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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2400 }
Medical Text: Admission Date: [**2117-4-30**] Discharge Date: [**2117-5-2**] Date of Birth: [**2046-12-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Back and bilateral lower leg pain Major Surgical or Invasive Procedure: Axillary bifemoral bypass graft with PTFE History of Present Illness: The patient is a 70 y/o F with known h/o AAA who has had increasing lumbar and bilateal lower extremity [**Last Name (un) **] for 1.5 months. She has had recent accelerating with progression of her symptoms. Pt reports pain, numbness, back pain, and cool mottled extremities below the waist. Past Medical History: HTN, AAA x 5 cm, Chronic lower back pain Social History: Pt is married with children Family History: Non contributory Physical Exam: HR 94 BP 126/78 Elderly woman in pain. Speaks appropriately. RRR CTAB Abd soft, nontender, no hernias Palpable radial pulses bilaterally R femoral pulse -- None L femoral pulse -- Weak R > L leg mottled Legs cold Brief Hospital Course: Pt was taken from the ER straight to the operating room where an emergent R axillary-bifemoral bypass graft was performed with PTFE to restore blood flow to the lower extremities after an acute aortic occlusion. Postopreatively, the patient initially did well. She was quickly extubated. Within a short amount of time the patient began to have problems maintaining adequate blood pressure requiring the use of pressors. She was found to have an acute metabolic acidosis for which the patient was placed on a bicarbonate drip. Over the course of the next 12 to 18 hours the patients condition worsened. A swan ganz catheter was placed to better monitor the patient's needs. She was found to have low SVO2's, High SVR's, low PAD's/CVP's/Wedges. The patient was bolused many liters of fluid. Because the patient's cardiac output/index were low she was tried on milrinone. This did not in effect help. It only made her tachycardic. Meanwhile the patient began to have respiratory distress. Emergent tracheostomy was performed as endotracheal intubation was not an option due to pharyngeal edema. Persistent lactic acidosis and developing renal failure then prompted consultation with the general surgery service. The patient was then taken to the OR for abdominal exploration. The patient had ischemic right colon but it did not appear dead. No resection was performed. Furthermore, the pt's hemodynamics improved with abdominal decompression indicating abdominal compartment syndrome. Over the next day the patient required large amounts of fluid and began to develop further problems with hemodynamic stability. In the early morning of [**2114-5-2**] the patient was being turned and became suddenly unable to be ventilated. The patient was amboo'd. Airway resistence was strikingly high. Auscultation revealed decreased breath sounds on the L lung field. An emergent chest tube was placed with immediate drainage of about 1400 cc of serosanguinous fluid. CO2 detectors were used to insure CO2 exchange which was confirmed present. A stat blood gas showed a PCO2 in the 20's and a PO2 in the 200's. Meanwhile, the pt began to brady down and become asystolic. CPR was performed for approximately 20 minutes while numerous chemical modalities were tried to revive the patient. Ultimately we were unsuccessful, and the patient was declared dead at 443 am on [**2117-5-2**]. Medications on Admission: Lipitor, Tamoxifen, Motrin, Atenolol, HCTZ, ASA Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Aortic occlusion Axillary bifemoral bypass graft with PTFE Ischemic colon Respiratory failure Cardiac arrest Metabolic acidosis Abdominal compartment syndrome Pleural effusion Shock AAA Mesenteric ischemia Exploratory laparotomy Coagulopathy Acute renal failure Discharge Condition: Deceased Discharge Instructions: Post mortem exam requested by family Followup Instructions: None ICD9 Codes: 5849, 2762, 5119, 4019, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2401 }
Medical Text: Admission Date: [**2170-4-8**] Discharge Date: Date of Birth: [**2170-4-8**] Sex: M Service: The child is being transferred to [**Hospital3 28900**] on [**2170-4-23**]. HISTORY: This infant was a 39-3/7 week 3505 gram male infant born to a 28 year old Gravida 3, para 0-1 woman with serology treated with several doses of antibiotics prior to delivery. She had a prenatal ultrasound which showed echogenicity on the liver. On delivery there was meconium and nuchal cord times one. The membranes were ruptured only for 9 hours. The infant was delivered by vacuum assistance with Apgars of 8 and 9. The child had a bath in Labor and Delivery and a temperature of 97.1. At 2 hours of life the infant went to hypothermia resolved with heat lamps but the child had poor feeding and a dextrose stick of 10. The infant was admitted from normal newborn and had a repeat dextrose stick of 14 and received an infusion of D10-W after a bolus of 3 cc's of D10-W per kilo for hypoglycemia. ADMISSION EXAMINATION: Weight was 3505 in the 75% percentile, length was 21-3/4 cm, head circumference 35 cm. The infant was vigorous, non-dysmorphic, anterior fontanel open and flat with a positive caput. Palate was intact. Respirations were unlabored. Breath sounds clear and equal. The infant had regular rate and rhythm. No murmur, was pink and well perfused. Femoral pulses were 2+ equal. The abdomen soft without distension. There were positive bowel sounds. Both testes were descended, normal male genitalia. There was a mongolian spot over the buttocks. The infant had a negative hip exam. Anus was patent. There was some mild jitteriness. SUMMARY OF HOSPITAL COURSE BY SYSTEMS 1. Respiratory. The infant was in room air since birth with a respiratory rate in the 30 to 50's, no issues. A blood gas on [**4-12**] was 7.37/38/94/27 and negative 2 for the base access. 2. Cardiovascular. There were no murmurs. Heart rate runs from the 120's to 140's. Blood pressure 60 to 70/30 to 40 with mean 45 to 57. No issues. 3. Fluid, Electrolytes and Nutrition: The infant breast fed with supplementation of breast milk or Enfamil 20 when the mother was not present. On admission an intravenous of D10-W was begun at 80 cc's per kg per day. The infant had persistent hypoglycemia. On day of life two we attempted to wean the intravenous rate down to 20 cc's per kg and the infant had a dextrose stick of 33. We went up on the glucose infusion to 40 cc's per kilo and also added an additional two calories per ounce to the formulary breast milk and the infant was placed on q 3 hour feedings. On day four of life we again attempted to wean the intravenous rate down to 20 cc's per day and the dextrose sticks went down to 27. We increased to 40 cc's per kilogram at that point. We were successful in discontinuing the intravenous on day of life five and on day of life seven the infant was switched to 20 calorie formula. Metabolic and endocrine consults were requested for persistent hypoglycemia. The electrolytes on day of life four which was on [**4-12**] were sodium 134, potassium 3.7, chloride 101, CO2 20. Metabolic workup was initiated on day of life four. There was no metabolic acidosis by the blood gas and CO2 was in normal range on the electrolytes. The infant had an ammonia initially of 165 and that was decreased to 118 on [**4-17**], day of life 9. A state screen was sent on [**4-11**] and that was within normal limits. The Cortisol level was less than one on [**2170-4-19**]. T4 was 7.5, TSH results pending. 17 HydroxyProgesterone was 13.5 by the State Screen. The calculated TBG was 1.07. The uptake was 0.84, the calculated FTI was 6.3. The insulin level was less than 2. Growth hormone was 3 on [**4-18**] and two on the [**4-19**]. Results were consistent with a panhypopituitarism of undetermined etiology. Final results for cranial MRI completed on [**4-20**] are pending at the time of dictation. Gastrointestinal: The infant had a liver scan on [**4-13**] which was normal. There was no echogenicity seen at that time. The infant was started on triple bank phototherapy on day of life four for a bilirubin of 22/0.5. Phototherapy was discontinued on day of life six and a rebound bili later that day was 11.5/0.3. The latest bilirubin on [**2170-4-19**] was 11.9/0.4. Hematology: The infant required no transfusion and had no type or cross match done. The initial hematocrit was 46.8 with a platelet count of 197. ID: The blood culture done on admission on [**4-8**] was negative for 48 hours and the child was never started on antibiotics. Initial white blood count was 7.8 with 40 polys and 4 bands. Neurology: On [**4-20**] he had a head magnetic resonance scan done which showed an ectopic posterior pituitary secondary to question of discontinuous pituitary infadibulum. The septum tosidum was present. The optic nerves were slightly atrophic. There was no intraorbital lesion seen. The right orbital globe had significant abnormalities which could be due to retinal detachment. At the recommendation of endocrinology we did a workup for septo-optic dysplasia. The ophthalmology exam on [**4-20**] showed left hypoplastic optic nerve on the right, there was a retrolental mass and there was question of a detached retina. A repeat ophthalmology exam done on [**4-23**] was suspicious for a right retinoblastoma. The infant was screened for hearing and passed with the Automated Auditory Brainstem Response also performed. [**Hospital1 69**] social work is involved with the family. The contact social worker is [**Name (NI) **] and she can be reached at [**Telephone/Fax (1) **]. CONDITION AT DISCHARGE: This child is stable from a cardiovascular perspective and is on full feeding with borderline Dextrose sticks, the last one being 56 and is being treated for pan hypopituitarism. The child is being transferred to [**Location (un) 86**] [**Hospital1 **] for further evaluation of a possible right retinoblastoma and continued management of pan hypopituitarism. CARE/RECOMMENDATIONS: This infant requires feedings at discharge of breast milk or Enfamil 20 if the mother is [**Name2 (NI) 16535**] for breast feeding. The child is on the following medications: 1.Hydrocortisone, 2 mg every morning and 1 mg at evening, that was switched over today. 2.Synthroid 37.5 mcg every day. 3.The infant is being treated for a monilial rash with Miconazole powder to the diaper area three times a day. The infant will be following up with the primary pediatrician who is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**],[**Telephone/Fax (1) 37875**], the Fax #[**Telephone/Fax (1) 49847**]. The infant will also require follow-up with Endocrine with Dr. [**Last Name (STitle) 49848**], Extension [**2073**] and Ophthalmology Dr. [**First Name (STitle) **], extension 1486. We recommend TFTs be repeated in six weeks at the recommendation of Endocrine and the infant will need ammonia levels drawn prior to discharge to follow-up on the elevated levels. Parents will need extensive training and glucose monitoring, medication administration and stress dose administration. DISCHARGE DIAGNOSIS: 1. Term AGA male. 2. Hypoglycemia. 3. Pan hypopituitarism. 4. Resolved hyperbilirubinemia. 5. Detached retina on the right eye. 6. Possible retinoblastoma on the right eye. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Name8 (MD) 49849**] MEDQUIST36 D: [**2170-4-23**] 16:23 T: [**2170-4-23**] 17:01 JOB#: [**Job Number 49850**] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2402 }
Medical Text: Admission Date: [**2107-1-10**] Discharge Date: [**2107-2-1**] Date of Birth: [**2036-6-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardial drain placement and removal PEG placement PICC placement Intubation/extubation, mechanical ventilation Thoracentesis X2 (bilaterally) History of Present Illness: The patient is a 70 yo man with ho DM2, HTN, and recent diagnoses of AFib who was transferred from OSH on [**2107-1-10**] for evaluation of pericardial effusion. Around [**2106-12-17**], pt had CHF-like symptoms, and he was started on diuretics. Four days prior to admission patient had new onset Atrial flutter and was started on Coumadin. On [**12-27**], the patient was admitted to [**Hospital1 3325**] for a worsening dyspnea over 4 weeks. He was intubated in the ED and transferred to the CCU, where he was started on a Dilt gtt and was eventually extubated on [**1-6**]. Then pt had AMS, thought to be metabolic and had a CT-chest showing a large pericardial effusion and bilateral upper lobe and RML air space disease. He started Imipenem and continued Levofloxacin. TTE at that time showed LVEF of 25%. He underwent a TEE with attempt to cardiovert, but he was found to have an atrial thrombus, so this was not attempted. He was transferred to [**Hospital1 18**] for further care and possible pericardiocentesis since effusion appears to progress. At OSH he also had ARF, hematuria, and anemia (hct 24). . On transfer his echo showed tamponade changes and he was transfered to the CCU for pericardial drainage. Repeat echo [**1-13**] showed no reaccumulation of fluid. Due to his garbled speech and dysphagia, neurology was consulted and felt he had a left parietal cardioembolic stroke (h/o A. fib). After failing S&S eval, decision has been made to pursue PEG after transfer to the floor. He was also found to have a pneumonia, so is being treated with Zosyn. On the floor he has had more agitation and has been given haldol 1mg and zyprexa 5mg. Then pt became more somulent and a ABG showed 7.19/92/56 on a shovel mask with 2 liters. HR was in the 80s and BP in 120s. He was transfered to MICU for airway concern and hypercabic resp failure. . On arrival to the MICU he was unresponsive. He did not tolerate placement of a BIPAP, so was intubated. On intubation he was noted to have a large amount of material in the thorat, possible food. He had some transient runs of bradycarida that quickly recovered to 90s without intervention. . Review of Systems: Unable to obtain due to solmulence and intubation. Past Medical History: DM2 HTN BPH Congestive Heart Failure Anxiety Disorder Atrial Fibrillation Alcohol dependance and abuse Social History: Per OSH medical records, the patient smokes 2 cigars and one cigarette daily. He drinks a six pack of beer daily. He lives with his wife. . Family History: Non-contributory Physical Exam: GEN: Middle aged man, AAOx1, in NAD VS: 126/70, P 66, R 16, O2 99% on 4L HEENT: PERRL, EOMI, Mucous membranes dry CV: Distant heart sounds. JVD elevated to angle of jaw. PULM: Coarse breath sounds throughout lung fields bilaterally ABD: +BS, NT, ND LIMBS: No edema. 5/5 strength bilaterally SKIN: No rashes or ecchymoses NEURO: AAOx1, Moving all extremities. Unable to follow commands. . On transfer to the MICU: Vitals: T: 96.9 BP: 97/38 P: 53-90 R: 19 O2: 97% on bag mask, then 100% on vent General: responsive to pain, solument HEENT: Sclera anicteric, dry MM, OP with debris Neck: supple, JVP not elevated, no LAD Lungs: rhonchi B, decreased left breath sounds, no crackles CV: Regular rate and rhythm, no murmurs, 2+ pulses Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with clear urine Ext: warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2107-1-11**] 03:49AM BLOOD WBC-12.6* RBC-2.82* Hgb-8.8* Hct-26.6* MCV-95 MCH-31.1 MCHC-32.9 RDW-16.0* Plt Ct-751* [**2107-1-11**] 03:49AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2107-1-11**] 03:49AM BLOOD PT-27.8* PTT-36.9* INR(PT)-2.7* [**2107-1-11**] 03:49AM BLOOD Glucose-171* UreaN-114* Creat-2.0* Na-143 K-4.1 Cl-100 HCO3-32 AnGap-15 [**2107-1-11**] 03:49AM BLOOD ALT-32 AST-41* LD(LDH)-288* CK(CPK)-88 AlkPhos-105 TotBili-0.8 [**2107-1-11**] 03:49AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.8* Mg-3.3* Iron-43* [**2107-1-11**] 03:49AM BLOOD calTIBC-229* VitB12-862 Folate-16.0 Ferritn-1190* TRF-176* ----------------- DISCHARGE LABS: ----------------- STUDIES: . PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes, monocytes, and mesothelial cells. . RHCath and Pericardiocentesis: 1. Right heart catheterization prior to pericardiocensis showed elevation and equalization of diastolic filling pressures (20-22mmHg) that were similar to the opening pericardial pressure (19mmHg). Pulsus paradoxus recorded via the a-line tracing was approximately 20mmHg. 2. Pericardiocentesis was performed with needle entry from the subxiphoid position. The opening pericardial pressure was 19 mmHg. 3. Subsequent to removal of 920 cc of blood fluid (all sent for studies) and confirmation by echocardiography of complete fluid removal, the pericardial pressure decreased to -2 to 1 mmHg and RA pressure decreased to 15 mmHg. 4. Anesthesia was present during the case to manage the patient's airway given his tenuous respiratory status. He was maintained on 100% oxygen therapy. FINAL DIAGNOSIS: 1. Pericardial tamponade with improvement in hemodynamics after removal of 920 cc of bloody fluid. 2. Pericardial drain in place. . CT HEAD [**1-11**]: There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles and sulci are prominent, most compatible with atrophic change. Note is made of bilateral atherosclerotic calcification within the carotid siphons. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. . ECHO [**1-11**] #1: No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a large pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic compression, consistent with impaired fillling/tamponade physiology. IMPRESSION: Large pericardial effusion with echo evidence of impaired filling/tamponade physiology. . ECHO [**1-11**] #2: Overall left ventricular systolic function is normal (LVEF>55%). RV with borderline normal free wall function. There is no residual pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2107-1-11**], pericardial effusion (post tap) has resolved. There is no longer evidence of RV compression. . ECHO [**1-13**]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . MR head without contrast: There is no acute infarct, hemorrhage, edema, or mass effect. The ventricles and sulci are prominent, consistent with age-related atrophy. Scattered T2 hyperintense periventricular and supratentorial white matter abnormalities represent mild chronic small vessel ischemic disease. The patient is intubated. Mild mucosal sinus thickening is seen in the bilateral maxillary, ethmoid, and frontal sinuses. The osteomeatal units appear patent bilaterally. There is partial opacification of the bilateral mastoid air cells. IMPRESSION: No acute intracranial process. . CT chest [**1-19**]: 1. Massive bilateral pleural effusions, responsible for severe atelectasis of the adjacent lung. 2. Severe aortic valvular calcifications, which represent severe aortic stenosis until proven otherwise. 3. Enlarged pulmonary arterial trunk, suggestive of pulmonary arterial hypertension. 4. No evidence of aspiration. . CT chest [**1-27**]: 1. Substantial improvement in previously large bilateral pleural effusions, stable pericardial effusion. No indication of malignant implants in the pleural space or development of tamponade. 2. New predominantly right lower lobe pneumonia or hemorrhage. 3. Marked improvement in previous lower lobe collapse. 4. Global cardiomegaly, probable pulmonary hypertension, probable calcific aortic stenosis, severe coronary and innominate artery atherosclerosis. 5. Mild emphysema. . ECHO [**1-24**]: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is an anterior space which most likely represents a fat pad. There are prominent bilateral pleural effusion. . ECHO [**1-28**]: The left and right atrium are moderately dilated. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.2cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2107-1-24**], global biventricular systolic function is less vigorous (now low normal), c/w diffuse process. The heart rate is also slightly lower. In the absence of a history of hypertension, an infiltrative process (e.g., amyloid) should be considered. Brief Hospital Course: 70 yo man with h/o HTN and recently diagnosed AFlutter who presented from OSH with pericardial effusion, AMS, and ARF. He was intubated for 10 days after presentation to OSH. A CT showed a pericardial effusion and RML PNA. He was transfered to [**Hospital1 18**] on Imipenem and Levofloxacin for management of the effusion. The effusion was bloody and large (1L), though he was on anticoagulation. After extubation, he had AMS with a notable Wernicke's aphasia with preserved repetition and limited but largely intact comprehension and direction following. After failing multiple speech and swallow evaluations, the plan was for the patient to receive a PEG (once his INR was within acceptable limits). In the interim, patient was found to have a pneumonia and was started on Zosyn. He became more agitated on the Medicine floor, and received Haldol 1mg and Zyprexa 5mg. He then became somnolent, hypercarbic and acidotic and was transferred to the MICU where he did not tolerate BiPap, so he was intubated. Upon intubation, large amounts of tube feeds were found in his throat, so that his acute respiratory failure was felt due to his chronic large bilateral pleural effusions in conjunction with an aspiration event. . # Altered Mental Status/CVA/Thrombocytosis: The patient has had AMS, waxing and [**Doctor Last Name 688**] delirium, since extubation at OSH. EEG was c/w metabolic encephalopathy, but common metabolic causes ruled out (normal folate/B12). An urgent head CT was ordered that did not demonstrate e/o of an acute intracranial process. Neurology was consulted and was concerned for CVA. Carotid U/S demonstrated <40% stenosis on L and 40-60% on R. Recommended MRI, but patient could not tolerate MRI without sedation. Neuro recommended anticoagulation, speech therapy, outpatient follow-up. Of note, patient was found to have a right atrial thrombus on OSH imaging and MRI/MRA once patient was intubated confirmed periventricular and supratentorial white matter abnormalities suggestive of cerebroembolic event; this was consistent with Neurology's findings on physical exam. Patient also had markedly elevated platelets, which in the setting of pneumonia can result in a hypercoagulable state (Arch Neurol. [**2106**];67(1):33-38) resulting in a thrombotic, small vessel CVA. At the same time, he has thrombocytosis (Platelets between 760-960), possibly myelodysplastic in origin, which could also cause a thrombo/embolic CVA. The workup of essential thrombocytosis was not pursued inpatient since it is very low yield (JAK2 mutations being positive in no more than 50% of ET cases) and the damage (stroke) had already been wrought. The patient was continued on a heparin drip in the MICU and started on bridge to Coumadin on [**1-28**], upon transfer back to the regular floors. At the time of discharge, the patient was taking 6mg of Coumadin with a subtherapeutic INR, compensated by Heparin gtt. . # Respiratory Distress/Pleural effusions: Patient's initial hypercarbic, respiratory acidotic episode was felt likely due to the exacerbation of his pulmonary status with the large pleural effusions by aspiration of food contents. Haldol and Zyprexa may have also slightly contributed. Patient was trialed on Bipap on admission to the MICU without significant improvement and was shortly intubated. Diagnostic thoracentesis showed exudative processes. Patient was extubated on [**1-22**] after Lasix diuresis but developed hypercarbic, respiratory acidosis 10 hours later. Etiology unclear - ?flash pulmonary edema as patient was hypertensive to SBP190s during this vs. tiring off the ventilator vs. continued significant pleural effusions. Ultimately, thoracenteses were done bilaterally, removing 3.5-4 liters total. All the fluid studies came back suggestive of exudative processes. Rheumatology was consulted in the setting of significantly elevated ESR and CRP but did not feel the patient had an underlying rheumatologic processes. Repeat CT chest & a CXR performed on the day of discharge did not show signs of infection, malignancy or reaccumulation of fluid. Etiology for patient's large pleural effusions remains unclear but the patient may benefit from anti-histone serology or cardiac MRI for further work-up if his effusions recur. . Patient also noted to have multiple apneic episodes as long as 20 seconds at a time. Pulmonology was consulted and felt that the patient's apnea was likely secondary to both a central and obstructive process. They felt that he was safe for discharge, but felt he would benefit from a sleep study to further evaluate the etiology of his apnea and determine whether he could benefit from CPAP once his delirium improved. . #. Pericardial effusion: Patient was transferred to [**Hospital1 18**] for pericardial effusion and tamponade physiology. Pericardial drain was placed, and bloody effusion was noted. Pericardial fluid is negative for malignant cells. No microorganism was isolated. Repeat TTE demonstrated no reaccumulation of the effusion, so drain was pulled on [**1-13**]. Repeat ECHOs showed no reaccumulation of pericardial effusion and patient's physical exam remained benign. The etiology of his pericardial effusion remained unclear, possibly due to a viral syndrome given his concurrent pleural effusions. Repeat ECHO on [**1-28**], after removal of large pleural effusions (and pericardial effusion), showed global biventricular systolic function was less vigorous (now low normal), consistent with a diffuse process. If patient's hypertension has not been long-standing, amyloidosis is on the differential and may explain both the pericardial and pleural effusions (per cardiology). Given the patient's functional baseline, however, myocardial biopsy was not pursued as an inpatient. A CXR on [**2-1**] did not demonstrate evidence of pericardial or pleural effusions. . #. Multifocal Pneumonia: The patient was found to have a suggestion of multifocal PNA on a CT dated [**1-9**]. He was transferred on Imipenem and Levofloxacin. Given the fact that the patient was intubated for 10 days, he may have had a HAP, but sputum cultures from OSH taken on [**1-4**] were negative. CXR demonstrated bilateral pleural effusions consistent with overload, but no obvious consolidation. Patient did not spike during this admission, but temperatures and WBC remained mildly elevated before normalizing. Upon admission to [**Hospital1 18**], he was treated with Zosyn for 8 day course from [**1-10**], last day [**1-20**] (given aspiration found when intubated). A PEG was ultimately placed with good effect while patient was intubated. Of note, multiple blood, urine and sputum cultures were drawn which were all no growth to date for an infectious etiology to his symptoms. Patient's EBV/CMV were also negative for acute infection. . #. Atrial Flutter/Atrial Fibrillation: Patient was initially in atrial flutter, but later during this hospital stay, he was in and out of atrial fibrillation. His RA thrombus noted at OSH is a contraindication to cardioversion. Digoxin & Cardizem were held and Metoprolol was continued. He was anticoagulated with Coumadin after pericardial drain was pulled. Patient had a number of bradycardic episodes initially while in the MICU that Cardiology felt was due to a vasovagal response to ETT placement. These episodes resolved, but he also had intermittent episodes of AF with RVR that responded to IV Metoprolol. Patient may benefit from discussions with EP as an outpatient regarding need for ablation for his AFib or pacer placement if he has recurrent episodes of bradycardia. . # Hypernatremia: Patient's Na was 143 on admission, which went up to 153 the next day. Urine Osm??????s and electrolytes supported a hypovolemic hyponatremia. Patient was given free water flushes with TF. His Na improved on this regimen. Once the PEG tube was placed, the patient was continued on small volumes of free water flushes with good effect. His sodium normalized and he was discharged with serum Na of 140. . #. Acute renal failure: The patient's creatinine increased at the OSH from his baseline of 0.5 to 2.6, in the setting of extensive diuresis. Cr quickly normalized to baseline after admission to [**Hospital1 18**]. Upon transfer out of the MICU back to the floor, patient's creatinine was back to baseline at 0.4 where it continued to be until discharge. . #. Hematuria: The patient was found to have hematuria at OSH while on anticoagulation, and there was concern for bladder cancer, given his history of smoking. Urology was consulted and recommended an outpatient cystoscopy. His hematuria improved after anticoagulation was held, but resumed with restarting Coumadin. The patient will need follow up with Urology as an outpatient and his home Flomax should be restarted prior to discontinuation of his Foley which was in place at the time of discharge. . #. Anemia: Patient with an anemia on admission. Guaiac was negative at OSH. B12 and folate were normal. Fe studies showed 19% saturation, Fe 43, and Ferritin 1190, consistent with ongoing inflammation and possible mild Fe deficiency. Ferrous Sulfate 325mg PO daily was continued. His hematocrit did intermittently decrease to lows of 23, felt likely due to the procedures he underwent. He did not require any pRBC transfusions while in the MICU or on the medicine floor and was discharged with a Hct of 24.8. . # Hypertension: Patient's home regimen is Lopressor 25mg twice daily and Nifedipine 30mg daily. While in the hospital, patient was kept on Amlodipine 10mg daily and his Lopressor was titrated to 50mg TID. His blood pressures were well-controlled on this regimen. . # Dysphagia: Patient developed dysphagia, likely secondary to stroke. PEG placed on [**1-18**] without any complications, but he continued to fail speech and swallow evaluations until the day of discharge and was recommended to remain NPO. . # CODE: Full Medications on Admission: Home Medications: Lasix 40 mg PO daily Lopressor 25 mg PO BID Flomax 0.4 mg PO daily Glucophage 500 mg PO BID Nifedipine 30 mg PO daily Coumadin 5 mg PO daily Ativan 1 mg TID prn . Medications on Transfer: Fluconazole 100 mg PO daily Imipenem 500 mg PO IV q12h Levofloxacin 500 mg IV qod Protonix 40 mg IV daily Combivent nebulizer qid Digoxin 0.25 mg via NG daily Cardizem 90 mg via NG q6h Lactobacillus 1 pack via NG TID with meals Metoprolol 25 mg NG TID Modafinil 200 mg NG daily Lovenox 100 mg SQ daily SSI Zyprexa 7.5 mg IM q4h prn Reglan 5-10 mg IV q6h prn Combivent nebulizers q2h prn Tylenol prn Colace prn Milk of Magnesia prn Zantac 150 mg NG daily prn Senna prn Artificial tears 1 gtt each eye prn Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary diagnoses: - pericardical effusion/tamponade - respiratory failure requiring intubation - stroke - atrial flutter/atrial fibrillation . Secondary diagnoses: - diabetes - hypertension Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive, with expressive aphasia Activity Status:Bedbound Discharge Instructions: It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You were admitted to [**Hospital1 18**] for fluid around your heart. A drain was placed, which provided sufficient drainage of the fluid. The drain was pulled out 3 days later after an echocardiogram confirmed no more accumulation of fluid. Furthermore, you were treated with antibiotics for your pneumonia. Your heart rhythm showed atrial flutter / atrial fibrillation, which are arrythmias coming from the top of your heart. You had some trouble with your speech and you had some mental status changes, so you were evaluated by our Neurology service. The Neurology consult concluded that you had a stroke. You will need to be on blood thinners for further stroke prevention. You were also seen by the Speech and Swallow service, who noted that you have a high risk of aspirations, so a gastric tube was placed by the Gastroenterology service. You will get tube feeds through this gastric tube. Your medications have been changed and are as follows: Acetaminophen 325-650 mg PO/NG Q6H:PRN pain/ fever Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Metolazone 5 mg PO DAILY Amlodipine 10 mg PO/NG DAILY Metoprolol Tartrate 50 mg PO/NG TID Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **] Ferrous Sulfate 300 mg PO/NG DAILY Senna 1 TAB NG [**Hospital1 **]:PRN constipation Warfarin 4 mg PO/NG QHS Followup Instructions: Please follow-up with a neurologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**], MD on [**2107-2-14**] at 2:00PM. To reschedule, please call:[**Telephone/Fax (1) 44**]. Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**], on [**2-16**] at 3:00PM. His offices are located at [**Last Name (un) 85842**]. [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 85843**]. To reschedule, please call: [**Telephone/Fax (1) 85844**]. Please schedule a pulmonology appointment at your convenience by calling: ([**Telephone/Fax (1) 513**]. Please scheduled a follow-up appointment with your regular cardiologist, but if you would like to see a [**Hospital1 18**] cardiologist, please call [**Telephone/Fax (1) 62**] to schedule an appointment. ICD9 Codes: 486, 5849, 2760, 2762, 5119, 2859, 4280, 4019
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Medical Text: Admission Date: [**2175-12-11**] Discharge Date: [**2175-12-23**] Date of Birth: [**2092-8-31**] Sex: F Service: MEDICINE Allergies: Atorvastatin / Celebrex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 83-year-old woman with chronic diastolic CHF (LVH, EF 75%), chronic atrial fibrillation on anticoagulation, severe pulmonary hypertension, diabetes, hypertension, dyslipidemia, and metastatic thyroid cancer undergoing cyberknife therapy, who presents to the ED today with complaints of 20-pound weight gain over the last two weeks and increasing shortness of breath, dyspnea on exertion, orthopnea, and PND. She denies any palpitations, presyncope, or syncope. She was evaluated by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2175-11-6**], at which point her digoxin was stopped due to her normal EF and her Lopressor was changed to Toprol XL and the dose was doubled. She subsequently has been undergoing CyberKnife therapy for her metastatic thyroid cancer, completing treatment [**4-16**] today. She complained of progressive symptoms and was referred in to the ED for further evaluation. . In the ED: VS - HR 130s, BP 80/54, Weight 148lbs (up from 124lbs). Her baseline SBPs are known to be in the 100s. ECG showed AFib w/ RVR. CXR showed no significant effusion, pneumothorax, or focal consolidation. She had a shock ultrasound that was negative and was started on Neosynephrine for her hypotension. She received Ceftriaxone as empiric coverage given concern for sepsis contributing to her hypotension and possible underlying pneumonia. She was seen by the CCU team in the ED and started on an Esmolol drip and IV Digoxin. Esmolol and Neosynephrine were titrated up and she received 1 more dose of IV Digoxin. She was also hypoxic, with room air ABG 7.35/51/61. She did not tolerate BiPAP so she was transitioned to NRB. She is being admitted to the CCU for further care. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: PAST CARDIAC HISTORY: 1. Chronic Diastolic Heart Failure: EF 75% 2. Atrial Fibrillation on Coumadin 3. Severe pulmonary hypertension . OTHER PAST MEDICAL HISTORY: 4. Type 2 DM: complicated by diabetic retinopathy and peripheral neuropathy 5. Hyperlipidemia 6. Chronic Lymphedema with multiple lower extremity ulcers 7. Goiter: prior Radioiodine therapy, followed Dr. [**Last Name (STitle) 80040**] 8. GERD 9. Crohn's Disease 10. Cholelithiasis - seen on U/S in past, no previous sx. 11. Achalasia 12. Sleep Apnea: h/o abnormal overnight pulse oximetry, but large thryoid goiter obstructs depending upon patient position . PAST SURGICAL HISTORY: 1. TAH-BSO 2. Tonsillectomy 3. Cataract surgery Social History: Widowed. Lives in [**Location 3915**], MA in an apartment by herself. Her son, [**Name (NI) **] leaves nearby, as do multiple grandchildren. Remote smoking history, occasional alcohol consumption, no illicit drugs. Family History: Father with coronary artery disease, Two children and five grandchildren alive and healthy Daughter with hyperthyroidism Physical Exam: VS: afeb, BP= 90s/40s, HR= 110s-130s, RR= 14-18, O2 sat= 96-99% NRB GENERAL: WD/WN elderly woman in moderate respiratory distress. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with significant JVD to just below the angle of the jaw. Large firm multinodular mass in the thyroid area. Carotid upstrokes normal in volume and contour, without bruits. Trachea is midline but not highly mobile. Tachycardia sensitive to Carotid Sinus Massage. CARDIAC: PMI located in 5th intercostal space, anterior axillary line. Irregularly irregular. Normal S1, widely split S2 w/ prominent P2, no S3 or S4. +[**2-16**] HSM at apex. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp tachypneic but unlabored, mild accessory muscle use. +Crackles and decreased breath sounds at the bases bilaterally. No rhonchi or wheezes. ABDOMEN: +BS, soft/NT/ND. Mildly obese. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: WWP, 2+ pedal edema bilaterally, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in compressive wrappings. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: Awake, A&Ox3, mood and affect appropriate. Fluently conversant w/ no focal neurologic abnormalities. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Radial 2+ Left: Carotid 2+ DP 2+ PT 2+ Radial 2+ Pertinent Results: ADMISSION LABS: [**2175-12-11**] 11:30AM WBC-4.6 RBC-4.15* HGB-10.5* HCT-33.0* MCV-79* MCH-25.3*# MCHC-31.8 RDW-17.5* [**2175-12-11**] 11:30AM GLUCOSE-82 UREA N-72* CREAT-1.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16 [**2175-12-11**] 11:45AM PT-26.2* PTT-32.8 INR(PT)-2.6* . Cardiac enzymes: [**2175-12-11**] 11:45AM CK(CPK)-62 [**2175-12-11**] 11:45AM cTropnT-<0.01 [**2175-12-11**] 08:00PM cTropnT-<0.01 [**2175-12-11**] 08:00PM CK(CPK)-49 . Thyroid labs: [**2175-12-11**] 08:00PM T4-9.2 FREE T4-1.7 [**2175-12-11**] 08:00PM TSH-0.067* . . Labs on Transfer: [**2175-12-21**] 05:31AM BLOOD PT-55.3* PTT-37.2* INR(PT)-6.5* [**2175-12-21**] 05:31AM BLOOD Glucose-177* UreaN-86* Creat-1.5* Na-143 K-4.4 Cl-95* HCO3-38* AnGap-14 . . CARDIOLOGY: . EKG [**2175-12-11**] Atrial fibrillation with rapid ventricular response. Right axis deviation. Low limb lead QRS voltage. RSR' pattern in lead VI. Persistent prominent S waves in the left precordial leads. Modest right precordial lead T wave changes. Findings are consistent with right ventricular hypertrophy/right ventricular overload. Clinical correlation is suggested. No previous tracing available for comparison. . TTE [**2175-12-12**] IMPRESSION: Markedly dilated right ventricle with moderate global hypokinesis and relative sparing of the basal right ventricular segments. Preserved left ventricular regional and global systolic function. Severe diastolic dysfunction. Moderate to severe pulmonary hypertension. Mild aortic and moderate mitral regurgitation. . . RADIOLOGY: CXR ([**2175-12-12**]): FINDINGS: Large right thyroid masses again appreciated with calcification and leftward deviation of the trachea. Numerous rounded masses within the chest bilaterally are again depicted consistent with known metastatic disease. No significant effusion or pneumothorax is detected. Double density with regard to the cardiac shadow is consistent with a large hiatal hernia. No focal consolidation to suggest pneumonia is detected. . CTA Chest ([**2175-12-13**]): IMPRESSION: 1. No pulmonary embolism. Large pulmonary artery measuring 3.4 cm, greater than the aorta. The heart is enlarged with large atria bilaterally, right ventricle greater than the left, although this has not changed in appearance since [**8-14**]. Septal thickening consistent with fluid overload. 3. Large pleural effusions, right greater than left, much worse than in [**Month (only) **]. Significant right and left lower lobe atelectasis. 4. Numerous metastatic pulmonary nodules as before. 5. Hiatal hernia. . CT Chest ([**12-21**]): pending Brief Hospital Course: ASSESSMENT AND PLAN: 83-yo woman w/ chronic dCHF (LVH, EF 75%), chronic A-fib on anticoagulation, severe pulm HTN, DM, HTN, HL, and metastatic thyroid Ca s/p CyberKnife therapy, p/w 20-pound weight gain x2 weeks and progressively worsening SOB and DOE, found to be in A-fib w/ RVR in the ED, hypotensive, and hypoxic, admitted to the CCU, improved w diuresis and transferred temporarily to regular floor. Readmitted to CCU for hypercarbic respiratory failure improved on BiPaP. Diltiazem had been used for rate control - beta blockers were discontinued given concern for ?contribution to respiratory decompensation on the floor. She was empirically started on vancomycin and zosyn for possible HAP on [**12-20**]. She was transfered to the MICU at the request of the patient's family. . # Hypercarbic/hypoxemic respiratory failure: Multiple potential etiologies, in part secondary to her hypervolemia as well as known pulmonary hypertension, cardiogenic pulmonary edema. Pulmonary consult was following the patient, then the patient was transfered to the MICU. Considered tapping pleural effusions, but determined to be technically difficult as the patient had elevated INR. The patient was aggressively diuresed with lasix drip. The patient was continued on BiPAP and was able to be weaned to NC only. Neurology was consulted, paradoxical breathing could be result of myopathy. However, the patient decided after much discussion that she desired to have comfort measures only. The patient was made comfortable, underwent respiratory arrest and cardiac arrest in minutes following. . #. PUMP: Pt w/ known chronic dCHF (LVH and EF 75%), p/w acute exacerbation in the setting of afib with RVR. She was overloaded on exam and was responsive to a lasix drip with improvement in volume status. TTE showed EF 70-75%, markedly dilated RV w/ moderate global HK, preserved LV regional and global systolic function, severe diastolic dysfunction, moderate to severe pulmonary hypertenion. Given hypotension and mild acute renal failure, lasix drip was continued with 1-1.5 L net diuresis daily. Spironolactone was also continued at home dose. With improvement in her volume status, she was transferred to the regular floor, however, readmitted to CCU for hypercarbic/hypoxemic respiratory failure. Pt i/o slightly net negative, but unable to adequately diurese secondary to hypotension. Nonetheless, the patient appears volume overloaded, restarted on lasix gtt yesterday. Continued lasix gtt, then switched to bolus lasix. . # RHYTHM: Pt was noted to have chronic atrial fibrillation, no previous attempts at cardioversion. She was in a-Fib w/ RVR on presentation to ED, w/ hypotension as below, in setting of worsening symptoms since stopping Digoxin and uptitrating Toprol XL. Low TSH also suggested a contribution of thyrotoxicity secondary to CyberKnife therapy for thyroid cancer. She was started on Esmolol gtt which was titrated to max in ED. Also given IV Digoxin 250mg x 2 in ED. Upon arrival to CCU, Diltiazem bolus + gtt were started with good effect, and esmolol was titrated off. No more digoxin was given. Rate was subsequently well controlled on PO and diltiazem, which were increased for goal HR <80. Coumadin was continued but INR became supratherapeutic. Now s/p diltiazem and esmolol drips on PO diltiazem and metoprolol with HR 90-100. Low TSH suggests probable contribution from thyrotoxicity likely from CyberKnife therapy to thyroid cancer. Due to supratherapeutic INR, coumadin was d/c'd. . # CORONARIES: No known CAD, but w/ many risk factors. . # HYPOTENSION: Pt w/ SBP 80s-90s in ED in the setting of RVR, and neosynephrine was started for BP support while on rate-controlling agents. She continued to mentate well even though hypotensive. She was briefly febrile, but no infection was identified and sepsis was considered unlikely. Random cortisol was high, ruling out adrenal insufficiency as a cause. Hypotension was attributed to poor forward flow from acute on chronic diastolic CHF and A-Fib/RVR. Blood pressure improved with rate control and diuresis. Now low normal BP with fluctuating mentation. Low UOP on lasix drip, ultrafiltration was considered. . # ACUTE RENAL FAILURE: Likely [**1-15**] poor forward flow from A-Fib/RVR. Will likely improve with HR control and diuresis. Urine lytes c/w prerenal physiology. Renal following. . # DIABETES: On oral meds at home for glycemic control. ISS while inpatient. . # CROHN'S DISEASE: continued home Pentasa, PPI. . # SUPRATHERAPEUTIC INR: Pt on coumadin for a-fib, but INR now > 6, unclear etiology. . # ETHICS: Pt was DNR/DNI, but family says pt confused. Patient says "I want to die" but son wants full code. Had family meeting with PCP and endocrinology. Ethics following. She has a tortuous trachea - ENT has eval'd think intubation would not be problem[**Name (NI) 115**]. Family meetings- pt to remain full code for now and aggrees to trial intubation if needed. Pt eventually CMO. Medications on Admission: - Lasix 60mg PO daily - Glyburide 2.5mg PO daily - Lisinopril 2.5mg PO daily - Lorazepam 0.5mg PO daily - Pentasa 1000mg PO BID - Toprol XL 200mg PO daily - Omeprazole 40mg PO daily - Spironolactone 25mg PO daily - Warfarin 5mg PO daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2175-12-26**] ICD9 Codes: 5849, 486, 4589, 4168, 4280, 2724, 3572
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Medical Text: Admission Date: [**2101-9-9**] Discharge Date: [**2101-10-7**] Date of Birth: [**2075-10-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Cervical esophageal perforation Major Surgical or Invasive Procedure: 1) Repair of cervical esophageal perforation with wide drainage of the neck 2) Right thoracotomy and exploration and wide drainage of the mediastinum 3) Placement of percutaneous endoscopic gastrostomy tube 4) Placement of left chest tube 5) Esophagogastroduodenoscopy 6) Flexible bronchoscopy 7) Left thoracoscopy with intrapleural pneumolysis and evacuation of loculated pleural effusion and empyema 8) Placement of intercostal rib locks-multiple History of Present Illness: Mr. [**Known lastname **] is a 25-year-old incarcerated gentleman who was beaten in a prison fight 4 days prior to presentation in the emergency room. He complained of diffuse pain but then this worsened to odynophagia and finally developed neck swelling and crepitus. On his preoperative studies, a chest CT noted the presence of pneumomediastinum and air around the cervical esophagus. There was pleural fluid which looked more complex than a simple effusion in both pleural spaces. A Gastrograffin swallow confirmed the location of the tear to be in the cervical esophagus. There did not appear to be any other esophageal pathology. Past Medical History: Depression Social History: Positive for Tobacco, alcohol and marijuana use. He denies IVDU. Physical Exam: On discharge, patient's physical exam is as follows: Vitals: AVSS Gen: NAD HEENT: PERRLA, EOMI, occipital decubitus CVS: RRR, no MRG PULM: CTA bilaterally ABD: soft, NT/ND, +BS EXT: no CCE Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2101-10-5**] 12:50PM 9.9 3.00* 7.9* 25.4* 85 26.4* 31.2 16.7* 489* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2101-9-19**] 07:33AM 81* 0 7* 9 1 0 0 2* 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2101-9-19**] 07:33AM 1+ NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2101-10-5**] 12:50PM 489* RADIOLOGY Final Report CHEST (PA & LAT) [**2101-10-5**] 1:54 PM Reason: eval for interval change, s/p pleural drain d/c [**10-4**] [**Hospital 93**] MEDICAL CONDITION: 25 year old man with rupt esophagus, 1 pleural drain to bulb suction s/p loculated bilateral pleural effusions; now w/ some pain s/p drian pull [**10-4**]. REASON FOR THIS EXAMINATION: eval for interval change, s/p pleural drain d/c [**10-4**] CHEST, TWO VIEWS INDICATION: 25-year-old man with ruptured esophagus. COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with previous study of [**2101-10-2**]. The left chest tube remains in place. There is continued small left pleural effusion with atelectasis in the left lung base. Minimal patchy atelectasis is seen at the right lung base. The lungs are clear otherwise. The heart and mediastinum are within normal limits. The tip of the right-sided PICC line is identified in the distal portion of the right subclavian vein. No pneumothorax is noted. RADIOLOGY Final Report ESOPHAGUS [**2101-9-28**] 2:22 PM Reason: swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for esopha [**Hospital 93**] MEDICAL CONDITION: 25 year old man with esophgeal rupture and repair. REASON FOR THIS EXAMINATION: swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for esophageal leak. BARIUM ESOPHAGRAM INDICATION: 25-year-old man with esophageal rupture and repair. BARIUM ESOPHAGRAM: Orally administered Optiray contrast was observed under fluoroscopic guidance passing freely into the stomach with no evidence for extra luminal extravasation. Thin barium was then orally administered for better resolution of the esophagus. There is no aspiration into the airway and no significant retention in the vallecular or piriformis sinuses. No structural abnormalities are detected in the region of the pharynx, cervical esophagus, or mid and distal esophagus. Normal primary peristaltic contractions. There is no evidence for extra luminal extravasation of contrast. IMPRESSION: No evidence for extraluminal extravasation. RADIOLOGY Final Report TEETH (PANOREX FOR DENTAL) [**2101-9-28**] 1:59 PM Reason: abscess [**Hospital 93**] MEDICAL CONDITION: 25 year old man with poor dentition REASON FOR THIS EXAMINATION: abscess HISTORY: Abscess, ____. Panorex single view. The mandibular condyles and TM joints are excluded from this view. There is increased density over the mental portion of the mandible, obscuring fine bony detail. There is a broken tooth posteriorly on the right. RADIOLOGY Final Report ESOPHAGUS [**2101-9-8**] 8:23 PM Reason: need swallow study under fluoro to assess for esophageal [**Doctor First Name **] Contrast: [**Hospital 13288**] [**Hospital 93**] MEDICAL CONDITION: 25 year old man with REASON FOR THIS EXAMINATION: need swallow study under fluoro to assess for esophageal leak ESOPHAGEAL STUDY INDICATION FOR STUDY: Evaluate for esophageal leak following trauma to neck. A scout film of the upper thorax and neck reveals free air within the mediastinum. Thereafter, a water-soluble esophageal study was performed which demonstrates a leak in the upper esophagus on the right side at the level of the manubrium. Free extravasation of air and contrast is noted to the right side of the esophagus at this level with passage of leaked contents both superiorly and inferiorly tracking along the right side of the esophagus. The remaining mid and distal esophagus is entirely normal with no leakage present or mucosal irregularities. IMPRESSION: Rupture of esophagus on right side at level of manubrium with leaked contents traveling both superiorly and inferiorly along the right side of the esophagus. These findings were communicated immediately to the ordering surgeon Dr. [**Last Name (STitle) **]. Brief Hospital Course: Mr. [**Known lastname **] was admitted to Dr.[**Name (NI) 2347**] service at [**Hospital1 18**] via the ED on [**2101-9-8**]. On that day, he underwent a repair of his cervical esophageal perforation with wide drainage of the neck, right thoracotomy, exploration and wide drainage of the mediastinum, placement of percutaneous endoscopic gastrostomy tube, placement of left chest tube, esophagogastroduodenoscopy and flexible bronchoscopy. For details of the procedure, see operative dictation. He was taken to the SICU post-operatively intubated and sedated. He was placed on Vancomycin, Zosyn and Fluconazole as prophylaxis. Upon presentation, his diagnosis was made via an esophagram which showed his esophageal rupture was at the level of manubrium with leaked contents traveling both superiorly and inferiorly along the right side of the esophagus. A follow-up esophagram was done on POD 9 but showed a continued leak. He was therefore kept NPO. This exam was then repeated on POD 20 with resolution of the leak. He was transitioned to sips of clears on that day and then slowly advanced thereafter; all of which was well tolerated and without issue. Lastly, he had been on tube feeds throughout his hospital course and which were begun on POD 4. He was then cycled starting on POD 23. These were discontinued on POD 25 given his very good PO intake. From an infectious disease standpoint, a sputum culture on [**9-11**] returned positive for Klebsiella and he was additionally placed on Unasyn. Furthermore, a JP fluid culture from [**9-22**] was also positive for Klebsiella and he was then switched from Unasyn to Levofloxacin on [**2101-9-24**] for more narrowed, specific antibiotic coverage. He, however, continued to spike intermittent fevers during his initial hospital course despite broad and specific spectrum antibiotic coverage. He was then taken back to the OR on [**2101-9-26**] for a Left VATS after two large loculated pleural effusions were noted on imaging. For details of the procedure, see operative dictation. His vancomycin was stopped at that time and he was continued on zosyn, fluconazole and levofloxacin which will continue for about one month after discharge from the hospital. On POD 25, he was deemed fit to return to his Corrections Facility. He had been afebrile for approximately a week--beginning a day or two after his left VATS. He was ambulating without difficulty and was tolerating a regular diet. He was then discharged in good condition in the care of the State Corrections System. He is asked to return each week for follow-up so that his last remaining neck drain may be evaluated and slowly removed. Medications on Admission: Seroquel Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 5. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*qs ML(s)* Refills:*0* 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*1 qs* Refills:*2* 8. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 4 weeks. Disp:*1 qs* Refills:*0* 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) for 2 weeks. Disp:*1 qs* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Esophageal rupture Empyema Discharge Condition: Good Discharge Instructions: Please call Thoracic Surgery/Dr.[**Name (NI) 2347**] office (Thoracic Surgery) at [**Telephone/Fax (1) 170**] for any post surgical issues. Left pleural drain remains in place. Zosyn IV, fluconazole po, levofloxacin po UNTIL left pleural drain discontinued. Pleural drain to be evaluated by Dr.[**Last Name (STitle) **] on a weekly basis, until drain discontinued. Appointment with Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am for follow-up visit.See details below. No heavy lifting or exertion for 4- 6 weeks. Zosyn IV, fluconazole po, levofloxacin po UNTIL left pleural drain discontinued. You may take a brief shower(no baths) every 2-3 days. Dry area near drain well, change dressing daily and after each shower Followup Instructions: Patient to be seen by Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am for follow-up visit at [**Hospital1 69**], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 86**], MA, [**Location (un) 8939**], Thoracic Surgery Clinic. If this appointment cannot be kept call [**Telephone/Fax (1) 170**]. Completed by:[**2101-10-7**] ICD9 Codes: 5185, 311, 3051, 2859
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Medical Text: Admission Date: [**2195-8-18**] Discharge Date: [**2195-8-24**] Date of Birth: [**2176-5-4**] Sex: F Service: SURGERY Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 4691**] Chief Complaint: Trauma: MVC: L hemo/pneumothorax s/p CT nondisplaced R iliac fracture L [**5-20**] rib fxs [**3-20**] flail grade III splenic laceration Major Surgical or Invasive Procedure: chest tube placement [**8-18**] removal of chest tube [**8-20**] History of Present Illness: HISTORY OF PRESENTING ILLNESS Hope Eu Critical is a 19-year-old woman who was the unrestrained driver of a car without airbags who hit a tree. The patient was seen and stabilized at [**Hospital 8641**] Hospital where she was diagnosed with a left hemopneumothorax, spleen laceration, pulmonary contusions, right iliac fracture. She had a left chest tube placed without difficulty, received a blood transfusion and has been hemodynamically stable during transport. Timing: Sudden Onset Quality: Sharp Severity: Moderate Duration: Hours Location: Left upper quadrant Context/Circumstances: Status post motor vehicle collision Mod.Factors: Worse with Movement Associated Signs/Symptoms: Hypotension Past Medical History: Hypothyroidism Social History: Denies Drugs and Smoking Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: [**2195-8-18**] Temp: 98.8 HR: 95 BP: 135/85 Resp: 20 O(2)Sat: 100 Normal Constitutional: Patient is awake, alert and responding to my questions. She is nontoxic in appearance HEENT: No evidence of head trauma, pupils are equal and reactive, Extraocular muscles intact No cervical bony tenderness Chest: Lungs are clear bilaterally Cardiovascular: Normal S1-S2 Abdominal: Her belly is soft, but tender in the left upper quadrant, no peritoneal signs Pelvic: Pelvis is stable Rectal: Normal rectal exam GU/Flank: No CVA tenderness Extr/Back: No extremity deformities Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2195-8-22**] 06:20AM BLOOD Hct-23.4* [**2195-8-21**] 07:15AM BLOOD WBC-7.1 RBC-3.03* Hgb-9.3* Hct-25.3* MCV-84 MCH-30.7 MCHC-36.8* RDW-13.9 Plt Ct-118* [**2195-8-20**] 05:59PM BLOOD Hct-24.6* [**2195-8-19**] 03:57AM BLOOD WBC-11.4* RBC-3.63* Hgb-11.0* Hct-29.8* MCV-82 MCH-30.3 MCHC-36.9* RDW-14.1 Plt Ct-144* [**2195-8-18**] 03:45PM BLOOD WBC-17.7* RBC-4.04* Hgb-12.3 Hct-33.7* MCV-83 MCH-30.5 MCHC-36.5* RDW-14.1 Plt Ct-188 [**2195-8-18**] 01:25PM BLOOD WBC-17.8* RBC-3.79* Hgb-11.8* Hct-32.2* MCV-85 MCH-31.0 MCHC-36.6* RDW-13.6 Plt Ct-205 [**2195-8-21**] 07:15AM BLOOD Plt Ct-118* [**2195-8-20**] 09:00AM BLOOD Plt Ct-117* [**2195-8-18**] 01:25PM BLOOD PT-13.1 PTT-21.7* INR(PT)-1.1 [**2195-8-21**] 07:15AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 [**2195-8-20**] 09:00AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-138 K-4.0 Cl-105 HCO3-27 AnGap-10 [**2195-8-21**] 07:15AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 [**2195-8-20**] 09:00AM BLOOD Calcium-8.3* Phos-2.0*# Mg-2.0 [**2195-8-18**]: chest x-ray: IMPRESSION: Left-sided chest tube with likely left hemothorax. There may be an air component as well when correlated to the outside imaging. Diffuse opacity in particular in the left lower lobe likely indicates some element of pulmonary contusion as well. Mediastinal shift and splaying of the ipsilateral ribs is worrisome for at least in part tension physiology. Left-sided rib fractures noted. [**2195-8-18**]: cat scan of the abdomen and pelvis: IMPRESSION: 1. Extensive left lower lobe pulmonary contusion and laceration with a small residual hemopneumothorax on the left and an indwelling chest tube as above. Chest tube repositioning is likely indicated. The trauma surgery team is aware. 2. Grade III splenic lacerations as detailed above. There is no active extravasation appreciated or significant increase in the perisplenic hemorrhage; however, there has been interval increase in the amount of pelvic hemoperitoneum identified. 3. Question low grade right renal laceration. Correlate with hematuria. Collecting system intact. 4. Deep pelvic linear high attenuation adjacent to the left aspect of the uterus. The overall course suggests an accessory uterine vein or arterial however, the morphology is slightly irregular and the possibility of extravasation from a small injured vessel is raised. The lack of extravasated contrast from prior imaging is reassuring; however, in light of the increasing pelvic hemoperitoneum and continued hemodynamic instability, attention on for further scanning is advised. This was discussed at length with Dr. [**Last Name (STitle) **] at approximately 3:00 p.m. on the day of study. [**2195-8-18**]: angiogram: IMPRESSION: Left common iliac and splenic arteriograms without evidence of active extravasation. [**2195-8-18**]: angiogram: FINDINGS: 1. Left common iliac arteriogram demonstrated normal anatomy with no contrast extravasation. 2. Splenic artery digital subtraction angiogram demonstrated parenchymal contrast blush in the spleen, corresponding to areas of post-traumatic hyperemia. Avascular areas were also noted within the spleen corresponding to known lacerations. No extra splenic contrast extravasation was visualized. [**2195-8-18**]: chest x-ray: FINDINGS: AP single view of the chest obtained with patient in supine position is analyzed in direct comparison with the next preceding supine chest examination obtained four and a half hours earlier during the same day. The patient is now intubated and ETT seen to terminate in the trachea some 4 cm above the level of the carina. An NG tube has been advanced and reaches below the diaphragm including its side port. A left-sided chest tube is in place and has changed its position in comparison with the next previous study. Whereas it earlier terminated in the upper hemithorax at the level of the fourth and fifth vertebral body, it has now been pulled back and the tip points towards the area of the seventh and eighth thoracic vertebral body. A diffuse haze that was overlying the left hemithorax on the previous study has regressed but basal density exists and coincides with the area of previously by chest CT identified pulmonary parenchymal contusion area. As on the previous examination, there may be a small left-sided apical pneumothorax but it has not increased during the latest examination interval. No new major displacements of the previously identified left-sided multiple rib fractures. The right-sided hemithorax appears intact. [**2195-8-19**]: chest x-ray: FINDINGS: In comparison to the earlier film, a small pneumothorax is seen apically in the left lung. The left chest tube remains in place. Patchy opacification of the left base persists; however, it is less dense than earlier today. [**2195-8-20**]: chest x-ray: FINDINGS: AP single view of the chest has been obtained with patient in upright position. Comparison is made with the next preceding supine chest examination of [**2195-8-19**]. During the interval, the left-sided chest tube has been removed. The previously described hazy density over the left lung base persists and is compatible with some pleural effusion. The tube has been removed, but no pneumothorax is identified anywhere in the left hemithorax, and the apical area is free. No new pulmonary abnormalities are seen, and no mediastinal shift can be identified [**2195-8-21**]: chest x-ray: FINDINGS: In comparison to the previous examination this radiograph is grossly unchanged. There remains a haziness in the left lower lung field which is likely a combination of atelectasis, pulmonary contusion, and pleural hemorrhage or effusion. The right lung is grossly clear. Mediastinal silhouette is unremarkable. Brief Hospital Course: 19 year old female, unrestrained driver, involved in a motor vehicle accident admitted to the acute care service from an outside hospital. She sustained a left hemo-pneumothorax for which a left sided chest tube was placed prior to admission. She also sustained left sided rib fractures. Radiographic imaging showed a grade 4 splenic laceration and a right iliac [**Doctor First Name 362**] fracture. She was hypotensive upon arrival to the emergency room and her chest tube was replaced. She underwent a cat scan with iv contrast and experienced shortness of breath and anxiety. She was subsequently treated with benadryl. Upon arrival to the intensive care unit, she was intubated for airway protection and because there was a concern for a contrast allergy. To further investigate any further bleeding into her abdomen, she underwent angiography to investigate the possibilty of a left pelvic bleed and bleeding from the spleen. No contrast extravasation was noted. She was extubated on [**8-19**]. She was evaluated by orthopedics for her iliac [**Doctor First Name 362**] fracture and recommendations made for follow-up in 4 weeks. Transferred to the surgical floor on [**8-20**]. Her left sided chest tube was discontinued. She was started on clear liquids with gradual advancement to to a regular diet. Her pain was controlled with oral analgesia. She was evaluated by physical therapy who recommended a walker for ambulation and home physical therapy. Because she had poor recollection of the accident, cognitive evaluation is recommended 1-2 weeks after discharge. Her vital signs are stable and she is afebrile. Her current hematocrit is 29 which is elevated from her baseline of 23-25. She is voiding without difficulty. She is preparing for discharge home with VNA physical therapy and follow-up visit with the acute care service, orthopedics, and cognitive neurology. Medications on Admission: [**Last Name (un) 1724**]: levothyroxine Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 2. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: may cause drowsiness, avoid driving while on this medication. Disp:*25 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Trauma: MVC: L hemo/pneumothorax s/p CT nondisplaced R iliac fracture L [**5-20**] rib fxs [**3-20**] flail Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane)( walker for support) Discharge Instructions: You were admitted to the hospital with after you were involved in a motor vehicle accident. You sustained a injury to your spleen and a fracture to the part of your hip. You also received a bruise to your lungs with a fluid collection for which you needed a chest tube placed. You were seen by orthopedics and they determined that you did not need surgery to repair your hip. As a result of the accident you did sustain left sided rib fractures. You are slowly recovering and you are ready to be discharged home with the following instructions: Because you had a splenic laceration please follow these instructions: AVOID contact sports and/or any activity that may cause injury to your abdominal area for the next 6-8 weeks. *If you suddenly become dizzy, lightheaded, feeling as if you are going to pass out go to the nearest Emergency Room as this could be a sign that you are having inernal bleeding from your liver or spleen injury. *AVOID any blood thinners such as Motrin, Naprosyn, Indocin, Aspirin, Coumadin or Plavix for at least 3-5 days unless otherwise instructed by the MD/NP/PA. You also sustained rib fractures from the accident, please follow these instructions: Your injury caused left sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule your appointment 24 hours after you are discharged by calling #[**Telephone/Fax (1) 600**]. Please let them know that you will need a chest x-ray prior to your visit. Please follow up with the Dr. [**First Name (STitle) **] in 1 week. You can schedule your appointment by calling # [**Telephone/Fax (1) 6335**] You will also need to follow up with Orthopedics, Dr. [**Last Name (STitle) 2637**] in [**3-18**] weeks. You can schedule this appointment by calling # [**Telephone/Fax (1) 1228**] Completed by:[**2195-8-24**] ICD9 Codes: 2449
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Medical Text: Admission Date: [**2132-5-29**] Discharge Date: [**2132-6-7**] Date of Birth: [**2055-10-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Atrial flutter ablation & D/C cardioversion ([**2132-5-30**]) Intubation for respiratory distress ([**2132-5-30**]) Left & right heart cardiac catheterization ([**2132-6-2**] & [**2132-6-6**]) Placement of ICD ([**2132-6-4**]) History of Present Illness: 76 y/o man with h/o CAD, s/p MI ([**2107**], [**2131**]), CHF EF 20%, DM, a. fib/flutter admitted to [**Hospital3 417**] hospital on [**2132-5-21**] for SOB. Of note, the pt had been admitted to [**Hospital3 417**] hospital on [**2132-4-26**] with the same complaints. At that time, he pt was found to be in respiratory distress and was intubated and diuresed (and extubated 1 day following intubation). His respiratory decompsensation on [**4-26**] was thought to be due CHF after missing 2 days of lasix. On [**5-21**], the pt's wife called 911 after the pt became acutely SOB at home. EMS intubated the pt en route to [**Hospital3 417**] hospital. Again, the pt was diuresed with rapid improvement, leading to extubation within days. There was question of PNA, for which he was tx'd with abx. Myoview stress testing during the admission was reportedly negative for ischemia. Echo on [**5-22**] showed EF = 10%. Pt found to be in AFR Creatinine w/ Crt peaking at 2 upon admission but came back to baseline (thought to be ~1.7). Additionally, during this admission to [**Hospital3 **], the pt was in afib. (The pt does not know when his afib started, and has never undergone electrocardioversion. He was started on coumadin in early [**Month (only) **].) On [**2132-5-29**], the pt was transferred to [**Hospital1 18**] to undergo EP evaluation and possible intervention. . Upon review of systems, the pt reported that he can walk the length of the hallway before getting short of breath. He denies lightheadedness, orthnopnea, PND, leg edema, or ascites. He had self-limited palpitations yesterday. No current SOB, and is comfortable and ambulatory on room air. Past Medical History: 1. a-fib - [**2132-5-13**] INR 3.0 2. CHF EF 20% - [**2132-4-27**] Echo: EF 20-25% with global hypokinesis, Trace TR, mild pulmonary hypertension. - [**2132-5-22**] Echo: severe global hypokinesis and EF of 10% c/w ischemic cardiomyopathy, mild LA enlargement, RV systolic function mildly reduced, moderate MR, IVC dilated. 3. MI in [**2107**] 4. LBBB 5. COPD 6. diabetes 7. hyperlipidemia 8. CRI with baseline Cr of 1.7 on [**2132-5-5**] 9. Anemia Social History: SH: retired, formerly worked as a carpenter. Has been married for 33 years with his second wife, has 7 children with his first wife. [**Name (NI) **] [**Name2 (NI) 1818**], 63 pack years. Rare alcohol use, no illicit drug abuse history. Family History: FH: No h/o CAD, no HTN. grandmother and brother with diabetes. Brother with laryngeal cancer, mom died of stomach cancer at 73, father died of aneurysm at 73. Physical Exam: Vitals T: 97.0oF HR: 88 BP: 110/50 RR: 16 O2sat: 96% RA Ht: 5??????9?????? Wt: 154lbs Glucose 465 Gen pleasant, NAD Derm skin normal coloration and texture for age, nails without clubbing or cyanosis. No rash. Hair of normal texture for age HEENT Anicteric. conjunctiva pink. PERRLA, EOMs normal, VFs full. Oropharynx clear. Mucous membranes moist. Trachea midline. Neck supple. No cervical LAD, no enlarged or tender thyroid. Pulm CTAB. No crackles or wheezes CV JVP 8 cm above the sternal angle at 45&#[**Numeric Identifier 18014**]; elevation. irregularly irregular pulse, pulsus alternans. normal S1, S2. No c/m/r/g. Pedal and radial pulses symmetrical and strong,. Abd Non-distended. No scars/herniae. +BS. No aortic/renal artery bruits. Hollow to percussion. S/NT/ND. Liver, spleen not palpable. Ext no c/c/e. Neuro MSE: alert, Ox3. Rest of MMSE not performed CN: II-XII intact to direct testing. Sensory: Light touch intact in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Motor: Good bulk and tone, ROM full and smooth. Strength 5/5 throughout. Coordination: Gait normal. Pertinent Results: [**2132-5-29**] 09:57PM GLUCOSE-358* UREA N-46* CREAT-2.6* SODIUM-135 POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-17 [**2132-5-29**] 09:57PM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.2 IRON-68 [**2132-5-29**] 09:57PM calTIBC-397 FERRITIN-135 TRF-305 [**2132-5-29**] 09:57PM WBC-10.2 RBC-3.27* HGB-10.2* HCT-28.8* MCV-88 MCH-31.1 MCHC-35.3* RDW-14.0 [**2132-5-29**] 09:57PM PLT COUNT-358 [**2132-5-29**] 09:57PM PT-15.5* PTT-27.8 INR(PT)-1.4* [**2132-5-29**] 09:57PM RET AUT-4.0* [**2132-6-6**] 11:37PM BLOOD Type-ART pO2-74* pCO2-39 pH-7.48* calTCO2-30 Base XS-5 [**2132-6-7**] 11:57AM BLOOD Glucose-151* [**2132-6-7**] 11:57AM BLOOD Hgb-8.7* calcHCT-26 O2 Sat-62 [**2132-6-6**] 05:08AM BLOOD freeCa-1.04* [**2132-6-6**] 10:02PM BLOOD CK(CPK)-1035* [**2132-6-7**] 06:02AM BLOOD CK-MB-38* [**2132-6-7**] 06:02AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 [**2132-6-7**] 06:02AM BLOOD Glucose-182* UreaN-15 Creat-1.9* Na-137 K-3.6 Cl-97 HCO3-30 AnGap-14 [**2132-6-7**] 06:02AM BLOOD WBC-11.1* RBC-2.88* Hgb-8.9* Hct-25.1* MCV-87 MCH-30.8 MCHC-35.3* RDW-14.7 Plt Ct-398 . TTE [**2132-5-30**]: 1. The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (~0.2m/s). No atrial septal defect is seen by 2D or color Doppler. 2.The left ventricular cavity is dilated. Overall left ventricular systolic function is severely depressed 15-20%. 3.There are complex (>4mm) atheroma in the descending thoracic aorta. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. 6.There is no pericardial effusion. . Cardiac Cath [**2132-6-2**]: COMMENTS: 1. Selective coronary angiography of this left dominant system revealed a one vessel coronary disease. The LMCA was without flow limiting stenosis. The LAD was a large vessel that gave rise to three diaginal branches. Proximal LAD had a diffuse 40% stenosis with a superimposed 90% focal stenosis before a take off of a major diagonal branch (D3). The LCx was a dominant vessel with a 30% proximal stenosis and a 30% stenosis of OM3. The RCA was a small non-dominant vessel with a mild diffuse disease throughout. 2. Left ventriculograhy was deferred given renal insufficiency. 3. Resting hemodynamics revealed a moderately high left sided filling pressures with a PCWP of 18. The CI was 2.47. 3. The proximal LAD lesion was predilated with a 2.5 x 15 maverick balloon and stented with a 3.0 x 28 balloon. The final angiogram showed TIMI III flow with no residual stenosis, no dissection, no embolisation and no perforation (see PTCA comments) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderately elevated left sided filling pressures. 3. Successful PTCA/stent of the proximal LAD with excellent result. Brief Hospital Course: I would like to mention at the onset that the patient has refused further care during this hospitalization and wants to go home. Fllowing is his brief hospital course: Upon arrival to [**Hospital1 18**], the pt underwent TEE followed by electric cardioversion and Aflutter albation. Post procedure, the pt was transferred to the floor and was noted to be agitated by wife. [**Name (NI) **] became hypertensive with SBP in 180s, tachypnic & hypoxemic. He was intubated, given IV lasix and nitro gtt and transfered to the CCU. After receiving lasix, the pt diuresed well and showed rapid improvement. No other cause of resp distress was found, other than acute pulmonary edema. Thus, he was extubated the following day. 24hrs s/p extubation the pt became anxious & SOB again, progressing to respiratory distress. He was found, as before, to be in acute pulmonary edema. Intubation was averted after giving morphine, nitro gtt, lasix, ativan and starting BiPAP. On [**2132-6-2**], pt underwent right & left heart cath with PTCI of LAD with drug eluting stent placement. On [**2132-6-4**], the pt underwent ICD placement. Despite medical therapy & the above interventions, the patient continued to have repeated episodes of acute pulmonary edema, each episode treated with morphine, lasix, ativan, +/- nebulizers and BiPAP, avoiding intubation in each instance. These episodes of acute (or "flash") pulmonary edema were triggered in some cases by a small to moderate volume load (for cardiac catheterization, for instance); however, other episodes were triggered by seemingly inocuous causes such as transfering onto a bed pan. The pt expressed the desire to not be intubated again, though he wants to have BiPAP therapy should he develop respiratory distress again. After discussing his prognosis and options for therapy with both him & his wife, he decided to be DNR/DNI on [**2132-6-5**]. He also expressed the desire to minimize interventions and the amount of time hospitalized. His goal is to go home, knowing that he could die there in his condition. His wish is to spend as much time with his wife as possible at home, though he does not want to undergo extensive hospital care and therapy to accomplish this. After making these decisions, the pt again went into acute respiratory distress on the AM of [**2132-6-6**]. He was treated with the same regimen as described above. His cardiac enzymes were elevated (w/ a troponin of 1.29). The pt agreed to undergo diagnostic catheterization to determine if his LAD stent had occluded and also to determine his hemodynamic numbers. If the stent was found to be occluded or a new lesion was found, he agreed to treatment through PTCI--with the aim of optimizing his condition before going home. At catheterization, the in-stent thrombosis was re-stented Additional Hospital Course Issues: ## CV: # CAD - From the outset, it was thought that the pt very likely had extensive baseline ischemia--given his h/o CAD, diabetes, smoking, and thick ventricle (diastolic failure). Based on this, he was taken for a diagnostic cath on [**6-2**], where he was found to only have LAD disease, which was stented with drug eluting stent. Based on these results, it was concluded that he most likely has idiopathic ischemic cardiomyopathy. He was treated medically with ASA, plavix, BB, & statin. On [**2140-6-5**], pt's SBP dropped & his anti-hypertensives were held. It is thought that a new ischemic event may have contributed to this. # [**Name (NI) **] - Pt's initial TEE revealed global hypokinesis (EF ~20%). Right heart cath on [**6-4**] showed PCWP 18 and cardiac index of 2.47. Post-LAD stenting echo revealed no improvement in LV function (estimated EF ~15%). # Rhythm - Pt was in flutter upon arrival at [**Hospital1 18**]. He underwent a.flutter ablation and cardioversion into NSR. His rhythm degenerated into afib after the procedure. Pt treated with heparin and later coumadin for afib. Pt underwent ICD placement and cardioversion on [**6-5**] (prior to deciding to be DNR/DNI). Given his disorganized atrial arrhythmias at times and his left atrial flutter and the apparent benefit of him being in sinus rhythm, he was started on amiodarone therapy (recommended by EP for month at 200mg [**Hospital1 **] and thereafter 200mg QD). . ## Respiratory Failure - Intubated on [**2132-5-30**] after developing respiratory distress, which was thought to be due to acute pulm edema as above. Pt extubated following day ([**5-31**]). . #Agitation/anxiety: likely contributed to episodes of shortness of breath. Pt started on ativan 0.5mg [**Hospital1 **], which was changed to longer acting clonazepam (started on [**6-3**]). . ## COPD - Though not previously documented, pt's appears to have COPD--CXR reveals significant hyperinflation of lungs. He refuses to stop smoking. Pt given spiriva inhalers & albuterol. . ## Anemia- reportedly has h/o anemia, though cause unknown. Pt's hct dropped during admission & he was transfused 1uPRBCs during admission. Hct stabilized thereafter. No obvious source of bleeding. . ## DM - Pt's outpt glipizide & NPH held. He was treated with RISS and NPH [**7-1**] (when not NPO). . ## CRI - baseline creatinine estimated to be approximately 1.7. Had ARF thought to be pre-renal in nature with Crt peaking at 2.3. ARF now resolved with Crt at 1.6. . ## Hyperlipidemia - atorvastatin continued. . ## code - DNR/DNI ## Communication - wife [**Name (NI) 382**], who is legally blind Medications on Admission: 1. digoxin 0.125mg qday 2. esomeprazole magnesium 40mg 3. salmeterol/fluticasone 250 1 puff [**Hospital1 **] 4. tiotropium bromide 18mcg qday 5. atorvastatin 20mg qday with supper 6. Mylanta 30mL q6h prn 7. aspirin 325 mg qday 8. furosemide 80mg qAM and 40mg qHS 9. glipizide 10mg [**Hospital1 **] 10. metoprolol 100mg [**Hospital1 **] 11. enoxaparin qday 12. acetaminophen 325-650mg q4-6h prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Digoxin 125 mcg Tablet Sig: 0.125mg Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hr prn as needed for shortness of breath or wheezing. Disp:*60 cc* Refills:*0* 5. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q2hr as needed. Disp:*10 Tablet(s)* Refills:*0* 6. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*10 patches* Refills:*0* 7. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tab Sublingual four times a day as needed for secretions. Disp:*30 * Refills:*0* 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 mdi* Refills:*0* 9. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Disp:*1 mdi* Refills:*0* 10. Morphine 10 mg/5 mL Solution Sig: 5-20 mg PO q1hr as needed for shortness of breath or wheezing. Disp:*120 ml* Refills:*0* 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Severe diastolic & systolic CHF with acute pulmonary edema, CAD, ischemic cardiomyopathy, afib & COPD Discharge Condition: Stable but patient has refused any further care Discharge Instructions: Continue taking aspirin and clopidogrel daily as instructed. DO NOT STOP these medications unless given permission by your cardiologist. Please take all medications as prescribed If you have chest pain, shortness of breath, dizziness, palpitations, pain in abdomen, vomitting, diarrhea please call your primary care provider Followup Instructions: Please call your PCP Dr [**Last Name (STitle) 17025**] ([**Telephone/Fax (1) 3183**]) to make a follow up appointment Completed by:[**2132-6-7**] ICD9 Codes: 5859, 496, 5185, 5849, 412, 2724
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Medical Text: Admission Date: [**2173-2-16**] Discharge Date: [**2173-2-21**] Date of Birth: [**2095-10-23**] Sex: F Service: Neurology CHIEF COMPLAINT: Left-sided weakness and left hand twitching. HISTORY OF PRESENT ILLNESS: This is a 77 year old female who was noted at around 2:40 PM on the afternoon of admission by the nursing staff to be slumped over while at group activity and then to become slightly confused and have slurred speech. her face was noted to be twitching around to the left side. Emergency medical services was called and they attempted to assess her grip strength but she was too confused to follow directions. Her fingerstick was normal. She was given 4 mg of Ativan and she initially arrived to the [**Hospital6 1760**] Emergency Department because she was felt to have convulsive status and was gargling. Because of the gargling she was intubated and brought to the Intensive Care Unit. She was initially suspected of having a stroke with onset of seizure by the admitting Intensive Care Unit and Neurology Team. The magnetic resonance imaging scan was negative and she was treated for a seizure with fosphenytoin load of 1 gm of Phenytoin equivalent. It was also noted that when she was brought to the Emergency Department she was minimally responsive and had twitching of her left arm. PAST MEDICAL HISTORY: 1. Seizures - Two years ago found alone in home after a seizure and suffered an myocardial infarction concomitantly. She did have a seizure 14 months prior to this admission with confusion, twitching and clutching of the hand although her daughter is not sure which side this is. There was also staring associated with that episode. She is maintained on Dilantin and her most recent level was 17 in [**2172-12-14**]. 2. Status post myocardial infarction. 3. Total abdominal hysterectomy ten years prior. MEDICATIONS ON ADMISSION: 1. Neurontin 300 mg p.o. t.i.d.; 2. Ativan 0.5 mg p.o. q.d.; 3. Dilantin 300 mg p.o. q.d.; 4. Metoprolol; 5. Aspirin 325 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives in [**Hospital3 **]. Husband had Alzheimer's disease. PHYSICAL EXAMINATION: Blood pressure 150/90, heart rate 70, respirations 20, afebrile. General: Well developed, elderly female lying in bed. Head, eyes, ears, nose and throat: Neck supple with no lymphadenopathy and no thyromegaly. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly. Extremities: No cyanosis, clubbing or edema. Neurological: Mental status on admission: Opens eyes slightly to painful stimulus. Does not follow any commands. No vocalizations. Cranial nerves, optic discs are sharp, the extraocular movements were notable for deviation to the left but with an intact oculocephalic reflex. Pupils were equally reactive. Corneas were intact. There was a 5+ facial nerve palsy. The tongue seemed deviated towards the left. Motor examination: Normal bulk. Diffusely hypotonic. Some spontaneous movements on the right arm, withdrew purposely from painful stimulus in all extremities except for the left arm. Deep tendon reflexes 2+ biceps, triceps and brachioradialis. Nothing at patella or ankle. Toes were down. No clonus. LABORATORY DATA: Laboratory data upon admission were unremarkable with normal coagulation screen and normal complete blood count. Chem-7 was normal as well. HOSPITAL COURSE: 1. Apparent seizure - The patient as mentioned was loaded on fosphenytoin 1 gm and started no Keppra 500 mg p.o. b.i.d. She was monitored closely in the Intensive Care Unit and extubated on [**2173-2-18**]. She did also receive 1 dose of Ceftriaxone prophylactically as she was having fevers. This was thought to be aspiration pneumonia by chest x-ray done on [**2-18**]. She was started on Levofloxacin and Flagyl. She did well over night and was transferred to the floor on [**2173-2-19**]. At the time of the transfer, she denied any major complaints and was talking fluently. She had amnesia for the event and was somewhat confused about to where she was but she was oriented to time. Review of systems was negative for shortness of breath, cough, abdominal pain, nausea, vomiting or diarrhea. As mentioned she was started on Keppra 500 mg p.o. b.i.d. and increased to 1 gm p.o. b.i.d. She was discontinued off of Neurontin. She will be continued on Dilantin and Keppra together. 2. Pneumonia - She completed the seven day course of Levofloxacin and Flagyl. 3. With the history of myocardial infarction she was ruled out with enzymes. She was kept on her Aspirin and statin. 4. Diabetes monitoring - The patient should have a hemoglobin A1c done by her primary care physician. DISPOSITION: The physical therapy and occupational therapy saw the patient and felt that she should be screened for rehabilitation. She was lives at [**Location **] Crossing which has a skilled nursing facility. I have faxed to the facility and she will be discharged there. RADIOLOGICAL STUDIES: Computerized tomography scan of the head done late [**2-16**] with no evidence of hemorrhage. Magnetic resonance of the head with angio and post gadolinium, there was no evidence of infarction and the magnetic resonance angiography was relatively normal. There was mild periventricular subcortical white matter intensities. Several portable chest x-rays which showed not only satisfactory positioning of the endotracheal tube, but also mild cardiomegaly with interstitial edema. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg p.o. q.d. 2. Levofloxacin 500 mg p.o. q.d. until [**2173-2-24**]. 3. Metronidazole 500 mg p.o. t.i.d. until [**2173-2-24**]. 4. Keppra 1 gm p.o. b.i.d. 5. Atorvastatin 10 p.o. q.d. 6. Phenytoin 300 mg p.o. q.d. 7. Heparin 5000 units subcutaneously q. 12 hours 8. Aspirin 325 mg p.o. q.d. CONDITION ON DISCHARGE: Good. DISPOSITION: To rehabilitation skilled nursing facility at [**Doctor First Name **] Crossing. FOLLOW UP: The patient is to follow up with her own primary care physician and her neurologist, Dr. [**Last Name (STitle) 52627**]. [**Name6 (MD) 52628**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**] Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2173-2-22**] 06:46 T: [**2173-2-22**] 07:02 JOB#: [**Job Number 52629**] ICD9 Codes: 5070, 412
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Medical Text: Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-15**] Date of Birth: [**2092-4-12**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman with mastocytosis activation syndrome with one urine histamine of 9000. She was admitted with chest pain on this admission. Previously, on [**2145-10-9**], she was admitted after a reaction to gadolinium in which she developed severe nausea, and airway tightness, and shortness of breath. She was given epinephrine and developed severe chest pain. Serial electrocardiograms at that time showed ST-T wave changes and a troponin of 20 which then decreased to 1.5. An echocardiogram at that time showed akinesis at the base of fraction of 35%. Since that admission, she has had chest pain every day, usually muscle pain episodes each day. The pain is worse with food, and occasionally worse with exercise, and occasionally awakens the patient from sound sleep. She uses nitroglycerin (two at a time) every two to three days. She also gets chest pain which radiates to her back accompanied by occasional shortness of breath. The chest pain has been worse over the past several days and finally has required her to seek treatment in the Emergency Department. The patient has chronic abdominal pain which improved on Gastrocrom 200 mg p.o. q.i.d. which was increased this Fall from 100 mg p.o. q.d. However, because the patient's abdominal pain was improved she decreased her dose to 100 mg of Gastrocrom q.i.d. She notes that the Gastrocrom did not help her chest pain. The patient has also been on Vistaril, [**Doctor First Name **], and Zantac for histamine suppression. On previous hospitalizations, she has required steroids. Additionally, the patient notes the presence of chills and joint pain. Her hands have become worse with swelling and erythema since discontinuing her Vioxx at last admission when she was started on Coumadin for cardiomyopathy. She denies any fevers or night sweats and has no headaches or change in her bowels. She does describe some malaise. She says she has not played tennis since her [**Month (only) 359**] admission. She has a minimal appetite and is forcing herself to eat. She does say she noted some bright red blood per rectum mixed with stool that had streaks of dark color on the day of admission. The patient does have a history of internal hemorrhoids. PAST MEDICAL HISTORY: 1. Cholecystectomy in [**2143**]; followed by a bile leak that was treated with a stent. She subsequently had pancreatitis in [**2143-7-3**] and in [**2144**]. She had increased liver function tests, and a sphincterotomy times two. 2. In [**2145-4-3**] she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16164**] procedure (uterine suspension) followed by increased lipase and liver function tests accompanied by abdominal pain. 3. In [**2145-10-3**], sural nerve biopsy, and endoscopic retrograde cholangiopancreatography muscle biopsy, and liver biopsy. Subsequently, multiple admissions for abdominal pain accompanied by increased liver function tests and increased amylase and lipase. 4. In [**2147-6-3**], tarsal tunnel release and subsequent neuropathy. 5. In [**2147-7-3**], abdominal pain with scleral icterus. 6. Esophagogastroduodenoscopy on [**2146-12-13**] showed prominent mass cells with granulation in the duodenum and mild esophagitis. 7. Additionally, the patient is status post multiple episode of anaphylaxis treated by epinephrine. 8. The patient also has seronegative arthritis. ALLERGIES: COMPAZINE, DROPERIDOL, GADOLINIUM, SULFA. MEDICATIONS ON ADMISSION: 1. Coumadin 7.5 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. Zantac 300 mg p.o. q.h.s. 5. [**Doctor First Name **] 180 mg p.o. q.d. 6. Ativan p.o. as needed. 7. Cromolyn 100 mg p.o. q.i.d. 8. Vistaril 25 mg p.o. q.h.s. 9. Glucosamine and chondroitin sulfate. FAMILY HISTORY: Mother with a myocardial infarction at the age 76. SOCIAL HISTORY: The patient is married and active in sports. Two children who are well. The patient is an Emergency Room technician. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98, blood pressure was 120/66, heart rate was 60, respiratory rate was 20, oxygen saturation was 100% on room air. In general, the patient was in pain, holding her chest. Head, eyes, ears, nose, and throat examination revealed anicteric. Erythematous lids. The mouth was moist without ulcers. The neck revealed no adenopathy. The thyroid was normal. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs. The lungs revealed inspiratory wheezes posteriorly on the left. Expiratory wheezes scattered bilaterally. Normal to percussion. The abdomen was nondistended with tenderness and guarding in the epigastric region. Positive bowel sounds. Rectal examination revealed no stool or blood, normal tone. Extremities revealed swelling and tenderness on the right and left proximal interphalangeal joint and distal interphalangeal joint, left third distal interphalangeal was warm to touch. The patient without lower extremity edema. There was mild palmar erythema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed white blood cell count was 5.1, hematocrit was 34.3, platelets were 231. Electrolytes were within normal limits. PT was 17.4, PTT was 32.1, INR was 2. Creatine kinases and troponin were normal times three. ALT was 22, AST was 32, amylase was 83, lipase was 93. RADIOLOGY/IMAGING: CT revealed left lung base with a small nodule. Splenic calcifications. Normal aorta, celiac, superior mesenteric artery, and internal mammary artery takeoff. No aneurysm. Electrocardiogram was notable for nonsloping ST-T wave changes, poor progression in V1 and V2, generally low voltage. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: The patient's primary issue during her hospitalization was her chest pain. She typically had three episodes of severe debilitating chest pain per day during her admission. She described these as 7/10 chest pain in general, radiating to her back, and were accompanied with nausea and dry heaves. On each occasion during her admission, an electrocardiogram was obtained, and there was never any change in her electrocardiograms. Her pain generally resolved with several sublingual nitroglycerin coupled with 2 mg to 4 mg of intravenous Dilaudid, and Zofran and Ativan were also frequently required. Her chest pain in general did not seem to improve during her admission, in that it did not decrease in frequency or severity. Her histamine blockade was increased with her Gastrocrom, and she was started on steroids, however, it became evident during her admission that she was throwing away her prednisone. Cardiology was involved and did not feel that her chest pain was consistent with a cardiac etiology. An echocardiogram was obtained and showed that her ejection fraction had rebounded to 75% from 35% on her last admission. An Allergy consultation was obtained, and there was some suggestion that histamine release could cause coronary with muscle spasm; however, this was felt to be somewhat less likely. Additionally as her repeat electrocardiogram showed no evidence of ischemia with chest pain, and her cardiac function was normal, we felt the patient's cardiovascular status was good. 2. GASTROINTESTINAL SYSTEM: Possible gastrointestinal etiology for the patient's symptoms were closely considered. This was felt to be somewhat likely given the patient's history of gastrointestinal manifestations of mast cell activation. There was suspicion for esophageal spasm given the resolution of symptoms with nitroglycerin in the presence of no electrocardiogram changes. GI was involved and an esophagogastroduodenoscopy was performed which was grossly normal. However, biopsy specimens were taken. The patient may still require [**Doctor Last Name **] test in the future for possible esophageal spasm. In terms of the patient's lower gastrointestinal bleed, a flexible sigmoidoscopy was performed and revealed only hemorrhoids. The patient's abdominal pain was well controlled throughout her admission with histamine blockade and Gastrocrom. 3. PULMONARY SYSTEM: As the patient's chest pain episodes continued throughout her admission, she began to experience increasing respiratory distress with these episodes. Her respiratory issues consisted of wheezing during her chest pain episodes and were worrisome for anaphylaxis. On two occasions, the patient received epinephrine which seemed to help symptoms to some degree. However, on the second occasion, after receiving racemic epinephrine and still having some stridorous sounds worrisome for anaphylaxis, the patient was transferred to the Medical Intensive Care Unit for observation. She was closely observed there but did not have any further events and was stable from a pulmonary perspective. It was unclear to what extent her wheezing was related to histamine release and anaphylaxis, as there also seemed to be some anxiety component that was worsening these episodes. Her arterial blood gas after the episode causing the Medical Intensive Care Unit transfer was consistent with some degree of a panic attack. The patient was started on a chromone inhaler in house. 4. HEMATOLOGY: The patient's mastocytosis syndrome was aggressively treated with antihistamines and cromolyn. Prednisone was started on admission; however, the patient refused this medication. A tryptase alpha and beta were sent. A 24-hour urine was performed; however, it was unclear to what extent to the 24-hour urine was collected properly. 5. PSYCHIATRY: On the day prior to discharge, the patient began to act in a hypomanic state. Her speech became tangential and pressured. The patient was adamant that she wanted to be discharged to home. It was revealed that the patient had been taking her own Effexor 75 mg p.o. q.d. throughout the hospital stay. Psychiatry was consulted, and it was felt that it was very likely that the patient's mood and anxiety contributed in some way to the patient's physical symptoms. Additionally, Psychiatry felt that she had no active psychiatric problem that should delay her discharge. She was to follow up with outpatient psychiatric treaters. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. Mastocytosis syndrome. 2. Internal hemorrhoids. 3. Anxiety. MEDICATIONS ON DISCHARGE: 1. [**Doctor First Name **] 180 mg p.o. b.i.d. 2. Vistaril 25 mg p.o. q.a.m. and 50 mg p.o. q.h.s. 3. Ranitidine 300 mg p.o. b.i.d. 4. Vioxx 25 mg p.o. q.d. 5. Gastrocrom 200 mg p.o. q.i.d. 6. Inhaled cromolyn 100 mg q.i.d. 7. Sublingual nitroglycerin as needed. 8. Isosorbide mononitrate 60 mg p.o. q.d. 9. Multivitamin. 10. Lisinopril 10 mg p.o. q.d. 11. Percocet one to two tablets p.o. q.4-6h. as needed for pain (the patient has home supply). DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 79**] in two weeks and to follow up with primary care physician in two weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**] Dictated By:[**Last Name (NamePattern1) 23006**] MEDQUIST36 D: [**2147-11-21**] 13:22 T: [**2147-11-22**] 10:16 JOB#: [**Job Number 23007**] ICD9 Codes: 4254
