result most likely due to
colonization.  The patient has a left nephrostomy tube in
addition to the ureterostomy of the left side and does not
have a Foley inserted into his neobladder obviously because
of drainage from that point of view.  Upon discharge from a
urological standpoint, the patient is stable.  His tubes are
draining clear urine and there is no blood present.  Some
blood may be noted in the urine with positional changes on
the patient and that is completely normal as long as it is
consistent with old blood and no massive bleeds.

EXTREMITIES:  The patient was found to have a lower extremity
deep venous thrombosis on 8-3, as well as 8-8 which found
upper extremity bilateral deep venous thromboses.  The
patient basically had deep venous thromboses x4 and was
started on a heparin drip continuously to resolve his deep
venous thromboses and heparin drip was continued until
Coumadin was started in the last two weeks of January prior
to his discharge.  An ultrasound of the upper extremities
done on Mr. Stephen on 9-12, showed that he resolved his
upper extremity clots completely with the exception of some
small residual clot at the left and right IJ.  The patient is
being discharged on Coumadin with the hope of achieving an
INR of approximately 2 to 2.5.  The most recent INR was 1.3,
came back on 9-18 and the patient continued to receive
Coumadin until he reaches his goal without any heparin.  In
addition, the patient's hematocrit has remained stable,
however.

HEME:  The patient has been on Coumadin.  His hematocrit has
remained stable as of late and his last blood transfusion was
on 7-12.  Since then, his hematocrit has remained stable at
around 29 to 28 with no acute signs of bleeding.  As far as
his renal function, the patient has been increasing sodium
and has been given free water to resolve that.  His
hematocrit is stable and his white cell count on 9-18 was
8.0.

INFECTIOUS DISEASE:  The patient was febrile postoperative
and several cultures were sent out.  Regarding his blood
cultures, from 7-8 to the middle of January, he did not
grow anything out.  He was on triple antibiotics which were
actually discontinued on 2121-8-29.  He failed to grow
anything however fluconazole was continued until 9-2 to rule
out any other type of infection and to make sure that there
was no acute yeast systemic process going on even though he
had colonized his tubes.  The patient became febrile again on
9-8 unfortunately with a T-max of 104.4??????.  The patient was
started immediately on vancomycin, Zosyn and fluconazole
until cultures came back.  Blood cultures and catheter
cultures came back revealing that the patient had been
infected and was handling what was later decided was probably
urosepsis for Klebsiella.  Based on this, the patient resumed
a 10 day treatment cycle of Levaquin based on infectious
disease's recommendation and the other antibiotics were
stopped.  This is actually day 8 of 10 of his levofloxacin
course and as of 2121-9-19 the patient will be receiving two
more days of Levaquin.

The patient upon discharge is afebrile and his surveillance
blood cultures have come back negative even though his
nephrostomy tubes which were changed showed some fungal
colonization growth.  His blood has remained negative for any
type of infection.  During his stay, other cultures sent off
included blood flowing through his catheter lines which were
negative except for that one change which was required on
9-8 after he became febrile.  His left subclavian has
changed.  Today, on 9-19, he has a right sided subclavian of
the left sided one which was considered a possible source of
infection.  His lines are not likely the source of the
infection.  It is hoped that he will get a PICC line before
he is discharged to rehabilitation today and his central line
will be taken out.

MICROBIOLOGY:  A spinal tap was also done and no consequence
of that resulted.  No significant findings.

Today, the patient is being discharged and he is on the
following medications:
1.  Glutamine 5 mg p.o. tube feeds to prevent excessive
stool, secondary to short-gut.
2.  NPH 8 units subcutaneous b.i.d.
3.  Thyroxine 200 mcg p.o. q.d.
4.  Vitamin C p.o. per the nasogastric tube every day.
5.  Insulin sliding scale 2, 4, 6, 8 which is not being used
much.
6.  Paxil 20 mg nasogastric tube q.d.
7.  Levofloxacin 500 mg intravenous to be continued for
another two days hopefully.
8.  Tincture of iodine 10 drops to every 500 cc of tube
feeds.

He received 2.5 mg of Coumadin last night.  He has not
received any recent Dilaudid or albuterol nebulizer
treatment.  He is receiving KCL 40 mg intravenous prn for low
potassium of less than 4, magnesium of 2 gm intravenous prn
for less than 2.0 magnesium levels, last dose on 9-18, as was the last dose of potassium.  The patient has not
been requiring any Ativan or Dilaudid or sedation as of
recently.  He was on Epogen for a hematocrit which has now
been stabilized, so it is no longer as issue.  It was felt
that the patient was in early on acute renal failure which
turned out to be a leak and the patient is not on renal
failure, no requiring any Epogen.  On this date, 9-19, Mr.
Stephen is basically receiving in addition to just the
glutamine 5 mg tube feeds, Synthroid which are outlined and
he is also getting Protonix 40 mg intravenous q.d. for
gastrointestinal prophylaxis, as well as Coumadin to keep an
INR of 2 to 2.4 for prophylaxis.

It is our hope that Mr. Schrack, despite his advanced
cancer and multiple surgeries, will be rehabilitated and able
to resume assemblance of his functional life.  We hope that
he continues receiving chest PT, that he is respiratorily
stable with no acute issues at this time.  We also hope that
he will eventually no longer require ventilatory support and
a collar could be used on him as well as eventually assume
breathing on room air.

Final Diagnoses:
1. Transitional Cell Ca of Bladder and Prostate, metstatic to
regional nodes
2. Multiple postoperative complications, including intestinal
perforation with peritonitis, neobladder infarction, sepsis,
vascular instability with hypotension, DVT, and renal
insufficiency.
3. Respiratory insufficiency
4. s/p tracheostomy



                            Michele Initial (NamePattern1)  Beaufort, MD  A79903668

Dictated By:Leon
MEDQUIST36

D:  2121-9-19  09:01
T:  2121-9-19  09:11
JOB#:  Job Number 39316

rp 2121-9-19
"