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 "