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Medical Text: Admission Date: [**2176-1-31**] Discharge Date: [**2176-2-7**] Date of Birth: [**2126-7-16**] Sex: M Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old male patient who had had no problems with his health. At a routine physical exam he was noted to have a cardiac murmur and was referred for echocardiogram in [**2175-7-16**], revealing an ejection fraction of 55 percent with severe mitral regurgitation and mitral valve prolapse with a thickened and redundant anterior mitral valve leaflet and a thickened posterior mitral valve leaflet. Also noted to have mild tricuspid regurgitation with a pulmonary artery pressure of 26 mm/Hg. He proceeded to have a stress echocardiogram on [**2175-8-10**], that showed no cardiac ischemia and at this time he was referred to Dr. [**Last Name (Prefixes) **] for evaluation for mitral valve replacement. PAST MEDICAL HISTORY: Significant only for an appendectomy in his childhood. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a Jehovah's Witness. He lives in [**Location **] with his wife and works full-time for a cleaning business. PHYSICAL EXAMINATION: On presentation height 5 feet 11 inches tall, weight 187 pounds. Blood pressure 160/90. Heart rate 51. General: The patient was in nonacute distress. Skin without rashes. HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive to light. Extraocular movements intact. No jugular venous distension. Neck without masses. Chest clear to auscultation bilaterally. Heart regular rate and rhythm with a 2/6 systolic ejection murmur at the apex. Abdomen soft and nontender, nondistended with positive appendectomy scar that is well healed. Extremities are warm and well perfused without edema or varicosities. Neurologically, the patient is intact, alert and oriented times three. Nonfocal exam. PREOPERATIVE LABS: White blood cell count 3.8, hematocrit of 38.0, platelets of 228. PT 13.1, PTT 23.1, INR 1.1, sodium 138, potassium 3.7, chloride 106, bicarbonate 24, BUN 13, creatinine 0.7 and glucose 127. ALT 14, AST 19. Alkaline phosphatase 58. T-bili 0.5, albumin 4.1. Preoperative EKG: Sinus bradycardia. Preoperative cardiac catheterization on [**2176-1-9**]: Severe three plus mitral regurgitation with an ejection fraction of 59 percent and no significant coronary artery disease. Slightly elevated right and left heart filling pressures. SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was admitted on his operative day, [**2176-1-31**], and proceeded to the Operating Room with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. He underwent mitral valve replacement with a [**Street Address(2) 12523**]. [**Male First Name (un) 923**] mechanical valve. Total cardiopulmonary bypass time was 101 minutes with a crossclamp time of 84 minutes. His operative course was uneventful. He was transferred to the Cardiac Surgery Recovery Unit with a mean arterial pressure of 76, CVP of 8, A-paced at a rate of 88 on a nitroglycerine drip. Please see operative report for complete details. On the evening of his operation he was successfully weaned and extubated. On postoperative day one his Neo-Synephrine was weaned and it was felt that he was stable for transfer to the in-patient floor for ongoing recovery and rehabilitation. On postoperative day two Mr. [**Known lastname **] continued to do very well. His chest tubes were discontinued and he was started on Coumadin for anticoagulation with his mechanical valve. His cardiac pacing wires were grounded. The evening of postoperative day two, Mr. [**Known lastname **] experienced short bursts of a junctional rhythm, for which cardiology consultation was obtained and noted that there was no evidence of AV block or prolonged AV conduction and recommended only observation with plan for followup with cardiology in three to four weeks with Holter monitor, two days prior to appointment. On postoperative day three, Mr. [**Known lastname 10437**] temporary cardiac pacing wires were discontinued and physical therapy was increased. On that evening, Mr. [**Known lastname **] was noted on telemetry to have a six second bout of asystole, proceeded by a run of A-flutter and spontaneous conversion to normal sinus rhythm. This was discussed with the primary team, as well electrophysiologist, who decided there was no need for intervention at this time and that it would be evaluated in the EP lab at a later date and beta blockers would be avoided. The patient did report some diaphoresis and presyncope with the episode. Mr. [**Known lastname **] was also started on heparin drip for anticoagulation while awaiting jump in his INR. Postoperative day five continued with bursts of atrial fibrillation and atrial flutter. Postoperative day six was significant for further asystolic pauses lasting up to seven seconds. First the electrophysiology team was again consulted and they agreed that they felt the patient needed a pacer, however, the patient was extremely reluctant to get a pacer. This was discussed at length between primary cardiac surgery team, electrophysiology team and Mr. [**Known lastname **]. On postoperative day seven it was decided that Mr. [**Known lastname **] would be safe for discharge home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and followup with the electrophysiology service within four weeks time to make a decision regarding his heart rhythm and possible ablation versus cardiac pacemaker placement. On postoperative day seven his INR had also risen to 2.2 and it was decided that his heparin could be discontinued and he could be discharged home. Mr. [**Known lastname 10437**] INR will be drawn on [**2-8**] by the visiting nurses and called in to us if his INR has dropped below 2. He will need intravenous heparin if it is at 2.2 or above. He will continue on his p.o. Coumadin dosing at home. CONDITION ON DISCHARGE: Stable DISCHARGE STATUS: Home with visiting nurses to follow. DISCHARGE DIAGNOSES: Mitral valve prolapse and mitral regurgitation status post mitral valve replacement with a 33 mm St. Jude valve. Postoperative atrial fibrillation, atrial flutter and asystolic pauses. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily 2. Ferrous sulphate 325 mg p.o. daily 3. Vitamin C 500 mg p.o. b.i.d. 4. Coumadin as daily directed by primary care physician with dose of 6 mg on [**2-7**]. 5. Acetaminophen codeine 300 - 30 mg tablets, 1-2 tablets p.o. q.4h prn for pain. FO[**Last Name (STitle) 996**]P: Followup with Dr. [**Last Name (Prefixes) **] within one month. Followup with Dr. [**Last Name (STitle) **] in two to three weeks, or as needed for INR checks. Followup with Dr. [**Last Name (STitle) **] within one month. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 28068**] MEDQUIST36 D: [**2176-2-7**] 17:31:16 T: [**2176-2-7**] 18:28:14 Job#: [**Job Number 59290**] ICD9 Codes: 4240
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Medical Text: Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-26**] Date of Birth: [**2100-9-20**] Sex: M Service: MEDICINE Allergies: Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Tegretol / Fentanyl / Thiopental / Succinylcholine / Vecuronium Bromide Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Weight gain Major Surgical or Invasive Procedure: PICC line placement Milrinone infusion admission to the cardiac intensive care unit right heart catheterization History of Present Illness: Mr. [**Known lastname 109642**] is 77M with h/o systolic and diastolic CHF, a-fib, cardiac amyloidosis, and multiple myeloma transferred from [**Hospital1 **] initially for volume overload and need for lasix drip and chemotherapy. The patient was recently discharged from [**Hospital1 18**] on [**2178-6-5**], at which time RV biopsy demonstrated cardiac amyloidosis, as well as a bone marrow biopsy with e/o multiple myeloma. ECHO showed e/o new systolic heart failure on top of preexisting diastolic heart failure and is s/p cardiac catheterization with e/o 50% left main disease, 50% LAD stenosis. Since discharge, the patient reports weight gain, as well as DOE. He denies orthopnea, PND, palpitations, syncope or presyncope. He waited until he was seen by Dr. [**Last Name (STitle) **] on [**2178-7-22**] where he was noted to have elevated JVD and 3+ LE edema. Lasix was switched to torsemide 40mg [**Hospital1 **] with continued spironolactone 50mg daily. When he initially presented to [**Hospital1 **], the patient was noted to have change in mental status that was attributed to uremia, [**Last Name (un) **], and medication side effect from torsemide. He also had a bandemia of 9% and was initially treated for a potential UTI. His CXR showed recurrent right pleural effusion. He was treated for acute on chronic systolic and diastolic heart failure with IV lasix but of note this was limited by his BP's. Weight prior to discharge from [**Location (un) 620**] 105kg. While on the [**Hospital1 1516**] service, the patient was being diuresed on Lasix drip 30 mg/hour, with diuresis limited by increasing creatinine. After discussion with Dr. [**First Name (STitle) 437**], it was thought that the patient could benefit from milronone drip in the setting of having a Swan placed to measure his wedge and his CO. The patient also has an element of systolic failure, which could also be improved with milronone. On transfer to the floor, the patient reports feeling well. Past Medical History: Afib on coumadin Diastolic heart failure (EF 60-65%) OSA Gout GERD with Barrett's esophagus Hiatal hernia Elevated PSA Erectile dysfunction s/p cholecystectomy ([**2172**]) s/p right hip replacement ([**2170**]) s/p tailers bunion, fascia release, prosthesis (left foot) ([**2169**]) s/p deviated septum repair ([**2168**]) s/p tailers bunion removal ([**2166**]) s/p multiple laminectomies ([**2164**], [**2151**], [**2148**]) s/p tendon repair right arm ([**2145**]) s/p hemorrhoidectomy ([**2126**]) s/p pilonidal cyst removal ([**2120**]) s/p appendectomy ([**2116**]) s/p bone removal left foot ([**2114**]) s/p tonsillectomy ([**2106**]) Social History: The patient is married and worked in the import business and worked for the navy in the shipyards. He never smoked. Family History: Positive for hay fever. Physical Exam: ADMISSION EXAM: VS - 97.9 117/63 72 18 98% on RA 105.7kg GENERAL - chronically ill appearing male in NAD, comfortable, slightly short of breath while speaking HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, JVP at 12, no carotid bruits LUNGS - bibasilar crackles HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 3+ pitting LE edema to upper thighs, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-13**] throughout DISCHARGE EXAM: 24hr I/O: 1236/1620 87.6 ->88 ->89.1 General: Well NAD,pleasant, well appearing, elderly gentleman in NAD, laying comfortably in bed HEENT: EOMI, PERRLA, no cerivcal lymphadenopathy, 12cm JVP LUNGS: Fine Crackles at right base, no wheezing, rhonchi HEART - PMI non-displaced, RRR, II/VI systolic murmur at apex, nl S1-S2, ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no rebound/guarding EXTREMITIES - 1+ pitting edema to calves, 2+ peripheral pulses (radials, DPs), PICC Line in right arm w/o errythema or tenderness. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-13**] throughout Pertinent Results: ADMISSION LABS: [**2178-8-3**] 11:39PM BLOOD WBC-10.8 RBC-3.43* Hgb-11.1* Hct-35.0* MCV-102* MCH-32.3* MCHC-31.6 RDW-15.7* Plt Ct-194 [**2178-8-3**] 11:39PM BLOOD Neuts-80.9* Lymphs-8.5* Monos-9.1 Eos-1.0 Baso-0.5 [**2178-8-3**] 11:39PM BLOOD PT-25.4* PTT-37.9* INR(PT)-2.4* [**2178-8-3**] 11:39PM BLOOD Glucose-119* UreaN-50* Creat-1.6* Na-138 K-4.3 Cl-98 HCO3-30 AnGap-14 [**2178-8-5**] 04:20PM BLOOD CK(CPK)-31* [**2178-8-5**] 04:20PM BLOOD CK-MB-4 cTropnT-0.14* [**2178-8-3**] 11:39PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4 TRANSFER LABS: [**2178-8-7**] 03:45PM BLOOD PT-27.2* INR(PT)-2.6* [**2178-8-7**] 03:10PM BLOOD Glucose-100 UreaN-81* Creat-2.3* Na-135 K-4.0 Cl-91* HCO3-31 AnGap-17 [**2178-8-7**] 03:10PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.6 [**2178-8-6**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2178-8-6**] 11:19AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 [**2178-8-6**] 11:19AM URINE Hours-RANDOM Creat-37 Na-74 K-38 Cl-88 DISCHARGE LABS: [**2178-8-26**] 04:26AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.2* Hct-28.3* MCV-94 MCH-30.4 MCHC-32.4 RDW-16.1* Plt Ct-233 [**2178-8-25**] 05:32AM BLOOD PT-22.4* PTT-36.2 INR(PT)-2.1* [**2178-8-26**] 04:26AM BLOOD Glucose-118* UreaN-66* Creat-1.7* Na-131* K-4.6 Cl-93* HCO3-29 AnGap-14 [**2178-8-15**] 06:40AM BLOOD ALT-22 AST-22 AlkPhos-93 TotBili-0.9 [**2178-8-26**] 04:26AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 Blood Culture, Routine (Final [**2178-8-26**]): NO GROWTH. URINE CULTURE (Final [**2178-8-21**]): NO GROWTH. KAPPA/LAMDA: Test Result Reference Range/Units FREE KAPPA, SERUM 20.0 H 3.3-19.4 mg/L FREE LAMBDA, SERUM 2.7 L 5.7-26.3 mg/L FREE KAPPA/LAMBDA RATIO 7.41 H 0.26-1.65 Cardiac Cath Report [**8-19**]: Elevated right- and left-sided filling pressures, moderate pulmonary arterial hypertension in the setting of left-sided heart failure, large V waves suggestive of moderate to severe mitral regurgitation. Normal cardiac output and index. EKG [**2178-8-25**] Atrial fibrillation. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Old inferior myocardial infarction. Compared to the previous tracing of [**2178-8-22**] no significant changes are noted. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 0 148 440/457 0 -70 107 CXR [**2178-8-20**]: As compared to the previous radiograph, the patient has received a Swan-Ganz catheter. The catheter needs to be pulled back given that the tip is projecting over distal parts of the right pulmonary artery. An opacity that pre-existed at the bases of the right upper lobe is no longer visible. However, the lung volumes have decreased and a small pleural effusion is unchanged at the right lung base. Unchanged moderate cardiomegaly. The right PICC line is constant in position. RENAL ULTRASOUND: 1. No hydronephrosis. Simple bilateral renal cysts. 2. Right pleural effusion and trace of ascites seen in the right upper quadrant. 3. Arterial and venous flow is documented within each of the kidneys, however, further Doppler analysis cannot be performed as the patient is unable to hold his breath. Social Work: Family has met w/ palliative team and wife expresses that the conversation is "premature". Pt and wife have not signed DNR and still solidifying long-term plans. Pt, wife and [**Name2 (NI) **] are aware of life expectancy ([**7-21**] mos) and reiterated to SW and physician that Pt is going to optimize highest level of care and the priority is to be at home. Pt and family met w/ infusion home care co. as an option for next steps. Physician communicated to pt/family that PT will be consulted on recommendations for home vs rehab. Family and Pt are continuing to explore all options and continue to look into rehab's that can manage current medications however family has reiterated that going home is their first preference. Assessment: Family and Pt is experiencing difficult adjustment to illness and next steps on the best approach for Pt. SW provided empathic listening, guidance on resources that are available, and encouraged Pt and family to continue to utilize clinicians to help make an informed decision on where Pt should transition to next. Brief Hospital Course: Mr. [**Known lastname 109642**] is 77M with history of atrial fibrillation on coumadin, systolic and diastolic heart failure, cardiac amylodosis, and multiple myeloma who initially presented from OSH with weight gain and need aggressive IV diuresis, requiring CCU admission for initiation of milrinone drip. . # Acute on chronic systolic and diastolic heart failure: Patient with baseline restrictive disease secondary to his cardiac amyloid. Also with systolic CHF first seen [**5-21**] with RV free wall hypokinesis. He presented with diffuse peripheral edema, worsening abdominal distention and JVP elevated to 12 cm, consistent with right sided failure. He also presented with right pleural effusion that represented transudate [**3-12**] CHF. He was initially diuresed with lasix drip and metolazone with good effect, but was stopped after increasing creatinine. He was then transferred to the ICU for diuresis with milrinone for inotropic effect and pulomary vasodilation allowing right sided unloading. His right heart pressures were monitored by swan-ganz cath with PA pressure 50 to 40s and wedge pressures of 28 to 19 after administartion of milrinone. He diuresed well in the CCU, was transfered to the floor, but after weaning milrinone, he required reinitiation of milrinone in the CCU due to drop off in energy level, urine output an reaccumulation of fluid. He tolerated reinstitution of milrinone infusion well and was transferred to the floor. He was also continued spironolactone and torsemide after period of autodiuresis from [**Last Name (un) **] ended. Over the course of the hospitalization he lost about 40lbs. His discharge weight was roughly equivalent to his dry weight at 89.1 kg (196 lbs). He was counseled on the importance of daily weights and CHF management. He will follow up with Dr. [**Last Name (STitle) **] in cardiology clinic. . [**Last Name (un) **]: Pt developed [**Last Name (un) **] in the setting of aggressive diuresis. Nephrology was consulted and felt this was likely ATN vs pre-renal due to hypoperfusion. It was unlikely a sequelae of MM or amyloid as no protein was found in the urine. After discontinuing Lasix gtt, he autodiuresed. Upon discharge, his Creatinine returned to his baseline of 1.7. . Community Acquired Pneumonia: Pt developed cough and leukocytosis with CXR findings of right upper lobe infiltrate. He was treated with Ciprofloxacin and then Levofloxacin caused him to have a supratherapeutic INR above 5. For the remainder of 10 day abx course, his coumadin was held. . # Cardiac amyloidosis with restrictive myopathy: The patient has history of cardiac amyloidosis confirmed on RV biopsy, and has resulting restrictive heart disease, with subsequent R sided dilation and R sided heart failure as above. . # Multiple Myeloma: During his last admission, patient was found to have a monoclonal kappa band and severe hypogammaglobulinemia on SPEP/UPEP. He underwent bone marrow biopsy which showed 40% plasma cells. Abdominal fat pad biopsy both performed [**5-28**], revealed no amyloid but RV cardiac biopsy was positive for amyloid. He also continued dexamentasone/velcade treatment while inpatient. Cycle4 Day8 Velcade administration on [**8-25**]. Will continue treatment with Dr. [**Last Name (STitle) 109643**]. . # Coronaries: The patient has history of 3VD s/p NSTEMI during his last admission. Cath from that admission with e/o 50% left main disease, 50% LAD stenosis. It was decided that the patient was too high risk for CABG, as well as PCI given his amyloidosis and was discharge on medical management of his CAD. He was continued on atorvastatin 80 mg daily, ASA 162 mg daily, metoprolol 12.5 mg [**Hospital1 **]. . # Afib: Stable. CHADS score of 2 (age and CHF). He was continued on coumadin for goal INR of 2.0-2.5 given for increased risk of bleeding with amyloid. During the hospital course, he reached a supratherapeutic INR ~5 after fluoroquinolones were addded. His coumadin was held for a few days and restarted to maintain appropriate anticoagulation. He will continue INR checks and Coumadin management through Dr. [**Name (NI) 109644**] office. . # BPH: stable, continued doxazosin . # GERD/Barrett's/hiatal hernia: stable, continued omeprazole, home tums . # DEPRESSION/sleep: stable, continued amitriptyline, zolpidem. . # GOUT: stable, continued allopurinol, colchine, tramadol prn . TRANSITIONAL ISSUES: -Cycle4 Day8 Velcade administration on [**8-25**]. will f/u with Dr. [**Last Name (STitle) 3759**] [**Name (STitle) **] monitored by Dr. [**Last Name (STitle) 3759**] [**Name (STitle) 30412**] not amenable to palliative care now -patient is a full code -?depression versus adjustment reaction with depression -Discharge and dry weight 89.1 kg (196 lbs). Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR OSH records. 1. Atenolol 12.5 mg PO DAILY 2. Aspirin 162 mg PO DAILY 3. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit Oral qAM 4. Multivitamins 1 TAB PO DAILY 5. Torsemide 40 mg PO BID 6. Omeprazole 20 mg PO BID 7. Spironolactone 50 mg PO DAILY 8. Amitriptyline 30 mg PO HS 9. Doxazosin 4 mg PO HS 10. Zolpidem Tartrate 5-10 mg PO HS 11. Allopurinol 100 mg PO QHS 12. Colchicine 0.6 mg PO HS 13. Guaifenesin Dose is Unknown PO Frequency is Unknown 14. Warfarin 5 mg PO DAILY16 15. TraMADOL (Ultram) 50 mg PO QID pain 16. Nitroglycerin SL 0.3 mg SL PRN CP 17. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion Discharge Medications: 1. Hospital Bed 2. Milrinone 0.26 mcg/kg/min IV INFUSION RX *milrinone in D5W 20 mg/100 mL (200 mcg/mL) 0.26 mcg/kg/min continuous infusion Disp #*1 Mutually Defined Refills:*12 3. Amitriptyline 30 mg PO HS 4. Aspirin 162 mg PO DAILY 5. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID 8. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 9. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*3 10. Warfarin 4 mg PO DAILY16 RX *warfarin 2 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*3 11. Zolpidem Tartrate 10 mg PO HS:PRN sleep 12. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *Milk of Magnesia 400 mg/5 mL 30 mL(s) by mouth every 6 hours Disp #*1 Bottle Refills:*3 13. Sarna Lotion 1 Appl TP DAILY:PRN itchy RX *Sarna Anti-Itch 0.5 %-0.5 % apply to itchy skin daily Disp #*1 Bottle Refills:*3 14. Senna 1 TAB PO BID:PRN constipation RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet Refills:*3 15. Simethicone 40-80 mg PO QID:PRN bloating RX *simethicone 80 mg 1-2 tablets by mouth four times a day Disp #*120 Tablet Refills:*3 16. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit Oral qAM 17. Nitroglycerin SL 0.3 mg SL PRN CP 18. Allopurinol 100 mg PO QHS 19. Outpatient Lab Work INR check on [**8-28**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109645**] at [**Telephone/Fax (1) 21962**]. ICD-9 427.31 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: PRIMARY -acute on chronic systolic heart failure -amyloidosis with restrictive myopathy -multiple myeloma -community acquired pneumonia -Hyponatremia -acute kidney injury -atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure caring for you while you were at [**Hospital1 18**]. You were admitted for treatment of your congestive heart failure. Our testing suggested this was a result of the effects on your heart from your multiple myeloma. You were started on a medication called milrinone that helped your heart pump better and given medications to help you urinate off all the excess fluid. Your weight was decreased by about 40 pounds. We tried to stop the milrinone infusion, but your clinical picture worsened without this medication and it was determined that you will need it chronically infusing from now on. Home services to assist with this have been set up for you. You also continued to recieve therapy for your multiple myeloma while and inpatient and will continue to see Dr. [**Last Name (STitle) 109645**] as an outpatient. You were discharged on diuretics (torsemide) in order to keep your weight down. Your discharge weight was 89.1 kg (196 lbs), you should call Dr.[**Name (NI) 10159**] office at [**Telephone/Fax (1) 9832**] if you notice your daily weight goes up by more than 3 lbs in a day or if you notice worsening swelling in your legs, shortness of breath while walking or any other symptoms that concern you. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2178-9-1**] at 2:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: TUESDAY [**2178-9-1**] at 3:30 PM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2178-9-1**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2178-8-30**] ICD9 Codes: 486, 5845, 2761, 4280, 2749, 412, 311, 4168
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Medical Text: Admission Date: [**2107-3-21**] Discharge Date: [**2107-4-4**] Date of Birth: [**2041-7-11**] Sex: F Service: VASCULAR CHIEF COMPLAINT: Left leg ischemia and cellulitis. HISTORY OF PRESENT ILLNESS: This is a 65-year-old female with severe bilateral lower extremity inflow and outflow disease who was scheduled for an aorto-bifemoral bypass on [**3-25**] with Dr. [**Last Name (STitle) **] with prior three-week history of left foot pain with ambulation. She requires wheelchair for ambulation. Prior to that, she ambulated independently without claudication symptoms. There was a painful cut on the left lateral foot which progressed to weeping and pain over the last three days. She was started on Augmentin two days prior to admission. She denied constitutional symptoms. The patient also has a history of carotid disease and stated that she was to have carotid endarterectomy prior to her aorto-bifemoral. She denied any symptoms. The patient was admitted for further vascular evaluation and treatment. PAST MEDICAL HISTORY: History of Hodgkin's lymphoma 13 years ago. Status post splenectomy and thoracic lymph node dissection. Status post radiation to the chest and mediastinum. History of hypercholesterolemia. History of hypertension. History of dementia, Alzheimer's type. History of hypothyroidism. History of asthma; she has not been intubated, no history of hospitalizations, or steroid use for her asthma. Status post cerebrovascular accident without residual. Peripheral vascular disease. SOCIAL HISTORY: She has greater than 103 pack-year smoking history. Nondrinker. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Lipitor 20 mg q.d., Aricept 5 mg q.d., Euthyroid 75 mg q.d., Pulmicort 1 q.d., Augmentin 500 mg b.i.d., Albuterol p.r.n. PHYSICAL EXAMINATION: Vital signs: 97.4, 101, 205/76, 18, 98% on room air. Blood pressure rechecked was 166/58. General: This was a pleasant but difficult to understand white female in no acute distress. She was oriented to person and place but not time. HEENT: Unremarkable. She had a left carotid bruit. Lungs: Clear to auscultation but diminished throughout. Heart: Irregular rate and rhythm. There was a 2/6 systolic ejection murmur at the right upper sternal border. Abdomen: Nontender and nondistended. There was a well-healed median abdominal incision. She has a palpable liver edge. Atympanic. Rectum: Unremarkable. Guaiac negative. No abdominal aortic aneurysm. Extremities: Pulse exam showed palpable femorals bilaterally. The dorsalis pedis and posterior tibial with Dopplerable signals only bilaterally. The left foot with diffuse streaky erythema and edema. There was a 1 cm diameter draining wound. There were small fissures along the lateral aspect of the left foot near the heel. There was no drainage or active bleeding. Neurological: Cranial nerves II-XII grossly intact. Left foot motor was intact with diminished sensation to light touch. Extremity strength was symmetrical without deficits. LABORATORY DATA: CBC with a white count of 19.2, hematocrit 40.9, differential with polys of 74, lymphs 17, no bands; electrolytes with a BUN of 21, creatinine 1.0, potassium 4.9, glucose 129. Electrocardiogram was normal sinus rhythm with inverted Ts in II, III, and AVF. There were no changes from previous electrocardiogram of [**2107-3-10**]. Chest x-ray showed no active cardiopulmonary disease. There was a small mediastinal irregular opacity without change from prior chest x-ray. Other studies included an arteriogram which showed extensive infrarenal aortic disease, left common iliac occluded, left internal iliac reconstructed by right collaterals from the external iliac, left common femoral profunda with multifocal SFA disease proximally, distal SFA and popliteal were patent, there was disease of the tibial, proximal posterior tibial, and peroneal arteries, the left AT is in major runoff vessel but diseased proximally and mid portions. Foot fed by collaterals. The right common iliac and external iliac diseased. The right common femoral profunda, SFA, popliteal were patent. There was two-vessel runoff via the posterior tibial and the dorsalis pedis on the right. A MIBI stress test on [**3-17**] showed no wall motion abnormalities, ejection fraction was calculated at 54%. The ultrasound of the carotid showed left internal carotid artery stenosis of 85-90%, right internal carotid stenosis of 60-70% at the origins, right internal carotid artery subvalvular stenosis of 85% 2 cm above the bifurcation. The left vertebral was totally occluded. The right vertebral was patent. The ultrasound of the carotids showed a 70-79% bilateral internal carotid artery stenosis with nonvisualized left vertebral artery. HOSPITAL COURSE: The patient was admitted to the Vascular Service. She was placed on Metoprolol 25 mg b.i.d., Levofloxacin 500 q.24, and Flagyl 500 mg q.8. Subcue Heparin was begun for DVT prophylaxis. She was continued on her preadmission medications. Dressings were normal saline wet-to-dry dressings b.i.d. with multi-podis boot of the affected foot. She was placed on a house diet. She was placed on bedrest with the leg elevated. She was allowed to receive Percocet tablets 5/325 one-half to one q.4-6 hours p.r.n. for pain. Vancomycin 1 g IV q.12 hours was begun with peak and trough levels with third dose. Lopressor was increased to 50 mg b.i.d. hospital day #2. Vancomycin was discontinued on [**3-24**], and Oxacillin 1 g q.6 hours IV was begun for MSSA. The patient underwent on [**3-25**] a left carotid endarterectomy. She tolerated the procedure well, and she was transferred to the PACU in stable condition. The patient was intubated, alert, and responded to commands. She was without chest pain. Her vitals signs were stable. She was hemodynamically stable. Her neck dressing was clean, dry, and intact. There was no hematoma. She was extubated in the PACU and transferred to the VICU for continued monitoring and care. Nitroglycerin was weaned off on postoperative day #1. She required reintubation in the PACU secondary to sedation. She was afebrile. Her hematocrit was 29.6. Her electrolytes remained stable. Her exam showed bilateral lung wheezing with generalized edema. She was diuresed. She received nebulizations around the clock. Stool for C-diff was sent. Her diet was advanced as tolerated. Her Foley was continued to monitor urinary output, and she remained in the VICU. Her Lopressor was dosed at 37.5 b.i.d. and required decreased dosing strength secondary to bronchospasm. Her chest x-ray showed mildly improved interstitial edema. Her hematocrit remained stable. Her wheezing was still present on auscultation of her lungs but diminished from prior exam. We continued aggressive pulmonary toiletry and physical therapy. Ambulation in the chair was begun. Diuresis was continued. The patient remained in the VICU. On postoperative day #3, the patient received a total of 40 Lasix IV during the previous 24 hours. She remained afebrile and hemodynamically stable. She was negative 2600. Her hematocrit remained stable at 33.2, although her white count remained elevated at 24. Chest x-ray was unremarkable. CPKs were obtained; total CPK peaked at 236, with an MB of 5, and a troponin less than 0.3. Her respiratory status seemed much improved. She continued on the current management. Narcotics were discontinued. She remained in the VICU. Because of the persistent white count elevation, Infectious Disease was consulted. Sputum culture from [**3-28**] showed greater than 25 polys, with 40 epithelials, but 1+ ................. consistent with oropharyngeal flora. A chest x-ray was pending. Urinalysis C&S was no growth. The foot swab gram was with no polys, 2+ gram positive cocci, pairs, chains, and clusters. It grew out MSSA. The blood cultures were no growth. The abdominal ultrasound showed normal liver with moderate distended gallbladder with no stones, no wall thickening, no dilated ducts. Chest x-ray showed resolved congestive failure with a left lower lobe atelectasis. The foot film showed no evidence of osteomyelitis. She was begun on Ceftriaxone for her left lower lobe infiltrate, and she was continued on Oxacillin. The Levofloxacin and Flagyl were discontinued. She remained in the VICU. On postoperative day #5, she was transferred out of the VICU. She remained afebrile. She did have some end expiratory wheezing, but otherwise the lungs were unremarkable. The left foot erythema was nearly gone. The white count was at 22.3. Her neutrophils were 68, lymphs 22, and monos 7. The patient continued to progress. Repeat x-ray was unremarkable, and the Ceftriaxone was discontinued. Recommendations of Infectious Disease were to continue her Oxacillin through her anticipated bifemoral surgery and then to continue antibiotics two weeks postsurgery. On [**2107-4-11**], the patient underwent a right axillo-bilateral femoral artery bypass with 8 mm [**Doctor Last Name 4726**]-Tex graft. She tolerated the procedure well. She required 1 U packed red blood cells intraoperatively and was transferred to the PACU in stable condition. Her immediate postoperative check revealed her to be stable. She was on Nitroglycerin at 3 mg/kg/min. Her hematocrit was 32. Chest x-ray was unremarkable. The patient was neurologically intact. Groin was without hematomas bilaterally, and she had palpable dorsalis pedis and posterior tibial on the right and Dopplerable dorsalis pedis and posterior tibial on the left. The patient continued to remain stable. She was continued on around-the-clock nebulizations and was transferred to the VICU for continued monitoring and care. She still required her Nitroglycerin to maintain her systolic below 110. Her exam was unremarkable. Her Nitroglycerin was weaned, and oral medications were begun. Fluids were Hep-Locked. Diet was advanced as tolerated. She was continued on subcue heparinization for DVT prophylaxis. On postoperative day #2, she continued to do well. Her hematocrit remained stable at 31.1. Her white count peaked at 28.3. Her electrolytes were unremarkable. Her CVL was discontinued, and a peripheral line was placed. The Foley was maintained. She otherwise did well. On postoperative day #3, there were no overnight events, and the hematocrit remained stable at 31.9, and the white count was decreased to 25.7. The right groin was mildly erythematous. There was no hematoma. The right dorsalis pedis and posterior tibial were palpable. The left dorsalis pedis and posterior tibial remained Dopplerable. Chest exam was unremarkable. A PICC line was placed for continued for continued antibiotic therapy. Physical Therapy was requested to see the patient and begin assessment for rehabilitation placement. The Foley was discontinued. The patient was discharged in stable condition. DISCHARGE MEDICATIONS: Aspirin 325 mg q.d., Tylenol 650 mg q.4 hours p.r.n., Flovent 2 puffs b.i.d., Lopressor 25 mg b.i.d., hold for systolic blood pressure less than 100, heart rate less than 60, subcue Heparin 5000 U t.i.d., Synthroid 75 mcg q.d., Oxacillin 1 g IV q.6 hours, this is to be continued for a total of two weeks from [**4-1**], to [**4-15**], Albuterol nebulizer q.4 hours p.r.n., Aricept 5 mg q.d., Lipitor 20 mg q.d. DISCHARGE DIAGNOSIS: 1. Bilateral carotid disease status post left carotid endarterectomy. 2. Left foot ischemic ulcerations with cellulitis, status post axillo-bifemoral bypass. 3. Asthma with exacerbation, treated. 4. Congestive heart failure, resolved. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2107-4-4**] 10:29 T: [**2107-4-4**] 10:41 JOB#: [**Job Number 33875**] ICD9 Codes: 4280, 4019, 2720
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Medical Text: Admission Date: [**2179-2-8**] Discharge Date: [**2179-2-12**] Date of Birth: [**2125-1-21**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 54 year old white female with a history of hypertension, hypercholesterolemia, and smoking history, who was transferred to [**Hospital1 69**] with acute anterior myocardial infarction, status post failed thrombolysis at outside hospital. The patient reports onset of symptoms on the morning of admission of acute midback pain with eventual radiation to the chest, seven out of ten, with radiation to her left upper extremity with associated shortness of breath, nausea and diaphoresis. She called EMS within five minutes and was brought to [**Hospital3 6454**] Emergency Department where she was found to have anterior ST elevations in V1 through V4. She was given Morphine 2 mg intravenously times two, sublingual Nitroglycerin and Nitroglycerin drip, Heparin and Reteplase times two. Per records, she arrived at the [**Hospital3 1280**] Emergency Department at 10:40 a.m. Symptom onset was approximated to be at 10:00 a.m. She received her first dose of Reteplase at 10:53 a.m. and her second dose at 11:23 a.m. Her symptoms did not improved and her ST elevation persisted and she was transferred to [**Hospital1 69**] for emergent catheterization. She arrived at the catheterization laboratory at 1:30 p.m. At cardiac catheterization, she was found to have a tortuous coronary circulation with a totally occluded distal left anterior descending which was stented with timi two flow post and complicated by grade B dissection distally. She was given intracoronary vasodilators and no further intervention was pursued. Her left circumflex, right coronary artery and left main coronary artery were without significant disease. A left ventriculogram was performed and notable for anteroapical and inferoapical akinesis with an ejection fraction of 40%. Right heart cardiac catheterization revealed pulmonary capillary wedge pressure of 18 and right atrial pressure of 13. Postprocedure, she was given full dose Integrilin for 18 hours. Upon arrival to the CCU, she had the chief complaint of nausea but denied shortness of breath or chest pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Osteoporosis. 4. History of atypical colitis, steroid dependent since [**9-4**]. History of diagnosis of collagenous colitis in the past. 6. Status post tubal ligation. MEDICATIONS ON ADMISSION: 1. Zestril 2.5 mg p.o. once daily. 2. Prednisone 20 mg p.o. once daily. 3. Asacol 1600 mg p.o. three times a day. 4. Rowasa enemas PR once daily. 5. Fosamax 10 mg p.o. once daily. 6. Prempro p.o. once daily. 7. Serax p.r.n. 8. Zomig p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: No history of early coronary artery disease or myocardial infarction. SOCIAL HISTORY: The patient lives in [**Location 38080**] with husband. She has two children. She has smoked one pack per day since college. She has one to two cocktails per night. Recently laid off. PHYSICAL EXAMINATION: On examination, temperature is afebrile, blood pressure 135/74, heart rate 90, respiratory rate 16, oxygen saturation 98% on two liters. In general, the patient is somnolent in no apparent distress. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are mildly dry. The neck is soft, supple, no lymphadenopathy, jugular venous distention, thyromegaly or masses. Cardiac examination - regular rate and rhythm, no murmurs, S4 gallop. The lungs are clear to auscultation bilaterally. The abdomen is soft, nondistended, nontender, no organomegaly or masses, normoactive bowel sounds. Extremities - right groin with small hematoma. Extremities without edema, warm and with good distal pulses. Neurologically, the patient is alert and oriented times three, grossly nonfocal. LABORATORY DATA: White count 15.8, hematocrit 36.5, platelets 238,000. INR 1.1. Sodium 137, potassium 4.7, blood urea nitrogen 7, creatinine 0.6, glucose 150. CK peak 1148, CK MB peak 150. Initial electrocardiogram normal sinus rhythm, normal axis, intervals, 2.[**Street Address(2) 2811**] elevations in V2 through V4 with peaked T waves, 1.[**Street Address(2) 2811**] elevations in I and II, 0.[**Street Address(2) 38081**] elevations in V5 and V6. HOSPITAL COURSE: 1. Coronary artery disease - Status post acute anterior myocardial infarction, total occlusion of the distal left anterior descending, status post left anterior descending stent, complicated by distal dissection and with timi two flow post intervention. The patient was hemodynamically stable throughout her hospitalization. Her CK peaked at 1148 and then trended down. She was treated with Integrilin for 18 hours postcatheterization and then received Aspirin, Plavix, beta blocker and ace inhibitor. She was also started on Lipitor for a lipid panel with total cholesterol of 249, and LDL of 143. She will be discharged on Aspirin, Plavix to finish one month course, Atenolol, Zestril and Lipitor. 2. Pump - Left ventriculogram during cardiac catheterization was notable for apical akinesis and ejection fraction of 40%. She had no signs or symptoms of congestive heart failure during her hospitalization. She was started on beta blocker and ace inhibitor as above. Given her apical akinesis, she was started on anticoagulation initially with Heparin drip and then with low molecular weight Heparin as well as Coumadin. She will be discharged on Lovenox and Coumadin, to have INR followed up as an outpatient. 3. Electrophysiology - The patient with no adverse events on telemetry during her hospitalization except for rare premature ventricular contractions. 4. Hematology - The patient with right groin hematoma, status post cardiac catheterization. She was also noted on the following evening to have a bruit over that area. An ultrasound revealed 1.7 by 2.0 centimeter pseudoaneurysm which was treated with thrombin injection with good result. Her anticoagulation was held temporarily during these events and then restarted without complications. At the time of discharge, the patient still has residual ecchymosis over her right lower extremity as well as a small but stable hematoma. 5. Gastrointestinal - The patient had no gastrointestinal symptoms during her hospitalization and was continued on her outpatient regimen of Asacol and Rowasa enemas. She received stress dose steroids pericatheterization and then was switched to a p.o. Prednisone taper starting at 60 mg to be tapered down to her baseline of 20 mg. 6. Endocrine - The patient has been on Prempro as an outpatient. This was held in the setting of her acute myocardial infarction but she will be able to restart this as an outpatient. MEDICATIONS ON DISCHARGE: 1. Enteric Coated Aspirin 325 mg p.o. once daily. 2. Plavix 75 mg p.o. once daily, to continue one month course. 3. Coumadin 5 mg p.o. once daily. 4. Lovenox 60 mg subcutaneous times three more doses. 5. Zestril 2.5 mg p.o. once daily. 6. Atenolol 25 mg p.o. once daily. 7. Prednisone taper down to 20 mg once daily. 8. Asacol 1600 mg p.o. three times a day. 9. Rowasa enema once a day. 10. Fosamax 10 mg p.o. once daily. 11. Prempro p.o. once daily. 12. Serax p.r.n. The patient has been ask to discontinue Zomig in the setting of coronary artery disease. DISCHARGE FOLLOW-UP: With primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 9959**] [**Name (STitle) 9960**], telephone [**2179**]. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Name8 (MD) 4925**] MEDQUIST36 D: [**2179-2-12**] 13:01 T: [**2179-2-15**] 17:11 JOB#: [**Job Number **] ICD9 Codes: 4019, 2720, 3051
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Medical Text: Admission Date: [**2181-11-17**] Discharge Date: [**2181-11-24**] Date of Birth: [**2126-10-22**] Sex: M Service: SURGERY Allergies: Penicillin G Attending:[**First Name3 (LF) 148**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 55 M hospitalized in [**2180**] for severe necrotizing pancreatitis. He was eventually discharged to rehab after multiple laparoscopic necrosectomies as well as takedown of an EC fistula and SBR. He was in his usual state of health until 3 days ago when he started having gradual onset of epigastric pain. Pain consistently worsened over the past 48 hours so he presented to [**Hospital3 **] where he got a CT abdomen and then transferred to [**Hospital1 18**]. En route he vomited 3 times. He denies fevers, chills, shortness of breath, or chest pain. Today he has had zero bowel movements, when normally he has 6 loose ones daily. He also reports that he resumed drinking [**Hospital1 **] 3 months ago (approximately [**1-20**] pints per day). Despite 2mg IV morphine every 15 minutes, he complains of severe abdominal pain. Past Medical History: PMH: Hypertension, Ulcerative colitis s/p colectomy, J pouch, Removal of nonmalignant brain tumor, [**Month/Day (2) **] abuse, Chronic Methadone Maintenance PSH: Takedown EC fistula with small-bowel resection and primary anastomosis, extended adhesiolysis, repair of enterotomy, G-tube placement, and J-tube placement [**2180-5-25**]; resection non-malignant brain tumor [**2161**]; colectomy [**2157**] Social History: Lives w/sister. History long-term smoking. Chronic [**Year (4 digits) **] use. Denies IVDU. Family History: Not-contributory Physical Exam: On discharge: The patient was afebrile with vital signs stable. Gen: AAOx3. NAD. Card: RRR. No r/g/m Pulm: CTA b/l. No r/r/w/c Abd: Soft. ND. NT. NO rebound tenderness or guarding noted on exam. Pertinent Results: [**2181-11-17**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2181-11-17**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2181-11-17**] 06:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2181-11-17**] 06:30PM URINE AMORPH-MOD [**2181-11-17**] 04:09PM LACTATE-3.0* [**2181-11-17**] 03:55PM GLUCOSE-152* UREA N-26* CREAT-1.6* SODIUM-139 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16 [**2181-11-17**] 03:55PM ALT(SGPT)-150* AST(SGOT)-160* ALK PHOS-655* TOT BILI-2.2* [**2181-11-17**] 03:55PM LIPASE-1334* [**2181-11-17**] 03:55PM WBC-9.8 RBC-3.73* HGB-12.0* HCT-35.6* MCV-96 MCH-32.2* MCHC-33.7# RDW-13.2 [**2181-11-17**] 03:55PM NEUTS-91.6* LYMPHS-3.7* MONOS-4.4 EOS-0.1 BASOS-0.3 [**2181-11-17**] 03:55PM PLT COUNT-326 [**2181-11-17**] 03:55PM PT-12.3 PTT-21.0* INR(PT)-1.0 Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. The patient arrived on the floor NPO, on IV fluids, with a foley catheter, Dilaudid PCA for pain control. The patient was hemodynamically stable. Neuro: The patient received morphine IV in the mergency department with minimal dimunition of pain as per patient. On admission the patient was placed on a Dilaudid PCA. CV: The patient was written for Hydralazine with holding parameters for proper blood pressure control. Vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was made NPO with IV fluids. The patient was placed on Protonix IV for GI prophylaxis, as well as Zofran for nausea. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. On HD#2, the patient developed signs of delirium tremens and acute [**Month/Day/Year **] withdrawal. The patient was transferred to the ICU and was placed on Diazepam, Lorazepam, and Midazolam as needed to control his delirium tremens. The patient was resuscitated wih IVF which was increased from 150 to 200. The patient was placed on Mechanical Ventilation with Assist control (Volume Targeted). Tidal volume was 500 cc. Respiratory rate was 18. PEEP was 5cm/h2o. FIO2 was maintained at 80%. The FiO2 was weaned to 40 by the evening of the same day. The patient was started on Ampicillin-Sulbactam. HD#3: The patient was given a PICC line for total parenteral nutrition. His Dilaudid PCA was switched to a PRN Dilaudid. The patient was also started on methadone. The ampicillin sulbactam was discontinued on the evening of that day. HD#4: The patient's mechanical ventilation was changed to CPAP (5 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %) early in the morning. After several hours tolerating this, the patient was extubated. The patient was given a PICC line. HD#5: The patient was started on sips, wich he tolerated. The patient was transferred to the floor, with a Dilaudid IV PRN for pain control, On IV fluids, on sips, and on telemetry. The patient had a clonidine patch as well as Hydralazine with hold parameters for blood pressure control. HD#6: The patient was found to have a swollen upper extremity. An UE U/S was obtained which revealed no DVT in the upper extremity. The patient was started on clear liquids and HCTZ which the patient tolerated. The Protonix was switched to PO from IV. The patient was written for PO medications including Mirtazapine and Citalopram. HD#7: The patient's Diazepam was weaned from Diazepam 5 mg PO/NG Q6H to Q8H. The patient's telemtry was stopped. Diet was advanced to full liquids. The patient was written fro tylenol and ibuprofen for pain control. HD#8: The patient's diet was advanced to regular which he tolerated. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. The PICC line was d/c'ed prior to discharge. Medications on Admission: klonopin 1', remeron 15 QHS, HCTZ 12.5', ? other anti-hypertensives but patient unsure Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: acute on chronic pancreatitis; [**Month/Day/Year **] withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [**Last Name (un) **] were seen in the hospital with acute on chronic pancreatitis. Your hospital stay was complicated by withdrawal and delirium tremens. You were given an appropriate course of valium to treat this very dangerous condition. This medication is being stopped before your discharge. Please return to the hospital if you experience palpitations, vomiting, nausea, excessive sweating, or fevers. You have been diagnosed with chronic pancreatitis. Your pancreas is inflamed and may be permanently scarred. The pancreas is an organ that produces chemicals and hormones that help you digest food and use sugar for energy. Gallstones are one of the most common causes of pancreatitis. These hard stones form in the gallbladder, which shares a passage with the pancreas into the small intestine. If gallstones block this passage, fluid can't escape the pancreas. The fluid backs up and causes inflammation and pain. Chronic use of [**Last Name (un) **] is another cause of chronic pancreatitis. Here's what you can do at home to help with your condition. Home Care Ask someone to drive you to appointments until you know how the illness has affected you. Tell your doctor about any medications you are taking. Some medications can cause pancreatitis. Ask your doctor about over-the-counter medications for pain. Work with your doctor to control blood sugar levels. Learn to take your own pulse. Keep a record of your results. Ask your doctor [**First Name (Titles) 6643**] [**Last Name (Titles) 21636**] mean that you need medical attention. Watch for symptoms that your pancreatitis is getting worse. These symptoms include abdominal pain, nausea and vomiting, and fever. Diet Changes Eat a low-fat diet. Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 81326**] and other diet information. Take vitamins A, D, and E, and add calcium to your diet. Stop drinking, especially if your illness was caused by [**Last Name (Titles) **]. Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] abuse programs and support groups such as Alcoholics Anonymous. Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 16615**] medications that can help you stop drinking. When to Call Your Doctor Call your doctor right away if you have any of the following: Fever above 100??????F Severe pain in your upper abdomen to your back Nausea and vomiting Abdominal swelling and tenderness Dizziness or lightheadedness Yellowing of your skin or eyes (jaundice) Bruises on your abdomen or back Rapid pulse Shallow, fast breathing Loss of weight without dieting Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2182-1-4**] 11:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]. You will have a MRI prior your appointment with Dr. [**Last Name (STitle) **], please call Dr. [**Name (NI) 60612**] office to clarify the date and time of the MRI. . Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-20**] weeks after discharge Completed by:[**2181-12-4**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2125-3-28**] Discharge Date: [**2125-4-6**] Date of Birth: [**2086-7-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25342**] Chief Complaint: found unconcious in front of drug deal outside [**Doctor First Name 60501**] place Major Surgical or Invasive Procedure: intubation in micu History of Present Illness: Patient is a 38 year old female with h/o etoh abuse, asthma, seizure d/o was found unresponsive outside [**Doctor First Name **] place. She was found with empty bottle of tegretol (2 wk supply, bottle date 4/5/5) Full bottle of Trazodone 400mg HS (date [**2125-3-17**]) Full bottle of Fluoxitine 80mg daily (date [**2125-3-17**]) Multiple samples of [**Doctor First Name **] in Backpack Was brought to [**Hospital1 18**], and did not respond to narcan so was intubated for airway protection. Tox screen + for benzo's and etoh. Was initially treated with levo/flagyl for emperic coverage for aspiration pneumonia but then was d/c'd on [**3-31**]. She was extubated on [**4-1**]. Was treated with propafol and then valium for withdrawal in MICU Now more awake, no n/v/d/cp/sob,patient is not complaining Past Medical History: According to [**Hospital3 2568**] notes, Asthma, Seizure DO, diet controlled DM? Social History: lives at pine street inn, long hx of etoh use. Has a husband (who only wants to be involved if consent is needed etc) and two teenage children. Family History: Family hx: NC Physical Exam: O: T 98.9 BP 136/90 P76 RR 20 Gen: NAD, tearful, slightly tremulous HEENT: anicteric, PERRLA, EOMI Lungs: mild scattered wheezes otherwise CTA x 2 Heart: S1, S2 no m/r/g Abd: soft, nd, mild tenderness in suprapubic area Ext: no c/c/e bilateral numbness up to knees, +pulses Pertinent Results: CXRAY [**4-3**]- neg [**2125-3-28**] 12:02PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2125-3-28**] 12:02PM ASA-NEG ETHANOL-263* CARBAMZPN-4.7 ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2125-3-28**] 12:02PM ALT(SGPT)-39 AST(SGOT)-67* LD(LDH)-262* CK(CPK)-177* ALK PHOS-50 AMYLASE-28 TOT BILI-0.3 iron (low nl), b12, folate, ferritin all wnl Brief Hospital Course: A/P: Patient is a 38 year old female who was transferred out of MICU s/p intubation for possible post ictal vs. toxic ingestion. On admission to the medical service patient was off ativan gtt. ETOH withdrawal-level 263 on arrival to ED, out of window for DT's on admission to medicine. She was started on a ciwa scale and did not require valium after the second day of admission. She was given folate, MVI, thiamine. At the day of discharge she was less tremulous and able to walk around with no withdrawal symptoms. seizure d/o- had a witnessed grand mal seizure night before admission, had adequate levels of tegretol at admission. Unclear etiology of seizure disorder. Is not followed by a neurologist (she was in the past but does not remember his name) She was continued on tegretol when admitted to medicine and her levels were within nl limits. asthma- nebs prn, will try to send patient with an inhaler when she leaves Psych- after their first meeting with the patient, psych did not think that the patient has capacity to leave, thought patient may have korsakoff's. However, pt/ot cleared the patient and the next day psych thought that she was much clearer stating that their initial concerns may have stemmed from mild withdrawal symptoms. They thought she was safe to leave the hospital. She wanted to leave b/c she wanted to see her son off to the prom. This was corrobarated with the son over the phone. -I have set her up with an outpatient psych appointment -I have only given her enough trazadone, and fluoxetine to last her to her pcp's appointment due to the worry that she may have overdosed. Initially the patient should be given short prescriptions for these meds until it is obvious that the patient is reliable and not overdosing. -I will continue the trazodone since this is vital for her seizure d/o numbness- unclear etiology, did improve over hospitalization, nl b12, may be diabetes related although fs wnl in micu, should have continued evaluation and monitor for progression. HTN- she was well controlled on outpatient clonidine .1 mg Anemia- normocytic, low nl iron, nl b12/folate full code this admission Medications on Admission: carbamazepine trazadone fluoxetine clonidine Discharge Medications: 1. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*50 Tablet(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-10**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*qs qs* Refills:*0* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Trazodone HCl 100 mg Tablet Sig: Four (4) Tablet PO at bedtime for 6 days. Disp:*24 Tablet(s)* Refills:*0* 8. Fluoxetine HCl 40 mg Capsule Sig: Two (2) Capsule PO once a day for 6 days. Disp:*12 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: asthma seizure d/o Discharge Condition: stable Discharge Instructions: Please come directly to the ED if you have chest pain, or shortness of breath. Please stop drinking alcohol- it may kill you. Followup Instructions: Please see a pcp next week as listed below Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-4-11**] 2:30 Completed by:[**2125-4-11**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2188-7-2**] Discharge Date: [**2188-7-17**] Date of Birth: [**2188-7-2**] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: This interim covers from dates of [**2188-7-2**] through [**2188-7-17**]. The patient is a 15-day-old former 34 and 3/7 weeks infant who is now corrected to 36 and 4/7 weeks gestational age. He was born at 1,800 gm by spontaneous vaginal delivery of a 30- year-old G 1, P 0 mother with the following prenatal labs: O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative. The pregnancy was complicated by supraventricular tachycardia with a normal cardiac workup. In addition, this was a spontaneous diamniotic-dichorionic twin pregnancy of which this infant was twin B. The mother's membranes were ruptured for approximately eight hours prior to delivery on twin A. However, this twin's membranes were not ruptured until the time of delivery. Nonetheless, the mother had received two doses of ampicillin prior to delivery. This infant emerged active but pale and limp. He had Apgar scores of seven and eight with unremarkable resuscitation. He developed some mild symptoms of respiratory distress and was admitted to the Neonatal Intensive Care Unit for further management of prematurity. PHYSICAL EXAMINATION: On admission, weight was 1,800 gm (fiftieth percentile), length 44.5 cm (fiftieth percentile), head circumference 31 cm (twenty-five to fiftieth percentile). General: Infant of stated gestation age. Vital signs: Temperature 98.1, heart rate 160, respiratory rate 56, 100 percent saturation on room air, blood pressure 56/43, D6 of 62. HEENT: Normocephalic, anterior fontanel open and flat, palate intact, neck supple. Cardiovascular: Regular rate and rhythm, no murmur. Femoral pulses two plus bilaterally. Lungs: Clear to auscultation bilaterally, decreased breath sounds, intermittent grunting with constant intercostal retractions and nasal flaring. Abdomen: Soft with active bowel sounds, no masses or distention. Genitourinary: Normal male, testes palpable bilaterally, anus patent. Spine: Midline without any dimpling. Hips: Stable. Clavicles: Intact. Neurological: Motor, tone and reflexes appropriate for gestational age. HOSPITAL COURSE: Respiratory: This infant had mild respiratory symptoms for which he was started on CPAP. The patient did quite well with need for CPAP support for only about 24 hour's duration. After that time, he has been on room air without any concerns. He is not on caffeine nor has he had any apnea of prematurity. Cardiovascular: The patient has been quite stable from a cardiovascular standpoint with intermittent soft murmur present. Fluids, electrolytes and nutrition: The patient was able to start feeds on day of life one with gradual advance. At present, he is on breast milk 24 k-cal at 150 cc/kg/day. He takes approximately one-half of this feed orally. The additional feeds are still by gavage. The patient is making gradual progress on his oral feeding, but still demonstrates dysmaturity. Gastrointestinal: The patient had a benign course from the standpoint of hyperbilirubinemia. He never required phototherapy and had reassuring levels. Hematology: Admitting CBC had a platelet count of 225 with a hematocrit of 43.7. Infectious Disease: This infant had a rule out sepsis at the time of delivery with reassuring CBC (white blood cell count of 9.0 with 22 polycytes and zero bands) and a negative culture. He has had no additional issues from an infectious standpoint. Health Maintenance: Hepatitis B was administered on [**2188-7-15**] with a normal DARE on [**2188-7-16**]. INTERIM DIAGNOSES: 1. Premature infant at 34 and 3/7 weeks gestation, twin B. 2. Mild HMD, resolved. 3. Rule out sepsis, negative. 4. Feeding dysmaturity. Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**] Dictated By:[**Last Name (NamePattern1) 55724**] MEDQUIST36 D: [**2188-7-17**] 16:19:33 T: [**2188-7-17**] 16:47:01 Job#: [**Job Number 58447**] ICD9 Codes: 769, 7742, V290
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Medical Text: Admission Date: [**2103-11-6**] Discharge Date: [**2103-12-9**] Date of Birth: [**2041-12-27**] Sex: M Service: SURGERY Allergies: Gluten Attending:[**First Name3 (LF) 598**] Chief Complaint: free air Major Surgical or Invasive Procedure: EGD x2 exlap, small bowel resection x2 with primary reanastamosis exlap, small bowel resection, jejunal stoma formation, mucous fistula formation for anastomotic breakdown percutaneous cholecystostomy tube placement percutaneous drainage of perihepatic fluid collection bilateral chest tube placement History of Present Illness: Mr. [**Known lastname 496**] is a 61 M with a medical history notable for celiac disease. Of note, he was recently admitted to [**Hospital1 18**] from [**2103-9-10**] to [**2103-9-19**] for worsening GI symptoms thought to be related to his difficult-to-control celiac disease. He was started on budesonide, loperamide, and TPN. An endoscopy performed during that admission revealed duodenitis. He reports feeling well at dischcarge on the TPN and was even able to travel on [**Hospital3 **]. However, approximately 3 weeks ago he noted marked fatigue and dyspnea on exertion. He is currently very weak and unable to perform basic activities around his house. His abominal cramping has also increased and his diarrhea has returned. His bowel movements are "muddy" with rare bright red blood (usually with straining), but no melena. No NSIADs or recent alcohol use. Since discharge he was started on prednisone and started on mercaptopurine on [**11-5**]. He was seen in [**Hospital **] clinic on [**11-5**]. After his routine laboratory studies returned with worsening anemia he was referred to the ED. Vital signs on arrival to [**Hospital1 18**] ED: T 98.2, P 100, BP 129/76, 100% RA. His evaluation in the ED was notable for a HCT of 22.5, guaiac positive stool, and a negative gastric lavage. In the ED he received pantoprazole 40mg IV, morphine, 1 unit of packed red blood cells, and IV fluids. On [**2103-11-7**] he underwent EGD showing friable duodenal mucosa with contact bleeding. Since the procedure he has had worsening abdominal pain, and was found to have copious free air on CXR and KUB. We were contact[**Name (NI) **] to evaluate him for possible perforation. Past Medical History: Hypertension Celiac disease diagnosed in [**2097**] after work-up for osteoporosis Social History: Patient lives with his wife. [**Name (NI) **] is a retired history teacher. He has two children. Patient reports smoking a pipe occassionally and previously drank wine on occasions but none recently. Family History: He is adopted and has no family history of sprue of which he is aware. Has two healthy children. Physical Exam: Vital Signs: T 99.3, P 83, BP 132/83, 96% on RA. Current pain [**4-23**]. Physical examination prior to EGD by GI on [**2103-11-7**]: - Gen: Thin male, appears chronically ill. - HEENT: Pale conjunctiva. Oropharynx clear w/out lesions. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP <5 cm. - Abdomen: Normal bowel sounds. He is diffusely tender throughout his abdomen with no rebound or guarding. - Extremities: 1+ ankle edema to the knees bilaterally. - Skin: No lesions, bruises, rashes. - Neuro: Alert, oriented x3. Good fund of knowledge. Able to discuss current events and memory is intact. CN 2-12 intact. Speech and language are normal. - Psych: Appearance, behavior, and affect all normal. Upon surgical evaluation after the EGD: 96.8 127 128/74 22 99% 2L uncomfortable, anxious no respiratory distress abdomen distended, tympanytic +rebound +guarding no scars, no hernias Pertinent Results: [**2103-11-5**] 09:44AM WBC-20.6* RBC-3.01*# HGB-8.0*# HCT-25.8*# MCV-86 MCH-26.7* MCHC-31.2 RDW-15.6* [**2103-11-5**] 09:44AM NEUTS-95* BANDS-0 LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2103-11-5**] 09:44AM CRP-126.1* [**2103-11-5**] 09:44AM TOT PROT-4.8* ALBUMIN-2.1* GLOBULIN-2.7 CALCIUM-7.3* PHOSPHATE-2.1*# MAGNESIUM-2.2 [**2103-11-5**] 09:44AM ALT(SGPT)-37 AST(SGOT)-18 LD(LDH)-183 ALK PHOS-209* TOT BILI-0.6 CXR [**2103-11-7**]: In comparison with the study of [**11-6**], there is a substantial amount of free intraperitoneal gas beneath the hemidiaphragms. Atelectatic change with possible effusion again seen at the right base. CTAP [**2103-11-8**]: 1. Extraluminal oral contrast seen adjacent to a loop of mid jejunum in the lower mid abdomen, presumably representing a site of small bowel perforation with resultant pneumoperitoneum and fluid in the abdomen. 2. Small bowel mural thickening, presumably related to known diagnosis of celiac sprue. 3. Large area of mesenteric adenopathy and 'mistiness'. This finding is unchanged since [**2103-9-11**] and though it may be related to reactive changes from the known celiac disease, lymphoma is another consideration and ongoing followup is recommended as per the previous study. 4. Distended gallbladder PATHOLOGY SMALL BOWEL RESECTION [**2103-11-8**]: 1) Small bowel, at 110 cm, resection (A-B, Q-AB): Small bowel segment with multiple perforations and associated full thickness ulceration, exudative inflammation and extensive granulation tissue. Adjacent intact mucosa with extensive villous blunting with increased intraepithelial lymphocytes consistent with prior history of refractory celiac disease. Atypical lymphoid infiltrate, refer to part 2 for further characterization. 2) Small bowel, resection (C-P, AC-AJ): Small bowel segment with multiple perforations and associated full thickness ulceration, exudative inflammation and extensive granulation tissue. Adjacent intact mucosa with extensive villous blunting with increased intraepithelial lymphocytes consistent with prior history of refractory celiac disease. Atypical lymphoid infiltrate, see note. PATHOLOGY SMALL BOWEL RESECTION [**2103-11-17**]: Small bowel, resection: 1. Small intestinal segment with acute and chronic inflammation, patchy ulceration, focal anastomotic site mucosal necrosis, prominent submucosal edema, and extensive serositis; no definitive perforation identified. 2. Viable margins with marked edema, focal mucosal ulceration and mild active inflammation. 3. Increased intraepithelial lymphocytes, villous shortening, and crypt hyperplasia, consistent with involvement by patient's known celiac disease; Paneth cells do not appear overall decreased in viable mucosal areas. See hemepath note. 4. One unremarkable lymph node. CT Torso [**2103-11-27**]: 1. Bilateral pleural effusions, increased compared with previous study. 2. Diffuse anasarca and diffusely abnormal small and large bowel wall thickening consistent with mucosal edema. Given the diffuse involvement this likely represents third spacing. 3. Diffuse mesenteric fat stranding and mesenteric lymphadenopathy. 4. Moderate amount of free fluid in the pelvis and both paracolic gutters. No discrete localized fluid collection seen however infection cannot be excluded. 5. Interval formation of bilateral stomas. 6. Lower abdominal wound dehiscence. 7. Distended gallbladder. 8. Left inguinal hernia containing fluid. CT guided percutaneous cholecystostomy tube placement [**2103-11-29**]: Technically successful percutaneous cholecystostomy tube placement. Sample sent for microbiology analysis. A total of 200 cc of dark green turbid bile were aspirated. CT guided percutaneous abdominal fluid collection drainage [**2103-11-29**]: Technically successful aspiration and drainage catheter placement right upper quadrant ascitic fluid pocket as above. 200 cc clear straw-colored fluid were aspirated to bag. CT Torso [**2103-12-5**]: 1. Stable bilateral pleural effusions. 2. New diffuse bilateral ground glass opacities, infectious vs. aspiration. 3. Thickened small and large bowel with surrounding mesenteric stranding and fluid, relatively unchanged from prior. 4. Stable midline wound with interval resolution of associated free air and contrast extravasation. Interval resolution of anterior abdominal fluid collection in the right upper quadrant, with interval placement of a peripherally placed percutaneous drain. GJ-tube in place. 5. Cholecystomy drain in place with surrounding decompressed gallbladder. 6. Stable pelvic fluid collection with stable adjacent enhancement of peritoneum. RUQ U/S [**2103-12-6**]: 1. No intrahepatic biliary ductal dilatation. 2. 3-mm CBD containing echogenic material, most likely representing sludge or pus. 3. Catheter within the gallbladder, which appears collapsed. 4. No ascites. 5. Right pleural effusion Cholangiogram through percutaneous cholecystostomy tube [**2103-12-6**]: free flow of contrast into the duodenum Brief Hospital Course: Mr. [**Known lastname 496**] is a 61 yo gentleman with severe, medically refractory celiac disease who underwent push endoscopy on [**2103-11-7**] with multiple biopsies. After this procedure, he developed significant abdominal pain and a chest xray and KUB showed massive free air. Follow up CT scan of the Abdomen revealed contrast extravasation from the bowel lumen indicative of perforation. For this reason, he was taken emergently to the OR on [**2103-11-8**] and underwent bowel resections x2 (over 160 cm of small bowel in total) with two primary reanastamoses. Unfortunately, these anastamoses broke down over the ensuing days likely secondary to his baseline poor nutrition as well as the inherent friability of his intestines secondary to his severe, medically refractory sprue. He ultimately required reoperation on [**2103-11-17**]. During this operation, a further 20 cm of bowel were resected and a jejunal stoma as well as a mucous fistula were created. The patient continued to do poorly overall and ultimately was transferred to the ICU on [**2103-11-28**] for respiratory distress and was intubated and later found to have developed a hospital acquired pseudomonal pneumonia. During the next 11 days, the patient developed a new fascial dehiscence with enterocutaneous fistula which was controlled with bag drainage. He also underwent percutaneous cholecystostomy tube placement for a distended gallbladder and a drain placed percutaneously into a perihepatic collection but this did little to alleviate his problems. [**Name (NI) **] further developed an acutely dropping hematocrit and underwent EGD which showed a fresh clot but no active bleeding in his stomach. This was treated with a pantoprazole drip. Concurrently, he developed worsening hepatic failure with cholestasis and a bilirubin rising to 18.0 and worsening coagulopathy indicative of liver failure. In a last ditch effort to identify a source of his sepsis and worsening organ failure, bilateral chest tubes were placed which drained serous fluid. In discussions with his family, it was decided to make him Comfort Measures Only on [**2103-12-9**]. He was terminally extubated and passed soon thereafter. His hospital course is summarized below by system: Neuro: His pain was controlled throughout his hospital stay on a combination of IV or PO medications. At the time of his terminal extubation, he was placed on a fentanyl and versed drip to ensure sufficient treatment of his pain, dyspnea, and anxiety. CV: For most of his hospital stay, he remained, in general, hemodynamically stable. In the last days of his hospitalization, he had an ever-worsening pressor requirement and was ultimately on levophed, neosynephrine, and vasopressin at the time of his extubation. After extubation, his demise was so quick that the pressors had not yet even been turned off. Pulm: For the most part, the patient did well from a pulmonary perspective. However, on transfer to the unit on [**11-28**], he had begun to develop respiratory failure and was intubated for hypoxemic respiratory failure thought to be secondary to pseudomonal pneumonia. He grew out numerous colonies of P. aeruginosa, most of which were resistant to numerous antibiotics. During his last few days, chest tubes were placed bilaterally to see if this would improve his pulmonary mechanics and function. After his terminal extubation, he quickly developed worsening hypoxemia and hypercarbia whereupon he passed away quickly. GI/FEN: After his endoscopy, he required emergent operation for bowel perforation. At his first operation, at 7 enterotomies were discovered in two different segments of bowel starting approximately 110 cm from the ligament of Treitz. These two areas of bowel (approximately 150 cm and 10 cm respectively) were resected with primary reanastamoses. Initially, he seemed to have tolerated the procedure as well as could be expected. However, he soon developed serous drainage from the superior portion of his wound and it was noted that he had a developing fascial dehiscence. He went back to the OR and had the intervening 20 cm of small bowel resected and the proximal end of his bowel was brought out in the LLQ as a jejunal stoma. The distal portion was brought out in the RLQ as a mucous fistula. A gtube was also placed to help with feeds. His abdomen was again reapproximated and retention sutures were left in place. His initial high output from his jejunal stoma was treated with tincture of opium as well as immodium and psyllium wafers without much improvement in the total output. Ultimately, his wound dehisced again along with the development of an enterocutaneous fistula which was controlled with a large ostomy appliance to the wound. He began growing pseudomonas from this wound as well. In addition, in order to rule out and treat other possible sources of his sepsis, he underwent percutaneous cholecystostomy tube placement as well as drainage of a perihepatic fluid collection. This proved to be futile. Although earlier in his course he was able to take some POs, his gut did not appear to tolerate any enteral nutrition either through the Gtube or PO. The patient had been on TPN prior to his hospitalization and this was continued in house due to concern over the ability of his gut to absorb nutrition as well as over his poor nutritional status in general. His albumin levels remained low accordingly and he required lots of colloid and crystalloid resuscitation as well as blood product transfusion, when indicated, in order to maintain intravascular volume although he developed progressively worsening anasarca indicative of his overall poor nutritional status and inability to tolerate enteral feeds. In the last week of his hospitalization, as part of his overall septic picture, he started to develop worsening liver failure with elevated bilirubin, progressive coagulopathy which was complicated by an UGIB as noted on repeat EGD. This was treated with transfusions, vitamin K, as well as a pantoprazole drip. GU: He had a foley in place for most of his hospital stay for urine output monitoring. At some point he also grew out pseudomonas from his urine as well. This infection was treated concurrently with his pneumonia with broad-spectrum antibiotics. Endo: After his initial surgery, he was given stress-dose steroids and then was tapered off the steroids completely due to concerns that they were adversely impacting his ability to heal his wounds. Due to concerns for adrenal insufficiency, he underwent a cortisol stimulation test which showed a normal response in his adrenal glands. Blood sugars were monitored and treated appropriately. Heme: Due to his many surgeries and critically ill state, the patient's white count and hematocrit were closely monitored. Ultimately he had a rising white count (into the 30s) as well as a falling hematocrit. He was treated with RBCs and other blood products as necessary in order to treat his coagulopathy and bleeding-induced anemia. ID: ID consultation was obtained due to the patient's resistant pseudomonus found in his sputum. He was treated with various antibiotics and was ultimately placed on vancomycin, doripenem, and amikacin for his hospital acquired PNA with double-coverage of the pseudomonas. Medications on Admission: Prilosec 20mg daily prednisone 40mg daily Percocet PRN pain mercaptopurine 50 mg daily labetalol 50mg once daily Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: PRIMARY DIAGNOSIS: CELIAC DISEASE, SEVERE TYPE 2 Multiorgan system failure secondary to sepsis Pseudomonas pneumonia enterocutaneous fistula anastomotic breakdown Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] ICD9 Codes: 0389, 5789, 2851, 4271, 5119, 4019
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Medical Text: Admission Date: [**2150-3-29**] Discharge Date: [**2150-4-1**] Service: MEDICINE Allergies: Anesthesia IV / Flagyl Attending:[**First Name3 (LF) 458**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: ICU monitoring History of Present Illness: [**Age over 90 **] year old female with a history of paroxysmal atrial fib presented to the ED with a chief complaint of chest pain. The patient was recently discharged from the [**Hospital1 1516**] service on [**2150-3-25**] after an attempt at chemical cardioversion with amiodarone infusion and question DC cardioversion. During that hospitalization, her rate was controlled and she was sent home with PO amiodarone 200mg daily. Her VNA called in the day following discharge that her rate was still elevated to 120s. She was instructed to take amiodarone 200mg [**Hospital1 **] for one week in an attempt to rate control. She was scheduled to follow up as an outpatient, however she was experiencing chest pain at home and presented to the ED. This morning she had chest pain while in bed, it was band like on her left chest. . In the ED, the patient's HR was in the 150s with a SBP at 156 on arrival. An ECG showed afib with LBBB. She had CEs sent which were negative. The patient received ASA, Dilt 10mg IV x 2 and attempted dilt drip temporarily, Amiodarone 400mg PO X1. Lopressor 5mg IV x 3 given with no response. SBP down to 80s following, although she was asymptomatic, she received 900ccs of IVF. On transfer to the CCU, she continued to have mild chest tightness and shortness of breath. She had a CXR which showed evidence of volume overload. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: HTN Paroxysmal afib Osteoarthritis Hearing loss s/p Appy 3 C sections Diverticulitis Mitral regurgitation- ECHO '[**42**] w/ EF 65%, 3+ MR, 2+TR, LVH Depression Osteoporosis s/p right knee replacement Social History: Social history is significant for the absence of current or past tobacco use. There is no history of alcohol abuse. Pt lives in duplex with her dtr living upstairs and her son next door. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T=98.6 BP=106/70 HR=145 RR=36 O2 sat=92% GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevation of JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular tachycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles BL, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ . Pertinent Results: ECHO: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus seen. Diffuse, but non-mobile aortic atheromata. . CXR [**2150-3-29**]: In comparison to the prior study, there has been progression of the interstitial and alveolar edema with slight enlargement of the left pleural effusion. Repeat radiography following appropriate diuresis recommended to assess for underlying infection . CXR [**2150-3-29**]: In comparison with the earlier study of this date, the pulmonary vessels appear somewhat less engorged. Continued left pleural effusion. Prominence of the right hilum persists, much of which may merely be vascular. Mild atelectatic changes are again seen at the left base. . CXR [**2150-3-31**]: As compared to the previous radiograph, moderate bilateral pleural effusions have newly occurred. There is associated retrocardiac atelectasis. The size of the cardiac silhouette is mildly increased; there is an increase in vascular diameters. In addition, mild peribronchial cuffing is seen. Overall, these findings are suggestive of moderate pulmonary edema. Otherwise, no relevant changes, there is no evidence of newly appeared parenchymal opacities suggesting pneumonia. . Lab Results: [**2150-3-29**] 10:30AM BLOOD WBC-14.1* RBC-5.36 Hgb-16.3* Hct-49.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-14.2 Plt Ct-383 [**2150-3-29**] 05:12PM BLOOD WBC-17.8* RBC-4.97 Hgb-14.7 Hct-45.6 MCV-92 MCH-29.7 MCHC-32.3 RDW-14.1 Plt Ct-368 [**2150-3-30**] 05:06AM BLOOD WBC-17.6* RBC-4.64 Hgb-13.8 Hct-41.9 MCV-90 MCH-29.7 MCHC-32.9 RDW-14.0 Plt Ct-322 [**2150-3-31**] 02:33AM BLOOD WBC-16.9* RBC-4.52 Hgb-13.5 Hct-40.6 MCV-90 MCH-29.8 MCHC-33.1 RDW-14.0 Plt Ct-317 [**2150-4-1**] 06:20AM BLOOD WBC-14.1* RBC-4.38 Hgb-12.9 Hct-39.1 MCV-89 MCH-29.5 MCHC-33.0 RDW-13.8 Plt Ct-332 [**2150-3-29**] 10:30AM BLOOD PT-13.9* PTT-37.8* INR(PT)-1.2* [**2150-3-29**] 05:12PM BLOOD PT-13.6* PTT-35.0 INR(PT)-1.2* [**2150-3-30**] 05:06AM BLOOD PT-14.3* PTT-142.8* INR(PT)-1.2* [**2150-3-31**] 02:33AM BLOOD PT-13.7* PTT-70.8* INR(PT)-1.2* [**2150-4-1**] 06:20AM BLOOD PT-14.8* PTT-58.8* INR(PT)-1.3* [**2150-3-29**] 10:30AM BLOOD Glucose-112* UreaN-26* Creat-1.2* Na-141 K-4.8 Cl-103 HCO3-25 AnGap-18 [**2150-3-29**] 05:12PM BLOOD Glucose-117* UreaN-27* Creat-1.1 Na-140 K-5.1 Cl-106 HCO3-21* AnGap-18 [**2150-3-30**] 05:06AM BLOOD Glucose-127* UreaN-29* Creat-1.3* Na-136 K-4.4 Cl-100 HCO3-24 AnGap-16 [**2150-3-31**] 02:33AM BLOOD Glucose-96 UreaN-40* Creat-1.7* Na-138 K-3.7 Cl-102 HCO3-23 AnGap-17 [**2150-3-31**] 01:50PM BLOOD UreaN-42* Creat-1.7* Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2150-4-1**] 06:20AM BLOOD Glucose-96 UreaN-43* Creat-1.6* Na-137 K-4.0 Cl-99 HCO3-26 AnGap-16 [**2150-3-29**] 10:30AM BLOOD CK(CPK)-22* [**2150-3-29**] 05:12PM BLOOD CK(CPK)-33 [**2150-3-30**] 12:11AM BLOOD CK(CPK)-28 [**2150-3-30**] 05:06AM BLOOD CK(CPK)-34 [**2150-3-29**] 10:30AM BLOOD cTropnT-<0.01 [**2150-3-29**] 05:12PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2150-3-30**] 12:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2150-3-30**] 05:06AM BLOOD CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: [**Age over 90 **] yo female with history of paroxysmal atrial fib admitted to the CCU for recurrent a fib with RVR. . # A fib: The patient is followed by Dr. [**Last Name (STitle) **] as an outpatient for this condition. She had taken amiodarone for years in the past, however discontinued and restarted recently following DC cardioversion. No clear cause of increased occurences of a fib with RVR, TSH on last admission wnl, UA and CXR today showed no signs of infection however pt has leukocytosis. Patient was placed on amiodarone drip after bolus for rate control. Esmolol drip was attempted, however patient's blood pressure did not tolerate. She was started on a heparin drip and then underwent TEE (which showed no clot) and DCCV after which she converted to NSR with a rate in the 60s on the amiodarone gtt. Per her outpatient cardiologist she was not on anti-coagulation with coumadin for her afib. Her cardiologist decided that she should be on coumadin 1mg as an outpatient for anticoagulation. She was transitioned off the amiodarone drip and started on an oral load. She will take 400mg QD for a month. At that time she will follow up with her primary cardiologist for further direction. She will need frequent INR checks at the acute rehab as amiodarone can effect the metabolism of coumadin. . # PUMP: Pt has history of diastolic dysfunction with LVH but preserved EF. Pt had evidence of volume overload after aggressive volume resuscitation in the ED on admission, likely worsened by her rapid ventricular rate. She was given 40mg of IV lasix on admission and thereafter was treated with PRN lasix for increased oxygen requirement. After converting to NSR, she only required one additional dose of 40mg IV lasix on the day of discharge. Her weight should be monitored daily as well as her respiratory status at the rehab facility. If she her weight increases by 3lbs or she has other signs of heart failure, she should be given 40mg of IV lasix. The patient had an increase in her Crn to 1.7 after diuresis, 1.6 at discharge. Chem 7 should be checked this week at rehab to trend renal function. . # CORONARIES: No previous cath, no previous history of MI. She was ruled out for MI with serial cardiac enzymes and continued on ASA. . # Hypertension: On recent admission lisinopril, amlodipine, metoprolol and HCTZ were discontinued. These medications were not restarted. Did not require anti-hypertensives during her hospitalization. . # Leukocytosis: Initially no clear sign of infection on CXR or UA and was thought likely stress reaction, as noted on previous admission as well. Spiked fever and had positive UA a few days into admission. Was started on ceftriaxone on [**2150-3-30**] and then discharged on cefpodoxime po. Plan to trend leukocytosis with CBCs and symptoms of UTI at rehab. . PROPHYLAXIS: -DVT ppx with heparin drip transitioned to coumadin, home ranitidine -Pain managment with tylenol -Bowel regimen with colace and senna CODE: Full Code Medications on Admission: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 6 days. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: give on sundays. 8. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 months: start [**2150-4-2**]. 12. Outpatient Lab Work Please send Chem-7, CBC and INR on thursday [**2150-4-2**]. Goal INR is [**1-13**] 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Atrial fibrillation with rapid ventricular response Urinary Tract infection Acute on chronic Diastolic congestive heart failure Discharge Condition: stable Discharge Instructions: You were admitted with chest pain and a rapid heart rate from your atrial fibrillation. We cardioverted you and restarted you on amiodarone. You are now in a regular rhythm. You were continued on an aspirin to prevent blood clots. A urine test showed you may have an infection so you were started on an antibiotic. You had some fluid overload because of your rapid heart rate and a diuretic was given to help your body eliminate the extra fluid. Weigh yourself daily, call Dr. [**Last Name (STitle) 713**] if you note that your weight is increasing more than 3 pounds in 1 day or 6 pounds in 3 days. Follow at 2000mg sodium diet. Call Dr. [**Last Name (STitle) 713**] if you notice that your feet are swelling, if you have trouble lying flat to sleep or develop a new cough. Also call for worsening shortness of breath. Medication changes: 1. STOP taking Norvasc, Metoprolol, Lisinopril and Hydrochlorothiazide 2. START taking cefpodoxime for your urinary infection, you will have 7 days total. 3. Start taking warfarin, a blood thinner to prevent a stroke. . Continue with Amiodarone, Aspirin, and Fosamax Followup Instructions: Primary Care: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2150-4-7**] 3:15 Cardiology: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-5-22**] 2:20 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-11-27**] 4:00 Completed by:[**2150-4-1**] ICD9 Codes: 5849, 5990, 4280, 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2418 }
Medical Text: Admission Date: [**2140-6-9**] Discharge Date: [**2140-6-17**] Date of Birth: [**2083-1-21**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Levaquin / Ciprofloxacin / Sulfa (Sulfonamides) / Percocet / Codeine Attending:[**First Name3 (LF) 7141**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, repair of enterotomy History of Present Illness: Ms [**Known lastname 9063**] is a 57F with h/o ovarian ca, POD #1 from laparoscopic IP port placement. She went home and had abdominal pain [**2-10**] hours after getting home. Pain bilateral lower abdomen near the groin and over the incision sites. Felt similar to prior episodes of pain with renal stones. Took 2 vicodin without significant improvement. She went to OSH where a CT without contrast showed some fat stranding and free air thought secondary to recent surgery. She was given meropenam and flagyl and transferred to [**Hospital1 18**]. . On presentation to [**Hospital1 18**], T 100.5, BP 86/58 HR 136 Was given 600cc IVF with SBP 120 and HR 110s. WBC of 37.4 and on exam noted to have significant abdominal pain, guarding so taken to OR for ex-lap. Prior to OR given Vanc/Cefepime and flagyl. . In the OR, patient noted to have a small bowel enterotomy, which was repaired. Recently placed port was removed and adhesions were lysed. There was no collection of pus or any abscess visualized. A JP drain was placed. Was given propofol for sedation. EBL 150, Received 3L LR and 1L NS. UOP 400 CC . ROS: received neulasta [**2140-5-24**]. Recent sinus infection 4 days ago. Past Medical History: Ovarian cancer Nephrolithiasis Ureteral stents . Past surgical history: - [**2140-6-8**] - peritoneal shunt placed. - [**2140-4-25**] Ex-lap, lysis of adhesions, resection of sigmoid mesocolon nodule, bilateral pelvic and periaortic lymph node sampling, infracolic omentectomy - [**2140-4-1**] Vaginal hysterectomy, laparoscopic BSO Social History: The patient has smoked one-half pack per day for 30 years. She does not drink. She is a nurse instructor. Family History: Significant for a mother who had breast and possibly ovarian cancer and died of one of these cancers at age 43. She also has a maternal aunt who died of a question of stomach cancer in her 40s. A maternal grandmother had bladder cancer. Physical Exam: General Appearance: No acute distress Eyes / Conjunctiva: PERRL, constricted Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Dressing Clean, Dry Intact Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: Hematology: [**2140-6-9**] 07:52PM BLOOD WBC-37.4*# RBC-4.05* Hgb-11.7* Hct-34.5* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.2 Plt Ct-455* [**2140-6-10**] 02:47AM BLOOD WBC-41.4* RBC-3.69* Hgb-11.0* Hct-31.5* MCV-86 MCH-29.9 MCHC-35.0 RDW-14.7 Plt Ct-411 [**2140-6-11**] 04:00AM BLOOD WBC-24.9* RBC-2.72*# Hgb-8.2*# Hct-23.2*# MCV-85 MCH-30.0 MCHC-35.1* RDW-14.8 Plt Ct-309 [**2140-6-11**] 12:51PM BLOOD WBC-17.9* RBC-2.73* Hgb-7.9* Hct-23.6* MCV-87 MCH-28.8 MCHC-33.3 RDW-14.4 Plt Ct-334 [**2140-6-12**] 04:32AM BLOOD WBC-14.3* RBC-3.08* Hgb-9.0* Hct-26.1* MCV-85 MCH-29.1 MCHC-34.4 RDW-14.8 Plt Ct-347 [**2140-6-13**] 04:04AM BLOOD WBC-9.7 RBC-3.03* Hgb-9.0* Hct-25.2* MCV-83 MCH-29.8 MCHC-35.8* RDW-15.0 Plt Ct-301 [**2140-6-14**] 05:18AM BLOOD WBC-10.2 RBC-3.29* Hgb-9.7* Hct-28.2* MCV-86 MCH-29.6 MCHC-34.6 RDW-15.0 Plt Ct-377 [**2140-6-15**] 05:38AM BLOOD WBC-6.5 RBC-3.04* Hgb-9.0* Hct-25.2* MCV-83 MCH-29.8 MCHC-35.8* RDW-15.2 Plt Ct-352 [**2140-6-9**] 07:52PM BLOOD Neuts-86* Bands-3 Lymphs-2* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2140-6-10**] 02:47AM BLOOD Neuts-88* Bands-5 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [**2140-6-13**] 04:04AM BLOOD Neuts-77.0* Lymphs-13.3* Monos-8.6 Eos-0.9 Baso-0.2 [**2140-6-14**] 05:18AM BLOOD Neuts-76.8* Lymphs-13.2* Monos-8.2 Eos-1.7 Baso-0.1 [**2140-6-9**] 07:52PM BLOOD PT-15.0* PTT-24.3 INR(PT)-1.3* [**2140-6-10**] 02:47AM BLOOD PT-15.0* PTT-26.6 INR(PT)-1.3* [**2140-6-11**] 04:00AM BLOOD PT-13.4 PTT-28.7 INR(PT)-1.2* [**2140-6-9**] 07:52PM BLOOD Glucose-141* UreaN-13 Creat-0.6 Na-136 K-3.9 Cl-108 HCO3-17* AnGap-15 [**2140-6-10**] 02:47AM BLOOD Glucose-155* UreaN-11 Creat-0.5 Na-136 K-4.1 Cl-110* HCO3-19* AnGap-11 [**2140-6-11**] 04:00AM BLOOD Glucose-101 UreaN-11 Creat-0.5 Na-136 K-4.0 Cl-108 HCO3-23 AnGap-9 [**2140-6-12**] 04:32AM BLOOD Glucose-85 UreaN-6 Creat-0.4 Na-134 K-3.6 Cl-103 HCO3-23 AnGap-12 [**2140-6-13**] 04:04AM BLOOD Glucose-93 UreaN-5* Creat-0.4 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-14 [**2140-6-14**] 05:18AM BLOOD Glucose-70 UreaN-6 Creat-0.4 Na-136 K-3.8 Cl-102 HCO3-25 AnGap-13 [**2140-6-15**] 05:38AM BLOOD Glucose-105 UreaN-3* Creat-0.4 Na-139 K-3.6 Cl-105 HCO3-27 AnGap-11 [**2140-6-16**] 07:02AM BLOOD Glucose-108* UreaN-2* Creat-0.5 Na-140 K-3.9 Cl-106 HCO3-27 AnGap-11 Brief Hospital Course: On presentation to [**Hospital1 18**], vital signs were as follows: T 100.5, BP 86/58 HR 136. Laboratory data was notable for a WBC count of 37.4. She was given Vancomycin, cefepime, and flagyl, and taken to the OR where she was noted to have a small bowel enterotomy, which was repaired. Her recently placed port was removed and adhesions were lysed. There was no collection of pus or any abscess visualized. A JP drain was placed. She was kept on assist control ventilation given the concern for septic shock. Details of the procedure are available elsewhere in a separate operative note. Upon transfer to the ICU, the patient was febrile and hypotensive. A right internal jugular central venous catheter and arterial line were placed, and the patient was volume resuscitated. Her mean arterial pressures and urine output were finally optimized, consistently >65 and 30cc/kg/hr respectively after about 11L of NS over 36 hour, she did not require any pressors to achieve this. She was continued on a regimen of vancomycin, cefepime, and flagyl for presumed gram negative sepsis. On her second ICU day she was successfully extubated. Vancomycin was discontinued on her third ICU day and she was transferred to GYN for further management. Upon arrival to the GYN surgical floor on POD#4 until her discharge on POD#8, she received routine postoperative care. She was transitioned from the fentanyl PCA to dilaudid SC, then subsequently to oral medications with her pain well controlled. Once ambulant without assistance, her foley was removed, and patient was voiding spontaneously. Given that she remained afebrile for greater than 48hours, the remaining antibiotics were discontinued. She did not develop any fevers subsequently. She remained somewhat nauseated, but never had an episode of emesis. Her diet was slowly advanced and she was tolerating a regular, although in small amounts, on POD#7. Given that she was able to take in adequate amount of fluid, her IV fluids were discontinued. Her right internal jugular line was removed on POD#8. She was discharged home on POD#8 in stable condition: afebrile, stable vital signs, ambulant, tolerating regular diet, voidnig spontaneously, and with pain controlled. Medications on Admission: [**Doctor First Name **] Prilosec calcium citrate vitamin D Prochlorperazine Edisylate Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lorazepam 2 mg/mL Syringe Sig: [**2-10**] Injection every 4-6 hours as needed for anxiety. 4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed: do not exceed 4g per 24h period. Disp:*60 Tablet(s)* Refills:*2* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: please take with food/fluid. Disp:*60 Tablet(s)* Refills:*0* 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Abdominal pain, enterotomy. Discharge Condition: Stable Discharge Instructions: - Please call your doctor if you experience fever > 101, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like material, or if your incision reopens. - No driving for two weeks and while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below. Followup Instructions: *** PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] OFFICE TO SCHEDULE A FOLLOW UP APPOINTMENT: [**Telephone/Fax (1) 5777**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2140-7-7**] 8:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2140-7-7**] 8:30 Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2140-7-7**] 10:00 Completed by:[**2140-6-17**] ICD9 Codes: 0389, 5185, 2851, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2419 }
Medical Text: Admission Date: [**2108-3-10**] Discharge Date: [**2108-3-16**] Date of Birth: [**2055-5-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: A fib with RVR, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] Major Surgical or Invasive Procedure: TEE ICU monitoring History of Present Illness: 52 yo male with history of a fib, HTN, hyperlipidemia, morbid obesity, transferred from [**Hospital 1474**] Hospital for management of A fib with RVR in the setting of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. The patient presented to his primary care physician [**Last Name (NamePattern4) **] [**2108-3-9**] with a chief complaint of malaise. The patient was recently treated for an episode of possible bronchitis at the end of [**Month (only) 404**] with a course of moxifloxacin. He reported he felt persistent productive cough since that time. The cough has been productive of clear to white sputum. Over the past two days prior to admission he reported worsening fatigue and malaise as well as dyspnea on exertion. The patient reports he was able to walk approximately 100feet before becoming short of breath. He does report at times he has felt lightheaded, however has never lost consciousness. He reports this episode was very similar to when he presented with a wide complex tachycardia in [**2107-1-7**]. He denies any orthopnea or PND. He denies any chest pain or palpitations. EMS gave the patient diltiazem en route to the [**Hospital1 1474**] ER as his rate was in the 180's. In the ER at [**Hospital1 1474**], he received another 110mg of diltiazem and 15mg of IV lopressor. Cardiology was consulted in the ER and recommended heparin drip, diltiazem drip, digoxin 0.25mg and lasix 40mg. After this treatment, the patient became transiently hypotensive to the 80's systolic. The diltiazem drip was discontinued while the patient was still in the ER. He was then given a bolus of amiodarone and continued on a drip following. On admission to the floor, the patient was continued on this regimen. DC cardioversion was discussed, however a TEE showed evidence of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. Upon further investigation, it was discovered that the patient has a history of WPW with wide complex tachycardia in [**2107-1-7**]. At this time, all nodal agents were held and digoxin was discontinued. The patient was also found to be febrile, have leukocytosis and productive cough. He was treated with ceftriaxone and azithromycin temporarily for presumed CAP, however this was discontinued prior to transfer. On transfer, the patient's HR was in the 170's, but normotensive. On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: [**Doctor Last Name 79**] Parkinson White syndrome, with wide complex tachycardia in [**2107-1-7**], converted with amiodarone and lopressor Cardiac catheterization: Normal Coronaries [**2107-3-8**] OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Hashimoto's Thyroiditis S/P Gastric banding [**9-11**] OSA, on CPAP at night, pressure of 10 Cholelithiasis CARDIAC RISK FACTORS: HTN, hyperlipidemia Social History: Clergy No hx of tobbacco, EtOH, recreational drug use Family History: Father has hypertension, no history of arrhythmias or sudden death Physical Exam: VS: Temp: 102.7 HR 175 BP 140/98 RR 25 O2 95% on 4L GENERAL: obese male in mild respiratory distress, able to speak in complete, however short, sentences, diaphoretic, flushed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. NECK: Supple unable to appreciate JVP given habitus CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, tachycardic, normal S1, S2. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi, however difficult to appreciate secondary to habitus. ABDOMEN: Soft, obese NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral bruits. SKIN: Stasis dermatitis BL, worse on left than right with redness worse on left than right, no ulcers, scars. PULSES: Right: Carotid 2+ Femoral 2+ DP 1 PT 1 Left: Carotid 2+ Femoral 2+ DP 1 PT 1 Pertinent Results: ECG: Atrial fibrillation with delta waves in II, III, and AVF at a rate of 188 TELEMETRY: Narrow complex tachycardia at a rate of 175-200 2D-ECHOCARDIOGRAM: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**], to be reviewed by TEE attending CARDIAC CATH: Per report, clean coronaries [**2106**] Admission Labs: [**2108-3-10**] 09:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025 [**2108-3-10**] 09:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD [**2108-3-10**] 09:40PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2108-3-10**] 05:35PM GLUCOSE-95 UREA N-25* CREAT-1.6* SODIUM-138 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 [**2108-3-10**] 05:35PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.8 CHOLEST-108 [**2108-3-10**] 05:35PM TRIGLYCER-119 HDL CHOL-41 CHOL/HDL-2.6 LDL(CALC)-43 [**2108-3-10**] 05:35PM FREE T4-1.7 [**2108-3-10**] 05:35PM WBC-15.4* RBC-4.07* HGB-11.8* HCT-34.8* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.1 [**2108-3-10**] 05:35PM PLT COUNT-222 [**2108-3-10**] 05:35PM PT-15.1* PTT-29.9 INR(PT)-1.3* Brief Hospital Course: # A fib with RVR: As the patient had a history of WPW with wide complex tachycardia, consistent with antidromic preexcitation in [**2107-1-7**], we refrained from using verapamil and digoxin as could have promoted conduction down the accessory pathway. Also, as the patient had evidence of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] on TEE, we refrained from DC or chemical cardioversion with procainamide especially since patient was stable on admission. Instead the patient was started on an amiodarone drip with beta blockers in an attempt to control his rate. Likely febrile illness and over treatment with levothyroxine for Hashimoto's thyroiditis contributed to patient's a fib with rapid ventricular rate. As the patient remained in a narrow complex tachycardia, the team felt comfortable using diltiazem for rate control in addition to beta blockers as his rate was not well controlled and the likelihood of him converting into a wide complex tachycardia was low. His rate was eventually controlled on a diltiazem drip and the amiodarone was discontinued. The patient then spontaneously converted into sinus rhythm with a wide QRS indicative of a right posterior/inferior bypass tract consistent with WPW. The diltiazem was discontinued and the patient was controlled on beta blockers alone. The patient was continued on a heparin drip for anticoagulation from the time of admission and coumadin was started during hospitalization. The patient was discharged on propranolol, as there is a possibility thyrotoxicosis could have initially contributed to the A fib with RVR, and coumadin for management of his A fib. He will be seen as an outpatient to discuss the possibility of ablation of the WPW bypass tract to prevent further episodes of wide complex tachycardia. # [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]: The patient presented with a TEE done at [**Hospital 1474**] hospital which showed evidence of a left atrial appendage thrombus. Our TEE attending reviewed the echo and could not rule out the presence of a thrombus. The patient was continued on a heparin drip during his hospitalization and started on coumadin. A TTE was done which could not visualize the left atrial appendage, therefore could not rule out the presence of a thrombus. A TEE was done here which showed no thrombus. The patient was discharged on coumadin with instructions to follow up with his primary care physician for an INR check on Monday following discharge. # Febrile Illness: Fever, leukocytosis and productive cough likely secondary to respiratory illness. As the patient has had cough, malaise and general body weakness flu was on differential, however ruled out during hospitalization. The CXR on admission showed possible LLL and RLL infiltrate, thus the patient was started on doxycycline and ceftriaxone for CAP. The patient also had a UA which showed possible evidence of a UTI however the urine culture was negative. The patient was continued on ceftriaxone and doxycycline during hospitalization and discharged on cefpodoxime and doxycycline to complete a 10 day course. # Hypertension: Initially held antihypertensives in the setting of A fib with RVR with episode of hypotension at OSH in order to up-titrate beta blocker for control of AF as much as possible. Once the patient was stable on propranolol 80mg TID, lisinopril and triamterene-hydrochlorothiazide were restarted. The patient was discharged on this regimen. # Hyperlipidemia: Lipids checked and were not elevated despite lack of statin therapy. As had clean coronaries in [**2106**] no indication for statin. # Hashimoto's Thyroiditis: Pt's TSH at OSH was 0.07, however free T4 and T3 within normal limits. TFTs here were similar. Consulted endocrine who said the patient was on too high of a replacement dose of levothyroxine. They recommended adding levothyroxine 150mcg back once stable. Discharged on this dose. # Depression: Continued sertraline. # S/P Gastric Banding: Continued vitamin supplementation and diet restrictions. # OSA: Continued on home CPAP settings, pressure of 10, while inpatient. # ACCESS: R IJ placed at [**Hospital1 1474**], confirmed placement with CXR. Was documented from OSH as sterile placement so was kept in place. The line was pulled prior to discharge. # CODE: Full Code # Contact: [**Name (NI) **] [**Last Name (NamePattern1) 1007**], sister, HCP, [**Telephone/Fax (1) 65282**], [**Name2 (NI) 1743**] [**Last Name (NamePattern1) 56192**], fiance [**Telephone/Fax (1) 65283**] Medications on Admission: Lopressor 100mg [**Hospital1 **] Levothyroxine 400mcg daily Lisinopril 40mg daily ? unclear if taking Sertraline 25mg daily Triamterene 37.5 mg daily Calcium with Vit D2 1000 units daily MVI daily Potassium 10mEq daily Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 4 days. Disp:*10 Capsule(s)* Refills:*0* 4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*10 Tablet(s)* Refills:*0* 9. Propranolol 60 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 10. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 11. Outpatient Lab Work Please have INR drawn 3 days after discharge at Dr.[**Name (NI) 65284**] office. They will have a lab slip waiting downstairs. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: - Atrial Fibrillation - [**Doctor Last Name 13534**] Parkinson White syndrome - Bronchitis/Community Acquired Pneumonia . Secondary Diagnoses: - Hypertension - Hashimoto's Thyroiditis - Morbid Obesity Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with a fast heart rate and respiratory illness. You were found to have atrial fibrillation and an accessory pathway in your heart called [**Doctor Last Name 13534**] Parkinson White. You were also thought to have a clot in your heart. A repeat echocardiogram was done here which showed no clot in your heart. You were treated with medications to slow your heart rate and to thin your blood. You will be continued on these medications as an outpatient. You were also treated with antibiotics for your respiratory illness. . These medications where added/changed: - Coumadin 7.5mg to be taken daily, you will have to have your INR checked in two days following discharge. - Propranolol 60mg three times a day, to be taken instead of your home metoprolol - please do not take both of these medications - Levothyroxine 150mcg daily, to be taken instead of the 400mcg you were taking previously - Doxycycline 100mg twice a day until [**2108-3-20**] - Cefpodoxime 200mg twice a day until [**2108-3-20**] . Your other medications should continue as prescribed, including Lisinopril 40mg daily Triamterene-Hydrochlorthiazide 1 cap daily Sertraline 25mg daily Multivitamin and Calcium with Vit D . If you experience worsening shortness of breath, chest pain, palpitations, fevers, chills or any other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 4 weeks for discussion of treatment options. The phone number to make an appointment is ([**Telephone/Fax (1) 2037**] . Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17025**], on Monday for an INR check. The phone number to make an appointment is [**Telephone/Fax (1) 6699**]. . Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2108-6-27**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2108-6-27**] 2:00 Completed by:[**2108-3-16**] ICD9 Codes: 486, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2420 }
Medical Text: Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-27**] Date of Birth: [**2058-6-9**] Sex: F Service: CARDIOTHORACIC Allergies: Indomethacin Attending:[**First Name3 (LF) 1283**] Chief Complaint: atypical chest pain Major Surgical or Invasive Procedure: s/p CABGx1(SVG-> prox RCA) [**2-20**] History of Present Illness: 61 year old woman with 2-3 year history of DOE. Work up revealed an anomolous RCA. She waws referred to cardiac surgery and was admitted for surgery on [**2-20**]. Past Medical History: HTN Hypercholesterolemia Obesity CCY Tubal Ligation Appy Cataracts Umbilical Hernia Repair Rt Varicose Vein stripping Social History: Lives with husband in [**Name (NI) 108**] Brother and mother-CABG [**Name2 (NI) 1403**] as home health aide Denies tobacco and ETOH Family History: Mother & brother CABG Physical Exam: Admission VS HR 67 BP 140/59 RR 16 02sat 99%RA Ht 4'8" Wt 165lbs Gen: NAD HEENT nl oropharynx, PERRL/EOMI, anicteric-noninjected. Supple no JVD or bruit\ Chest CTA bilat CV RRR no M/R/G Abdm soft, NT/ND/+BS Ext warm, well perfused, 1+LE edema. Rt leg superficial varicosities/left ok Discharge VS T98.1 HR65 SR BP 98/48 RR 18 02sat 99%RA Gen NAD Neuro nonfocal Pulm CTA- bilat CV RRR no murmur Abdm soft, NT/+BS Ext warm, trace edema. Lft SVG site CDI Pertinent Results: [**2120-2-20**] 02:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2120-2-20**] 02:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2120-2-20**] 02:40PM URINE RBC-[**3-13**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 RENAL EPI-<1 [**2120-2-20**] 12:12PM GLUCOSE-91 NA+-139 K+-3.6 [**2120-2-20**] 12:04PM UREA N-15 CREAT-0.7 CHLORIDE-114* TOTAL CO2-24 [**2120-2-20**] 12:04PM WBC-10.9 RBC-3.75* HGB-11.2* HCT-32.1* MCV-86 MCH-29.8 MCHC-34.7 RDW-13.3 [**2120-2-20**] 12:04PM PLT COUNT-218 [**2120-2-20**] 12:04PM PT-13.4 PTT-31.8 INR(PT)-1.2* [**2120-2-26**] 07:25AM BLOOD WBC-7.1 RBC-3.16* Hgb-9.0* Hct-27.8* MCV-88 MCH-28.3 MCHC-32.2 RDW-13.3 Plt Ct-325 [**2120-2-26**] 07:25AM BLOOD Plt Ct-325 [**2120-2-26**] 07:25AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-138 K-4.3 Cl-100 HCO3-31 AnGap-11 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2120-2-22**] 2:40 PM CHEST (PORTABLE AP) Reason: eval ptx s/p CT d/c [**Hospital 93**] MEDICAL CONDITION: 61 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval ptx s/p CT d/c TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: Status post bypass surgery. Evaluate after chest tube removal. FINDINGS: AP single view of the chest obtained with patient in semi-upright position is analyzed in direct comparison with a preceding similar study of [**2120-2-20**]. During the interval the patient has been extubated and both chest tubes and the remaining right internal jugular sheath have been removed. No pneumothorax has developed, no new infiltrates are detected. IMPRESSION: Satisfactory findings after instrument removal. DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] Approved: [**Doctor First Name **] [**2120-2-22**] 6:51 PM [**Known lastname 7405**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76155**] (Complete) Done [**2120-2-20**] at 9:09:51 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-6-9**] Age (years): 61 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0 Test Information Date/Time: [**2120-2-20**] at 09:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW209-9:1 Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventicular systolic function. The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2120-2-23**] 13:03 Brief Hospital Course: Patient was a direct admission to the operating room for scheduled CABG. In summary she had SVG-prox RCA, please see OR report for details. She tolerated the operation well and was transferred from the OR to Cardiac surgery ICU in stable condition. She did well in the immediate post-op period was weaned from the ventilator and extubated. She remained hemodynamically stable on the day of surgery and on POD1 was transferred to the floors for continued post-op recovery. Once on the floor the patient had an uneventful recovery, her chest tubes and epicardial wires were removed on POD 2&3. She worked with nursing and PT to increase her activity level daily. On POD 4 she was noted to have intermittent Afib and was started on Amiodarone. On POD 7 it was decided she was ready for discharge to her hotel. She is to have f/u with Dr [**Last Name (STitle) **] in 2 weeks following which she will return home. Medications on Admission: Lopressor 50 tid Diovan 80/12.5 1tab QD Niaspan 500QHS ASA 81 QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Qhs (). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: [**Hospital1 **] x 7days then 200mg QD. Disp:*35 Tablet(s)* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD s/p CABG HTN, ^chol, s/p CCY, s/p R vein stripping, s/p bilat cataract surgery, s/p appy Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp>101.5 Do not use creams, lotions, or powders on wounds. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 76156**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 2 weeks. Make an appointment with Dr. [**Last Name (STitle) 76157**] for 4 weeks. Completed by:[**2120-2-27**] ICD9 Codes: 4019, 2720
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Medical Text: Admission Date: [**2108-5-8**] Discharge Date: [**2108-5-22**] Date of Birth: [**2026-11-18**] Sex: F Service: SURGERY Allergies: Amlodipine / Pro-Banthine / Zyprexa / Bactrim Ds / Iodine; Iodine Containing Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: Diffuse, severe, non-radiating crampy abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy Extensive lysis of adhesions Reduction and repair of incisional hernia History of Present Illness: Ms [**Known lastname **] is an 81 year old italian speaking female with multiple medical problems who presented to the emergency department with complaints of severe non-radiating, crampy abdominal pain with associated nausea and vomiting for 24 hours. She complained of constipation, and reported no bowel movement for the past 3 days. Past Medical History: PMH: hypothyroid, h/o SBO, thrombocytopenia secondary to heparin: no diagnosed HIT. renal insufficiency, depression, Breast CA, DM2, HTN, hypercholestremia, GERD, Neuropathy,Hernia, stent x 4 years. Past surgical history: exploratory lap for small bowel obstruction [**2101**]. Arthroplasty, left knee. Social History: Lives at home with supportive son [**Name (NI) **] and daughter in law [**Name (NI) 2152**], who is health care proxy. Family History: n/c Physical Exam: T: 99.0 HR 76 BP 160/70 RR 18, Spo2 94% on RA HEENT: aniceteric, no acute distress, PERRLA, membranes dry, no JVD. Cardivascular: Regular S1S2. Pulmonary: Clear to auscultation bilaterally Abdomen: obese, distended, diffusely tender, hernia in upper midline Rectal: guaic negative, normal tone Pertinent Results: CT abd/pelvis [**2108-5-8**] IMPRESSION: Dilated proximal loops of small bowel and collapsed distal ileum and colon are consistent with small-bowel obstruction. Focal transition points are located within two adjacent but separate right anterior abdominal wall hernias. Findings suggest that there is some passage of fluid containing oral contrast beyond the transition points. There are no findings to suggest strangulation/incarceration. . ADDENDUM: Delayed images 3 hours after the initial study were obtained to assess passage of contrast. There is some progression of contrast in proximal small bowel loops, though there is no significant progression of contrast into distal loops, which remain collapsed, suggesting a high-grade obstruction. These findings were discussed with the surgery resident, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 5:30 am on [**2108-5-8**]. . Cardiac cath PTCA COMMENTS: The angiogram showed a mid circumflex lesion of 90 percent. We planned to treat this lesion with POBA and stent only if needed. We used Bivalirudin, Aspirin and Clopidogrel prophylactically. A 6F XB 3.5 guide provided adequate support. A Prowater wire crossed in to the distal vessel easily. We then performed PTCA of the lesion with a 2.5 X 15mm Voyager balloon at10 atm X 3. The final angiogram showed TIMI III flow with no residual stenosis, small non flow limiting dissection, no perforation and no embolisation. The patient left the lab in a stable condition. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. The totally occluded diagonal branch is not suitable for angioplasty. 2. New-onset atrial fibrillation with rapid ventricular response and hypotension. 3. Patient intubated. 4. Successful POBA of the mid LCX lesion . Echo Conclusions: The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is small. Right ventricular systolic function is normal. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. . Right upper extremity ultrasound IMPRESSION: No evidence of deep venous thrombosis of the left upper extremity . [**2108-5-8**] 04:09PM GLUCOSE-138* LACTATE-3.6* NA+-137 K+-3.8 CL--110 [**2108-5-8**] 04:09PM TYPE-ART PO2-163* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 INTUBATED-INTUBATED [**2108-5-9**] 01:53AM BLOOD CK-MB-15* MB Indx-1.3 cTropnT-0.05* [**2108-5-9**] 10:08AM BLOOD CK-MB-37* MB Indx-1.9 cTropnT-0.08* [**2108-5-9**] 06:16PM BLOOD CK-MB-52* MB Indx-2.6 cTropnT-0.18* [**2108-5-10**] 02:35AM BLOOD CK-MB-52* MB Indx-3.3 cTropnT-0.32* [**2108-5-18**] 05:45AM BLOOD proBNP-223 [**2108-5-14**] 03:06AM BLOOD ALT-9 AST-17 AlkPhos-113 Amylase-44 TotBili-1.4 DirBili-1.0* IndBili-0.4 [**2108-5-7**] 08:50PM BLOOD Glucose-114* UreaN-32* Creat-1.1 Na-136 K-5.9* Cl-100 HCO3-20* AnGap-22* [**2108-5-12**] 03:06AM BLOOD Glucose-159* UreaN-34* Creat-0.8 Na-137 K-3.8 Cl-105 HCO3-24 AnGap-12 [**2108-5-21**] 06:00PM BLOOD Glucose-122* UreaN-37* Creat-1.1 Na-135 K-5.0 Cl-97 HCO3-29 AnGap-14 [**2108-5-7**] 10:56AM BLOOD WBC-14.3* RBC-4.55 Hgb-14.3 Hct-44.9 MCV-99*# MCH-31.5 MCHC-32.0 RDW-13.8 Plt Ct-293 [**2108-5-21**] 06:00PM BLOOD WBC-11.9* RBC-3.77* Hgb-12.1 Hct-36.5 MCV-97 MCH-32.1* MCHC-33.1 RDW-14.6 Plt Ct-393 [**2108-5-9**] 01:53AM BLOOD WBC-22.2*# RBC-3.66* Hgb-11.6* Hct-35.5* MCV-97 MCH-31.8 MCHC-32.7 RDW-14.1 Plt Ct-270# Brief Hospital Course: Ms [**Known lastname **] was evaluated in the ED and found to have a high grade small bowel obstruction. She was taken to the OR directly. She tolerated the procedure well, she was extubated and transferred to ICU. . Cardiovascular: POD#1 developed low blood pressure and was started on low dose Neo. POD#2, had positive troponins, ruled in for MI. She was sent for emergent cardiac cath. She recieved angioplasty of the left circumflex artery. Developed afib, and was cardioverted. She was initiated on amiodarone drip. Converted to sinus rhythm. Femoral sheaths pulled POD#5. Had persistent hypertension throughout ICU course, managed by her PCP. [**Name10 (NameIs) **] with nitro and metoprolol. Diuresed throughout admission with lasix. . Pulmonary: Was reintubated POD#2 secondary to NSTEMI. POD#3 developed right upper lobe nosocomial pneumonia. Initiated on Vanco/Zosyn. Extubated POD#5. Respiratory status improved with antibiotics, weaned to room air at time of discharge. . Abdomen: remained soft, nontender with midline incision intact. 2 JP drains in place. JP#1 removed POD#11. JP#2 removed POD#12. Staples removed POD#14. Incision remains dry and intact. . GI: Pt remained with NGT in place due to an ileus. NGT removed and ileus resolved POD#7. Developed frequent diarrhea POD#8, CDiff positive. Initiated Vanco liquid, due to intolerance to Flagyl. On Vanco taper per Dr. [**First Name (STitle) 10113**], gastroenterology. . GU: Recieved aggressive fluid resuscitation for low urine output. Foley catheter until POD#10. Incontinent of urine. . Nutrition: On TPN until POD#8. Tolerated regular diet on POD#9. Monitored with calorie counts to ensure adequate oral intake. TPN tapered off on POD#11. . Extremities: Edema of upper and lower extremities at times during admission, due to aggressive fluid resuscitation and history of CHF. Left upper extremity was swollen POD#9. Ultrasound revealed no thrombus. . Musculoskeletal: PT worked with her consistently for strengthening and conditioning. . Pt was transferred to med-[**Doctor First Name **] floor on POD#8. She continued to follow an uneventful post-op course. . Medications on Admission: Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily () as needed for breast ca Lipitor 10 mg po qd Cipro 250 mg po qd Lasix 20 mg po qd Gabapentin 300 mg po qd Humulin 70/30 Topamax 25/50 Lopressor 25 mg po bid Elavil 10 mg po qhs Omeprazole 20 mg po qd Paxil 40 mg po qd Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily () as needed for breast ca. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 17. insulin Breakfast Dinner 70 / 30 25 Units 70 / 30 22 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [**1-10**] amp D50 [**1-10**] amp D50 [**1-10**] amp D50 [**1-10**] amp D50 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 3 Units 3 Units 3 Units 2 Units 141-160 mg/dL 6 Units 6 Units 6 Units 4 Units 161-180 mg/dL 9 Units 9 Units 9 Units 6 Units 181-200 mg/dL 12 Units 12 Units 12 Units 8 Units 201-220 mg/dL 15 Units 15 Units 15 Units 10 Units 221-240 mg/dL 18 Units 18 Units 18 Units 12 Units 241-260 mg/dL 21 Units 21 Units 21 Units 14 Units 261-280 mg/dL 24 Units 24 Units 24 Units 16 Units 281-300 mg/dL 27 Units 27 Units 27 Units 18 Units 301-320 mg/dL 30 Units 30 Units 30 Units 20 Units 18. Amiodarone After completion of 14 days of amiodarone 200 mg [**Hospital1 **], taper dosing to Amiodarone 200 mg po qd. [**2108-5-22**] is day 2 of her dose of amiodarone 200mg [**Hospital1 **]. 19. Vancomycin Vancomycin 250 mg po liquid q6 hours x 7 days. then Vancomycin 250 mg po TID x 7 days. then Vancomycin 250 mg po BID x 7 days. then Vancomycin 250 mg po qd x 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Incarcerated incisional hernia NSTEMI post-op ileus nosocomial pneumonia Atrial fibrillation Discharge Condition: stable Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**10-22**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2108-6-5**] 10:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2108-6-8**] 10:20 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**] Date/Time:[**2108-6-15**] 11:20 You have an apointment to see Dr. [**Last Name (STitle) **] on [**5-28**] at 12:45. [**Telephone/Fax (1) 8792**]. [**Street Address(2) **], [**Location (un) **] [**Apartment Address(1) **] west. Please make an appointment to see your cardiologist in 1 month for follow up of your amiodarone. Please call [**Telephone/Fax (1) 96976**] and schedule an appointment to see Dr. [**First Name (STitle) 10113**] in 1 month. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2108-5-22**] ICD9 Codes: 9971, 486, 4280, 5849, 2875, 5185, 2449, 311, 4019
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Medical Text: Admission Date: [**2195-12-3**] Discharge Date: [**2195-12-10**] Date of Birth: [**2132-11-18**] Sex: F Service: MEDICINE Allergies: Aspirin / Nifedipine / Premarin / Morphine / Crestor / Atorvastatin / Codeine Attending:[**First Name3 (LF) 2932**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: 63 year olf female with history of DMII, CAD, CVA s/p recent hospitalization for GIB, UTI presents within one day of returning home from rehab with nausea, vomiting. In ED, her emesis and stool were black, her hct was 32 (baseline 30) and she was hemodynamically stable (hypertensive). Of note she was scoped 1 week ago, colonoscopy showed 2 polyps that were removed and EGD showed gastritis with no active bleeding. She complains of vomiting x 1 day and nausea for past several days. She does not know the color of her stool/emesis as she is blind. SHe denies abdominal pain, chest pain, SOB, palps, dysuria. In the ED, hypertensive to 180s/100s. Hct 32. She had an AG of 16. ABG was 7.46/42/185. Groin line place b/c unable to get peripherals. Got 2L IVF, Cipro and Flagyl. On arrival to [**Hospital Unit Name 153**] she was given insulin 10 units IV and started on insulin drip for her diabetic ketosis. Her ECG showed TWI in lateral leads, CKs were flat, trop 0.04. She was given metoprolol 5 IV and her BP improved. Past Medical History: HTN DMII Hyperlipidemia h/o CVA w/ residual L sided hemiparesis CAD- w/ stent '[**86**] and '[**89**] Asthma Rheumatic fever Femoral Bypass - [**1-15**] complication of most recent cath Asthma - last hospitalization mult years ago, uses rescue albuterol inhaler 1-2 times per week migraine headaches - tx with vicodin or tylenol Breast Cancer - node negative (surgery only, no chemo, no rad) Degenerative Disk Disease Osteoarthritis Osteoporosis GERD Social History: lives alone at home [**Location (un) 6409**]; wheelchair bound s/p CVA; no h/o ETOH or tobacco use Family History: non-contributory Physical Exam: Physical Exam on Admission: VS: 98 182/108 80 [**11-28**] 100% 5LNC HEENT: dry MM, no elevated JVP Cor: RRR no MRG LUNGS: clear ABD: soft/NT/ND/+BS NEURO: Appropriate, oriented, speaking in full sentences, pupils not reactive (hard to tell) EXT: 1+ pedeal pulses on R, 2+ on L Pertinent Results: Laboratory studies on admission: [**2195-12-3**] WBC-12.7 HGB-11.7 HCT-32.1 MCV-81 RDW-14.0 PLT COUNT-149 NEUTS-87.8 LYMPHS-10.0 MONOS-2.1 EOS-0.1 BASOS-0 CK-MB-NotDone cTropnT-0.04 GLUCOSE-446 UREA N-33 CREAT-1.3 SODIUM-145 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-30 PT-11.9 PTT-24.6 INR(PT)-1.0 Laboratory studies on discharge: [**2195-12-10**] WBC-6.8 Hgb-10.4 Hct-29.2 MCV-82 RDW-13.9 Plt Ct-131 Neuts-62.3 Lymphs-27.4 Monos-7.6 Eos-2.6 Baso-0.2 PT-11.8 PTT-25.0 INR(PT)-1.0 Glucose-172 UreaN-12 Creat-1.0 Na-144 K-3.7 Cl-105 HCO3-33 [**12-3**] EKG: Sinus rhythm. No significant change from the tracing of [**2195-9-26**]. The tracing continues to show left ventricular hypertrophy by voltage in lead aVL and non-specific ST-T wave abnormalities which may be due in part to the left ventricular hypertrophy. Radiology [**12-3**] CXR: No evidence of cardiopulmonary process. [**12-6**] bleeding scan: No GI bleeding focus identified. Endoscopy: [**12-8**] colonoscopy: Grade 2 internal hemorrhoids. Polyps in the sigmoid colon and ascending colon [**11-24**] colonoscopy: Polyp in the proximal ascending colon (polypectomy, path c/w adenoma). Polyp in the descending colon/40cm (polypectomy, path c/w hyperplastic). Diverticulosis of the sigmoid colon and distal descending colon. Grade 1 internal hemorrhoids. [**11-24**] upper endoscopy: Patchy discontinuous erythema of the mucosa with no bleeding was noted in the stomach body and antrum. These findings are compatible with Gastritis. Cold forceps biopsies were performed for histology at the stomach antrum (normal pathology) Brief Hospital Course: 63 year old female with type II diabetes presents with nausea/vomiting/melena. She was initially admitted to the intensive care unit, where she became hypotensive and her HCT dropped to 23. She was transfused 2 units of PRBC and transferred to the general medical floor on the evening of [**2195-12-5**]. 1) GI bleeding/acute blood loss anemia: The melena/coffee-ground emesis on admission was most likely secondary to gastritis versus possible [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear in the setting of vomiting (possibly from gastroparesis versus gastroenteritis). As indicated above, she received 2 units of PRBC in the intensive care unit. GI was consulted, who did not recommend repeat EGD, given recent EGD [**2195-11-24**] (see results section). She remained stable until [**2195-12-6**], when she had bright red blood per rectum and a hematocrit drop to 25. She was transfused 2 units of PRBC along with 1 unit of platelets given thrombocytopenia (see below) with stabilization of her hematocrit. She underwent a bleeding scan, which was negative. On the evening of [**12-7**], she had another episode of BRBPR; she was prepped for a colonoscopy, which she underwent [**12-8**]. Although the preparation was poor, no bleeding source was identified. The GI service felt that her rectal bleeding was most likely from her [**11-24**] polypectomy sites. At the time of discharge, her hematocrit was stable at 29, despite re-initiation of Plavix. She will follow-up with gastroenterology as an outpatient and have a repeat hematocrit checked within 1 week. She was continued on a PPI twice a day for gastritis. 3) Type II diabetes poorly controlled with complications: The patient had previously been on 22 units of lantus with a sliding scale in [**9-/2195**], recently switched to metformin alone. As mentioned above, she was briefly on an insulin drip while in the ICU given concern for DKA. At time of discharge, her blood sugars were well-controlled on metformin alone. 4) UTI: The patient's urine culture grew >100k E. coli resistant to quinolones, sensitive to ceftriaxone. She will complete a 7 day course of cefpodoxime. 5) Thrombocytopenia: The patient's platelet count nadired at 84, rising to 133 at time of discharge. The etiology is unclear, but it may have been related to acute illness. Her fibrinogen/PT/PTT were not consistent with DIC and HIT antibody was negative. Her platelet count should be monitored as an outpatient; if thrombocytopenia persists, an outpatient hematology consult may be considered at the discretion of her PCP. 6) h/o CVA: No embolic source had been identified during her prior admission, but she had been started on coumadin and Plavix, although her INR was only 1 on admission. Her neurological exam remained stable, and she was restarted on Plavix as indicated above. She will have a repeat hematocrit checked within 1 week; if she remains stable, her coumadin can be restarted by her PCP for [**Name Initial (PRE) **] goal INR 2-2.5. 7) CAD: The patient's EKG showed lateral ST depressions on admissions, however cardiac enzymes were not consistent with active ischemia. She was continued on beta-blocker and, as mentioned above, Plavix was restarted by the time of discharge. 8) HTN: The patient's blood pressure remained labile. At time of discharge, she had been restarted on her home doses of Coreg, Lasix, and lisinopril. 9) Full Code Medications on Admission: coumadin 5mg qHS - Coreg 6.25mg [**Hospital1 **] - plavix 75mg qD - zyrtec 10mg qHS - senna 2 tab [**Hospital1 **] PRN - ocean nasal spray 2 spray TID - glucophage 850mg qAM, 500 qPM - lisinopril 40mg qD - prilosec 20mg [**Hospital1 **] - lasix 40mg qD - neurontin 300mg qD - welchol 625mg [**Hospital1 **] - compazine 25mg PR q12h PRN Discharge Medications: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*0* 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 8. Colesevelam 625 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO once a day. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO qHS (). Disp:*30 Tablet(s)* Refills:*0* 12. Compazine 25 mg Suppository Sig: One (1) suppository Rectal twice a day as needed for nausea. Disp:*30 suppositories* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: gastrointestinal bleeding Secondary: acute blood loss anemia, hypertension, Type II diabetes well-controlled with complications, thrombocytopenia, hypercholesterolemia, urinary tract infection, history of stroke Discharge Condition: Good Discharge Instructions: 1) Please follow-up as indicated below 2) Please take all medications as prescribed. You should not restart coumadin until instructed to do so by your PCP. [**Name10 (NameIs) **] will take 5 more days of cepodoxime to treat the urinary tract infection. 3) Please come to the emergency room or see your PCP if you develop rectal bleeding, nausea/vomiting, black stool, fevers, chills, or other symptoms that concern you. Followup Instructions: 1) Primary Care Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2195-12-18**] 10:00 - you should have a repeat hematocrit and platelet count checked at that time to ensure stability 2) Gastroenterology Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST OFFICE (SB) Date/Time:[**2195-12-30**] 1:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2195-12-10**] ICD9 Codes: 2851, 5849, 2875, 5990, 4019, 2720
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Medical Text: Admission Date: [**2101-7-11**] Discharge Date: [**2101-8-18**] Date of Birth: [**2050-8-25**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5037**] Chief Complaint: nausea, vomiting, dysuria Major Surgical or Invasive Procedure: [**2101-7-22**] Incision and Drainage of perinephric Mass [**2101-7-27**]: Resection of medial [**1-24**] of right clavicle. Resection of sternoclavicular joint. Partial resection of sternum and costochondral junction of the 1st rib. [**2101-8-3**] 1. Surgical preparation of chest wound 12 x 12 cm. 2. Pectoralis myofascial flap. 3. Local tissue advancement and rearrangement of skin for closure of chest defect 12 x 12 cm. Right thoracentesis with chest tube placement and subsequent removal History of Present Illness: This is a 50 year old female with PMH of asthma, questionable TIA vs. complex migraine 2 months ago, poorly controlled DM1 with last A1C of 13 and HTN c/b ESRD s/p living related donor renal transplant in [**2092**] presenting with 4 days of dysuria and 2 days of nausea and non-bloody, non-bilious emesis. She was seen today at her PCP's office and referred to the ED after being found to be orthostatic with a BP of 118/62 lying, 82/36 sitting, and 70/40 standing. She has had no urinary frequency or hematuria and was noted to be extremely anxious about potential renal failure. Of note, she was also seen last week for fever to 102, cough, and diarrhea and prescribed azithromycin with resolution of her symptoms. She currently denies any F, abd pain, diarrhea, constipation, or cough. She has been having some chest burning likely related to esophageal irritation from frequent vomiting. She has also been having some right shoulder pain which she attributes to an injury she had from grabbing the toilet in an episode of violent vomiting. She has also noted dyspnea on exertion and chills as of late. . In ED, vitals were 98.2 82 129/58 16 97% RA. Per her PCP's exam, she was noted to have some difficulty standing for orthostatics and mild epigastric tenderness. She was also noted to have right shoulder pain worse with movement, coughing, and lifting. On ED exam her graft was not TTP. Per the [**Last Name (LF) **], [**First Name3 (LF) **] EKG did not show any changes from prior. A CXR was also performed and did not show any acute cardiopulmonary abnormality per the ED. A renal transplant ultrasound was performed but not reviewed in the ED. Labs were significant for a WBC count of 25.4, thrombocytosis to 980, floridly positive UA, hyponatremia to 127, creatinine of 2.5, and an anion gap of 15. She was given Maalox/simethicone/lidocaine which did not help her chest burning and she reported vomiting it up, morphine 4mg IV for right shoulder pain, cipro 400mg IV, and 2L of NS. Blood cultures were performed, but urine culture was not sent. She was admitted for UTI and acute renal failure. Most recent vitals: 97.8 108 124/56 18 100RA. . Review of sytems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest tightness, palpitations. Denied diarrhea, constipation. Past Medical History: -Hypertension -Type 1 diabetes since [**2063**], poorly controlled with last A1C of 13 -Asthma -ESRD s/p living-related renal transplant in [**2092**] -TIA vs. complex migraine in [**5-2**], started on Plavix thereafter Social History: She lives with her mother at home and is her mother's primary caretaker. [**Name (NI) **] brother has flown in from [**Name (NI) 4565**] to care for her while she is hospitalized. She does not have any children but reports good social support from friends and [**Name2 (NI) **]-workers. She works for the Massport website full-time. She does not smoke or drink EtOH. Family History: Father had ALS but otherwise not significant. Physical Exam: ADMISSION: VS - Temp=99.2, BP=102/60, HR=110, R=20, O2-sat 99% RA GENERAL - well-appearing female in NAD, comfortable, appropriate, with intermittent chills noted HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no JVD. LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - tachycardic, 2/6 SEM noted ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, no c/c/e. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-26**] throughout, sensation grossly intact throughout. DISCHARGE: General: no longer with intermittant rigors Heart: RRR, 2/6 SEM at RUSB Lungs: rales at the bases of the posterior lung fields bilaterally Extremities: 2+ pitting edema in the lower extremities bilaterally Otherwise unchanged from admission Pertinent Results: ADMISSION LABS: [**2101-7-11**] 02:16PM BLOOD WBC-25.4*# RBC-4.34 Hgb-11.1* Hct-35.1* MCV-81*# MCH-25.4* MCHC-31.4 RDW-13.0 Plt Ct-980* [**2101-7-11**] 02:16PM BLOOD Neuts-92.1* Lymphs-5.5* Monos-1.6* Eos-0.7 Baso-0.2 [**2101-7-11**] 02:16PM BLOOD Plt Ct-980* [**2101-7-13**] 04:35AM BLOOD PT-14.2* PTT-33.9 INR(PT)-1.2* [**2101-7-11**] 02:16PM BLOOD Glucose-187* UreaN-70* Creat-2.5*# Na-127* K-4.6 Cl-91* HCO3-21* AnGap-20 [**2101-7-11**] 02:16PM BLOOD ALT-13 AST-15 AlkPhos-108* TotBili-0.3 [**2101-7-11**] 04:22PM BLOOD Type-[**Last Name (un) **] pO2-66* pCO2-29* pH-7.30* calTCO2-15* Base XS--10 Comment-GREEN TOP PERTINENT LABS: [**2101-7-16**] 04:20AM BLOOD ESR-24* [**2101-8-11**] 06:40AM BLOOD ALT-14 AST-28 LD(LDH)-366* AlkPhos-120* TotBili-0.3 [**2101-8-8**] 04:55AM BLOOD Lipase-8 [**2101-8-8**] 04:55AM BLOOD cTropnT-<0.01 [**2101-7-13**] 04:35AM BLOOD calTIBC-139* Hapto-362* TRF-107* [**2101-7-16**] 12:50PM BLOOD CRP-194.9* [**2101-7-22**] 04:25AM BLOOD PEP-NO SPECIFI [**2101-7-26**] 11:05AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- [**2101-7-26**] 11:05AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-Test [**2101-7-22**] 04:25AM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA BASED-Test [**2101-7-18**] 12:46PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- [**2101-7-16**] 12:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [**2101-7-16**] 12:50PM BLOOD B-GLUCAN-Test [**2101-7-15**] 05:45PM BLOOD ADENOVIRUS PCR-Test Name MICROBIOLOGY: BLOOD CX [**2101-7-11**]: neg URINE CX [**2101-7-11**]: lactobacillus species VRE Swab negative Urine Cx [**7-14**]:neg Blood culture [**7-14**], [**7-15**]: neg Mycobacteria and Fungal cultures 6/25: neg [**7-17**] Stool culture-neg, [**7-17**] C. Diff Toxin A and B-neg, [**7-17**] Campybacterium culture-neg [**7-17**] stool viral culture -prelim neg [**7-22**] CMV viral load neg [**7-22**] perinephric mass biopsy culture: PMNs seen on gram stain. culture beta streptococcus group B SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B | CLINDAMYCIN----------- S ERYTHROMYCIN---------- S ANAEROBIC CULTURE (Final [**2101-7-26**]): NO ANAEROBES ISOLATED [**7-22**] chest swab PMNs on gram stain; beta strep group B on culture. [**7-22**] fluid from chest PMNs, no growth on culture [**7-22**] peri-nephric mass fluid beta strep group B. [**7-27**] right sternoclavicular joint first rib *** [**7-27**] pectoralis muscle *** [**7-27**] sternoclavicular fluid *** [**7-19**] Urine cytology: Urothelial cells, histiocytes, and neutrophils.Many squamous cells, anucleate squames, and bacteria consistent with vaginal contamination.Note: Atypical squamous cells consistent with low grade squamous intraepithelial lesion (LSIL) are present. no other blood/urine cultures positive PATHOLOGY: PeriNephric Mass Biopsy [**7-20**] Fragments of fibrovascular tissue and chronic inflammation. See note. Note: The biopsy is mostly comprised of fibrous tissue and lymphocytes with some crush artifact. A separate discrete aggregate of plasma cells are identified. These plasma cells are small with eosinophilic cytoplasm and eccentrically located nuclei. No atypical forms are seen. By immunohistochemistry the plasma cells are positive for CD138 and Bcl-2 and are polytypic by Kappa and Lambda staining. CD20 and CD10 are negative in the plasma cells with CD20 staining scattered B-cells. CD3 and CD5 highlight admixed T-cells. Overall, the findings are non-specific. The differential diagnosis includes a reactive process (favored). Since an early evolving (hyperplasia) post-transplant lymphoproliferative disorder cannot be excluded (due to sampling) a repeat excision may be warranted if clinically indicated. Addendum: Kappa and lambda ISH reveals a mixed polytypic plasma cell population. [**Last Name (un) **] is negative. Overall features do not suggest a clonal process; No evidence of PTLD seen. The above diagnosis remains unchanged. Immunophenotyping [**7-22**] Three color gating is performed (light scatter vs. CD45) to optimize blast/lymphocyte yield. Due to paucicellular nature of the specimen, a limited panel is performed to determine B-cell clonality. B cells are scant in nature precluding evaluation of clonality. [**7-22**] Biopsies of Chest wall and Perinephric Mass 1. Mass, right chest wall (A-B): a. Skeletal muscle with chronic, patchy mildly active inflammation. b. Fibroadipose tissue. c. No malignancy identified. 2. Mass, peri-nephric (C): Fibroadipose tissue with acute and chronic inflammation and fat necrosis consistent with abscess wall. [**8-10**] Pleural Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS. ULTRASOUNDS: RENAL U/S [**2101-7-11**]: IMPRESSION: 1. Abnormal intrarenal waveforms with blunted waveforms and lack of diastolic flow in the interpolar region. Findings concerning for graft dysfunction. 2. A 3.7 x 3.2 x 2.8 cm hypoechoic lesion with internal vascularity in the interpolar region of the transplant kidney is concerning for a neoplasm. Further assessment with MR is recommended. U/S Chest Wall [**7-21**] Soft tissue mass which is hypoechoic, predominantly solid, but with areas of partial liquefaction. This is avascular and most likely represents a focus of PTLD as the appearance is not dissimilar from the peri-transplant masses, which were biopsied yesterday. [**2101-7-21**] Chest U/S: CONCLUSION: Soft tissue mass which is hypoechoic, predominantly solid, but with areas of partial liquefaction. This is avascular and most likely represents a focus of PTLD as the appearance is not dissimilar from the peri-transplant masses, which were biopsied yesterday. [**2101-7-21**] Right Upper Extremity U/S 1. No right upper extremity DVT. 2. Extensive right supraclavicular lymphadenopathy. [**7-26**] LENIs: No evidence of deep vein thrombosis in either leg. CT SCANS [**2101-7-21**] CT Chest without contrast 1. Chest wall abnormality could represent PTLD, but extention into the thoracic cavity and associated bone destruction raises concern for infection. In an immunocompromised host, this could be due to invasive fungal organisms, actinomycosis, and TB, among others. 2. Lung consolidation, pleural effusions and interlobular septal thickening are nonspecific. Such findings have been associated with PTLD but can also be associated with infection and hydrostatic edema. [**2101-7-26**] CT Abdomen and Pelvis IMPRESSION: 1. Multiloculated rim-enhancing fluid collection in the right anterior chest with internal foci of gas and minimal osseous destruction of the encased first rib, thought to represent abscess has had a minimal decrease in size. 2. Bilateral pleural effusions with worsening right lower lung opacification, may represent ateletasis but underlying pneumonia cannot excluded. 3. Four fluid collections identified around the transplanted kidney in the left lower quadrant. Two had recent instrumentation and drainage, superior and lateral, and are decreased in size compared to recent MRI. Two larger collections noted medial and inferior demonstrate rim enhancement and intermediate density fluid concerning for infectious process. 4. Foci of gas in the collecting system of the transplanted kidney, likely due to air reflux from bladder foley placement, less likely pyelitis. 5. Hyperdensities in native kidneys, particularly in the right upper pole likely represent hemorrhagic cysts, particularly given appearance on recent MRI. 6. Volume overload is demonstrated by bilateral pleural effusions, pericardial effusion, anasarca, periportal edema and mild ascites. 7. Linear lucency in right second rib likey due to recent surgery. Please correlate with operative note when available. [**8-8**] CT Chest Abdomen and Pelvis: IMPRESSION: 1. Increased size of mild pericardial effusion with hyperenhancing pericardium. 2. Right labia is enlarged with indurated subcutaneous fat without focal fluid collection. 3. Decrease in size of anterior right chest wall abscess with two drains in place and minimal residual fluid. 4. Increased bilateral pleural effusions and atelectasis. 5. Increase in periportal and pericholecystic fluid with hyperenhancing gallbladder wall suggestive of edema versus gallbladder contraction. 6. Decrease in size of collections surrounding the transplanted kidney and collection along the lateral abdominal wall measuring 3.3 and 2.0 cm respectively from 4.8 and 2.1 cm on prior examination. 7. Air again seen in transplanted kidney, likely refluxing air. MRI: [**2101-7-15**] MRI Abdomen and Pelvis: IMPRESSION: 1. Transplanted kidney in left lower quadrant. At least three perirenal masses suspicious for PTLD or lymphoma. The lesions are accessible by percutaneous biopsy. 2. Multiple native renal cysts, some of them with hemorrhagic/proteinaceous content. 3. Bilateral pleural effusions, right moderate amount, on the left small amount. [**7-19**] shoulder MRI:IMPRESSION: 1. Motion-degraded study. No evidence of septic arthritis. 2. Nonspecific mild edema involving the infraspinatus, teres minor, and teres major. 3. Abnormality adjacent to the coracoid process which is suboptimally evaluated on this motion-degraded study - recommend further evaluation with contrast-enhanced CT, as this could represent a mass or lymphadenopathy; collection of fluid is less likely given imaging characteristics. 4. Large signal intensity abnormality in the peripheral aspect of the right upper lung, corresponding to known consolidation. [**8-4**] MRI/MRA: IMPRESSION: 1. Acute infarct involving rostrum of corpus callosum. 2. Multiple focal dilatations involving ACA and MCA branches bilaterally. 3. Both the infarction and the vascular abnormalities suggest multiple septic emboli. ECHOCARDIOGRAMS ECHO [**2101-7-18**]: MPRESSION:No endocarditis or abscess seen. Moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. ECHO [**2101-7-27**]: This is a limited examination to r/o endocarditis. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is an echo dense mass a probable vegetation on the P2 portion of the mitral valve. It measures 2- 3mm in size. Dr [**First Name (STitle) 6507**] present to confirm findings as well. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was notified in person of the results on [**2101-7-27**] at 1245pm. ECHO [**2101-8-8**]: The left atrium is normal in size. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary gradient (30mmHg peak) is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2101-7-18**], the pericardial effusion and mid-cavitary gradient are now identified. Serial evaluation is suggested. ECHO [**2101-8-10**]: IMPRESSION: Very small echodensity attached to the posterior mitral annular calcification at the level of the P2 scallop. Compared to the prior study dated [**2101-7-27**] (images reviewed), the echodensity is smaller and less mobile and probably c/w with healing vegetation. Small circumferential pericardial effusion without evidence of tamponade. ECHO [**2101-8-15**]: NO effusion: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation with mild leaflet thickening, but no discrete vegetation. Compared with the prior study (images reviewed) of [**2101-7-18**], the findings are similar.CLINICAL IMPLICATIONS: Based on [**2097**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CHEST X-RAYS [**2101-7-11**]: IMPRESSION: No acute cardiopulmonary abnormality. [**2101-7-16**]:FINDINGS: There are bilateral pleural effusions with volume loss at both bases. There is new right mid lung infiltrate. Overall, the pulmonary appearance has worsened compared to the film from five days ago. [**2101-7-18**]:FINDINGS: Largely loculated moderate dependent bilateral pleural effusions with associated atelectasis are new or substantially larger from [**2101-7-11**]. Difference in effusion size from [**2101-7-16**] is likely due to depth of inspiration. Improved aeration in the non-dependent lungs on the lateral decubitus views is secondary to positioning. The right upper lobe pneumonia is unchanged. No new consolidation is seen in the left lung. No pneumothorax. [**2101-7-21**]: IMPRESSION: Stable chest findings in comparison with preceding study of [**2101-7-18**]. Recommend CT examination to evaluate alleged new anterior chest wall mass. [**2101-7-25**]: There are low inspiratory volumes and slightly less penetration of the film compared with [**2101-7-21**]. Allowing for this, no significant interval change is detected. Again seen are small effusions at the right and left bases, with underlying collapse and/or consolidation. There is a hazy opacity in the right mid zone, corresponding to the right lung abnormality seen abutting the anterior chest wall on the [**2101-7-21**] CT scan. There is upper zone redistribution, without other evidence of CHF. [**2101-7-27**]: AP UPRIGHT VIEW OF THE CHEST: There is new moderate right-sided pneumothorax with partial collapse of the entire right lung following resection of the medial one-third of the right clavicle and first anterior rib. Minimal leftward shift of the mediastinum may be related to large left lower lung atelectasis. Small right effusion is present. Heart size is enlarged. [**2101-7-27**]: There is still present right large pneumothorax with significant collapse of the right lung, left mediastinal chest and left lower lobe consolidation. Pneumomediastinum cannot be excluded. The patient is after recent resection of the part of the clavicle and adjacent chest wall debridement. [**2101-7-27**]: On the current study, there is evidence of significant decrease in the right pneumothorax with only small amount of pneumothorax is seen. There is still present pneumomediastinum. Reexpanding right lung is noted associated with small pleural effusion. Left lower lobe consolidation is unchanged. [**2101-7-28**]: Current study demonstrates bibasal consolidations, bilateral pleural effusions and small amount of pneumothorax is still present as well as potentially small amount of pneumomediastinum. [**2101-7-29**]: Previous mild pulmonary edema has largely cleared, moderate right pleural effusion is smaller, but bibasilar atelectasis is still severe. No pneumothorax. Heart size normal. Stomach is moderately distended with air and fluid. Medial right clavicle has been resected. [**2101-7-31**]: There are low inspiratory volumes. There are small bilateral effusions with underlying collapse and/or consolidation. There is borderline cardiomegaly. There is upper zone redistribution, but no overt CHF. The medial aspect of the right clavicle is not visualized, consistent with history of resection, and the medial right clavicle is inferiorly displaced with respect to its normal position. Of note, there is some faint opacity in the right suprahilar region, more pronounced than on [**2101-7-29**], which may represent a re-developing pneumonic infiltrate. [**2101-8-1**]: Persisting bilateral pleural effusion and bibasilar atelectases. Stable right suprahilar opacity which likely represents atelectasis/consolidation [**2101-8-1**]: Stable bilateral pleural effusion and bibasal atelectasis No evidence of pneumothorax [**2101-8-2**]: IMPRESSION: 1. Tip of the PICC line is 5.4 cm below the cavoatrial junction. 2. Stomach has been consistently distended since at least [**7-21**], [**2101**]. Such distension might increase the likelihood of aspiration. 3. No acute cardiopulmonary changes compared with last chest x-ray. [**2101-8-3**]: Mild interstitial edema. Left lower lobe atelectasis. No pneumothorax. [**2101-8-4**]: IMPRESSION: Little overall change. [**2101-8-4**]: FINDINGS: In comparison with the earlier study of this date, there again is evidence of increased pulmonary venous pressure, mild enlargement of the cardiac silhouette, bilateral pleural effusions, and evidence of resection of the medial aspect of the right clavicle. Central catheter remains in place. Dilatation of the gas-filled stomach persists, for which a nasogastric tube might be helpful. [**2101-8-8**]: FINDINGS: In comparison with the study of [**8-4**], there is little overall change. Continued enlargement of the cardiac silhouette with evidence of elevated pulmonary venous pressure and bilateral pleural effusions with compressive atelectasis. Evidence of resection of the medial half of the right clavicle is again seen. Dilatation of the gas-filled stomach appears to have resolved. [**2101-8-10**]: There has been interval decrease in right pleural effusion after positioning of right chest tube. Left pleural effusion is unchanged. Bibasilar atelectasis are larger on the left side. Cardiomegaly is stable. medial chest drains are again noted. Surgical clips project in the right medial hemithorax. There are low lung volumes. Discharge Labs: Brief Hospital Course: Patient is a 50 year old female with PMH of asthma, poorly controlled DM1 with last A1C of 13, HTN, ESRD s/p living related donor renal transplant in [**2092**], who was admitted for fevers and UTI, and found to have pneumonia, vegetative endocarditis and abscesses of chest wall and perinephric growing group B strep. Also with acute infarct of rostrum of corpus callosum and possible mycotic aneurisms (neurologically intact), and episodic hypotension. . Acute Care: . 1. Endocarditis: A small vegetation seen on mitral valve with mild mitral regurgitation on [**2101-7-27**]. This is the probable origin of septic emboli seeding patient's perinephric abscess and chest wall abscess. Microbiology from patient's abscesses grew PCN-sensitive GBS. Given patient's history of PCN allergy, she was started on IV vancomycin for coverage of the abscesses. When patient was showing only slow improvement, and there were new findings of infarct of the rostrum of patient's corpus callosum and formation of mycotic aneurisms, it was decided that patient should undergo PCN de-sensitization in the ICU and initiate PCN therapy. After treatment with IV PCN, repeat echocardiogram on [**2101-8-15**] was unable to revisualize the vegetation, consistent with healing. . 2. Right Chest Wall Abscess: Patient was found to have a large abscess of the right chest wall involving the soft tissue, clavicle, and first rib and extending to the pleural space. Cardiothoracic surgery debrided the abscess and removed infected portions of patient's clavicle and first rib. Plastic surgery closed the wound with a flap, and patient was discharged with instructions to follow up in office for suture removal and JP drain removal. IV PCN therapy was administered as definitive treatment for patient's GBS infection. . 3. Perinephric Abscess: A mass discovered adjacent to patient's grafted kidney was found by biopsy to be an abscess. In the OR, the abscess was drained, but there were portions that were not ammenable to drainage. Culture of the drainage grew GBS sensitive to PCN, and served as the target organism for antibiotic therapy with regards to patient's multiple areas of infection. Repeat imaging showed decrease in size of abscess on discharge. Patient was d/c'd with a PICC line and instructions to follow up with infectious disease as she is completing PCN therapy at rehab. . 4. Infarct of Rostrum of Corpus Callosum and Mycotic Aneurisms: Patient experienced several vasovagal syncopal episodes in house, and during the workup of one of these episodes, the findings of acute infarct of the rostum of the corpus callosum and two areas of probable mycotic aneurism were seen on MRA. Patient had no neurologic deficits on multiple neurologic exams. Felt to be caused by septic emboli from patient's vegetative endocarditis, these lesions were treated with IV PCN as were patient's other infectious foci. . 5. Vasovagal episodes: Patient had a total of 4 vasovagal syncopal episodes in this hospital stay. Patient's heart rate dipped below 40, she lost consciousness and quickly recovered without lasting deficit within minutes each time. Two occured after using the bathroom, one ocurred post-surgically, and one occured after eating a large meal and was followed by vomiting. These episodes can be explained by patient's rapidly changing fluid status related to multiple surgeries, and by a degree of relative adrenal insufficiency in the setting of prolonged stress from surgery and infection. Telemetry revealed episodic atrial tachycardia, so patient was placed on low dose metoprolol. Patient was without further episodes for several days with persistently stable vital signs for several days before discharge. . 6. Acute renal failure: On presentation, patient's creatinine was as elevated to 2.2 from baseline 1.1. There was likely an initial component of AIN due to NSAID use, but also a pre-renal component related to fluid loss from vomiting and insensible losses on presentation. Patient was given IV fluids during her hospitalization and by discharge patient's creatinine recovered to baseline. . 7. Anasarca: With multiple surgeries and procedures, and with possible relative AI and low vascular tone in the setting of infection, patient intermittantly required administration of crystalloid solution to support intravascular volume. This led to the accumulation of large lower extremity edema, bilateral pleural effusions, and pericardial effusion. Patient also experienced asymetric labial swelling. The right pleural effusion was tapped, a chest tube was temporarily placed, and labs showed transudative fluid so chest tubes were discontinued. With some days of accelerated diuresis with loop diuretics, the pleural effusions, the pericardial effusion, the lower extremity edema, and the labial swelling improved. . 8. Oozing of blood from sites of intervention: Patient had a drop of Hct on [**8-12**] and she had oozing of blood from previous sites of intervention including site of chest tube. Her plavix, which she was on for throbocytosis and previous episdode of TIA, was held for concern of bleeding. Given vasocagal episodes in-house concern for fall led to this being held as well, though she was stable and without incident in-hospital for days before discharge. She was discharged with instructions to follow up with hematology for potential re-start of plavix. . Chronic Care: . 1. S/p living related donor renal transplant. Patient was transplanted in [**2092**]. On this stay her tacrolimus was continued. Cellcept was held for concern of PTLD, but once ruled out and patient was stable, cellcept was restarted. Prednisone was continued but at stress dosing and was decreased on discharge. . 2. DM1: A1c 13.6 most recently. The [**Hospital **] Clinic was consulted on this admission and good glucose control was achieved on insulin schedule. . 3. hyperlipidemia: Patient was continued on home lipid-lowering [**Doctor Last Name 360**]. . 4. Depression: Social work followed patient during this admission. . 5. TIA history: Patient had an episode of a migraine with neurologic symptoms 2 months ago. She has a history of migraines in the past with blurry vision. MRI from [**2-/2101**], showed Punctate focus of slow diffusion in the left posterior frontal lobe consistent with a tiny acute infarct. Background mild microangiopathic small vessel disease as well. Patient was taking plavix but because of concern for bleed and fall it was held. . Transitional Care: Patient has multiple follow-up appointments to keep with her PCP, [**Name10 (NameIs) **], neurology, nephrology, transplant nephrology, Hematology, Plastic Surgery, and [**Hospital **] Clinic. Patient should have a repeat head MRA around [**2101-9-5**] to evaluate status of mycotic aneurisms and infarct of corpus callosum. Patient will have follow-up CT scan [**2101-9-5**] for imaging of perinephric abscess. Patient is to complete PCN G therapy in rehab until [**9-16**]. #. Contact - patient, her mother is [**Name (NI) **] [**Name (NI) 9780**] [**Telephone/Fax (1) 31412**] brother, [**Name (NI) 401**] [**Name (NI) 9780**] cell [**Numeric Identifier 31413**] or home [**Telephone/Fax (3) 31414**] # Full Code Medications on Admission: -ATORVASTATIN 10 mg by mouth once a day -CLOPIDOGREL 75 mg by mouth daily -FUROSEMIDE 20 mg by mouth once a day -METOPROLOL TARTRATE 50 mg by mouth four times a day - taking 3x/day -MYCOPHENOLATE MOFETIL 1000 mg by mouth twice a day -PREDNISONE 1 mg by mouth once a day -TACROLIMUS 2 mg by mouth twice a day -INSULIN REGULAR sliding scale 5 units qam and prn -NPH 40units sq qam, 10 units q pm Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous QAM. 3. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous QACHS: please follow sliding scale. 4. Outpatient Lab Work Please check labs - Chem-7, CBC, and LFTs weekly while patient is on penicillin and have the results faxed to ([**Telephone/Fax (1) 21403**] 5. penicillin G potassium 20 million unit Recon Soln Sig: 4 million Recon Solns Injection Q4H (every 4 hours): Until [**9-16**] for a course of 6 weeks. . 6. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day. 13. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 14. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO four times a day as needed for heartburn. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO every six (6) hours: hold for SBP<100 or HR<60. 17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: 1) Vegetative endocarditis 2) Perinephric and chest wall abscess 3) Mycotic Aneurism and Infarct of Rostrum of Corpus Callosum 4) Urinary Tract Infection 5) Pneumonia 6) Acute Kidney Injury Secondary: 1) s/p renal transplant 2) Type 1 Diabetes Mellitus 3) Hypertension 4) Thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 9780**], It was a pleasure taking part in your care. You were admitted to the hospital with 4 days of painful urination and two days of nausea and vomiting. In the hospital we found that you had a urinary tract infection, a growth of bacteria on one of the valves of your heart, and multiple areas of infection related to this. One was around your kidney, another was in your chest wall, and there were a few small areas of the brain that were concerning for infection as well. You were treated with surgery for the chest wall and kidney, and you were treated with penicillin for ramaining infection. Repeat imaging was unable to detect growth on your heart valves after receiving treatment. Please make the following changes to your medications: STOP clopidogrel STOP Lasix CHANGE Prednisone to 7.5mg by mouth daily CHANGE Mycophenolate Mofetil to 500mg by mouth twice daily CHANGE Metoprolol to 12.5mg by mouth every 12 hours CHANGE Insulin to Lantus 40 units in the morning and sliding scale with meals and before bed CHANGE Tacrolimus to 5mg by mouth every 12 hours START Penicillin G at 4million units by IV every 4 hours until [**9-16**] START Nystatin 5mL by mouth four times daily until [**9-16**] Please continue all other medications you were taking prior to this admission. Please keep all of your follow-up appointments. Followup Instructions: Please follow-up with the following appointments: - Please call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] for an appointment 2 weeks following discharge from rehab or hospital This is the apopintment with transplant nephrology - Please call [**Telephone/Fax (1) 4652**] for an appointment in Plastic Surgery clinic for drain removal and suture removal. Your appointment should take place on the first Friday after your discharge. -Please call for a confirm your follow-up appointment with Dr. [**First Name (STitle) 805**], your nephrologist. The appointment has been made, so please confirm date and time. ([**Telephone/Fax (1) 3637**] Department: RADIOLOGY When: MONDAY [**2101-9-5**] at 3:00 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: MONDAY [**2101-9-5**] at 4:20 PM With: XMR [**Telephone/Fax (1) 327**] Building: CC [**Location (un) 591**] [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2101-9-9**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) 14591**], [**First Name3 (LF) 14590**] N. MD Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appointment: Monday [**2101-8-29**] 2:30pm Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: HEMATOLOGY/BMT When: WEDNESDAY [**2101-9-21**] at 2:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are working on a follow up appointment in Neurology with Dr. [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**]. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [**Telephone/Fax (1) 31415**]. [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**] ICD9 Codes: 486, 2761, 2762, 5849, 5119, 2767, 4019, 2724, 311
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Medical Text: Admission Date: [**2123-2-22**] Discharge Date: [**2123-3-16**] Date of Birth: [**2047-7-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: SOB, R sided chest pain Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: 75 yo Male with COPD, CHF (EF 55%), Coomb's positive hemolytic anemia (transfusion dependent), 5Q Syndrome(loss of long arm of chromosome 5 causing transfusion dependent anemia - subtype of MDS), remote history of DVT, DM II, presents with sudden onset SOB, new orthopnea, R-sided pleurtic chest pain, and new lower extremity edema. Pt was transfused one unit [**Unit Number **] days prior to admission and he had recently stopped prednisone for coomb's positive hemolytic anemia. Pt denies fever and chills at home. Pt was admitted with similar complaints in [**2122-11-6**] at NEBH. At the time, the BAL cultures were negative and the patient was treated with abx and steroids. CT at time of discharge demonstrated worsening cystic formation. . In the ED, ECG showed ST depressions in leads V4-V6. The patient was subsequently started on heparin gtt. Given CXR findings of increased perihilar haziness, and R infrahilar haziness, in conjunction with fever to 100.4 and a lactate of 3.5, he also received azithro 500mg x1, ceftriaxone 1g IV x1, and Lasix 20mg IV x 1. After diuresis, the patient subsequently became hypotensive with decrease in SBP from 130s to 90s. He was then given NS 250 cc with some return of SBP to 110s. The patient did not receive a CTA to rule out a PE due to the developing acute renal failure. (No urine output to lasix.) . The patient was evaluated by the MICU resident on night of admission for respiratory distress. He was subsequently intubated due to hypoxia and respiratory distress. The patient was subseqeuntly found to have bilateral PEs on CTA consistent with findings of DVT on LE dopplers. The patient was not started on anticoagulation however given the concern for bleeding with several episodes of hemoptysis. In addition the patient also had a presumed aspiration PNA with an as yet unisolated organism. He had multiple cystic lesions which were concerning for infection, super infection or intrinsic lung disease and multiple bronchoscopy and BAL were unable to identify neither the infection or the underlying lung disease. However the patient did improve clinically on vancomycin, levofloxacin and flagyl. Although extubation was initially complicated by persistent secretions and poor spontaneous breathing trials, the patient was successfully extubated on [**2123-3-9**]. During his MICU course, the patient also received several blood transfusions for his Anemia and 5Q syndrome as well as multiple boluses of fluid to maintain blood pressure. The patient did well for 24 hours post extubation and was transferred to the floor hemodynamically stable. Past Medical History: 1. Chronic obstructive pulmonary disease/ emphysema. 2. Hypertension. 3. Sideroblastic anemia. 4. Cholecystectomy four years ago. 5. Status post appendectomy. 6. History of right-sided deep venous thrombosis. [**2101**] 7. h.o ETOH abuse 8. Recent ICU stay [**Month (only) 359**] at [**Hospital1 **] for Pneumonia requiring intubation. 9. IDDM 10. 5Q Minus Syndrome (loss of long arm of chromosome 5 causing anemia and MDS) 11. CHF, EF 55%, last echo [**2-8**]--> 1+ MR, mild PA HTN 12. Coomb's positive hemolytic anemia, recent at NEBH Social History: Pt is a retired architect who was raised in RI. He admits to having smoked 3ppd for over 20+ years but quit smoking tobacco in [**2087**]. He also admits to drinking 1 [**Doctor Last Name 6654**] and 0.5 bottle of wine every night with dinner. He has been drinking for 50+ years. The patient denies any illicit drug use ever. Family History: Mother - deceased at age [**Age over 90 **] due to "natural causes" Father - first MI at age 70s 3 sisters all of whom are healthy Physical Exam: Physical Examination on Admission to [**Hospital1 18**] VS: T: 100.4 BP: 107-63 HR: 101 RR: 20 SaO2: 93% on 4.5L NC Gen: elderly male, labored breathing, sitting bolt upright in bed HEENT: EOMI, PERRL, mmm Neck: fleshy CV: RRR, difficult to auscultate above breath sounds Lungs: bibasilar rales, rhonchi [**2-7**] way up right side, no wheezes Abd: obese, soft, NT, ND, no hepatosplenomegaly Ext: bilateral 2+ LE edema l>R (normal for patient) . . Physical Examination on Transfer to Floor [**2123-3-10**]: VS: BP: 179/76 HR: 62 RR: 20 SaO2: 97% on 4L and 93% on RA Gen: caucasian male lying in bed wearing NC in NAD. Pt is conversing in full sentences, no accessory muscle use. HEENT: PERRL, HEENT, anicteric, pale conjunctiva, mmm, posterior pharynx with mild erythema. Neck: no LAD, supple, full ROM CV: RRR S1, S2, no murmurs, rubs, gallops Chest: crackles on right side, however pt with large bandage over former chest tube site Abd: obese, soft, NT, ND, BS+, 8cm patch of petechiae over right upper abd below bandage Ext: 3+ pitting edema [**4-9**] way up shins, slightly cold, intact to sensation Neuro: A+Ox3 (although pt initially thought it was [**2068**], he corrected himself soon after), CN II-XII intact, sensation intact to light touch. . Pertinent Results: [**2123-2-21**] 11:30PM WBC-4.5 RBC-3.69*# HGB-11.1* HCT-30.9* MCV-84# MCH-30.0# MCHC-35.8* RDW-15.0 [**2123-2-21**] 11:30PM NEUTS-75.8* LYMPHS-15.3* MONOS-6.9 EOS-1.2 BASOS-0.9 [**2123-2-21**] 11:30PM MICROCYT-1+ [**2123-2-21**] 11:30PM PLT COUNT-331# [**2123-2-21**] 11:30PM PT-13.8* PTT-23.2 INR(PT)-1.2 [**2123-2-21**] 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2123-2-21**] 11:30PM ACETONE-NEG [**2123-2-21**] 11:30PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-2.3* MAGNESIUM-1.5* [**2123-2-21**] 11:30PM GLUCOSE-244* UREA N-38* CREAT-1.6* SODIUM-134 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17 [**2123-2-21**] 11:30PM ALT(SGPT)-88* AST(SGOT)-37 CK(CPK)-71 ALK PHOS-116 AMYLASE-28 TOT BILI-1.0 [**2123-2-21**] 11:30PM cTropnT-0.04* [**2123-2-21**] 11:30PM CK-MB-NotDone [**2123-2-22**] 06:00AM CK-MB-NotDone cTropnT-0.04* [**2123-2-22**] 06:00AM CK(CPK)-89 [**2123-2-22**] 08:49AM CK-MB-4 cTropnT-0.03* [**2123-2-22**] 08:49AM CK(CPK)-183* [**2123-2-22**] 05:41PM CK-MB-4 [**2123-2-22**] 05:41PM cTropnT-0.02* [**2123-2-22**] 06:04PM TYPE-ART TEMP-36.9 PO2-86 PCO2-30* PH-7.48* TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA [**2123-2-22**] 06:51PM O2 SAT-84 . . CXR [**2123-2-21**]: "FINDINGS: Cardiac and mediastinal contours are unchanged with mild cardiomegaly and a tortuous and unfolded aorta. There is increased perihilar haziness. There is also patchy increased opacity in the right infrahilar region. No definite effusions are identified. Lung volumes overall are slightly reduced. There is no pneumothorax. The osseous structures are unremarkable. IMPRESSION: 1. Increased perihilar haziness compared to the prior study may represent early CHF. 2. Increased right infrahilar opacity, concerning for pnemonia given the history of fever." . . Bilateral LE US [**2123-2-22**]: "The veins of the right lower extremity from the groin to below the popliteal trifurcation show normal color flow, normal Doppler with augmentation and normal compressibility. On the left side, however, the popliteal vein and anterior tibial vein are distended, noncompressible and partially occluded. The superficial femoral vein, greater saphenous and common femoral vein all show normal flow, compressibility, and Doppler wave forms. CONCLUSION: Acute DVT involving the left popliteal and anterior tibial veins. The remainder of the venous system is fully patent." . . TTE [**2123-2-23**]: "Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic root is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Right ventricular cavity enlargement with preserved biventricular systolic function. Compared with the prior study (tape reviewed) of [**2121-9-9**], the rhythm is now atrial fibrillation, and the right ventricular cavity appears larger. Based on [**2115**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. " . . [**2123-3-1**] IVC filter placement: "Successful placement of retrievable Recovery nitinol IVC filter just inferior to the level of the renal veins. The filter can be removed up to three months from the time of placement, or left in place permanently." . . [**2123-3-1**] CTA: "1) Filling defects in the right main pulmonary artery and a left lower lobe segmental branch. There is also necrotizing pneumonia involving the right lower lobe. These findings may represent two separate processes. Infarction involving the right lower lobe complicated by superinfection may also be considered in the differential diagnosis. The filling defect in the right main pulmonary artery directly abuts the dense consolidation in the right lower lobe raising the possibility of an invasive infectious process such as aspergillosis involving the right pulmonary artery. 2) Fullness of the left adrenal gland with a Houndsfield unit value of 4.5, likely representing an adrenal adenoma." . . [**2123-3-3**] TTE: "MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.57 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Right Ventricle - Diastolic Dimension: *3.6 cm (nl <= 2.1 cm) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave Deceleration Time: 235 msec TR Gradient (+ RA = PASP): *29 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [**2123-2-23**]. LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2123-2-23**], there is no significant change. " . . [**2123-3-4**]: "UNILAT UP EXT VEINS US RIGHT P Reason: RUE SWELLING [**Hospital 93**] MEDICAL CONDITION: 75 year old man with PNA, interstitial lung disease now with RUE swelling. REASON FOR THIS EXAMINATION: rule out DVT STUDY: Doppler ultrasound of upper limb veins. INDICATION: The patient with pneumonia. Right upper arm swelling. Rule out thrombosis. TECHNIQUE: Standard grayscale, color flow and pulse wave Doppler interrogation of the deep veins of the right upper limb was performed. Dynamic compression maneuvers were used where appropriate to evaluate the venous patency. COMPARISON: No study available for comparison. REPORT: The internal jugular vein, subclavian vein, brachial vein, basilic vein and cephalic vein are all clearly visualized and are patent. These demonstrate normal compressibility, augmentation, and respiratory variation where appropriate. There is no evidence of DVT. CONCLUSION: No evidence of right-sided upper extremity DVT." . . EMG [**2123-3-12**]: "Pt. is a 75 yo male with a complicated PMHx including MDS on steroids, CHF, COPD amd recent prolonged hospitalization for respiratory distress during which he was intubated and sedated. Upon awakening he was profoundly weak. Directed examination revealed severe weakness of all extremities, approxiamately 1-2/5 except for triceps and wrist extensors which were 2+/5. Sensory exam was essentially normal except for vibratory loss in the toes and [**Last Name (un) 64146**]. He was areflexic, atonic, and edematous throughout all four extremities. This study was requested to rule out a generalized myopathy. FINDINGS: Motor nerve conduction studies(NCSs) of the left median nerve revealed severely reduced response amplitude(RA) with distal stimulation, no response with proximal stimulation and normal distal latency; F waves were unobtainable. Motor NCSs of the left ulnar nerve revealed severely reduced RA with normal conduction velocity below the elbow, mildly slowed velocity across the elbow and a mildly prolonged distal latency; F waves were unobtainable. Motor responses of the left tibial nerve recording abductor hallicis and of the deep peroneal nerve recording extensor digitorum brevis and tibialis anterior were unobtainable. Sensory NCS of the left median nerve revealed moderately reduced RA with normal conduction velocity. Sensory NCS of the left ulnar nerve revealed moderately reduced RA with normal conduction velocity. Sensory NCS of the left radial nerve revealed mildly reduced RA with normal conduction velocity. Sensory NCS of the right sural nerve revealed moderately decreased RA with moderate slowing of conduction velocity. Sensory response of the left sural nerve was unobtainable. 3HZ repetitive nerve stimuation of the left ulnar nerve recording abductor digiti minimi did not reveal any signficant decrement. There was no facilitation of the left abductor digiti minimi compound muscle action potential with 10 seconds of maximal voluntary contraction. Concentric needle electromyography(EMG) of the left deltoid and biceps revealed early recruitment of motor units with an excess of small amplitude, short duration, polyphasic motor units; a few fibrillation potentials were noted in biceps. EMG of the left tibialis anterior revealed early recruitment of motor units with an excess of small amplitude, short duration, polyphasic motor units without evidence of denervation. Exam of the left vastus lateralis revealed early recruitment of markedly small amplitude, short duration, polyphasic motor units without denervation. IMPRESSION: Abnormal study. There is electrophysiologic evidence for a severe, generalized myopathic process with evidence for scant ongoing denervation (as can be seen in critical illness myopathy). The generalized reduction in sensory amplitudes may be due to the patient's generalized edema; however, a generalized polyneuropathy cannot be excluded. The findings do not suggest a pre- or post-synaptic disorder of neuromuscular transmission." . . . MRI C-spine [**2123-3-13**]: "MR [**Name13 (STitle) **] W& W/O CONTRAST [**2123-3-13**] 6:49 PM MR [**Name13 (STitle) **] W& W/O CONTRAST; MR CONTRAST GADOLIN Reason: please do w/ and w/o gad, fat sats, looking for epidural abs Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 75 year old man with chf, copd, mds, recent icu stay now with weakness in all extrm REASON FOR THIS EXAMINATION: please do w/ and w/o gad, fat sats, looking for epidural abscess CLINICAL INFORMATION: Patient with weakness in all extremities for further evaluation. The examination is performed to rule out epidural abscess. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 gradient echo and T1 axial images of the cervical spine were acquired. The patient was unable to continue and was unable to hold still leading to motion artifacts on the images. FINDINGS: The examination is limited due to motion artifact. No evidence of high-grade spinal stenosis is seen. On gradient echo and T1 axial images, no evidence of extrinsic spinal cord compression is appreciated. On sagittal T2 and inversion recovery images, artifacts have limited evaluation of the spinal canal and spinal cord. There is no evidence of vertebral malalignment seen. No evidence of ligamentous destruction is noted. IMPRESSION: Markedly limited study secondary to motion. On axial images, no evidence of high-grade spinal stenosis is seen. A repeat study with sedation would be helpful for further evaluation of the spinal canal if clinically indicated." . . [**2123-3-1**] BAL: "NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages, neutrophils and lymphocytes. No viral inclusions or fungus seen. " "GRAM STAIN (Final [**2123-3-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2123-3-3**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2123-3-2**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. WORK-UP REQUESTED BY DR [**Last Name (STitle) **],[**Doctor Last Name 9406**] . FURTHER IDENTIFICATION TO FOLLOW. ACID FAST SMEAR (Final [**2123-3-2**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Final [**2123-3-2**]): TEST CANCELLED, PATIENT CREDITED. DUPLICATE SPECIMEN. PLEASE REFET TO SPECIMEN # 182-7308S [**2123-3-1**] FOR RESULTS. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2123-3-2**]): TEST CANCELLED, PATIENT CREDITED. DUPLICATE SPECIMEN. PLEASE REFER TO VIRAL CULTURE ON SPECIMEN # 182-7308S [**2123-3-1**] FOR RESULTS. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2123-3-2**]): BUDDING YEAST. " . . Brief Hospital Course: A/P: 75yo Male with COPD, 5Q minus syndrome, Coombs positive hemolytic anemia, HTN, and CHF who presents w/ acute onset SOB, low grade fever(despite several Tylenol doses), and hypotension responsive to 250cc Bolus concerning for PNA and ? dehydration. . 1. Respiratory failure: Initially on admission to [**Hospital1 18**], the etiology of the respiratory failure was unclear. However at time of presentation, he was found to be in profound respiratory distress and was transferred immediately to the Medical ICU. On initial CXR, the patient was found to have a spontaneous right apical pneumothorax and infiltrate concerning for possible PNA vs. CHF. A chest tube was placed by thoracic surgery to decompress the pneumothorax. A subsequent LE US demonstrated left popliteal DVT and the patient was started anticoagulation with a heparin gtt for presumed pulmonary embolus. A CTA was eventually performed which confirmed the diagnosis of pulmonary embolus.. Later during the course of his hospital stay, the patient developed hemoptysis and the heparin gtt was stopped. In addition, the patient was started on antibiotics for his PNA (vancomycin/ceftriaxons/flagyl). A chest CT was not initially performed due to his hemodynamic instability. He was intubated on [**2123-2-23**] for worsening respiratory distress. A Bronchoscopy performed at the time was not revealing for any obvious pathology and BAL returned negative for all cultures. During his ICU stay, he had work up for fungal process x 2. BAL x 2 here without any isolation of organimss. The patient clinically responded well to abx treatment and althoug had some difficulty with extubation secondary to persistent secretions, he was extubated on [**2123-3-9**]. Since extubation, he has remained stable and was transferred to the floor. Since arrival to floor, he remained stable from a hemodynamic and respiratory standpoint. (see subsections below for more details). . A) Infection: Pt initially admitted with low grade fever and SOB (as well as hypotension which was responsive to fluids). The CXR was consistent with a blossoming PNA RLL (necrotizing component as per report). And a following CT demonstrated diffuse ground glass opacity, LLL abscess, and honeycombing. New cystic areas were noticeable compared to [**9-9**]. His workup however was not revealing for any particular organism. Stool was found to be negative for c.diff x3, urine cultures did not result in any growth from [**2-22**] and [**2-26**], sputum grew out only sparse bacillus and was negative for yeast. BAL demonstrated no fungus, legionella, PCP, [**Name10 (NameIs) 11381**], [**Name11 (NameIs) 103824**] on two separate occations ([**2-23**] and [**2-25**]). Blood cultures were also negative throughout his hospital course and the patient tested negative for galactomannan. Although no organism grew from any source, his rapid response to antibiotics made it likely that he was infected with possible a pneumococcus (given his residence within the community, and sudden onset. A VATS was considered and CT surgery was consulted, they did not feel it was indicated considering his rapid improvement on antibiotics. . B) PE: Pt with documented bilateral PEs on CTA. An IVC filter was placed by IR (the filter is a 3 month filter which can be removed at the time). The patient was initially started on anticoagulation with heparin, howeve due to episodes of hemoptysis, the anticoagulation was stopped. TTE on [**2-23**] demonstrated mild pulmonary HTN with EF >55%. We recommend, re-starting anticoagulation with coumadin with target INR of [**3-11**] several weeks from discharge and removal of IVC filter in 3 months as it may become thrombogenic at that point. . C) Pneumothorax: The patient was found to have right apical pneumothorax on admission CXR on [**2-21**]. As the pneumothorax was enlarging by CXR on [**2-23**], thoracic surgery was consulted and a chest tube was placed. The CXR was removed a week later without complication and surveillance CXR since then showed complete resolution of CXR. . D) COPD: Pt did not appear to have an acute exacerbation of his COPD. He was continued on nebulizers without an issue. . 2. Anemia: Pt with a history of 5Qminus syndrome (a subset of MDS with mutation leading to loss of function of epo receptor on RBC) and a history of Coomb's positive hemolytic anemia which was previously treated with decadron. The patient has been followed by Dr. [**Last Name (STitle) **] (heme/onc - can be reached at [**Telephone/Fax (1) 103825**]). He was admitted on thalidomide for his MDS and decadron for his hemolytic anemia. However the thalidomide was held while in house. A daily Hct was followed with intention to transfuse for goal Hct >25. After the patient recovered from respiratory distress and was extubated successfully, he was transferred to the floor. There he was started on rituximab (865 IV once a week for 4 weeks) as per Dr. [**Last Name (STitle) **]. The decadron was tapered down to 6mg once daily with intentions to decrease decadron even further. Dr. [**Last Name (STitle) **] will follow the patint while at [**Hospital3 **] for his rituximab dosing as well as his decadron taper (anticipate decreasing decadron to 4mg PO once daily on Thurs [**2123-3-18**]). IVIG was considered for immune re-constitutions as well as for his MDS, however this will be started as an outpatient at Dr. [**Last Name (STitle) 103826**] discretion. Recommend following CBC every two-three days to monitor for signs of blood loss. . 3. CHF: On admission to [**Hospital1 18**], the patient was initially hypotensive responsive to fluids. While in the MICU, the patient was given numerous fluid boluses to maintain blood pressure and overall resulted in gross anasarca. On transfer to the floor, he was found to have 3+ pitting edemea bilaterally in both the upper and lower extremities. He was aggressively diuresed with lasix 40mg IV BID with goal to diurese 2L/day. On day of discharge, the patient had significantly improved from a clinical standpoint - upper extremity edema was resolved and the patient had 1+ lower extremity edema. The patient was placed back on his outpatient regimen of lasix 80mg PO once daily in addition to aldactone 25mg PO TID. The creatinie was stable during the active diuresis at 0.5 and BUN of 20s. The patient did have an isolated episode of hyponatremia. This was thought to be due to hypervolemic hyponatremia given his gross anasarca. The hyponatremia resolved with continued diuresis. Recommend continued diuresis until euvolemic. . 4. Myopathy: On transfer to the floor, the patient was found to have significant weakness - myopathy. At the time, this was though to be due most likely to ICU myopathy vs. steroid myopathy as pt was intubated and sedated for 16 days while on chronic steroids. Neurology was consulted and an C-spine MRI as well as EMG was performed. The clinical findings as well as the results of the EMG was consistent with ICU myopathy and no pathology was found on C-spine MRI. The patient continued to receive PT while on the floor and improved steadily. However he still required significant help with all ADLs. Anticipate several months of intensive rehab necessary to regain his funcational status. . 5. AFib: Pt developed afib with rapid vent response on [**2-23**]. At the time, the patient failed DCCV X 2 but reverted back to sinus rhythm spontaneously later on. Patient was loaded on IV amio and placed on amio gtt. Patient is now on amiodarone 200mg once daily with good control. Lopressor was added for additional control in MICU. Since transfer to floor, the patient has been in NSR without evidence of afib. . 6. ARF: Pt was initially found to be in ARF. This was thought to be due to pre-renal failure secondary. After fluid boluses the ARF resolved with Creatinine back to baseline. Creatinine was stable even after aggressive diuresis on the floor. 7. DM: Pt required insulin gtt while in unit due to decadron. The patient was placed back on outpatient dose of 20/30 20units [**Hospital1 **] with tight RISS. The FS remained within the normal range on his outpatient regimen for diabetes after titration of decadron. . 8. Hypotension: The patient was admitted with hypotension which was responsive to fluids. [**Last Name (un) **] stim test was negative. Lactates trended down and BP was no longer an issue after his acute management. . 9. Code: DNR but intubatable. Confirmed with patient on multiple occasions. . 10. If you have any question, please page Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital1 69**] at #[**Numeric Identifier 9522**]. . Medications on Admission: On Admission to [**Hospital1 18**]: 1. Thalidomide 2. Coumadin 3. 70/30 20units [**Hospital1 **] 4. Lisinopril 5. Diovon 6. Toprol 7. Lasix 80mg once daily 8. Spironolactone 25mg TID 9. Advair Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puffs Inhalation Q2H (every 2 hours) as needed. 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-7**] Puffs Inhalation Q4H (every 4 hours). 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) tx Inhalation Q4H (every 4 hours). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) tx Inhalation Q4H (every 4 hours). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. 13. Vancomycin HCl 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous Q12H (every 12 hours) for 6 days. 14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 19. Insulin 70/30 70-30 unit/mL Suspension Sig: Twenty (20) units Subcutaneous twice a day. 20. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 21. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO once a day. 22. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Pulmonary Embolus, Pneumonia, Spontaneous Pneumothorax Secondary: 5Q minus Syndrome, Coombs Hemolytic anemia, HTN, COPD, CHF Discharge Condition: Stable. Discharge Instructions: Please take all of your medications. Please follow up with your doctors, especially Dr. [**Last Name (STitle) **] If you notice any shortness of breath, difficulty breathing or fever please call your Dr. [**Last Name (STitle) **]. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within one week of discharge. You must call him for your rituxin dosing prior to Mon [**2123-3-22**]. Please call for an appointment: [**Telephone/Fax (1) 103825**]. Completed by:[**2123-3-17**] ICD9 Codes: 5849, 4280
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Medical Text: Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-16**] Date of Birth: [**2122-12-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 562**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: R internal jugular central line History of Present Illness: 51 yo male with AIDs (dx [**2158**], on HAART, VL undetectable, CD4 90 [**1-3**], h/o thrush and esophagitis) admitted with back pain/flank pain and fevers. He was in hus USOH until [**2174-1-27**] when he went to his PCP's with R sided pleurtic chest pain. He also had a resurangence of fevers to 102 - 105 and night sweats which he had had for 13 years, then stopped 2 years prior when he started HAART. CXR on [**2174-1-27**] showed infiltrate within the left upper lobe and an opacityl at the right heart border. He was started on Levaquin at that time. Then on [**2174-2-3**], he went to [**Hospital1 **] [**Location (un) 620**] with L calf pain. He was admitted with a DVT and multiple PEs. Chest CT at that time also showed multiple bilateral segments and subsegmental pulmonary emboli, consolidation vs. infarct in the posterior left upper lobe and anterior right lower lobe, multiple bilateral pulmonary nodules, and mediastinal lymphadenopathy. MDs there were also concerned that he could have TB as he had weight loss, fevers, and pulm nodules. He underwent bronch on [**2174-2-7**] which was "normal". Cytology showedd atypical flora. Cultures/labs from there showed negative crypto ag, oral flora from the bronch, AFB smear negative, culture pending. He was started on coumadin and heparin and a second of levofloxacin. During this stay, he had no pulmonary symptoms. . On discharge from [**Location (un) 620**], he noticed his Right leg now was tender, where it had not been before. He then was switched to a course of Doxy on [**2-11**] my his PCP. [**Name10 (NameIs) **] was not doing well at home since he was having extreem pain in both his legs. The swelling in the LLE diminished, but the right increased. He had no pulmonary symptoms until the afternoon on [**2-18**] when he began to become SOB. He came to the ED. . In ED, initial vitals were 103.6, HR 145, BP 78/62, RR 18, 98% -> 100% on 2L .He was complaiing of worsening SOB and pleurtic right chest pain. Code sepsis called, RIJ placed. Initial CVP was 7. he was boluesd 8 L NS in the ED. Of note, his O2 sat on arrival was 98% RA, then 100% 2l in the ED,94% on 4L NC on arrival to MICU. he was started on Dopamine and levophed. He was given 1 gram of vancomycin, 1 gram of CTX, and a DS bactrim. Blood cultures and urine cultures were sent. A ct chest revealed a left upper lobe opacity, subsegmental PE's, multiple B pulm nodules. . Currently, he is SOB and c/o pleurtic right sided and posterior chest pain and bilateral calf pain. He has been having fevers to 102 - 105 daily with night sweats. Denies large weight gain (he has had touble with weight loss since his MAC). No HA. No neck pain. No nausea. No vomiting. Has one loose BM daily [**3-3**] HAART. Denies missing any of his medicine. Quit smoking 2 eeks agi. No recent PPD. No TB contacts. [**Name (NI) **] Rashes. No recent travel. Past Medical History: AIDS on HAART c/b thrush H/O MAC infection of unknown site DVT left leg- [**2174-2-3**] COPD- bullous changes intermittent diplopia asymptomatic UTI Moderate cervical spondylosis with moderate spinal canal stenosis and multilevel bilateral neural foraminal narrowing seen on MR cervical spine- [**2170**] Epidermal inclusion cyst- right thigh Social History: +tobacco ([**1-31**] pack a day) x35 years and quit 2 weeks ago, no ETOH. no illict drugs, lives alone. Works part-time with caterers. Family History: Mother- breast cancer, stomach cancer Father: CVA, heart disease Physical Exam: wt: 62kg, 97.9 po, p123, 108/75 (dopamine 9, levophed .2), r28, 96% on 4l nc (ED 8liter in and 1500cc out) General: mild resp distress, talkitave. Able to relate history well. HEENT: NC/AT, PERRLA. dentures in, no thrush seen. no scleral icterus noted, MMM. Neck: Supple, JVP normal Pulmonary: Anterior reveals a three componet pulmonary rub. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: diffusly tender with voluntary guarding. normoactive bowel sounds, no masses or organomegaly noted. extreme right CVAT Extremities: 1+ pitting edema bilaterally on calf. VERY tender gastroc. 2+ radial, DP and PT pulses b/l. Neurologic: A and O x3; srength grossly normal. Brief Hospital Course: Assessment: 51 yo m with AIDS, recent diagnosis of PE, pulmonary nodules, fevers, and shock. His shock is most likely due to sepsis given his increasing WBC and low CVP making right heart strain from PE unlikley. . Plan: # Septic shock: He seems to be in distributive shock. Most likely this is sepsis, given that he is immunocompromised with fevers and respiratory distress. However, Adrenal insufficiency unlikely given normal [**Last Name (un) 104**] stim test. Given his immunocomprimised state, he has many potential sources for sepsis including bactreial, fungal, and viral. Infectious disease was consulted who recommended continue treatment with caspofungin, azithromycin, imipenem-cilastin. Continue antiretrovirals and bactrim ppx. Unclear source at this point. So far all cultures NGTD, cryptococcus, CMV, and histo serologies negative, AFB x3, PCP stain, [**Name9 (PRE) 20613**] ag, negative. Pt was placed on Sepsis protocol. With frequent NS fluid bolus for CVP >12 and pressors. He had episode of NSVT on arrival while on dopamine and was changed over to levophed, which he required for several days of his addmision to keep MAP>65. Given persistent hypotension concern for neurogenic shock secondary to autonomic dysfunction, Neuro consult was obtained who did not think that patient has autonomic dysfunction on initial assessement. . # Respiratory distress - as above, most likely secondary to pulmonary infection complicated by pulmonary emboli. Required significant oxygen supplementation initially but this was reduced by 6 days of hospitalization from NRB to 40% by facemask. . # PE/DVT: Hx of DVT and PE on recent hospitalization. RL LENI shows DVT this admission. Given likely coumadin failure IVC filter was placed. Pt was started on heparin initially and then changed over to lovenox 1mcg/kg [**Hospital1 **]. [**2-27**] AM with RUE swelling as well, with DVT. Heme onc consulted, started on heparin as developing DVTs through lovenox. - Given recurrent dvt and ?pulmonary nodules and enlarged lymphnode concern for malignancy in setting of hypercoguble state high. - Currently morphine prn. . #. hemoptysis - likely secondary to underlying pulmonary processes. Consider bronchoscopy only if this worsens (currently stable). . #Polyuria - Unclear etiology. Continues to urinate to the point of hypotension despite IVF being stopped. [**Month (only) 116**] have neprogenic DI [**3-3**] ambisome. [**Month (only) 116**] also not be able to concentrate urine to excrete all the salt he has gotten on the sepsis portocol causing an solute diuresis. Gave dose of ddAVP to see if can concentrate urine. Ambisome switched to caspofungin. - Renal was consulted given concern for DI. They did not think that the pt has diabetes insipidus given that the patient has had normal Uosm and Una. More likely, this is consistent with a solute diuresis from the large amounts of fluid the patient has received during this hospitalization. It is unclear whether he is intravascularly depleted or overloaded, and his weight is up approx 6kg. If he is making appropriate urine to previous IVF administration, would expect his urine now to more accurately match his input. With restriction on NS IVF, pt's urine output has improved. . # Infection - unclear etiology most likely source of infectionis pulmonary, but differential in this immunocompromised patient is very broad. ID following. So far all cultures NGTD, cryptococcus, CMV, and histo serologies negative - on retrovirals, azithro/bactrim - imipenem dc'd- continuing with vanco . ## Neuro - pt with c/o diplopia this morning which is new. Also with nystagmus on exam concerning for brainstem process. - per discussion with neuro attg, given pt's likely hypercoaguble state need to rule out stroke. - MRI/MRA -small L cerebellar stroke, w/ sluggish basilar artery flow, CTA also showed no thrombus but decreased basilar artery flow. Per Neuro ordered TTE w/ bubble, no ASD or PFO - Daily CT showed no change (needs daily CTx7 day to assess no hemorrhagic development . #Hemoptysis - likel secodary to PE and PNA. Stable in amount and frequency. Is small amounts at this time. If decompensates of hemoptysis progresses beyond tsp amounts will need bronchoscopy and possible surgical consult. . ## Neuro - pt with c/o diplopia this morning which is new. Also with nystagmus on exam concerning for brainstem process. - per discussion with neuro attg, given pt's likely hypercoaguble state need to rule out stroke. - MRI/MRA to eval for stroke. . # AIDS: Initially held HAART therapy. Restarted on [**2173-2-24**]. #. pulm nodules - concern for malignancy given fevers, LAD. o/w infection as above. with LUL mass, discuss timing of biopsy as differential includes lymphoma vs lung neoplasm, will need to discuss holding anticoagulation. . PPx: PPI, no pneumoboots, lovenox, increase bowel regimen given constipation, no bowel movement since admission per pt FEN: po diet as resp status stable Access: RIJ, R art line, PIV Communication: sister [**Name (NI) **] Dispo: ICU until HD stable # Code Status: Full, discussed extensively with paitent and HCP, [**Name (NI) **], his sister. [**Name (NI) **] is very nervous about intubation, but agrees that he may benefit from it in the short term. # Dispo: ICU for now given hypotension. # Contact: [**Name (NI) **], sister ... The patient had a prolonged intensive care unit stay. He developed further progressive thromboses. An IVC filter was placed to prevent further pulmonary emboli. He developed ischemic bowel with thrombosis of celiac and mesenteric arteries. After extensive discussion with patient and his sister [**Name (NI) **], the patient was made care and comfort measures only. He was treated with IV morphine and expired peacefully on [**2174-3-16**]. Medications on Admission: Truvada Reyataz 150' Norvir 100' Bactrim DS' Azithromycin twice weekly Ambien prn Doxycycline 100 mg [**Hospital1 **] since [**2-11**] Vicodin 5/725 prn for leg pain Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Acquired immune deficiency syndrome adenocarcinoma of lung pulmonary emboli mesenteric ischemia Discharge Condition: Deceased Discharge Instructions: Remains released to funeral home Followup Instructions: None ICD9 Codes: 0389, 496, 486, 4168
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Medical Text: Admission Date: [**2136-1-16**] Discharge Date: [**2136-1-30**] Date of Birth: [**2136-1-16**] Sex: M Service: HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 42484**] is the number one first born triplet of a 34 and [**1-11**] week gestation pregnancy born to a 36 year-old G4 P2 woman. Estimated date of confinement was [**2136-2-26**]. Prenatal screens blood type B negative, antibody positive, anti-D treated with RhoGAM, hepatitis C surface antigen negative, RPR nonreactive, Rubella immune, group beta strep status unknown. Pregnancy was complicated by pregnancy induced hypertension. This was a spontaneous triplet conception. This infant was born by cesarean section. Apgars were 9 at one minute and 9 at five minutes. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity and respiratory distress. PHYSICAL EXAMINATION: Weight 2.090 kilograms, length 43.5 cm, head circumference 32 cm. General, age appropriate with obvious respiratory distress. Head, eyes, ears, nose and throat normocephalic, atraumatic. Scalp palate intact. Red reflex present bilaterally. Neck supple with no masses. Chest lungs with poor air entry, active grunting, intercostal retractions and nasal flaring. Cardiovascular regular rate and rhythm. No murmur. Abdomen soft with active bowel sounds. Femoral pulses 2+. Hips stable by midline. Anus patent. Genitourinary male with testes present bilaterally in canal. Neurological tone and reflexes consistent with gestational age. HOSPITAL COURSE/PERTINENT LABORATORY DATA: 1. Respiratory: [**Known lastname **] required intubation and received one dose of surfactant. He was extubated on room air on day of life number one and remained in room air through the rest of his Neonatal Intensive Care Unit admission. He has had no episodes of spontaneous apnea or bradycardia. 2. Cardiovascular: [**Known lastname **] has maintained normal heart rates and blood pressures, a soft murmur was heard on day of life 12. Has been intermittent since then. It is felt to be benign in nature. 3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially NPO and maintained on intravenous fluids. Enteral feeds were started on day of life number one and gradually advanced to full volume. He has been all po since day of life number 10 [**2136-1-26**]. At the time of discharge he is taking Enfamil 24 calories per ounce minimum of 130 cc per kilogram per day. Discharge weight is 2.37 kilograms with a length of 47 cm and a head circumference of 33 cm. 4. Infectious disease: Due to the unknown etiology of his respiratory distress [**Known lastname **] was evaluated for sepsis and treated presumptively. A white blood cell count was 14,300 with a differential of 30% polys, 0% bands. The blood culture was obtained prior to starting antibiotics. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal: Peak serum bilirubin occurred on day of life number three a total of 5.6/0.3 mg per deciliter direct. He did not require treatment. 6. Neurological: [**Known lastname **] has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge. 7. Sensory: Audiology, hearing screen was performed with automated auditory brain stem responses. [**Known lastname **] passed in both ears. 8. Hematological: [**Known lastname **] is blood type A positive, Coombs negative. Birth hematocrit was 43.5%. CONDITION ON DISCHARGE: Good. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1894**] [**Last Name (NamePattern1) 53133**] General Medical associates [**Apartment Address(1) 53134**], [**Location (un) 86**], [**Numeric Identifier 53135**]. Phone number [**Telephone/Fax (1) 53136**]. Fax number is [**Telephone/Fax (1) 53137**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Enfamil 24 calories per ounce ad lib. 2. No medications. 3. Car seat position screening was performed. [**Known lastname **] was observed in his car seat for 90 minutes without any episodes of desaturation or bradycardia. 4. State new born screen: Initial was sent on [**2136-1-19**] with a repeat on the day of discharge [**2136-1-30**]. No notification of abnormal results to date. 5. Immunizations received: Hepatitis B vaccine was administered on [**2136-1-25**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criterias, first born at less then 32 weeks; second born between 32 and 35 weeks with two of three of the following; day care during RSV season, smoker on the household, neuromuscular disease, airway abnormalities, or school age siblings; or thirdly with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months age. Before this age the family and other care givers should be considered for immunization against influenza to protect the infant. 7. Follow up appointments: Recommended with Dr. [**Last Name (STitle) 53133**] within three days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and [**1-11**] week gestation. 2. Triplet number one of triplet gestation. 3. Respiratory distress syndrome. 4. Suspicion for sepsis ruled out. 5. Intermittent heart murmur likely benign [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 50655**] Dictated By:[**Last Name (Titles) 37548**] MEDQUIST36 D: [**2136-1-30**] 06:37 T: [**2136-1-30**] 06:27 JOB#: [**Job Number 53138**] ICD9 Codes: 769, V290, V053
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Medical Text: Admission Date: [**2144-5-19**] Discharge Date: [**2144-5-27**] Date of Birth: [**2059-7-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 832**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 20741**] is an 84 yo M with COPD (not on home oxygen), asbestos exposure, OSA, and CAD s/p CABG (LIMA->LAD) in [**2144-4-21**] who presents from [**Hospital 100**] Rehab with acute onset shortness of breath and R sided chest pain. The patient has been hospitalized multiple times over the past month. Briefly, the patient underwent elective minimally invasive, endoscopic CABG on [**2144-4-21**] after experiencing worsening exertional chest pain. His hospital course was complicated by the need to return to the OR for re-exploration of his chest for bleeding after increased chest tube output was noted, and a L sided pleural effusion, have an increased oxygen requirement at that time that was unable to be weaned. He was discharged to [**Hospital1 **] for cardiac rehab on [**4-29**]. The patient re-presented on [**5-6**] with fever and abdominal pain and diagnosed with acute cholecysitis. He was deemed a poor surgical candidate, so a perc chole was placed on [**5-8**], capped on [**5-15**] due to poor drainage through cystic duct noted on T-tube cholangiogram, and he completed a 10 day course of cipro/flagyl (completed on [**5-17**]). This hospital course was c/b an acute stroke on [**5-12**] where the pt experienced decreased sensation on the right upper extremity which was improving, as well as a right field cut, a right upper motor neuron hemiparesis, and a right hemisensory deficit. His Head CT and MRI showed acute infarctions in the left occipital lobe, left thalamus, left cerebellar hemisphere and right superior cerebellum. TEE on [**5-15**] negative for left atrial thrombus. The etiology was thought to be cardioembolic, and lifelong anticoagulation was recommended with coumadin. He was discharged to [**Hospital 100**] Rehab on [**5-15**] to complete his heparin bridge to coumadin. Per discussion with the family, the patient was progressing well at rehab over the past few days, although he has had an new oxygen requirement (minimal 2-3 L NC) since his CABG. Last Saturday, the patient was noted to walk 250 feet and experiencing only mild SOB. Over the weekend, he developed a low grade fever, and [**Name8 (MD) **] MD notes was noted to be hypoxic to 86% on RA (improved to 95% on 2L). CXR at rehab showed multiple scars, patchy bilateral radio-opacities, and evidence for pleural thickening with fluid on the left. Yesterday, around 4 pm, one of his family members also noted that he was back on oxygen at the rehab and was a bit more lethargic than usual, and perseverating. He also developed a new leukocytosis. (10.4 on [**5-16**] ->21.0 on [**5-19**]). On the morning of admission, the patient endorsed R sided pleuritic chest 'tightness' and 'inability to catch his breath.' Hewas given lasix 20 mg IV x1, started on a heparin gtt, and transferred to [**Hospital1 18**] ED for further evaluation. In ED VS were 99.7 85 112/49 21 95% on 3 L. His labs were significant for a WBC of 23.1 with a left shift, plt of 691, CK 15 Trop-I < 0.01, INR of 2.3. EKG without new ischemic changes. CTA Chest showed no evidence of PE, but worsening BL pleural effusions with evidence of loculation, pneumonia could not be excluded. T-tube test of perc chole showed patent flow. Bedside U/S per report showed no pericardial effusion. CT surgery was consulted and did not think his pleural effusions were significantly larger than before, and recommended no emergent surgical intervention. He was given Vancomcyin 1 gram IV x1 and Zosyn 4.5 grams IV x1, combivent nebs x1, and 2 L NS. Lactate trend was 2.4-> 1.2 ->0.9. Patient was admitted to the medicine floor. Per report from ED resident to floor medicine resident Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], patient appeared comfortable on nasal cannula alone. When the patient arrived to the floor, he was noted to be tachypneic to the 30s and on 12 L ventimask. His oxygen saturations on 2 L NC was 84%. ABG was 7.45/34/65. MICU resident was consulted for transfer to MICU for further monitering given hypoxia, increasing oxygen requirement. His VS were 34, 88 119/50 94% 6 L NC + 50% venti face mask prior to transfer to the ICU. On the floor prior to transfer, the patient was AOx2 (name, '[**Hospital1 18**]'). He stated his breathing was more 'shallow' than normal. Denied any chest pain or abdominal pain. He is unable to bring up any sputum with his coughing. Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - CAD s/p right coronary artery stent x2 ([**10-3**], [**3-4**]) and s/p elective CABG on [**2144-4-21**] (LIMA-> LAD), c/b re-exploration required for bleeding - acute cholecystitis s/p perc chole placement on [**2144-5-12**] - Hypertension - Hyperlipidemia - Chronic obstructive pulmonary disease - Asbestos exposure - Chronic back pain, - Insomnia and obstructive sleep apnea (untreated) Social History: Lives with wife. Exposure to asbestos. Defers all medical decisions to son who is a chiropractor. Occupation: retired postal worker. Tobacco: 3 PPD x 30 years, quit 45 years ago ETOH: None Family History: Non-contributory. Physical Exam: VS: 99 91 123/60 74 26 91-94% on 50% venti face mask GA: elderly male, AOx2, mild respiratory distress but not using accessory muscles to breathe. HEENT: PERRLA. MM dry. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: poor air movement, increased expiratory phase. decreased BS at the bases. Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. perc chole not erythematous, tube capped. Extremities: DPs, PTs 2+. decreased temperature noted in both feet BL. Neuro/Psych: CNs II-XII intact. 4/5 strength in U/L extremities. DTRs 1+ BL (biceps, achilles, patellar). sensation intact grossly. cerebellar fxn intact (FTN, HTS). gait deferred. decreased sensation over RUE to light touch. Pertinent Results: ADMISSION LABS: [**2144-5-19**] 11:10AM WBC-23.1* RBC-3.67* Hgb-11.6* Hct-36.0* MCV-98 Plt Ct-691* [**2144-5-19**] 11:10AM Neuts-92.9* Lymphs-3.7* Monos-2.7 Eos-0.3 Baso-0.3 [**2144-5-19**] 11:10AM PT-27.0* PTT-88.6* INR(PT)-2.6* [**2144-5-19**] 11:10AM UreaN-14 Creat-1.1 Na-133 K-4.5 Cl-97 HCO3-27 AnGap-14 [**2144-5-19**] 11:10AM ALT-14 AST-15 CK(CPK)-15* AlkPhos-99 TotBili-0.4 [**2144-5-19**] 11:10AM Lipase-27 [**2144-5-19**] 11:10AM CK-MB-1 [**2144-5-19**] 11:10AM cTropnT-<0.01 [**2144-5-19**] 11:10AM Calcium-9.0 Phos-3.7 Mg-1.8 [**2144-5-19**] 11:10AM D-Dimer-4272* [**2144-5-19**] 11:14AM Lactate-2.4* URINE: [**2144-5-19**] 04:30PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022 [**2144-5-19**] 04:30PM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG OTHER PERTINENT LABS: [**2144-5-19**] 11:10AM CK(CPK)-15* CK-MB-1 cTropnT-<0.01 [**2144-5-20**] 02:10AM CK(CPK)-14* CK-MB-NotDone cTropnT-<0.01 [**2144-5-20**] 06:44PM CK(CPK)-12* CK-MB-NotDone cTropnT-<0.01 [**2144-5-19**] 09:30PM Type-ART pO2-65* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 MICRO: [**5-19**] BCx: NGTD [**5-20**] UCx: NEGATIVE [**5-20**] BCx: NGTD STUDIES: [**5-19**] EKG: Sinus rhythm. Poor R wave progression that is non-diagnostic. Diffuse T wave changes that are non-specific [**5-19**] CXR: Bilateral pleural effusions, left greater than right, but unchanged from prior study; no new opacity. [**5-19**] CT chest: 1. No pulmonary embolism or acute aortic syndrome. 2. Indwelling cholecystostomy drain as detailed above. Overall, the gallbladder again demonstrates marked circumferential uniform wall thickening but remains incompletely distended with numerous small gallstones. The appearances as best can be compared grossly stable relative to the prior chest CT dated [**2144-5-13**] in which the gallbladder was not fully evaluated. 3. Bilateral pleural effusions have increased in size and demonstrate morphology suggestive of loculation with associated atelectasis, but no definite pneumonia. 4. Incidental note is made of extensive pleural plaques consistent with prior asbestos exposure. 5. Renal lesions as detailed above. 6. Extensive atherosclerotic disease as detailed above. Post-CABG. [**5-19**] Cholangiogram: Appropriate placement of percutaneous cholecystostomy drain with contrast strange into the duodenum as expected. DISCHARGE LABS: *** Brief Hospital Course: 84 yo M with COPD, asbestos exposure, CAD s/p CABG who presents with acute worsening of SOB and increasing oxygen requirement. # Shortness of Breath: SOB likely multifactorial: fluid overload, PNA, COPD exacerbation. He was initially admitted on 12LNC, then required BiPAP for ~12hours. He was quickly weaned off and back down to his new baseline of 4LNC. Given the fast improvement, the pt likely flashed and improved with Lasix IV. However, given his tenuous respiratory status, recent hospitalizations and rehab admissions over the the past month, leukocytosis, increased sputum production, and worsened loculated pleural effusions, the patient was also started on treatment for HAP with Vanc/Zosyn/Levo. He was also started on treatment for COPD exacerbation with IV steroids and weaned to PO prednisone prior to transfer from the ICU to the floor. Chest CT showed new R sided pleural effusions in addition to old L sided pleural effusions - the patient was evaluated by CT [**Doctor First Name **], but no procedure was necessary at this time as the effusions were not large enough. He also has multiple underlying pulmonary diseases including emphysema, OSA, and pleural thickening likely from asbestos exposure. On [**5-25**], his IV abx (zosyn and vanc) were discontinued, partly because there was no evidence of infiltrate and partly because his increasing vancomycin trough was likely compounding his renal failure (below). He was discharged on levaquin for a 10 day course. He occassionally desaturated with ambulation. However, on the day of discharge, he did not and was therefore not sent home on O2. FOLLOW UPS: 1. Hypoxia - patient tolerating ambulation without supplemental O2 on discharge. The need for further supplementation is to be assessed dynamically by [**Name6 (MD) 269**] and MD's. 2. Presumed HAP - the patient received 6 days of IDSA reccommended antibiosis before discontinuation in the face of renal failure, persistent afebrile condition and lack of pulmonary infiltrates. He is to be continued on levaquin for a 10 day course. This will have implications for his coumadin dosign # s/p stroke: Patient with acute stroke on [**5-12**] with multiple R sided deficits and mild lethargy. His Head CT and MRI showed acute infarctions in the left occipital lobe, left thalamus, left cerebellar hemisphere and right superior cerebellum. TEE on [**5-15**] negative for left atrial thrombus. Deemed to be thromboembolic and now on lifelong coumadin. FOLLOW UP: 1. Coumadin dosing - patient was supratherapeutic on 4mg with antibiotics. He was discharged on 2mg. The appropriate dosing must be re-evaluated dynamically in the coming weeks. # CAD: Patient with know 2 VD (RCA s/p 2 stents and LAD s/p elective CABG with LIMA->LAD on [**4-21**]). Patient's R sided CP is pleuritic and unlike his anginal equivalent, which is exertional in nature. EKG without new ischemic changes and CE were negative x3. He was continued on his BB and Plavix, and restarted on [**Month/Year (2) **]. FOLLOW UP: 1. The need for dual anti-platelet therapy with coumadin should be addressed by outpatient providers # Acute CCY: Denies abd pain. s/p perc chole placement. Recent T-tube placement demonstrates patent internal flow. Will need cholecystectomy once infectious issues have resolved. FOLLOW UP: 1. The patient has an appointment with General Surgery to have the tube addressed and the possibility of a definitive cholecystectomy determine. # HTN: continued BB. # HLD: continue statin #FEN: regular diet, replete electrolytes prn, IVFs/encourage PO fluid intake #PPX: H2 blocker, bowel regimen, therapeutic on coumadin #Code: FULL (confirmed with patient) #Communication: [**Name (NI) 2013**] (wife and HCP) [**Telephone/Fax (1) 44999**] Son [**Name (NI) **] [**Telephone/Fax (1) 45000**] ("spokesperson") #Dispo: Medical ICU REVIEW OF FOLLOW UPS: 1. Hypoxia - patient tolerating ambulation without supplemental O2 on discharge. The need for further supplementation is to be assessed dynamically by [**Name6 (MD) 269**] and MD's. 2. Presumed HAP - the patient received 6 days of IDSA reccommended antibiosis before discontinuation in the face of renal failure, persistent afebrile condition and lack of pulmonary infiltrates. He is to be continued on levaquin for a 10 day course. This will have implications for his coumadin dosign 3. Coumadin dosing - patient was supratherapeutic on 4mg with antibiotics. He was discharged on 2mg. The appropriate dosing must be re-evaluated dynamically in the coming weeks. 4. The need for dual anti-platelet therapy with coumadin should be addressed by outpatient providers 5. The patient has an appointment with General Surgery to have the tube addressed and the possibility of a definitive cholecystectomy determine. Medications on Admission: Metoprolol Tartrate 25 mg PO TID Docusate Sodium 100 mg PO BID 3. Plavix 75 mg PO once a day. Ranitidine HCl 150 mg Tablet [**Name6 (MD) **]: One (1) Tablet PO once a day. Tramadol 50 mg PO every 4-6 hours as needed for pain. Acetaminophen 325 mg Tablet [**Name6 (MD) **]: 1-2 Tablets PO q4H:PRN pain. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Name6 (MD) **]: One (1) Disk Dose Inhalation [**Hospital1 **] (2 times a day). Simvastatin 20 mg PO DAILY Tiotropium Bromide 18 mcg INH daily. Zolpidem 5 mg Tablet PO [**Hospital1 **]:PRN insomnia. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: 1-2 Puffs Inhalation Q6H (every 6 hours). Warfarin 4 mg Tablet PO once a day: goal Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO HS (at bedtime). Multivitamin Plavix 75 mg PO daily Ranitidine 150 mg PO BID Bisacodyl Suppository 10 mg PR daily Nitroglycerin SL PRN: chest pain Discharge Medications: 1. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 3. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 8. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) puff Inhalation twice a day. 10. Levofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours) for 3 days: last day is [**2144-5-29**]. [**Year (4 digits) **]:*3 Tablet(s)* Refills:*0* 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Year (4 digits) **]: One (1) puff Inhalation once a day. 12. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Once Daily at 4 PM. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*2* 14. Zolpidem 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. Aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable PO DAILY (Daily). 16. Outpatient Lab Work 1. [**Year (4 digits) 2974**] [**5-30**]: INR, Na, K, Cl, HC03, Creatinine and BUN check. Communicate results to PCP. 17. Lasix 20 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day: do not start taking this medication until you are instructed to by your PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 18. Cholecystostomy Tube Please provide dressing changes and teaching regarding tube/drainage bag care Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area [**Location (un) 269**] Discharge Diagnosis: primary: pulmonary edema secondary: pneumonia, acute renal failure, chest pain syndrome Discharge Condition: Mental Status: confused sometimes Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for trouble breathing. We gave you antibiotics and a fluid pill called lasix to try to take some fluid out of your lungs and you got better. You experienced some kidney troubles that were likely related to the lasix, cat-scan dye and antibiotics. This was improving by the time you were discharged. Additionally, you had some chest pain that was not related to any further heart muscle damage . NEW MEDICATION 1. Antibiotics - Levaquin - you will need to take this for 3 more days NEW DOSES 1. Coumadin - there were issues with the thin-ness of your blood this admission. this is because your coumadin interacts with antibiotics. We ask you to take 2 mg daily - that is ONE HALF of your previous dose. Your blood MUST be monitored while taking this medication with antibiotics and this dose IS subject to change. The need for this medication long term will be determined by your PCP. 2. Lasix - this will prevent fluid from building up in your lungs. Only start taking this medication when you are instructed to do so by your PCP. . RETURN TO THE HOSPITAL IF: you have fevers, chills, chest pain that does not resolve with 2 nitroglycerin tablets (5 minutes apart), or any other symptoms that concern you. . WEIGH YOURSELF DAILY! And if your weight changes by 3 pounds or more, call your PCP. . Keep your gall bladder drainage tube clean. Daily dressing changes. Followup Instructions: Please go to the following appointments that we have arranged for you: Name: [**Last Name (un) **],PERMINDER When: [**Last Name (LF) 2974**], [**2145-5-29**]:30am Address: [**Apartment Address(1) 45001**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 29110**] . Department: CARDIAC SURGERY When: MONDAY [**2144-6-1**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Department: SURGICAL SPECIALTIES When: [**Doctor First Name **] [**2144-6-19**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD [**Telephone/Fax (1) 1231**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: WEDNESDAY [**2144-7-1**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2144-5-27**] ICD9 Codes: 2724, 4019, 486, 5849
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Medical Text: 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. [**Name (NI) **] is to be discharged home with visiting nurse assistant for wound care. Mr. [**Known lastname **] 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.[**Name (NI) 1863**] office for follow up appointment this coming week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**First Name (STitle) 30359**] MEDQUIST36 D: [**2135-7-2**] 10:51 T: [**2135-7-2**] 11:14 JOB#: [**Job Number 18599**] ICD9 Codes: 5119
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Medical Text: Admission Date: [**2148-9-19**] Discharge Date: [**2148-9-25**] Date of Birth: [**2089-3-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: angina Major Surgical or Invasive Procedure: [**2148-9-19**] Coronary Artery Bypass graft x1 off pump (left internal mammary artery > left anterior descending) History of Present Illness: 59 year old male with exertional angina for 1 year. Angina continued to increase and occurring at rest occassionally. Underwent cardiac work up that revealed coronary artery disease. Past Medical History: Coronary artery disease Hypertension Left ventricular hypertrophy Elevated cholesterol Social History: Works as housekeeper Lives with wife [**Name (NI) 1139**] quit 17 years ago ETOH social Family History: no premature cardiovascular disease Physical Exam: General WDWM in NAD Skin, HEENT unremarkable Neck full rom, supple Chest CTA bilat Heart RRR Abd soft, NT, ND +BS Ext warm well perfused no edema, pulses palpable Neuro grossly intact Pertinent Results: [**2148-9-23**] 07:20AM BLOOD WBC-7.9 RBC-3.46* Hgb-11.2* Hct-33.2* MCV-96 MCH-32.4* MCHC-33.8 RDW-12.2 Plt Ct-302 [**2148-9-19**] 09:48AM BLOOD WBC-8.4 RBC-3.50* Hgb-11.5*# Hct-33.1* MCV-94 MCH-32.8* MCHC-34.8 RDW-12.1 Plt Ct-193 [**2148-9-24**] 06:40AM BLOOD PT-12.4 INR(PT)-1.1 [**2148-9-23**] 07:20AM BLOOD Plt Ct-302 [**2148-9-19**] 09:48AM BLOOD Plt Ct-193 [**2148-9-19**] 09:48AM BLOOD PT-15.7* PTT-33.8 INR(PT)-1.4* [**2148-9-19**] 09:48AM BLOOD Fibrino-251 [**2148-9-23**] 07:20AM BLOOD Glucose-118* UreaN-14 Creat-0.9 Na-141 K-3.6 Cl-103 HCO3-27 AnGap-15 [**2148-9-19**] 10:39AM BLOOD UreaN-16 Creat-0.7 Cl-109* HCO3-24 [**2148-9-23**] 07:20AM BLOOD Amylase-93 [**2148-9-23**] 07:20AM BLOOD Lipase-44 [**2148-9-23**] 07:20AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3 RADIOLOGY Final Report CHEST (PA & LAT) [**2148-9-22**] 7:58 AM CHEST (PA & LAT) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 59 year old man with s/p POD 3 OP CABG REASON FOR THIS EXAMINATION: interval change EXAMINATION: PA and lateral chest. INDICATION: Status post CABG. Single AP view of the chest is obtained on [**2148-9-22**] at 0830 hours and compared with the prior radiograph of [**2148-9-20**]. The patient is status post CABG. Again is seen increased retrocardiac density on the left side consistent with airspace disease/atelectasis at the left base. Linear atelectasis is seen in the right base. There appears to be a small left pleural effusion. Allowing for technical differences, there has not being any marked change since the prior examination. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Approved: SUN [**2148-9-22**] 10:53 AM Cardiology Report ECG Study Date of [**2148-9-19**] 12:25:42 PM Sinus bradycardia. Possible inferoposterior myocardial infarction. Compared to previous tracing of [**2148-9-17**] no definite change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 52 192 98 468/454 21 -8 43 Cardiology Report ECHO Study Date of [**2148-9-19**] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG procedure Height: (in) 69 Weight (lb): 194 BSA (m2): 2.04 m2 BP (mm Hg): 123/67 HR (bpm): 72 Status: Inpatient Date/Time: [**2148-9-19**] at 09:47 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW2-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Ascending: *3.9 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 7 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A Ratio: 1.75 INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: 1. No atrial septal defect is seen by 2D or color Doppler. 2.Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. Post revascularization biventricular systolic function is unchanged. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2148-9-19**] 14:38. [**Location (un) **] PHYSICIAN Brief Hospital Course: Admitted [**9-19**] and underwent OPCABG x1 with Dr. [**Last Name (STitle) **]. Transferred to the CSRU in stable condition on a propofol drip. Extubated that afternoon and transferred to the floor on POD #1 to begin increasing his activity level. Chest tubes and pacing wires removed without incident. Went into Afib and was treated with amiodarone and coumadin. Made excellent progress and was cleared for discharge to home with VNA services on POD #6. First blood draw is scheduled for Friday [**9-27**]. Pt. to make all appts. as per discharge instructions. Medications on Admission: plavix zocor diovan/hctz toprol xl ASA NTG Discharge Medications: 1. Outpatient Lab Work Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for atrial fibrillation results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**] 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: 400 mg [**Hospital1 **] until [**9-30**], then 400 mg daily for 7 days, then 200 mg daily ongoing until stopped by cardiologist. Disp:*50 Tablet(s)* Refills:*1* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 1 doses: 3 mg today and tomorrow, then daily dosing per Dr. [**Last Name (STitle) 14522**]. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p CABG Post op atrial fibrillation Hypertension Left ventricular hypertrophy elevated cholesterol Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 14522**] in [**1-9**] week ([**Telephone/Fax (1) 14525**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**])- Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for atrial fibrillation results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**] Completed by:[**2148-9-25**] ICD9 Codes: 9971, 4019, 2720
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Medical Text: Admission Date: [**2142-8-22**] Discharge Date: [**2142-8-23**] Date of Birth: [**2074-11-21**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Elective Right Internal Carotid Artery angioplasty and stenting. Major Surgical or Invasive Procedure: Right Internal Carotid Artery angioplasty and stenting. History of Present Illness: Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and recent Right Carotid U/S on [**2142-7-3**] revealing a 95% ulcerated lesion. He was admitted for elective angioplasty and stenting of his right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST study). Baseline SBP prior to intervention was 200. Pt is very active at baseline without dyspnea on exerction. Pt denies symptoms of CP/SOB/visual changes/HA/numbness/weakness. Past Medical History: 1. HTN 2. hypercholesterolemia 3. PVD 4. BPH 5. Colonoscopy w/ polypectomy on [**4-22**] 6. h/o melanoma s/p resection 7. s/p hand surgery Social History: Married with 3 children. Employeed as engineer. Quit tob many years ago with a 12 pack year history. EtOH; [**2-20**] drinks per night. Family History: No family h/o premature CAD <55 years of age. Physical Exam: T 96.2 142/60 57 20 Wt 105 kg Sat 99% RA Gen: well appearing, NAD HEENT: MMM, anicteric, PERRL Neck: No JVD CV: brady, regular, normal S1S2. No M/R/G. No S3S4. Lungs: CTAB Abd: obese, soft, NT/ND, pos BS Ext: no C/C/E Neuro: A&Ox4, CN II-XII intact, [**5-23**] UE strength, [**5-23**] dorsi/plantar flexion Pertinent Results: [**2142-8-22**] 05:01PM POTASSIUM-4.1 [**2142-8-22**] 05:01PM CK(CPK)-60 [**2142-8-22**] 05:01PM CK-MB-NotDone [**2142-8-22**] 05:01PM PLT COUNT-143* Brief Hospital Course: Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and Right Carotid Stenosis admitted for elective angioplasty and stenting of his right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST study). 1. Right Internal Carotid Stenosis. Pt underwent angioplasty and stenting without complications. His BP was maintained at goal between 120 and 150 post procedure without requiring Neosynephrine, Nipride, or Norvasc. Pt had no change in his neurological status post-op or evidence of vagal episodes. He remained on Plavix and ASA. He was seen by Dr. [**Last Name (STitle) **] prior to discharge. 2. HTN. The pt was restarted on Accuretic at dicharge. He is to call Dr. [**First Name (STitle) **] in 4 days with his BP, and will add Norvasc if needed at that time. 3. Hyperchol. LDL of 105. Goal LDL <100. Consider increasing Lipitor 20 as outpatient. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Norvasc 5 mg Tablet Sig: One (1) Tablet PO as per Dr. [**First Name (STitle) **] on Monday. Discharge Disposition: Home Discharge Diagnosis: Right Internal Carotid Artery Stenosis with angioplasty and stenting. Discharge Condition: Stable. Discharge Instructions: Please call your physician if you experience confusion, change in vision, bleeding, or any other problems. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2142-9-11**] 1:00 2. Please call Dr. [**First Name (STitle) **] on Monday to report your Blood Pressure. Do not take Norvasc unless advised by Dr. [**First Name (STitle) **]. 3. Please follow-up with Dr. [**Last Name (STitle) **] in one month. ICD9 Codes: 4019, 2720, 4439
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Medical Text: Admission Date: [**2169-9-30**] Discharge Date: [**2169-10-6**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: fall Major Surgical or Invasive Procedure: NG tube History of Present Illness: Patient is an 87 year old female s/p ? mechanical fall with head contusion. Taken to [**Hospital6 1597**] where she had a head CT which showed bilateral SDH. Pet [**Hospital3 2568**] reports, she was confused and slow to follow commands. As a result, she was intubated for airway protection and transferred to [**Hospital1 18**]. On arrival, patient had a blood pressure 200/95 and intubated but moving purposeful. She was motioning for the tube to come out. Past Medical History: HTN, hypercholesterolemia, glaucoma, vertigo, syncope Social History: unknown Family History: nc Physical Exam: O: T:AF BP: 200/82 HR: 84 R 16 O2Sats 100%40% FIO2 Gen: intubated/seated HEENT: traumatic with left occiput swelling, eyes: surgical, clera, ears - no otorrhea, nose patent, tube at 27cm at teeth Pupils:PERRL EOMs - full Neck: Supple, ETT in place Lungs: CTA bilaterally, good chest rise b/l Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: GCS E:4,V1M5-6 11T Pupils are surgical, no papilledema of fundoscopic exam Patient is purposeful bilateraly, moves for tube, nods to question, wants the tube out. MAEs fully. Grimaces to pain No clonus Toes downgoing bilaterally Pertinent Results: CT HEAD W/O CONTRAST [**2169-10-1**] IMPRESSION: 1. Diffuse extra-axial hemorrhage including bilateral frontoparietal subdural hematomas and subarachnoid hemorrhage. 2. Mild posterior layering intraventricular hemorrhage. No signs of developing obstructive hydrocephalus. 3. Large inferior frontal intraparenchymal hemorrhagic contusions. 4. No midline shift or evidence of impending herniation. CT HEAD W/O CONTRAST [**2169-10-5**] CONCLUSION: 1. Slight increase in the size of the right subdural hematoma with increased mass effect on the sulci and right lateral ventricle. 2. Slight increase in leftward shift of normally midline structures. 3. Stable appearance of left subdural hematoma, bifrontal parenchymal hematomas, bilateral subarachnoid hematomas and slight decrease in the intraventricular hematoma. [**2169-9-30**] 03:30PM BLOOD WBC-14.8* RBC-4.03* Hgb-12.2 Hct-37.1 MCV-92 MCH-30.2 MCHC-32.8 RDW-12.6 Plt Ct-262 [**2169-10-5**] 06:10AM BLOOD WBC-8.3 RBC-3.70* Hgb-11.0* Hct-33.6* MCV-91 MCH-29.7 MCHC-32.7 RDW-13.3 Plt Ct-261 [**2169-9-30**] 03:30PM BLOOD Neuts-88.9* Lymphs-6.6* Monos-3.0 Eos-0.9 Baso-0.6 [**2169-9-30**] 03:30PM BLOOD Plt Ct-262 [**2169-9-30**] 04:30PM BLOOD PT-9.8 PTT-25.7 INR(PT)-0.9 [**2169-10-5**] 06:10AM BLOOD PT-10.4 PTT-26.9 INR(PT)-1.0 [**2169-10-5**] 06:10AM BLOOD Plt Ct-261 [**2169-10-1**] 04:00AM BLOOD Fibrino-237 [**2169-9-30**] 03:30PM BLOOD Glucose-98 UreaN-16 Creat-0.7 Na-136 K-3.6 Cl-101 HCO3-22 AnGap-17 [**2169-10-5**] 01:00PM BLOOD Glucose-197* UreaN-27* Creat-1.1 Na-148* K-4.2 Cl-115* HCO3-19* AnGap-18 [**2169-10-1**] 04:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 [**2169-10-5**] 01:00PM BLOOD Calcium-8.0* Phos-4.2 Mg-2.3 [**2169-9-30**] 03:46PM BLOOD pO2-77* pCO2-43 pH-7.39 calTCO2-27 Base XS-0 Comment-GREEN TOP [**2169-9-30**] 04:00PM BLOOD Type-ART Rates-14/ Tidal V-400 PEEP-5 FiO2-50 pO2-206* pCO2-36 pH-7.45 calTCO2-26 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2169-10-5**] 01:08PM BLOOD Lactate-3.3* Na-143 K-3.8 Cl-116* [**2169-10-5**] 01:15PM BLOOD Lactate-3.8* [**2169-9-30**] 04:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2169-9-30**] 04:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2169-10-4**] 08:00PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2169-10-4**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2169-10-5**] 10:09AM URINE Hours-RANDOM UreaN-864 Creat-67 Na-11 K-70 Cl-36 [**2169-10-5**] 10:09AM URINE Osmolal-529 Brief Hospital Course: 87 y/o F s/p fall presents with bilateral SDHs, bifrontal contusions, subarachnoid hemorrhage, and intraventricular hemorrhage. ACTIVE ISSUES: # MECHANICAL FALL C/B INTRACRANIAL HEMATOMAS: She was admitted to the neurosurgery with bilateral SDHs, bifrontal contusions, subarachnoid hemorrhage, and intraventricular bleed S/P mechanical fall and placed in the ICU for close monitoring. She was started on dilantin. On examination, patient was slightly confused, but alert to place and name. She was moving all extremities with good strength. On [**10-1**], repeat head CT was performed which showed blossoming of bifrontal contusions and stable SDHs with SAH and IVH. She remained in the ICU for close monitoring with a stable exam. Dilantin level was 12.9. On [**10-2**] the patient had a waxing and [**Doctor Last Name 688**] level of alertness, only responsive to noxious stimuli at times. She was sent for a repeat CT of the head which showed a minimally increased hematoma and no evidence of herniation. When the patient was transferred to medicine on [**2169-10-4**], she was sleepy but roused to verbal commands and oriented only to self. Though she could repeat "[**Hospital3 **]", she did not know that this was a hospital. Her neurologic exam on [**10-5**] changed to show a flattening of the left nasolabial fold. A repeat study on the 23rd showed evidence of right subdural hematoma expansion with midline shift. The brainstem was not compromised. # Hyponatremia, hyperkalemia: The patient was held NPO with minimal IVF. Her serum sodium slowly trended up and her potassium slowly trended down. On [**10-4**], the patient was transferred to the medicine service for management of a Na of 157 and a K of 2.5. The patient's free water deficit was calculated at approximately 2.5 liters and with the aid of a nephrology consult, her sodium was corrected slowly so as to avoid any intracranial edema in the setting of six already known bleeds. She was corrected at less than 0.5 mEq/L/hr. Her potassium was also repleted. # Atrial fibrillation: the patient was found to be in new atrial fibrillation on [**2169-10-4**] when she was transferred to the medicine service. This was thought likely due to her low intravascular volume status with possible contribution from her severe electrolyte disturbances. Her medication regimen was changed and she responded very well to PO metoprolol, mostly remaining in sinus afterwards. Further episodes of atrial fibrillation responded very well to IV metoprolol. # Tachypnea: On approximately 1230 on [**10-5**], the patient's respiratory rate abruptly increased to the mid 30s and her oxygen saturation dropped to the 50s. This increased to the 80s with a non-rebreather, but her tachypnea did not respond. She was seen immediately by the medical team. Her lungs were clear at the time and NG tube yielded only scant dark liquid. A stat chest X ray showed clear lungs, which corroborated the exam. Therefore acute cardiac decompensation was ruled out. It was thought most likely that she had had a massive pulmonary embolism despite her heparin prophylaxis. The possibility of an expansion of one of her six head bleeds was also entertained, but considered less likely given her tachypnea. Her sodium had been corrected very slowly to avoid any cerebral edema and CT head confirmed this. Although the patient may have aspirated, the sudden and dramatic desaturation with the most recent PO intake having been a small amount of tea and broth several hours earlier that morning made this unlikely. The primary team had extensive discussion with the family and the decision was made to transition the patient to comfort measures only. Her oxygen hunger was treated with morphine and benzodiazepines. She died on the morning of [**2169-10-6**]. Medications on Admission: Losartan 50mg [**Hospital1 **] HCTZ 25mg daily, Mirtazapine 50mg qhs timolol opthalmic solution daily Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Bifrontal contusions Bilateral SDH IVH SAH Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased ICD9 Codes: 2760, 2851, 2762, 4019, 2724, 2768
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Medical Text: Admission Date: [**2170-11-2**] Discharge Date: [**2170-11-11**] Date of Birth: [**2108-6-17**] Sex: M Service: UROLOGY Allergies: Synvisc Attending:[**First Name3 (LF) 824**] Chief Complaint: hematuria, obstructed foley Major Surgical or Invasive Procedure: s/p cystectomy, urostomy History of Present Illness: 62M s/p TURBT for recurrent hematuria, foley obstruction with blood clots, now s/p cystectomy and urostomy. Past Medical History: diabetes, type 2 hypertension stroke [**2165**], no residual sx bladder cancer [**2166**] former smoker 20py Physical Exam: afebrile, vital signs normal NAD, NCAT, EOM full Chest clear Heart regular, no murmurs/rubs/gallops Abdomen obese, soft, NT, ND, NABS; urostomy pink, slightly retracted, yellow urine Penis with foley in place LE with trace pitting edema Pertinent Results: [**2170-11-2**] 09:11PM BLOOD WBC-28.8*# RBC-4.25* Hgb-12.4* Hct-36.9* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.2 Plt Ct-397 [**2170-11-3**] 03:17PM BLOOD Hct-31.6* [**2170-11-4**] 12:23AM BLOOD Hct-28.5* [**2170-11-4**] 03:52AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.3* Hct-29.8* MCV-88 MCH-30.5 MCHC-34.5 RDW-14.5 Plt Ct-240 [**2170-11-4**] 01:07PM BLOOD WBC-16.7* RBC-3.96* Hgb-11.9* Hct-35.5* MCV-90 MCH-30.0 MCHC-33.5 RDW-14.4 Plt Ct-249 ---------------- CHEST (PORTABLE AP) [**2170-11-3**] 5:17 AM CHEST (PORTABLE AP) Reason: evaluate ET tube placement and evaluate for volume overload [**Hospital 93**] MEDICAL CONDITION: 62 year old man intubated s/p cystoprostatectomy REASON FOR THIS EXAMINATION: evaluate ET tube placement and evaluate for volume overload PORTABLE CHEST, [**2170-11-3**] AT 05:59 HOURS. COMPARISON STUDY: [**2170-11-2**] CLINICAL INFORMATION: ET tube placement, question volume overload FINDINGS: There are low lung volumes. There is mild bibasilar atelectasis and mild prominence of central pulmonary vasculature which may indicate a small degree of volume overload. The endotracheal tube terminates at the thoracic inlet. The nasogastric tube courses below the diaphragm but the tip is not seen. IMPRESSION: Low lung volumes, and mild volume overload. ---------------- [**2170-11-9**] 09:00AM BLOOD WBC-10.6 RBC-3.87* Hgb-11.4* Hct-33.8* MCV-87 MCH-29.5 MCHC-33.8 RDW-13.8 Plt Ct-453* ----------------- PORTABLE ABDOMEN [**2170-11-9**] 1:38 AM PORTABLE ABDOMEN Reason: portable KUB requesting for possible post-op ileus [**Hospital 93**] MEDICAL CONDITION: 62 year old man with upper epigastric pains REASON FOR THIS EXAMINATION: portable KUB requesting for possible post-op ileus INDICATION: _____ ? postop ileus. COMPARISON: No abdominal films for comparison. There are dilated loops of small bowel which are consistent with ileus. No evidence of free air on this supine view. There are surgical clips in the pelvis. There are staples in the overlying skin. The limited views of the bones show osteophytes in the lumber spine. IMPRESSION: _____ consistent with postoperative ileus. Followup radiographs recommended. DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] PORTABLE ABDOMEN [**2170-11-10**] 7:53 AM PORTABLE ABDOMEN Reason: ileus vs obstruction [**Hospital 93**] MEDICAL CONDITION: 62M s/p cystectomy, ileal conduit, now emesis REASON FOR THIS EXAMINATION: ileus vs obstruction EXAMINATION: Portable supine abdomen, one view. INDICATION: Status post cystectomy with ileal conduit presenting with emesis. COMPARISON: Comparison is made with the previous portable abdomen from [**2170-11-9**]. FINDINGS: There are diffuse and dilated loops of both small and large bowel which are relatively unchanged when compared to the previous radiograph and are consistent with ileus. This is a supine radiograph and an assessment of free air cannot be made. Surgical clips are seen in the pelvis with some staples overlying the skin. IMPRESSION: Dilated loops of both small and large bowel which are unchanged and appearances are consistent with ileus. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: SUN [**2170-11-11**] 11:03 AM -------------- [**2170-11-11**] 06:10AM BLOOD WBC-7.3 RBC-3.61* Hgb-10.4* Hct-31.3* MCV-87 MCH-28.7 MCHC-33.1 RDW-13.9 Plt Ct-532* [**2170-11-11**] 06:10AM BLOOD Glucose-87 UreaN-17 Creat-1.0 Na-140 K-3.4 Cl-104 HCO3-26 AnGap-13 Brief Hospital Course: GU: Admitted postoperatively after cystectomy and urostomy creation. Ureteral stents into ileal conduit and visible through stoma. Immediately postop, good urine output with some mucous. IVF were discontinued on POD5 and he was allowed to auto-diurese, producing good urine output even while off IVF and taking only sips on POD7-8. CV: Immediately postop, the pt went to the ICU and was hypotensive, requiring pressors through POD1. By POD2, pressors were weaned and the pt was hemodynamically stable, returning to baseline hypertension; he was transferred to the floor and started on IV lopressor. On POD4, he was started on his home diuretics and metoprolol 12.5 [**Hospital1 **], remaining normotensive. On POD6, after an episode of LUQ pain and emesis an EKG was done, which demonstrated stable findings when compared to his pre-operative EKG from [**10-10**]. The pt was continued on perioperative beta-blockade through POD8 after which the metoprolol was discontinued. Pulm: Pt was weaned off O2 by POD1 and did not require supplemental O2 after this time. Saturations remained >94% on RA. He did require occasional nebulizer treatments for intermittent wheezing during this hospitalization. GI: The patient passed flatus on POD3 and on POD4 he was started on sips and advanced to clears. By POD 5, after a small bowel movement, he was advanced to a regular diet without any problems. [**Name (NI) **] continued to pass flatus. On POD6, the pt developed LUQ abdominal pain that did not resolve with simethicone or morphine. He had two episodes of non-bloody emesis, after which the pain resolved. KUB demostrated no obstructions, but dilated loops throughout, consistent with ileus. On POD7, his diet was limited to sips of clears. On POD9, after being emesis free for 40 hours, his diet was advanced to clears then regular diabetic diet, which he tolerated well. Prior to admission, the pt had one loose and one formed bowel movement. Heme: Intraoperatively, difficult procedure with EBL of 3L; pt was transfused 8 units of red cells in the OR, and required an additional 2 units of red cells on POD1 for a hematocrit that was trending down to 28.5 at its lowest point. It remained stable at 32-33 for the remainder of the hospitalization. ID: Pt was on ancef perioperatively and did not require additonal antibiotics. His wound became minimally erythematous by POD5, but this slowly resolved without antibiotics. TLD: Pt was discharged with urostomy and bag in place; teaching was done in-house and follow up with a visiting nurse was arranged upon discharge. Discharge Medications: 1. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two (2) Cap PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 976**] VNA Inc Discharge Diagnosis: bladder tumor s/p cystectomy, urostomy, postop ileus Discharge Condition: good Discharge Instructions: You may shower but do not bathe, swim or otherwise immerse your incision. Do not lift anything heavier than a phone book. Do not drive or drink alcohol while taking narcotic pain medications. Resume all of your home medications, but please avoid aspirin and motrin/advil for 1 week. Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up appointment in [**12-5**] weeks, or if you have any questions. If you have fevers> 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up appointment in [**12-5**] weeks, or if you have any questions. Follow up with your primary care provider [**Last Name (NamePattern4) **] 1 week. ICD9 Codes: 5185, 2851, 4019, 2749
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Medical Text: Admission Date: [**2156-7-16**] Discharge Date: [**2156-7-20**] Date of Birth: [**2102-5-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Face and right sided chest pain Major Surgical or Invasive Procedure: none History of Present Illness: this is a 54 year old patient with PMHx significant for CAD with 4 drug eluting stents on Plavix who was riding his motorcycle on [**7-16**] when he swerved to avoid traffic going approximately 40 miles per hour and ended up crashing his motorcycle into the pavement without striking another vehicle. He remembers striking his head on the pavement and was helmeted. He denies LOC at the time of the crash. He came to [**Hospital1 18**] via EMS following the crash and was found to have multiple injuires including a left temporal SAH and contusions, high right frontal IPH, and left tentoial SDH. Other injuries included ? right orbital fx, rigth periorbital ecchymosis, right clavicle fx, right 4th and 5th rib fx's, and right gluteal hematoma. Past Medical History: PMH: HTN (multiyear history, untreated), ankle & shoulder fractures in childhood PSH: none Social History: Married, lives with wife, no tobacco, no ETOH Family History: non contributory Physical Exam: Temp 99 BP 140/70 HR 90 RR 20 O2 sat 95% RA Gen: multiple abrasions, obese, in no distress HEENT: large right periorbital hematoma Pupils: PERRL EOMs intact Neck: cervical collar in place 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, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-19**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are grossly full to confrontation, difficult to fully assess given eye injury. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: RUE extremity strength is limited by right clavicle injury but is full in bicep, tricep, grasps, and wrist extensors and flexors. LUE, LLE< and RLE are full. Normal bulk and tone bilaterally. No abnormal movements, tremors. Not able to assess pronator drift given R clavicle fracture limiting movement of proximal RUE Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [**2156-7-16**] 05:40PM WBC-8.0 RBC-4.17* HGB-12.7* HCT-37.1* MCV-89 MCH-30.4 MCHC-34.2 RDW-14.3 [**2156-7-16**] 05:40PM PLT COUNT-211 [**2156-7-16**] 05:40PM PT-12.3 PTT-23.5 INR(PT)-1.0 [**2156-7-16**] 05:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2156-7-16**] 05:40PM UREA N-17 CREAT-0.8 [**2156-7-16**] 05:55PM GLUCOSE-146* LACTATE-3.6* NA+-143 K+-3.1* CL--103 TCO2-25 [**2156-7-16**] 10:18PM HCT-26.4*# [**2156-7-16**] Chest Xray : Distal right clavicular fracture. Otherwise, no acute cardiopulmonary abnormality [**2156-7-16**] Head CT : 1. Multifocal intracranial hemorrhage including left frontal and temporal lobe subarachnoid hemorrhage, left subdural hematoma and two foci of right intraparenchymal hemorrhage at the vertex in the right frontal lobe. 2. Right periorbital hematoma with extension along the lateral rectus muscle, which appears to be extraconal and causes some proptosis. 3. Small foci of pneumocephalus in the left temporal fossa without definite temporal bone fracture identified. A temporal bone CT can be obtained for further evaluation. [**2156-7-16**] CT C spine : 1. No acute fracture or malalignment. 2. Mild multilevel degenerative changes, most prominent at C5-C6 where there is mild canal narrowing and neural foraminal stenosis. [**2156-7-16**] CT Chest/Abd/pelvis : 1. No acute intrathoracic, abdominal or pelvic abnormality. 2. Right gluteal muscle hematoma with active extravasation. 3. Comminuted right clavicular fracture. 4. Nondisplaced right fourth and fifth lateral rib fractures. 5. Radiopaque density in the anterior abdominal wall of uncertain significance. Clinical correlation recommended. 6. 7-mm enhancing focus in the left lobe of the liver, possibly a vascular shunt, flash-filling hemangioma, or arterially enhancing lesion such as an adenoma or area of FNH. If the patient has a history of hepatitis, chronic liver disease, or malignancy then further evaluation with MRI is recommended. [**2156-7-17**] Head CT : 1. Continued evolution of left-sided subarachnoid hemorrhage and subdural hematoma. 2. Stable appearance of the right frontal lobe intraparenchymal hemorrhagic contusions. 3. Resolving right-sided subgaleal and periorbital hematoma with new resolved right-sided proptosis, with right lateral orbital wall fracture. NOTE ADDED IN ATTENDING REVIEW: There are also extensive hemorrhagic contusions in the left temporal lobe, with evolving adjacent vasogenic edema. [**2156-7-18**] Head CT : 1. Similar appearance of right frontal intraparenchymal hemorrhage, left frontotemporal subarachnoid hemorrhage, left temporal hemorrhagic contusions, and left tentorial subdural blood; slightly increased prominence of the intraventricular hemorrhage layering in the occipital horns of the lateral ventricles. 2. Improved appearance of right frontal subgaleal and periorbital soft tissue swelling. Brief Hospital Course: Mr. [**Known lastname 4109**] was evaluated by the Trauma team in the Emergency Room and scans were reviewed. He had a subarachnoid and subdural hemorrhage with a right intraparenchymal hemorrhage in the setting of taking aspirin and Plavix. He was seen by the Neurosurgery service and admitted to the Trauma ICU for close neurologic monitoring. He began Dilantin therapy prophylactically. He was also evaluated by the Plastic Surgery service for his right orbital wall fracture which was deemed non operable. The Opt homology service also evaluated him on a number of occasions to rule out a retrobulbar hematoma which was not present. During his ICU stay he remained hemodynamically stable despite active extravasation. His hematocrit on admission was 37 and after resuscitation was in the 23 range consistently. He did receive a platelet transfusion on admission but never required packed cells. Head CTs were followed daily as his second scan showed continued evolution of his SAH and SDH. His neurologic exam did not change ad he had no seizure activity. Following transfer to the Trauma floor he continued to progress. His aspirin and Plavix were resumed on [**2156-7-18**] without any deleterious effects. He was evaluated by the Physical and Occupational Therapy services for a cognitive screen and full evaluation for ambulating. His cognitive screen revealed some deficits with memory and he was referred to the Cognitive Neurology service for an out patient evaluation. The Physical Therapist worked with him on numerous occasions and recommended home physical therapy to maximize his functional capacity. His right clavicle fracture is not displaced and non operative. He is in a sling for comfort and should do pendulum exercises three times a day plus range of motion to his elbow and wrist. The home physical therapist can review that with him and he should follow up in 2 weeks here or in [**Doctor Last Name 792**]if he chooses. He was tolerating a regular diabetic diet, walking independently and his hematocrit remained stable. After an uncomplicated recovery he was discharged to home on [**2156-7-20**]. Medications on Admission: lisinopril 20', bystolic 10', simvastatin 40', metformin 500'', plavix 75', asa325' Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO three times a day: thru [**2156-7-22**]. Disp:*10 Capsule(s)* Refills:*0* 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Bystolic 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: VNS of Greater rRode Island Discharge Diagnosis: S/P MCC 1. Left SAH 2. Left SDH 3. Right IPH 4. Right lateral orbital wall fracture 5. Right clavicle fracture 6. Right rib fractures [**3-23**] 7. Right gluteal hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital after your motorcycle accident with multiple injuries including bruising in your brain, a broken collar bone, rib fractures, facial fracture and a large hematoma on your right buttock/upper thigh . * Your right ribs [**3-23**] are fractured which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Keep your right arm in a sling for comfort and don't put any weight in it. * The large hematoma on your thigh will resolve over time and color changes will continue to take place. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ), visual changes, headaches or any other symptoms that concern you. Followup Instructions: Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up appointment in 4 weeks. You will need a non contrast head CT prior to your appointment and the secretary can arrange that for you. Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive Neurology at [**Telephone/Fax (1) 1690**] for a follow up appointment in 1 week. Call the Plastic Surgery Clinic at [**Telephone/Fax (1) 6742**] for a follow up appointment on Friday [**2156-7-23**]. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks. If you prefer you can follow up with an orthopedist in [**Doctor Last Name 792**]in 2 weeks. Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**1-22**] weeks. Call your Eye doctor [**First Name (Titles) **] [**Last Name (Titles) **] for a follow up appointment in [**1-22**] weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2156-7-20**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2137-11-13**] Discharge Date: [**2137-11-20**] Date of Birth: [**2070-3-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14820**] Chief Complaint: acute dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 67 yo M with DM2, HTN, and recent dx of a-fib 1 month ago presents with acute dyspnea and found to be in afib with RVR. The patient recently started taking diltiazem and coumadin 3 weeks ago. He was feeling well until he acutely felt short of breath yesterday morning. He presented to his PCP's office where an EKG was significant for afib with RVR in the 140s. He was then sent to [**Hospital3 **] for further evaluation. CXR revealed pulmonary edema and fluid overload. He was started on a hep gtt for a sub-therapeutic INR, diltiazem gtt, nitro gtt, and transferred to [**Hospital1 18**] for further care. . In the ED, initial vitals BP 96/68 HR 107. He was given 80 then 160 mg IV lasix with approximately 1L urine output. In spite of a diltiazem gtt, his HR remained in the 110s. A repeat CXR showed small bilateral pleural effusions and mild pulmonary edema. Labs were significant for a troponin leak up to 0.66 with flat CKs, BNP [**Numeric Identifier 39390**], INR 1.5, and Cr 1.7. While in the ED overnight, he desatted down to low 80s and was placed on BIPAP and then a NRB with sats improving to >94%. He was unable to be weaned off the NRB in spite of putting out approximately 1 L urine to IV lasix. Due to continued tachycardia, respiratory distress, and ? hemodynamic instability, the pt was taken for TEE/cardioversion. TEE revealed a left atrium thrombus. He was then admitted to the CCU for further care. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He reports having calf pain on exertion and is on cilastazol for peripheral arterial disease. He also reports have 2 incidents of hypoglycemia in the past month; his beta-blocker was stopped and he was started on a CCB. All of the other review of systems were negative. . Cardiac review of systems is notable for dyspnea, but the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. Past Medical History: DM II HTN Erectile Dysfunction Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension, Former smoker Social History: Social history is significant for the absence of current tobacco use. He quit over 20 years ago. There is no history of alcohol abuse. Family History: non-contributory Physical Exam: VS: T 98.3 , BP 132/72 , HR (112-126), RR 36 , O2 96% on NRB Gen: elderly male, in moderate resp distress on NRB appears more comfortable, Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of [**12-20**] cm. CV: irregular, tachycardic; normal S1, S2. No S4, no S3. Chest: Resp were labored, with accessory muscle use. decreased BS bilateral bases with crackles halfway up posterior lung fields. few scattered expiratory wheezes Abd: Obese, soft, NTND, No HSM or tenderness. Ext: No c/c/e. Skin: venous stasis changes bilateral lower extremities. Pulses: Right: Carotid 2+; radial 2+; 1+ DP/PT [**Name (NI) 2325**]: Carotid 2+; radial; 2+; 1+ DP/PT Pertinent Results: [**2137-11-20**] 05:45AM BLOOD WBC-7.8 RBC-4.34* Hgb-13.7* Hct-39.8* MCV-92 MCH-31.5 MCHC-34.3 RDW-14.2 Plt Ct-335 [**2137-11-20**] 05:45AM BLOOD PT-17.3* PTT-90.2* INR(PT)-1.6* [**2137-11-20**] 05:45AM BLOOD Glucose-101 UreaN-29* Creat-1.3* Na-138 K-4.1 Cl-100 HCO3-30 AnGap-12 [**2137-11-13**] 11:29PM BLOOD CK(CPK)-51 [**2137-11-12**] 05:30PM BLOOD CK(CPK)-135 [**2137-11-13**] 03:51PM BLOOD CK-MB-NotDone cTropnT-0.66* [**2137-11-12**] 05:30PM BLOOD CK-MB-12* MB Indx-8.9* proBNP-[**Numeric Identifier 39390**]* [**2137-11-17**] 06:15AM BLOOD Albumin-3.6 Calcium-11.3* Phos-4.2 Mg-3.0* [**2137-11-18**] 05:35AM BLOOD Digoxin-1.1 [**2137-11-16**] 09:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2137-11-16**] 09:00AM URINE Blood-LGE Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2137-11-16**] 09:00AM URINE RBC-11* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 . IMAGING: . [**2137-11-12**] CXR IMPRESSION: Cardiomegaly with bilateral small pleural effusions and mild pulmonary edema . [**2137-11-14**] CXR FINDINGS: In comparison with the study of [**11-12**], there is continued cardiomegaly with apparent worsening of the pulmonary edema. Generalized haziness bilaterally is consistent with large pleural effusions . [**2137-11-15**] CXR There is marked improvement in the bilateral perihilar parenchymal opacities representing marked improvement of pulmonary edema. There is no change in bilateral moderate pleural effusions and bibasal atelectasis. The moderately enlarged heart is stable and there is no change in the mediastinal contours. . [**2137-11-17**] CXR: Previous pulmonary edema and bilateral pleural effusions have resolved. Mild cardiomegaly and upper lobe vascular congestion remain following substantial improvement in congestive heart failure. No pneumothorax. . [**2137-11-13**] TEE: The left atrium is dilated. No spontaneous echo contrast or thrombus/ mass is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A probable thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. Mild spontaneous echo contrast is seen in the right atrial appendage. The right atrial appendage ejection velocity is depressed (<0.2m/s). No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. LV systolic function and right ventricular systolic function appears depressed. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (severity of mitral regurgitation may be UNDERestimated due to limited views). There is no pericardial effusion. . IMPRESSION: Probable left atrial appendage thrombus. Moderate mitral regurgitation (may be underestimated). Biventricular systolic dysfunction. . [**2137-11-18**] TTE: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are moderately thickened with characteristic rheumatic deformity/restricted anterior and posterior leaflet motion.. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild to moderate ([**1-8**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Minimal rheumatic mitral stenosis. Mild-moderate mitral regurgitation. Low normal left ventricular systolic function Mild pulmonary artery systolic hypertension. . [**2137-11-12**] ECG: Atrial fibrillation, average ventricular rate 100-110. Non-specific repolarization changes. Compared to the previous tracing of [**2135-3-21**] normal sinus rhythm has given way to atrial fibrillation and the ventricular rate has increased. . [**2137-11-16**] ECG: Atrial fibrillation with rapid ventricular response Left ventricular hypertrophy Diffuse nonspecific ST-T wave abnormalities Since previous tracing of [**2137-11-15**], further ST-T wave changes present Brief Hospital Course: 67 yo male with Afib diagnosed 1 month ago presents with Afib with RVR and hypervolemia admitted for cardioversion but found to have left atrial appendage thrombus on TEE, admitted to CCU for monitoring and diuresis. . # Rhythym: AFib with RVR. unable to cardiovert due to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] thrombus on TEE. The patient was initially started on digoxin and a diltiazem gtt for rate control. The diltiazem was converted to a PO dosing regimen which the patient tolerated well. His HR continued to be slightly fast, therefore low dose metoprolol was started. As an outpatient, the patient had been on high doses of Toprol likely causing his adverse reactions and no response to hypoglycemia, but the patient's glucose was well controlled during his hospitalization and he tolerated the metoprolol dosing well. The patient was started on a heparin gtt, and was bridge to coumadin with lovenox as an outpatient. His goal INR is [**2-9**] and will need to be followed by his PCP. [**Name10 (NameIs) **] will followup in cardiology clinic for his A.fib. He will need a repeat TEE in [**4-12**] weeks to determine resolution of the left atrial appendage thrombus if he will have cardioversion. . # Pump: CHF with EF of 43% at OSH. TEE not able to accurately determine EF. A TTE prior to discharge showed an EF of 50%. The patient was diuresed with IV lasix initially, but was then converted to a PO dosing schedule to further keep him even to slightly negative as an outpatient. . # Ischemia: elevated troponin likely from demand ischemia in setting of AFib with RVR. The patient did not have cardiac catheterization during this hospitalization. He will likely need an outpatient stress test or catheterization based on the decision of his cardiologist. The patient did not complain of chestpain throughout this hospitalization. He will continue on aspirin, statin, and metoprolol as an outpatient. . # HTN-The patient's blood pressure was well controlled on his regimen of diltiazem, metoprolol, and lisinopril. He will continue these medications as an outpatient. . # DM: The patient initially had blood glucose levels in the 400s. His NPH and HISS were up-titrated for improved control. Prior to discharge, the patient was on NPH 30/14 with a tight HISS with good glucose control 120-150s. He has a long history with Dr. [**Last Name (STitle) 19862**] at the [**Last Name (un) **] who follows him as an outpatient. Dr. [**Last Name (STitle) 19862**] was informed of the patient's admission, and the patient will followup at the [**Last Name (un) **] with his scheduled appointments. Medications on Admission: Lasix 40 mg daily Lipitor 20 mg daily Cardia 180 mg QAM cilastazole 100 mg [**Hospital1 **] warfarin 2.5 mg QHS Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once Daily at 16). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: AS DIRECTED units Subcutaneous twice a day: 30 units at breakfast, 14 units at dinner. Disp:*QS units* Refills:*2* 10. Insulin Regular Human 100 unit/mL Solution Sig: AS DIRECTED units Injection four times a day: per home sliding scale. 11. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) units Subcutaneous twice a day for 2 weeks: please continue until INR [**2-9**]. . Disp:*QS syringe* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Atrial Fibrillation with Rapid Ventricular Rate Secondary Diagnosis: Pulmonary Edema Hypertension Discharge Condition: stable, off O2 Discharge Instructions: You were admitted for atrial fibrillation with a rapid heart rate and fluid overload, predominantly in your lungs. You were started on medications to slow down your heart rate, and you were also given medication to decrease the fluid in your body. Initially, you required oxygen via a mask at admission, but by the time of discharge, you were off of oxygen and were able to walk around without difficulty. Please take all medications as prescribed. Please make all appointments as scheduled. VNA services will teach you how to administer lovenox until your INR is therapeutic. They will also check your INR and adjust accordingly with the help of Dr. [**Last Name (STitle) 18323**]. When VNA no longer come visit please go back to coming to the hospital as previously for your INR checks. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 4023**] Date/Time:[**2137-12-4**] 1:40 PLEASE SCHEDULE AN APPOINTMENT WITH YOUR PCP TO BE SEEN WITHIN 1-2 WEEKS ICD9 Codes: 4280, 4019
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Medical Text: Admission Date: [**2150-10-12**] Discharge Date: [**2150-10-28**] Date of Birth: [**2125-2-22**] Sex: M Service: NEUROSURGERY Allergies: Amoxicillin Attending:[**First Name3 (LF) 3227**] Chief Complaint: s/p unrestrained driver in MVA vs telephone pole Major Surgical or Invasive Procedure: [**10-13**]: ICP Monitor Placement [**10-6**]: Tracheostomy and PEG placement History of Present Illness: This is a 25 year old male who is status post motor vehicle accident and was found at the scene with a GCS 3. He was brought to an outside hospital and intubated and transferred here for further care.His parents arrive to the emergency department after the initial patient evaluation.At the outside hospital the patient recieved dilantin 1 gram, rocuronium, propofol. Past Medical History: none Social History: parents mom- cell [**Telephone/Fax (1) 87035**] [**First Name8 (NamePattern2) **] [**Known lastname **]/ dad cell [**Telephone/Fax (1) 87036**] [**First Name8 (NamePattern2) **] [**Known lastname **]. Patient does not live at home with his parents. Family History: unknown Physical Exam: Gen: intubated- GCS=6T HEENT: right head laceration Pupils:L NR 4mm, right 4-3.5 sluggish reaction EOMs no eye opening Neck: hard cervical collar Extrem: Warm and well-perfused. Neuro: Mental status: intubated no eye opening, non verbal Orientation: Not oriented person, place, and date. Recall/Language:intubated non verbal Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3.5 mm bilaterally.visual fields unable to test III, IV, VI, V, VII, VIII,IX, X,[**Doctor First Name 81**],XII:unable to test Motor: Strength withdraws X4. Pronator drift-unable to test Toes downgoing bilaterally Physical Exam upon discharge: Movesd all extremities, Pupils 8mm/5mm, EO to noxious, follows simple commands Pertinent Results: CT HEAD W/O CONTRAST [**2150-10-12**] 1. Multiple punctate foci of hemorrhage. While some of these may be in the subarachnoid space, some appear at the [**Doctor Last Name 352**]-white junction, raising the question of [**Doctor First Name **]. 2. Right frontal subgaleal and subcutaneous hematoma with several foreign bodies. No underlying fracture. CT C-SPINE W/O CONTRAST [**2150-10-12**] No acute fracture or malalignment CT head [**2150-10-12**] 1. Right frontal lobe bolt placement with small foci of hemorrhage along it. 2. Multiple foci of punctate hemorrhages at the [**Doctor Last Name 352**]-white matter junction, consistent with diffuse axonal injury. 3. Newly visualized subarachnoid hemorrhage in the interhemispheric fissure and in bilateral frontal lobes, consistent with shifting of blood. 4. Unchanged right frontal subgaleal hematoma CT head [**2150-10-14**] This study is significantly limited by motion. However, in the visualized portions, the intraventricular hemorrhage appears unchanged. Fluid in the ethmoidal air cells and sphenoid sinuses which could be related to intubation CTA Chest [**10-15**]: Bilateral upper, lower and lingular consolidations have now progressed. These likely represent areas of pneumonia. ETT is very high and should be advanced by 3-4 cm MRI Head [**10-17**]: IMPRESSION: 1. Multiple foci of hemorrhagic diffuse axonal injury in the bifrontal and left posterior temporal subcortical white matter, as well as abutting the temporal [**Doctor Last Name 534**] of the right lateral ventricle. Non-hemorrhagic diffuse axonal injury in the posterior limb of the left internal capsule and in the splenium of the corpus callosum. 2. Bilateral subarachnoid hemorrhage again noted along the convexities. Small amount of intraventricular hemorrhage also again noted MRI C-spine [**10-18**]: IMPRESSION: No findings suggestive of ligamentous injury or cord injury in the cervical spine. Mild cervical spondylosis as above. MRI/A Brain & C-spine [**10-19**]: IMPRESSION: 1. No evidence of dissection in the vertebral, or carotid artery. 2. Diffuse axonal injury, and small amount of blood in the occipital [**Doctor Last Name 534**] of the lateral ventricles, better evaluated on dedicated MR head from [**2150-10-17**]. MRI Shoulder [**10-19**]:IMPRESSION: 1. Limited exam due to suboptimal technique. Infraspinatus edema and probable bursal surface fraying of the infraspinatus tendon. This is nonspecific and most likely represents posttraumatic musculotendinous tear. Lower in the differential diagnosis are etiologies such as early denervation and inflammatory etiologies. 2. Possible small tear of the anteroinferior labrum. Lack of joint fluid limits evaluation of the labrum. Brief Hospital Course: 25 y/o M s/p MVA vs telephone pole presents to [**Hospital1 18**] with a GCS of 3. CT head concerning for [**Doctor First Name **] and punctate hemorrhages. Mannitol bolus was given in the ED and will continue at 50Q6H. On examination, patient is more brisk with his L side spontaneous and purposeful, on the R he flexes and w/d to noxious stimuli, no eye opening or commands. He was admitted to the ICU and a bolt was placed with an ICP of 23. His ICP was subsequently medically managed with hyperosmlar therapy. Repeat head CT was stable. [**2070-10-13**] Repeat CT head on [**10-14**] remained stable and his ICP remained stable on hyperosmolar therapy. On [**10-15**] he was started on vancomycin, cefepime,flagyl and cipro for significant hospital aquired pneumonia and respiratory failure. He reamined intubated. He had a CTA Chest that was negative for a PE. On [**10-16**] - his ICPs remained <20 and his exam remained stable. His ICP monitor was discontinued on [**10-17**]. An MRI in the afternoon revealed multiple foci of hemorrhagic diffuse axonal injury in the bifrontal and left posterior temporal subcortical white matter. His mannitol was weaned to 12.5mg QD, and SQH was started that evening. On [**10-19**], his mannitol was discontinued. Due to persistent ventilation requirement, a consult for a PEG/Treach by General Surgery was obtained, and he went to the OR on [**10-21**] to have these placed. Pt's antibiotics changed to vancomycin only per ID recommendation on [**10-22**]. Pt was febrile on [**2150-10-23**] and blood cultures were obtained. He was transferred to the SDU on [**2150-10-24**]. On [**10-25**] & [**10-26**] pt remained neurologically stable and afebrile. Infectious Disease team recommended discontinuing antibiotics as the pt had completed sufficient course. PT and OT were consulted for assistance with discharge planning and acute rehab was recommended. On [**10-27**] the patient was again stable and cleared for discharge to rehab facility pending bed availability. He remained stable following this and on the morning of [**10-28**] he was discharged to [**Hospital1 **] for rehab Medications on Admission: None Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 5. oxycodone 5 mg/5 mL Solution Sig: [**5-25**] ml PO Q3H (every 3 hours) as needed for pain. 6. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 9. lorazepam 2 mg/mL Syringe Sig: 0.25 ml Injection Q4H (every 4 hours) as needed for agitation. 10. hydralazine 20 mg/mL Solution Sig: 0.5 ml Injection Q6H (every 6 hours) as needed for SBP greater than 160. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Lorazepam 1 mg IV Q4H:PRN agitation agitation Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: [**Doctor First Name **], punctate hemorrhages, RIVH Discharge Condition: Mental Status: Confused - always. Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2150-10-28**] ICD9 Codes: 5185
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Medical Text: Admission Date: [**2197-7-12**] Discharge Date: [**2197-7-20**] Service: Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Nurse practitioner HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old gentleman who was transferred on [**7-12**] from [**Hospital 882**] Hospital with a right thalamus/post ventricular/subarachnoid hemorrhage and hydrocephalus, status post a ventricular drain placement. The patient was admitted to an outside hospital on [**2197-7-7**] with shortness of breath and fever. He was diagnosed with pneumonia and a chronic obstructive pulmonary disease exacerbation. Initially, he did well. His mental status improved. He then suddenly experienced mental status changes and was transferred to the Intensive Care Unit. At that time, he was obtunded and was noted to have an acute intracerebral hemorrhage. He computed tomography revealed a small amount of blood in the right basal ganglia as well as bilateral ventricles as well as blood in the superior cerebellar cistern, as well as hydrocephalus, and obstruction of the cerebral duct. He was transferred to [**Hospital1 69**] for management. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Chronic obstructive pulmonary disease. 2. Dementia. 3. History of cerebrovascular accident. 4. Hypertension. 5. Diabetes mellitus. 6. History of traumatic brain injury. 7. History of methicillin-resistant Staphylococcus aureus; positive sputum. 8. Peripheral vascular disease. 9. Status post recent coiling of an aneurysm at [**Hospital3 2358**] in [**2196-10-4**]. BRIEF SUMMARY OF HOSPITAL COURSE: He arrived at [**Hospital1 346**] sedated and intubated. He was opening his eyes spontaneously. He was not following commands. The lungs were noted to have bilateral coarse breath sounds. Heart revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. The abdomen was soft, nontender, and obese. Extremities revealed no edema. On neurologic examination, he opened his eyes spontaneously. He did not follow commands. The right pupil was fixed and dilated. The left pupil was 2 mm to 1.8 mm reactive. He had minimal movement noted on the left side with no movement of the left upper extremity. He did have positive movement of the left lower extremity to noxious stimuli. He did have good movement on the right side with good strength. He was admitted to the Neurology Intensive Care Unit. The patient's condition remained unchanged. A right ventricular drain was placed. A left radial arterial line was also placed on [**2197-7-11**]. The patient developed respiratory problems despite aggressive pulmonary toilet. A family conference was called. He was made comfort measures only. The patient died on [**7-20**] at 0018. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Doctor First Name 51026**] MEDQUIST36 D: [**2197-12-14**] 12:24 T: [**2197-12-16**] 08:28 JOB#: [**Job Number 51027**] ICD9 Codes: 486, 4019
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Medical Text: Admission Date: [**2176-6-13**] Discharge Date: [**2176-6-15**] Date of Birth: [**2108-8-25**] Sex: M Service: MEDICINE Allergies: Chocolate Flavor Attending:[**First Name3 (LF) 2704**] Chief Complaint: Claudication-->re-look LE angiography. Claudication-->Elective PERIPHERAL VASCULAR angiography Major Surgical or Invasive Procedure: S/P PTA of L SFA & CFA, athrectomy of R CFA, PTA/Stent (3) of R SFA & PTA of R TPT History of Present Illness: This 67 year old man has a history of hypertension, hyperlipidemia, tobacco abuse, CAD s/p CABG and known PVD, s/p many prior LE interventions. Mr [**Known lastname 30301**] presents for a relook LE angiography. The patient's daughter reports that about three weeks ago her father began to have recurrent leg claudication, occurring with walking about half a block. She is unclear on which leg may be bothersome. After his last revascularization, for a brief period, he had some improvement of his claudiation, which has returned since. . In terms of cardiac symptoms, he has no chest discomfort. He does have dyspnea with activity such climbing up one flight of stairs. It is worse with the recent increase in humidity. He is on oxygen 2l via nasal cannula at night while sleeping. Past Medical History: -HTN -CAD s/p CABG ([**2169**]: ([**Hospital1 18**]) LIMA to LAD, SVG to RAMUS) -PVD s/p multiple interventions (see below) -cigarette smoking 1ppd/50+yrs -Polio as a child -BPH -emphysema/COPD, uses 2 liters nasal cannula at hs -hyperlipidemia -s/p lung resection 40+ years ago after a stab wound -Right inguinal hernia repair -Back pain -Cataracts (surgery scheduled for [**2176-7-9**]) -[**3-30**]: Paroxysmal atrial flutter Peripheral vasc. history includes: [**2175-4-3**] ABI: 0.51 right, 0.59 left [**2175-7-10**] Lower extremity angiogram: Right- Internal iliac artery occluded. External iliac artery occluded at the exit to the CFA. The CFA had a short occlusion to the SFA/PFA bifurcation with the PDA filling the distal SFA. Left- Common iliac artery was normal. External iliac artery was occluded at the bifurcation with the internal iliac artery. Common femoral artery occluded. SFA patent below the occlusion. S/P successful Right CFA and [**Month/Day/Year 30302**] intervention with cryoplasty to the SFA. [**2175-8-2**]: successful recanalization of the [**Female First Name (un) 7195**] followed by atherectomy and stenting [**2176-2-14**] LE angio: (right brachial artery access): RLE: diffuse disease in the CIA. IIA with an 80% stenosis. CFA totally occluded. LLE: moderate diffuse disease of the CIA. Prior EIA stent with an 80% lesion and no flow down the external iliac artery. SFA totally occluded proximally. Attempt at revascularization of the left EIA unsuccessful. [**2176-2-15**]: (access via left brachial artery):PTA of the origin of the left internal iliac artery with a 5.0 mm balloon. Successful PTA of the totally occluded RCFA and SFA with a 4.0 balloon. [**2176-2-16**] LLE angiography: prior stent and CFA patent with a distal dissection noted in the CFA with ulceration. SFA flush occluded at the origin, PFA patent with collateralization of the distal SFA. Successful recanalization of the Left SFA with PTA using a 5.0 mm balloon. Successful cryoplasty of the [**Doctor First Name **], LCFA into the [**Doctor First Name 30303**]. [**2176-4-23**]:MRI of LE: Mild atherosclerotic disease in the iliac arteries and LE's. No hemodynamically significant stenosis present. [**2176-6-7**] MRI/MRA of abdomen (limited examination): Moderate focal stenosis of the origin of the celiac artery. Diffuse narrowing of the left common iliac artery with approximately a 7 mm long segment of moderate to severe stenosis in the proximal left common iliac artery, about 5mm from its origin. Possible severe stenosis at the origins of the internal iliac arteries. Several areas of mild stenosis in the right external iliac artery. No definite flow seen in the right SFA consistent with occlusion. LLE: (limited due to opacification)-Appearance of flow in the left SFA although evaluation is limited. Flow in the popliteal appears less than compared to the right. Flow in the left AT to the level of the ankle noted with poor appearing flow in the distal left anterior tibial and dorsalis pedis arteries. Social History: Pt lives alone in [**Hospital1 1474**]. Close with daughter. Drinks 3+ [**Name2 (NI) 17963**] a day & smokes (as above). Family History: (-) FHx CAD Physical Exam: VS: 107/53, HR 70's, O2 92% RA Gen- a&ox3, nad Chest-CTAB Heart- (Post-procedure) R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with baseline L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with baseline R Brachial Site: mild bruit (-) hematoma or ooze Pertinent Results: Angiography & PTA -- [**2176-6-13**] *** Not Signed Out *** FINAL DIAGNOSIS: 1. Diffuse and critical bilateral CFA, SFA disease. 2. successful PTA of the LCFA 3. succesful PTA of the [**Month/Day/Year 30303**] 4. Successful PTA and stenting of the [**Month/Day/Year 30302**] 5. Successful PTA of the popliteal perforation 6. Successful PTA of the RCFA. . ART DUP EXT UP UNI LMTD RIGHT [**2176-6-14**] FINDINGS: No pseudoaneurysm or AV fistula involving the right brachial access site. A focal area of velocity elevation in the brachial artery just above the antecubital fossa is identified, reaching 486 cm/sec. This indicates a high-grade stenosis in this area. . Angiography & PTA -- [**2176-6-14**] *** Not Signed Out *** FINAL DIAGNOSIS: 1. Occluded RBA treated with PTA 2. Occluded RCFA treated with stenting and thrombectomy Brief Hospital Course: Mr [**Known lastname 30301**] presents for a relook LE angiography. He has a ho multiple LLE interventions in the past. He also has a background of CABG, current smoking and COPD. . He underwent angiography & PTA of LCFA & [**Name (NI) 30303**], PTA and stenting of the [**Name (NI) 30302**], PTA of the popliteal perforation, PTA of the RCFA. Following the procedure, the pt underwent duplex scan of his right arm, which suggested a significant obstruction in his R brachial artery. The pt was taken back to the cath lab for further evaluation with angiography. During catheterization, the pt was found to have occluded RBA treated with PTA. He was also found to have occluded RCFA treated with stenting and thrombectomy. . The pt recovered well from the procedures. However, his HCT dropped and he was transfused 2uPRBCs. The drop was thought to be due to blood loss & fluids given peri-procedure. His Hct repsonded appropriately to the transfusion. He was discharged following transfusion. Medications on Admission: Aspirin 325mg daily Zestril 20mg daily HCTZ 12.5mg daily Metoprolol 75mg tablets twice a day Colace 100mg twice a day Folic acid 1mg daily Theophylline 200mg one tablet daily Lipitor 40mg daily Prednisone 5mg daily Pletal 100mg twice a day Digitek .25mg daily every morning Plavix 75mg daily Methocarbamol 750mg three times a day Thiamine 100 daily Percocet 1-2 tablets every 8 hours prn MVI Advair 500/50 twice a day Spiriva 18mcg one puff once a day Albuterol inhaler, prn Albuterol nebulizer 2-4 times per day Cromolyn sodium 20mg (nebulizer)2-4 times per day Omeprazole 40mg daily Ambien 10mg prn at bedtime Ensure plus one can daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for refills please call Dr. [**First Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*11* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Zestril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Theophylline 200 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO DAILY (Daily). 9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Digitek 250 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed. 16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Ensure Liquid Sig: One (1) PO once a day. 19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: PVD Anemia Seconday: CAD BPH COPD HTN Hyperlipidemia Discharge Condition: Stable VS: 107/53, 70's, 92% RA Labs: hct 34.5 (after tranfusion of 2uPRBC's), plt 339, k 4.4, buncr 10/0.7, alt 17, ast 24, ck 86 R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with baseline L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with baseline R Brachial Site: mild bruit (-) hematoma or ooze Discharge Instructions: -Continue taking all of your medications as directed. -Take Aspirin 325mg & Plavix 75mg daily. Do not stop these medications unless directed by Dr. [**First Name (STitle) **] [**Name (STitle) **] are not longer taking pletal -You need to return in 2 weeks for an intervention on your left leg & right brachial artery in your arm, you will be called regarding scheduling this. -Seek immediate medical attention for any recurrent symptoms, temperature change, pain or discoloration of your extremities, any issues with your groin site including fever or any other concerning symptom. Followup Instructions: -Dr. [**First Name (STitle) **] will call you tomorrow to check on you. If you have any questions, you may try to reach him at his office, phone: ([**Telephone/Fax (1) 7236**]. -You have an appointment at in the Vascular Lab at [**Hospital1 18**] on Monday, [**2176-6-17**], Time: 10:00. This is for a VASCULAR STUDY. Please call if you need directions or have any questions Phone:[**Telephone/Fax (1) 327**] - Please make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1 week. -Return to lab in 2 weeks for LLE & R Brachial intervention. ICD9 Codes: 496, 4019, 2724, 3051, 2859
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Medical Text: Admission Date: [**2188-3-1**] Discharge Date: [**2188-3-15**] Date of Birth: [**2131-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: transfer from NEBH for SOB, possible need for cath given rising troponin Major Surgical or Invasive Procedure: Cardiac Catheterization Coronary Artery Bypass Grafting LIMA-->LAD, SVG-->OM, SVG-->PDA History of Present Illness: 56 y/o male patient of Dr. [**Last Name (STitle) **] with HTN, hypercholesterolemia, DM2, current smoking, PVD s/p Left CEA and totally occluded [**Country **], with chest discomfort begining three weeks ago which he describes as "stressed out feeing" right before the holidays. Denies pain or associated symptomes of SOB, diasphoresis, light headedness, nausea, or leg swelling. He has been chest dicomfort free for the last several weeks since then, with the exception of increased SOB, mostly at night, and increased leg swelling, cough, and PND. He presented to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39934**] office with SOB, cough, and sputum production, was treated with antibiotics with no resolution of symptomes, and had a CXR suggestive of pulm edema, and so was referred to NEBH ambulatory services for evaluation. He was admitted to NEBH for r/o MI, troponins 1.82 to 4.16 to 5.35 with CK 173 to 161 to 181. Started on asa, plavix, lovenox and transferred for possible cath/CABG given rising troponins. Denies chest pain currently. Denies SOB. Past Medical History: HTN hypercholesterolemia DM2 current smoking PVD s/p Left CEA and totally occluded [**Country **] Hypothyroidism S/P Cholecystectomy S/P Cervical Surgery S/P B/L Knee Surgery Social History: Smoker of 35 years at 2 ppd. No recent alcohol use, but remote history of frequent use. Family History: Father had MI at 65 years old. Physical Exam: General: Well appearing man in no distress. Approproately responsive. Vitals: T 96.2 BP 131/54 HR 61 RR 18 Sat 100% 1L O2 NC FS 58 Wt 110kg HEENT: normal, anicteric sclera Neck: Carotid bruits B/L R>L Chest: Lungs with decreased breath sounds at bases, otherwise clear ABD: Scar over RUQ and above umbilicus, +bowel sounds, soft, NT, ND, no organomegaly EXT: No edema. Good femoral pulses B/L without bruits. Pertinent Results: INDICATIONS FOR CATHETERIZATION: NSTEMI, low EF, 30 beats of monomorphic VT PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 6 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. Cardiac output was measured by the Fick method. Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French angled pigtail catheter, advanced to the left ventricle through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 catheter, with manual contrast injections. Left Ventriculography: was performed in the 30 degrees [**Doctor Last Name **] projection, using 33 ml of contrast injected at 11 ml/sec, through the angled pigtail catheter. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.21 m2 HEMOGLOBIN: 14 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 15/16/9 RIGHT VENTRICLE {s/ed} 45/15 PULMONARY ARTERY {s/d/m} 45/18/28 PULMONARY WEDGE {a/v/m} 24/25/22 LEFT VENTRICLE {s/ed} 141/24 AORTA {s/d/m} 141/64/71 **CARDIAC OUTPUT HEART RATE {beats/min} 55 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 38 CARD. OP/IND FICK {l/mn/m2} 7.3/3.3 **RESISTANCES SYSTEMIC VASC. RESISTANCE 680 PULMONARY VASC. RESISTANCE 66 **% SATURATION DATA (NL) SVC LOW 70 PA MAIN 68 AO 88 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. LEFT VENTRICULOGRAPHY: Volumetric data: LV ejection fraction (nl 50%-80%). 25 Qualitative wall motion: [**Doctor Last Name **]: 1. Antero basal - hypokinetic 2. Antero lateral - hypokinetic 3. Apical - hypokinetic 4. Inferior - hypokinetic 5. Postero basal - hypokinetic Other findings: Mitral valve was normal. Aortic valve was normal. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 50 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DISCRETE 95 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DIFFUSELY DISEASED 70 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX DISCRETE 70 13) MID CX DIFFUSELY DISEASED 13A) DISTAL CX DIFFUSELY DISEASED 14) OBTUSE MARGINAL-1 DISCRETE 95 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour41 minutes. Arterial time = 0 hour25 minutes. Fluoro time = 5.6 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 83 ml, Indications - Hemodynamic Premedications: ASA 325 mg P.O. Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Fentanyl 25 mcg IV Versed 0.5 mg IV Lasix 20 mg IV Cardiac Cath Supplies Used: 200CC MALLINCRODT, OPTIRAY 200CC 100CC MALLINCRODT, OPTIRAY 100CC COMMENTS: 1. Selective coronary angiography revealed a right dominant system. There was no angiographically apparent CAD in the LMCA. The LAD had a long diffusely diseased segment with a 70% stenosis. The LCX had a 70% proximal stenosis. The OM had a 95% origin stenosis. There was moderate diffuse distal disease in the LCx. The RCA had a 50% mid vessel stenosis and 95% bifurcation disease at the PDA and PL. 2. Hemodynamics on entry showed elevated filling pressures, mild to moderate pulmonary hypertension, and a normal cardiac output. There was no gradient across the aortic valve on pullback. 3. Left ventriculography showed a dilated ventricle which was globally hypokinetic. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate systolic and mild diastolic ventricular dysfunction. 3. Mild to moderate pulmonary hypertension. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) 10897**] B. ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S. Cardiology Report ECG Study Date of [**2188-3-5**] 3:51:14 PM Ectopic atrial rhythm. Ventricular premature beat with possible pacemaker fusion. Lone pacemaker spike in the third beat of the rhythm strip. Consider sensing malfunction. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 51 [**Telephone/Fax (3) 32880**]/446.86 -53 95 -157 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2188-3-7**] 12:47 PM CHEST (PORTABLE AP) Reason: PTX [**Hospital 93**] MEDICAL CONDITION: 56 year old man with increasing dyspnea s/p CABG now s/p R-IJ change over wire and d/c CTs REASON FOR THIS EXAMINATION: PTX CHEST, SINGLE AP FILM History of CABG and increasing dyspnea with CV line change. Status post CABG. Right jugular CV line is in the SVC. No pneumothorax. The right costophrenic region is not included on the film. There is opacity at the left base obscuring the left hemidiaphragm consistent with atelectasis in the left lower lobe and associated small left pleural effusion. Status post cervical spine fusion. DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**] Approved: [**First Name9 (NamePattern2) **] [**2188-3-7**] 2:55 PM RADIOLOGY Final Report CAROTID SERIES COMPLETE [**2188-3-4**] 3:40 PM CAROTID SERIES COMPLETE Reason: please eval for extent of carotid stenosis b/l [**Hospital 93**] MEDICAL CONDITION: 56 year old man with h/o PVD s/p left CEA and known [**Country **] occlussion. ON exam with b/l carotid bruits R>L and diminsihed R carotid pulse. REASON FOR THIS EXAMINATION: please eval for extent of carotid stenosis b/l HISTORY: Status post left carotid endarterectomy with right carotid occlusion. TECHNIQUE: [**Doctor Last Name **] scale ultrasound, color Doppler, and spectral Doppler interrogation of the extracranial carotid arteries were performed. RIGHT: No flow was demonstrated within the right internal carotid artery. Peak systolic velocity in the right external carotid artery was 193 cm/sec, common carotid artery 43 cm/sec. Blood flow within the right vertebral artery was antegrade. LEFT SIDE: Mild calcified plaques were noted at the origin of the left internal carotid artery. Peak systolic velocities were as follows: 112 cm/sec ICA, 71 cm/sec CCA, 132 cm/sec ECA. Blood flow direction within the left vertebral artery was antegrade. The ICA-CCA ratio on the left was 1.57. IMPRESSION: 1. Right internal carotid artery is occluded. 2. Nonhemodynamically significant stenosis of less than 40% was demonstrated in the left internal carotid artery. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 39935**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39936**] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: WED [**2188-3-5**] 9:51 AM Brief Hospital Course: 56 y/o male with HTN, hypercholesterolemia, current smoking, DM2, PVD S/P L CEA and occluded [**Country **] presents from outside hospital after completed MI with shortness of breath, was chest pain free and ruled out for active ischemic event. He was started on metoprolol and captopril. His shortness of breath improved with diuresis (40 mg IV lasix QD). He had a 30 second episode of monomorphic VT symptomatic with lightheadedness on [**2188-3-3**]. He went for elective cath on [**2188-3-4**], which showed 3VD, and so he was scheduled for CABG. He was started on amiodarone for VT. He was continued on his home regimen of 60 units 75/25 QD before breakfast for DM2, but his evening dose of 60 units NPH was halved for morning hypoglycemia. He had a carotid US for his h/o PVD with CEA of left carotid and known totally occluded [**Country **]. It showed 40% Left Stenosis and totally occluded [**Country **]. He had an abnormally elevated TSH to 25, but his free T4 was normal. We continued his home dose of levothyroxine 300 mcg QD. He may need an EP study for possible ablation of ventricular focus given his episode of monomorphic VT as an Outpatient per Dr. [**Last Name (STitle) **]. He may also need an ICD given his low EF an documented episode of symptomatic monomorphic VT. Mr. [**Known lastname 3075**] [**Last Name (Titles) 1834**] cardiac catheterization where he was found to have no angiographically apparent CAD in the LMCA. The LAD had a long diffusely diseased segment with a 70% stenosis. The LCX had a 70% proximal stenosis. The OM had a 95% origin stenosis. There was moderate diffuse distal disease in the LCx. The RCA had a 50% mid vessel stenosis and 95% bifurcation disease at the PDA and PL. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner. On [**2188-3-5**] he successfully [**Date Range 1834**] CABGx (LIMA->LAD, SVG->PDA, SVG->OM). Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He was weaned from ventilator support, extubated, and pressors were weaned. On POD 2 he was then transferred to the cardiac stepdown unit for further recovery. His chest tubes were removed without complication. He was gently diuresed toward his preoperative weight with lasix. Beta blockade, aspirin, and plavix were resumed. The physical therapy service was consulted to assist with his postoperative strength and mobility. Electrolytes were repleted as needed. On POD 3 his epicardial pacing wires were removed without complication. The Electrophysiology service was consulted regarding history of ventricular tachycardia that occurred preoperatively. Consideration was given to performing an EP study with ablation however due to his continued tenuous pulmonary status Dr. [**Last Name (STitle) **], Mr. [**Known lastname 39937**] cardiologist elected to continue observation and perform any further work up as an outpatient. Also on POD 3 he began to complain of decreased sensation and flexion to his left calf and shin. This was attributed to peroneal nerve injury from fluid accumulation or positioning, for which the physical therapy service gave an ankle foot orthotic. We will continue watchful waiting for the return of his left lower extremity function. If indicated further workup will be conducted as an outpatient. He continued to improve his ability to ambulate including climbing stairs without severe respiratory distress or chest pain. His room air saturations improved to 98% despite continuing to require combivent, albuterol, and advair. On POD 9 Mr. [**Known lastname 3075**] was at his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, dry, and intact, however he was placed on levaquin 500mg for seven days due to sersanquinous drainage at the inferior portion of his sternotomy. He was discharged to home on POD 9, with cardiac diet, sternal precautions, and instructed to follow up with his PCP and cardiologist in [**2-18**] weeks. He will follow up for a wound check on Mon or Tues. at [**Hospital Ward Name 121**] 2. He will follow up with Dr. [**Last Name (STitle) **] in four weeks. Medications on Admission: Home Meds: Valium 5 mg TID Humulin N 60 units QD at dinnertime Humalog 75/25 60 units QD before breakfast Levothyroxine 300mcg QD Percocet 5mg/325mg [**2-18**] Q4H PRN Additional Meds on transfer: ASA 325 QD Plavix 300 once Nitro Paste 2inches Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs* Refills:*2* 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs* Refills:*2* 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every 4-6 hours. Disp:*qs qs* Refills:*2* 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous once a day. Disp:*qs 30* Refills:*2* 17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: One (1) 60 Subcutaneous qBreakfast. Disp:*qs 30* Refills:*2* 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 60 Subcutaneous at bedtime. Disp:*qs 30* Refills:*2* 19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*qs ML(s)* Refills:*0* 20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: care group Discharge Diagnosis: CAD, PVD s/p Left CEA, totally occluded [**Country **], Hypothyroidism, s/p CCY, cervical injury, s/p Bilateral knee replacement with intra-op brady arrest, IDDM, HTN, Hypercholesteremia Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] in four weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 5456**] in [**2-18**] weeks [**Telephone/Fax (1) 25798**] Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2394**] in [**2-18**] weeks Completed by:[**2188-3-15**] ICD9 Codes: 4280, 4271, 4019, 2720, 3051, 4439, 2449, 4168
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Medical Text: Admission Date: [**2107-10-21**] Discharge Date: [**2107-10-25**] Date of Birth: [**2020-2-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: CABG X4 (LIMA-LAD, SVG-OM, PDA,PLD) on [**2107-10-21**] History of Present Illness: 87 year old male, known to our service (see H&P from [**2107-8-12**]), who sustained an STEMI in [**2107-7-24**]. A bare metal stent was placed to the RCA at that time. A TTE on [**2107-8-13**] showed inferior hypokinesis and an EF of 35-40%. He was seen by cardiac surgery and was considering CABG at the time of discharge however wanted to wait for the time being. Since that time he has felt quite well and has been symptom free. He walks 20 minutes daily without issue. He was seen by Dr. [**Last Name (STitle) 911**] in consultation and it was recommended that he would be best served with going forward with surgical revascularization. Recent echo showed left ventricular wall motion abnormalities and overall left ventricular systolic function that are significantly improved compared to prior echo. He presented for surgical discussion. Past Medical History: Glaucoma Mechanical fall c/b left proximal ulnar fracture [**4-/2105**] Mild cognitive impairment Left peroneal impairment Prostate Cancer s/p TURP and Lupron therapy 12 years ago GERD Past Surgical History: s/p TURP Past Cardiac Procedures: [**2107-8-12**] s/p BMS to RCA Social History: Race: Caucasian Last Dental Exam: 3 months ago Lives with: alone Contact: [**Name (NI) 84169**] (son) Phone #[**Telephone/Fax (1) 84170**] Occupation:retired Cigarettes: Smoked no [x] yes [] Other Tobacco use: Never ETOH: < 1 drink/week [x] [**3-1**] drinks/week [] >8 drinks/week [] Illicit drug use: Denies Family History: The patient has a twin brother who has a history of heart disease and heart failure Physical Exam: Pulse: 59 Resp: 16 O2 sat: 100/RA B/P 140/75 Height: 5'8" Weight: 75.7 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] No Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:1+ Left:1+ Carotid Bruit Right: - Left: - Pertinent Results: [**2107-10-24**] 05:40AM BLOOD Hct-28.5* [**2107-10-23**] 06:15AM BLOOD WBC-9.7 RBC-3.15* Hgb-9.2* Hct-27.9* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.1 Plt Ct-128* [**2107-10-22**] 02:37AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-28.8* MCV-88 MCH-29.4 MCHC-33.3 RDW-14.8 Plt Ct-126* [**2107-10-21**] 07:27PM BLOOD Hct-29.0* [**2107-10-24**] 05:40AM BLOOD UreaN-25* Creat-1.2 Na-132* K-4.3 Cl-100 [**2107-10-23**] 06:15AM BLOOD Glucose-108* UreaN-22* Creat-1.2 Na-135 K-4.1 Cl-103 HCO3-26 AnGap-10 [**2107-10-22**] 02:37AM BLOOD Glucose-149* UreaN-19 Creat-1.3* Na-136 K-4.8 Cl-108 HCO3-22 AnGap-11 [**2107-10-21**] 12:17PM BLOOD UreaN-19 Creat-1.2 Na-141 K-4.3 Cl-114* HCO3-22 AnGap-9 [**2107-10-21**] TTE Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is paced, on no inotropes. Preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on **** where the patient underwent *********. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. ***** was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD **** the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged ***** in good condition with appropriate follow up instructions. Medications on Admission: ATORVASTATIN 80 mg tablet 1 tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] 75 mg tablet once a day LISINOPRIL 5 mg by mouth once a day METOPROLOL SUCCINATE [TOPROL XL] 25 mg tablet,extended release 1 Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT] - Nitrostat 0.4 mg sublingual tablet 1 tablet(s) sublingually as directed PRN TIMOLOL MALEATE - Dosage uncertain ASPIRIN 325 mg tablet,delayed release 1 Tablet(s) by mouth once a day Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*100 Tablet Refills:*0 2. Atorvastatin 80 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Tartrate 50 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days Hold for K+ > 4.5 RX *potassium chloride 20 mEq 1 by mouth daily Disp #*1 Tablet Refills:*0 6. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **] 8. Furosemide 20 mg PO DAILY Duration: 7 Days RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 9. Lisinorpil 5 mg po daily 10. Plavix 75 mg po daily Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**First Name (STitle) **] on [**2107-11-22**] at 2:30pm Cardiologist: Dr. [**Last Name (STitle) 911**] [**2107-11-16**] at 3:20pm ([**Hospital Ward Name 23**] 7) Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**4-28**] weeks [**Telephone/Fax (1) 2010**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2107-10-25**] ICD9 Codes: 412, 2859
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Medical Text: Admission Date: [**2123-8-10**] Discharge Date: [**2123-8-20**] Service: [**Hospital Unit Name 14178**] CHIEF COMPLAINT: Admission from clinic for tachycardia. HISTORY OF THE PRESENT ILLNESS: This is an 85-year-old African-American female with a past medical history of hypothyroidism and hypertension who presented to her primary care physician with new onset shortness of breath, dyspnea, lightheadedness, and PND. Symptoms have progressed over the past two weeks prior to admission. Upon presentation to her primary care physician, [**Name10 (NameIs) **] showed narrow complex tachycardia and an old known left bundle branch block. The patient's pulse in the office was at 128, at which point, the patient was referred to the Emergency Department. Of note, the patient does not have any cardiac history. She was 100% functional without experiencing shortness of breath prior to this episode. In the Emergency Department, a CTA ruled out a pulmonary embolism. The patient was given IV Lasix and 12.5 mg Lopressor empirically for CHF. A chest x-ray revealed basilar congestion and atelectasis but no evidence of CHF. The patient developed bradycardia with a pulse of 35 and hypotension with a blood pressure of 60-40 after having received the Lopressor. The patient was fluid resuscitated and the blood pressure was raised to 120. The patient again became tachycardiac with a pulse of 120 and was admitted to [**Hospital Unit Name 196**] and scheduled for EP. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Hypertension. 3. Remote GI bleed. 4. Breast biopsy in [**2112**]. 5. Knee surgery in [**2115**]. 6. Hip surgery in [**2121**]. HOME MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q.o.d. 2. Levothyroxine 100 micrograms q.d. 3. Hydrocortisone 2.5% twice as needed to scalp. 4. Triamcinolone. 5. Acetamide 0.1% twice as needed. 6. Tylenol p.r.n. pain. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: History of diabetes mellitus in mother and hypertension. SOCIAL HISTORY: The patient lives with a roommate. She has a remote history of smoking one to two cigarettes a day for approximately 20 years. The patient admits to quitting 15 years ago. The patient denied alcohol use, denied any other drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile, blood pressure 124/81, heart rate 140s, respiratory rate 12. The 02 saturation was 97% on room air. HEENT: No JVD noted, no scleral icterus. Mucosa moist. Cardiovascular: Distant heart sounds, tachycardiac, S1 and S2 present, I/VI holosystolic murmur. Respiratory: Positive bibasilar crackles, worse on the right, diffuse wheezing. Abdomen: Tender in the epigastric region, otherwise nondistended, soft, bowel sounds present. Extremities: There were +2 pedal pulses, no edema noted. LABORATORY/RADIOLOGIC DATA: Hemoglobin 13.1, hematocrit 37.8, white blood cells 8.2, and platelets 176,000. Electrolytes: Sodium 140, potassium 3.2, chloride 102, bicarbonate 24, BUN 10, and creatinine 1.1, sugar 104. CKs were 136, MB 3, and troponin 0.01. Enzymes were continued to be cycled and the patient was ruled out for acute MI. HOSPITAL COURSE: Upon admission to [**Hospital Unit Name 196**] on the floor, the patient developed torsades which was attributed to treatment with beta blockade in the ED and resultant prolongation of QRS on the background of bradycardia. The patient was transferred to the CCU where she was given 2 mg of magnesium sulfate and converted to sinus. The next morning, [**2123-8-11**], the patient underwent EP study with RFA radiofrequency ablation and dual-chamber pacemaker placement. This RFA addressed her supraventricular tachycardia. The pacemaker addressed her bradycardia. Post EP study and pacemaker insertion on the floor, the patient developed tachypnea and diaphoresis with a rising blood pressure to 208/119, pulse 120, and SA02 of 90% on 2 liters. Chest x-ray done at that time showed evidence of congestion and the patient was given 40 mg of IV Lasix. Echocardiogram also performed at this time showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 14179**] left ventricular [**Last Name (Titles) 14179**] LV and EF of 30%. The next morning, [**2123-8-12**], the patient underwent a catheterization which showed 100% RCA ostium occlusion and otherwise patent LAD and circumflex. A stent was placed in the RCA. Mitral regurgitation was assessed as moderate by left ventriculogram. Post catheterization, the patient continued to be in congestion with significant pleural effusion. The CHF Service, under Dr. [**Last Name (STitle) **], were also on consult following the patient. The patient was started on Nisiritide on [**2123-8-15**] and was continued on Nisiritide with successful diuresis until [**2123-8-20**]. Throughout the course, the patient received Captopril for afterload reduction and beta blockade. The patient improved significantly and is able to ambulate with PT. The patient is on room air and saturating at 97% oxygen. The patient was discharged to [**Hospital6 14180**]. FINAL DIAGNOSIS: 1. Ischemic cardiomyopathy. 2. Mitral regurgitation 3. Acute congestive heart failure due to number two. 4. Supraventricular tachycardia. 5. Hypertension. 6. Hypothyroidism. RECOMMENDED FOLLOW-UP: 1. Follow-up with cardiologist, Dr. [**Last Name (STitle) 73**], in one week, phone number [**Telephone/Fax (1) 902**]. 2. Follow-up with outpatient echocardiogram on [**2123-9-3**] at 11:00 [**Initials (NamePattern4) **] [**Hospital Ward Name 516**]. 3. Follow-up with Dr. [**Last Name (STitle) 8499**], primary care physician, [**Name10 (NameIs) **] three weeks. POSTDISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Lisinopril 10 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Spironolactone 25 mg p.o. q.d. 5. Lipitor 10 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Digoxin 0.125 mg p.o. q.d. 8. Levothyroxine 125 micrograms p.o. q.d. 9. Protonix 40 mg p.o. q.d. 10. Acetaminophen 325 mg tablets, p.r.n. 11. Albuterol sulfate solution p.r.n. for wheezing. DISCHARGE STATUS: Good. CONDITION ON DISCHARGE: Good. DR.[**Last Name (STitle) 14181**],[**First Name3 (LF) 2064**] 12-ABZ Dictated By:[**Name8 (MD) 9784**] MEDQUIST36 D: [**2123-8-20**] 01:15 T: [**2123-8-20**] 13:18 JOB#: [**Job Number 14182**] cc:[**Hospital6 14183**] ICD9 Codes: 4240, 4280, 4271, 2449, 4019
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Medical Text: Admission Date: [**2122-8-10**] Discharge Date: [**2122-8-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: Hematochezia and weakness Major Surgical or Invasive Procedure: 3 PRBC Blood transfusion. Flexible Sigmoidoscopy. History of Present Illness: [**Age over 90 **] year old man with history of alcohol abuse, paroxysmal atrial tachycardia and frequent lower gastrointestinal bleeding, presenting with 1 week history of bright red blood per rectum with bowel movements. Patient reports he was in his otherwise good state of health until last Monday, when he began having diarrhea with bright red blood, which stained his toilet water red. Patient also complains of weakness, fatigue when going up a single set of stairs (different than his baseline) The patient also Complaints of "nose/throat issues" and reports a scratchy feeling in his throat. Denies any recent travel, fevers, chills, nausea, vomiting, chest pain, but does report feeling dizzy. In ED, Temp: 99.4 HR: 86 BP: 89/51 RR: 19 O2 Sat:99% RA. Patient given 1 unit of PRBC with improvement in SBP to 100's. Hct found to be 18 (baseline 34). Patient admitted to MICU for further management. Past Medical History: - alcohol abuse; drank an average of 2 large bottles of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] per week (per prior OMR notes) patient reports he has since quit (x 1 month) - paroxysmal atrial tachycardia - anemia, mild leukopenia - dementia (baseline oriented to person, place) - BPH s/p TURP - chronic LGIB (question of AVM vs Diverticuli) - gout Social History: Patient had history of [**1-22**] drinks of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] per day as documented in OMR. Prior tobacco, quit in 60s. Lives with his wife. [**Name (NI) **] has two kids and 2 grandkids. Family History: Non-contributory, no colon CA Physical Exam: Vital signs: Temp: 99.4 HR: 92 BP: 133/50 RR: 25 O2 Sat: 100% GEN: Elderly man in no acute distress, well appearing. Alert, oriented to self, place, year, month and day of the week. HEENT: PERRL with anicteric sclera, pale conjuctivae. CV: Irregular rate with frequent beats out of sequence. No murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally, no rales, rhonchi or wheezes. Abdomen: Soft, non tender, non distended. Ext: Warm, well perfused. Pertinent Results: ================== ADMISSION LABS ================== WBC-7.6 RBC-1.84* Hgb-5.3* Hct-18.3* MCV-100* MCH-28.8 MCHC-28.9* RDW-14.3 Plt Ct-323 Neuts-73.2* Lymphs-19.9 Monos-6.2 Eos-0.6 Baso-0 PT-13.3 PTT-26.4 INR(PT)-1.1 Glucose-117* UreaN-12 Creat-1.2 Na-143 K-3.8 Cl-106 HCO3-26 AnGap-15 ALT-10 AST-15 AlkPhos-47 TotBili-0.3 Lipase-20 =============== SIGMOIDOSCOPY =============== [**2120-1-21**] Findings: Protruding Lesions Medium internal hemorrhoids with stigmata of recent bleeding were noted. There was erythema and red spots on the internal hemorrhoids. Excavated Lesions Multiple severe diverticula with wide-mouth openings were seen in the sigmoid colon and descending colon. [**2118-1-20**] Impression: Diverticulosis of the sigmoid colon and descending colon internal and external hemorrhoids Flat Lesions A few angioectasias that were not bleeding were seen in the rectum. An Argon-Beam Coagulator was applied for hemostasis successfully. Excavated Lesions Multiple diverticula were seen in the left colon. Brief Hospital Course: [**Age over 90 **] year old man with h.o. alzheimers dementia, Etoh abuse, HTN, paroxysmal atrial tachycardia s/p 3u PRBC transfusion for GI bleed admitted to the ICU with dizziness and hematochezia. ##. Hematochezia: Mr. [**Known lastname **] presented to the ED with a 1 week history of hematochezia, weakness, fatigue. In the ER he was noted to have a Hct 18 and was thus transfused 3units of PRBCs and transferred to the ICU. In the ICU he was noted to have a post transfusion Hct of 27 that remained stable. Pt was transferred back to the floor and received a sigmoidoscopy that showed sigmoidal polyp and grade II internal hemorrhoid. Pt has been seen in the past by Dr. [**Last Name (STitle) **] for hemorrhoidal banding, on discharge pt was given instructions to contract Dr. [**Last Name (STitle) **] to band his hemorrhoid. ##. Alcohol abuse: Pt had an extensive history of Alcohol abuse however he has not had an alcoholic drink for 4 weeks. Whilst in the hospital Mr. [**Known lastname **] showed no signs of withdrawal and was given thiamine, folate, and multivitamin supplementation. ##. Paroxysmal atrial tachycardia: Patient was controlled on his home regimen of Diltiazem. ##. Glaucoma: Patient was continued on his outpatient eye drops. Medications on Admission: ALLOPURINOL - 300 mg Tablet - [**1-21**] Tablet(s) by mouth once a day BRIMONIDINE TARTRATE - 0.15% Drops - ONE DROP EACH EYE EVERY 8 HOURS DILTIAZEM HCL [DILT-XR] - 180 mg Capsule POTASSIUM CHLORIDE - 8 mEq Tablet Sustained Release - 1 Tablet(s) by mouth once a day TIMOLOL MALEATE - 0.25% Drops - ONE DROP EACH EYE TWO TIMES A DAY FERROUS SULFATE - 250 mg Capsule, Sustained Release Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Lower GI Bleed, likely internal hemorrhoids Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to the hospital for a lower gastrointestinal bleed, you needed a blood transfusion as your blood level was low. Please go to the surgery clinics as scheduled on [**2122-8-19**] to have further treatment of your hemorrhoids. Before you left the hospital you were able to eat a full meal without bleeding again. We stopped your diltiazem medication. Please do not take this medication at home. You will be given a presciption for Pantoprazole (Protonix) which is an indigestion pill, please take it as instructed. You will also be given a medication called Docusate Sodium (Colace) which will help soften your bowel movements, please take as instructed. If you start bleeding again please return to the ER. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-9-1**] 2:30 2. Please call Dr. [**Last Name (STitle) **] for an appointment next week to have your stage II internal hemorrhoid banded. ICD9 Codes: 2851, 4589, 2749, 4019
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Medical Text: Admission Date: [**2171-12-29**] Discharge Date: [**2172-1-1**] Date of Birth: [**2093-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2387**] Chief Complaint: Throat and arm pain Major Surgical or Invasive Procedure: cardiac catheterization with thrombectomy of stent and promus drug eluting stent to the mid right coronary artery History of Present Illness: 78 year old female with history of NIDDM, MI x 3, and COPD who presents who presents with chest pain found to have EKG changes concerning for STEMI. . The patient was in her usual state of health until about two weeks ago when she developed intermittent throat and arm pain. This happened a few times but has increased in frequency over the last three days, which is when she noted the developed of chest pain as well. At around 1300 today, the pain became constant, rated at an [**2170-9-11**], which was very concerning to the patient so she called EMS at 1800 and was brought to [**Hospital1 18**] ED for further evaluation. Of note, the patient reports poor compliance with her home medications of late, which include PO antihyperglycemics, aspirin, and plavix. . She received ASA 325mg in the ambulance and rated her pain at [**2170-3-7**] on arrival to the ED. She denied any SOB and reports the pain was different than the pain she experienced with her prior MI. In the ED, EKG was concerning for STEMI and cardiology was notified. She received heparin gtt, plavix 600mg, and integrillin and was sent for urgent cardiac catheterization. During the cath, she was found to have a in-stent thrombosis in the RCA, which was suctioned and angioplastied. Per report, "successful primary angioplasty for inferior STEMI with 80% thrombotic stenosis in the mid portion of previously placed stent; this was treated with PCI and stenting utilizing 3.5x23mm Promus DES, post-dilated to 3.75mm with excellent result." The patient tolerated the procedure well and is being admitted to the CCU for further monitoring. . On arrival to the CCU, vital signs were T- 97.6, HR- 90, BP- 103/77, RR- 19, SaO2- 88% on RA. The patient denies chest pain, shortness of breath or headache. She remains hemodynamically stable. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems, at this time, is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: . CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: - CABG: n/a - PERCUTANEOUS CORONARY INTERVENTIONS: AMI in [**2159**]- tPA followed by PTCA/PCI of RCA and LCx. She has had two other interventions with a total of four stents placed - PACING/ICD: n/a 3. OTHER PAST MEDICAL HISTORY: 1. Coronary artery disease status post multiple PCIs. 2. Diabetes mellitus- non-insulin dependant, with peripheral neuropathy 3. Hyperlipidemia. 4. COPD from smoking 5. Status post hysterectomy. 6. Status post right common femoral arterial thrombectomy in [**2164-11-2**]. Social History: #SOCIAL HISTORY: Patients husband died at age 41, she has worked as a waitress all of her life. Until recently worked as a cashier at CVS. Lives at home with her Daughter [**Name (NI) **] [**Telephone/Fax (1) 25793**], son-in-law and grand children. Able to complete all ADLs/IADLS. No etoh or IV drugs Family History: #FAMILY HISTORY: Mom MI [**35**] Son died mi [**97**] Brother died MI Aunt MI [**01**] DAD bone cancer died 92 Physical Exam: ON admission: VS: T- 97.6, HR- 90, BP- 103/77, RR- 19, SaO2- 88% on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with normal JVP. CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Bibasilar crackles with no wheezes or rhonchi. no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . On discharge: Vitals - Tm/Tc: 97.8/97.1 HR: 73-76 BP:102-123/48-51 RR:20 02 sat: 96% RA In/Out: Last 24H: [**Telephone/Fax (1) 25794**] Last 8H: Weight: 66.2 (68.5) . Tele: SR, few PVC's . FS: 273/211/191 . GENERAL: 78 yo F in no acute distress, lying flat in bed HEENT: no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: crackles right base, [**Month (only) **] BS on left CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, obese, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. NEURO: A/O, pleasant and conversant, MAE, good memory of recent events SKIN: no rash Pertinent Results: ON admission: [**2171-12-29**] 07:10PM BLOOD WBC-6.1 RBC-4.21 Hgb-12.4 Hct-40.0 MCV-95 MCH-29.5 MCHC-31.1 RDW-12.4 Plt Ct-242 [**2171-12-30**] 04:03AM BLOOD Glucose-284* UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-31 AnGap-9 [**2171-12-30**] 04:03AM BLOOD CK(CPK)-213* [**2171-12-30**] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17* [**2171-12-30**] 12:02PM BLOOD CK(CPK)-187 [**2171-12-30**] 06:20PM BLOOD CK(CPK)-129 [**2171-12-30**] 04:03AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0 . On discharge: [**2172-1-1**] 06:55AM BLOOD WBC-6.1 RBC-3.92* Hgb-11.8* Hct-36.6 MCV-93 MCH-30.0 MCHC-32.1 RDW-12.7 Plt Ct-225 [**2172-1-1**] 06:55AM BLOOD Glucose-222* UreaN-20 Creat-0.7 Na-138 K-4.2 Cl-101 HCO3-32 AnGap-9 [**2171-12-30**] 04:03AM BLOOD CK-MB-22* MB Indx-10.3* cTropnT-0.39* [**2171-12-30**] 12:02PM BLOOD CK-MB-16* MB Indx-8.6* cTropnT-0.25* [**2171-12-30**] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17* . Cardiac catheterization: [**12-29**] 1. Selected coronary angiography in this right dominant system demonstrated 2 vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a 30-40% mid vessel stenosis slightly worsened from [**2164**]. The LCX in known to have a total flush occlusion. The mid RCA is diffulsely disease with an 80% in stent restenosis and possible thrombus suggestive of very late ISRS. There is a focal 50% lesion at the distal RCA bifurcation worsened from [**2164**]. THE RPLV (very substantive vessel) stent placed in [**2164**] is widely patient. 2. Limited resting hemodynamics revealed a normotensive central systemic arterial pressure of 124/71 mm Hg. 3. Successful thrombectomy and PCI to the mRCA using 3.5x23mm Promus DES. 4. No complications. FINAL DIAGNOSIS: 1. 2 vessel coronary artery disease with in stent restenosis of RCA. 2. Successful PCI to the mRCA with Promus DES. 3. No complications. . ECHO [**12-30**]: preliminary only Brief Hospital Course: # Right coronary artery ST elevation myocardial infarction: S/P RCA STEMI with succesful DES to site of in-stent thrombosis and early resolution of EKG abnormalities. NO further chest pain, CK's have downtrended. On BB, ACEi, statin, plavix and ASA. ECHO with poor windows and no WMA, preserved EF on first read, reviewed by Dr. [**Last Name (STitle) **] who felt there was an inferior wall motion abnormality with EF 45%. Appears euvolemic. Plan to continue clopidogrel for 1 year/month for DES and likely forever. NP and SW saw pt for her history of medicaton non-complience. She is able to afford her medicines, just stated she was "stubborn" and didn't feel that she needed the medicine anymore. Her diabetes regimen is also onerous to her and she wishes it could be simplified. She states she now realizes that she needs to take her medications daily. . # RHYTHM: SR, no VEA . # Hyperlipidemia- high dose atorvastatin for now, change back to rosuvastatin at discharge because of her history of myalgias on high dose statin. She has [**Last Name (un) **] tolerating 20 mg of rosuvastatin so far. . # Diabetes mellitus- on glypizide and onglyza at home, struggling to do fingersticks 4 times per day and take her meds. Last A1c in [**11/2171**] was 10.5. Followed by Dr. [**Last Name (STitle) **] from [**Last Name (un) **] in [**Location (un) 620**]. Her home PO meds were restarted at discharge and she has a f/u appt with Dr. [**Last Name (STitle) **] at the end of the week. . Transitional issues: 1. VNA at home to monitor for medication compliance and to do diabetic teaching 2. ASA and plavix for one year at least 3. F/U with Dr. [**Last Name (STitle) **] in 2 weeks. 4. VNA to check BP and HR on new lisinopril and metoprolol Medications on Admission: HOME MEDICATIONS: confirmed with [**Company 25795**] 1. Glipizide XL 10 mg daily 2. Onglyza 5 mg daily 3. Crestor 20 mg daily 4. Aspirin 81mg daily 5. Plavix 75mg daily (did not fill for one month) 6. Amytripiline- 25mg qHS 7. Omeprazole 20 mg daily 8. Hydrocodone/acetaminophen 7.5/750mg TID as needed Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. Onglyza 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 9. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: ST elevation myocardial infarction Diabetes Mellitus type 2 Coronary artery disease Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [**Hospital1 18**]. You had a heart attack that was caused by a clot in an earlier stent from being off your plavix. The clot was removed and another drug eluting stent was placed over the previous stent. You will need to take a full aspirin (325mg) and Plavix 75 mg every day for the next year and likely longer. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you to. This is very important to prevent another heart attack or possibly death. An echocardiogram showed that your heart function is good. . We made the following changes to your medicines: 1. Increase aspirin to 325 mg for the next year 2. Continue Crestor at 20 mg daily 3. STOP taking omeprazole (prilosec), take ranitidine instead for your heartburn 4. START lisinopril to lower your blood pressure 5. START metoprolol to lower your heart rate and help your heart recover from the heart attack. Followup Instructions: Dr. [**Last Name (STitle) **] on Monday [**1-13**], the office will call you at home with an appt. Dr. [**Last Name (STitle) **] on Friday [**1-3**] as previously scheduled. ICD9 Codes: 2724, 496, 3572, 3051
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Medical Text: Admission Date: [**2126-1-24**] Discharge Date: [**2126-2-4**] Service: HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old woman admitted from [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **], where she has been living since [**2125-9-20**] with acute respiratory distress, hypoxia with oxygen saturation registered at 50% to 70%. In the Emergency department, the patient was evaluated for hypoxia and perfuse secretions per her trach. There were thick, yellow sections suctioned. The oxygen saturation, following suctioning, improved to 98% on room air and 100% on full trach mask. The patient's trach was changed from cuff trach and she was placed on the ventilator. Chest x-ray revealed right greater than left infiltrate consistent with pneumonia. The patient was so Levofloxacin and Vancomycin. Arterial line was placed and the patient was transferred to the medical ICU. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft. 2. Aortic stenosis status post aortic valve replacement. 3. Hypertension. 4. Elevated cholesterol. 5. Diabetes mellitus. 6. Chronic renal insufficiency. 7. Depression. 8. History of cerebrovascular accident in [**2118**]. 9. History of atrial fibrillation. MEDICATIONS ON ADMISSION: 1. Lorazepam 0.25 mg p.o.q.d. and p.r.n. 2. Enteric coated aspirin 325 mg p.o.q.d. 3. Colace 100 mg p.o.q.d. 4. Effexor 50 mg q.a.m.; 25 mg q.p.m. 5. Levoxyl 150 mcg p.o.q.d. 6. Metoprolol 25 mg p.o.b.i.d. 7. Trazodone 50 mg p.o.q.h.s. 8. Nitroglycerin 0.4 mg sublingual p.r.n. 9. Pureed tube feeds per G tube. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: No alcohol, no smoking. PHYSICAL EXAMINATION: Admission physical examination revealed the following: VITAL SIGNS: 98.6, blood pressure 184/70, heart rate 83, oxygen saturation 99% on 100% trach mask. The patient is alert and responsive to commands. HEENT: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Sclerae anicteric. Oropharynx clear. CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2; 2/6 systolic ejection murmur appreciable at the left upper sternal border. LUNGS: Lungs revealed bilateral coarse rhonchi. ABDOMEN: Soft, nontender, nondistended with active bowel sounds. EXTREMITIES: No appreciable edema. LABORATORY DATA: Admission laboratory studies revealed the following: white blood count 19.4, hematocrit 42.5, platelet count 223,000, sodium 126, chloride 95, bicarbonate 20, BUN 26, creatinine 1.2, and glucose 232. Initial blood gas revealed the pH of 7.31, pCO2 55, pAO2 of 63 on 100% nonrebreather. Chest x-ray revealed bilateral infiltrates right greater than left, urinalysis negative. HOSPITAL COURSE: (by system) PULMONARY: The patient was admitted for respiratory distress with copious-purulent secretions from the trach and evidence of pneumonia by chest x-ray. The patient was afebrile, but with elevated white blood count. The patient was treated for a right-sided pneumonia, possibly aspiration in origin with a ten-day course of Levaquin and Vancomycin. The patient was treated with Vancomycin and given a history of Methicillin resistant Staphylococcus aureus. Sputum cultures were negative, except for evidence of oropharyngeal flora. Bronchoalveolar lavage was performed on the second day of admission, which revealed relatively normal-looking bronchi. Lavage was positive for polys and gram-negative rods, which turned out to be oropharyngeal flora. Legionella cultures, fungal cultures, and RSV cultures were negative. Blood cultures remained negative throughout this hospitalization with the exception of one bottle, which grew out Vancomycin-resistant Enterococcus thought to be contaminate versus colonized as it was repeated and not reproducible. The patient was evaluated by the Interventional Pulmonary Service, namely Dr. [**Last Name (STitle) **], for trach, which had been placed within the last year for the diagnosis of tracheomalacia status post prolonged intubation for status post coronary artery bypass graft. The patient had had a prior tracheal stent placed, which had been discontinued and has since been on a trach mask since that time with plans for a larger trach versus repeat stenting. Bronchoscopy on this admission revealed mild tracheitis, but otherwise, normal trachea. it was thought that her problems with secretions and intermittent tracheal obstruction were largely related to supraglottic edema secondary to persistent regurgitation versus chronic aspiration. Bronchoscopy revealed supraglottic edema as noted. This had been confirmed to a lesser extent by the patient's ENT physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The patient was again evaluated by ENT during this hospitalization and it was felt that her supraglottic edema would ultimately resolve on a strict antireflux regimen with strict anti-aspiration precautions and management of secretions. Ultimately, one the supraglottic edema resolved, it is thought that the patient may be able to have her trach removed without need for a stent or more long-term trach placement. The Interventional Pulmonary Service agreed. ENT team, with Dr. [**Last Name (STitle) **], planned to see the patient again prior to discharge to confirm long-range management plans. The patient was started on b.i.d. Protonix IV and then ultimately transitioned to Prevacid suspension b.i.d. through the PEG tube. CARDIOVASCULAR: The patient has a history of coronary artery disease. She was continued on her aspirin and Lopressor. Captopril was added and titrated up for blood pressure control. This was thought to be especially important given significant proteinuria noticed on urinalysis. The patient also has an elevated protein:creatinine ratio. The patient was intermittently hypertension throughout her hospitalization at times to the 220s systolic, asymptomatic, often in the setting of agitation and difficulty with the trach. For the acute exacerbation she was treated with IV Hydralazine. Following the placement of a new trach and weaning from the vent, the patient's blood pressure did improve, but remained consistently in the 150s to 160s systolic. She was continued on her Lopressor and her ACE inhibitor was gradually titrated up to control. Heart rate in the 50s did not allow much room for titration of the beta blocker. INFECTIOUS DISEASE: In addition to the pneumonia noted above, the patient was found to have Urinary tract infection positive for yeast. She was treated with a seven-day course of Fluconazole. As noted above, the patient had [**11-23**] blood-culture bottles positive for Vancomycin-resistant enterococcus. This was thought to be colonized, as it was not replicable on repeat blood cultures. She was not treated for this per se. ENDOCRINOLOGY: The patient has a history of diabetes mellitus with poorly controlled blood sugars. She was initially maintained on just a regular insulin sliding scale. She was later started on low-dose Glyburide with dramatic improvement in her fingersticks. NEUROLOGICAL: The patient had significantly depressed mental status, poorly responsive for much of her MICU course, ultimately deemed secondary to weaning from her sedatives. She took a long time to awakened after being weaned off the vent. Additional administration of Haldol and p.r.n. narcotics perpetuated her depressed mental status. By the time the patient was transferred to the floor, she was at her baseline. RENAL: The patient was noted to have proteinuria by urinalysis and elevated protein:creatinine ratio. She was started on an ACE inhibitor and should ideally have renal followup at the time of discharge. This is attributable to either hypertensive versus diabetic nephropathy versus other etiology. GASTROINTESTINAL: The patient was noted to have C. difficile colitis. The patient was treated with a ten-day course of Flagyl. She had persistently guaiac-positive loose stools. This was thought to be secondary to GI bleed versus C. difficile infection. Hematocrit gradually trended down, and she was transfused two units of packed red blood cells to which she responded appropriately. Hematocrit remained stable for the remainder of her hospitalization. She should be evaluated as an outpatient with a colonoscopy. The primary care physician is aware of this. PSYCHIATRY: The patient has history of depression treated with Effexor at prior dose. The patient was noted to have improved mood as per her family. ACCESS: The patient had a right PIC placed for blood draws and IV access. PROPHYLAXIS: The patient was on Protonix and Pneumoboots during this hospitalization. COMMUNICATION: There were several family meetings held during this hospitalization to keep the family up-to-date on the progress of the interventions and long-term planning. CODE STATUS: The patient was a full code. Please see addendum to discharge summary for the remainder of the hospital course following transfer to the medical floor, as well as for long-term discharge planning and discharge medications. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684 Dictated By:[**Last Name (NamePattern4) 97564**] D: [**2126-2-4**] 16:40 T: [**2126-2-4**] 16:46 JOB#: [**Job Number 97565**] ICD9 Codes: 5070, 5990
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Medical Text: Admission Date: [**2189-3-24**] Discharge Date: [**2189-3-29**] Date of Birth: [**2121-3-25**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 165**] Chief Complaint: CP with exertion Major Surgical or Invasive Procedure: CABGx4 History of Present Illness: 67 M with increasing angina and pos nuclear stress. Referred to cath - positive multivessel disease. Past Medical History: HTN hyperlipidemia T&A Social History: 10 PY hx quit in [**2152**], social ETOH, lives with wife Family History: brother with CABG in 60's Physical Exam: AAOx3 NAD RRR CTAB Sternum stable c/d/i soft NT/ND Pertinent Results: [**2189-3-29**] 05:30AM BLOOD Hct-26.2* [**2189-3-28**] 04:25AM BLOOD WBC-11.5* RBC-2.78* Hgb-8.9* Hct-25.8* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.3 Plt Ct-175 [**2189-3-25**] 02:12PM BLOOD PT-15.3* PTT-31.0 INR(PT)-1.4* [**2189-3-28**] 04:25AM BLOOD Glucose-123* UreaN-21* Creat-1.0 Na-137 K-4.2 Cl-99 HCO3-29 AnGap-13 [**2189-3-24**] 06:08PM BLOOD ALT-32 AST-27 LD(LDH)-200 AlkPhos-72 TotBili-0.3 [**2189-3-24**] 06:08PM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE [**2189-3-26**] 01:18PM BLOOD Glucose-116* K-3.6 Brief Hospital Course: Pt underwent CABG x4 without complications. Chest tubes were d/c'd POD1Wires were taken out [**3-28**]. POD1 he was sent to the floor. He worked with PT and tolerated his diet being advanced. He is in good condition for discharge. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). Disp:*40 Packet(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease Discharge Condition: Good Discharge Instructions: Please call or return if you have fevers >101, chest pain, shortness of breath, or anything that causes you concern. [**Last Name (NamePattern4) 2138**]p Instructions: Call Dr. [**Last Name (Prefixes) **] for an appointment - [**Telephone/Fax (1) 170**] Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) 17010**] cardiologist Appointment should be in [**7-28**] days Provider: [**Name10 (NameIs) 17010**] PCP [**Name9 (PRE) **] to schedule appointment [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-4**] Service: MEDICINE Allergies: Iodine / Xylocaine / Nitroglycerin Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterizations: [**2113-3-30**] & [**2113-3-31**] History of Present Illness: 85F with hypertrophic cardiomyopathy, paroxysmal atrial fibrillation on amiodarone, reported EF of 32% who reports with increasing substernal [**7-14**] chest pressure lasting 15 minutes to hours with radiation to her neck, associated with palpitations, exacerbated with movement, alleviated with rest. Patient reports that she's had increasing chest pain over the past few months who presents with increasing chest pain pver 5 days refusing to go to the ED but came to Dr. [**Last Name (STitle) 1911**]??????s office on [**2113-3-29**]. He did blood tests and told her to go to the ED. She did not and instead went home. The labs came back with a troponin of 2.28 so he called her and had her come to [**Location (un) **] ED for transport to our cath lab. Of note she had a nuclear stress test in [**12-10**] that was reported as completely normal. Her EF was 32%. . Labs at [**Location (un) **]: WBC 8.3 Hgb 14.9 Hct 42.5 Plt 180 INR 1.0 Calcium 8.9 Na 131 K 3.9 Cl 86 CO2 29 [**Name8 (MD) **] Crt CPK 173 MB 19.8 Index 11.2 Troponin 2.28 Past Medical History: CAD Hypertrophic cardiomyopathy Paroxysmal atrial fibrillation dermatomyositis Social History: Etoh neg Tob neg Illicits neg Family History: NC Physical Exam: VS: T:95.3 BP:68/41 HR:65 RR:18 O2:99% 2LNC Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 2 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI SEM along precordium. No rubs or gallops. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles. No wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: bilateral lower extremity ecchymosis. No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Imaging: C.CATH Study Date of [**2113-3-29**] COMMENTS: 1. Coronary angiography of this left dominant system revealed severe single vessel coronary artery disease. The left main coronary artery had no angiographically apparent flow limiting stenoses. The LAD had a 90% stenosis in the mid segment involving the bifurcation of the first major diagonal branch. The LCX was a large caliber dominant artery and had no angiographically apparent flow limiting stenoses. The RCA was a small caliber nondominant vessel with no angiographically apparent flow limiting stenoses. 2. Resting hemodynamics revealed low right sided filling pressures (mean RA pressure was 3 mm Hg and RVEDP was 4 mm Hg). Pulmonary artery pressures were normal (PA pressure was 30/11 mm Hg). Left sided filling pressures were normal (mean PCW pressure was 13 mm Hg). Systemic arterial pressure ranged from low to normal (aortic pressure averaged 90/47 mm Hg). Cardiac output was low (CI was 2.1 L/min/m2). Post intervention and bolus administration normal saline, left sided filling pressures were slightly higher (mean PCW pressure was 14 mm Hg). 3. Successful PCI/stent to mid LAD/Diagonal bifurcation with a 3.0x23mm Cypher stent deployed at 14atms. Excellent result with normal flow and no residual stenosis in both vessels. Patient left cathlab painfree. FINAL DIAGNOSIS: 1. Severe single vessel coronary artery disease. 2. Low right sided filling pressures and relatively low left sided filling pressures. 3. Successful rotation atherectomy, angioplasty, and stenting with DES of the mid LAD with rescue of the first diagonal branch. . CT PELVIS W/O CONTRAST [**2113-3-30**] 9:32 AM IMPRESSION: 1. No evidence of retroperitoneal bleed but hematoma in right groin in soft tissues at site of recent cath. 2. Heavy coronary artery and aortic calcifications. 3. Low-attenuation lesion in segment 3 of the liver which is too small to characterize but may represent a cyst. 4. Minimal free fluid in the pelvis. 5. Catheter in situ in right common femoral artery and vein . CHEST (PORTABLE AP) [**2113-3-30**] 7:05 AM IMPRESSION: Interval resolution of pulmonary edema and effusions. . ECHO Study Date of [**2113-3-30**] Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (ejection fraction 40-50 percent) secondary to hypokinesis of the interventricular septum and apex. There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis (preacceleration of flow in the left ventricular outflow tract may also be contributing to the elevated flow velocity across the aortic valve). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. Impression: 1. septal and apical hypokinesis 2. left ventricular hypertrophy 3. Mild-to-moderate left ventricular outflow tract obstruction 4. Minimal mitral stenosis (from severe annular calcification) 5. At least moderate-to-severe mitral regurgitation 6. Possible minimal aortic stenosis . C.CATH Study Date of [**2113-3-31**] COMMENTS: 1. Patent mid LAD stent. 2. Diagonal branch has no significant stenosis 3. Normal dominant LCX and RCA FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Patent mid LAD stent with no major stenosis in diagonal side branch. . ECHO Study Date of [**2113-3-31**] Conclusions: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of basal and mid-anterior septum. Right ventricular chamber size and free wall motion are normal. Mild (1+) aortic regurgitation is seen. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focused study, showing mild regional left ventricular systolic dysfunction. Mild aortic regurgitation. Moderate-to-severe mitral regurgitation. . CHEST (PA & LAT) [**2113-4-1**] 6:13 PM IMPRESSION: New small bilateral pleural effusions with adjacent basilar atelectasis. . FEMORAL VASCULAR US RIGHT [**2113-4-1**] 2:01 PM IMPRESSION: No evidence of AV fistula, pseudoaneurysm, or large hematoma. . Micro: [**2113-4-1**] Sputum Cx: no growth [**4-3**] Urine Cx: pending . Admission Labs: [**2113-3-29**] 06:29PM O2 SAT-98 [**2113-3-29**] 06:29PM NA+-121* K+-2.8* [**2113-3-29**] 06:29PM TYPE-ART PO2-152* PCO2-39 PH-7.43 TOTAL CO2-27 BASE XS-2 INTUBATED-NOT INTUBA [**2113-3-29**] 07:25PM CALCIUM-7.0* PHOSPHATE-4.2 MAGNESIUM-1.7 [**2113-3-29**] 07:25PM estGFR-Using this [**2113-3-29**] 07:25PM GLUCOSE-154* UREA N-17 CREAT-0.9 SODIUM-123* POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-24 ANION GAP-13 [**2113-3-29**] 08:31PM PT-12.8 PTT-150* INR(PT)-1.1 [**2113-3-29**] 08:31PM PLT COUNT-159 [**2113-3-29**] 08:31PM WBC-6.6 RBC-3.83* HGB-13.1 HCT-38.1 MCV-99* MCH-34.3* MCHC-34.5 RDW-16.6* [**2113-3-29**] 08:31PM URINE OSMOLAL-233 [**2113-3-29**] 08:31PM URINE HOURS-RANDOM CREAT-6 SODIUM-47 [**2113-3-29**] 08:31PM FREE T4-1.5 [**2113-3-29**] 08:31PM TSH-0.34 [**2113-3-29**] 08:31PM OSMOLAL-281 [**2113-3-29**] 08:31PM ALBUMIN-2.9* CALCIUM-6.8* PHOSPHATE-4.1 MAGNESIUM-1.6 [**2113-3-29**] 08:31PM CK-MB-22* MB INDX-10.0* [**2113-3-29**] 08:31PM CK(CPK)-219* [**2113-3-29**] 08:31PM GLUCOSE-175* UREA N-15 CREAT-0.9 SODIUM-126* POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-19* ANION GAP-16 [**2113-3-29**] 10:07PM URINE RBC-[**2-6**]* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2113-3-29**] 10:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2113-3-29**] 10:07PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030 [**2113-3-29**] 11:30PM UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-4.8 Brief Hospital Course: Pt is a 85F with NSTEMI s/p catheterization and DES to LAD, with subsequent hypotension, transiently on pressors, currently normotensive without support. . #) CAD: Patient with diagnosed CAD, s/p Cypher stent to mid-LAD. Pateint underwent repeat cardiac catheterization on [**3-31**] in the setting of chest pain,. Probability of instent thrombosis was low and cath revealed patent mid-LAD cypher stent. Patient never had EKG changes. Patient also had US or R groin given a new bruit, although, as reported above, there was no evidence of fistula or aneurysm. The patient was continued on ASA & Plavix, and had daily EKG without changes. She had episodic bouts of chest pain without EKG changes and it was thought that these this pain was no ischemic. She was not given nitrates in the setting of mild HCM, and this pain responded well to low dose opiates. . #). Chest Pain: Patient with transient chest pain, nonpositional, nonpleuritic, not associated with SOB, and temporally associated with food intake. Probability of ischemia is low, recent re-cath negative, EKGs without significant changes. Patient may have an esophageal component of chest pain. Ddx includes DES, Zenker's diverticulum, GERD. Other less likely etiologies include Boerhaave's/MWT, Schatzki's ring. Patient has been CP free for over 24 hours and may benefit from an outpatient workup for possible GI relates issues. . #) Pump: Given Right heart catheterization, patient presented hypovolemic and is also hypotensive. Patient with known HCM and the best BP support for her was fluids. She was also transiently on neosynephrine to which she responded well. She received aggressive volume support and had mild pulmonary edema, that of which she autodiuresed well. Her diuretics were held and these were not restarted upon discharge. She was hoever, started on Toprol XL. . .#) Rhythm: hx of pAF, although not on Coumadin given prior hx of bleeding risk. Patient has hx of cardioversion in 2/[**2111**]. Patient was continue on Amiodarone 200 qd and monitored on telemetry without event. . #)UTI- Patient with urinary symptoms, and was started empirically on Bactrim for a 3 day course. . #) Dermatomysositis: - Continue Prednisone 2.5 mg po qd Medications on Admission: Prednisone 2.5 mg daily LD this am Methotrexate weekly LD [**2113-3-21**] Amiodarone 200 mg daily LD this am Fosamax weekly LD was Sunday [**3-26**] Aldactazide 2.5/25 mg daily LD this am ASA 325 mg @ 12:40pm today Benadryl 50 mg po @ 12:40 pm today Zantac 150 mg po @ 12:40 pm today Solumedrol 60 mg IV @ 12:40 am today Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*3* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 10 days. Disp:*10 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 13. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day for 10 days. Disp:*5 Tablet Sustained Release 24 hr(s)* Refills:*0* 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary Diagnosis: Myocardial Infarction . Secondary Diagnoses: Hypertrophic cardiomyopathy Paroxysmal atrial fibrillation S/P DCCV in [**1-/2112**] CHF Dermatomyosistis diagnosed [**2107**] - on MTX/Prednisone Osteoporosis Cataracts Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted for treatment of a heart attack. You had a stent placed into one of the main arteries of your heart. You also had low blood pressure that was treated with fluid hydration. . 1. Please take all medication as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Please call your PCP: [**Last Name (LF) 32375**],[**First Name3 (LF) 2801**] M. [**Telephone/Fax (1) 32376**] . Please call [**Doctor First Name **] [**Doctor Last Name 1911**] for a follow-up appointment . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2113-5-19**] 3:40 Completed by:[**2113-4-4**] ICD9 Codes: 4254, 4280, 5990
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Medical Text: Admission Date: [**2171-10-18**] Discharge Date: [**2171-10-26**] Date of Birth: [**2109-4-20**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: right shoulder - pain- RUL lung tumor for excision s/p chemotherapy and radiation Major Surgical or Invasive Procedure: Right posterior and lateral thoracotomy, right upper lobectomy with en bloc chest wall resection of ribs 2 and 3. 2. Right cervical incision with scalene fat pad and lymph node resection as well as mobilization of superior sulcus tumor off of 1st rib and division of the 2nd rib anteriorly. 3. Thoracic lymphadenectomy. 4. Flexible bronchoscopy. History of Present Illness: 62-year-old woman who developed right shoulder pain and was found to have a large right upper lobe tumor invading into the 2nd and 3rd ribs and abutting up against the 1st rib. She underwent cervical mediastinoscopy as well as peripheral metastatic workup. There were no positive lymph nodes and no metastasis. She underwent induction of chemoradiotherapy to shrink the tumor away from the subclavian artery and subclavian vein as well as the brachial plexus. She has been restaged and was found to have excellent response. We, therefore, took her forward for a resection of the superior sulcus tumor. Our plan was to biopsy the scalene fat pad and lymph nodes and if there is no evidence of tumor to move on to mobilize the superior sulcus tumor from the cervical incision, including division of ribs as necessary. We would then move on to a posterolateral thoracotomy for completion of the procedure. Past Medical History: Gastric esophogeal reflux disease, Coronary artery disease, diabetes type 2, chronic obstructive pulmonary disease, Non small cell lung cancer s/p chemotherapy and radiation. Social History: lives at home, has many family members nearby. [**Name2 (NI) **] in past Physical Exam: General-Elderly female NAD Resp- Course diminished BS throughout- baseline Cor-RRR Abd- Sl distended, NT, + BS, Ext- no edema Neuro- fully intact, no R sided deficits Skin- anterior and posterior thorax incisions. Staples removed, incision clean and dry. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2171-10-25**] 06:10AM 8.9 3.15* 9.9* 29.0* 92 31.4 34.1 15.4 289 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2171-10-26**] 09:20AM 13.4* 27.9 1.2 INHIBITORS & ANTICOAGULANTS LMWH [**2171-10-26**] 11:10AM 0.781 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2171-10-25**] 06:10AM 145* 12 0.5 137 4.4 97 311 13 1 NOTE UPDATED REFERENCE RANGE AS OF [**2171-6-21**] ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2171-10-23**] 04:50PM 128 [**2171-10-23**] 03:48PM 115 [**2171-10-23**] 09:30AM 148* CPK ISOENZYMES CK-MB cTropnT [**2171-10-23**] 04:50PM 2 [**2171-10-23**] 03:48PM 1 [**2171-10-23**] 09:30AM 2 <0.011 1 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2171-10-25**] 06:10AM 8.4 4.2 2.0 RADIOLOGY Final Report CHEST (PA & LAT) [**2171-10-24**] 11:29 AM Reason: eval for PTX [**Hospital 93**] MEDICAL CONDITION: 62 year old woman with lung CA post CT pull REASON FOR THIS EXAMINATION: eval for PTX HISTORY: 62-year-old woman with lung cancer status post surgical resection. Please evaluate for pneumothorax. TECHNIQUE: PA and lateral views of the chest were obtained and compared to [**2171-10-22**]. FINDINGS: There has been interval removal of two right apical chest tubes. No definite pneumothorax identified. There are post-surgical changes at the right apex including signs of volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. Again noted are multiple surgical rib defects at the right apex. The right lung base and the left lung are grossly clear. Heart size and cardiomediastinal contours are stable given differences and patient rotation. IMPRESSION: Interval removal of right apical pleural drains. No definite pneumothorax. Surgical changes at the right apex with associated volume loss of the right hemithorax. Brief Hospital Course: Pt was admitted on [**2171-10-18**] for ecxision of Pancoast tumor in RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split receiving both bupivicaine .1% thru epidural and dilaudid PCA because she has a wide incision on multiple dermatomes and a neck incision. She was supported w/ low dose neo while on epidural. Briefly intubated in ICU and, successfully extubated. POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus, gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/ Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction. Activity OOB > chair, PT, IS. POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR. Re-bolused amiodarone iv and placed back on gtt. Lopressor cont po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o complication, #2 remained to w/s w/ moderate drainage. Incision anterior and posterior clean and dry, staples intact. POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had episodes of HR 40 SB-150 Afib, treated with IV lopresssor and Dilt IV with fair rate control. Cardiology consulted.Lopressor [**Month (only) **]'d 25 [**Hospital1 **].NSR resumed during day. CT #2 d/c w/o complication. PT, IS, ambulation cont w/ high compliance. BS course, very good airation. Inhalers cont. Remains on [**12-23**] L O2. Pt R/O'd for MI by enzymes and EKG. POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont. Lovenox started for anticoagulation in setting of intermittent Afib post epidural d/c. Evidence of left antecubital phlebitis(red, swollen, min discomfort) at old IV site present, Keflex po x10 days started, warm soaks locally w/ small improvement. Chest tube drainge moderate from CT site. Dressing changed prn. POD#6-Remains NSR on Amiod [**Hospital1 **]; PCA weaned, PO Dilaudid started w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS compliance excellent. Staples removed and steri-strips applied. Incision- no erythema, small amount serous drainage superior posterior incision. BS course- good airation, inhalers cont. O2 weaned to off w/ good sat at rest and w/ ambulation- 95%RA. POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 [**Hospital1 **], restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ([**12-25**] daily dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med changed to percocet w/ very good effect. BM- occurred. Plan for discharge in am POD#8. Discharge plans arranged for anticoagulation follow-up with: VNA for blood draw and post op nursing care, Cardiology clinic short term, then [**Company 191**] coumadin clinic as of [**2171-12-3**]. Follow-up appointments w/ [**Company 191**] [**10-31**], Cardiology [**11-5**] made. PCP, [**Name10 (NameIs) **] NP, Cardiology NP and Cardiologist informed of plans.Discharge instructions, new medication regimen and instructions reviewed with patient POD#8-Patient discharged to home in stable condition in company of family. Discharge instructions given and reviewed w/ patient and family. Medications on Admission: ALBUTEROL 90, ATIVAN 1"PRN, ATROVENT, AZMACORT, ecASA 325', HUMULIN 70/30 36qam, HUMULIN N 100 20-22qhs, HUMULIN R 100 10-12QDINNER, IMDUR 60', LIPITOR 10', LISINOPRIL 5", METFORMIN 850 TT/T, METOPROLOL 100", SLNG 300 MCG (1/200 GR), PROTONIX 40MG' Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation [**Hospital1 **] (2 times a day). 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)): and 1 pill at bedtime . Disp:*90 Tablet(s)* Refills:*1* 14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*75 Tablet(s)* Refills:*0* 18. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: as directed. Disp:*30 Tablet(s)* Refills:*1* 19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: as directed. Disp:*60 Tablet(s)* Refills:*0* 20. hospital bed semi electric lung cancer s/p chemotherapy, radiation, RUL pancoast tumor excision. coronary artery disease, COPD, DM2, GERD Positioning-pt unable to lie flat while sleeping. 21. overnight pulse oximetry on room air for oxygenation evaluation at night 22. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 4 days. Disp:*8 syringe* Refills:*1* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Gastric esophogeal reflux disease, Coronary artery disease, diabetes type 2, chronic obstructive pulmonary disease, Non small cell lung cancer s/p chemotherapy and radiation. Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office for: fever, shortness of breath, chest pain, redness drainage from incision site. Take medication as directed on discharge. Your medications and dosages have changed. Coumadin dosage Sat [**10-26**] =5mg; Sunday [**10-26**] 2.5mg. No dose on Monday [**10-28**] until called by Cardiology NP. If she has not called by 3pm, call her at[**Telephone/Fax (1) 14926**]. Take pain medication as directed. No driving until off narcotic pain medication. You will be followed by [**Company **]--[**Telephone/Fax (1) 24704**]-- who will draw your blood for coumadin level and call/fax result to Cardiology clinic at [**Hospital1 18**] -[**Telephone/Fax (1) 127**] phone; [**Telephone/Fax (1) 14926**] fax. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 496**]/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nurse Practitioners will be following you there until you will be followed by [**Hospital 197**] Clinic in [**Hospital6 733**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24705**] office. You may shower Sunday [**10-27**], remove dressing and replace with bandaid as needed after showering. Followup Instructions: Call Dr.[**Name (NI) 1816**]/Thoracic office for an appointment in [**12-23**] weeks- [**Telephone/Fax (1) 170**].[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] [**Hospital Ward Name 23**] clinical Center 7 th floor Date/Time:[**2171-11-5**] 3:45 Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] appointment [**10-31**] at 5pm. You can call [**Doctor First Name **] to reschedule as needed. [**Hospital Ward Name 23**] clinical Center [**Location (un) **] An you have a previously scheduled appointment on [**2171-12-10**] @10:20am Completed by:[**2171-10-29**] ICD9 Codes: 496, 3051
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Medical Text: Admission Date: [**2113-9-25**] Discharge Date: [**2113-10-1**] Service: [**Hospital Unit Name 196**]/CCU HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of coronary artery disease with two-vessel disease on [**7-3**] who had a catheterization that showed total occlusion of the right coronary artery and 50% left anterior descending without percutaneous intervention, history of hypertension, insulin-dependent diabetes, who presented with the acute onset of progressively worsening substernal chest pain radiating to her right arm, throat, teeth and back. She also complained of abdominal pain that followed the chest pain. She denied nausea, vomiting and diaphoresis. She reported that the pain was 8 out of 10 and was associated with shortness of breath and radiation as above similar to the episode in [**2112-7-2**] prior to her catheterization. She has had no recent changes in her exercise tolerance. She denied paroxysmal nocturnal dyspnea. She did report orthopnea, and she did report increasing lower extremity edema. In the Emergency Room was started on a Nitroglycerin drip, Lopressor, 2 mg Morphine x 2 with resulting decrease in her blood pressure and resolution of her chest pain. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2112-7-2**], status post catheterization in [**2112-8-1**] with total occlusion of the right coronary artery with collaterals and 50% left anterior descending; no percutaneous intervention was done; ejection fraction of 30-40%; equivocal stress test in [**2112-12-2**]. 2. Hypertension. 3. Diabetes mellitus, Insulin dependent. 4. Elevated lipids. 5. Status post left carotid endarterectomy. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Lipitor 10 mg q.d., Toprol XL 25 mg q.d., Levaquin discontinued, Lisinopril 5 mg q.d., Isordil/Imdur, Lasix, Doxycin, Folate, NPH 100 q.a.m., 100 q.p.m. with Humalog sliding scale, p.r.n. Darvocet, Aspirin. FAMILY HISTORY: Father with myocardial infarction at age 60. SOCIAL HISTORY: No tobacco; he quit 30 years ago. No alcohol. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, blood pressure [**Telephone/Fax (3) 109323**]/80-150/70 in the Emergency Department, heart rate 100, respirations 16, oxygen saturation 98% on 2 L. General: The patient was in no apparent distress. He was alert and oriented times three. Obese. HEENT: Oropharynx clear. Moist mucous membranes. Chest: Clear to auscultation bilaterally. Cardiovascular: regular rhythm. No rubs or gallops. There was a 2 out of 6 systolic murmur at the left upper sternal border. JVP at 10 cm. Abdomen: He had positive right upper quadrant tenderness. No guarding. No rebound tenderness. He had decreased bowel sounds diffusely. No hepatosplenomegaly. No chest wall tenderness. Extremities: He had 1+ edema. No rash. Rectal: Guaiac negative stool. LABORATORY DATA: White count 9.2, hematocrit 30.7, platelet count 284; potassium 5.3, bicarb 21, acetone negative, troponin 0.05, CK 106, MB 5, second set troponin 0.31, MB 16, CK 181. Electrocardiogram normal sinus rhythm at 70 beats per minute, 3-[**Street Address(2) 109324**] depressions in V3-V5, leads I, II and AVL, normal axis. CT of the chest showed diffuse aortic atheromatous disease, no PE, no abdominal aortic aneurysm, no dissection. Dense left anterior descending, right coronary artery calcifications, mural thrombus in the aortic arch, question of small intimal flap, no PE. HOSPITAL COURSE: The patient was admitted to the Cardiac Medicine Service initially. 1. Coronary artery disease: The patient had improved, diffuse downsloping ST depressions after heart rate and blood pressure went down with elimination of chest pain. This was concerning for coronary ischemia, especially in a patient with known two- vessel disease on catheterization in [**2112-7-2**], who was hypertensive and diabetic with positive cardiac biomarkers. She was treated with Aspirin, Lipitor, Heparin drip, Nitroglycerin and Integrilin with a plan for early cardiac catheterization and possible percutaneous intervention. She was placed on telemetry for. However, given the concern for a possible intimal flap on the aorta, MRI was planned to clarify the issue of early dissection flap in the aorta; however, the study could not be completed, and the patient was sent back to the floor where she had some episodes of nausea, tiredness and frustration after awaiting all day for this test. She described some back pain, and Morphine was prescribed. The Cardiology fellow spoke with the patient, and the patient clearly said that she did not want to go back for completion of her MRI and that she was consistent and understood the consequences including myocardial infarction or death. She was very adamant about this, and it was decided to respect her wishes, since she seemed to be mentating normally at the time and understood the consequences of her decision. The plan was to do an early morning MRI to definitively rule out dissection flap which would then allowing cardiac catheterization and full adjunctive anticoagulation if necessary. The medical intern at the time had again spoken with the patient regarding the risks of refusing MRI, and the patient was aware of the possibility of aortic dissection and the risk of hemorrhage and death. She had capacity for decision making at the time. Plan was for MRI in the morning. At around midnight that night, the patient suffered an asystolic, PEA, ventricular fibrillatory arrest which required intubation and chest compressions. The patient was noted to be posturing at the time. She was resuscitated using ACLS protocol and sent to the CCU Cardiology fellow spoke with the sister regarding this situation, and the patient was transferred to the CCU Service. Her care was transferred at this point to Dr. [**Last Name (STitle) 911**] and the CCU team. In the CCU, the patient was ventilated and hemodynamically monitored. During the day, the patient was transfused with packed red blood cells for a hematocrit of 28.5, both for better oxygenation carrying capacity, as well as precatheterization. 2. Cardiovascular: We continued Aspirin and increased her beta-blocker, titrated to a goal heart rate of 60s. We continued Aspirin and statin and oxygen. Her blood pressure medication was changed to Hydralazine from ACE inhibitor since she was not tolerating any p.o., and we continued to follow her peak CKs. The patient remained hemodynamically stable during her hospital course in the CCU with no evidence of recurrent hemodynamically significant arrhythmia. No difference in blood pressures was noted in both arms. Because of continued hemodynamic stability without clinical evidence of propagating aortic dissection, investigation of possible aortic dissection was not undertaken until her neurologic prognosis was determined. 3. Myocardial: Her ejection fraction was 20-30%, and she was given appropriate afterload reduction. 4. Conduction: She had a history of asystole, question of ventricular fibrillation. There appeared to be a stable rhythm. She continued to be monitored on telemetry. 5. Respiratory: The patient was placed on AC ventilation. The plan was to decrease her FIO2 and hope for improvement of her ventilation; however, it was noted that in reducing support, she had no spontaneous respirations on the ventilator. 6. Renal: The patient's creatinine increased moderately after her arrest. Urinalysis exam showed muddy brown casts and consistent with acute tubular necrosis due to transient ischemia after the arrest. We followed her urine output and minimized nephrotoxic agents and repleted her potassium. The creatinine stabilized at 2.4 which was consistent with previous baseline values. 7. Infectious disease: The patient had a urinary tract infection, and she was treated with Levofloxacin. Urine cultures were pending at the time. 8. Gastrointestinal: The patient had elevations in her liver function transaminases and had initial bilious emesis, although not consistent with cholestatic picture. The patient had no obvious abdominal tenderness during her stay in the CCU. Her statin was discontinued. We considered right upper quadrant ultrasound. The suspected diagonosis was shock liver due to asystolic event and she was managed conservatively and enzymes began to decrease. 9. Prophylaxis: The patient was maintained on pneumoboots for DVT prophylaxis. Protime pump inhibitor was given for GI prophylaxis and Tylenol for fever. 10. Access: The patient had a left subclavian. 11. Neurological: Given the fact that the patient was posturing and may have suffered a significant amount of time without circulation, Neurology was consulted regarding the management of this patient. The impression was that the patient had suffered anoxic encephalopathy with a guarded prognosis. An EEG to assess higher cortical functions was performed to rule out any suspect on nonconvulsive status after the anoxia. EEG was performed that showed diffuse encephalopathy with minimal brainstem responses. A head CT was also performed which showed loss of [**Doctor Last Name 352**] white matter, border differentiation and severe edema with no focal area of new infarction. Repeat EEG was done with the sedation in hopes that he had an improved examination, but this was still consistent with diffuse encephalopathy and minimal brainstem responses. Neurology reported that according to accepted criteria, the patient's hope of significant neurologic recovery at one year was minimal. Given the grim prognosis, a discussion was made with the attending, Dr. [**Last Name (STitle) 911**], in the CCU regarding the EEG and Neurology consultants regarding the prognosis for recovery. A family meeting was called, and the decision was made that the patient should have no further resuscitation measures. On [**9-29**], the decision was made to make the patient comfort measures only with a Morphine drip intravenously started and ventilatory support weaned off. Intravenous antibiotics and blood pressure medications were discontinued at that time. On [**10-1**] at approximately 4:45 a.m., the intern was called to pronounce the patient's death. Given the fact that she was on the Morphine drip, on arrival the patient was warm. She had nonreactive pupils and no spontaneous movement, no heart sounds for two minutes, no breath sounds for two minutes, and no response to noxious stimuli, at which point the patient's family was informed of her death. The time of death was recorded as 0445. The attending was [**Name (NI) 653**], and the patient's family refused the postmortem examination. Communication: With the patient's family, including sister, brother-in-law and son. DISPOSITION: The patient expired on [**2113-10-1**], at 4:45 a.m. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2113-11-7**] 13:41 T: [**2113-11-7**] 13:57 JOB#: [**Job Number 109325**] ICD9 Codes: 5845, 4275, 4280, 5990
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Medical Text: Admission Date: [**2166-12-29**] Discharge Date: [**2167-1-2**] Service: CCU HISTORY OF THE PRESENT ILLNESS: The patient is an 83-year-old female with COPD, atrial fibrillation, CHF, and aortic stenosis who has had progressive worsening of her shortness of breath. Previous evaluation by echocardiogram at an outside hospital revealed worsening of her aortic valve stenosis and mitral regurgitation. The patient was referred to [**Hospital1 18**] for possible aortic valve replacement. On[**Last Name (STitle) 53680**]ate of admission, a TEE was performed which showed an aortic valve area of 0.8 as well as no evidence of mitral valve regurgitation. Given these findings, Dr. [**Last Name (Prefixes) **], the cardiothoracic surgeon, felt that further investigation of her dypnea was preferable since the aortic stenosis may not have been the primary culprit in her symptoms. A valvuloplasty was considered as a diagnostic tool and the surgery was postponed. The patient was transferred to the CCU Service for medical management and work-up. PAST MEDICAL HISTORY: 1. COPD. 2. CHF with an ejection fraction of 35%. 3. Atrial fibrillation. 4. Aortic stenosis. 5. Osteoporosis. 6. Osteoarthritis. 7. GERD. 8. Esophageal spasm, status post esophageal dilation. PAST SURGICAL HISTORY: 1. Pacemaker in [**2165-12-6**]. 2. Hip arthroplasty. 3. Hernia repair. 4. Hysterectomy. ADMISSION MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Prilosec 20 mg p.o. q.d. 3. Actonel 35 mg p.o. q. weekly. 4. Lasix 40 mg p.o. q.d. 5. Clonazepam 0.25 mg p.o. b.i.d. 6. Amiodarone 200 mg p.o. q.d. 7. Prednisone 2.5 mg p.o. q.d. 8. Mirapex 0.125 mg p.o. b.i.d. 9. Calcium carbonate. 10. Vitamin D. 11. Senna. ALLERGIES: The patient is allergic to morphine, methadone, Percocet, Darvocet, Albuterol, penicillin, and ampicillin. SOCIAL HISTORY: The patient lives in [**Hospital3 **]. Her two daughters are very involved in her care. She denied a history of smoking. She denied a history of a history of alcohol use. FAMILY HISTORY: Her mother died from heart disease. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile with a blood pressure of 118/67, heart rate 77, respiratory rate of 20, oxygen saturation 99% on face mask following extubation. The physical examination is notable for labored breathing but no accessory muscle use. There are no crackles or wheezes on examination. The patient has a III/VI systolic ejection murmur heard throughout the precordium. There is no lower extremity edema. HOSPITAL COURSE: 1. AORTIC STENOSIS: The patient was recently discharged from [**Hospital1 18**] approximately a month prior to admission following cardiac catheterization. At that time, she was found to have an aortic valve area of 0.9 with a cardiac index of 3.1 and a peak gradient of 31. In the interim since her discharge, the patient had an outpatient echocardiogram at an outside hospital. At that time, it was felt that her aortic valve area had worsened to 0.6 and that there was also evidence of mitral valve regurgitation. The patient was referred by her primary cardiologist for aortic valve and mitral valve replacement. On the date of admission, the patient was taken to the Operating Room. A transesophageal echocardiogram was performed prior to the procedure. It showed an aortic valve area of 0.8 and no evidence of mitral valve regurgitation. On the following day, the patient was taken to cardiac catheterization for repeat evaulation and standby valvuloplasty. She was found to have a cardiac output of 5.14 and a cardiac index of 3.61. Her aortic valve area was measured at 0.8 with an area index of 0.53. The aortic valve gradient was 43.14. The patient had normal filling pressures. Due to these findings, namely her relatively preserved cardiac output and normal filling pressures, it was decided not to perform valvuloplasty on the patient. It was felt that her aortic stenosis was not severe enough to explain her dyspnea in isolation. Of note, an echocardiogram done on the day of cardiac catheterization showed [**First Name8 (NamePattern2) **] [**Location (un) 109**] initially of 0.4 cm. Upon review, it was noted that the MR jet was eccentric and was overestimating the stenosis and gradient. 2. ATRIAL FIBRILLATION: The patient has a history of atrial fibrillation. She had a pacemaker placed in [**2165-12-6**]. Multiple EKGs showed a V-paced rhythm. She was continued on her home dose of Amiodarone as well as aspirin. The patient experienced no episodes of atrial fibrillation during the hospitalization. 3. CONGESTIVE HEART FAILURE: The patient has a history of congestive heart failure with an ejection fraction of 38%. The patient was started on a low-dose of an ACE inhibitor which she tolerated well. Her systolic blood pressures remained stable in the low 100s. She was also restarted on her home dose of Lasix 40 mg p.o. q.d. prior to discharge. 4. PULMONARY: Since it was not felt that her pulmonary symptoms could be entirely explained by her aortic stenosis, a pulmonary consult was obtained. According to the patient's primary pulmonologist, Dr. [**Last Name (STitle) 36953**], the patient has a history of a mild obstructive picture. Dr. [**Last Name (STitle) 36953**] had performed a thorough pulmonary workup in the past including PFTs and chest CT. Although unusual considering the patient has no smoking history, the patient's picture most likely fits COPD. During the hospitalization, pulmonary function tests were obtained which revealed a FEV1 of 540 cc (41% predicted), an FVC of 0.98 liters (47% predicted), and an FEV1/FVC ratio of 86% predicted. Her lung volumes were also decreased. Her total lung capacity was 2.47 (65% predicted). Her DLCO was also decreased at 4.16 (28% predicted). The patient was found to have no desaturations on ambulation with a good pulse ox [**Location (un) 1131**]. A chest CT was obtained which showed mild emphysematous changes but no evidence of interstitial disease or bronchiectasis. She also had a focal ground glass opacity in the right lung apex as well as small branching opacity of the right lower lobe consistent with a focal mucoid impactation or focal atelectasis. The ground glass opacity is of unknown significance. Pulmonary consult was asked to comment on the findings. They felt that the results were consistent with a moderate to severe restrictive pattern secondary to her severe kyphoscoliosis and possibly in part from her cardiomegaly although the percent predicted was not that impression given the patient's age and size. They felt that the decrement was likely very significant. However, they were not able to offer any therapy for her chest wall deformity. The DLCO decrement was felt to correct for lung volume and they were reassured that the patient did not desaturate during ambulation. Pulmonary consult felt that possible etiologies for the trend down as compared to previous PFTs included the small ground glass opacity, mucous, possible history of aspiration due to esophageal dilation, pulmonary edema, or Amiodarone. Pulmonary consult recommended repeating a CT to follow the ground glass opacity seen in the right upper lobe. They also recommended an outpatient speech and swallow evaluation to rule out aspiration given the patient's history of esophageal dilation. They recommended stopping Amiodarone, although the patient is on Amiodarone for her atrial fibrillation. Seeing how her pulmonary status is likely to continue worsening, it was felt that the patient's primary care physician, [**Name10 (NameIs) 2085**], or pulmonologist should discuss code status considering the need for oxygen or ventilation. An attempt will be made to contact Dr. [**Last Name (STitle) 36953**] to discuss these new findings. 5. RIGHT FEMORAL AV FISTULA: The day following cardiac catheterization, the patient was found to have a right femoral bruit on examination. There was no evidence of hematoma at that site. A femoral vascular ultrasound was performed which showed an AV fistula but no evidence of pseudoaneurysm. Following discussion with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Vascular Surgery, it was decided to make a follow-up appointment with him as well as a follow-up femoral ultrasound study in three to four weeks following discharge. 6. OSTEOPOROSIS: The patient has severe osteoporosis as evidenced by kyphoscoliosis and a history of compression fractures. The patient was continued on calcium, vitamin C, and Actonel during the hospitalization. CONDITION ON DISCHARGE: Stable. Saturating 98% on room air and ambulating with a walker. DISCHARGE STATUS: The patient is discharged back to her [**Hospital3 **] facility. DISCHARGE DIAGNOSIS: 1. Dyspnea. 2. Aortic stenosis. 3. Restrictive lung disease secondary to kyphoscoliosis. 4. Congestive heart failure. 5. Paroxysmal atrial fibrillation. 6. Osteoporosis. 7. AV fistula. 8. Gastroesophageal reflux disease. 9. Osteoporosis. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Amiodarone 200 mg p.o. q.d. 3. Mirapex 0.125 mg p.o. b.i.d. 4. Calcium carbonate 500 mg p.o. b.i.d. 5. Vitamin D 400 units p.o. q.d. 6. Actonel 35 mg p.o. q. weekly. 7. Lisinopril 5 mg p.o. q.d. 8. Prilosec 20 mg p.o. q.d. 9. Lasix 40 mg p.o. q.d. 10. Senna p.o. b.i.d. p.r.n. constipation. FOLLOW-UP PLANS: The patient is asked to follow-up with the following: 1. Primary cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**]. 2. Primary pulmonologist, Dr. [**Last Name (STitle) 36953**]. 3. Primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 27598**]. 4. Vascular surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in three weeks. 5. An outpatient femoral ultrasound study to evaluate the AV fistula on Friday, [**2167-1-23**], at 10:30 a.m. Attempts were made to make appointments for the patient; however, since it was a holiday, offices were not open. The patient and her family were given phone numbers to call to make these appointments. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2167-1-2**] 01:39 T: [**2167-1-3**] 17:52 JOB#: [**Job Number 53681**] ICD9 Codes: 4241, 4280, 496
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Medical Text: Admission Date: [**2144-3-13**] Discharge Date: [**2144-4-3**] Date of Birth: [**2076-8-1**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypoxia, shortness of breath, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 67 M with poorly controlled IDDM, afib on coumadin, s/p partial right foot amputation p/w erythema, swelling, & wounds on RLE. Pt states that symptoms began 4 day ago with purulent drainage from foot lesions. Endorses fevers at home yesterday. Pt recently treated for cellulitis in RLE 1 months ago with good resolution. No antecedent trauma but pt scratching legs vigorously. . Also endorses decreased appetite with 20 lb weight loss in the past month. . Vital signs in the ED: 98.0, 149/70, 80, 18, 98% 2L . In the [**Name (NI) **], pt given IV vancomycin in ED. . REVIEW OF SYSTEMS: (+): As above (-): Chest pain, SOB, abdominal pain, nausea, vomiting, diarrea, headache. Past Medical History: -CHF EF 45% ([**12/2143**]) - on home oxygen 1-2L -CAD s/p 4 MI's ([**2125**], [**2134**], [**2142**]), s/p 3 vessel CABG and recent BMS of D1 ([**3-27**]) -Chronic Atrial Flutter -Diabetes mellitus type II c/b Neuropathy, Retinopathy, diabetic foot ulcer s/p amputations -PVD -Hypertension -Hyperlipidemia -GERD -Depression -h/o alcoholism- stopped drinking 25 years ago -Ischemic colitis -Left Subclavian Stenosis (45 mmHg pressure drop across the stenotic lesion, Cath [**5-/2142**]) . Past Surgical History: L 2nd toe amp R TMA R partial colectomy for ischemic colitis 3 vessel CABG R fem-DP l fem-[**Doctor Last Name **] with stent bilaterally s/p aortoiliac stenting Social History: Patient lives in [**Location **] with 3 of his brothers. [**Name (NI) **] retired in his late 50s but he previously owned a radiator repiar business. No ETOH X 25 years, but hx of heavy drinking X 15 years ("all day long"), Hx of tobacco use (4ppd X 15 years), no IVDU. Family History: -no CAD, lung disease, or DM in the family -HTN in father -Breast cancer in mother Physical Exam: ON ADMISSION: Tcurrent: 37 ??????C (98.6 ??????F) HR: 94 (94 - 94) bpm BP: 121/32(53) {121/32(53) - 121/32(53)} mmHg RR: 21 (21 - 22) insp/min SpO2: 98% Heart rhythm: AF (Atrial Fibrillation) GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. muddy sclera. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of in line with jaw line CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Crackles at bilateral bases, good air movement throughout ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. missing front foot on R, missing toes and ulcerations on remaining on left, RLE dressing c/d/i PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ . AT DISCHARGE: Pertinent Results: - ECG: LBBB at rate 90-112. Greater than 5mm ST elevations than previous, although hard to delineate ST baseline. . - ECHO: [**12-27**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the inferior, inferolateral and basal inferoseptal segments. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2143-1-15**], the findings appear similar. . - CARDIAC CATH: RHC [**1-26**]: COMMENTS: 1. Resting hemodynamics revealed normal right ventricular filling pressures with RVEDP 7 mmHg and mildly elevated left sided filling pressures with PCWP 19 mmHg. There was pulmonary arterial hypertension with a mean PA pressures of 33 mmHg (PA prrresure 55/19 mmHg). The pulmonary vascular resistance was 157 dynes-sec/cm5. The cardiac index was normal at 3.26 L/min/m2. 2. Treatment with 100% FiO2 demonstrated lowering of the pulmonary artery resistance (97 dynes-sec/cm5) due to a rise in calculated cardiac index (5.27 L/min/m2) with a stable PCW of 19 mmHg. The mean PA pressure was measured at 33 mmHg. 3. Treatment with inhaled NO at 40 ppm in addition to 100% FiO2 did not change the pulmonary pressures significantly with a mean PA pressure of 30mmHg. There was just a mild change in the mean PCWP measured at 17 mmHg. The pulmonary artery resistance was (107 dynes-sec/cm5) due to a rise in the calculated cardiac index (4.43 l/min/m2). FINAL DIAGNOSIS: 1. Pulmonary arterial hypertension at baseline with no improvement in mean PA pressures with 100% o2 and iNO at 40ppm. 2. Mildly elevated left ventricular filling pressures. . LHC [**5-26**]: COMMENTS: 1. Coronary angiography in this left-dominant system revealed diffuse coronary artery disease. The LMCA was a small caliber vessel without disease. The LAD had 60-70% calcified stenoses of the proximal section, as well as the diagonal branch, and was occluded after the mid-section. The LCX had sequential stenoses of the proximal and distal LCX, with occluded OM1 and OM2 branches, and total occlusion after the distal LCX. The RCA was a non-dominant vessel with sequential 80% stenoses. 2. Selective graft venography revealed a widely patent SVG-PDA and LPL graft. The SVG-OM1 graft had a 30-40% stenosis in the mid-SVG, and was patent to the OM1 branch. 3. Selective graft arteriography revealed a widely patent LIMA-LAD graft. 4. Resting hemodynamics revealed elevated right- and left-sided filling pressures, with mean RA pressure of 15 mmHg, and mean PCW pressure of 30 mmHg. The wedge tracing was notable for a prominant v-wave with pressure of 51 mmHg, consistent with possible mitral regurgitation. There was mild pulmonary hypertension with mean PA pressure of 38 mmHg, and mild systemic hypertension, with SBP of 140mmHg. The cardiac output was normal at 5.1 L/min. There was no aortic stenosis detected by pullback technique. 5. Nonselective left subclavian injection revealed a 70% stenosis of the proximal left subclavian artery, with a 45 mmHg pressure drop across the stenotic lesion. FINAL DIAGNOSIS: 1. Diffuse coronary artery disease. 2. Elevated left- and right-sided filling pressures. 3. Mild pulmonary and systemic hypertension. 4. Subclavian stenosis. Brief Hospital Course: Patient expired as explained in OMR Death Note summarized here: At approximately 12:30AM, telemetry in the ICU demonstrated ventricular tachycardia. Dr. [**Last Name (STitle) 39070**] [**Name (STitle) 39071**] was present at bedside and the patient was found to be pulseless. Code status was noted to be DNR and he became asystolic shortly thereafter. Dr. [**Last Name (STitle) 39071**] called the time of death to be 12:36AM on [**2144-4-3**] after listening for breath sounds bilaterally and not appreciating any. He also listened for heart sounds and did not appreciate any. He felt for peripheral pulses for 1 minute at both radial arteries, and did not appreciate any. He had absent corneal reflexes bilaterally. Dr. [**Last Name (STitle) 39071**] has made several phone calls to patients brothers in attempt to inform them of grave situation. Organ bank was also notified by Dr. [**Last Name (STitle) 39071**] and they have declined. Below is a brief summary of his hospital course: Mr. [**Known lastname 17029**] is a 67 year old man with a past medical history significant for CABG, CAD, sCHF, DM, PVD, originally admitted for RLE cellulitis who was transferred to the CCU after developing acute pulmonary edema. His course was complicated by pulseless VT arrest on [**3-21**] and respiratory failure and is now in the MICU for further management . # Hypoxemic Respiratory Failure: Initially upon admission, Mr. [**Known lastname 17029**] had an SpO2 of 100% on 2L. Given appearance of hypovolemia on exam, and concern for infection his home torsemide was held and he was given 1L NS. On the first night of admission, he became hypoxemic to SpO2 in the 70s. CXR at the time demonstrated pulmonary edema. SBP was 150. Hypoxemia initially improved with BiPap and diuresis. He was transferred to the CCU for further management given concern for ACS. On [**3-15**] he was able to be weaned from bipap with lasix gtt and nitro gtt after 2L of diuresis, however on [**3-15**] he removed his NRB mask and desaturated to the 60s, was obtunded and bradycardic in aflutter with variable block and he was intubated. ABG initially demonstrated a moderate P/F ratio of ~250 suggestive of [**Doctor Last Name **] which has roughly remained constant. CT chest demonstrated bilateral ground glass opacities worsened in non-dependent areas since [**1-26**] of unknown etiology. Overall, non-resolving infiltrates were seen as likely secondary to flash pulmonary edema with component of alveolar hemorrhage given profound coagulopathy on admission. Given spike to 102 on [**2143-3-20**] and CXR with worsening bilateral infiltrates, VAP was seen as likely and broad spectrum Abx (Vanc, Zosyn, and Levofloxacin) were started. Furthermore, Swan on [**2143-3-21**] demonstrated wedge of 15-18 indicating a smaller component of L heart dysfunction than previously thought. Furthermore PVR in 800s indicated that pulmonary hypertension occurred out of proportion to left heart dysfunction. After 1 week of intubation, his mental status had improved to the point where he could be safely extubated on [**2144-3-24**]. P/F ratio prior to extubation demonstrated a ratio of 250 which was similar to his baseline. For one day following extubation, he was able to maintain an SpO2 of 97-99% on the high flow mask, but progressively became more tachypneic and demonstrated paradoxical respirations. Bipap was initiated on [**2144-3-25**]. . He was transferred to the MICU for further care [**3-26**]. Upon arrival his mental status was poor and appeared having significant difficulty on bipap. It was decided to re-intubate the patient. He was continued on vancomycin and meropenem. A bronchocsopy was performed which showed hemosiderin laden macrophages. His hypoxia was felt to be a combination of cardiogenic pulmonary edema given elevated V waves on swan plus intrinsic pulmonary process of undiagnosed etiology. A lung biopsy was considered. . # PULSELESS VT ARREST: While Mr. [**Known lastname 17029**] was being weaned from sedation on [**2144-3-21**], he experienced an episode of pulseless VT. There was no evidence of cardiac ischemia, electrolytes were within normal limits, and QTc was 420. He had ROSC after 1 shock and an amiodarone load. The etiology of this event was unclear, but was thought to occur secondary to catecholamine surge in the setting of sedation wean and profound agitation. In the MICU, the patient had increased ectopy and NSVT. Due to the increasing frequency, he was restarted on amiodarone with improved ectopy. . # [**Last Name (un) **] ?????? With diuresis, Mr. [**Known lastname 54896**] renal function progressively deteriorated to a peak BUN/Cr of 178/4.5 from a baseline of 34/1.7. After a peak Cr of 4.5, Mr. [**Known lastname 54896**] cr began to improve to a Cr of 2.8 upon transfer to the MICU. HE continued to maintain good UOP and followed closely by nephrology. He did not need renal replacement therapy while in the MICU. . # Hypernatremia: Mr. [**Known lastname 17029**] became quite hypernatremic when his tube feeds were held following extubation. Initial attempts to replete with 1/2 NS were unsuccessful, and his Na was 157 on [**2144-3-26**] consistent with a 6.5 L free water deficit. D5W and free water flushes were started with good effect. . #AMS ?????? A large component of Mr. [**Known lastname 54896**] prolonged intubation was altered mental status. Following initial sedation with fentanyl and midazolam he became quite sedated and would not follow commands. Sedation was changed to propofol after inadequate sedation with precedex. Given supratherapeutic INR, CT head was obtained which demonstrated atrophy but no acute changes. Neuro consult was obtained, and their assessment was that his delerium was secondary to toxic metabolic causes (sedation, uremia, hypernatremia, and ICU delerium). EEG shows metabolic encephalopathy, no epileptiform activity. As his renal function and hypernatremia improved, the patient's mental status slowly improved while on the vent. . # Nutrition: Upon transfer to the MICU, mental status precluded PO intake, and Bipap precluded nasogastric tube feeds. Tube feeds were initiated in the MICU. . # DM ?????? Blood sugars were difficult to control in the CCU, and an insulin drip was started. [**Last Name (un) **] was consulted and saw the patient often for close monitoring of his blood sugars. . # Fevers/Infection: Fever to 102 on [**2144-3-22**] with leukocytosis peak to 24 on [**2144-3-26**]. There existed concern for VAP with prolonged intubation (no definite infiltrates for VAP), as well as UTI given prolonged foley catheterization (prior UA with WBCs but urine cx with only yeast). Less likely was meningitis given AMS, because time course/physical exam was inconsistent (he became altered before fevers started and no nuchal rigidity). Initially vanc/zosyn/levofloxacin were started for VAP on [**2144-3-18**]. Levofloxacin was stopped on [**2144-3-21**] following VT arrest and concern for QT prolongation. He was broadened to vancomycin and [**Last Name (un) 2830**] upon transfer to the MICU and his wbc improved. . # CAD ?????? Mr. [**Known lastname 17029**] experienced chest pain in setting of respiratory decompensation on admission without EKG changes from baseline, cardiac enzymes peaked on [**3-15**] with MB of 21 and trop of 1.21. Troponin was baseline and worsened with worsening CKD. Overall his MB bump was seen as demand related to his hypoxemia and there was little concern for ACS. He remained CP free since initial decompensation. # LIVER: LFTs were elevated on admission to ALT/AST in the 300s. Etiology is likely secondary to congestive hepatopathy as RUQ US ruled out abscess or reversal of flow, but was suggestive of CHF and congestive hepatopathy. HCV ab was negative. HBV serologies negative. Given downtrending LFTs with diuresis, further workup was deferred. Furthermore, INR improved dramatically with Vit K administration c/w malnutrition. . #Anemia. Hematocrit slowly worsened from baseline of 29 on admission to a nadir of 22.1. He was transfused on [**2143-3-21**] due to low SvO2 of 35%. Cause of anemia has been thought to be secondary to CKD and/or anemia of chronic disease. Hemolysis was ruled out with negative smear for schistocytes, elevated haptoglobin, and normal fibrinogen. In light of brown guiac positive stools, protonix [**Hospital1 **] was initiated. In the MICU, he had a low Hct of 20.6 and received two units of pbrcs with good effect. Medications on Admission: - Aspirin 81 mg QD - Trazodone 100 mg QHS PRN - Atorvastatin 80 mg QHS - Sertraline 100 mg QD - Clonazepam 0.5 mg TID PRN anxiety - [**Hospital1 23928**] 10 mg QD - Torsemide 20 mg QD - Warfarin 1 mg QD - Spironolactone 12.5 mg QD - Isosorbide mononitrate 60 mg ER QD - Fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] - Metoprolol succinate 12.5 mg ER QD - Albuterol sulfate 90 mcg MDI [**2-17**] INH Q6H PRN SOB, wheeze - Humulin-N 100 unit/mL Suspension 20 units QAM, 24 units QPM - Humalog 100 unit/mL Solution 10 units QAM, 12 units QPM Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 486, 5849, 2760, 2762, 4271, 4280, 4439, 311, 4275, 2875
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Medical Text: Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-11**] Date of Birth: [**2049-2-4**] Sex: F Service: MEDICINE Allergies: Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone Attending:[**First Name3 (LF) 45**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD, moderate mitral and tricuspid regurgitation, atrial fibrillation on coumadin s/p PPM placement who presents s/p fall at home. The patient said that she had just recently been discharged from Rehab. She said that she was doing well there, walking freely and at times with a walker or a cane. She went home, where she lives alone, but has frequent visitors. She was sitting on her bed trying to put her sock on and she slipped off the bed and fell. She hit her coccyx. She was on the ground for 3 hours, until she was found by a friend who brought her to [**Hospital1 18**]. She said that at the time of the fall, she had no lightheadedness or dizziness, no palpitations, diaphoresis, chest pain, SOB, LOC. She repeatedly said she just slipped off the bed. She said that this year she has fallen 3 times, but prior to that she had not had a history of falls. She said the other 2 times were also mechanical. One time she slipped in the rain outside and the other time she was walking with tea in her hand at home and she tripped over a stool. She says that usually she is able to walk well. She manages her own finances. She says she does her own cooking and cleaning. She has friends shop for her. She has had visiting nurses in the past, but no permanent home care attendent because she felt there was no need for that. She has lots of friends and family who visit. In the ED, initial vitals are as follows: 97.6 80 96/56 16. Labs notable for trop 0.02 with 2nd trop 0.01, INR - 1.8, H/H: 11.3/38.6 The pt underwent CT head - No acute intracranial process, CT C-spine - No fracture. Large bilateral pleural effusions, CXR - Mild pulmonary edema, with b/l pl effusions (stable). L basilar opacification, atelectasis vs infxn, Lumbar spine, pelvis plain films - No acute fracture or subluxation The pt received ceftriaxone and azithromycin in the ED for lactate of 3.0. Vitals prior to transfer: T 98.3 p 75 rr 18 bp 137/88 sa02 unable (blood gas drawn and pending) 92 % on abg, patient was not suitable for PT/CM in the ED so being admitted to the floor. Currently, lying in bed, upset that she is being asked all the same questions. ROS: Per HPI Past Medical History: - Hypertension - s/p BMS to proximal LAD on [**2131-12-17**] - CAD s/p NSTEMI in [**11/2131**] - Dilated cardiomyopathy, EF 25% on [**2133-2-9**] TTE - Valvular Disease: 2+ MR, 2+ TR on [**2133-2-9**] TTE - s/p BMS to proximal LAD on [**2131-12-17**] - Atrial fibrillation, diagnosed [**10/2132**] s/p failed cardioversion and s/p PPM placement, on Coumadin - Hypertension - Arthritis - Left breast cancer s/p mastectomy, node dissection, radiation in [**2113**] - h/o gastritis/GI bleed - Macular degeneration - presumed SIADH (see d/c summary from [**11/2131**]) s/p tolvaptan at that time Social History: Lives alone, never married, no children. Nephew [**Name (NI) **] [**Name (NI) 7049**] is her HCP. Denies alcohol, tobacco, or illicit drug use. Former dancer-singer on the [**First Name8 (NamePattern2) **] [**Location (un) **] Show. Family History: Mother died of ? stomach cancer in her 70s. Father died of natural causes in his 70s. 9 siblings, all deceased, no medical problems. Denies family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T: 97.4 BP: 97/50 HR: 73 RR: 20 02 sat: 92% on ABG as difficult to get pulse ox GENERAL: Pleasant, tired appearing woman, lying flat in bed and speaking comfortably HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Very dry MM. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Holosystolic murmur heard throughout LUNGS: CTAB anteriorly (patient did not want to sit up for full lung exam) ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Left arm larger than right. Patient with 3-4+ pitting edema of feet and slowly tapers up to knees. Also with sacral edema. PT pulses dopplerable, unable to doppler DP pulses (nurse able to doppler [**12-29**] DP pulses, patient hands cool to touch and slightly cyanotic. Patients feet were cold to touch and cyanotic, she was able to move her feet with full range of motion and 5/5 strength although her sensation to light touch was depressed. She had skin tears on her feet bilaterally that weren't healing, toenails were long, her feet were tender to touch NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. PSYCH: Listens and responds to questions appropriately, pleasant . DISCHARGE PHYSICAL EXAM: Vitals (CMO): RR 14-20 I&Os: [**Telephone/Fax (1) 105938**] General: Awake patient lying in bed in NAD, comfortable. HEENT: EOMI. Dry MM. Tongue midlline CV: Regular rate and rhythm. 2/6 systolic murmur appreciated at the LLSB and at the cardiac apex. Lungs: Absent breath sounds at the bases bilaterally. Crackles in the mid-lung fields bilaterally, posteriorly. No wheezes. No increased work of breathing. Abdomen: Soft. ND. BS+. Tenderness in RUQ. Ext: Cyanosis present of the R hand. No clubbing. 2+ pitting edema of the ankles bilaterally, with pitting edema extended to the mid-shins bilaterally, worse on the left (2+) than on the right. Pertinent Results: ADMISSION LABS [**2133-5-28**] 12:00PM BLOOD WBC-6.0 RBC-4.20 Hgb-11.3* Hct-38.6 MCV-92 MCH-27.0 MCHC-29.3* RDW-16.8* Plt Ct-359 [**2133-5-28**] 12:00PM BLOOD Neuts-73.9* Lymphs-19.9 Monos-5.5 Eos-0.3 Baso-0.5 [**2133-5-28**] 12:00PM BLOOD PT-19.0* PTT-33.2 INR(PT)-1.8* [**2133-5-28**] 12:00PM BLOOD Glucose-78 UreaN-28* Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-24 AnGap-18 [**2133-5-28**] 12:00PM BLOOD CK(CPK)-189 [**2133-5-28**] 12:00PM BLOOD cTropnT-0.02* [**2133-5-28**] 05:52PM BLOOD cTropnT-0.01 [**2133-5-29**] 07:50AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.2 Mg-1.8 [**2133-5-28**] 12:00PM BLOOD Digoxin-2.0 [**2133-5-28**] 11:11PM BLOOD Type-ART pO2-76* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 [**2133-5-28**] 09:31PM BLOOD Lactate-3.0* [**2133-5-28**] 11:11PM BLOOD Lactate-1.4 [**2133-5-28**] 03:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2133-5-28**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2133-5-28**] 03:20PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0. MICRO [**2133-5-29**] 1:00 am BLOOD CULTURE **FINAL REPORT [**2133-6-4**]** Blood Culture, Routine (Final [**2133-6-4**]): NO GROWTH. [**2133-5-28**] 9:20 pm BLOOD CULTURE **FINAL REPORT [**2133-6-3**]** Blood Culture, Routine (Final [**2133-6-3**]): NO GROWTH. . IMAGING -[**5-28**] PELVIS XR: FINDINGS: No acute fracture or dislocation is present. Diffuse demineralization of the osseous structures is noted. There is no diastasis of the pubic symphysis or sacroiliac joints. No suspicious lytic or sclerotic osseous abnormalities are seen. Scattered phleboliths are seen within the left hemipelvis. There are surgical clips noted pelvis. There are mild degenerative changes with joint space narrowing of the hips. IMPRESSION: No acute fracture or dislocation. . 5/31 L-spine XR IMPRESSION: No acute fracture or subluxation. . [**5-28**] CXR: IMPRESSION: Mild pulmonary edema, with continued bilateral pleural effusions, moderate on the left and small on the right. Fluid is noted to track over the apices bilaterally. Left basilar opacification may reflect compressive atelectasis though infection is difficult to exclude. . [**5-28**] C-spine w/ contrast: IMPRESSION: 1. No fracture or change in alignment. 2. Bilateral pleural effusions. . [**5-28**] Head CT: FINDINGS: There is no acute hemorrhage, edema, or shift of normally midline structures. Prominence of the ventricles and sulci is compatible with age-related atrophy. There is no large territorial vascular infarction. Diffuse periventricular white matter hypodensities, though nonspecific, likely relate to chronic small vessel ischemic disease. Again noted are small air-fluid levels within the mastoid air cells associated with mild sclerosis suggesting a chronic inflammatory process. The remaining visualized paranasal sinuses are well aerated. Calcifications are seen within the carotid siphons and within the subcutaneous portion of the skin overlying the anterior skull. There is no fracture identified. IMPRESSION: No acute intracranial process. . [**6-4**] TTE The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to global hypokinesis as well as marked ventricular interaction. The right ventricular free wall thickness is normal. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload with consequent ventricular interaction. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2133-2-19**], mitral and tricuspid regurgitation are significantly increased. Right ventricular pressure and volume overload are much more prominent, with consequent increased ventricular interaction further reducing left ventricular systolic and diastolic performance. [**6-5**] Head CT: FINDINGS: There is no hemorrhage, edema, shift of midline structures, or territorial infarction. The ventricles and sulci are prominent, consistent with global atrophy. Subcortical and periventricular white matter hypodensities, most marked in the frontal lobes are unchanged and consistent with chronic small vessel ischemic disease. The calvaria are unremarkable. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. Brief Hospital Course: 84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD, moderate mitral and tricuspid regurgitation, atrial fibrillation on coumadin s/p PPM placement who presents s/p fall at home. She was r/o for traumatic fractures in the ED, and was admitted for monitoring and eval prior to dispo to rehab. On [**6-2**], she triggered for SBP's to the 70's amidst a presyncopal episode, likely vasovagal in the setting of orthostasis/intravascular depletion and having a large bowel movement (her BP's improved shortly after being returned to bed). On 6/6am, she became abruptly unresponsive while being assisted to go to the bathroom, and was transferred to the MICU for unresponsiveness and then subsequently transferred to the cardiology service for diuresis and continued management for end-stage heart failure, who was later made CMO. ============================================================ General Medicine Floor Course: . # Unresponsiveness: On 6/6am, she became abruptly unresponsive while being assisted to go to the bathroom, and did not respond to painful stimuli. She was afeb with SBP's in the 100s; EKG's and CXR were unremarkable other than mild pulmonary edema; she was given 1mg IV ativan for empiric seizure treatment. After about an hour, she began slowly regaining responsiveness and was moving all 4 limbs with nonfocal neuro exam, but did not regain full baseline cognition. She was transferred to the MICU. # Delirium: The patient was delirious o/n on [**5-29**] when she required a small dose of IM haldol for extreme agitation (calling 911 from room). The delirium was likely [**1-29**] hospital delirium, possibly exacerbated by the diazepam which the patient consistently takes. Toxic metabolic etiology was unlikley as her labs were largely unremarkable; infection or injury were also unlikely given no localizing evidence (clean UA, CXR, no fever). Per the patient's PCP, [**Name10 (NameIs) **] patient insists on taking and needs her diazepam so this likely cannot be down-titrated, although it may contribute to her underlying delirium. The patient was monitored on fall precautions, aspiration precautions. . # s/p Mechanical Fall: Upon presentation, the patient had no active sign/symptoms of bleeding, fracture, or other acute process; all trauma scans were unremarkable. Patient's fall may have been mechanical, although she has had increased number of falls at home this year. Her feet have decreased sensation and poor blood flow likely worsening her ambulatory abilities. In addition, while her strength was intact, at rest, her legs appeared limp as if very weak. She lives at home with no help for most of the day, but particularly at night. She is a high risk for repeated fall, but she may not be amenable to placement. PT eval recommended dispo to rehab. . ============================================================= ICU Course ([**6-3**] -> [**6-5**]) The patient was transferred to the ICU on the morning of [**6-3**] after an episode of unresponsiveness and for worsening cyanosis. Neurology was consulted and thought the picture was most consistent with either a metabolic encephalopathy - possibly related to hypoxia and cardiogenic shock. A diagnosis of hypoactive delirium was also entertained. EEG showed R temporal epileptic discharges. Neurology recommended repeat Head CT - both were unremarkable for acute causes. Her mental status improved over the course of her ICU stay, and she was conversant and oriented x 2 prior to being called-out. For her worsening cyanosis, cardiology recommended optimizing her systolic function. CXR showed volume overload and TTE showed worsening MR, TR and volume overload. She was bolused with lasix and then started on a lasix drip as well as metolazone to try and improve diuresis. The patient's urine output remained poor at the time of call-out. Vascular surgery was also consulted for the patient's peripheral cyanosis - they thought it to be most consistent with global hypoperfusion with superimposed PVD. Coumadin was held for an INR of 5.3. Digoxin level was sent with plans to restart reduced dose. Her chronic valium was held due to altered mental status and had not been restarted prior to call-out. . =============================================================== Cardiology Floor Course: . # CARDIOGENIC SHOCK: Upon transfer from the unit, the patient was on a lasix drip but appeared to be in cardiogenic shock with cold extremities and cyanosis. Urine output was monitored, and the patient made a great deal of urine to the lasix drip. Her color and temperature of extremities improved. Electrolytes were monitored and repleted as needed to maintain potassium of 4 and magnesium of 2. Lasix drip was discontinued after the patient pulled her PICC line. She was subsequently transitioned to an oral dose of torsemide. Medical team met w/ patient's HCP, her nephew [**Name (NI) **]. Discussed with [**Doctor Last Name **] the end-stage nature of her heart failure. Palliative care became involved during this [**Hospital 228**] hospital course, and the decision was made to transition to comfort measures only. Initially, she was given oral torsemide at a daily dose, but the patient consistently made approximately 3 liters of fluid daily with poor oral intake. Thus standing doses of torsemide were discontinued with the plan to give the patient 40mg of oral torsemide as needed for shortness breath. ****** The following issues were also addressed initially during the patient's Cardiology floor stay prior to the decision to make the patient comfort measures only: # ELEVATED INR: Etiology was unclear; differential included DIC (in light of elevated PTT and falling HCT) versus congestive hepatopathy in light of worsening heart failure. DIC was ruled out. With rising LFTs, the cause of the elevated INR was attributed to congestive heaptopathy in light of systolic heart failure. LFTs were initially trended and noted to be decreasing with downtrending INR. With the decision to transition care towards comfort, no further INRs were drawn. # ATRIAL FIBRILLATION: INR supratherapeutic upon admission to the cardiology service. Coumadin was held as was the digoxin. Patient's INR downtrended. With decision to focus care on comfort, no other lab draws were done. # CAD: Initially continue ASA 81mg daily, losartan, metoprolol (with holding parameters) until the decision was made to focus care of comfort. # ARTHRITIS: Acetaminophen PRN for management of pain control. # LEFT BREAST CANCER S/P MASTECTOMY: Chronic lymphedema in left arm, no BP checks in left arm or lab draws were attempted. # HYPOTHYROIDISM: Normal TSH on [**6-2**]. Continued home levothyroxine, until the decision was made to transition care to comfort measures only. TRANSITION OF CARE: --Focus of patient's care is towards comfort measures only. All medications with the exception of her diuretic and rate regulating medication were discontinued. --Administer torsemide 40mg orally as needed for symptoms of shorntess of breath. Medications on Admission: - Adult Low Dose Aspirin 81 mg Tab, Delayed Release 1 Tablet(s) by mouth once a day - acetaminophen 500 mg Tab 1 Tablet(s) by mouth four times a day as needed - diazepam 2 mg Tab 1 (One) Tablet(s) by mouth four times a day - furosemide 20 mg Tab 4 Tablet(s) by mouth daily - losartan 25 mg Tab 0.5 (One half) Tablet(s) by mouth daily - digoxin 125 mcg Tab 1 Tablet(s) by mouth daily - Lo-Peramide 2 mg Tab 1 Tablet(s) by mouth twice daily as needed for diarrhea - levothyroxine 25 mcg Tab 1 Tablet(s) by mouth daily - warfarin 2 mg Tab [**12-29**] Tablet(s) by mouth daily or as directed - multivitamin Tab 1 Tablet(s) by mouth daily - metoprolol succinate ER 50 mg 24 hr Tab one and [**12-29**] Tablet(s) by mouth once a day Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Anxiety. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day as needed for shortness of breath or wheezing. 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: HOLD for HR < 60 . Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary diagnosis: --status post fall --Cardiogenic shock Secondary diagnoses: - Hypertension - Coronary artery disase - Atrial fibrillation - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 7049**], It was a privilege to provide care for you here at the [**Hospital1 1535**]. You were admitted because you had a fall at home. You received various X-rays and CT-scans, which did not show fractures. During this admission, you had a very serious heart failure exacerbation. You were diuresed initially and responded well. Family meetings were conducted during this admission, and the decision was made to transition your care to comfort meausres only. Medications that focus on your comfort have been continued, including medications for anxiety, pain, and shortness of breath. Followup Instructions: Patient will be managed symptomatically at [**Hospital1 1501**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] ICD9 Codes: 2930, 4240, 4280, 4019, 4439, 2449, 412
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Medical Text: Admission Date: [**2111-12-20**] Discharge Date: [**2111-12-24**] Date of Birth: [**2046-8-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: History of TIA Major Surgical or Invasive Procedure: [**2111-12-21**] Minimally Invasive Closure of Patent Foramen Ovale History of Present Illness: This is a 65 year old male with history of hypertension and multiple TIA's. His first neurological event took place in [**2088**]. His most recent was in [**2111-9-17**]. Evaluation at [**Location (un) 47**] was notable for a patent foramen ovale which was detected by transesophageal echocardiogram. He now presents for cardiac surgical intervention. Past Medical History: Patent Foramen Ovale, History of TIA's, Hypertension, Hip Arthritis, Prior Hernia Repair Social History: He is a bartender. Admits to 16 pack year history of tobacco. He denies excessive ETOH. Family History: Father died of throat cancer at age 52. Mother died in her 80's. Physical Exam: Vitals: BP 140's/90-100, HR 65, RR 20, SAT 95% on room air Weight: 71.6 kg General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2111-12-20**] 11:19PM BLOOD WBC-9.5 RBC-4.07* Hgb-14.3 Hct-39.1* MCV-96 MCH-35.2* MCHC-36.7* RDW-12.7 Plt Ct-223 [**2111-12-20**] 11:19PM BLOOD PT-11.3 INR(PT)-0.8 [**2111-12-20**] 11:19PM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-143 K-4.2 Cl-102 HCO3-28 AnGap-17 [**2111-12-23**] 06:25AM BLOOD WBC-12.1* RBC-3.15* Hgb-10.9* Hct-29.3* MCV-93 MCH-34.7* MCHC-37.3* RDW-14.3 Plt Ct-152 [**2111-12-24**] 06:40AM BLOOD UreaN-22* Creat-1.0 K-3.9 [**2111-12-24**] 06:40AM BLOOD Mg-2.4 Brief Hospital Course: Upon admission, patient underwent surgical closure of his patent foramen ovale which was performed through a minimally invasive incision. The operation was uneventful and he was brought to the CSRU in stable condition. Within 24 hours, he awoke neurologically intact and was extubated without incident. He was started on low dose beta blockade. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. He required gentle diuresis. Beta blockade was slowly advanced as tolerated. He remained in a normal sinus rhythm. He required multiple medications for adequate pain control. He continued to make clinical improvements and was cleared for discharge to home on postoperative day three. Discharge chest x-ray revealed a tiny residual right apical pneumothorax with some subcutaneous emphysema in the right chest wall. There were small bilateral effusions and atelectasis at both lung bases. Vitals at discharge were BP 120/70 with heart rate 78 in sinus and 96% on room air. All surgical incisions were clean, dry and intact. Medications on Admission: Aggrenox [**Hospital1 **], Lipitor 20 qd, HCTZ 25 qd, Mobic 7.5 mg qd, Selenium Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:*14 Packet(s)* Refills:*0* 6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Home Health and Hospice at St. Josephs Discharge Diagnosis: Patent Foramen Ovale; History of TIA's; Hypertension; Hip Arthritis; Prior Hernia Repair Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-21**] weeks, call [**Telephone/Fax (1) 170**]. Local PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45802**] in [**2-19**] weeks - office will call patient. Local cardiologist in [**State 1727**] in [**2-19**] weeks - will be arranged by PCP. Completed by:[**2111-12-24**] ICD9 Codes: 5119, 5180, 4019
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Medical Text: Admission Date: [**2129-2-11**] Discharge Date: [**2129-2-14**] Date of Birth: [**2086-5-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 42 y/o male with HIV, Hep C, cardiomyopathy, hypertension, polysubstance abuse including cocaine in addition to membranous GN now ESRD on HD presenting with acute SOB, epigastric pain, respiratory distress. The patient is a heavy smoker and per verbal report from mother, patient and girlfriend broke up more recently, and consumption of cocaine may have surrounded this event. . In the ED, he triggered on arrival for sat of 84% on RA. He usually is not hypoxic. On exam he was hypertensive and clinically had fluid overload. CXR demonstrated diffuse pulmonary infiltrates consistent with volume overload. Started on nitro drip and BIPAP in addition to 2.5mg IV enaparil. . An EKG in sinus tachycardia with depressions V4-V6 slightly worse than his baseline. His overall status improved with BiPAP -> agitation decreased, although still confused mildly. Trop and BNP sent. Dilaudid, Ativan, refused straight cath, on nitro drip with improved BP from 200/110 to 186/110. . WBC 24k, no report of fevers but covered with levo/vanco/flagyl. On transfer BP 186/104 97.7 96 RR high 20's 90% on NRB. . Past Medical History: 1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors included unprotected heterosexual sex as well as intravenous drug use. His nadir CD4 count is 91 and he has no known opportunistic infections. Last viral load undetectable, CD4 556 ([**10-31**]). 2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**]. 3. Cryoglobulinemia 4. Cardiomyopathy with an EF of 45-50%. 5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and hypertensive nephrosclerosis 5. GERD. 6. Hypertension. 7. Gynecomastia; s/p bilateral gynecomastia excision with liposuction [**2126-7-23**]. 8. Polysubstance abuse, including cocaine and alcohol. 9. Anemia, hematocrit 20-24. 10. Hypertriglyceridemia - TG 282 in [**3-/2126**] 11. Right hydrocele. 12. A subacute infarct in the right caudate head seen on MRI in [**1-29**] 13. Influenza B, [**2126-2-22**]. 14. Erectile dysfunction. 15. Depression 16. Inguinal hernia repair in [**2123**]. 17. Left ankle ORIF in [**2122**]. 18. Appendectomy in [**2101**]. Social History: History of incarceration for 4 yrs. Is self-employed, unmarried. He has three children. Denies alcohol. Reports marijuana use daily, denies tobacco or cocaine. Family History: Mother and father have hypertension; has 3 bros, 3 sis: all healthy, none with HTN. There is also a family history of type 2 diabetes mellitus. No family history of sudden death and premature atherosclerotic cardiovascular disease. Physical Exam: On admission: 97.9, 88-105, 137/90 (137-197/90-114), 97% 3L NC GEN: Sleeping initially, no acute distress. Mild diaphoresis. HEENT: MMM Heart: S1+, S2+, RRR Lungs: CTA b/l Ab: scar from appendectomy, soft, non-distended, minimal abdominal tenderness in the epigastric region. No rebound or gaurding. Ex: No edema. Fistula site on left without skin breakdown or erythema or warmth. Skin: No rashes, mild diaphoresis. . On Discharge: Physical exam: Tm/c: 98.6/96.7, BP 106/74 (82-106/55-74), HR: 76 (60-76), RR: 16, O2 97% GEN: Awake in bed, no acute distress. HEENT: MMM, no LAD, neck supple Heart: S1+, S2+, RRR, harsh murmur in right upper sternal border, Lungs: CTA b/l Ab: scar from appendectomy, soft, non-distended, minimal abdominal tenderness in the epigastric region. No rebound or gaurding. Ex: No edema. Fistula site on left without skin breakdown or erythema or warmth. +thrill over fistula site Skin: No rashes, mild diaphoresis, multiple tattoos, one on left chest and left hand homemade, while right shoulder seems professional, multiple scars on right chest from HD lines. Pertinent Results: CBC: [**2129-2-11**] 08:20PM BLOOD WBC-24.6*# RBC-3.83* Hgb-12.9* Hct-38.1* MCV-99* MCH-33.6* MCHC-33.8 RDW-14.0 Plt Ct-301 [**2129-2-12**] 03:00AM BLOOD WBC-31.2* RBC-3.38* Hgb-11.4* Hct-32.7* MCV-97 MCH-33.6* MCHC-34.7 RDW-14.1 Plt Ct-271 [**2129-2-14**] 06:30AM BLOOD WBC-12.9* RBC-3.56* Hgb-11.9* Hct-35.4* MCV-99* MCH-33.4* MCHC-33.6 RDW-13.8 Plt Ct-258 . Diff: [**2129-2-11**] 08:20PM BLOOD Neuts-95.1* Lymphs-2.5* Monos-2.1 Eos-0.2 Baso-0.1 [**2129-2-13**] 06:25AM BLOOD Neuts-87.5* Lymphs-6.7* Monos-4.6 Eos-0.6 Baso-0.7 . Coags: [**2129-2-11**] 08:20PM BLOOD PT-14.8* PTT-29.5 INR(PT)-1.3* [**2129-2-13**] 06:25AM BLOOD PT-19.6* PTT-33.3 INR(PT)-1.8* [**2129-2-14**] 09:55AM BLOOD PT-18.5* PTT-32.5 INR(PT)-1.7* . BMP: [**2129-2-11**] 08:20PM BLOOD Glucose-153* UreaN-40* Creat-4.1* Na-143 K-4.3 Cl-99 HCO3-28 AnGap-20 [**2129-2-13**] 06:25AM BLOOD Glucose-104* UreaN-46* Creat-4.8* Na-139 K-4.8 Cl-93* HCO3-30 AnGap-21* [**2129-2-14**] 06:30AM BLOOD Glucose-97 UreaN-79* Creat-7.4*# Na-137 K-4.4 Cl-92* HCO3-26 AnGap-23* . LFT: [**2129-2-11**] 08:20PM BLOOD ALT-19 AST-29 LD(LDH)-236 AlkPhos-183* TotBili-0.5 [**2129-2-14**] 06:30AM BLOOD ALT-24 AST-25 LD(LDH)-149 CK(CPK)-23* AlkPhos-137* TotBili-0.6 . Cardiac Enzymes: [**2129-2-11**] 08:20PM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 95484**]* [**2129-2-12**] 03:00AM BLOOD cTropnT-0.03* [**2129-2-13**] 06:25AM BLOOD CK-MB-2 cTropnT-0.07* [**2129-2-14**] 06:30AM BLOOD CK-MB-1 cTropnT-0.18* . Mineral: [**2129-2-11**] 08:20PM BLOOD Albumin-4.4 Calcium-10.2 Phos-4.6*# Mg-2.2 [**2129-2-14**] 06:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.8* Mg-2.5 [**2129-2-11**] 08:26PM BLOOD Glucose-155* Lactate-2.7* K-4.5 [**2129-2-13**] 07:27AM BLOOD Lactate-2.5* ########################################################## [**2129-2-11**] CXR FINDINGS: There is diffuse interstitial and alveolar opacity throughout both lungs, favoring the lung bases. Slightly more confluent opacity is noted at the medial right lung. The mediastinum is unremarkable. The cardiac silhouette has actually decreased significantly in size from the prior exam suggesting a resolved pericardial effusion. There are bilateral pleural effusions, left slightly greater than right. No pneumothorax is seen. The osseous structures are unremarkable. IMPRESSION: Overall, the radiographic features favor diffuse interstitial and alveolar edema. The opacity at the medial right lung base may indicate confluent edema or possibly underlying concurrent infection or significant aspiration. Correlate clinically. Repeat radiography after appropriate diuresis is recommended to assess for underlying infection. . [**2129-2-12**] CXR FINDINGS: As compared to the previous radiograph from [**3-14**], the signs of bilateral diffuse pulmonary edema have completely resolved. No remnant focal parenchymal opacities. Borderline size of the cardiac silhouette. No pleural effusions. No pneumothorax. . [**2129-2-14**] ECHO The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = quantitative 44%). Systolic function of apical segments is relatively preserved. The estimated cardiac index is normal (>=2.5L/min/m2). 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: Symmetric left ventricular hypertrophy with mild global hypokinesis c/w diffuse process (toxin, metabolic, etc.). Dilated ascending aorta. . Compared with the prior study (images reviewed) of [**2128-11-18**], global left ventricular systolic function is slightly less vigorous. Brief Hospital Course: 42 y/o male with MMP, ESRD on dialysis presents with hypertensive emergency and shortness of breath in the setting of likely cocaine use. . #) Hypertensive emergency: The patient's baseline hypertension is very difficult to control--per our records he is on isosorbide, hydralazine, carvedilol, and clonidine at baseline. On his first night in the MICU, his blood pressure decrased approximately 20% on nitro drip and enalapril IV; diastolic stable at 100. Potential for concurrent cocaine use makes treatment additionally challenging. Beta blockers were avoided given cocaine use. Pt started on amlodipine 10mg daily, as well as valsartan 160mg daily x 1. He received dialysis on the morning after admission. After dialysis his hypertension resolved. There was some concern that his hypertensive episode was related to cocaine use (though pt adamently denied). He has had previous admissions for similar symptoms and each time he has tested positive for cocaine. He refused tox screen at this time. He is more aware of this now as he knows it may interfere with his transplant prospects. The patient stabilized and he was transferred to the floor for further management. His BP meds were continued and this was no longer an active issue. In fact, his blood pressure was borderline low on less medications than he reportedly takes at home raising the question of noncompliance as an outpatient. . #) Inferior lead ST depressions: Likely demand ischemia, but given initially flat troponins there was unclear [**Name2 (NI) 68402**]. The patient was asymptomatic. He received an ECHO, which was unrevealing and had no wall motion abnormalities. There was evidence of known non-ischemic cardiomyopathy. Repeat EKG had persistent depressions and unclear as to the underlying cause, but ECHO was negative. He was continued on aspirin 81 daily, beta blocker and nitrate and will follow up with his PCP. . #) Leukocytosis: likely stress response in context of pulmonary edema/hypertension. No clear evidence of infection. Pt was empirically started on vanc/zosyn that was later removed and his white count trended down without Abx. He remained afebrile and no further workup was done. . Abd Pain: pt having persistent chronic abdominal pain. There was initial concern that this pain, was different and new, but after speaking with the patient, he said it was the same pain and did not want further imaging since all CT scanning has come back negative. He is scheduled for repair of his ventral hernia in [**Month (only) 956**] and believes that this is the source of the pain. He said if this surgery does not resolve his pain he will seek medical help for further evaluation. . #) HIV: HAART regimen restarted on the morning after admission. This was not an active issue during this hospitalization. . #) Substance abuse: Unclear if patient is on methadone currently, and if so for pain or for chronic abuse. Attmepted to clarify dose while in the MICU, but unable to reach his methadone clinic. Started on reported home dose of 40mg daily, pending verification. I was able to reach the patient's methadone clinic while he was on the floor, but he was being discharged that day and so the paperwork that needed to get faxed over to verify his dose was never sent. If he returns, he will need his dose verified. He goes to the community clinic in [**Location (un) **] MA for his methadone. . #)GERD: Ranitidine. This was not an active issue during his hospital stay. Medications on Admission: Abacavir 300 x 2 Carvediolol 50mg [**Hospital1 **] Clonidine 0.4 TID Sustiva 600 daily Hydral 50 Q8 Isosorbide 30 daily Lamivudine 2.5 after HD Methadone 50mg daily Ranitidine 150 [**Hospital1 **] Terazosin 3mg QHS Discharge Medications: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. lamivudine 10 mg/mL Solution Sig: 2.5 PO three times/week after HD (). 6. methadone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. docusate sodium 100 mg Capsule Sig: [**1-23**] Capsules PO twice a day. 11. [**Doctor First Name **]-Vite 0.8 mg Tablet Sig: One (1) Tablet PO once a day. 12. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 13. hydralazine 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Emergency . Secondary Diagnosis: 1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors included unprotected heterosexual sex as well as intravenous drug use. His nadir CD4 count is 91 and he has no known opportunistic infections. Last viral load undetectable, CD4 556 ([**10-31**]). 2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**]. 3. Cryoglobulinemia 4. Cardiomyopathy with an EF of 45-50%. 5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and hypertensive nephrosclerosis 5. GERD. 6. Hypertension. 7. Gynecomastia; s/p bilateral gynecomastia excision with liposuction [**2126-7-23**]. 8. Polysubstance abuse, including cocaine and alcohol. 9. Anemia, hematocrit 20-24. 10. Hypertriglyceridemia - TG 282 in [**3-/2126**] 11. Right hydrocele. 12. A subacute infarct in the right caudate head seen on MRI in [**1-29**] 13. Influenza B, [**2126-2-22**]. 14. Erectile dysfunction. 15. Depression 16. Inguinal hernia repair in [**2123**]. 17. Left ankle ORIF in [**2122**]. 18. Appendectomy in [**2101**]. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were intially admitted to the hospital for extremely elevated blood pressure and difficulty breathing. You were admitted to the intensive care unit and you receive emergency hemodialysis to have the fluid removed from your body. After that, your breathing greatly improved and you were ready to be transferred to the general medicine floor. There were some concerning lab values that were likely all secondary to the stress your body went through during the elevated blood pressure and fluid overload. You also had some abdominal pain, but this pain was the same as chronic pain you have had in the past. We wanted to do a further work up of this pain and do some abdominal immaging, but you denied this as you have said this was done multiple times in the past and always negative. You said you have a hernia that is being repaired in [**Month (only) 956**]. You will be discharged from the hospital with close follow up with your PCP. . please take all your medications as prescribed. Followup Instructions: Department: PAT-PREADMISSION TESTING When: FRIDAY [**2129-2-18**] at 11:00 AM With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2129-2-25**] at 11:40 AM With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2129-3-4**] at 11:10 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: LIVER CENTER When: FRIDAY [**2129-3-4**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage ICD9 Codes: 5856, 4254, 2724, 311, 3051
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Medical Text: Admission Date: [**2141-9-12**] Discharge Date: [**2141-9-20**] Date of Birth: [**2078-2-12**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: collapse, transfer from OSH in coma Major Surgical or Invasive Procedure: tPA, cerebral angiography, c/b groin/femoral hematoma, resolved with pressure, pressure-dressing History of Present Illness: [**Known firstname 87998**] [**Known lastname **] is a 62 yo man working today on [**Hospital3 635**] as a landscaper when he suddenly collapsed around 1pm. He was initially brought to [**Hospital3 **] Hospital and found to be in Afib. SBP on arrival was in the 160s-180s. GCS was 3; he was subsequently intubated and sedated. CT head showed possible edema of the posterior fossa. CTA was then obtained and demonstrated basilar artery thrombus as well as thrombus in the left vertebral artery. IV tPA was given and the patient was life flighted to [**Hospital1 18**] for further care. On arrival here. A repeat CT of the head was showed evolution of a left cerebellar infarct and a hyper density in the left vertebral artery. The patient was taken immediately to the Angio suite for clot retrieval. There, off of propofol, his pupils where pinpoint and non-reactive; there was no spontaneous movement. Angiography demonstrated a clear basilar with clots in the bilateral PCAs and these where successfully removed. Past Medical History: Have documents from pts pharmacy in [**Location (un) 15158**] NY (Kraupner Pharmacy- [**Telephone/Fax (1) 87999**]). This documents listed [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88000**], MD as his PCP (Phone: ([**Telephone/Fax (1) 88001**]) and was able to receive the following information. Pt was last seen in her office in [**2141-3-2**]. Her past medical history for the patient was noted as: - Gunshot wound [**2115**] with bowel injury - Hypertension - Hyperlipidemia (last cholesterol 167) simvastatin LDL - Atrial Fibrillation on Coumadin (last INR by PCP in [**Name9 (PRE) 547**] was therapeutic at 2.2) - No known surgeries, implants. No known allergies Social History: Pt was working as a landscaper. In speaking with is niece, he has been living on [**Location (un) 945**] since [**Month (only) 958**] or [**Month (only) 547**]. It is unclear if he has been seen by a PCP or as continued to take his medications. He is married, wife is [**Name (NI) 88002**] [**Name (NI) **] and has 2 daughters, [**Name (NI) **] [**Name (NI) **] (who consented to the procedure today) and [**Female First Name (un) 88003**], all of whom live in NY. Family History: nc Physical Exam: (on admission, just prior to angiography procedure) Extremely limited. This exam was with the patient off propofol for 20minutes during prep for angio. Pupils pinpoint, non-reactive. No spontaneous movements, no withdrawal. Unable to test brainstem reflexes further. <<See scanned inpatient notes in OMR for progression of physical/neurologic examination during his 1wk stay in the ICU [**9-12**] - [**9-20**]> Pertinent Results: >> [**2141-9-12**] 10:05PM WBC-13.5* RBC-4.86 HGB-15.2 HCT-46.1 MCV-95 MCH-31.3 MCHC-33.0 RDW-14.2 [**2141-9-12**] 10:05PM PLT COUNT-233 [**2141-9-12**] 08:46PM %HbA1c-6.0* eAG-126* [**2141-9-12**] 06:57PM TYPE-ART PO2-333* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-1 [**2141-9-12**] 06:57PM GLUCOSE-139* LACTATE-1.7 NA+-141 K+-4.0 CL--101 [**2141-9-12**] 06:57PM HGB-15.1 calcHCT-45 [**2141-9-12**] 06:57PM freeCa-1.10* [**2141-9-12**] 05:45PM GLUCOSE-116* UREA N-19 CREAT-1.0 SODIUM-140 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 [**2141-9-12**] 05:45PM estGFR-Using this [**2141-9-12**] 05:45PM cTropnT-<0.01 [**2141-9-12**] 05:45PM WBC-14.4* RBC-4.75 HGB-15.1 HCT-45.2 MCV-95 MCH-31.7 MCHC-33.3 RDW-14.1 [**2141-9-12**] 05:45PM NEUTS-86.5* LYMPHS-9.5* MONOS-2.7 EOS-0.9 BASOS-0.4 [**2141-9-12**] 05:45PM PLT COUNT-223 [**2141-9-12**] 05:45PM PT-15.8* PTT-46.5* INR(PT)-1.4* CT brain without contrast on [**2141-9-12**]: IMPRESSION: 1. Hypodensity within left cerebellar hemisphere may reflect acute infarct, although MRI would be more sensitive for this evaluation. 2. Mucosal thickening and air-fluid levels in the sinuses secondary to patient's intubated status. [**2141-9-12**] Conventional angiogram: IMPRESSION: Mr. [**Known firstname 87998**] [**Known lastname **] underwent diagnostic cerebral angiogram, which demonstrated embolic occlusion of the proximal bilateral P2 segments of the posterior cerebral arteries. The basilar artery and left vertebral artery were widely patent at the time of the exam. After discussion with the stroke team, the decision was made to perform intervention with direct intra-arterial injection of TPA and mechanical thrombectomy. Post intervention left vertebral artery angiogram demonstrated widely patent right PCA and partial recanalization of left PCA. Due to failure of angioseal device, direct pressure was necessary for 3-1/2 hours, during which time a large right groin hematoma formed. Vascular surgery was consulted at the beginning of the direct pressure procedure and was made aware of the groin hematoma. The right groin hematoma was stable in size for the last hour and half of the procedure. The patient was taken to the ICU and closely monitored by the ICU staff prior to and after hemostasis. CT brain on [**2142-9-18**]: IMPRESSION: 1. Worsening of obstructive hydrocephalus with complete effacement of the fourth ventricle and interval dilation of the third and lateral ventricles with transependymal flow. 2. Tonsillar herniation. 3. No new hemorrhage identified. Brief Hospital Course: Mr. [**Known lastname **] was thought on admission to our Neurology service (in SICU-B) to have a presentation suggestive of top-of-the-basilar syndrome, most likely due to cardioembolism from AFib and subtherapeutic INR. He was given IV/IA tPA and close neurological monitoring. MRI/DWI confirmed extensive infarction. He was never extubated, and his exam did not improve and although he was producing spontaneous respirations while intubated on a ventilator, his Neurological status, especially his extensive brainstem infarction and poor airway/secretions clearance, did not permit extubation. He was maintained on 3% NaCl IV to minimize intracranial pressure with anticipated brainstem swelling from his extensive posterior circulation infarct and reperfusion after tPA. His family was reluctant to withdraw artificial life support, and a decision re. tracheostomy was delayed. He developed sepsis and hypotension overnight 11/2-3, and became pulseless (PEA arrest) [**9-20**] mid-morning requiring CPR/ACLS as his family had requested that he remain full-code. He was coded (CPR-ACLS) for roughly 30min without return of pulse, and I declared death that morning at 8:58am. The family did not request autopsy. Medications on Admission: Last documented medications: - Warfarin 5mg/7.5 - Flomax 0.4 - Amlodipine 2.5mg - Enalapril 10mg daily - Simcor 500/20 Discharge Medications: died [**2141-9-20**] Discharge Disposition: Expired Discharge Diagnosis: died [**2141-9-20**] in SICU-B with brainstem swelling ([**12-20**] brainstem stroke) and septic shock Discharge Condition: died [**2141-9-20**] Discharge Instructions: n/a (died) Followup Instructions: n/a (died) Completed by:[**2142-3-16**] ICD9 Codes: 2760, 5180, 2724, 4019
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Medical Text: Admission Date: [**2168-7-15**] Discharge Date: [**2168-7-28**] Date of Birth: Sex: M Service: CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: This is a 67 year-old gentleman with a history of heavy smoking, noninsulin dependent diabetes, recently diagnosed large cell lung cancer transferred from OMED Service to the [**Hospital Unit Name 153**] for worsening of respiratory distress. He was initially admitted to the hospital on [**7-15**] to the OMED Service status post right neck wedge biopsy, which revealed large cell lung cancer. He did spike a fever to 101 on [**7-17**], but the chest x-ray was unremarkable and culture was also negative. He was thought to have aspiration events in the setting of over sedation. He received a dose of chemo with Carboplatin and Paxil on [**7-21**]. He tolerated the chemo well, but started to have desaturation episodes with increased O2 requirements. His chest x-ray showed increased bilateral basilar infiltrates with left greater then right. His white count also trended upwards with increased bandemia up to 29%. He was then started on Levofloxacin and Flagyl for possible aspiration pneumonia on [**7-22**]. He remained in NPO in the past two to three days given concern for aspiration. He was transferred to the [**Hospital Unit Name 153**] on [**7-23**] for worsening of hypoxia and impending respiratory failure. PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes mellitus. 2. Status post cataract surgery. 3. Status post left retinal detachment. 4. Status post colonoscopy in [**2167-9-20**], showed positive sigmoid diverticuli. ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Percocet. 2. Glicazidium. SOCIAL HISTORY: Heavy smoking since age 35. FAMILY HISTORY: Mother died of colon cancer at age 85, father died of accident, sister who is in good health at age 55. PHYSICAL EXAMINATION ON TRANSFER TO [**Hospital Unit Name 153**]: Temperature 100.2. Heart rate 120. Blood pressure 100/44 went down to 80/40s. Respirations 28. O2 sat 94% on nonrebreather. General, cachectic elderly man, tachycardic with nonrebreather. Head and neck examination anicteric sclera. Palpable lymphadenopathy bilaterally. Cardiovascular distant heart sounds. Regular rate by pulses. Lungs coarse breath sounds bilaterally. No wheezing. Abdomen soft, nontender, nondistended. Extremities no edema, 1 to 2+ distal pulses. Neurological alert, awake and oriented times three. LABORATORIES ON TRANSFER TO [**Hospital Unit Name 36166**] [**7-23**]: White blood cell count of 15.7, hematocrit 27.2, 23% bands, platelets 430, PT 14.8, PTT 26.3, INR 1.5. Sodium 125, potassium 5.2, chloride 86, bicarb 22, BUN 64, creatinine 1.6 up from baseline of .6 to .8. Glucose 170, albumin 2.6, total bili .5, ALT 27, AST 79, alkaline phosphatase 184, LDH 375. Calcium 7.9, magnesium 1.9, phos 6.0. Amylase 32, lipase 16. Arterial blood gas 7.41, 38, 115 then went down to 7.45, 34 and 77. Sputum four gram stain culture showed 2+ oral flora and on [**7-23**] showed 4+ yeast, 2+ oral flora. Cultures still pending, uric acid 13.5. Blood cultures on [**7-22**] pending. Urinalysis showed negative nitrites, negative leukocyte esterase, 5 red blood cells, no white blood cell, rare bacteria, less then 1 epi. Positive for uric acid crystals. TSH 3.0, cortisol 17. HOSPITAL COURSE: The patient was intubated on the day of transfer to the MICU. He was started on broad antibiotic coverage for sepsis. He remained hypotensive and tachycardic for which he was started on multiple pressors. However, despite aggressive measures the patient continued to deteriorate clinically. After a long discussion with the family and Dr. [**Last Name (STitle) **] the patient's oncologist the decision was made to withdraw care given his extremely poor prognosis. The patient passed away in peace on [**2168-7-28**]. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Sepsis. 3. Acute renal failure. 4. Large cell lung cancer. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], M.D. [**MD Number(1) 8654**] Dictated By:[**Last Name (NamePattern1) 4432**] MEDQUIST36 D: [**2168-8-31**] 11:49 T: [**2168-9-2**] 10:31 JOB#: [**Job Number 36167**] ICD9 Codes: 5070, 5849, 0389, 2765
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Medical Text: Admission Date: [**2140-11-3**] Discharge Date: [**2140-11-7**] Date of Birth: [**2081-3-15**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 59 year-old gentleman with severe triple coronary artery disease, had a positive stress test prior to admission. He was referred for cardiac catheterization. Cardiac catheterization showed a 100% circumflex lesion, 80% RCA blockage, and 80% LAD lesion. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. Status post back surgery [**63**] years ago. 4. Status post bowel surgery as a child. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 milligrams q day. 2. Zestril 20 milligrams q day. 3. Atenolol 50 milligrams q day. 4. Ativan 0.5 milligrams [**Hospital1 **]. 5. Imdur 30 milligrams q day. LABORATORY DATA: He did have preoperative work up done prior to his admission for his cardiac catheterization. PHYSICAL EXAMINATION: He had a negative HEENT exam. No pulmonary symptoms. No cardiac symptoms. He was obese. His blood pressure was 126/86 with a heart rate of 65. He had no carotid bruits. His heart was regular rate and rhythm. His lungs were clear. He had good bowel sounds. His extremities had normal peripheral pulses and no varicosities. HOSPITAL COURSE: This gentleman was to go home and return for his cardiac surgery which was scheduled for [**2140-11-3**]. On [**2140-11-3**] he underwent coronary artery bypass grafting times three with a LIMA to the LAD, a vein graft to the PDA and a radial artery to the OM. He was transferred to the Cardiothoracic ICU in stable condition on a Neo-synephrine drip, nitroglycerin and Propofol. On postoperative day one he had been extubated. His blood pressure was good. He was hemodynamically stable with a pressure of 104/58. He was in sinus rhythm in the 80s. His post extubation gas was good. His hematocrit was 30.9 with a white count of 10.5, platelet count 198,000, sodium 138, potassium 4.8, chloride 107, CO2 25, BUN 12, creatinine 1.2. He was awake and alert. His heart was regular rate and rhythm. His lungs were clear. His sternum was stable with chest tubes in place. His left hand was warm with good sensation and motor function intact and good capillary refill. He remained on Neo-Synephrine and a nitroglycerin for his radial artery. His nitroglycerin was discontinued and he was switched back over the po Imdur and started his Lopressor, Lasix diuresis and aspirin again. He was transferred out to the floor. He was seen by Physical Therapy for evaluation on the floor. On postoperative day two he had some pain issues which were controlled with narcotics. He had positive air leak in his chest tubes. His breath sounds were decreased bilaterally with crackles on the right. His dressings were clean, dry and intact. His sternum had minimal exudate. His heart was regular rate and rhythm. His abdominal exam was negative. Chest films were ordered to evaluate his air leak. He continued his Physical Therapy and rehabilitation on the floor. On postoperative day three he was comfortable, no pain issues. Blood pressure 115/73, heart rate 102, saturation 95% on two liters. He had no air leak but did put out 255 from his chest tube on the day prior. His lungs were clear bilaterally. His abdominal exam was negative. He was doing well and ambulating very well. He had only put out 45 since midnight so his chest tube was discontinued. He continued to work on his ambulation and rehabilitation on the floor. On[**Last Name (STitle) 14810**]perative day five he was doing well. His vital signs were stable. His wires were pulled. His sternum was stable. His Lopressor was increased. He was instructed about Lasix diuresis for approximately one week. He was seen again by Physical Therapy for final evaluation and was discharged to home on [**2140-11-7**] with instructions to follow up with Dr. [**Last Name (Prefixes) 411**] at three to four weeks. DISCHARGE MEDICATIONS: 1. Lopressor 100 milligrams po bid. 2. Lasix 20 milligrams po q day times seven days. 3. K-Dur 20 milliequivalents po q day. 4. Colace 100 milligrams po bid. 5. Zantac 150 milligrams po bid. 6. Aspirin 325 milligrams po q day. 7. Isosorbide 30 milligrams po q day. 8. Nicotine Patch q day. 9. Thiamine 100 milligrams po bid. 10. Multi vitamin 1 tab q day. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass grafting times three. 2. Coronary artery disease. 3. Hypertension. 4. Obesity. 5. Status post back surgery [**63**] years ago. 6. Status post bowel surgery as a child. DISCHARGE CONDITION: The patient was discharged to home in stable condition on [**2140-11-7**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2141-2-1**] 09:42 T: [**2141-2-1**] 10:10 JOB#: [**Job Number 37714**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2169-2-15**] Discharge Date: [**2169-3-3**] Date of Birth: [**2102-1-19**] Sex: M Service: MEDICINE Allergies: Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents Attending:[**Known firstname 1881**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: This is a 67 yom s/p tracheostomy, h/o Pseudomonas/Acineterbacter MDR PNA who is admitted from [**Hospital 100**] Rehab with T 104.6 rectally. Mr. [**Known lastname **] was recently admitted twice to [**Hospital1 18**] MICU green from [**Date range (1) 95399**]/09 and then [**Date range (2) 95402**] for similar system of complaints. During that admission he was initially treated with Vancomycin/Amikaicin and Colistin for treatment of his history of MDR Pneumonia. He was seen by ID during that admission and decision was made to stop amikacin/colistin as his sputum cultures grew only MRSA. He was treated for an MRSA pneumonia and completed his course of Vancomycin on [**2168-2-12**]. Per his wife, Mr. [**Known lastname **] was doing well at the rehab center until yesterday when he [**Known lastname 28316**] to 101 at the rehab center. He was alert yesterday morning and then became more somnolent. She also reports that he stated he was feeling nauseous on monday, no emesis. Per records from [**Hospital 100**] Rehab, Mr. [**Known lastname **] [**Last Name (Titles) 28316**] a temperature to 101.4 on [**2169-2-14**]. He was pancultured. CXR was done which showed no change from CXR from [**2169-2-9**]. PICC line was discontinued and the tip sent for culture. Blood cultures were drawn from the PICC line and from the periphery. Foley was changed and UA, UCx were sent. Sputum culture was sent as well. WBC 18.3, HCT 28.3, PLT 220. Today, Mr. [**Known lastname **] became febrile to 104.6 rectally, with HR 120, BP 118/70 at the rehab center. UA showed > 50 WBC, [**11-24**] RBC, neg nitrite, 3+ Leuk esterase. Midline was placed. He was given Vancomycin 1gm IV x 1, Amikacin 750mg IV x 1. Chem 7 done and showed Cr rise from 1.5 ([**2169-2-12**]) to 3.0 on [**2169-2-15**]. He was sent to [**Hospital1 18**] for further evaluation. In the ED on arrival, VS were Temp 103, HR 108, BP 118/70, RR 16. He was given 3L IVF. UA showed > 50 WBC, Mod Bacteria, +leuks, neg nitrites and Many yeast. Blood Cx sent. CXR showed Mild CHF and bilateral pleural effusions. bibasilar air space opacities likely related to atelectasis. Past Medical History: - [**8-/2168**] fall + subdural hematoma c/by S. bovis endocarditis. Tx 6 weeks ceftriaxone. Course c/by MRSA, Enterococcal thought to be line-related bacteremia. - [**11/2168**] PCN/Vanc sensitive Enterococcal aortic valve endocarditis. Tx 6 weeks vancomycin (pcn allergic) - completed 6 weeks tx [**2168-12-21**]. - [**11/2168**] admit c/by Acinetobacter in sputum (? colonization versus VAP), treated with tobramycin and unasyn (plan was to d/c on [**12-1**]). - [**Date range (3) 95358**], one day after discharge, resp failure, re-intubated. ESBL Klebsiella pna: treated with Meropenem x 12 days. Tracheostomy. Sputum later grew Acinetobacter on [**2168-12-10**] -> unasyn and tobramycin as above. [**Date range (3) 95400**]. DC [**12-16**] on trach mask. - Morbid obesity - DM type 2 poorly controlled with complications - Chronic renal insufficiency (new baseline as of [**12-12**] - Cr 1.6-2) - HTN - reactive airways disease - h/o asbestos exposure with pleural plaques - GERD - Parkinson's disease - detrusor instability - gout - hypothyroidism - aortic stenosis, valve area 0.9cm2, peak gradient 24, median gradient 48 - Anemia - h/o nephrolithiasis Social History: -- has wife, [**Name (NI) **], who is HCP; also with two daughters -- no alcohol or tobacco use -- currently resides at [**Hospital 100**] Rehab -- formerly owned pizzaria restuarants Family History: non-contributory Physical Exam: VS on arival to MICU: T 99.5, HR 106, BP 105/67, RR 23, AC 550/12/5/0.50 General: Mild distress,diaphoretic; obese HEENT: +tracheostomy LUNGS: +mild crackles anterior lung fields CARDIO: +S1/S2, no M/R/G, tachycardic ABD: + BS, NT/ND, obese EXTREMITIES: no c/c. +1 peripheral edema NEURO: responds to verbal stimuli Pertinent Results: [**2169-2-28**] 05:01AM BLOOD WBC-8.9 RBC-2.65* Hgb-7.5* Hct-24.6* MCV-93 MCH-28.4 MCHC-30.6* RDW-15.7* Plt Ct-196 [**2169-2-24**] 03:56AM BLOOD PT-15.6* PTT-39.5* INR(PT)-1.4* [**2169-2-28**] 05:01AM BLOOD Glucose-108* UreaN-96* Creat-3.6* Na-147* K-4.6 Cl-116* HCO3-22 AnGap-14 [**2169-2-24**] 03:56AM BLOOD ALT-19 AST-32 LD(LDH)-263* AlkPhos-81 TotBili-0.2 [**2169-2-28**] 05:01AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.3 [**2169-2-22**] 04:07AM BLOOD Vanco-20.4* Micro: GRAM STAIN (Final [**2169-2-24**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2169-2-27**]): OROPHARYNGEAL FLORA ABSENT. ACINETOBACTER BAUMANNII. HEAVY GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 267-4170W([**2169-2-17**]). PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 32 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 8 I MEROPENEM------------- 8 I PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ <=1 S GRAM STAIN (Final [**2169-2-17**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2169-2-21**]): OROPHARYNGEAL FLORA ABSENT. ACINETOBACTER BAUMANNII COMPLEX. 10,000-100,000 ORGANISMS/ML.. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. STAPH AUREUS COAG +. ~5000/ML. Isolates are considered potential pathogens in amounts >1000 cfu/ml. SENSITIVITIES PERFORMED ON REQUEST.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | PSEUDOMONAS AERUGINOSA | | AMPICILLIN/SULBACTAM-- 16 I CEFEPIME-------------- =>64 R 32 R CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R 2 I GENTAMICIN------------ =>16 R 8 I IMIPENEM-------------- 8 I MEROPENEM------------- 4 S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 32 S TOBRAMYCIN------------ 4 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood Culture, Routine (Final [**2169-2-23**]): [**Female First Name (un) **] ALBICANS. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 267-2475N [**2169-2-15**]. Aerobic Bottle Gram Stain (Final [**2169-2-19**]): YEAST(S). Brief Hospital Course: 67 yom s/p tracheostomy, h/o Pseudomonas/Acineterbacter MDR PNA who is admitted from [**Hospital 100**] Rehab with sepsis, found to have fungemia, Coag neg staph bacteremia as well as Klebsiella UTI. Patient expired peacefully after family decision to make comfort care only. #. Sepsis/Fungemia: The pt had a history of recurrent MDR PNA as well as history of endocarditis. Recent admission with MRSA PNA, completed 14 day course of vancomycin on [**2-12**] now readmitted with fever. Blood cultures with yeast (prelim- C. albicans) and Coagulase negative Staph. Urine cultures with Klebsiella. He was treated with Vanc/Meropenem/caspofungin which was changed to fluconazole and then no therapy once made comfort care only. # Acute on Chronic Renal Failure: Pt with history of AIN from colistin, Cr had improved to 1.5 but then rose. The patient had peristent tube feeds until made comfort measures by the family. Tube feeds were stopped during his comfort course when it became clear that he had limited GI motility. # R UE Pain ?????? Pt developed right wrist pain which was evaluated with x-ray. During the terminal aspect of his care his pain was controlled with Dilaudid. # Right Brachial DVT: RUE with swelling on admission, +brachial DVT on U/S. As this is not proximal, decision was not to treat at this time. # Respiratory Failure: has had a tracheostomy for 2 months. Started on AC but changed back to tracheal mask #. PARKINSON's DISEASE: Continued Sinemet and Ropinirole. #. HYPOTHYROIDISM: Levothyroxine 88 mcg continued until made comfort care when stopped. . #. ANEMIA: Hx of chronic anemia. Received 2uPRBC on admission Medications on Admission: Albuterol Neb q4h ASA 81mg Calcium Carb 650mg [**Hospital1 **] Carbidopa/levodopa QID Chlorhexadine 12mg [**Hospital1 **] Vit D 1000u daily Docusate 100mg [**Hospital1 **] Ferrous Sulfate 325mg [**Hospital1 **] Lantus 30u SQ qHS HISS Levothyroxine 88mcg daily Omeprazole 20mg daily Ropinirole 1mg QID Senna [**Hospital1 **] Simvastatin 10mg qHS Vancomycin 1gm IV [**2169-2-14**] at 2200 Amikacin 750mg IV x 1 [**2169-2-15**] 0100 Discharge Disposition: Expired Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Parkinson's Disease Fungemia Discharge Condition: Patient expired [**Known firstname **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**] ICD9 Codes: 5990, 5849, 2930, 2760, 5859, 4241, 2749, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2457 }
Medical Text: Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-15**] Date of Birth: [**2057-7-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old woman with a past medical history significant for coronary artery disease, status post coronary artery bypass graft in [**2115**], hypertension and elevated cholesterol who presented on [**2133-5-28**] with burning epigastric pain. This was originally thought to be cardiac ischemia and the patient was taken to cardiac catheterization and found to have patent vein grafts. Laboratory studies then revealed that the patient had pancreatitis with an amylase of approximately 3300. The patient was intubated somewhat prophylactically in the catheter lab and then admitted to the Medical Intensive Care Unit. The Medical Intensive Care Unit course was complicated by hypotension. The patient was on dopamine transiently, which was thought to secondary to a gastrointestinal infection. She was anemic to 24 and received multiple units of packed red blood cells. She also began to spike some temperatures on [**2133-6-1**], despite being on antibiotics and continued to have fevers up until her transfer to the floor. The patient was covered with ceftriaxone and clindamycin initially for a multilobar vent associated pneumonia. Sputum grew out Serratia which was sensitive to ceftriaxone. The patient was ultimately transitioned from clindamycin to Flagyl in part because there was concern that the patient might have Clostridium difficile colitis. Flagyl was ultimately discontinued after the patient had three negative Clostridium difficile cultures. The patient also had some transient oliguria, presumably from fluid sequestration while in the Intensive Care Unit. Over the course of her Medical Intensive Care Unit stay, she became approximately 10 liters positive. Her liver function tests, amylase and lipase decreased to normal and the patient improved clinically an was extubated on [**2133-6-9**] and transferred that day to the general wards. The patient currently denies any shortness of breath, chest pain or abdominal pain. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft performed at [**Hospital1 2025**] 15 years ago with a diagonal to LAD graft and saphenous vein graft to PDA graft. 2. Hypertension 3. Elevated cholesterol 4. Question history of chronic obstructive pulmonary disease HOME MEDICATIONS (to be confirmed by her primary care physician): 1. Aspirin 2. Atenolol 3. Lipitor 4. Hydrochlorothiazide 5. Vasotec TRANSFER TO FLOOR MEDICATIONS FROM MEDICAL INTENSIVE CARE UNIT: [**Unit Number **]. Regular insulin sliding scale 2. Protonix 40 mg intravenous q 24 hours 3. Ceftriaxone 1 gm intravenous q 24 hours 4. Miconazole cream 5. Flagyl 500 mg intravenous q 8 hours 6. Lopressor 10 mg intravenous q6h 7. Nitroglycerin drip for which the patient was currently being weaned off. ALLERGIES: No known drug allergies. PHYSICAL EXAM AT TRANSFER TO THE GENERAL FLOOR: VITAL SIGNS: Temperature 98.8??????, pulse 90, blood pressure 169/84, respiratory rate 20s, pulse oximetry 98% to 99% on a shelf mask. GENERAL APPEARANCE: The patient was awake, alert and mildly uncomfortable, appearing in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Dry oral mucosa, no oral lesions. NECK: Jugular venous pressure was prominent. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no murmurs. LUNGS: Bilateral rales and crackles. There were no wheezes. Breath sounds were decreased at the bases bilaterally. ABDOMEN: Soft, nontender, nondistended with active bowel sounds. EXTREMITIES: The patient complained of left wrist pain which later resolved after re-siting of the patient's peripheral intravenous. NEUROLOGIC: The patient moved all four extremities and followed commands. IMAGING AND LABORATORY STUDIES ON [**2133-6-10**]: White blood count 20.1, hematocrit 32.6, platelets 636. INR 1.2, sodium 145, potassium 3.3, chloride 106, bicarbonate 26, BUN 32, creatinine 0.6, glucose 136. The patient had a prior echocardiogram which showed a normal ejection fraction of 61% with posterobasal wall motion abnormalities, normal filling pressures on cardiac catheterization of [**2133-5-28**]. In addition to sputum culture on [**2133-6-6**] revealing Serratia sensitive to ceftriaxone, urine cultures on [**2133-6-8**] revealed greater than 100,000 organisms per ml of yeast. In response to this culture result, the patient's Foley catheter was discontinued and replaced. HOSPITAL COURSE BY SYSTEM: 1. INFECTIOUS DISEASE: The patient ultimately presented to the Intensive Care Unit intubated with evidence of a vent associated pneumonia. Sputum cultures were positive for Serratia, sensitive to ceftriaxone for which the patient received a 14 day course of antibiotics. The patient was temporarily on anaerobic coverage for question of aspiration pneumonia, as well as for question of Clostridium difficile colitis. The patient gradually defervesced on antibiotics and her respiratory status improved substantially to the point where she was saturating 95% on room air by the time of discharge. The patient continued to have bilateral crackles which were thought to be consistent with some underlying interstitial lung disease which will be confirmed with her primary care physician prior to discharge. Regarding the question of Clostridium difficile, the patient had three negative cultures and was taken off Flagyl following her transfer to the floor. The patient's only other infectious issue was a question of a sinusitis, given recurrent fevers on antibiotics and the patient's history of having a nasogastric tube in place while she was in the Intensive Care Unit. CT of the sinuses did reveal some paranasal sinus thickening and partial opacification of the mastoid air cells. Given that the patient was essentially afebrile following her transfer to the floor, she was taken off of Flagyl and this etiology was not further pursued. We did hesitate to place an additional nasogastric tube for feeding purposes given this result. 2. GASTROINTESTINAL: Patient with presumed gallstone pancreatitis resolved by the time of her transfer to the floor. Her amylase and liver function tests had essentially returned to baseline. The patient received TPN for nutrition while in the Intensive Care Unit. Please see the nutrition section for further details. The patient denied any abdominal pain through the remainder of her hospital stay and tolerated her advanced diet. 3. CARDIOVASCULAR: The patient with a history of hypertension by report. As she was unable to take po's, she relied on intravenous Lopressor and hydralazine for blood pressure control. After she was started back on po's, she was put on po Lopressor, po hydralazine and po Vasotec. The doses of these will be confirmed with her primary care physician and noted in page 1. The patient also with a history of coronary artery disease. She underwent a cardiac catheterization when she was admitted thinking that her symptoms were related to cardiac ischemia. This study revealed patent grafts. She has an intact ejection fraction with some posterobasal wall motion abnormality as noted on recent cardiac echocardiogram. During her course on the floor, the patient was gently diuresed to keep her 500 cc to 1 liter negative per day, given the fact that she was 10 liters positive and seemed to mobilizing a lot of fluid following her extubation in the Medical Intensive Care Unit. The patient was noted to have some short runs of supraventricular tachycardia for which she was asymptomatic while in the Intensive Care Unit. She was kept in telemetry during her floor course for further monitoring. 4. ENDOCRINE: Patient with slightly elevated blood sugars while on TPN. Her sugars were followed as we returned her to her regular diet. She had no known history of diabetes. 5. NUTRITION: The patient relied on TPN while in the Medical Intensive Care Unit. She failed a swallowing study upon her return to the floor and was continued on TPN for several days. A repeat swallowing study on [**2133-6-15**] revealed good tolerance of po's. She was subsequently taken off of TPN and her diet gradually advanced. 6. HEMATOLOGICAL: The patient was anemic requiring transfusion in the setting of her Intensive Care Unit presentation. 7. ORTHOPEDICS: The patient initially complained of some left wrist pain while in the Intensive Care Unit. She had negative wrist x-rays. After resetting of her intravenous, she exhibited full range of motion without pain of that extremity. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSIS: 1. Coronary artery disease with a history of coronary artery bypass grafts x2 2. Hypertension 3. Pancreatitis 4. Serratia pneumonia 5. Interstitial lung disease DISCHARGE MEDICATIONS: Please see page 1 for full details. 1. Enteric coated aspirin 325 mg po qd 2. Protonix 40 mg po qd 3. Hydralazine 25 mg po tid 4. Lopressor 25 mg po bid 5. Lipitor 10 mg po qd 6. Vasotec dose to be confirmed by her primary care physician 7. Albuterol metered dose inhaler 2 puffs q 4 to 6 hours prn. DISCHARGE INSTRUCTIONS: At rehabilitation, the patient should receive physical therapy and occupational therapy. She should have pulmonary toilet as necessary. She should have outpatient follow up schedule with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42281**], whose phone number is ([**Telephone/Fax (1) 42282**]. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern4) 4689**] MEDQUIST36 D: [**2133-6-16**] 07:25 T: [**2133-6-16**] 07:34 JOB#: [**Job Number 42283**] ICD9 Codes: 5070, 2859, 4589
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Medical Text: Admission Date: [**2123-4-7**] Discharge Date: [**2123-5-11**] Date of Birth: [**2044-2-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Loose stools and fevers Major Surgical or Invasive Procedure: [**2123-4-8**] right chest tube (pleurex tube) [**2123-4-13**] ERCP [**2123-4-15**] removal of pleurex tube and insertion of pigtail catheter [**2123-4-30**] Right-sided pigtail catheter drainage [**2123-5-4**] Talc pleurodesis right lung [**2123-5-7**] ERCP History of Present Illness: 79F s/p segment VII resection of metastatic colon CA to liver ([**3-1**]). Was here to have pleurex catheter placed but was having abdominal pain, fevers, and nausea and was sent to the ED. She reports passing flatus and stool. Past Medical History: Past Medical History: Bipolar HTN Past Surgical History; TAH Appendectomy Social History: Married, lives with husband and son, drinks one glass of wine per day, former smoker Family History: Non-contributory Physical Exam: In ED 97.4, 94, 86/54 to 149/71 96% 3L NC NAD RRR decreased Breath sounds in bases R>L Abdomen soft, obese, nondistended, no tympany, Midline incision inferior to umbilicus well healed with 2 small incisional hernias. Bowel easily reducible. EXT: warm and dry Pertinent Results: JP drain fluid GRAM STAIN (Final [**2123-4-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. [**2123-4-7**] 12:05PM BLOOD WBC-19.7*# RBC-4.20 Hgb-11.5* Hct-35.2* MCV-84 MCH-27.4 MCHC-32.7 RDW-14.1 Plt Ct-316# [**2123-4-7**] 12:05PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.4* Monos-2.0 Eos-0.1 Baso-0.1 [**2123-4-8**] 08:40AM BLOOD PT-16.1* PTT-28.2 INR(PT)-1.4* [**2123-4-8**] 05:30AM BLOOD Glucose-106* UreaN-14 Creat-1.1 Na-135 K-3.9 Cl-101 HCO3-27 AnGap-11 [**2123-4-7**] 12:05PM BLOOD ALT-15 AST-24 AlkPhos-156* TotBili-0.4 [**2123-4-8**] 05:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 [**2123-4-7**] 12:17PM BLOOD Lactate-2.9* [**4-7**] CT chest/abd/pelvis IMPRESSION: 1. Dilated loops of small bowel up to 3.5 cm, with air-fluid levels, and transition point in small ventral hernia in the midline lower abdomen, after which bowel loops are decompressed, and contain no oral contrast. This appearance is concerning for small-bowel obstruction, although the presence of gas within the colon and rectum suggests that it may be an early obstruction, or a partial obstruction. 2. Heterogeneous 6.3 x 2.5 cm fluid collection posterior to the right hepatectomy resection margin could represent post-surgical change and material such as Surgicel, although it is difficult to exclude abscess formation. 3. Increased size of multiple hypodense lesions within the liver concerning for progression of metastatic disease. 4. Unchanged appearance of ill-defined hypodense lesion within the spleen. This lesion was characterized by MRI from [**2123-1-10**] as having features suggestive of a lymphangioma. 5. Large right pleural effusion and right lower lobe atelectasis Small left pleural effusion. 6. Small-volume ascites. . Labs at discharge: [**2123-5-8**] WBC-8.4 RBC-4.27 Hgb-11.6* Hct-36.5 MCV-85 MCH-27.1 MCHC-31.8 RDW-14.4 Plt Ct-298 Glucose-99 UreaN-10 Creat-0.7 Na-144 K-3.7 Cl-104 HCO3-33* AnGap-11 ALT-14 AST-20 AlkPhos-111 Amylase-35 TotBili-0.4 Albumin-2.5* Brief Hospital Course: Patient was seen in ED and admitted to General Surgery service. IV cipro and flagyl was started, an NGT and Foley were placed, and she was kept NPO with IVF. An abdominal CT was done showing dilated loops of small bowel up to 3.5 cm, with air-fluid levels. Point of obstruction appeared to be a ventral hernia in the lower abdominal wall. A heterogeneous 6.3 x 2.5 cm fluid collection posterior to the right hepatectomy resection was noted. There was increased size of multiple hypodense lesions within the liver concerning for progression of metastatic disease and small-volume ascites. A large right pleural effusion and right lower lobe atelectasis with a small left pleural effusion was noted. . Interventional pulmonology was contact[**Name (NI) **] and on [**Name (NI) 58274**] a right pleurex catheter was placed and attached to a pleuravac and suction. This initially drained ~ one liter of straw colored fluid. She remained on O2 nasal cannula with diminished breath sounds in the lower lobes. On [**4-13**], 700cc of serous fluid was removed from the pleurx tube. The pleurx catheter was removed on [**4-14**] due to persistent leaking at the connection site to the pleuravac. A right pleural 14 french pigtail catheter was placed at the 5th ICS. The pigtail was connected to a pleuravac. On [**2123-5-4**] a talc pleuradesis was performed on her right lung with follow-up CXRs with no PTX and stable pleural effusion. She remains on O2 via nasal cannula. O2 sats drop into high 80's when ambulating, she remains asymptomatic. Most recent Chest xray on [**5-7**] shows: the bilateral moderate pleural effusions are unchanged with associated right lower lobe atelectasis. . On [**4-9**], the NG tube was removed. Diet was advanced slowly and tolerated. LFTs remained stable as well as chemistries. . The JP continued to drain bilious fluid. This fluid was cultured and grew two species of E.coli resistent to ampicillin and cipro, but sensitive to Bactrim. Therefore, Bactrim DS [**Hospital1 **] was started on [**4-11**]. The JP drainage averaged approximately 70cc/day. On [**4-13**], ERCP was performed noting bile leak. Sphincterotomy was done with stent placement. Post ERCP, the JP drainage decreased to ~ 30cc/day. WBC was 17 on admission with downward trend to 11. She had a second ERCP on [**5-7**] and she had a stent exchanged. She will remain on Bactrim on discharge. The JP drain remians in place. . She had a UTI with a resistant strain of E coli. She received 10 days of Meropenem IV. There was also concern for urinary retention. She should be encouraged for frequent toileting and bladder training. Urine culture from [**5-4**] was no growth. A surveillance culture was sent on [**5-11**] prior to discharge and should be followed up as an outpatient. . Dr.[**Name (NI) 3377**] team was consulted regarding possibility of repairing ventral hernia. Given bile leak, infection and effusion repair was deferred at this time. . PT/OT evaluated her. She was safe to transfer and ambulate with nursing, but continued to require PT. The plan was for her to go to rehab facility for further rehab, as she is requiring assistive devices and has increased O2 requirements with activity. Medications on Admission: atenolol 50', lasix 20', keppra 500", risperidol 1.5', mvi', folic acid' Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: abdominal pain right pleural effusion UTI Bile leak Discharge Condition: Stable Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever >101, chills, nausea, vomiting, abdominal distension or increased abdominal pain, jaundice, shortness of breath, Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 673**] [**2123-5-19**] 2:00 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**] 11:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**] 11:30 ERCP 2 (ST-4) GI ROOMS Date/Time:[**2123-7-20**] 4:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2123-5-11**] ICD9 Codes: 5119, 5180, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2459 }
Medical Text: Admission Date: [**2177-3-29**] Discharge Date: [**2177-4-5**] Date of Birth: [**2104-1-22**] Sex: M Service: C-MEDICINE CHIEF COMPLAINT: Dyspnea. HISTORY OF PRESENT ILLNESS: This is a 73 year old African American male diagnosed with congestive heart failure in [**11-9**], who presents with sudden fatigue, weakness and dyspnea while bringing out his trash. The patient felt well until the morning of admission and was brought to the [**Hospital1 346**] Emergency Department by ambulance. In the Emergency Department, the patient was asymptomatic and denied previous oxygen requirement or lower extremity edema. He has been compliant with his congestive heart failure medication including low sodium diet and daily weights. He states that he is without symptoms at this time. In the Emergency Department, he was noted to have atrial flutter with heart rate 120 to 130 with mild hypotension. Due to his abrupt symptoms, the patient underwent VQ scan which indicated low probability for pulmonary embolus. Review of systems was negative for fever, chills, upper respiratory infection symptoms, chest pain, positive for shortness of breath, negative for nausea, vomiting, diaphoresis or abdominal pain. PAST MEDICAL HISTORY: 1. Congestive heart failure diagnosed in [**11-9**]. Catheterization at that time was negative except for apical and septal akinesis, ejection fraction noted to be 12%. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus which is diet controlled. 4. Prostate cancer, status post prostatectomy. 5. ? multiple myeloma. 6. Hernia, status post herniorrhaphy. 7. Keloid scars. 8. Status post bilateral total knee replacement. 9. Carpal tunnel syndrome. 10. Prolapsed rectum. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Univasc 15 mg p.o. q.d. 2. Norvasc 10 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Lasix 20 mg p.o. q.d. 5. Carvedilol 3.125 mg p.o. b.i.d. SOCIAL HISTORY: The patient has a history of alcohol use. He also has a history of tobacco use approximately one pack per day for thirty-five to forty years, but quit twenty years ago. FAMILY HISTORY: Mother died of myocardial infarction at age 80. Brother died of diabetes mellitus in his 30s and sister died of diabetes mellitus/systemic lupus erythematosus in her 50s. PHYSICAL EXAMINATION: Vital signs revealed temperature of 96.5, blood pressure 122/70, pulse 113, respiratory rate 20, oxygen saturation 97% on three liters, weight 74.5 kilograms. In general, this is a moderately obese African American male lying in bed in no acute distress. Extraocular movements are intact. Anicteric sclera. Mucous membranes are moist. No lymphadenopathy. No jugular venous distention. Cardiovascular - the heart rate was fast but regular, no murmurs, rubs or gallops. The lungs are clear to auscultation bilaterally. The abdomen revealed normoactive bowel sounds, nontender, nondistended, no masses. Extremities - no cyanosis, clubbing or edema, no swelling, good dorsalis pedis and posterior tibial pulses. LABORATORY DATA: On admission, white count was 10.1, hematocrit 38, platelets 276,000. Prothrombin time 14.2, partial thromboplastin time 28.0, INR 1.4. Chem7 showed a sodium of 140, potassium 4.7, chloride 105, bicarbonate 25, blood urea nitrogen 46, creatinine 1.9, blood sugar 175, calcium 9.5. Electrocardiogram showed normal axis, wide QRS with possible Q waves in V1 through V3 with poor R wave progression. There is right bundle branch block. HOSPITAL COURSE: 1. Cardiovascular - atrial flutter - The patient was started on Heparin in the Emergency Department and underwent transesophageal echocardiogram on [**2177-3-31**], which showed the following: dilated left atrium with no spontaneous echocardiographic contrast seen in the body of the left atrium or left atrial appendage with markedly reduced left atrial appendage emptying. There were two mobile echogenic masses seen in the left atrial appendage on multiple views consistent with probable thrombus. There was also severe global left ventricular hypokinesis with right ventricular systolic function appearing depressed. There are small echogenic masses on the ventricular surface of the aortic valve. Mitral regurgitation 1+ was seen. At that time, direct cardioversion was held secondary to the possibility of emboli/clot. That night, the patient was noted to have hypotension to the 70s to 80s which was moderately responsive to intravenous fluids. It was thought secondary to poor atrial kick and decompensation of the heart. The following morning the patient underwent atrial flutter ablation with mild improvement of systolic blood pressure to 90s. The patient continued to have poor response to intravenous fluids with poor urine output. Creatinine was noted to be increased from 2.1 on [**2177-4-1**], to 2.5 on [**2177-4-2**]. At that time, he was transferred to the CCU for intravenous Dopamine for improvement of pressure and diuresed with Lasix drip. Right IJ and right arterial line were introduced at that time. Pulmonary artery catheter was introduced as well noting introductory pressures of the following: right atrial pressure 16 with pulmonary artery pressure of 47/32 with a wedge of 32, cardiac index 2.21 and SVR 1200. He was started on Dopamine with approximate 6.3 liters diuresis after Lasix drip. Wedge decreased to 22 to 23 with cardiac output increased to 6.0 and cardiac index improved to 2.5. The patient was gradually weaned off Lasix drip and placed on p.o. Lasix b.i.d. Dopamine was weaned off on [**2177-4-3**]. On [**2177-4-4**], the patient was transferred back to the floor for further management. That night, Carvedilol was restarted with good effect. 2. Renal - The patient was noted to have times of prerenal, acute renal failure on [**2177-3-31**], at admission with blood urea nitrogen and creatinine both increased. He was given mild intravenous fluids with worsening of creatinine the following day. On [**2177-4-2**], creatinine was noted to be 2.5 with potassium 5.4. He was given Kayexalate to improve his hyperkalemia. Urine electrolytes noted prerenal defect with FENA of 0.21%. At that time, he was transferred to the CCU for Lasix drip and severe diuresis. Blood urea nitrogen and creatinine were noted to be improved. Creatinine on [**2177-4-4**], was noted to be 1.4 which is almost back to baseline. 3. Hematology - The patient was noted to have hematocrit of 38.0 on admission which has decreased after every procedure. Hematocrit on [**2177-4-4**], was noted to be 28.5. Analysis and iron study laboratories were sent off. Heparin and Coumadin were continued for left atrial thrombus and to prevent embolization. DISPOSITION: The patient will likely be discharged home on [**2177-4-5**]. He will follow-up with Dr. [**Last Name (STitle) **] in approximately two to three weeks in Advanced [**Hospital **] Clinic. MEDICATIONS ON DISCHARGE: 1. Lovenox 60 mg subcutaneous b.i.d. 2. Amiodarone 400 mg p.o. q.d. times three months and then switch to 200 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Coreg 3.125 mg b.i.d. 5. Enalapril 2.5 mg p.o. b.i.d. 6. Lasix 40 mg p.o. b.i.d. 7. Coumadin 5 mg p.o. q.d. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. New atrial flutter, status post ablation. 2. Congestive heart failure. 3. Hypertension. 4. Noninsulin dependent diabetes mellitus. 5. Prostate cancer. 6. Herniorrhaphy. 7. Keloid scar. 8. Bilateral total knee replacement. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2177-4-4**] 13:26 T: [**2177-4-5**] 09:27 JOB#: [**Job Number 96473**] ICD9 Codes: 4280, 5849, 4254, 4019
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Medical Text: Admission Date: [**2192-8-9**] Discharge Date: [**2192-9-4**] Date of Birth: [**2125-2-14**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: I am here for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: 67M with no significant past medical history who noted enlarged groin lymph nodes several weeks ago. One of these was excised and while the pathology was pending he became quite ill. He vomited 5 days ago and was noted to be jaundiced by his wife. [**Name (NI) **] was then admitted to [**Hospital6 33**] for liver and renal failure. The pathology on his inguinal node is diffuse large B-cell lymphoma. He was transferred here for further evaluation and treatment. His most recent bilirubin is 21, Cr 2.6, LDH 2500. Past Medical History: Hypertension Social History: Married and lives with his wife, worked at [**Location (un) **] air base, now retired. Stopped smoking in [**2147**], occasional EtOH. Family History: Mother with hx unknown cancer, father with heart disease. Physical Exam: Vitals: T:99.5 BP:126/60 P:101 R:38 O2: 95% 2L General: Alert, oriented, no acute distress, jaundiced HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs [**2192-8-9**] 07:24PM GLUCOSE-129* UREA N-55* CREAT-2.4* SODIUM-127* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-16* ANION GAP-19 [**2192-8-9**] 07:24PM estGFR-Using this [**2192-8-9**] 07:24PM ALT(SGPT)-85* AST(SGOT)-264* LD(LDH)-2448* ALK PHOS-820* TOT BILI-23.7* DIR BILI-18.9* INDIR BIL-4.8 [**2192-8-9**] 07:24PM ALBUMIN-2.2* CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.9* URIC ACID-4.3 [**2192-8-9**] 07:24PM PT-19.4* PTT-33.2 INR(PT)-1.8* [**2192-8-9**] 07:24PM FIBRINOGE-532* [**2192-8-9**] 07:14PM WBC-11.5* RBC-3.43* HGB-10.5* HCT-31.4* MCV-92 MCH-30.5 MCHC-33.4 RDW-18.2* [**2192-8-9**] 07:14PM NEUTS-80* BANDS-0 LYMPHS-13* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3* [**2192-8-9**] 07:14PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL [**2192-8-9**] 07:14PM PLT SMR-LOW PLT COUNT-144* [**2192-8-9**] 07:12PM TYPE-ART PO2-96 PCO2-26* PH-7.42 TOTAL CO2-17* BASE XS--5 [**2192-8-9**] 07:12PM LACTATE-4.8* K+-4.0 [**2192-8-9**] 07:12PM freeCa-1.01* . Discharge labs . [**2192-9-4**] 12:00AM BLOOD WBC-8.5 RBC-2.51* Hgb-8.3* Hct-24.2* MCV-97 MCH-33.0* MCHC-34.1 RDW-24.1* Plt Ct-138* [**2192-9-4**] 12:00AM BLOOD Neuts-96.3* Lymphs-1.4* Monos-1.7* Eos-0.6 Baso-0.1 [**2192-9-4**] 12:00AM BLOOD PT-12.2 PTT-19.8* INR(PT)-1.0 [**2192-9-2**] 12:22AM BLOOD Fibrino-423* [**2192-8-27**] 12:00AM BLOOD Gran Ct-3698 [**2192-9-4**] 12:00AM BLOOD Glucose-309* UreaN-33* Creat-0.8 Na-135 K-4.0 Cl-100 HCO3-24 AnGap-15 [**2192-9-4**] 12:00AM BLOOD ALT-64* AST-30 AlkPhos-213* TotBili-2.7* [**2192-9-4**] 12:00AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9 [**2192-8-18**] 12:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE [**2192-8-18**] 03:27PM BLOOD Smooth-NEGATIVE [**2192-8-18**] 03:27PM BLOOD [**Doctor First Name **]-NEGATIVE [**2192-8-19**] 12:05AM BLOOD HIV Ab-NEGATIVE [**2192-8-18**] 12:30AM BLOOD HCV Ab-NEGATIVE [**2192-8-21**] 12:00AM BLOOD ANTI-PLATELET ANTIBODY-TEST . CXR [**2192-8-25**] Right internal jugular line tip is at the level of cavoatrial junction. The heart size is normal. Mediastinum is normal. There is slight interval decrease in the right pleural effusion as compared to [**2192-8-10**]. There are no new focal consolidations worrisome for infectious process. There is no evidence of failure. If clinically warranted, further evaluation with cross-sectional imaging toexclude the possibility of occult infection. . ECG [**2192-8-25**] Sinus tachycardia, rate 131. Moderate baseline artifact. Consider left atrial abnormality. Late transition. No previous tracing available for comparison. . ECHO [**2192-8-20**] The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Small LV cavity size with moderate symmetric LVH and hyperdynamic LV systolic function. Consequently, there is an intra-cavitary gradient which likely occurs at the mid-ventricular level.. Mildly thickened mitral and aortic valves without significant stenosis or regurgitation. . CT TORSO [**2192-8-12**] contrast IMPRESSION: 1. Moderate right pleural effusion, and small left pleural effusion, and bibasilar atelectasis, worse on the right. 2. Bilateral prominent axillary lymph nodes, and prominent hilar and mediastinal lymph nodes. 3. Multiple liver hypodensity, suboptimally characterized due to size and single-phase contrast. 4. Splenic hypodensities concerning for splenic lymphoma involvement, or splenic infarct. 5. Large lymph nodes in periportal area. 6. Multiple prominent lymph nodes in mesentery and retroperitoneum and along pancreas and splenic hilum. 7. Bilateral prominent lymph nodes in inguinal and groin area. 8. Small amount of ascites. 9. Right groin fluid collection, could be evolving hematoma, seroma, or lypmhocele. Correlate if history of recent biopsy/intervention in area. . Abdomen U/S [**2192-8-10**] 1. Diffusely increased hepatic echogenicity with multiple hypoechoic masses scattered throughout the liver. This appearance is highly suspicious for malignancy. Further characterization of these findings with MR imaging is recommended. 2. Multiple enlarged periportal lymph nodes as described. 3. Mild splenomegaly. Please note that a large left abdominal mass mentioned in the history was not identified with ultrasound and further evaluation could be obtained with CT if clinically indicated. 4. Gallstones along with gallbladder sludge. No intra- or extra-hepatic biliary duct dilation. 5. Small right pleural effusion. . CXR [**2192-8-10**] The right central venous line tip was repositioned and is currently at the low SVC. There is slight interval increase in bilateral pleural effusions in the interim. Mild vascular engorgement cannot be excluded. Mediastinal widening in particular along the right paratracheal area at the level of the azygos vein as well as at the aortopulmonic window is unchanged and most likely consistent with diagnosis of B-cell lymphoma. Brief Hospital Course: # Diffuse B-cell lymphoma: Mr [**Name13 (STitle) 11752**] was admitted with newly diagnosed diffuse large B-cell non-Hodgkin's lymphoma. He received dexamethasone and mechlorethamine while in the ICU on [**2192-8-10**]. His dexamethasone was changed to daily solumedrol upon return to the floor [**2192-8-11**]. A CT of his torso to evaluate the burden of his disease revelaed extensive para-aortic and hilar lymphadenopathy and intrahepatic involvement. Rituxan was initiated on [**8-14**] to decrease his tumor burden and was repeated on [**8-17**]. Tumor lysis labs were followed and Mr. [**Name13 (STitle) 11752**] was continued on allopurinol therapy. The initiation of standard therapy could not be initiated until his liver function improved. His AST and ALT eventually normalized, however his total bilirubin took longer to normalize. The goal to initiate therapy was a total bilirubin of 2, so as to not compromise standard therapy of R-CHOP through significant re-dosing. On [**2192-8-31**], it appeared that Mr. [**Name13 (STitle) 87096**] total bilirubin had plateaued at 3. Mechlorethamine was administered, 10mg twice over two days. Mr. [**Name13 (STitle) 87096**] tolerated the therapy well, he was treated with 5 days of high dose steroids after chemotherapy and experienced a slight increase in LFTs likely as a result of the therapy. As Mr. [**Name13 (STitle) 87096**] was clinically stable, it was decided to discharge him to home with regular follow-up for evaluation for future care. . # Acute Kidney Injury: Mr. [**Initials (NamePattern4) 87096**] [**Last Name (NamePattern4) **] was likely prerenal. He was transferred to the ICU briefly after admission secondary to tachypnea likely from metabolic acidosis. His [**Last Name (un) **] resolved with IV fluids and he was transferred back to the floor. . # Hepatic failure: He was noted to have elevated liver enzymes with LDH of 2400 and T. Bili of 24.0 on admission. His liver function tests continued to rise throughout his admission, maximally elevated at ALT 128 and AST 264 with peak LDH 2448, maximal Alkphos of 833 and total bilirubin of 26.3. His cholestatic liver disease began to improve on HD 6. Rituxan was initiated on [**8-14**] and [**8-17**]. Mr. [**Name13 (STitle) 87096**] encephalopathy improved throughout his hospital stay. He was clinically at baseline at the time of discharge. . # Urinary Tract Infection: Mr. [**Known lastname 16968**] began to develop symptoms of dysuria on HD 5. A urine culture grew coagulase negative staph aureas and Mr. [**Known lastname 16968**] was started on PO ciprofloxacin. Mr. [**Name13 (STitle) 87096**] foley catheter was not removed or replaced at this time, because of significant edema, ongoing chemotherapy and the need to follow urine out-put during chemotherapy. On Day 2, ciprofloxacin was changed to IV given Mr. [**Name13 (STitle) 87096**] bowel edema to ensure adequate therapy. . # Edema: Mr. [**Name13 (STitle) 87096**] was admitted to the hospital with significant edema that initially worsened throughout his stay. Evidence of bowel edema and mild ascities on CT. He responded well to IV Lasix. His edema was significantly improved at the time of discharge. . # Right Inguinal Node Biopsy Site: Mr. [**Name13 (STitle) 87096**] developed poor wound healing at the site of his lymph node biopsy at an OSH. The bx site was deep between skin folds. Evidence of a hematoma or seroma was visualized on CT. General Surgery was consulted to examine the wound, antibiotic therapy was deferred and wet to dry dressing was applied three times a day. Wound culture grew MRSA, he was treated for several days with IV Daptomycin, as Mr. [**Known lastname 16968**] reportedly has a vancomycin allergy, which was discontinued as the culture appeared more consistent with a contaminant. A wound vacuum was applied for almost a week to help with wound healing. The vacuum was discontinued prior to discharge. Mr. [**Known lastname 16968**] was discharged to home with nursing assistance to continue dressing changes. Medications on Admission: Zofran 4 mg IV q 4 PRN Dilaudid 1 mg IV q 4 prn Reglan 5 mg TID Lovenox 30 mg q day Protonix 40 mg q 12 IV Levaquin 500 Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for groin skin changes. Disp:*1 Bottle* Refills:*0* 4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*120 Tablet(s)* Refills:*2* 5. Prednisone 5 mg Tablets, Dose Pack Sig: 4-1 Tablets, Dose Packs PO once a day for 3 days: Take 4 pills on day 1 ([**2192-9-5**]), take 2 pills on day 2 ([**2192-9-6**]) and take 1 pill on day 3 ([**2192-9-7**]). Disp:*7 Tablets, Dose Pack(s)* Refills:*0* 6. Outpatient Physical Therapy 67 year old gentleman with new diagnosis large B cell lymphoma with de-conditioning after a long hospital stay. 7. Neupogen 480 mcg/1.6 mL Solution Sig: One (1) Injection once a day for 10 days. Disp:*10 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: 1. Large B Cell Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for initiation of treatment of Large B Cell Lymphoma. Your liver function was affected by the lymphoma preventing standard treatment, which requires normal liver function. You were given special chemotherapy treatments (Mechlorethamine and Rituxan) to help restore your liver function in hopes of initiating standard treatment. Your treatment course was complicated by kidney failure, that required several days in the intensive care unit. Your kidney is now functioning normally. Your oncologist is Dr. [**First Name (STitle) **], who is the physician who admitted you. You will follow up in clinic on Friday [**2192-9-7**] to check your blood counts and receive a third dose of Rituxan. You have been started on a new medication, Neupogen, on the day of your discharge to help with your counts. You also developed a wound at the site of your lymph node biopsy. Our general surgeons were consulted. They treated the wound with a vacuum and eventually wet-to-dry dressing. A home nursing aid will change your dressing daily. You were started on several medications during your hospital stay, that people with lymphoma often take during treatment. Please continue taking the allopurinol, ursodiol and acyclovir as directed. Your blood sugars have been high for the last several days because of the high dose steroids you received over the weekend with the chemotherapy. We expect your blood sugars to return to normal on their own. Your home nursing aid will check your blood sugars for you. We are also sending you home on a steroid taper to ease yourself off prednisone. Followup Instructions: 1. Date/Time:[**2192-9-7**] 9:00Provider: BED 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F 2. Date/Time:[**2192-9-10**] 3:00Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC Phone:[**Telephone/Fax (1) 3241**] 3. (Primary Oncology) Date/Time:[**2192-9-10**] 3:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 19272**], MD Phone:[**Telephone/Fax (1) 3237**] ICD9 Codes: 5849, 5990, 2762, 4019, 2749, 2875, 2859
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Medical Text: Admission Date: [**2178-8-29**] Discharge Date: [**2178-9-7**] Date of Birth: [**2124-1-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization Aortic balloon pump insertion arterial line placement intubation swan-ganz catheter placement History of Present Illness: Pt is a 54 y/o man w/ a PMH significant for HTN who developed substernal chest pressure while working outside in his yard. He went inside and lay down on the floor in front of the fan where he was found by his wife. She called EMS and he denied fall or LOC when they arrived. He received aspirin, nitro, and NS and was transfered to the [**Hospital3 3583**]. In [**Hospital1 46**], he was hypertensive to 164/118 and bradycardic to 42. His EKG was significant for complete heart block with ST elevations in II, III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2. He was started on heparin, aggrastat, asa and morphine prior to being transfered to [**Hospital1 18**]. Of note, his wife said that he has developed mild pedal edema over the past few days and states that his exercise tolerance has dropped recently. . In the cath lab, he was seen to be actuely vagal with hypotension and emesis. He was also acutely acidotic and hypoxic. He was intubated for airway protection. An intra-aortic balloon pump was placed secondary to his hypotension. He had several episodes of VT that aborted with amiodarone 150mg bolus and lidocaine 75mg bolus. He was started on an amiodarone drip. His cath demonstrated a totally occluded mid-RCA that was stented. His RPL was ballooned. His right sided filling pressures were elevated with a PCW 37, RA 27, RV 62/18, and PA 62/38. He had no step up. He received 80mg of lasix in the lab. Past Medical History: HTN asthma lumbar disc herniation Social History: no smoking, social alcohol, no ivdu. lives w/ wife and daughter. Family History: father died at 49 from MI and mother w/ cardiac issues "at birth" and died at 49 from "cardiac issues". siblings w/out medical issues Physical Exam: Gen: Pt intubated and sedated with an OG tube HEENT: PERRL Neck: -LAD CV: RRR, s1/s2 intact, -M/G/R Lungs: Coarse breath sounds b/l Abd: S/NT/ND, + BS Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B Ext: -C/C/E, palpable LE pulses b/l Pertinent Results: [**2178-8-29**] 03:57PM BLOOD WBC-18.3* RBC-4.67 Hgb-14.6 Hct-41.6 MCV-89 MCH-31.4 MCHC-35.2* RDW-13.6 Plt Ct-223 [**2178-8-29**] 03:57PM BLOOD Neuts-85.3* Lymphs-10.9* Monos-3.4 Eos-0.2 Baso-0.1 [**2178-8-29**] 03:57PM BLOOD PT-16.4* PTT-150* INR(PT)-1.8 [**2178-8-29**] 03:57PM BLOOD Glucose-159* UreaN-18 Creat-1.4* Na-139 K-3.4 Cl-108 HCO3-15* AnGap-19 [**2178-8-29**] 11:30PM BLOOD CK(CPK)-3357* [**2178-8-30**] 04:51AM BLOOD CK(CPK)-4161* [**2178-8-30**] 11:49AM BLOOD CK(CPK)-4962* [**2178-8-31**] 12:37AM BLOOD CK(CPK)-4473* [**2178-8-31**] 04:43AM BLOOD CK(CPK)-3865* [**2178-9-1**] 03:57AM BLOOD ALT-104* AST-169* LD(LDH)-975* AlkPhos-40 TotBili-1.8* [**2178-8-29**] 11:30PM BLOOD CK-MB-GREATER TH [**2178-8-30**] 04:51AM BLOOD CK-MB-GREATER TH [**2178-8-30**] 11:49AM BLOOD CK-MB-420* MB Indx-8.5* [**2178-8-31**] 12:37AM BLOOD CK-MB-235* MB Indx-5.3 cTropnT-10.06* [**2178-8-31**] 04:43AM BLOOD CK-MB-149* MB Indx-3.9 [**2178-9-2**] 03:27AM BLOOD calTIBC-186* VitB12-210* Folate-11.4 Ferritn-451* TRF-143* [**2178-8-30**] 04:51AM BLOOD Triglyc-80 HDL-43 CHOL/HD-3.2 LDLcalc-80 . ECHO [**8-21**]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior and inferio-lateral hypokinesis. The RV size and systolic function are probably within normal limits (suboptimal views). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. . Cath [**8-21**]: 1. Selective coronary angiography revealed a right dominant system with acute occlusion of a large right coronary artery before it gave off any marginal branches. The LMCA had no significant disease. The LAD had mild diffuse luminal plaquing up to 40% along its length. The LCx was non-dominant and had no significant coronary artery disease. After the RCA thrombotic stenosis was treated, there was evidence of distal emoblization with an abrupt cut off of the terminal R PDA. 2. Hemodynamics revealed severely elevated left and right heart filling pressures. The RV and PA pressures were elevated above 50mm Hg systolic, suggesting some element of chronic pulmonary hypertension. The cardiac output and index were preserved however this was in the face of dopamine infusion which was probably causing some degree of splanchnic vasodilation and L > R shunting. 3. Left ventriculography was not performed. 4. Successful placement of temporary 5 French pacing wire during procedure for heart block via the right femoral vein without complications. The pacing wire was removed at the conclusion of the procedure. 5. Successful placement of 8 French, 40 cc IABP via the left femoral artery under fluoroscopic guidance without complications. Appropriate systolic unloading and diastolic augmentation were noted with invasive hemodynamic measurements. 6. Intubation for hypoxemia, acidemia, and airway control during the procedure without complications and with fluoroscopic confirmation of appropriate ETT placement. 7. Successful treatment of culprit mid-RCA with a 3.5 x 18 mm Cypher drug-eluting stent postdilated with a 3.75 mm balloon. Final angigraphy demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 8. Successful treatment of thrombus migration to the r-PL using balloon inflations with a 2.5 x 15 mm Voyager balloon. Final angiography demonstrated no significant residual stenosis, no angiographically apparent dissection, and normal flow Brief Hospital Course: A/P: Pt is a 54 y/o man w/ a PMH significant for HTN who presented to [**Hospital1 18**] for urgent cath in the setting of an acute infero-posterior STEMI. . 1. CAD - pt presented after an acute infero-posterior STEMI and received an RCA stent. he was intubated during this process for respiratory compromise in the setting of cardiogenic shock during his catheterization. he was started on aspirin, statin, bb, plavix, and ace in the post-catheterization setting. he received an echo showing an EF of 45% and inferior/infero-lateral hypokinesis. he developed a large hematoma at the groin site that resolved throughout his stay. he did not have cp after the intervention and tolerated PT evaluation w/out complaint. he was d/c home on his inpatient medications w/ close follow-up. . 2. Hypotension: the patient developed cardiogenic shock during his catheterization requiring IABP and dopamine. he received 9 L total between OSH and [**Hospital1 18**]. he was weaned off both the pressors and iabp in the ccu in the days after his catheterization w/out problem. his bp was monitored w/ an a-line until transfer to the floor. he was started on bb and ace after his pressors were weaned and his pressure had normalized. he tolerated both of these well and was d/c home to continue bp titration as an outpatient. . 3. Arrhythmia - pt w/ VT in the cath lab that spontaneously aborted and was most likely secondary to ischemia and subsequent reperfusion. he was transiently placed on an amiodarone drip overnight but was taken off this the next morning and did not have recurrence of arrhythmia throughout his stay. . 4. Respiratory - pt w/ a hx of asthma and was intubated for airway protection during cath. he bit through his ngt while in the ccu and was noted to have aspirated. empiric abx were started and the pt subsequently developed a fever/wbc bump that responded well to abx. he was slowly weaned off his sedation and extubated successfully following a spontaneous breathing trial. he was on supplemental oxygen after extubation but this was slowly weaned both in the ccu and on the floor. . 5. ARF - pt developed mild arf w/ Cr of 1.4 here (1.2 at outside hospital). his cr normalized throughout his stay and his ace-i was started after his cr normalized. . Medications on Admission: Univasc primatene mist Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*12 Capsule(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Infero-lateral ST elevation MI Discharge Condition: Stable Discharge Instructions: Please keep all your appointments as scheduled Please take all of your medications as directed Do NOT stop your plavix or aspirin without taking to your cardiologist first. Return to the ER/Call your PCP [**Name Initial (PRE) **]: 1. chest pain 2. shortness of breath 3. fever to 101 4. fainting spells 5. other alarming symptoms Followup Instructions: Please see Dr. [**Last Name (STitle) 63700**] in [**Hospital Ward Name 23**] 7 on [**2178-10-5**] at 1:15pm ([**Telephone/Fax (1) 4022**]) Please see Dr [**Last Name (STitle) 32467**] Completed by:[**2178-10-20**] ICD9 Codes: 4280, 5849, 5070, 4019, 4168
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Medical Text: Admission Date: [**2120-4-24**] Discharge Date: [**2120-4-27**] Date of Birth: [**2092-9-12**] Sex: M Service: MEDICINE Allergies: Effexor Attending:[**First Name3 (LF) 613**] Chief Complaint: acute mental status changes and agitation Major Surgical or Invasive Procedure: None History of Present Illness: 27 yo M with PMHx of polysubstance of abuse, bipolar disorder, transfer from [**Hospital1 **] for AMS. He was there on a section 12 for lamictal 100mg OD on [**4-19**] after presenting with lethargy and nausea to [**Hospital3 **]. His tox was found to be positive for Cannibis. Per report he has taken [**9-14**] pills in an intentional overdose but denied SI but was reportedly disorganized and not a reliable historian. He was treated with haldol, ativan, risperidone, benadryl, and cogentin. On the first few days after admission, he became more clear and was able to participate in thepary, however is mental status began to decompensate yesterday. He was referred here for confusion and worsening mental status. There was a question of what or not he might have ingested drugs over the weekend (from visitors). Vitals signs at bornewood notable for [**2120-4-23**] HR 136 am and 100pm and [**2120-4-24**] 136am 100 pm. Prior to transfer BP 97.2 115/81 117 20 97%. In the ED, 98.5 84 120/76 18 98% RA. Reported initial improvement in mental status and plan for discharge. However, when EMS arrived to take the patient back to [**Hospital1 **], he became very agitated. He was given ativan 2mg and haldol 5mg but continued to be aggitated. He appeared confused and was having auditory and visual hallucinations. Pulse transiently 151 prior to physostigmine. Tox c/s thought he had anticholinergic toxicity symptoms including dry skin and garbled speech. Thought he improved to physostigmine 2mg over 5 minutes. Speech cleared. Then agitated in angry way which was different. Thought this was diagnostic. VS prior to transfer 76 117/82 18 97%RA. Normal head CT. Labs normal. Tox wants to old all antipsychotics, use benzos. In 4 points and ativan prior to sedation. In the ICU, patient was agitated and whimpering. He wanted to get out of his restraints. Still not oriented to person, place or time. Past Medical History: -polysubstance abuse->dependent on cannabis -depression -?bipolar disorder Social History: Smoke [**12-3**] ppd, marijuana 1 joint per day. Periodic alcohol use. Family History: Unknown Physical Exam: Exam on Admission: VS: Temp: 96.7 BP: 126/73 HR:85 RR:13 O2sat 96% on RA GEN: agitated and trying to get out of restraints HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: tachycardia, RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters, multiple piercings and tattoos NEURO: Purposeful movement, AAOx0, could not participate in formal exam Exam on discharge: GEN: calm, A/Ox3 man sitting in chair, in NAD HEENT: EOMI, anicteric, MMM RESP: CTA b/l with good air movement throughout CV: RRR, normal S1 and S2, no m/r/g ABD: soft, nontender, nondistended, +b/s EXT: no c/c/e. SKIN: no rashes/no jaundice, multiple piercings and tattoos Mental Status: A/Ox3, talkative, answers questions with poor insight Pertinent Results: [**2120-4-24**] 03:22PM URINE HOURS-RANDOM [**2120-4-24**] 03:22PM URINE HOURS-RANDOM [**2120-4-24**] 03:22PM URINE GR HOLD-HOLD [**2120-4-24**] 03:22PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2120-4-24**] 03:22PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2120-4-24**] 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2120-4-24**] 10:10AM GLUCOSE-103* UREA N-8 CREAT-0.8 SODIUM-140 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13 [**2120-4-24**] 10:10AM estGFR-Using this [**2120-4-24**] 10:10AM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-56 TOT BILI-1.0 [**2120-4-24**] 10:10AM LIPASE-21 [**2120-4-24**] 10:10AM ALBUMIN-4.8 CALCIUM-10.5* PHOSPHATE-3.9 MAGNESIUM-2.0 [**2120-4-24**] 10:10AM AMMONIA-21 [**2120-4-24**] 10:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-4-24**] 10:10AM WBC-6.9 RBC-4.77 HGB-14.6 HCT-41.8 MCV-88 MCH-30.7 MCHC-35.1* RDW-12.4 [**2120-4-24**] 10:10AM NEUTS-66.1 LYMPHS-26.5 MONOS-5.6 EOS-1.4 BASOS-0.4 [**2120-4-24**] 10:10AM PLT COUNT-289 EKG: sinus arrhythmia at 79bpm, borderline right axis, NI, TWF in V1, TWI in V3 and III, otherwise no Q waves or ST deviations. Imaging: CT head: Normal non-contrast head CT. CXR [**4-26**]: Current study demonstrates no evidence of radiopaque foreign bodies seen on the previous examination. Heart size is normal. Mediastinum is normal. Azygos lobe, anatomical variant is noted. Lungs are essentially clear. There is no appreciable pleural effusion or pneumothorax seen. Brief Hospital Course: 27 yo M with history of polysubstance of abuse, bipolar disorder, and a mood disorder who was transfered from [**Hospital1 **] for acute mental status changes. # Toxic metabolic encephalopathy: Likely secondary to alcohol withdrawal. The patient's acute mental status changes were initially thought to be due to delirium in the setting of possible anticholinergic syndrome from benadryl and congentin in addition to other psych meds. In support of this, he was reported to improve with physostigmine. The patient was also treated with a total of 60mg Valium over 24 hours, with resolution of his agitation. It subsequently became clear that the patient drinks a very large amount of alcohol, and in retrospect, it seemed likely that his symptoms may have also been due to EtOH withdrawal. Toxicology followed the patient in-house as did Psychiatry. He continued to receive 5mg Haldol [**Hospital1 **] PRN for agitation. His mental status improved to baseline. He had a 1:1 sitter throughout his hospital stay. Section 12 was filed by psychiatry and he is being discharged to inpt psychiatry at [**Hospital1 18**]. #Polysubstance abuse: Per report, the patient has a history of benzo abuse and likely alcohol abuse. He has poor insight. He was placed on a CIWA scale with 5mg of Valium given for CIWAs > 10. His valium was self-tapered in this way. He was continued on MVI, thiamine, folate, and a nicotine patch throughout his hospitalization. # Anxiety/mood disorder: The patient's mood is likely unstable at home given a recent possible overdose to "sleep off his emotions." Psychiatry followed throughout his hospitalization, and recommended an inpatient psychiatric hospitalization for further management. He was not started on any standing psychiatric medications during this hospitalization. He was only given haldol for agitation as above. # Radiodense foreign body: On radiograph, the patient was observed to have a curvilinear radiodensity overlying his abdomen, which was gone on repeat x-ray. The patient denied having swallowed anything. A search of his skin did not reveal any evidence of a foreign body, making it possible that this finding was something external to him. He did not complain of abdominal pain and was otherwise asymptomatic. Medications on Admission: No prescription medications prior to admission to [**Hospital1 **]. He had not seen a PCP in years. Medications at [**Hospital1 **]: -risperidone 2mg [**Hospital1 **] -Ativan 1mg q4h prn -nicotine patch -ibuprofen 400mg q4 prn -haldol 5mg PO q4hr prn Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 18**] [**Hospital1 **] 4 Discharge Diagnosis: Primary Diagnosis: Anticholinergic toxicity Secondary diagnoses: Polysubstance Abuse Mood Disorder, NOS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with confusion and agitation. It was likely from either withdrawal from alcohol or benzodiazepines or an anticholinergic toxicity. We may never know exactly what it was. You improved with proper treatment. Because of your overdose, we had the psychiatrists see you. They wanted to make some changes to your medications and watch you for the next few days while receiving these medications. - Please take take only the medications recommended by the psychiatrists. We made the following changes to your medications: We STARTED thiamine, folate, multivitamin and nicotine patch. Followup Instructions: Please follow up with your new primary care physician [**Name Initial (PRE) 176**] [**12-3**] weeks after discharge. Please follow up with your mental health providers as directed by your inpatient mental health team. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2120-4-27**] ICD9 Codes: 3051
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Medical Text: Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-17**] Date of Birth: [**2047-10-19**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with a past medical history of hypothyroidism and hypercholesterolemia. She presented with chest pain. For the past one year the patient has been having exertional angina on fast walking. She felt this was related to her breathing. On [**2105-4-10**] the patient felt a short episode of chest pain at rest, sharp substernal pain, no radiation, associated with diaphoresis. The pain would wax and wane over the weekend but got worse on the night prior to admission. She presented to an outside hospital and was transferred here for catheterization which showed severe three-vessel disease with total occlusion of the distal right coronary artery. She described no orthopnea and no paroxysmal nocturnal dyspnea, no edema, no claudication, no recurrent illnesses or recent illnesses, no urinary symptoms, no diarrhea, no melena, no bright red blood per rectum. PHYSICAL EXAMINATION: Temperature 98.7, heart rate 77, blood pressure 104-109/46-47, respiratory rate 18, 98% on room air. General: No apparent distress, alert and oriented x 3. HEENT: Normocephalic, atraumatic, malformation of right eyelid with right eye blindness since birth. Cardiovascular: S1 and S2, no murmurs, gallops, or rubs. Respiratory: Clear to auscultation bilaterally anterior. Abdomen: Soft, nontender, no distention, bowel sounds positive with an ecchymosis at the catheterization site, no bruit. Extremities: No cyanosis, clubbing or edema. Strong distal pedal pulses. MEDICATIONS ON ADMISSION: 1. Aspirin, which she was not taking. 2. Lipitor, not taking although both prescribed. 3. Levoxyl 100 mcg per day. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Hypercholesterolemia. 3. Recurrent bronchitis. 4. The patient is blind in her right eye from birth secondary to trachoma. SOCIAL HISTORY: No tobacco, occasional glass of wine with dinner; self-employed. Of note the patient is a Jehovah's Witness, no blood products. LABORATORY DATA: White blood cell count 8.2, hematocrit 40.8, platelet count 226, INR 1.6, PTT 150, sodium 138, potassium 4.6, chloride 106, CO2 17, BUN 12, creatinine 0.6, glucose 118, ALT 32, AST 91, CK 549, troponin greater than 50. EKG showed normal sinus rhythm, rate of 100, normal axis, normal intervals; 2-[**Street Address(2) 2051**] elevations in 2, 3, and aVF with reciprocal changes in the precordial leads, and 3-4 mm depressions in 1, aVL, and V2. HOSPITAL COURSE: Coronary artery disease: Patient was started on Lopressor, heparin drip, Aggrastat and Plavix at the outside hospital. These were continued. At catheterization she was found to have no left main disease, left anterior descending coronary artery 40-50% proximal occlusion and 80% mid occlusion; left circumflex coronary artery was 70% proximal and distal and diffuse occlusions; right coronary artery 70% mid occlusion with a distal total occlusion, also diffusely diseased. She received stents in the RCA and LAD. The patient has diffuse coronary artery disease. She was found to have the culprit occlusion in the distal right coronary artery as well as a severe lesion in the left anterior descending coronary artery. These were both stented. The catheterization was complicated by a large hematoma at the catheterization site in the groin as well as slight oozing. This was associated with an hematocrit drop from approximately 40 to 33 to 35. Hematocrit was then afterward stable. The patient had no pain. Distant pulses were unchanged. The patient was started on aspirin, Plavix, Lipitor, Lopressor and lisinopril which she tolerated well. She was also given ranitidine and kept on her thyroxine while in the hospital. She was educated about her coronary artery disease and scheduled with Dr. [**Last Name (STitle) 10543**], who is associated with her primary care physician, [**Name10 (NameIs) **] close follow up. The patient has been educated about the nature and severity of her illness and the necessity for adequate follow up and compliance with medications. She had no arrhythmias during the hospitalization and there was no evidence of clinical heart failure. An ejection fraction done at this hospitalization was 40-45% with the expected inferior wall abnormalities. This echocardiogram should be repeated in the future to assess residual damage. No other systems were active during this hospitalization. The patient recovered uneventfully and was discharged to home on [**2105-4-17**]. DISCHARGE MEDICATIONS: 1. Lopressor 25 b.i.d. 2. Lisinopril 2.5 mg q.d. 3. Aspirin 325 mg q.d. 4. Plavix 75 mg p.o. q.d. 5. Levothyroxine 100 mcg p.o. q.d. 6. Lipitor 10 mg p.o. q.d. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Acute inferior myocardial infarction. 3. Hyperlipidemia. 4. Hypothyroidism. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2105-4-16**] 13:32 T: [**2105-4-22**] 07:21 JOB#: [**Job Number 49477**] ICD9 Codes: 2449, 2720
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Medical Text: Admission Date: [**2186-2-13**] Discharge Date: [**2186-2-21**] Service: NEUROLOGY Allergies: Naprosyn / Vicodin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: stroke vs. seizures Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 84 year-old right-handed woman with a PMH of HTN, HLD, afib and recent bilateral parieto-occipital infarcts and smaller bilateral frontal infarcts. She is known to me from her last presentation as a code stroke in [**2185-7-19**]. At that time she presented with the infarcts described above. . This morning she was reportedly in her USOH and was then found at breakfast "not answering questions". Details of this are not known but she was taken to [**Hospital3 **] hospital where she was reportedly witnessed to have a R sided seizure, and a question of L eye deviation. Her BS was reportedly 140 and her BP 160. She was given 1mg of Ativan and then was reportedly awake but details of her exam are not known. It appears that she was given serial NIHSS from 9-11am with scores in the 30's, however it is not listed if she was awake during this time (or encephalopathic vs post -ictal). She was then given dilantin 1gm and flumazenil 0.25mg IV. She had a screening CT at the OSH which reportedly showed new infarct however on review and comparison with her CT's here, there is no clear change. Screening labs with a CBC,UA, and chemistry were unremarkable, however her INR was 3.1. She was then intubated "for airway protection prior to med flight" and transferred here. Past Medical History: - paroxysmal afib - OA - HTN - HLD - depression - C7 compression fracture - Schmorl's node - transient global amnesia - memory impairments - macular degeneration - BSO - bilateral parieto-occipital infarcts and smaller bilateral frontal infarcts - recent syncope in [**12-26**] with w/u of unknown results Social History: -lives in [**Hospital3 **] -former tobacco (remote) -no EtOH or tobacco Family History: mother: died of stroke Physical Exam: Vitals: T: 96.6 P: 116/47 R: 15 BP: 116/47 SaO2: 100% vent General: NAD HEENT: NC/AT, no scleral icterus noted, ET in place Neck: Supple, no carotid bruits appreciated Pulmonary: decreased breath sounds at the bases Cardiac: regular, nl S1,S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema Skin: no rashes or lesions noted. . Neurologic: -Mental Status: unresponsive to nox stim . CN I: not tested II,III: pupils 1.5mm sluggishly reactive, unable to visualize fundi III,IV,V: no dolls V: + corneals & nasal tickle VII: face appears symmetrical VIII: UA to formally test IX,X: + gag [**Doctor First Name 81**]: UA to formally test XII: UA . Motor: increased tone in all extremites with ankles flexed, no withdrawal to nox stim in any extremity . Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 0 Extensor R 2 2 2 2 0 Extensor -Sensory: no withdrawal to nox stim in any extremity -Coordination: NA -Gait: NA Pertinent Results: Admission Labs: [**2186-2-13**] 01:58PM NEUTS-77.5* LYMPHS-17.8* MONOS-3.5 EOS-0.9 BASOS-0.4 [**2186-2-13**] 01:58PM WBC-7.6 RBC-3.80* HGB-11.9* HCT-34.4* MCV-91 MCH-31.2 MCHC-34.5 RDW-12.9 PLT COUNT-277 [**2186-2-13**] 01:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2186-2-13**] 01:58PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.2 [**2186-2-13**] 01:58PM CK-MB-NotDone cTropnT-<0.01 [**2186-2-13**] 01:58PM ALT(SGPT)-27 AST(SGOT)-33 CK(CPK)-81 ALK PHOS-73 TOT BILI-1.0 [**2186-2-13**] 01:58PM GLUCOSE-111* UREA N-23* CREAT-1.0 SODIUM-140 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16 [**2186-2-13**] 02:05PM FIBRINOGE-300 [**2186-2-13**] 02:05PM PT-35.5* PTT-55.0* INR(PT)-3.8* [**2186-2-13**] 03:44PM URINE RBC-0-2 WBC-[**6-28**]* BACTERIA-OCC YEAST-NONE EPI-0-2 [**2186-2-13**] 03:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2186-2-13**] 03:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 . MRI/A Head: FINDINGS: In comparison with the prior examinations, there are persistent T2 and FLAIR hyperintensity areas consistent with encephalomalacia from prior ischemic event involving both parietal lobes. Cortical areas of hyperintensity signal are demonstrated on T1, possibly consistent with pseudo-laminar necrosis, multiple T2 and FLAIR hyperintense foci are also visualized in the subcortical and periventricular white matter consistent with chronic microvascular ischemic changes. No diffusion abnormalities are detected, or acute ischemic changes. After the administration of gadolinium contrast material, mild gyriform enhancement is identified in the prior ischemic events. Bilateral patchy mastoid mucosal thickening is identified. The orbits are unremarkable. . IMPRESSION: Sequelae of prior infarctions involving the parietal lobes, producing encephalomalacia as described above. Multiple areas of hyperintensity signal are noted in the subcortical and periventricular white matter consistent with chronic ischemic changes. No diffusion abnormalities are detected, or acute ischemic changes. There is no evidence of abnormal enhancement. . MRA OF THE HEAD. FINDINGS: Again there is a small basilar artery, possibly related with bilateral fetal PCAs . No significant change is identified since the prior study. The carotid arteries and vertebral arteries are patent with no evidence of occlusion or stenosis. . IMPRESSION: No significant change since the prior study. The carotid and vertebral arteries are patent without evidence of stenosis or occlusion. . EEG: Borderline abnormal EEG due to persistant slowing for the majority of the recording. This could be due to excessive drowsiness although it may also be due to a mild encephalopathic state. Nevertheless there were no epileptiform features noted. Brief Hospital Course: Patient is a 84 year old RHW here with acute onset of speech difficulties followed by a witnessed right-side seizure during her evaluation at OSH. She was treated with Ativan, loaded with dilantin, sedated, intubated and transferred to [**Hospital1 18**] for further management. She is well-known to the stroke service and she wasn't able to provide any history at the time of admission. Her initial labs were noted for elevated INR of 3.8. Head CT showed no ICH or early signs of ischemia. It only showed old bilateral parietal infarcts and MRI also showed no new ischemia. The most likely explanation for her current presentation is a focal seizure secondary to her known old left parietal infarct. EEG was obtained which ruled out non-convulsive seizure and also showed no epileptiform focus. She was successfully extubated and transferred to neurology floor service where she continued to make clinical improvements including mental status. Her Dilantin was switched to Keppra and her Coumadin was titrated with goal INR 2~3. She was evaluated per PT/OT who recommeds acute rehab given deconditioning from the admission including the ICU stay. She will also require close INR monitoring with Coumadin titration. She will be following up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as outpatient. Medications on Admission: -lisinopril 10 mg daily -Protonix 40 mg daily -metoprolol 100 mg b.i.d. -Lipitor 10 mg q.h.s. -Lexapro 5 mg daily -alendronate 70 mg once per month -calcium carbonate and vitamin D -Lasix 20 mg daily -warfarin 4 mg on Tuesdays, Thursdays and 3 mg all other days Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. Outpatient Lab Work Daily INR with goal INR between 2~3 until Coumadin dosing stable - may be spaced out further (1~2x/week) once INR therapeutic and Coumadin dosing stable. Please forward the results to PCP (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]) for instructions. Discharge Disposition: Extended Care Facility: Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **] Discharge Diagnosis: Seizure disorder Atrial fibrillation hx of biparieto-occipital stroke Discharge Condition: Stable - oriented to self but fluent speech although frequent word finding difficulty; ambulatory with assistance. Discharge Instructions: You were admitted after a witnessed episode of generalized tonic-clonic seizure activity and you were initially intubated for airway protection. You were successfully extubated within 48 hrs and you were transferred out of the ICU to the neurology floor where you remained stable without further seizure activity. You were evaluated further including MRI/A of head which showed no new infarcts hence your seizure was likely precipitated by the old stroke. Also, your INR was supratherapeutic (INR 3.5) on admission hence your Coumadin was held until for 2 days before restarting and the dose was continually titrated during this admission. Your INR is 2 on the day of discharge and current dose is 2mg daily but will need to be continually monitored and titrated as needed based on INR with goal INR 2~3. You also had EEG which showed generalized slow background but no epileptiform activity. However, given that you are at increased risk factor for recurrent seizure activity from the stroke and since you already had witnessed event, you need to be continued on Keppra indefinitely. Given the deconditioning with this admission which included an ICU stay, physical and occupational therapy recommends rehabilitation in an inpatient facility. Please take your medication as scheduled - your Coumadin dosing may further change based on your INR (goal INR 2~3). Also, please follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) as scheduled and please see your PCP [**Name Initial (PRE) 176**] 2~3 weeks of discharge from rehab for follow-up. If you have new weakness, numbness, visual problems, speech problems such as slurring, and/or other concerns, please call your PCP. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2186-3-17**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2186-4-24**] 1:30 - [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] Completed by:[**2186-2-21**] ICD9 Codes: 4019, 2724, 311
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Medical Text: Admission Date: [**2174-6-6**] Discharge Date: [**2174-6-16**] Date of Birth: [**2121-12-16**] Sex: F Service: MEDICINE Allergies: Compazine / Reglan / Opioids-Morphine & Related Attending:[**First Name3 (LF) 30**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation Thoracentesis (multiple) Chest Tube History of Present Illness: 52 year old female with a history of lone atrial fibrillation and Lyme meningitis presenting with progressive shortness of breath over past 2 weeks. On [**5-23**], patient awoke with 10/10 pleuritic pain radiating down to left shoulder to left arm associated with SOB and diaphoresis. She went to PCP who ordered [**Name Initial (PRE) **] CTA which was negative for PE and diagnosed her with pleurisy. She was prescribed motrin 800mg TID. . Her pain was mildy improved with the motrin but she developed DOE which progressed to dyspnea at rest over the past 2 weeks. Also endorsing chest heaviness, pleuritis left sided/LUQ pain, orthopnea and PND. Her pain would be releived sitting forward. Denies LE edema. 1 week ago she experienced 1 day of vomiting x5 episodes NBNB. In the past few days had fevers/chills and abd distention associated with constipation and low grade headache. TMax of 101.3. Also had dry cough. Saw PCP who took CXR which showed pna with b/l pleural effusions. . In the ED, initial vitals were T 101 HR 120 BP 120/77 RR 18 Pox 89% RA. Resp distress. CXR L>R effusion and pericardial effusion. Triggered in the ED for hypoxia to 89% RA, placed on O2 by N/C + abx(CTX and lev), 2L bolus, followed by 150/hr. Cards c/s: resolving pericardial effusion, decided not to tap. Labs notable for ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3 WBC to 17 (no bands). Believe that pleural effusion may be bigger issue. Had thoracentesis in ED 1200cc straw colored fluid. Prior to transfer, 99.4, 110, 122/85, 20, 100% by N/C 5L. . Upon arriving to the ICU, patient was in [**10-31**] left sided pleuritic chest pain. She felt SOB slightly improved. Pain worse and different after thoracentesis. Also endorsed "contact" dermatitis with couple blisters on lower extremities worse 2 weeks ago thought to be a nickel allergy. She has been drinking POs well recently but appetite poor. Endorsed 1 year of nightsweats which she believes are postmenopausal. Of note, she missed her [**2173**] mammogram. . ROS: Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No recent weight loss or gain. HEENT: No sinus tenderness, rhinorrhea or congestion. CV: No palpitations. PULM: No wheezing. GI: No nausea, diarrhea, or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: SHOULDER PAIN, LEFT-S/P LABRAL TEAR REPAIR AND AC REPAIR FRACTURE, FINGER OSTEOPENIA MENOPAUSAL STATE LYME DISEASE meningitis [**2170**] s/p 3 years of abx(seasonal plaquinel plus doxycycline alternating with clarithromycin, finished in [**12-31**] ATRIAL FIBRILLATION-PAROXSYMAL since age 24 MIGRAINE HERPES SIMPLEX COSTOCHONDRITIS Social History: She has one dtr age 8. She is a landscape designer who runs her own business. She does not smoke. Denies recent travel. Does live in [**Location (un) 1514**] and has hiked recently but no noted ticks. Denies ever having PPD placed ETOH: [**1-23**] martinis a week. Tobacco: none Illicits: none Family History: Mother-MI [**95**] but survived 4 younger siblings healthy father died of [**First Name9 (NamePattern2) 18275**] [**Last Name (un) 3711**] at 54, grandfather died of lung ca in 50s, a smoker, paternal aunt had [**Name2 (NI) 18276**] cancer died in 50s Physical Exam: VS: 97.3 113 122/76 93%3L, pulsus 12mmHg GEN: pleasant, visibly in discomfort from L sided chest pain HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP to jaw, no carotid bruits, no thyromegaly or thyroid nodules RESP: decreased bS at b/l bases with poor airmovement [**2-23**] effort and pain CV: RR, S1 and S2 wnl, no m/r/g ABD: mild distension, +b/s, soft, TTP in b/l upper quadrants, no masses or hepatosplenomegaly, no rebound or guarding EXT: no c/c/e SKIN: no jaundice/no splinters, left skin with 1inch diameter round erythematous plaque, ? EN, right posterior LE with small 1 cm erythmatous bliser NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL:deffered Pertinent Results: EKG: sinus tachycardia at a rate of 117, normal axis, non-specific ST,T changes, diffusly low voltage, RBBB pattern. right bundeloid. ST, T changes are new since [**2-1**]. . 2D-ECHOCARDIOGRAM: ([**2174-6-6**]) The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion (1.3 cm anteriorly and 1.8 cm around the right atrium). The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Stranding is visualized within the pericardial space c/w organization. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic invagination. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. . Compared with the prior study (images reviewed) of [**2174-3-9**], the pericardial effusion is new. No overt tamponade is seen however elevated intrapericardial pressure is suggested. . Echo: [**6-14**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The small pericardial effusion is echo dense, consistent with blood, inflammation or other cellular elements and appears largely organized with minimal free fluid. The pericardium may be thickened. . Compared with the prior study (images reviewed) of [**6-8**]/201, the pericardial effusion now appears slightly smaller . LABORATORY DATA: 140 104 14 ---|----|---|------< 17.4 >------< 424 3.9 26 0.8 33 Troponin < 0.01 ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3 AST: 33 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 17 PT: 15.9 PTT: 30.5 INR: 1.4 . Micro: Pleural, Blood, Urine cultures, Urine Legionella negative. RUBEOLA ANTIBODY IgG positive. . CXR [**6-6**]: Extensive left pleural effusion, that occupies approximately one-half of the left hemithorax. A small right basal pleural effusion. Additional mild fluid markings of the fissures and slight distention of the vasculature suggests mild pulmonary edema. Subsequent areas of bilateral atelectasis. The contour of the cardiac silhouette cannot be reliably determined. . CXR post [**Female First Name (un) 576**]: Infiltrate worse on right, improved on left, no PTX . [**5-23**] CTA Grossly normal study, specifically no evidence of pulmonary embolism. . CXR: [**2174-6-15**] INDICATION: Bilateral pleural effusions, status post right thoracocentesis. . COMPARISON: [**2174-6-15**] at 01:33 p.m. (approximately three hours earlier). . CHEST RADIOGRAPH, PORTABLE VIEW: Interval removal of left pigtail catheter. When compared to the most recent study, there has been decrease in bilateral pleural effusion, now small. . No pneumothorax is noted. Bibasilar atelectasis is again noted, left more than right. . The cardiomediastinal and hilar silhouettes appear unchanged. . Pleural fluid: [**2174-6-15**] ATYPICAL. Rare atypical epithelioid cell in a background of reactive mesothelial cells, histiocytes, and lymphocytes; see note. Note: One hematology slide labeled 1556E-[**2174-6-15**] was reviewed and demonstrates mesothelial cells; no atypical cells seen. . Brief Hospital Course: 52 year old female with a history of lone atrial fibrillation and Lyme meningitis presenting with progressive shortness of breath and DOE over past 2 weeks admitted to the MICU with pleural effusions and a pericardial effusion in the setting of presumed viral pleurisy and pericarditis that developed into an effusion after chronic NSAID use possible aspiration/CAP PNA who developed AFIB with RVR secondary to pain and pericardial effusion, transaminitis with cholestasis and acute renal failure in the setting of anemia and NSAID use who has a persistent O2 requirement with pleuritic pain and resolving pericardial effusion. She improved clinically prior to discharge after CT placement for her L effusion and a thoracentesis to remove her R sided pleural effusion. . # SOB/CP/hypoxia: Likely multifactorial with most obvious etiologies being pleural, pericardial effusions, and . PE was less likely given [**5-23**] CTA negative. Due to her effusions, it was thought she may have an underlying PNA and she was started on levaquin for CAP. She was given a prolonged course due to concern that she may have had infection in her pericardial fluid. The day after admission ([**6-7**]) she was intubated for hemodynamic control(Afib RVR 150s), pain control, and for potential procedure for a possible pericardial window. From a respiratory prospective she was comfortable prior to intubation which was done under rapid sequence given signs of early tamponade. She was extubated without event when it was determined that cardiology did not think her pericardal effusion needed to be drained. Instead, cardiology recommended serial Echo's to follow the effusions size. An echo on [**6-14**] showed that the effusion was reduced in size compared to prior imaging. . #Afib with RVR: The Patient has a history of lone atrial fibrillation. On day of admission patient went to Afib to 200s briefly sustaining in the 160s. This was thought [**2-23**] to pain and infection vs tamponade physiology. She received metroprolol IV and dilt drip. When patient was intubated, she converted back to sinus rhythm and maintained in sinus rhythm. After extubation and while on the floor the patient did not have any palpitations or further episodes of Afib wtih RVR. - She will need to discuss with her outpatient physician [**Name9 (PRE) **] with aspirin when her pericardial effusion resolves. . # Pleural Effusions: She presented with pleuritic chest pain which was initially attributed to her pleural effusions. Initially, the DDx was broad including infectious(Lyme/parvo negative, [**Location (un) **] pending), malignant(cytology ultimately negative), and rheumatologic([**Doctor First Name **] negative and C3/C4 normal). CHF and cirrhosis unlikely based on H+P. Lipase normal makes pancreatits unlikely. Thoracentesis reveals exudate, likely parapneumonic given fevers, and a viral pleuritis was also considered. ID was consulted who recommended empiric coverage for CAP with a prolonged course of Levofloxacin (14 days - finish on [**6-20**]) due to a concern that the pericardial fluid could [**Hospital1 **] infection. Cytology negative, cultures negative. Morphine and fentanyl pleuritic CP. The most likely diagnosis was a viral infection with a superimposed bacterial process possibly in the setting of aspiration 1 week prior. Of note her effusions persisted despite antibiotic therapy and NSAID therapy. She was given diuretics with lasix which did not reduced the size of her effusion. Therefore, a L sided chest tube placement by IP in addition to a right sided thoracentesis. After subsequent removal of her bilateral pleural effusions, her symptoms of SOB and O2 requirement resolved. . # Pericardial Effusion: Initially echo concerning for early but not overt tamponade physiology and exam was concerning. Patient was given IVF to maintain preload. Serologies were sent as above. Her pulsus was monitored closely and was never above 12mmHG. Cardiology consult followed closely and serial echos showed improvement in effusions. The decision was made not to drain effusions for diagnostic purposes given the risks involved. She was restarted on NSAID therapy for viral pericarditis. Of note, her effusion improved by echo prior to discharge. . # CAP: Given her exudative effusion and viral pleuritis there was concern for CAP and possible aspiration. She was given a two week course of levofloxacin to finish on the date listed above. . # Diarrhea: She had transient episode of diarrhea while on antibiotics, and her diarrhea resolved. . # [**Last Name (un) **]/Low UO: Dark urine and poor output early in ICU course. Thought potentially from NSAIDs. Renal spun urine and it was not active. She had low UOP, which improved with IVF. . Cholestasis and Hepatitis: She was noted to have to have abnormal LFT's with cholestatsis in addition to pleuritic R sided abdominal pain. There was concern that she could have either a viral induced hepatitis with cholestasis versus a congestive hepatopathy in the setting of mild volume overload. Cholecystitis was less likely given the absence of a white count. Her LFT's trended down independent of diuresis thereby suggesting/confirming a possible viral etiology for her hepatitis and cholestasis. Of note her hepatitis serologies were negative. . # Anemia: Baseline hct 40s most recently in [**2171**]. No signs or symptoms of bleeding. Likely from systemic process going on. Normal colonoscopy in [**2171**]. Of note, she is currently menopausal, and has iron studies that suggest she has anemia of chronic disease, or at least anemia with acute inflammation. - She will need a CBC as an outpatient. Medications on Admission: -ASPIRIN TAB 81MG EC (ASPIRIN) 1 QD Discharge Medications: 1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) pack PO DAILY (Daily) as needed for constipation. Disp:*30 packets* Refills:*0* 2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*5 Adhesive Patch, Medicated(s)* Refills:*0* 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for Prior to Morphine: Please take before Morphine as needed for itching. Please do not drive after taking this medication. Disp:*20 Capsule(s)* Refills:*0* 7. morphine 10 mg Capsule, Ext Release Pellets Sig: One (1) Capsule, Ext Release Pellets PO every six (6) hours as needed for pain: Please do not drive after taking this medication. Disp:*20 Capsule, Ext Release Pellets(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pleuritis with Bilateral Pleural Effusion and Pericardial Effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance Discharge Instructions: Dear Mrs. [**Known lastname 3271**], You were admitted for worsening shortness of breath due to fluid in your lungs and around your heart. The exact cause of this is unknown. Your breathing has markedly improved and you are presently able to breathe without use of supplemental oxygen. You will need to be followed by your primary care physician. [**Name10 (NameIs) **] were started on an antibiotics and ibuprofen. The following medicaiton changes were made: ADDED: levaquin, ibuprofen, miralax, morphine, lidocaine patch, benadryl, morphine, colace STOPPED: aspirin Followup Instructions: Please visit your primary care physician for [**Name9 (PRE) 702**] bloodwork and to determine whether you will need to take more Lasix (the 'water-pill' that you during your stay in the hopsital). Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: PERSONAL [**Hospital **] HEALTH CARE, P.C. Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 1408**] Appt: [**6-21**] at 4pm Completed by:[**2174-7-12**] ICD9 Codes: 486, 5849, 2859
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Medical Text: Admission Date: [**2127-1-13**] Discharge Date: [**2127-1-25**] Date of Birth: [**2083-8-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: hypothermia, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a 41 homeless man with no known medical history who was found down in the park today. The patient had been in the park drinking Listerine with a friend. When the patient was found by EMS he had a temp of 74. They were unable to obtain a blood pressure or a pulse. . On arrival to [**Hospital1 18**] his temp was 74.6, BP 57/49, R16. Upon arrival the patient was able to open his eyes, but he was not responsive. Given his clinical picture, he was intubated. The patient received a bear hugger. He was resuscitated with warm fluids. Head CT was obtained and showed a comminuted nasal bone fracture. No acute hemorrhage. CTA was negative for a PE. EKG showed NSR at 55, no ST elevations or depressions Past Medical History: MHX: unknown Physical Exam: PE: T97.2 HR100 BP 104/56 AC O2sat 99% GEN: thin, poorly groomed Caucasian male who is intubated and sedated HEENT: poorly dental hygeine, dried dirt in nares HEART: nl rate, S1S2, no gmr LUNGS: CTA-anteriorly ABD: benign EXT: cool, +DP bilaterally Neuro: unable to assess Pertinent Results: [**2127-1-13**] 02:50PM PLT SMR-VERY LOW PLT COUNT-79* [**2127-1-13**] 02:50PM WBC-11.1* RBC-4.79 HGB-17.0 HCT-47.9 MCV-100* MCH-35.4* MCHC-35.4* RDW-14.1 [**2127-1-13**] 02:50PM ASA-NEG ETHANOL-261* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2127-1-13**] 02:50PM AMYLASE-132* [**2127-1-13**] 02:50PM GLUCOSE-23* UREA N-20 CREAT-0.8 SODIUM-145 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-13* ANION GAP-34* [**2127-1-13**] 03:10PM CK-MB-36* MB INDX-1.2 cTropnT-0.01 [**2127-1-13**] 03:10PM CK(CPK)-2987* [**2127-1-13**] 06:35PM WBC-4.5# RBC-3.35*# HGB-11.9*# HCT-34.4*# MCV-103* MCH-35.4* MCHC-34.5 RDW-13.3 [**2127-1-13**] 06:35PM OSMOLAL-345* [**2127-1-13**] 06:35PM ALBUMIN-2.7* CALCIUM-6.2* PHOSPHATE-3.8 MAGNESIUM-1.7 [**2127-1-13**] 06:35PM GLUCOSE-95 UREA N-17 CREAT-0.5 SODIUM-146* POTASSIUM-3.2* CHLORIDE-115* TOTAL CO2-11* ANION GAP-23* [**2127-1-25**] 07:02AM BLOOD WBC-5.0 RBC-3.26* Hgb-11.4* Hct-31.7* MCV-97 MCH-34.9* MCHC-35.9* RDW-13.5 Plt Ct-187 [**2127-1-25**] 07:02AM BLOOD Glucose-138* UreaN-12 Creat-0.8 Na-140 K-4.0 Cl-105 HCO3-22 AnGap-17 [**2127-1-22**] 04:35AM BLOOD ALT-40 AST-31 AlkPhos-70 TotBili-0.5 . CT spine: 1. Comminuted nasal bone fractures. 2. Severe mucosal thickening in the ethmoid sinuses and nasal cavity. 3. No evidence of acute intracranial hemorrhage. . CXR: 24 year-old male with hypothermia, intubation. A single portable view of the chest reveals slight rotation to the right. No evidence of a pneumothorax. An endotracheal tube is in satisfactory position. The lungs are well inflated. The ribcage is intact with no evidence of a fracture. A nasogastric tube tip lies in the stomach. . EKG: Baseline artifact. Sinus bradycardia. Modest non-specific intraventricular conduction delay. Prominent"J" point in leads V4-V6 - possible [**Doctor Last Name **] wave. Findings suggest hypothermia. Clinical correlation is suggested. No previous tracing available for comparison. . CTA: 1. No evidence of pulmonary embolism. 2. Moderate-to-large bilateral pleural effusions with associated atelectasis. 3. Airspace opacity and infiltrate noted in the lungs, most predominantly in the left lower lobe. Diffuse patchy nodular opacities also seen scattered throughout the upper and right middle lobes. Nodular findings could represent infection versus metastasis, and followup imaging following treatment is recommended to document resolution. . ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no systolic anterior motion of the mitral valve leaflets. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: 43 year old white male with hypothermia and unknown source of fevers. 1. Pulmonary - Patient was initally intubated for airway production but rapidly extubated after improvement of hemodynamics, metabolic acidosis, and mental status. Upon extubation, patient had a nonproductive cough and fevers concerning for PNA. Although he had a clear CXR, given LOC and possible aspiration event, he was started on Unasyn. His fever and cough persisted with a continued O2 requirement despite antibiotics. Antibiotics were thus changed to Zosyn. The patient was started on vancomycin for persistent fevers and tachypnea. He received nebulizer treatments and chest PT given possible underlying obstructive lung disease. Seven days prior to discharge, patient was changed to oral cefpdoxime (with plan to end course on [**1-27**]); patient's respiratory status was at baseline, on room air, satting well with ambulation. No evidence of hospital acquired organisms. . 2. Hypothermia - Unclear etiology of hypothermia, although likely secondary to exposure in setting of LOC vs early SIRS. Patient was warmed with bear hugger and warmed IV fluids. Workup for hypothyroidism was negative. At the time of transfer, the patient had been warmed to normal body temperature. . 3. Cardiovascular - Patient was admitted with hypothermia, low WBC, and hypotension concerning for sepsis. Resuscitated with large volumes of IV fluids to which his blood pressure responded. He remained bradycardic throughout his time in the ED however maintained a normal blood pressure after fluid resuscitation without further intervention. Patient had two, asymptomatic episodes of bradycardia while on the floor. His heart rate was maintained between 60-70s prior to discharge. . 4. Neuro/Psyche - Patient had altered mental status on admission, likely secondary to hypothermia, hypoglycemia, or intoxication. At the time of transfer, his mental status improved and he was alert and oriented to person, place, and time. He remained oriented to time and place throughout his stay. Psychiatry was consulted to address a possible underlying depression, for which remeron treatment was initiated. He was ruled out for a dual diagnosis and not deemed appropriate for an inpatient hospitalization. - Alcoholism: Patient received thiamine iv x3 days, folate, and an MVI. He was treated for withdrawal with lorazepam by CIWA scale and was seen by the addiction nurse. - Extremity tingling - was initiated on neurontin 200 qhs two days prior to discharge. Patient should follow up with his PCP regarding possible EtOH induced neuropathy. . 5. Rhabdomyolysis: Patient was admitted with elevated CK likely secondary to prolonged LOC. He was treated with aggressive fluid hydration to prevent renal failure. Serial CKs demonstrated a steadily decreasing CK. Creatinine was 0.5 at the time of transfer. Renal function remained stable throughout stay. . 6. Pancreatitis: Admitted with elevated pancreatic enzymes, likely secondary to EtOH. His enzymes trended down throughout his admission. He was asymptomatic through the admission and tolerated a PO diet at the time of transfer. - hepatitis serologies were checked, which showed prior exposure to hepatitis B. . 7. Left hand swelling: Likely [**1-24**] trauma. He was followed clinically without any evidence of compartment syndrome or clot. Edema had resolved at time of transfer. . 8. Heme: - Thrombocytopenia: Unknown etiology/baseline. HIT negative. Question secondary to alcoholism/hypersplenism. [**Month (only) 116**] be secondary to marrow suppression in setting of acute illness. HIV was negative - Anemia: Normocytic, although MCV 96. Unknown etiology/baseline. Likely marrow suppression in setting of alcoholism. [**Month (only) 116**] be secondary to marrow suppression in setting of acute illness. HIV was also on differential but was negative. . 9. Comminuted nasal fracture: The patient was seen by plastic surgery, who believed the fracture to be chronic. No further management was deemed necessary. Medications on Admission: unknown Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 doses: To complete course on [**2127-1-27**]. Disp:*14 Tablet(s)* Refills:*0* 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypothermia Pneumonia Lung nodules . Secondary: Elevated liver function tests Alcholism Anemia Thrombocytopenia Comminuted nasal fracture Pancreatitis Rhabdomyolosis Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were admitted for hypothermia (low body temperature) and decreased ability to breath. You subsequently acquired fevers, with no obvious source found, but you clinically improved. Your breathing also improved a few days after admission. . Please contact a physician if you experience fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, diarrhea, or any other concernging symptoms. . Please take your medications as prescribed. . Please see Dr.[**Name (NI) 5118**], your physician, [**Name10 (NameIs) **] receive your medical care. Followup Instructions: 1. Dr.[**Doctor Last Name 5118**] - he will set this appt up for you or you should go to his clinic within 2 weeks to set it up. He visited you here in the hospital and knows of your discharge from here. . Patient needs a follow-up CT scan to assess lung nodules. CT scan showed airspace opacity and infiltrate noted in the lungs, most predominantly in the left lower lobe. Diffuse patchy nodular opacities also seen scattered throughout the upper and right middle lobes. Nodular findings could represent infection versus metastasis, and followup imaging following treatment is recommended to document resolution. . Patient was evaluated by psychiatry while an inpatient. It was recommended that Mr. [**Known lastname 38758**] follow-up with a psychiatrist as an outpatient. . Patient will need a colonoscopy for routine screening (with anemia signs by laboratories). ICD9 Codes: 5070, 2875, 0389, 2762, 5180, 4280
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Medical Text: Admission Date: [**2156-3-20**] Discharge Date: [**2156-3-22**] Date of Birth: [**2096-5-10**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: Necrotizing Pancreatitis, Abdominal Compartment Syndrome Major Surgical or Invasive Procedure: [**3-21**] - Exploratory Laparotomy [**3-22**] - Exploratory Laparotomy, Total Abdominal Colectomy, Small Bowel Resection, Partial Necrosectomy History of Present Illness: 59 F with no significant medical history being transferred from [**Hospital6 **] hemodinamically unstable, on 3 pressors with severe abdominal pain. Patient has a history of heavy alcohol use, and had developed a severe abdominal pain since 1 day prior to presentation, after drinking some alcohol (unknown how much). Per OSH recors, pt had pain mostly in the upper abdomen, associated with nausea and vomiting, reason why pt went to [**Hospital **] hospital and was found to have a necrotizing pancreatitis. At the OSH, she was doing progressively worse requiring intubation and 3 pressors to keep her stable. Bladder pressures extremely high up to 200 and peak pressures in the 40s by the time she was transferred to us. Past Medical History: None Past Surgical History: None Social History: H/o tob. ~2 glassed red wine/day Family History: Mother w/ lung Ca Physical Exam: On Admission: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm, tense and dilated, diffusely tender to palpation, with severe guarding. Ext: No LE edema, LE warm and well perfused On Discharge: Deceased Pertinent Results: CT A/P (OSH): Large right and small left pleural effusion with extensive adjacent atelectasis. Small amount of pericardial fluid or pericardial thickening. Small to moderate ascites with large amount of fluid surrounding the pancreas. No free air. Segmental mural thickening involving jejunum from treitz, secondary to ascites vs. enteritis vs. ischemic causes Brief Hospital Course: The patient was seen in the emergency department and admitted directly to the surgical icu. At the time of admission, she was requiring three pressors to maintain a perfusing pressure. She was taken to the operating room for a decompressive laparotomy, and tolerate the procedure without an acute change in her status. Her abdomen was left open with a [**Location (un) **] bag in place, and the patient returned to the ICU overnight. Over the course of the night, she continued to require three pressors and had lactates ranging from [**5-20**]. Her LFTs were rising, consistent with shock liver. Additionally, her abdominal pressures continued to be in the upper twenties despite her open abdome. On [**3-22**] she returned to the operating room were she was found to have ischemia of her entire colon, ileum and large segments of the jejunum. This was resected and the patient was left in discontinuity. A small area of necrotic pancreas was also resected. The patient was left with an open abdomen and returned to the ICU. A family meeting was held regarding the patients condition and it was determined that CMO status was most in line with her wishes. On [**3-22**] she was made CMO and was pronounced at 16:19. Medications on Admission: None Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Necrotizing Pancreatitis Mesenteric/Colonic ischemia Abdominal Compartment Syndrome Discharge Condition: Deceased Discharge Instructions: N/a Followup Instructions: N/a ICD9 Codes: 0389, 5119, 5849, 2875
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Medical Text: Admission Date: [**2185-8-10**] Discharge Date: [**2185-9-1**] Date of Birth: [**2122-7-2**] Sex: M Service: MEDICINE Allergies: Adhesive Tape Attending:[**First Name3 (LF) 3918**] Chief Complaint: headaches Major Surgical or Invasive Procedure: -R IJ dialysis line placement -CVVHD -Lumbar puncture History of Present Illness: 62 y/o M with hx of renal transplant and diagnosis of diffuse Large B Cell Lymphoma s/p [**Hospital1 **] chmotherapy and recent intrathecal chemotherapy presents with headache. pt has been apparently getting worsening headache since 15th with some photophobia and some confusion at times. no focal neurological complaints. no fever/chill/rigor. no neck stiffness or photophobia. no visual disturbances or nausea. pt subsequently saw Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-8**] and underwent MRI of brain for evaluation. This apparently demonstrated extensive lesion in both hemispheres but restricted to white matter only, he was therefore referred to the ED for evaluation. In [**Name (NI) **] pt was seen by neurology consult, onc consult and renal consult. his only current complaint is mild headache which responded to po tylenol. he underwent LP per neuro recommendation and is admitted for further evaluations. . In the hospital pt was LP'd and had brain bx which confirmed B lymphoma. He subsequently underwent high dose MTX therapy via CVVH which completed. His course was complicated by enterococcus UTI treated with amoxicillin and C. Diff treated with Flagyl. Of note pt is on atovaqon for PCP prophylaxis and is getting lekovorin for rescue. He was just switched from [**Last Name (un) **] to FK due to falling counts. today he under went LUE uss for possible dvt which was negative. . Past Medical History: # Chronic renal failure secondary to diabetic nephropathy s/p Kidney transplant [**4-/2180**] # Brittle DM on insulin w/ multiple episodes of hypoglycemia # Right lenticulostriate/basal ganglia stroke found on [**2185-2-28**] # CAD s/p CABG [**2173**] # HTN # Hyperlipidemia # s/p aortoilliac bybass # s/p AKA amputation during [**Country 3992**] after gunshot with phantom limb pain # Osteomylitis of L hip # h/o kidney stone # MVA s/p splenectomy [**6-/2181**] # Diabetic retinopathy # Bilateral carotid stenosis # s/p cervical fusion # Anxiety with PTSD # h/o colitis in [**2183**] s/p colonoscopy w/ ileitis/colitis, ? crohns vs microscopic colitis Social History: Lives with his wife and son. Worked as a counselor at the VA. Remote 15-20 pack/yr smoking history. No alcohol use. No illicit drug use. Family History: Mother: Died with ovarian cancer Father: Diabetes, "brain tumor" Oldest of 9 children, several with DM, CHF. No history of blood disorders, leukemia or lymphoma. No history of strokes. Physical Exam: temp 98.6, hr 70/min, rr 16/min, sats 96% on 3L neck supple, no jvd rrr, nl s1+s2, no m/r/g bilateral wheeze worse on right [**Last Name (un) 103**] soft, non tender, nl bs ext warm, leg amputation, good pulse in other leg cns [**3-24**] intact Pertinent Results: [**2185-8-10**] 06:14AM BLOOD WBC-3.8*# RBC-3.23* Hgb-10.7* Hct-33.0* MCV-102* MCH-33.1* MCHC-32.3 RDW-19.1* Plt Ct-97* [**2185-8-29**] 12:00AM BLOOD WBC-3.5*# RBC-2.72* Hgb-8.8* Hct-26.8* MCV-99* MCH-32.3* MCHC-32.8 RDW-18.9* Plt Ct-79* [**2185-8-27**] 12:00AM BLOOD Gran Ct-1305* [**2185-8-29**] 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-79* [**2185-8-29**] 12:00AM BLOOD Glucose-190* UreaN-67* Creat-1.8* Na-144 K-5.0 Cl-114* HCO3-20* AnGap-15 [**2185-8-29**] 12:00AM BLOOD ALT-11 AST-15 LD(LDH)-368* AlkPhos-82 TotBili-0.6 [**2185-8-29**] 12:00AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.2 Mg-2.0 [**2185-8-28**] 05:29AM BLOOD tacroFK-5.8 TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES NEGATIVE COMMENT: NEGATIVE PF4 HEPARIN ANTIBODY BY [**Doctor First Name **] MRI OF THE HEAD WITH AND WITHOUT CONTRAST CLINICAL INDICATION: 63-year-old man with history of CNS lymphoma, status post high dose of chemotherapy, now with worsening mental status change, MRI to evaluate progression of CNS lymphoma. COMPARISON: Multiple prior examinations of the head, the most recent consistent with CT of the head without contrast dated [**2185-8-25**] at 1034 hours, prior MRI of the head dated [**2185-8-12**] and [**2185-8-9**]. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,axial FLAIR, axial T2, axial magnetic susceptibility and axial diffusion-weighted sequences. After the administration of gadolinium contrast, the T1-weighted images were repeated in axial T1, sagittal MP-RAGE and multiplanar reconstructions. FINDINGS: In comparison with the most recent MRI dated [**2185-8-10**], there is evidence of larger pattern of vasogenic edema, involving the right temporal lobe, apparently extending at the right parahippocampal formation (4:10), the pattern of abnormal enhancement on the right temporal lobe lesion remains similar, extending at the head of the caudate nucleus on the right. The pattern of abnormal enhancement involving the left occipitoparietal region remains stable with a new area of enhancement tracking the biopsy site, post-surgical changes are identified on the left parietal convexity consistent with a burr hole. On the diffusion-weighted sequence, there is evidence of a heterogeneous area of high signal at the head of the caudate nucleus, which is not clearly identified on the corresponding ADC map, however, the possibility of small areas with subacute ischemia cannot be completely excluded (702:16). Normal flow void signal is identified in the major vascular structures. There are no new areas with abnormal enhancement. The area of abnormal enhancement on the right temporal lobe measures approximately 18.6 x 22.7 mm in size. The area of abnormal enhancement on the head of the caudate nucleus measures approximately 9.9 x 15.3 mm and the area of abnormal enhancement on the left parietooccipital region measures approximately 32.8 x 32.5 mm in maximum dimensions. Persistent mucosal thickening is identified on the left maxillary sinus, presumably a small mucous retention cyst. IMPRESSION: Larger area of vasogenic edema and effacement of the sulci involving the right temporal lobe as described above, apparently extending at the right hippocampal formation, no definite uncal herniation is identified, the perimesencephalic cisterns are patent. The pattern of enhancement in the different lesions located at the right temporal lobe, right head of the caudate nucleus and left parietooccipital regions remain stable with similar pattern of enhancement and vasogenic edema, new track of abnormal enhancement is identified in the surgical site with associated surgical changes consistent with a left parietal burr hole. Questionable area of restricted diffusion identified on the diffusion-weighted sequence of the head of the caudate nucleus (702:16), which is not clearly identified on the corresponding ADC map, however, ischemic changes cannot be completely excluded, please correlate clinically. Brief Hospital Course: 63-year-old male with DM-II, HTN, CAD, CKD, non-Hodgkin B-cell lymphoma s/p chemotherapy (no radiation therapy), s/p kidney transplant (on Rapamune & Prednisone) who presented with worsening HTN urgency and 2 weeks of throbbing headaches and found to have extensive bihemispheric white matter lesions on MRI (R temporal and L parieto-occipital). . #HEME/Oncology: The patient was diagnosed with B-cell lymphoma diagnosed [**1-/2185**] and is s/p 6 cycles of chemotherapy (R-[**Hospital1 **] x5, R-CHOP x1) and 2 cycles of IT ara-C with last dose given on [**2185-7-13**] per OMR. The had an LP and imaging which showed significant mets to the brain. He was treated with methotrexate. The patient also recieved leucovorin, bicarb and CVVHD to aid in renal protection. The patient developed an acutely worsening mental status. He was given steroids and had repeat imaging which showed worsening of mets in increased brain edema. The decision was made to start whole brain radiation as treatment. After two treatments with whole brain radiation, and worsening of clinical condition, the family decided to make the patient comfort measures only. The whole family was present for the decision and the patient's death. Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] were informed of the decision. He was started on a morphine drip and standing ativan. . #Headaches: While presentation was initially concerning for hypertensive urgency, multiple lesions were found on brain MRI and thought to be the cause of his pain. Pt was sent for brain biopsy which was highly suggestive of lymphoma. Patient was treated initially with tylenol for pain, however required IV pain medications for severe headaches. . #Hypertension: Prior to admission, pts SBPs have been intermittently in the 170s over last month per OMR notes and his usual lisinopril and lasix have been discontinued for unclear reasons (likely related to his chemotherapies). On admission he was hypertensive to the 180s-200s. He was treated with PO labetalol and clonidine while in the ICU; pt also required labetalol gtt to achieve post-surgical BP goals of 130-160. Pt was transitioned to home regimen of carvedilol 12.5 mg [**Hospital1 **] and clonidine 0.1 mg [**Hospital1 **]. . #Renal transplant: His was improved from his usual baseline of 1.6-1.7 for most of his ICU stay. He is on sirolimus and prednisone for immunosuppression which were continued in the ICU. He underwent CVVHD following methotrexate therapy to preserve remaining renal function. CVVHD therapy was complicated by filter clotting but was continued to achieve a methotrexate level of <0.05. Due to concern of worsening thrombocytopenia, sirolimus (switched to tacrolimus), bactrim and acyclovir were discontinued. . # Thrombocytopenia: HIT ab negative, concern for chemotherapy-induced thrombocytopenia. [**Month (only) 116**] also be a result of sirolimus treatment so switched to prograft on [**8-18**] for immunosuppression. Also d/ced bactrim (switched to atovoquone) and acyclovir. . # UTI: Pt was cultured on [**8-15**] for fevers. Urine grew enterococci susceptible to ampcillin. Empiric therapy with vancomycin was switched to ampcillin. . # Diabetes mellitus II: Etiology of his renal failure per OMR. Usually on home Lantus with humalog sliding scale. Followed by [**Hospital **] Clinic. Lantus dose was decreased while inpatient for hypoglycemia and was supplemented by ISS. . # Coronary artery disease: status-post 3V CABG in [**2173**]. No chest pain, EKG with no ischemic changes on admission. He remained asymptomatic currently in [**Hospital Unit Name 153**]. Aspirin on hold due to IT chemotherapy per OMR. Anti-hypertensives continued. . #Phantom limb pain: continue tylenol as needed, recently stopped taking Vicodin. . Medications on Admission: Acyclovir 400 mg PO TID Carvedilol 12.5 mg PO BID Clonazepam 1 mg PO QHS Clonidine 0.1 mg PO BID Clotrimazole 1 TROC PO QID Fluconazole 100 mg PO Daily Hydrocodone-Acetaminophen 5 mg-500 mg 1-2 Tabs PO Q12 hours PRN Pain Novolog Sliding Scale SC QID Insulin Glargine 24 Units SC QHS Lidocaine Viscous 20 mg/mL Solution 1 mL PO TID PRN Pain Lorazepam 0.5 mg 1-2 Tabs PO Q4Hours PRN Nausea Ondansetron 8mg PO Q8hours PRN Nausea Pantoprazole 40 mg PO BID Prednisone 2.5 mg PO Daily Prochlorperazine 10 mg PO Q6h PRN Nausea Caphosol QID Sirolimus 2mg and 3mg alt days Docusate Sodium 100 mg PO BID Senna 1 Tab PO BID:PRN Constipation Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] ICD9 Codes: 486, 5990, 2875, 2767, 4439, 4019, 2724
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Medical Text: Admission Date: [**2130-5-23**] Discharge Date: [**2130-6-15**] Date of Birth: [**2070-8-30**] Sex: F Service: PLASTIC Allergies: Amoxicillin / aspirin / Tylenol / lisinopril / Augmentin Attending:[**First Name3 (LF) 36263**] Chief Complaint: Suicide attempt with tylenol/benzo overdose and self inflicted bilateral wrist lacerations Major Surgical or Invasive Procedure: [**2130-5-23**] 1. Exploration complex laceration left wrist. 2. Repair ulnar artery with reverse interposition vein graft from dorsum left foot. 3. Repair complex laceration left wrist. . [**2130-6-6**] 1. Irrigation and debridement of skin, subcutaneous tissue, flexor tendon. 2. Left open carpal tunnel release. . [**2130-6-12**] 1) Left below elbow amputation, left upper extremity. 2) Removed neuromas, removed nerve x6, left forearm. History of Present Illness: 59F s/p suicide attempt with presumed Tylenol and Klonopin overdose as well as wrist lacerations. Patient has history of depression and anxiety but she stopped her medications about 3 weeks ago because she didn't think it was working and so she weaned herself off. She was found by EMS at mid-day on [**5-22**] and taken to [**Hospital **] Hospital. She was taken for surgical repair of her wrist lacerations early in the morning of [**5-23**]. She was deemed unfit to consent for the procedure by the psychiatry service. She remained intubated following surgery for her mental status. Per report, she was initially A&O x 3. Following surgery she was obtunded. Her LFTs spiked significantly between her admission and the following morning. Her acetaminophen level on admission was 33, and 15 on redraw. She was transferred to the SICU at [**Hospital1 18**] for evaluation of acute liver failure. Past Medical History: lupus scleroderma depression/anxiety (prior suicide attempt [**9-14**]) HTN PUD prior GIB endometriosis Raynauds disease . PSH: unknown Social History: SH: Prior suicide attempts. [**Known firstname 4457**] owns her home and works FT for a limo company making reservations. She is a former (25 years ago) RN. [**Known firstname 4457**] has a company vehicle. Her roommate [**Doctor First Name 4051**] doesn't drive and doesn't have a vehicle. [**Known firstname 4457**] is single, has one son [**Doctor Last Name **] but there is a restraining order against him because he is physically abusive, her parents are deceased, and she has no siblings. [**Known firstname 4457**] smokes "a lot" of cigarettes a day but doesn't use any other drugs that her friends know of and she is not a drinker. Physical Exam: Vitals: 103.8 125 108/72 28 100% on AC 100/450 x 20/5 wt 72kg General: intubated, sedated, opens eyes minimally to voice . RUE Laceration over volar wrist closed with intact sutures. Dopperable radial and ulnar pulses as well as superficial arch. Arm, forearm and hand compartments soft. Digits warm and well-perfused with cap refill < 2sec. . LUE Laceration over volar wrist closed with intact sutures. No dopperable ulnar pulse. Weak dopplerable superficial arch. Arm, forearm and hand compartments soft. Index, long, ring, and small fingers mottled to palmar crease. Poor cap refill >2sec. Pertinent Results: ADMISSION LABS: [**2130-5-23**] 06:20PM GLUCOSE-150* UREA N-30* CREAT-2.3* SODIUM-141 POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-18* ANION GAP-17 [**2130-5-23**] 06:20PM ALT(SGPT)-[**2041**]* AST(SGOT)-1337* ALK PHOS-56 TOT BILI-0.6 [**2130-5-23**] 06:20PM CALCIUM-8.0* PHOSPHATE-3.1# MAGNESIUM-1.6 [**2130-5-23**] 06:20PM ACETMNPHN-9* [**2130-5-23**] 06:20PM WBC-17.0* RBC-2.88* HGB-8.6* HCT-26.7* MCV-93 MCH-29.9 MCHC-32.2 RDW-14.4 [**2130-5-23**] 06:20PM PLT COUNT-105* [**2130-5-23**] 06:20PM PT-16.2* PTT-37.5* INR(PT)-1.5* [**2130-5-23**] 06:20PM FIBRINOGE-338 [**2130-5-23**] 03:58PM TYPE-ART PO2-154* PCO2-33* PH-7.32* TOTAL CO2-18* BASE XS--8 [**2130-5-23**] 03:58PM LACTATE-1.1 [**2130-5-23**] 03:58PM freeCa-1.07* [**2130-5-23**] 03:36PM URINE HOURS-RANDOM UREA N-263 CREAT-140 SODIUM-28 POTASSIUM-96 CHLORIDE-<10 AMYLASE-427 TOT PROT-35 CALCIUM-6.4 PHOSPHATE-42.3 MAGNESIUM-5.8 URIC ACID-10.4 TOTAL CO2-LESS [**First Name8 (NamePattern2) **] [**Doctor First Name 674**]/CREAT-3.1 PROT/CREA-0.3* [**2130-5-23**] 03:36PM URINE OSMOLAL-374 [**2130-5-23**] 03:36PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016 [**2130-5-23**] 03:36PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2130-5-23**] 03:36PM URINE RBC-5* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2130-5-23**] 03:36PM URINE GRANULAR-4* HYALINE-4* [**2130-5-23**] 03:36PM URINE MUCOUS-RARE [**2130-5-23**] 01:10PM TYPE-ART PO2-356* PCO2-30* PH-7.33* TOTAL CO2-17* BASE XS--8 [**2130-5-23**] 01:10PM LACTATE-1.0 [**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL CO2-21 BASE XS--5 [**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL CO2-21 BASE XS--5 [**2130-5-23**] 12:56PM freeCa-1.10* [**2130-5-23**] 12:40PM GLUCOSE-125* UREA N-32* CREAT-2.9* SODIUM-138 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15 [**2130-5-23**] 12:40PM estGFR-Using this [**2130-5-23**] 12:40PM ALT(SGPT)-2376* AST(SGOT)-[**2124**]* LD(LDH)-2404* ALK PHOS-54 AMYLASE-496* TOT BILI-0.4 [**2130-5-23**] 12:40PM LIPASE-66* [**2130-5-23**] 12:40PM CK-MB-14* cTropnT-0.03* [**2130-5-23**] 12:40PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-1.2* MAGNESIUM-1.7 [**2130-5-23**] 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-11 bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2130-5-23**] 12:40PM WBC-14.3* RBC-3.22* HGB-9.9* HCT-30.1* MCV-93 MCH-30.7 MCHC-33.0 RDW-14.0 [**2130-5-23**] 12:40PM NEUTS-87.5* LYMPHS-8.5* MONOS-3.7 EOS-0 BASOS-0.2 [**2130-5-23**] 12:40PM PLT COUNT-127* [**2130-5-23**] 12:40PM PT-20.0* PTT-40.8* INR(PT)-1.9* [**2130-5-23**] 12:40PM FIBRINOGE-281 [**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29 POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7 [**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29 POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7 [**2130-5-23**] 12:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG . DISCHARGE LABS: [**2130-6-11**] 05:40AM BLOOD WBC-15.2* RBC-3.21* Hgb-9.7* Hct-30.4* MCV-95 MCH-30.1 MCHC-31.8 RDW-15.4 Plt Ct-594* [**2130-6-11**] 05:40AM BLOOD Glucose-83 UreaN-4* Creat-0.6 Na-136 K-3.9 Cl-101 HCO3-24 AnGap-15 [**2130-6-8**] 02:04AM BLOOD ALT-63* AST-31 AlkPhos-68 TotBili-0.7 [**2130-6-11**] 05:40AM BLOOD Albumin-3.0* Calcium-9.2 Phos-3.5 Mg-1.5* . CARDIOLOGY; The left atrium is normal in size. There is mild 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . RADIOLOGY Radiology Report CT HEAD W/O CONTRAST Study Date of [**2130-5-23**] 4:19 PM : IMPRESSION: 1. No acute intracranial process. 2. Prominence of the ventricles and sulci, inappropriate for the patient's age. . [**2130-5-27**] 12:51 am URINE Source: Catheter. **FINAL REPORT [**2130-5-31**]** URINE CULTURE (Final [**2130-5-31**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMPICILLIN------------ 8 S <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S 32 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S Brief Hospital Course: She was admitted to the SICU at [**Hospital1 18**] on [**2130-5-23**]. The NAC drip was continued and she was evaluated by transplant surgery and hepatology. She was deemed not a transplant candidate given her suicide attempts but aggressive supportive care was maintained. Her course, by systems: . Neuro: Per reports, she was AAOx3 on presentation to the OSH but became increasingly obtunded and especially after her radial artery repair at the OSH. At [**Hospital1 18**], she became progressively more responsive though demonstrated limited movement of her extremities. She received flumazenil initially and was believed to be improving; the flumazenil was therefore held. The tylenol level was 11 on admission (33 at the OSH) and trended downward; the NAC drip was dc'd on [**5-25**]. On [**5-27**] she was noted to be less responsive in the AM than prior and a STAT Head CT demonstrated no changes. She gradually improved over the course of the day into the next morning, following commands and ultimately moving her extremities. She was extubated on [**2130-5-29**] and was alert and interactive though demonstrating slight confusion. Her confusion resolved and she was alert and oriented x 3 for the rest of the hospitalization. . Psych: Consulted for evaluation after extubation. They determined the pt to be unsafe for home discharge considering her suicide attempt. She was placed under section 12, had 1:1 sitter at all times while an inpatient. She was discharged to inpatient psych facility following this hospitalization. . CV: Baseline hypertension on home atenolol but allowed to be hypertensive to the 160s (treated with metoprolol around the clock/labetalol only for SBP>160) to allow for improved perfusion to the extremities. She was ultimately transitioned to nifedipine q8 during this hospitalization and her BP was allowed to be mildly elevated w/ sbps in 140s-150s to allow for better perfusion of her extremities during surgery. She was discharged with orders to restart her atenolol dose. . Resp: She was weaned on the vent and tolerating CPAP 5/5 as of [**5-28**]. She was noted to have a small left apical pneumothorax on CXR [**5-25**]. It was followed by serial CXR and had decreased in size on [**5-26**] and remained stable. She was extubated on [**5-29**]. She was weaned successfully to room air and remained that way during the rest of this hospitalization. . GI: Her LFTs trended downwards during her admission. Initially she presented with ALT 2376 AST [**2124**] AP 54 Tb 0.4 and a lipase of 66. By [**5-28**] ALT/AST were 432/112. Her Tb and AP remained within normal limits. Following administration of NAC her LFTs normalized. She was tolerating a regular diet and having normal Bowel movements at time of discharge. . GU: She was in acute renal failure on admission with a Cr of 2.9. She was hydrated with progressive improvement. Cr was 0.6 as of [**5-28**]. She received lasix 10 IV BID to good effect on [**5-31**]. Her kidney function remained normal throughout the rest of the admission. . Endo: She was maintained on RISS and methylprednisolone 12 mg daily (to account for her home prednisone) initially then switched to Prednisone 15mg daily, her home dose. . Heme: LENIS on [**5-26**] due to perceived asymmetry of RLE vs. LLE on exam (RLE>LLE), it was negative for DVT. She was started on a heparin drip after her ulnar artery revision on [**5-23**] and this was continued until [**5-31**]. Patient was then maintained on subcutaneous heparin injections and encouraged to ambulate as much as possible during the remainder of her inpatient stay. . ID: Febrile on admission to 103.8. She was pan cultured (cultures did not grow anything) and continued to spike low-grade fevers until [**5-27**] when she spiked a temperature of 102.0. She was re-cultured again, including sputum culture, and was started empirically on vanc/cefepime. Her urine culture returned positive for e.coli and enterococcus which were both pan sensitive. She completed a five day course of Ceftriaxone. The rest of her cultures were negative during this admission. . Upper Extremities: As noted, she had bilateral lacerations with repair of the radial artery injuries at the OSH. At [**Hospital1 18**], she was urgently taken back to the OR on [**2130-5-23**] for exploration and repair of her left ulnar and radial arteries (thrombosed). Post-operatively, she demonstrated ischemic gangrene of the left hand along the ulnar artery distribution. She returned to the OR on [**2130-6-6**] for surgical debridement for necrotic tissue of the left hand. Patient had a wound vac in place to her left hand wound but exhibited poorly healing granulation tissue, exposed bone, tendon and nerve. She ultimately requested a left hand amputation after lengthy discussion of poor healing and utility prognosis for her left hand. Patient underwent a left below elbow amputation on [**2130-6-13**] and tolerated this well. Her left forearm stump sutures were clean and intact upon discharge. The patient's right hand did not require any surgical intervention on our part and continued to heal well and gain full function after her reparative surgery at [**State 792**]Hospital. Medications on Admission: 1. Atenolol 50 mg PO DAILY 2. PredniSONE 15 mg PO DAILY 3. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain 4. Klonopin (clonazepam, alprazolam, ambien, and fluvoxamine in the past) Discharge Medications: 1. PredniSONE 15 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 600 mg PO TID 4. Nicotine Patch 14 mg TD DAILY 5. OLANZapine 2.5 mg PO HS 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 7. Pantoprazole 40 mg PO Q24H 8. Senna 1 TAB PO BID:PRN constipation 9. Atenolol 50 mg PO DAILY Discharge Disposition: Extended Care Discharge Diagnosis: 1) acute liver failure s/p suicide attempt (acetaminophen overdose) 2) acute renal failure 3) left hand ischemia 4) right wrist laceration Discharge Condition: Alert and oriented x 3 Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were recently admitted to the hospital for acute liver failure and treatment for bilateral wrist lacerations. Your liver function recovered well and is now normalized. Unfortunately, the damage to your left hand was irreversible and you required an amputation to the [**Last Name (un) **] of your mid-forearm. You have sutures in place to that wound and these will need to be removed in 2 weeks at your follow up visit to our Hand Clinic. Your right wrist laceration, repaired at another hospital, has healed well and your sutures have now been removed. . * Your left forearm sutures may be left open to air, without a dressing. * If you note swelling of your left arm, then you should elevate it above the level of your heart to help alleviate this. * You may shower. * You should continue to increase your walking to increase your stamina after your inpatient hospital stay. * Monitor your left forearm suture site for any signs of infection; redness, increased pain at site, swelling, and drainage. Any evidence of infection should be reported to Plastic/Hand surgery team: [**Telephone/Fax (1) 9986**] Pager [**Numeric Identifier 88994**] Followup Instructions: You should follow up with Primary Care Provider after discharge to review the details of your recent hospitalization. . You will need to follow up in our hand clinic in two weeks to remove the sutures from left arm. DATE: Tuesday, [**2130-6-27**] TIME: 9AM LOCATION: Dept of Orthopaedics, [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **] NUMBER: ([**Telephone/Fax (1) 2007**] The clinic is open from 8-12pm most Tuesdays. The clinic is located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. Completed by:[**2130-6-14**] ICD9 Codes: 5849, 2762, 5990, 4019, 3051
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Medical Text: Admission Date: [**2189-12-24**] Discharge Date: [**2189-12-30**] Date of Birth: [**2124-7-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Scapular pain Major Surgical or Invasive Procedure: [**2189-12-24**] Redo-Sternotomy, Coronary Artery Bypass Graft x 3 (SVG to Diag to OM, SVG to PDA), Aortic Valve Replacement w/ 25mm CE Magna pericardial tissue valve History of Present Illness: 65 y/o male s/p CABG in [**2179**] now experiencing mild scapular back pain. Cardiac cath revealed severe native coronary artery disease with patent grafts. Echo performed showed severe aortic stenosis with a valve are of 0.7cm2. He was then referred for surgical intervention. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft [**2179**], s/p PTCA of RCA [**2178**], Hypertension, Hypercholesterolemia, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Anemia, s/p Anal fistulotomy Social History: Patient smoked one ppd x 53 years, quit in [**2189-5-23**] Divorced and lives alone. He has four children. Retired, used to work as a cop. Family History: Father died at age 77 from an MI. Mother was diabetic and had an MI in her 70's. Physical Exam: VS: 70 14 140/80 5'9" 220# Skin: Unremarkable with well-healed MSI HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR, 4/6 SEM Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, 2+ pulses throughout, -edema or varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2189-12-24**] Echo: PRE-CPB: The left atrium is mildly dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. Right ventricular systolic function is normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. No masses or vegetations are seen on the aortic valve. There is moderate aortic valve stenosis (area 0.8-1.19cm2) Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. POST-CPB: On phenylephrine infusion. There is a well-seated bioprosthetic valve in the aortic position with no AI seen. Flow is seen in the LMCA. The measured gradient across the aortic valve is now 6 mmHg. There is preserved biventricular systolic function. LVEF 65%. There is no [**Male First Name (un) **]. MR is trace. The aortic contour is normal post decannulation. [**2189-12-29**] CXR: Bilateral pleural effusions have significantly decreased in size since prior exam. Small bilateral pleural effusions remain. The cardiac silhouette, mediastinal and hilar contours are stable in size status post CABG and AVR. The pulmonary vasculature is normal and there is no pneumothorax. No consolidations are seen bilaterally. [**2189-12-24**] 01:33PM BLOOD WBC-13.8*# RBC-3.33*# Hgb-7.3*# Hct-22.3*# MCV-67* MCH-21.9* MCHC-32.8 RDW-15.0 Plt Ct-65*# [**2189-12-26**] 05:10PM BLOOD WBC-8.2 RBC-2.90* Hgb-6.5* Hct-19.3* MCV-67* MCH-22.3* MCHC-33.6 RDW-15.5 Plt Ct-110* [**2189-12-30**] 05:50AM BLOOD WBC-7.4 RBC-3.51* Hgb-8.5* Hct-24.9* MCV-71* MCH-24.3* MCHC-34.3 RDW-18.7* Plt Ct-273# [**2189-12-24**] 01:33PM BLOOD PT-19.5* PTT-50.7* INR(PT)-1.9* [**2189-12-28**] 06:25AM BLOOD PT-16.0* INR(PT)-1.5* [**2189-12-29**] 06:10AM BLOOD PT-35.0* INR(PT)-3.8* [**2189-12-29**] 10:55AM BLOOD PT-43.4* INR(PT)-5.0* [**2189-12-30**] 05:50AM BLOOD PT-32.3* INR(PT)-3.5* [**2189-12-24**] 03:18PM BLOOD Glucose-93 UreaN-11 Creat-0.6 Cl-115* HCO3-28 [**2189-12-30**] 05:50AM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-139 K-4.1 Cl-100 HCO3-33* AnGap-10 Brief Hospital Course: Mr. [**Known lastname 80687**] was a same day admit (underwent pre-op work-up as on outpatient) and was brought directly to the operating room where he underwent a redo coronary artery bypass graft x 3 and aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. He was then transferred to the telemetry floor. On post-op day three his chest tubes and epicardial pacing wires were removed. Post-op his HCT was low and on day three it was 19. He was therefore transfused with several units of blood. By discharge it was 24.9. Also on post-op day three he had an episode of atrial fibrillation. He was bolused with Amiodarone and given Lopressor. Lopressor was titrated, Amiodarone was eventually given PO and he was started on Heparin. Coumadin was started on post-op day four and titrated for goal INR between [**12-26**]. INR abruptly rose up to 5 by post-op day five and Coumadin was held and INR trended down towards therapeutic level by discharge. On post-op day five antibiotics were started d/t left arm phlebitis. Physical therapy followed patient during entire post-op course for strength and mobility. He appeared to be doing well on post-op day six and was discharged home with VNA services and the appropriate follow-up appointments. Dr. [**Last Name (STitle) **] was contact and will manage his Coumadin as an outpatient. Medications on Admission: Aspirin 325mg qd, Benicar 40mg qd, Avandamet 500mg qd, Ninpeolomine 3mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*1* 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg [**Hospital1 **] for 1 week. Then 200mg [**Hospital1 **] for 1 week. Then 200mg QD until stopped by your cardiologist. Disp:*60 Tablet(s)* Refills:*1* 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 10 days. Disp:*30 Capsule(s)* Refills:*0* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 14. Nifedipine (Bulk) Powder Sig: One (1) Miscellaneous TID (3 times a day) as needed for anal fissures: 0.2% gel rectally for anal fissures. Disp:*30 1* Refills:*0* 15. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*90 Packet(s)* Refills:*0* 16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Adust dosage according to Dr. [**Last Name (STitle) **]. Goal INR 2-3.0. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Coronary Artery Disease/Aortic Stenosis s/p Redo-Sternotomy, Coronary Artery Bypass Graft x 3, Aortic Valve Replacement PMH: s/p Coronary Artery Bypass Graft [**2179**], s/p PTCA of RCA [**2178**], Hypertension, Hypercholesterolemia, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Anemia, s/p Anal fistulotomy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Dr. [**Last Name (STitle) **] will manage your Coumadin. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) **] in 2 weeksProvider: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-1-29**] 12:00 Completed by:[**2189-12-30**] ICD9 Codes: 4241, 9971, 496, 2859, 4019
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Medical Text: Admission Date: [**2167-11-8**] Discharge Date: [**2167-11-17**] Date of Birth: [**2092-9-7**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 74-year-old man with known coronary artery disease status post RCA stent in [**2164-8-11**]. He presented to an outside hospital in the afternoon of [**2167-11-8**], with chest pain that began in the morning with minimal exertion. He states the chest pain was accompanied by shortness of breath, diaphoresis and pallor with radiation to both of his arms. In the Emergency Department he was noted to have ST elevation in 2, 3 and AVF and he was transferred to the [**Hospital1 188**] for cardiac catheterization. Catheterization demonstrated a left main stenosis of 40 percent, LAD 70 percent, proximal with mid stenosis, 80 percent, left circumflex 60 percent, intermedius 70 percent, RCA 95 percent, mid PDA at 60 percent. At that time he was referred to the cardiac surgery service for evaluation for coronary artery bypass grafting. He remained an in-patient, undergoing evaluation for cardiac surgery until [**2167-11-12**], when he underwent a CABG x 3. PAST MEDICAL HISTORY: Significant for coronary artery disease status post stent in [**2164-8-11**], hypertension, hyperlipidemia, gastroesophageal reflux disease, benign prostatic hypertrophy and cataracts. ALLERGIES: INTEGRILIN CAUSES LOW PLATELETS AND PENICILLIN CAUSES RASH MEDICATIONS PRIOR TO ADMISSION: Aspirin 81 mg daily Lipitor 10 mg daily Lopressor, unknown dose Multivitamin daily PHYSICAL EXAMINATION: On admission his examination showed a heart rate in the 70s, sinus rhythm. BP 110-130/70-80. General appearance was within normal limits. Neck with no JVD. Respiratory good effort and clear to auscultation. Neurologic alert and oriented with good mood and affect. Cardiovascular examination revealed a regular rate and rhythm with S1 and S2, no MR or G. GI, abdomen soft and nontender, nondistended with positive bowel sounds. Post catheterization he was noted to have a 1 cm x 1 cm right groin hematoma with good pulses and distal extremities. SUMMARY OF HOSPITAL COURSE: As above in HPI. The patient proceeded to the Operating Room on [**2167-11-12**] and underwent a CABG x 3 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with a LIMA to the LAD saphenous vein graft, diagonal and saphenous vein graft to the PDA. Total cardiopulmonary bypass time of seventy-four minutes and a cross-clamp time of forty-six minutes. He was transferred to the cardiac surgery recovery room in a normal sinus rhythm, rate of 86, MAP of 70 and CVP of 3 on Neo- Synephrine and propofol drips for support. The evening of his surgical day was uneventful with successful extubation, weaning of his IV drips, medications, discontinuation of his Foley catheter and he was transferred to the in-patient floor on postoperative day one. Postoperative day two continued with physical therapy, increasing activity level, increase of his Lopressor dose and discontinuation of his chest tubes and temporary cardiac pacing wires. Postoperative day three and four were significant only for patient complaints of increasing acid reflux, not found to be related to cardiac etiology and treated with p.o. Zantac with good relief. The physical therapy team followed Mr. [**Known lastname **] throughout his hospital stay and on [**2167-11-16**] found that he was familiar with the activity guidelines and was safe for discharge home having met all goals of evaluation. On postoperative day five, [**2167-11-17**], Mr. [**Known lastname **] was found to be medically ready for home and was discharged with a visiting nurse. CONDITION ON DISCHARGE: Vital signs: Temperature 98.8, pulse 80 and sinus rhythm, BP 109/75, respiratory rate 18, oxygen saturation 95 percent on room air. Weight 73 kg, up from preoperative weight of 69 kg. Physical exam: Neurologic - alert and oriented, nonfocal. Pulmonary - lungs clear bilaterally. Cardiac - regular rate and rhythm, S1 and S2. Sternal incision without drainage or erythema. Sternum stable and incision with Steri-Strips. Abdomen - soft, nontender and nondistended with positive bowel sounds. Extremities - warm without edema. Left leg incision clean and dry with Steri-Strips intact. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass graft times three. Hypertension. Hyperlipidemia. Gastroesophageal reflux disease. Benign prostatic hypertrophy. Cataracts. Bladder neck contractures. DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily for fourteen days Calcium chloride 20 mEq p.o. daily for fourteen days Colace 100 mg p.o. b.i.d. Aspirin 81 mg p.o. daily Plavix 75 mg p.o. daily Lipitor 10 mg p.o. daily Polysaccharide-iron complex 150 mg p.o. daily Vitamin C 500 mg p.o. b.i.d. for one month Folic acid 1 mg p.o. daily for one month Flomax 0.4 mg capsule p.o. daily Hydromorphone 2 mg tablets, 1-2 tablets p.o. q.4-6h prn Lopressor 25 mg p.o. b.i.d. FOLLOW UP: The patient was discharged with visiting nurses association. He will return to the postoperative wound clinic in two weeks and plans to followup with Dr. [**Last Name (STitle) 5310**], in three to four weeks and Dr. [**Last Name (STitle) 70**], in six weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) 28068**] MEDQUIST36 D: [**2167-11-17**] 12:33:23 T: [**2167-11-17**] 14:23:39 Job#: [**Job Number 35868**] ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-24**] Date of Birth: [**2061-12-10**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 67 year old man with a history of coronary artery disease, peripheral vascular disease, status post bilateral above the knee amputation, chronic renal insufficiency, diabetes mellitus, abdominal aortic aneurysm, who presented with a two day history of cough, and one day of nausea and vomiting without producing any sputum. The patient also noted feeling hot and experiencing diaphoresis. He awoke on the day of admission and ate a normal breakfast and felt nauseated and vomited once. He was [**Doctor Last Name 352**], he denied hematemesis, hemoptysis, diarrhea, bright red blood per rectum, melena or abdominal pain or dysuria. The patient called his primary care physician and was referred to an outside hospital where he was evaluated and found to have increased creatinine to 2.1, baseline in the high 1.0 range, and a potassium of 6.2. He also had increased amylase and lipase of 188 and 368. His CPK was 88 and troponin I was 0.9. At the outside hospital, he subsequently became hypotensive into the 70s systolic and tachycardic into the 120s. He was placed on Dopamine and transported to [**Hospital1 69**] for further management. Symptoms were felt to be secondary to pancreatitis with acute on chronic renal failure and hyperkalemia. Chest x-ray was clear and electrocardiogram was without changes. PAST MEDICAL HISTORY: 1. Coronary artery disease with a myocardial infarction in [**2104**], coronary artery bypass graft in [**2112**], most recent ejection fraction was 15 to 20%. 2. History of Guillain-[**Location (un) **] disease. 3. History of peripheral vascular disease, status post bilateral above the knee amputation. 4. Ischemic bowel in [**2121**]. 5. Ischemic colitis [**10/2128**]. 6. Chronic renal insufficiency with creatinine 1.9 to 2.4. 7. Diabetes mellitus, type II. 8. Abdominal aortic aneurysm with a right iliac aneurysm. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Lopressor 50 milligrams once a day. 2. Zestril 10 milligrams once a day. 3. Lasix 20 milligrams once a day. 4. Aldactone 25 milligrams once a day. 5. Protonics 40 milligrams once a day. 6. Enteric Coated Aspirin 325 milligrams once a day. 7. Lipitor 40 milligrams once a day. 8. Iron 325 milligrams once a day. 9. Digoxin 250 once a day. 10. Allopurinol 300 milligrams once a day. TRANSFER MEDICATIONS: 1. Subcutaneous Heparin. 2. Enteric Coated Aspirin 325 milligrams once a day. 3. Allopurinol 300 milligrams once a day. 4. Lipitor 40 milligrams once a day. 5. Digoxin 0.25 milligrams once a day. 6. Colace 100 milligrams twice a day. 7. Prilosec 20 milligrams once a day. LABORATORY DATA: On admission to [**Hospital1 190**] were troponin 0.9, CK 88. Chem7 revealed sodium 133, potassium 6.2, chloride 96, bicarbonate 25, blood urea nitrogen 56, creatinine 2.9. White count 7.4, hematocrit 43.0, amylase 188, lipase 368, total bilirubin 0.6, ALT 15, AST 19, alkaline phosphatase 132. INR was 1.1,. Chest x-ray was without infiltrate or congestive heart failure. KUB showed no ileus and no free air. HOSPITAL COURSE: In the Medical Intensive Care Unit, the patient's hypotension responded well to boluses of intravenous fluid. The following day he was ready for transfer to the floor. The patient did well on the floor tolerating a regular diet by his second day on the floor. He had an abdominal CT scan to rule out pancreatic phlegmon and had no abdominal tenderness. His lipase and amylase trended steadily downward. In addition, his blood urea nitrogen and creatinine returned toward their baseline values with a creatinine on the day of discharge being 2.1. The patient was discharged in stable condition. He will follow-up with Doctor [**Doctor Last Name 11679**] one week after discharge. DISCHARGE MEDICATIONS: 1. Lopressor 50 milligrams once a day. 2. Zestril 10 milligrams once a day. 3. Lasix 20 milligrams once a day. 4. Aldactone 25 milligrams once a day. 5. Protonics 40 milligrams once a day. 6. Enteric Coated Aspirin 325 milligrams once a day. 7. Lipitor 40 milligrams once a day. 8. Iron 325 milligrams once a day. 9. Digoxin 250 once a day. 10. Allopurinol 300 milligrams once a day. DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Hypotension. 3. Chronic renal insufficiency. 4. Acute renal failure. 5. Diabetes mellitus. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 21980**] Dictated By:[**Name8 (MD) 19393**] MEDQUIST36 D: [**2129-1-24**] 15:05 T: [**2129-1-24**] 19:33 JOB#: [**Job Number 29294**] ICD9 Codes: 5849, 2767, 5990, 2765, 4280
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Medical Text: Admission Date: [**2109-4-24**] Discharge Date: [**2109-5-12**] Date of Birth: [**2109-4-24**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [**Known lastname 2398**] [**Known lastname 25731**] is a former 2.06-kilogram product of a 32 and [**7-1**] week gestation pregnancy born to a 40-year-old gravida 2, para 1 (now 2), woman. PRENATAL SCREENS: Blood type A positive, antibody negative, Rubella immune, rapid plasma reagin nonreactive, hepatitis B surface antigen negative, and group B strep status unknown. The pregnancy was complicated by elevated blood pressures. The mother went into spontaneous labor. Rupture of membranes occurred two hours prior to delivery. The mother was treated for unknown group B strep status with antepartum antibiotics. The infant by spontaneous vaginal delivery. Apgar scores were 8 at one minute and 9 at five minutes. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION ON PRESENTATION TO NEONATAL INTENSIVE CARE UNIT: Weight was 2.060 kilograms (50th percentile), length was 44 cm (50th percentile), and head circumference was 31.5 cm (50th percentile). In general, a nondysmorphic preterm infant. Skin intact. No rashes or lesions. Head, eyes, ears, nose, and throat examination revealed anterior fontanelle open and flat. Symmetric facial features. Positive red reflex bilaterally. Palate was intact. Chest revealed mild subcostal retractions and audible grunting. Lungs with slightly diminished breath sounds. Cardiovascular examination revealed no murmurs. A regular rate and rhythm. Pulses were 2+ and equal. Abdomen revealed no hepatosplenomegaly. A 3-vessel cord. No masses. Genitourinary revealed testes descended bilaterally. Normal phallus. The anus was patent. Trunk and spine were intact. Extremity examination revealed moving all extremities and well perfused. The hips were stable. Neurological examination revealed activity and reflexes consistent with gestational age. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (INCLUDING LABORATORIES): 1. RESPIRATORY ISSUES: [**Known lastname 2398**] had increased work of breathing over the first few hours in the Neonatal Intensive Care Unit. He was placed on continuous positive airway pressure. He maintained adequate oxygenation on room air. He remained on continuous positive airway pressure through day of life two. He briefly required nasal cannula oxygen on day of life three and then weaned to room air on day of life four and continued on room air throughout the remainder of his Neonatal Intensive Care Unit admission. He had mild apnea of prematurity, with the last episodes on [**2109-4-27**]; he never required methylxanthine treatment. At the time of discharge, he was on room air with comfortable respirations with a rate of 30 to 50. 2. CARDIOVASCULAR ISSUES: [**Known lastname 2398**] has maintained normal heart rates and blood pressures. No murmurs have been noted during admission. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: [**Known lastname 2398**] was initially nothing by mouth. Enteral feedings were started on day of life two and gradually advanced to full volume. He has been breast feeding or feeding expressed breast milk fortified to 24 calories per ounce. At 48 hours prior to discharge, he has been almost exclusively breast feeding and manifests better coordination with breast than bottle feeds. After discharge, we recommend that supplementation, if needed, be accomplished with expressed breast milk fortified to 24 per ounce with cow-milk-based formula powder such as Enfamil or Similac. He would be a good candidate for a supplemental nursing system rather than bottled supplements. Serum electrolytes were checked in the first week of life and were within normal limits. Discharge weight was 2.425 kilograms, with a length of 49.5 cm, and a head circumference of 33.25 cm. 4. INFECTIOUS DISEASE ISSUES: Due to the unknown etiology of the respiratory distress, and unknown group B strep status of the mother, [**Name (NI) 2398**] was evaluated for sepsis at the time of admission. His white blood cell count was 14,400 with a differential of 27% polymorphonuclear cells and 0% band neutrophils. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth at 48 hours, and antibiotics were discontinued. 5. GASTROINTESTINAL ISSUES: [**Known lastname 2398**] required treatment for unconjugated hyperbilirubinemia with phototherapy. His peak serum bilirubin occurred on day of life six, a total of 14.4/0.3 mg/dL. He continued on phototherapy for approximately eight days. His rebound bilirubin on [**2109-5-5**] was 9.3 total over 0.5 direct. A repeat on [**2109-5-7**] had a total of 11, a direct of 0.2, for an indirect of 10.8. He appears clinically well, and our impression was that this was likely prolonged physiologic jaundice as well as possibly breast milk jaundice. 6. HEMATOLOGIC ISSUES: Hematocrit at birth was 60% and on [**5-1**] (day of life 7) was 52.2%. [**Known lastname 54539**] blood type is A positive, and his direct Coombs was negative. He did not receive any transfusions of blood products during admission. 7. NEUROLOGIC ISSUES: [**Known lastname 2398**] has maintained a normal neurological examination during this admission, and there were no neurologic concerns at the time of discharge. 8. SENSORY/AUDIOLOGY ISSUES: A hearing screen was performed with automated auditory brain stem responses, and [**Known lastname 2398**] passed in both ears. 9. PSYCHOSOCIAL ISSUES: The parents have been involved during discharge, and there were no social concerns at the time of discharge. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 2312**] Pediatric Associates, [**Apartment Address(1) 54540**], [**Location (un) 538**], [**Numeric Identifier 41119**] (telephone number [**Telephone/Fax (1) 37109**]; fax number [**Telephone/Fax (1) 37110**]). CARE A RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: On demand breast feeding or breast feeding and supplementation if needed with mom's milk fortified to 24 calories per ounce with powdered cow-milk-based formula. 2. Medications: Ferrous sulfate (25 mg/mL solution), 0.2 mL by mouth once per day. 3. Car seat position screening was performed - [**Known lastname 2398**] was observed in his car seat for 90 minutes without any episodes of bradycardia or oxygen desaturation. 4. State newborn screen was sent on [**4-27**] and on [**2109-5-7**] with no notification of abnormal results to date. 5. Parents have declined hepatitis B vaccine at this time. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with 2/3 of the following: plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings; and/or (3) with chronic lung disease. Influenza immunization should be considered annually in the Fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers to protect the infant. DISCHARGE INSTRUCTIONS/FOLLOWUP: Visit with primary pediatric provider within five days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 32 and 6/7 weeks gestation. 2. Respiratory distress secondary to retained fetal lung fluid, resolved. 3. Status post sepsis evaluation. 4. Status post unconjugated hyperbilirubinemia. 5. Apnea of prematurity, resolved. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**First Name (Titles) **] [**Last Name (Titles) 42702**] 50-563 Dictated By:[**Last Name (Titles) 37548**] MEDQUIST36 D: [**2109-5-12**] 07:11 T: [**2109-5-12**] 10:45 JOB#: [**Job Number 54541**] ICD9 Codes: V290, 7742
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Medical Text: Admission Date: [**2177-10-13**] Discharge Date: [**2177-11-17**] Date of Birth: [**2177-10-13**] Sex: M Service: NEONATOLOGY HISTORY: This is the 1.315 kg product of a 28 [**1-9**] week twin gestation, born to a 27-year-old GI P0-II mother. Prenatal screens notable for maternal blood type A positive, antibody surface antigen negative, group B strep unknown. This is a Ultrasound at 23 weeks showed size discordance, attributed to twin-twin transfusion syndrome. Subsequent ultrasound showed increasing oligohydramnios but good biophysical profiles. The mother completed steroid therapy. These patients were delivered by cesarean section. Twin I emerged apneic but minutes. 1. Respiratory: The child was intubated and given 2 doses of surfactant, and rapidly weaned to CPAP and then nasal cannula. Intermittently the child had to go back on CPAP for increased spelling. He was started on caffeine and subsequently weaned onto nasal cannula on DOL #16 and onto RA on DOL#34. He is currently on caffeine. He has occasional spells. 2. Fluids, electrolytes and nutrition: He was initially nil by mouth and started on intravenous fluids. His feeds were advanced as tolerated .He is currently tolerating 150 cc/kg of PE28 with ProMod po/pg. 3. Infectious Disease: The patient had started antibiotics. Culture were negative at 48 hours, and these were discontinued. When he had increased spells, repeat CBC and blood cultures were done, but no further antibiotics were started. He is currently off all antibiotic therapy. 4. Cardiovascular: He never required blood pressure support, although he did have a murmur and was given a course of indomethacin. His murmur persisted. An echocardiogram was performed, which showed that he had a mild biventricular outflow obstruction, probably secondary to hypovolemia, but no structural heart disease and no duct. Repeat ECHO on DOL#28 revealed improved but mild biventricular hypertrophy, which will need to be followed as an outpatient at the Cardiology Clinic. 5. Hematology: He received a blood transfusion of 50 cc/kg since his hematocrit was relatively low and his echocardiogram was consistent with hypovolemia. He did require phototherapy for hyperbilirubinemia, however, at this time, he is off of phototherapy, with normal bilirubin levels. 6. Neurology: HUS on [**10-15**] and [**10-23**] were within normal limits Follow up HUS on [**2177-11-13**] revealed caudothalamic groove cyst PHYSICAL EXAMINATION: He is 2.170kg, he is non-dysmorphic. His cardiac examination shows a II/VI systolic murmur, regular rate and rhythm. His lung examination is clear bilaterally. His abdomen is soft and nondistended. The rest of his physical examination is within normal limits. CONDITION AT THE TIME OF THIS SUMMARY: Stable. FOLLOW UP 1. Paediatric Cardiology in mid [**Month (only) **] to F/U biventricular hypertrophy- parents will need to call for appointment 2. ROP screen on [**2177-11-19**] MEDICATION Caffeine 15mg po/pg qd Vit E 5 IU po/pg qd Ferrinsol 0.15cc po/pg qd DIAGNOSIS LIST: 1. Prematurity 2. Status post twin-twin transfusion 3. Mild apnea of prematurity 4. Status post rule out sepsis 5. Mild biventricular hypertrophy 6. Right subependymal cysts with resolved bilateral germinal matrix haemorrhages DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477 Dictated By:[**Name8 (MD) 45197**] MEDQUIST36 D: [**2177-10-31**] 17:56 T: [**2177-11-1**] 00:00 U: [**2177-11-17**] 09:00 JOB#: [**Job Number 35882**] ICD9 Codes: 7742
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Medical Text: Admission Date: [**2154-12-14**] Discharge Date: [**2155-1-4**] Date of Birth: [**2074-11-21**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1973**] Chief Complaint: Delta MS, respiratory distress Major Surgical or Invasive Procedure: R chest tube place Intubation and mechanical ventilation R IJ central line placed L SC central line placed PICC line placed History of Present Illness: 80yo M with h/o hyperlipidemia, RA, new diagnosis of glioblastoma multiforme (grade 4) p/w altered mental status and respiratory distress. He was diagnosed in [**Month (only) 1096**] with GBM (by biopsy) in the setting of increasing confusion, memory loss. He was started in [**Month (only) 1096**] on high dose radiation therapy at which time he was also started on high dose decadron w/ q3day taper (most recently on 3mg); last radiation session was late [**Month (only) 1096**]. He also recently had a port placed through which he was receiving avastin (last 2 weeks ago). His family reports mildly productive cough (cold sx) beginning approximately 1 week ago; he had a CXR 3-4 days ago which reportedly was negative for pneumonia and took atovaquone. . After the onset of these pulmonary symptoms, he later developed left knee "bursitis" last week for which he received injection most recently yesterday by PCP (presumably steroid injection). He had largely been bed bound over the last few days [**1-4**] to left knee pain. Beginning this morning, he was very exhausted. He took a nap this morning and when he awoke, he was confused, somnolent, lethargic. His wife called EMS and he was transferred to [**Hospital1 18**] ED. En route to the ED, he was noted to be in a.fib with RVR for which he received diltiazem. . In the ED initial vitals were T 96.7 HR 112 BP 105/67 RR 28 O2 sat 85% RA. CXR showed multifocal PNA at RUL, RLL, LLL. He was placed on NRB and shortly thereafter O2 sats again dropped to the 80s, thus he was intubated 4:30 pm. Blood cultures were drawn and he received levofloxacin 750g IV x1, vancomycin 1g IV x1, ceftriaxone 1g IV x1, and azithromycin 500mg x1. He also received 10mg IV decadron. He was initially normotensive, but dropped pressure at 6:30 pm into 70s requiring initiation of phenylephrine gtt. Over his entire ED course, received total 5L NS. . Head CT demonstrated "no new findings" and was reportedly reviewed by [**Hospital1 18**] neurosurgery however there is no note in chart/OMR. Additionally he was seen by his neurologist who follows him at [**Hospital1 2025**], however there is no documentation of this. Past Medical History: # Grade 4 glioblastoma multiforme left temporal lobe; s/p high dose radiotherapy, previously on high dose steroids, recently tapered. Recently placed Portacath with steristrips still present. # Rheumatoid arthritis; on remicade until recently # L knee bursitis # Hyperlipidemia Social History: Lives at home with wife. [**Name (NI) **] and daughter-in-law (who is [**Name8 (MD) **] MD) live locally. Smoking, Etoh history unknown. Family History: nc Physical Exam: S: Temp: 97.2 BP: 99/69 HR: 138 a. fib RR: 22 O2sat 92% AC 500/19 PEEP 14 FiO2 1.0 GEN: Intubated, unresponsive on minimal sedation HEENT: Pupils pinpoint, symmetric, unresponsive to light, scleral mildy icteric, dry MM, Multiple pinpoint white plaques on roof of mouth NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules CHEST: Portacath site right anterior chest with steri strips in place, mildly erythematous, no significant increase warmth/induration/fluctuance RESP: Clear anteriorly, decrease BS right laterally, no wheezing/rales CV: irreg irreg, no mrg appreciated ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ pedal edema b/l, right foot cooler than left 1+ DP on right, 2+ DP on left, palpable PT pulses b/l, left knee with small effusion, increased warmth without significant increased erythema SKIN: appears mildly jaundiced NEURO: Downgoing toes b/l. DTRs [**Name (NI) 20772**] throughout including biceps, patellar, achilles. Pertinent Results: ADMISSION LABS [**2154-12-14**] 04:45PM BLOOD WBC-6.0 RBC-3.78* Hgb-11.7* Hct-34.3* MCV-91 MCH-31.0 MCHC-34.1 RDW-13.6 Plt Ct-74* [**2154-12-14**] 04:45PM BLOOD Neuts-80* Bands-6* Lymphs-9* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2154-12-14**] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2155-1-2**] 02:38AM BLOOD Plt Ct-179 [**2155-1-2**] 02:38AM BLOOD PT-14.6* PTT-35.5* INR(PT)-1.3* [**2154-12-14**] 04:45PM BLOOD PT-13.3 PTT-31.5 INR(PT)-1.1 [**2154-12-14**] 04:45PM BLOOD Plt Smr-VERY LOW Plt Ct-74* [**2154-12-14**] 04:45PM BLOOD Glucose-98 UreaN-44* Creat-1.1 Na-138 K-5.3* Cl-105 HCO3-23 AnGap-15 [**2154-12-14**] 04:45PM BLOOD CK(CPK)-52 [**2154-12-14**] 04:45PM BLOOD CK-MB-NotDone [**2154-12-14**] 04:45PM BLOOD Calcium-8.0* Phos-3.7 Mg-2.7* UricAcd-3.4 [**2154-12-14**] 10:47PM BLOOD calTIBC-146* VitB12-1418* Folate-3.5 Ferritn-1409* TRF-112* [**2154-12-14**] 10:47PM BLOOD TSH-0.69 [**2154-12-15**] 06:26AM BLOOD Cortsol-26.9* [**2154-12-14**] 06:50PM BLOOD Type-ART pO2-60* pCO2-50* pH-7.30* calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2154-12-14**] 07:15PM BLOOD Lactate-2.2* [**2154-12-15**] 12:25AM BLOOD O2 Sat-98 [**2154-12-15**] 12:25AM BLOOD freeCa-1.10* Brief Hospital Course: Note: the majority of this hospital course refers to the patient's ICU course. He was on the medical floor for 16 hours prior to discharge and was stable during this time. . # Septic Shock: Met criteria for septic shock. On presentation had clear pulmonary source of infection. Initial sputums grew out pneumococci. Patient relatively immunocompromised due both to cancer diagnosis and chronic steroid use secondary to brain tumor. On admission patient had central line placed, CVPs maintained [**7-15**]. Patient needed pressors to maintain BP initially. On levophed, but developed some tachyarrhythmnias (Afib with RVR) so was switched to neo. Initially covered with Zosyn, levoflox and vanco. Patient was continued on atovaquone for PCP [**Name Initial (PRE) 6187**]. Patient was also intubated on presentation, and maintained on AC. Patient had EKGs without signs of ischemia, and multiple sets of normal cardiac enzymes. Pressors were largely weaned by HD #3. He did rarely require brief periods of neosynepherine, due to too-rapid diuresis. The patient had a normal cortisol stim test. Historically, it was noted that the patient had a red left knee a few days prior to admission. This knee was tapped by ortho and found to be floridly septic. He was taken to the OR and washed out by Ortho (please see seperate op note for full accounting of this procedure). This infection was found to be MSSA, which also grew out of his blood and eventually out of his R chest chemo-port, which was removed by surgery. He was maintained on a 6week course of Nafcillin for this staph infection. A TEE demonstrated no signs of endocarditis. Infectious disease was consulted and assisted with his antibiotic regimen. The patient completed a full 14d course of Levoflox for pneumonia. The patient also had a full course of Clinda for a question of toxic shock syndrome or aspiration pneumonia. His Vanco was d/c'd after 5d due to only MSSA growing out. On [**12-20**] his pre-existing R chest chemo port was noted to be purulent and was removed by surgery. This grew out MSSA. Once more, the nafcillin was continued for 6week total course. A [**12-21**] culture grew out yeast and he was started on a course of fluconisol as per ID. He recieved a full Ophtho eval which demonstrated no ocular involvment. Planned course of treatment is for nafcillin for total of 6 weeks to end [**1-30**], fluconazole for 2 weeks total to end [**1-9**], and ceftriaxone to end [**1-10**]. . # Afib c RvR: New-onset afib in the face of sepsis, hypotension, infection. Patient initially controlled with boluses of Diltiazem or Lopressor. Often returned into Afib during times of increased activity or stress. Used neosynepharine which seemed less arrhythmagenic. Amiodarone was tried initially for control, but the patient became to bradycardic on this [**Doctor Last Name 360**]. As patient was weaned from pressors he was begun on a regimen of metoprolol which seemed to control his rate well. He did ocassionally return to RVR, which was treated with boluses of dilt or lopressor with good effect. He was then restarted on amiodarone [**1-1**] and responded to it well. Due to his brain tumor he was note anticoagulated during his time in the ICU. The risks and benefits were discussed. It was felt that the risks of ICH outweighed the benefits of stroke prevention at this time. Plans were made to readdress this issue once the patient's mental status improved. . # Septic Arthritis: As above, had septic arthritis of L knee treated via washout by ortho on [**12-17**]. Nafcillin x6weeks per ID started on [**12-19**]. Nafcillin is scheduled to finish on [**1-30**]. Patient did have a swollen L wrist later in his course, but this was tapped by Ortho and never grew out any bacteria. Plastics-hand was consulted and felt clinically that this was not a septic joint, instead just a manifestation of his chronic RA. Ortho also felt it was not prudent to washout his R knee, which was clinically asymptomatic during his ICU course. His L knee healed well and the staples and drain were removed without incidence. He has been signed off from direct ortho care, and is weight-bearing as tolerated at time of ICU discharge. . #Respiratory status: Patient was maintained on ARDS-style ventilation while on the ventilator. He has a bronchoscopy on [**12-18**] which showed diffuse thick bloody sputum greatest in the R LL. By [**12-19**] the patient was changed to pressure support ventilation. The patient was activily diuresed at this time, with good effect and improving respiratory status. The patient tested negative for legionella and influenza. The patient was quickly weaned to CPAP+PS of [**4-7**], but was difficult to wean fully from the vent due mainly to his mental status. He was extubated on [**12-24**] with great success. On [**12-25**] the patient was noted to have an increasing o2 requirement and a CXR demonstrated a moderate-sized R pneumothorax. Thoracic surgery was consulted and placed a chest tube. This tube was intermittantly to wall-suction, water-seal or clamped. On [**1-2**] it was d/c'd, with the pneumothoax smaller in size. . #GBM: Head CTs compared to his baseline [**Hospital1 2025**] scans showed no interval change. He was maintained on his baseline 3mg of Dexamethasone while inpatient here. It appears that neurooncs original plans were to taper the dexamethasone. We were unable to contact primary neuro-oncoligist to discuss steroid taper but this should be discussed with Dr. [**Last Name (STitle) **] when he becomes available. . #Anemia/thrombocytopenia: Had anemia of chronic disease, admitted with thrombocytopenia attributed to Avastin and timador. His thrombocytopenia was asymptomatic during his hospital course, and steadily improved. His anemia was mild, and did require occasional transfusion. . # Hyperglycemia: Intitally hyperglycemic in face of sepsis, controlled with SS insulin and resolved on its own. . #R Chest wound: Con't to drain purulent material s/p removal of port. Surgery recommended QID dilute([**12-6**]) Dakin's solution and close f/u. Any fluctuant areas must be debrided. . #Mental Status: The patient presented with altered mental status felt to be due to sepsis. He did take some days to awaken from his intubated and sedated state. He continued to be Aox1-2 in the MICU, with symptoms consistent with delerium. A repeat head CT showed no change; his delerium was felt to be mainly post-septic and ICU related and appeared to be slowly intervally improving each day. . #Prophylaxis: Patient was initially on pneumoboots and then Heparin SC, a bowel regmimen and a Gi prophlyaxsis throughout his hospital course. . # Electrolytes: The patient required extensive repletion of his potassium during his ICU course, often requiring q6hr lyte checks and 100-200meq of K+ per day. This was felt to be mostly due to a diarrhea and thus GI loss, and was resolving at the end of his hospital course as diarrhea resolved. . # Nutrition: The patient was maintained on TF while intubated, and also s/p intubation as he failed his initial speech and swallow exams. On [**1-3**] he passed his speech and swallow bedside test. . #LFTs: Patient had elevated LFTs on presentation which were attributed to sepsis. This abnormality resolved as the patient's clinical picture improved. He should continue on weekly LFT checks due to his continuing nafcillin. . # PT/OT: after extubation the patient was followed actively by PT and OT. Medications on Admission: # Naproxen prn # Mepron (prophylaxis) # Hydrocodone # Dexamethasone 3mg # Avastin (last received 2wks ago, due on Monday [**2154-12-16**]) # Lipid lowering [**Doctor Last Name 360**] (wife unsure of name) # Timador (was previously on this, but was stopped [**1-4**] to thrombocytopenia) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). 4. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 6. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 weeks: last day [**1-9**]. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for HR<50 and SBP<100. 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): [**Hospital1 **] until [**1-7**] then 400mg daily. 12. Famotidine 10 mg/mL Solution Sig: Twenty (20) mg Intravenous Q12H (every 12 hours). 13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours). 14. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q6H (every 6 hours) for 6 weeks: last day [**1-30**]. 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous twice a day. 17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding scale Subcutaneous four times a day: sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Septic Shock Community Aquired Pneumonia Respiratory Failure Acute Renal Failure Septic Arthritis (L Knee) Bacteremia Infected R Chest Catheter Afib with RVR Delerium Anemia Thrombocytopenia Hyperglycemia Pneumothorax (R) Hypokalemia Transaminitis Secondary: # Grade 4 glioblastoma multiforme left temporal lobe; s/p high dose radiotherapy, previously on high dose steroids, recently tapered. Recently placed Portacath with steristrips still present. # Rheumatoid arthritis; on remicade until recently # L knee bursitis # Hyperlipidemia Discharge Condition: fair - multifactorial delirium with waxing and [**Doctor Last Name 688**] mental status A+Ox1-2 Discharge Instructions: You were admitted for pneumonia and multiple infections including of your knee and blood stream. you were treated with several antibiotics and had a stay in the intensive care unit which required intubation. Currently you are being treated for these infections and are on tube feedings and slowly eating again. Regarding your brain tumor, we felt that this issue, while serious, was stable during your stay here. It is very important that you followup with your neuro-oncologist Dr. [**Last Name (STitle) **] at [**Hospital1 2025**]. You need to discuss with him whether you should be on blood thinners. . Followup Instructions: f/u with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 1005**] of orthopedic surgery at ([**Telephone/Fax (1) 15940**] to schedule a followup appointment in 1 month. f/u with your outpatient rheumatologist in [**1-6**] weeks. f/u with your outpatient neurooncologist Dr. [**Last Name (STitle) **] on Monday by phone - he should be involved in deciding steroid taper and deciding about anticoagulation. Some of your labs will be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of infectious disease at ([**Telephone/Fax (1) 1353**] (phone ([**Telephone/Fax (1) 17490**]), she will contact you regarding followup. ICD9 Codes: 5070, 5849, 2930, 2760, 2724, 2768
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Medical Text: Admission Date: [**2153-10-22**] Discharge Date: [**2153-10-25**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 1936**] Chief Complaint: mast cell degranulation flare Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 61 yo F with Mast Cell Degranulation Syndrome s/p 3 intubations, htn, depression, GERD and erosive OA who presents with SOB, CP, epigastric pain and n/v/d consistent with her typical mast cell degranulation attacks. . Pt was admitted twice since [**2153-9-3**]; in [**Name (NI) **] pt was intubated prophylactically for laryngeal edema in the context of a flare. Last admission was in early [**Month (only) 359**] and pt was sent home on a steroid taper which was completed 4 days PTA and a Z-pack completed 1 wk PTA. Pt reports the day PTA, she developed worsening epigastric pain which bores through to her back, constant squeezing chest pain, wheezing, and shortness of [**Month (only) 1440**]. While she has similar symptoms at baseline, these symptoms worsened gradually over the day yesterday and she went to the ED. She also had diarrhea x 4 BM yesterday, x2 today, and vomitting x 2 today. She reports a chronic productive cough of yellow-green sputum and several weeks of low grade fevers and night sweats. She denies wt loss. . ROS was notable for ha similar to her typical headaches and stiff neck. Pt denies photophobia, confusion, dysuria, hematuria, melena, bloody stool. She is unaware of any particular stressor (no falls, recent illness). . In the [**Name (NI) **] pt had an EKG showing sinus tach. VS were 97.4 120 141/89 24 97% RA. Pt received epi 0.3 1:1000 SQ epi, 2mg iv dilaudid x 2, 50iv benadryl x1 and 25mg x1, Solumedrol 80mg, Zofran 8mg, albuterol neb, ativan iv lmg. CXR no pneumonia, no acute process. Symptoms intitially got better then recurred. . On the floor, pt reports symptoms have improved from the ED. She now reports [**7-12**] epigastric pain, unchanged. Her wheezing has improved. She reports her breathing is uncomfortable and worrisome, but not yet at the point of intubation. Past Medical History: PMH: - Mast Cell Degranulation Syndrome as above - sx for >10 [**Month/Year (2) 1686**] but dx 6 [**Month/Year (2) 1686**] ago. Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **], allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI ;has had LFT abnl with attacks in past. Has been intubated three times, most recently [**9-10**]. Hospitalized 10 times in [**2152**] for attacks. - MI after given wrong dose of epi in anaphylaxis - HTN - pt reports is episodic and exacerbated during flares - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - spinal stenosis - anemia - ? iron deficiency; received 2 transfusions in the past - Hemorrhoids - ADHD - depression/anxiety - hospitalized once after husband's divorce. - pt reports EGD demonstrated vegetable bezoar (?[**12-7**]). - h/o hyperparathyroidism with nl Ca, low nl Vit D [**2151**]; never had BMD - h/o MRSA infection (porthacath associated) - h/o L wrist cellulitis concerning for necrotizing fasciitis s/p what appears to have been a fasciotomy - portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection - portacath placed [**2151-6-9**] . PSH: - s/p cholecystectomy - s/p tonsillectomy - Status post hysterectomy and oophorectomy Social History: Pt lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. She is divorced after 37 yr marriage. Her son [**Name (NI) **] is her HCP [**Telephone/Fax (1) 21738**]; he lives in [**Location **] ME . She denies every using ETOH/recreational drugs / smoking. Pt reports frustrated mood but no current depression; no SI/HI. Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: Vitals - 98.2 168/96 107 20 98% on 2L GENERAL: obese woman with cushingoid face, eyes closed, easily distracted, in mild respiratory distress HEENT: NC, AT, MM dry, tongue appears red but not obstructive. no cervical lymphadenopathy. Neck supple. End expiratory wheeze in tracheal area; no stridor currently. CARDIAC: tachycardiac, regular no m/g/r LUNG: CTAB. No wheezes. ABDOMEN: soft, mild tenderness to palpation diffusely. No CVAT. No spinal tenderness. EXT: warm, 2+pulses, trace edema SKIN: many bruises on arm, larm bruise on L breast after fall prior to last admission. Pertinent Results: [**2153-10-22**] 07:05AM GLUCOSE-251* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 [**2153-10-22**] 07:05AM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-2.0 [**2153-10-22**] 07:05AM WBC-8.8 RBC-3.52* HGB-10.4* HCT-30.3* MCV-86 MCH-29.6 MCHC-34.4 RDW-15.3 [**2153-10-22**] 07:05AM PLT COUNT-247 [**2153-10-22**] 07:05AM PT-12.1 PTT-26.8 INR(PT)-1.0 [**2153-10-22**] 12:35AM NEUTS-74.0* LYMPHS-19.0 MONOS-5.7 EOS-1.2 BASOS-0.2 Brief Hospital Course: 61 yo F with Mast Cell Degranulation admitted for likely acute mast cell degranulation attack. . # Mast Cell Degranulation: Pt's symptoms were classic for a flare (CP, SOB, ha, n/v). On admission, pt was started on solumedrol 80 IV Q8, Famotidine 20 mg Q12H and she continued home Gastrocrom 300 mg Oral qid, cromolyn, fexofenadine. She was given supportive cocktail of Dilaudid 2mg IV q-4h, Benadryl 50mg IV q4h, Ativan 1mg IV q3h, Albuterol nebs q4h. On day 2 of admission, she reported increasing difficulty breathing and her tongue was moderately edematous and erythematous. She requested an epi pen, which was given with no effect as well as supplements from her cocktail. After an hour she still exhibited signs of acute respiratory distress and she requested prophylactic intubation. She was intubated and transferred to the MICU. Per anesthesia, there was no sign of laryngeal edema and intubation was easy. However, anesthesia team noted that prophylactic intubation is necessary in this pt given her cushingoid habitus and difficult intubation if laryngeal edema was present. After return from MICU to the floor, pt was transitioned to PO medications and started a 2 wk course of steroid taper, starting at 60 mg PO prednisone QD. . # Chronic pain - after pt's extubation, pt demanded IV Dilaudid and threatened multiple times to leave the hospital AMA. She also refused PO pain medications at this time, stating that they do not work. She complained of headache and chest pain. The team counseled her that headaches do not require IV pain medicines unless they are very serious and require imaging. She replied that she knew this was a mast flare and they required IV Dilaudid only. At this time, she had no shortness of [**Month/Day/Year 1440**], wheezing, pruritus, neuro sx, or any other symptoms. She appeared well and was pacing about the room. She was finally convinced to take PO medications, including multiple extra doses of Benadryl and Ativan. Pt reports that at baseline, she takes Dilaudid at home for headaches. . # Chest pain/SOB - While sx were classic for flare, CXR was obtained to r/o infx which showed no signs of pna or congestion. PCP was considered given pt's chronic steroids, and sputum obtained during intubation was negative. LDH was not checked due to chronic elevation. Pt's allergist at OSH was also contact[**Name (NI) **] re:PCP prophylaxis with Bactrim but allergist never responded. Per providers at [**Hospital1 18**], PCP prophylaxis has been discussed without resolution. . # diarrhea - pt complained of diarrhea on admission, but did not supply stool sample until day prior to discharge. Given pt's recent exposure to antibx (z-pack as outpt), C dif was checked and was negative. . # anemia - HCT 30, MCV 86; baseline HCT 30-35. Per pt, has been told she has iron deficiency in the past. Colonoscopy in [**2151**] showed hemorrhoids. Pt was recommended to consider iron replacement as an outpt. . # HTN: pt was continued on her home dose of diltiazem. Her bp ran high, but per pt, this is normal for her flares. . # chronic steroids/iatrogenic [**Location (un) **] - per pt, is on steroids >50% of year. Pt has very cushingoid appearance that per multiple providers, has increased over the past year. HbA1c was 6.1%; she was treated with an insulin SS while on high dose steroids. Pt continued Ca/Vit D, and pt was recommended to get BMD as outpt. Bactrim prophylaxis was considered, and pt was counseled to discuss with her allergist risks/benefits. . gastritis/GERD - cont ranitidine, omeprazole [**Hospital1 **] . # Depression/anxiety: - team discussed contribution of severe anxiety to her flares. Team recommends outpt psychiatry follow-up. Pt continued home Duloxetine, Ativan, Doxepin. . # ADHD - pt continued home Amphetamine-Dextroamphetamine . # Osteoarthritis: - pt continued home Plaquenil . # hx of hyperPTH with nl ca - etiologies most often due to Vit d deficiency . - pt now on Vit d/ca. Pt was recommended BMD as outpt. . . MICU COURSE: [**10-23**] - [**10-24**] . On the floor, pt reports symptoms have improved from the ED. She now reports [**7-12**] epigastric pain, unchanged. Her wheezing has improved. She reports her breathing is uncomfortable and worrisome, but not yet at the point of intubation. . Since admission she was given Solumedrol 80mg IV q8H x 3 with plan to transition to a prednisone taper the day of transfer. She was also on a supportive cocktail of Dilaudid 2mg IV q-4h, Benadryl 50mg IV q4h, Ativan 1mg IV q3h with planned transition to po. Day of transfer to the MICU, patient complained of worsening SOB without concomitant CP. Her O2 sat remained > 92. Given epi-pen, diphenhydramine IV, Ativan IV and Dilaudid IV. Code blue was called for elective intubation. ABG with pH 7.42, pCO2 40, pO2 526, HCO3 27 while being bag-masked. Patient was intubated by anesthesia on the floor without complication and transported to the MICU for further management. Upon transfer, patient was following commands. . # Shortness of [**Month/Year (2) 1440**]: This represented the 4th intubation for the patient. Per the intubating anesthesiologist, there was no evidence of tracheal or laryngeal edema. Of not the patient was without desaturation by pulse-oximetry or ABG. Thus, not truly hypercarbic or hypoxic respiratory failure. In the past, patient has been on steroid tapers which seemingly have helped her flairs. The patient was briefly placed on pressure support and continued on her regimen of Q4H ipratroprium/albuterol, steroids IV, diphenhydramine IV q6 and ranitidine for possible H2 component. The patient was subsequently extubated without complication. . # Mast Cell Degranulation: Pt initially stated that her presenting symptoms are consistent with her flairs. The patient was continued on solumedrol 80 IV BID; transition to PO prednisone post-extubation, Famotidine IV, continued pt on home Gastrocrom 300 mg Oral qid, cromalyn, fexofenadine. Once extubated the pt was continued on her home cocktail of Dilaudid 2mg IV q-4h, Ativan 1mg IV q3h, her scheduled diphenhydramine, Albuterol nebs q4h and Zofran. The pt was continued on insulin SS while on steroids. . Medications on Admission: Zolpidem 10 mg PO HS prn insomnia Hydroxyzine HCl 25 mg PO QID Ranitidine HCl 300 mg PO HS Duloxetine 60 mg Capsule once a day Hydroxychloroquine 200 mg PO BID Fexofenadine 180 mg PO BID Omeprazole 20 mg [**Hospital1 **] Cromolyn 100 mg/5 mL Solution 600 mg PO QID Diltiazem HCl Sustained Release 180 mg PO DAILY Hydromorphone 4 mg every four 4 hours as needed for pain. Amphetamine-Dextroamphetamine SR 15 mg once a day. Promethazine 12.5 mg TID prn nausea Doxapine 50 mg [**Hospital1 **] Epi pen prn Gastrocrom 30Ml (3amps) QID Iron Ca/Vit D Miralax PRN Discharge Medications: 1. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Cromolyn 100 mg/5 mL Solution Sig: Six (6) PO twice a day. 9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 11. Amphetamine-Dextroamphetamine 15 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 12. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 13. Doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 14. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular as needed. 15. Gastrocrom 100 mg/5 mL Solution Oral 16. Iron Oral 17. CALCIUM 500+D Oral 18. Miralax Oral 19. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 13 days: 60mg x 1 days 40mg x 2 days 20mg x 2 days 10mg x 4 days 5mg x 4 days. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Mast cell degranulation flare Respiratory failure Hypertension GERD Depression/anxiety Discharge Condition: Hemodynamically and respiratory stable to home. Discharge Instructions: You were admitted to the hosptial for a mast cell degranulation flare. Blood tests were done, which showed that you are anemic, meaning you have low blood counts. Your level of anemia is unchanged from your baseline. You were treated with IV steroids (solumedrol) for 24 hours, and switched to prednisone. You were also treated with dilaudid, benadryl, albuterol nebulizers, zofran and ativan. Your other home medications were continued. You should follow up with your allergist, Dr. [**Last Name (STitle) **], and your primary care doctor after leaving the hospital. If you develop shortness of [**Last Name (STitle) 1440**], severe wheezing or chest pain, please go to the ED or call your doctor immediately. Followup Instructions: Please call your allergist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) and make an appointment for within 2 weeks of leaving the hospital. Please also call your primary care doctor, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21748**]. Please discuss with him your anemia. Please also discuss with him the bennefits of a bone mineral density scan for you, a tool to screen for osteoporosis. Completed by:[**2153-10-27**] ICD9 Codes: 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2477 }
Medical Text: Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-24**] Date of Birth: [**2071-3-16**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Percocet Attending:[**First Name3 (LF) 297**] Chief Complaint: failure to decannulate Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 66 F with history of CAD s/p CABG [**2118**], PCI recently, OSA, bipolar, on [**1-27**] went to [**Hospital1 336**] for an elective left hip replacement, which was complicated with post-op AFIB with RVR that required cardioversion. She became septic, had a VAP secondary to pseudomonas, UTI [**2-22**] VRE. She improved, was trached and pegged, and transferred to [**Hospital **] [**Hospital **] Rehab. She was there for 2 months, where they could not decannulate her. Bronch was done at [**Hospital1 **] - tracheomalacia was seen in the subglottic region to trach. She was transferred here for evaluation of tracheal stenosis after failed attempts at decannulation. . She was changed from a 6 uncuffed to a 7 cuffed trach. En route in ambulance, she had SOB with frothy secretions. She had to stop at [**Hospital 17679**] medical center for trach management, CT chest was done to assess for PE, she was suctioned and doing fine, then transferred here. . She was admitted to the IP service. She has been trached for [**4-25**] months. She went for bronch today and IP found severe supraglottic edema compatible with GERD. IP decided not to do anything with her trach until this edema was fixed first. She was started on PPI. She had a trach change this afternoon, in which her trach was downsized back down to 6 uncuffed. She was going to be discharged and seen in 4 weeks by IP. . She decannulated herself today by coughing up her trach today, and a respiratory code was called on [**4-23**] at 1430 when she became hypoxemic. IP came and changed her trach to a 7 cuffed trach, bronched her, saw frothy secretions in the trachea. She was significantly hypoxic: 7.37 / 53 / 54 / 32, and was hypertensive 220/120 during the code. Blood / mucus was suctioned from her bronchi, and she was sitting up and coughing. She may have negative pressure pulmonary edema or diastolic dysfunction. She had normal vitals and was transferred to MICU green for monitoring. . Past Medical History: s/p CABG Left total hip replacement Bipolar disorder Depression AFIB Chronic constipation Trach and PEG HIT on Fragmin (Arixtra Social History: noncontributory Family History: noncontributory Physical Exam: VS: 99.3 / 120/65 / 90 / 34 / 97% on PS 400 / 20 / 8 / 8 / 0.8 GEN: Alert, in good mood, communicates clearly HEENT: Trach site clean with minimal erythema LUNGS: Diffuse rhonchi bilaterally HEART: RRR, no m/r/g ABD: Soft, +BS, ND NT EXTR: No c/c/e NEURO: Gait not tested Pertinent Results: [**2137-5-24**] 08:06AM BLOOD Hct-29.8* [**2137-5-24**] 04:30AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.6* Hct-28.7* MCV-91 MCH-30.3 MCHC-33.4 RDW-19.3* Plt Ct-291 [**2137-5-23**] 02:49PM BLOOD WBC-8.8 RBC-3.82* Hgb-11.6* Hct-34.3* MCV-90 MCH-30.3 MCHC-33.7 RDW-18.9* Plt Ct-349 [**2137-5-23**] 12:35AM BLOOD WBC-11.8* RBC-4.08* Hgb-12.3 Hct-36.4 MCV-89 MCH-30.0 MCHC-33.6 RDW-19.0* Plt Ct-351 [**2137-5-24**] 04:30AM BLOOD Neuts-74.7* Lymphs-17.9* Monos-3.7 Eos-3.2 Baso-0.5 [**2137-5-23**] 02:49PM BLOOD Neuts-79.7* Lymphs-14.4* Monos-3.4 Eos-2.2 Baso-0.2 [**2137-5-23**] 12:35AM BLOOD Neuts-88.5* Bands-0 Lymphs-7.4* Monos-3.3 Eos-0.6 Baso-0.2 [**2137-5-24**] 04:30AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+ [**2137-5-23**] 02:49PM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+ [**2137-5-23**] 12:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2137-5-24**] 04:30AM BLOOD Plt Ct-291 [**2137-5-24**] 04:30AM BLOOD PT-13.4* PTT-30.5 INR(PT)-1.2* [**2137-5-23**] 02:49PM BLOOD Plt Ct-349 [**2137-5-23**] 02:49PM BLOOD PT-13.1 PTT-50.3* INR(PT)-1.1 [**2137-5-23**] 12:35AM BLOOD Plt Smr-NORMAL Plt Ct-351 [**2137-5-23**] 12:35AM BLOOD PT-12.9 PTT-30.4 INR(PT)-1.1 [**2137-5-23**] 02:49PM BLOOD Ret Aut-2.4 [**2137-5-24**] 04:30AM BLOOD Glucose-112* UreaN-22* Creat-1.0 Na-141 K-3.3 Cl-103 HCO3-32 AnGap-9 [**2137-5-23**] 02:49PM BLOOD Glucose-209* UreaN-22* Creat-1.1 Na-136 K-3.6 Cl-97 HCO3-31 AnGap-12 [**2137-5-23**] 12:35AM BLOOD Glucose-129* UreaN-26* Creat-1.1 Na-138 K-4.1 Cl-97 HCO3-33* AnGap-12 [**2137-5-23**] 02:49PM BLOOD ALT-7 AST-15 LD(LDH)-199 CK(CPK)-50 AlkPhos-87 Amylase-52 TotBili-0.8 [**2137-5-23**] 02:49PM BLOOD Lipase-31 [**2137-5-24**] 08:06AM BLOOD proBNP-2166* [**2137-5-23**] 02:49PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2137-5-24**] 04:30AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8 [**2137-5-23**] 02:49PM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.9 Mg-2.0 UricAcd-11.6* Iron-38 [**2137-5-23**] 12:35AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.0 [**2137-5-23**] 02:49PM BLOOD calTIBC-330 Ferritn-280* TRF-254 [**2137-5-23**] 02:49PM BLOOD TSH-1.8 [**2137-5-24**] 02:27AM BLOOD Type-ART Tidal V-400 PEEP-8 FiO2-80 pO2-90 pCO2-47* pH-7.43 calTCO2-32* Base XS-5 AADO2-451 REQ O2-75 Intubat-INTUBATED Vent-IMV [**2137-5-23**] 02:48PM BLOOD Type-ART pO2-54* pCO2-53* pH-7.37 calTCO2-32* Base XS-3 Intubat-NOT INTUBA [**2137-5-24**] 02:27AM BLOOD Glucose-98 K-3.2* [**2137-5-24**] 02:27AM BLOOD freeCa-1.19 Brief Hospital Course: 66 F with history of COPD with respiratory failure on tracheostomy since [**1-27**] following L total hip replacement. She was brought in to be evaluated by interventional pulmonary for failure to decannulate. Bronchoscopy show supraglottic edema in addition to tracheal stenosis. Plan was to start her on PPI and follow up with interventional pulmonary in 4 weeks. On the medicine floor, she coughed up her trach tube and a respiratory code was called. She was recannulated and transferred to medical ICU for overnight monitoring. THroughout the night, her blood pressure was slightly low. It was likely medication related as it resolved by itself in the morning. She also had slight hematocrit drop, likely related to traumatic recannulation of her trach. She was initially on SIMV +PS 400 x20, PEEP 8, PSV 8 and FiO2 of 0.80. Her CXR show interstitial edema, likely from negative pressure during her decannulation. Her pulmonary edema resolved w/ positive pressure and she was eventually weaned to trach mask again. Medications on Admission: ASA 81 QD Lipitor 80 QD Zyprexa 5 [**Hospital1 **] Paxil 10 QD MVI Combivent 6puff QID Colace 100 [**Hospital1 **] Senna 2 QHS Lactulose 30 [**Hospital1 **] Lasix 30 [**Hospital1 **] Aldactone 30 [**Hospital1 **] Metoprolol 25 [**Hospital1 **] Ativan 1 q4 prn Zegerid 40' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 4. Paroxetine HCl 10 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mg PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q6H (every 6 hours). 7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg PO BID (2 times a day). 8. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2 times a day). 9. Furosemide 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day): hold for BP<100. 11. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 12. Zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 13. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 14. Spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 15. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: Six Hundred (600) mg PO Q8H (every 8 hours) as needed for pain. 16. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily). 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 18. Fondaparinux 2.5 mg/0.5 mL Syringe [**Last Name (STitle) **]: 2.5 mg Subcutaneous DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Discharge Diagnosis: supraglottic edema likely from gastroesophageal reflux and tracheal stenosis Discharge Condition: stable on trach mask. Discharge Instructions: Please call DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**] to schedule a repeat bronchoscopy in 4 weeks. Call if you develop any problems with your trach tube. Continue PPI [**Hospital1 **]. Please continue all medications prior to admission. Followup Instructions: schedule bronch in 4 weeks( DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**]) Completed by:[**2137-5-24**] ICD9 Codes: 4280, 4019, 4589, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2478 }
Medical Text: Admission Date: [**2121-7-29**] Discharge Date: [**2121-8-1**] Date of Birth: [**2054-3-5**] Sex: M Service: MEDICINE Allergies: codiene Attending:[**First Name3 (LF) 3256**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Embolization of bleeding History of Present Illness: 67 year old male presents with bright red blood per rectum. He had a screening colonoscopy on [**2121-7-21**] at [**First Name8 (NamePattern2) 1495**] [**Hospital **] Hospital, at which time a large adenoma in the cecum was removed. Also noted to have L sided diverticulosis. Reports distention and cramping since the colonoscopy, then at 6pm yesterday had BRBPR x [**2-2**] before presenting to the ER. In the ER, he had multiple more episodes. Past Medical History: -HTN -Bladder CA in [**2114**] s/p BCG q3 months for two years now under surveillance. s/p Transurethral resection of the bladder for cancer [**2114**] -IBS -OSA -GERD Social History: Works as a Latin teacher. Denies tobacco, alcohol, illicit drugs. Family History: Unremarkable for GI malignancy, PUD, IBD. M died of DM and Gallbladder disease at age 86. F died of stroke at age 88. Physical Exam: Admission Physical Exam: Vitals: P 90 BP 138/90 Pox 99 RA RR 12 General: Alert, oriented, no acute distress, lying in bed HEENT: Sclera anicteric, mucous membranes dry, 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, markedly distended. + bowel sounds, no rebound tenderness or guarding Rectal: BRB on the glove Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact Skin: No rash. Physical exam on discharge: 98.2, 157/84, 78, 18, 99%RA GEN Alert, oriented, no acute distress HEENT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal Pertinent Results: Admission Labs: [**2121-7-29**] 10:50PM WBC-8.1 RBC-3.73* HGB-12.2* HCT-33.9* MCV-91 MCH-32.6* MCHC-35.9* RDW-13.1 [**2121-7-29**] 10:50PM NEUTS-80.1* LYMPHS-14.6* MONOS-3.8 EOS-1.2 BASOS-0.3 [**2121-7-29**] 10:50PM PLT COUNT-147* [**2121-7-29**] 10:18PM LACTATE-1.2 [**2121-7-29**] 08:10PM GLUCOSE-109* UREA N-14 CREAT-0.8 SODIUM-144 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-29 ANION GAP-13 [**2121-7-29**] 08:10PM estGFR-Using this [**2121-7-29**] 08:10PM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-85 TOT BILI-0.4 [**2121-7-29**] 08:10PM LIPASE-36 [**2121-7-29**] 08:10PM ALBUMIN-4.4 [**2121-7-29**] 08:10PM WBC-5.9 RBC-4.45* HGB-14.2 HCT-40.5 MCV-91 MCH-31.8 MCHC-35.0 RDW-13.3 [**2121-7-29**] 08:10PM NEUTS-73.1* LYMPHS-19.6 MONOS-4.6 EOS-1.9 BASOS-0.7 [**2121-7-29**] 08:10PM PLT COUNT-161 [**2121-7-29**] 08:10PM PT-12.1 PTT-33.0 INR(PT)-1.1 Imaging: CTA ABD & PELVIS Study Date of [**2121-7-29**] IMPRESSION: 1. Active extravasation of contrast within the cecum at the site of recent adenoma resection, findings consistent with the source of active lower GI bleed. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. 3. Stable left adrenal adenoma. 4. Bilateral renal cysts and right renal cortical thinning as previously characterized on prior MR. [**Name13 (STitle) **] hydronephrosis or suspicious renal mass. ECG Study Date of [**2121-7-30**] 6:41:22 AM Sinus rhythm. Within normal limits. No significant change compared to previous tracing of [**2116-4-6**]. Radiology Report [**Numeric Identifier 7536**] EMBO NON NEURO Study Date of [**2121-7-30**] FINDINGS: 1. Conventional SMA anatomy. 2. Area of active extravasation within the right cecum corresponding to CTA findings. This is arising from a distal branch of the ileocolic artery. Multiple projections and angiograms were performed including selective catheterization of four fourth-order branches. The exact source of bleeding was difficult to identify; however, a dominant branch was identified demonstrating extravasation from a small side branch. 3. Coil embolization with two coils of the dominant distal ileocolic branch to stasis successfully. Discharge Labs: [**2121-8-1**] 04:00PM BLOOD Hct-35.3* [**2121-8-1**] 07:55AM BLOOD WBC-5.5 RBC-3.94* Hgb-12.0* Hct-34.8* MCV-89 MCH-30.5 MCHC-34.5 RDW-14.5 Plt Ct-132* [**2121-8-1**] 07:55AM BLOOD Plt Ct-132* [**2121-8-1**] 07:55AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-142 K-3.3 Cl-106 HCO3-28 AnGap-11 [**2121-8-1**] 07:55AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 [**2121-7-31**] 05:01AM BLOOD Type-[**Last Name (un) **] pH-7.41 [**2121-7-31**] 05:01AM BLOOD Lactate-0.5 [**2121-7-31**] 05:01AM BLOOD freeCa-1.13 Brief Hospital Course: Mr. [**Known lastname 6483**] is a 67 year old male who is presenting with bright red blood per rectum in the setting of a recent colonoscopy with polypectomy. #) BRBPR: Patient presented with BRBPR in setting of recent polypectomy and was admitted to the ICU. He underwent CTA, which showed active extravasation in the cecum at polypectomy site. He subsequently went to IR. Per report, SMA, ileocolic, and selective catheterization of 4th order distal branches performed where active extravasation was seen. Distal branch supplying area of extravasation identified and coiled successfully. The surgical team followed, although no surgical intervention was needed. He was briefly hypotensive on admission. Hematocrits were followed initially every four hours and then every 12 hours when levels stabilized. The patient was transfused a total of 6 units of packed red cells and one unit of platelets. Lactate on presentation of 1.2 which trended down to 0.5. The patient was hemodynamically stable for 24 hours with a stable hematocrit when transferred from the ICU to the medicine floor. Hematocrits were stable on the floor and patient was hemodynamically stable without further episodes of bleeding. He will follow up with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] after discharge. #) HTN: Home antihypertensives initially held in setting of GIB and hypotension, however systolic blood pressures quickly became elevated to 130s-150s. The patient was then restarted on his home medications valsartan and verapamil. He had no further episodes of hypotension and remained hemodynamically stable. #) OSA: Patient has obstructive sleep apnea. He was placed on home CPAP overnight without issue. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Valsartan 80 mg PO DAILY 2. Fish Oil (Omega 3) 1000 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Verapamil SR 180 mg PO Q24H 5. Ibuprofen Suspension 400 mg PO TID:PRN pain Discharge Medications: 1. Valsartan 80 mg PO DAILY 2. Verapamil SR 180 mg PO Q24H 3. Omeprazole 20 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Docusate Sodium 200 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: GI Bleed post polypectomy Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 6483**], You were admitted to [**Hospital1 69**] with a gastrointestinal bleed after a polyp removal. You were treated with embolization of the bleeding vessel and blood transfusions as needed. The bleeding subsequently stopped. Medication changes: -Please stop taking Ibuprofen for pain, you may take Tylenol up to 4 grams per day -Please take colace 100-200 mg [**Hospital1 **] as needed for constipation Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] as instructed below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] Location: [**Location (un) **] ASSOCIATES Address: [**Street Address(2) **], [**Apartment Address(1) 86334**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 27929**] Appt: [**8-7**] at 11am Department: DIV. OF [**Month (only) 864**] When: TUESDAY [**2121-8-19**] at 1 PM With: [**Doctor First Name 23138**] [**First Name8 (NamePattern2) 23139**] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2479 }
Medical Text: Admission Date: [**2193-2-25**] Discharge Date: [**2193-2-28**] Date of Birth: [**2142-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 50yo man w/ sarcoidosis & HTN who presents with SSCP since 2pm. Of note, pt was seen in [**Hospital1 18**] ED on [**2193-2-22**] w/ HTN urgency, which was noted incidentally as he was being prepped for an outpatient lung biopsy scheduled for same day, though the procedure was cancelled due to pt's HTN. The patient's dose of lisinopril was increased & he was discharged home. He reports being in his USOH until the day of presentation when, while walking up stairs, he developed [**10-25**] SSCP radiating to jaw & l arm. Associated w/ diaphoresis & light-headedness. He initially presented to [**Hospital 26580**] hospital, where his EKG was reportedly unchanged from priors--though I do not have these to confirm this finding. His TropI was 1.97. He received asa 81mg (?x2), nitro, lovenox, morphine and lopressor and was to transferred to [**Hospital1 18**] ED. Prior to transfer his pain had improved to [**1-24**]. . In [**Hospital1 18**] ED, VS 97.8, 64, 143/98, 18, 97% on RA. His pain was [**6-25**]. EKG showed LAD, LAFB, IVCD, new Q waves lateral precordial leads (V4 &5), TWI in III, flattened TW in avF and V1, V3, V4, and ?V5, also ~1mm STE in lead II. Cardiology was consulted. The patient's nitro was increased and heparin gtt was started. Pt also received IV morphine. Pain reportedly resolved, thus, pt was not started on integrillin. . He arrived on the floor and reported a pain of [**2195-2-18**]. His nitro gtt was increased and he was given morphine 4mg IV x2 w/o significant change. His EKG showed no change from than in the ED. Integrillin gtt was started for refractory pain. A plavix load was also given. Past Medical History: - Sarcoidosis--affecting abd & lungs (dx'd at [**Hospital1 112**] years ago) - HTN - CVA 2yr ago --> residual r sided weakness/ pfo v. asd/ stress in [**2189**] (may have been done at [**Hospital1 112**]) - H/o DVT - Chronic pain - l adrenal adenoma - s/p splenectomy, cholecystectomy, ? adrenalectomy - asthma Social History: From [**Location (un) 17927**]. Divorced. Lives w/ mom who is his HCP. Family History: N/C Physical Exam: VS - 97.6, 52, 133/94, 16, 96% Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP not elevated. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM. Areas of induration throughout abd. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG demonstrated EKG showed LAD, LAFB, IVCD, new Q waves lateral precordial leads (V4 &5), TWI in III, flattened TW in avF and V1, V3, V4, and ?V5, also ~1mm STE in lead II. Significantly changed from prior. . OTHER TESTING: AP UPRIGHT CHEST: The study is compared to a chest radiograph from [**2-22**], [**2193**]. Additional history not provided on requisition includes sarcoid. The cardiac, mediastinal, and hilar contours are unchanged given differences in technique with tortuosity of the thoracic aorta and prominence of the hila. Mild cardiomegaly is stable. The previously noted vague opacity in the left mid lung is not as well seen on the current study; however, please note that the previous study was a dedicated PA and lateral chest. No other areas concerning for consolidation are identified. The left costophrenic angle has been excluded; however, no large pleural effusions are noted. There is no pulmonary vascular congestion. . Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . OSH: tropi 1.97, CK 310 WBC 17.4, DDimer 1.4 (<1.3 nml), hct 45 Trop-T: 0.94 Comments: cTropnT: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2357 On [**2193-2-25**] cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi . Cardiac catheterization: 20 % LAD, mild disease in the LCX and mild disease in the RCA with thrombotic occlusion of the distal wrap around PDA "dottered with balloon" with improvement in flow and partial resolution of thrombus . Cardiac Enzymes [**2193-2-25**] 09:45PM BLOOD cTropnT-0.94* [**2193-2-25**] 09:45PM BLOOD CK(CPK)-529* [**2193-2-26**] 06:30AM BLOOD CK-MB-56* MB Indx-11.5* cTropnT-1.59*[**2193-2-26**] 06:30AM BLOOD CK(CPK)-485* [**2193-2-27**] 05:44AM BLOOD CK-MB-11* MB Indx-7.1* cTropnT-1.13* [**2193-2-27**] 05:44AM BLOOD CK(CPK)-154 [**2193-2-28**] 06:30AM BLOOD CK(CPK)-83 . MISC [**2193-2-26**] 06:30AM BLOOD Triglyc-119 HDL-42 CHOL/HD-5.2 LDLcalc-152* . CBC [**2193-2-25**] 09:45PM BLOOD WBC-17.6* RBC-4.71 Hgb-14.2 Hct-42.3 MCV-90 MCH-30.1 MCHC-33.5 RDW-14.3 Plt Ct-460* [**2193-2-26**] 06:30AM BLOOD WBC-18.8* RBC-4.41* Hgb-13.4* Hct-39.7* MCV-90 MCH-30.4 MCHC-33.8 RDW-14.4 Plt Ct-397 [**2193-2-26**] 01:15PM BLOOD Hct-37.3* Plt Ct-388 [**2193-2-27**] 05:44AM BLOOD WBC-16.0* RBC-4.07* Hgb-12.8* Hct-36.9* MCV-91 MCH-31.5 MCHC-34.8 RDW-14.6 Plt Ct-345 [**2193-2-28**] 06:30AM BLOOD WBC-15.4* RBC-4.25* Hgb-13.0* Hct-39.1* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.3 Plt Ct-392 . Chem 7 [**2193-2-25**] 09:45PM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-140 K-4.2 Cl-105 HCO3-25 AnGap-14 [**2193-2-26**] 06:30AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-139 K-3.8 Cl-102 HCO3-25 AnGap-16 [**2193-2-27**] 05:44AM BLOOD Glucose-136* UreaN-8 Creat-0.8 Na-137 K-3.5 Cl-104 HCO3-28 AnGap-9 [**2193-2-28**] 06:30AM BLOOD Glucose-100 UreaN-10 Creat-1.0 Na-139 K-3.9 Cl-105 HCO3-28 AnGap-10 Brief Hospital Course: The patient was admitted with an NSTEMI for cardiac catheterization. On cardiac catheterization, an RCA thrombus with thrombotic occlusion of distal wrap around PDA was found. Angioplasty was attempted but unsuccessful. During the procedure, the patient developed CP and with small ST elevation on EKG. CP was reduced with morphine but was in some pain after catheterization with EKG rvealing some resolution of ST elevations in V3-V4. He was started on heparin, integrilin and nitro drips. He was also started on Simvastatin, Aspirin, Plavix Troprol XL and nicotine patch and tolerated all of these medications well. He was monitored in the CCU overnight. His cardiac enzymes were followed and continued to trend down. He was transfered to the floor. On the floor, he had mild [**2-24**] constant "aching" chest pain that patient reported was chronic, related to severe sarcoid and unlike his CP on admission or in the cath lab. An echo was obtained showing a normal EF and no wall motion abnormalities. A lipid panel was obtained with an elevated LDL 152. Simvastatin 40mg daily was started. He was discharged with baseline CP with cardiology and pulmonology follow up. Medications on Admission: oxycontin 80mg q12hr lisinopril 20mg daily (?) xanax 2mg [**Hospital1 **] prevacid 30mg qd prozac 20mg qd norvasc 10mg Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Xanax 2 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. 5. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non-ST Segment Elevation Myocardial Infarction. Discharge Condition: improved Discharge Instructions: You were admitted for chest pain. You had a heart attack because of a blockage in one of your coronary arteries. A stent was not placed due to the inability to pass through the clot. Instead, you were given medications to stabalize the clot and prevent further clot formation. . If you have chest pain, significant worsening of shortness of breath or extreme sweating (diaphoresis), you should call your doctor and come to the emergency room. . The following changes were made to your medications. You should take all other medications as previously prescribed. 1. Start taking Aspirin daily 2. Take Plavix every day for one month 3. Start taking Toprol Xl daily. 4. Nicotine patch. Followup Instructions: Please call [**Telephone/Fax (1) 1989**] to arrange a follow up appointment with Dr. [**Last Name (STitle) 171**] (cardiology) in the next 1-2 weeks. . You should also follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**] on 10:45 on Februaruy 29, [**2193**]. Please call [**Telephone/Fax (1) 37774**] if you need to reschedule this appointment. . You should also make an appointment to see your pulmonologist in the next 2-3 weeks. ICD9 Codes: 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2480 }
Medical Text: Admission Date: [**2131-9-16**] Discharge Date: [**2131-10-5**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 783**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Intubation in the medical intensive care unit History of Present Illness: 52 y/o woman with IDDM, diabetic polyneuropathy, HTN, [**Doctor Last Name 933**], Hepatitis C who has been extremely depressed at home, stating that "she wants to die" and refusing to take her medications per her daughter who brought her to the [**Name (NI) **] for nausea, vomiting, AMS. On arrival in the ED, she was found to be febrile to 101.6, tachy to 131, hemodynamically stable, yet somnolent and oriented only to person. Her initial labs were remarkable for a glucose of 1300, a gap of 31, ketonuria, and a K of 6.3. Her ECG did not show any ischemic changes, but did have diffuse peaked TW changes. She was given IV insulin 5 U push, put on 5 U per hour infusion, given 6 litres of NS bolus, calcium gluconate, levaquin and flagyl emperically. Her UA was negative, CXR clear. Blood cultres were sent times two. Past Medical History: 1. IDDM diagnosed in [**2127**], followed at [**Last Name (un) **] by Dr. [**Last Name (STitle) **]. No recent HbA1c on file. 2. Diabetic polyneuropathy 3. Hypertension 4. Grave's disease, on tapazole 5. Reactive airway disease 6. Seronegative arthritis, followed in rheumatology 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, no on antiviral therapy 8. GERD 9. Migraines 10.Bilateral knee arthroscopy in [**5-24**] 11.s/p TAH and pelvic floor surgery with bladder lift Social History: She lives at home with her 2 daughters, aged 24 and 21. No sick contacts. She is a life-long non-smoker. No EtOH. Family History: Positive for DM, mother died of colon cancer. Physical Exam: per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] T 101.6 115 141/92 29 100% on RA Gen - somnolent but arousable to voice HEENT - non-icteric, EOMI, PERRLA, MM dry CV - tachy, reg, no m/r/g Lungs - CTA anteriorly, poor compliance with exam Abd - diminished BS, Soft, NT, ND Ext - no edema or rash, dry skin Neuro - somnolent but arousable to voice, moves all four, oriented to person only Pertinent Results: ED Labs: Glucose 1356 BUN 31 Cr 1.5 Na 126 K 6.3 HCO3 13 anion gap of 31 ketonuria EKG: no ischemic changes but positive peaked T waves UA negative CXR clear . Admission Labs: 149 I 120 I 11 --------------< 139 3.4 I 23 I 0.7 . pH 7.32 pCO2 33 pO2 47 HCO3 18 BaseXS -8 . Trop-*T*: <0.01 CK: 28 MB: Notdone Ca: 8.9 Mg: 2.1 P: 2.3 D ALT: 16 AP: 133 Tbili: 0.4 Alb: 3.3 AST: 18 [**Doctor First Name **]: 15 Lip: 12 TSH:<0.02 Free-T4:2.5 . 12.1 18.8 >----< 343 36.2 PT: 12.5 PTT: 22.0 INR: 1.1 Lactate:5.5 Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative . Cultures: blood cultures negative except [**2131-9-21**]: coag neg staph CSF cultures negative Urine cultures negative Sputum: 2+ gm pos cocci, 1+ gm pos rods . CSF: ANALYSIS WBC RBC Polys Lymphs Monos Macroph 4th 10 609* 67 12 0 21 1st 17 7650* 67 23 0 10 HSV Negative . Thyroid: FT4 2.5 to 0.9 HIV Negative . Imaging: CXR Portable AP [**9-16**]: Portable semi-upright chest radiograph reviewed. The lungs are grossly clear. The pleura are normal without pneumothorax. The heart and mediastinal contours are within normal limits. Pulmonary vasculature is normal. The right subclavian central venous catheter overlies the lower SVC. . CT Spine: negative for fracture Head CT: negative . MRI head: Diffusion images demonstrate no evidence of acute infarct. The ventricles and extraaxial spaces are normal in size. There are no focal signal abnormalities or evidence of age inappropriate brain or medial temporal atrophy. Following gadolinium, no abnormal parenchymal, vascular, or meningeal enhancement seen. Mild mucosal thickening is seen in both mastoid air cells. Again noted is occipitalization of C1 with mild tonsillar ectopia. IMPRESSION: No significant change or evidence of acute infarct. No enhancing lesions. No mass effect, hydrocephalus, or focal signal abnormalities. . EEG: This is an abnormal EEG in the waking and sleeping stages due to the bursts of generalized slowing seen in drowsiness. This is a nonspecific finding which may be observed with deep midline subcortical dysfunction, or could represent a state of altered sleepiness. . Right upper ex ultrasound: no DVT Brief Hospital Course: 52 year old woman with IDDM, HTN, [**Doctor Last Name 933**], Hep. C, depression admitted with altered mental status thought likely due to DKA. HOSPITAL COURSE BY PROBLEM . 1) DM1- DKA on admission. In the ICU, pt was started on insulin gtt and seen by the [**Last Name (un) **] consult team. Weaned off insulin gtt within a few hours as her AG closed and started on NPH 70/30. DKA thought secondary to medication non compliance. However, an evaluation for occult infection was also performed as well (see below). She was transferred to the floor and was stable. Subsequently she had a hypoglycemic seizure. She was seen by neuro and transferred back to the MICU. She was intubated briefly for airway protection. Her blood glucose stabilized and she was transferred back to the floor. We adjusted her insulin regimen so that she now is getting glargine 33mg qhs and insulin humalog sliding scale FOUR times a day. She has very close followup with [**Last Name (un) **]. . 2) Infectious Diseases - The pt was febrile to 101.6 in ED with occasional fevers while in the ICU and on the floor. The pt was pan-cultured several times (see above). C.diff was also sent given the pt's diarrhea, however was negative. Had leukocytosis on admission which trended down. She had fevers after her seizure so an LP was performed. It showed 10 WBCs which, in the setting of a seizure and altered mental status - she was treated for presumed meningitis with vanco and meropenem for 10d. Her fevers stopped and she successfully completed her antibiotics. . 3) Psych: The patient had a flat affect and even was catatonic briefly during her stay. She was evaluated closely by the neurologists and psychiatrists. We performed multiple imaging modalities and lab studies. Her only metabolic abnormality was thyroid disease (see below). We started remeron 30mg qhs and then zoloft 25mg qd during her stay. She had significant improvement in her mood. She had also experienced some dementia/neurocognitive deficits associated with this depression. The etiology was unclear. However, given the lack of imaging abnormalities and her improvement, it was thought not to be neurologic in origin. We scheduled her for neurocognitive testing as an outpatient. We also scheduled her for a VNA and also "best" program to help with her mood and deficits. Her family was counseled substantially on the importance of assisting the patient with her illnesses. . 3) HTN - As the pt was hypotensive on admission, BP meds were held while in the ICU, but were restarted once transferred to the floor with good result. . 4) [**Doctor Last Name 933**] disease - On admission, had an undetectable TSH and elevated free T4, likely [**2-22**] medication non-compliance. Pt's hyperthyroid state may have contributed to compliants of diarrhea. Methimazole was restarted and [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, the pt will likely need RAI ablation of thyroid for more definitive treatment in the future. Will recheck TFTs in four days to check for response on methimazole treatment. . 5) Reactive Airways disease - The pt was continued on outpatient meds. . 6) Hepatitis C - LFTs stable. The pt has never been on antiviral therapy. Medications on Admission: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Methimazole 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**] Drops Ophthalmic PRN (as needed). 5. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO qday prn. 6. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Serevent Diskus Inhalation 12. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO twice a day. 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 14. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 15. HYZAAR 100-25 mg Tablet Sig: One (1) Tablet PO once a day. 16. Hyoscyamine Sulfate 0.375 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 17. Insulin Take 80 units qam and 90 units qpm, as directed by your PCP Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-22**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 unit* Refills:*2* 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). Disp:*60 Capsule, Sust. Release 12HR(s)* Refills:*2* 5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) inh Inhalation twice a day. Disp:*1 unit* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 9. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 10. Methimazole 10 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). Disp:*15 Tablet(s)* Refills:*2* 15. Insulin Glargine 100 unit/mL Solution Sig: Thirty Three (33) Units Subcutaneous at bedtime. Disp:*1 Bottle* Refills:*2* 16. Humalog 100 unit/mL Solution Sig: variable units Subcutaneous at breakfast, lunch, AND dinner: Take blood sugar at each meals. Adjust insulin dose as follows: if blood glucose=61-80 take 0 units, if 81-120 take 4u, if 121-160 take 6u, if 161-200 take 8u, if 201-240 take 10u, if 241-280 take 12u, if 281-320 take 14u, if 321-360 take 16u, if 361-400 take 18u. Disp:*1 bottle* Refills:*2* 17. Humalog 100 unit/mL Solution Sig: variable units Subcutaneous at bedtime: check blood sugar at nighttime. if 61-200, give 0 units. if 201-240 give 2u, if 241-280 give 3u, if 281-320 give 4u, if 321-360 give 5u, if 361-400 give 6u. Disp:*1 bottle* Refills:*2* 18. Insulin Syringes (Disposable) Syringe Sig: One (1) syringe Miscell. four times a day: Please provide patient with a syringe that goes up to 50 units. . Disp:*120 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] [**Hospital 2256**] Discharge Diagnosis: 1. Insulin Dependent Diabetes Mellitus (type 1) 2. Diabetic polyneuropathy 3. Hypertension 4. Grave's disease, on tapazole 5. Reactive airway disease 6. Seronegative arthritis, followed in rheumatology 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, no on antiviral therapy 8. GERD 9. Migraines 10.Bilateral knee arthroscopy in [**5-24**] 11.s/p TAH and pelvic floor surgery with bladder lift 12.Major Depression 13.hypoglycemic seizure 14.possible CNS infection 15. Anemia Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital with extremely high blood sugar levels. You were treated in the ICU with insulin and transferred to the floor. You then experienced a seizure and were transferred back to the ICU. You were followed very closely by the neurologists and the psychiatrists, and we think your seizure was related to hypoglycemia. We also treated you with IV antibiotics. You were showing symptoms of depression which we treated medically. You improved during your stay. . It is extremely important for you to keep all of your followup appointments. We have made some adjustments to your insulin medications so you very much need to keep your appointments at [**Last Name (un) **]. Your family has agreed to help you with your medications and we also are sending a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] in your care. . Please check your blood sugars FOUR times a day and use the appropriate amount of insulin to balance your blood sugar levels. If you have an extremely high level (>400) please contact your doctor immediately. If you have a low level (<60) please eat some crackers and drink 4 oz of juice. Recheck your blood sugar in 15 minutes and if it continues to be low, please call your doctor or visit an emergency department. . If you experience chest pain, shortness of breath, severe abdominal pain, nausea, vomiting, or fever please call your doctor or visit an emergency department. . Please follow up with your primary care provider and your [**Name9 (PRE) **] doctor within 1 week of discharge. . It is very important for you to have a colonoscopy in the next three months. Followup Instructions: You need to call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**], to schedule an appointment within the next week. He can be reached at [**Telephone/Fax (1) **]. Please keep your appointment with Dr.[**Name (NI) 102660**] [**Name (STitle) **] Practitioner, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**], on [**10-9**] at 1:00pm. [**Telephone/Fax (1) **] Please keep your appointment with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] on [**2131-11-28**] at 8:30am Colonoscopy: Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Date/Time:[**2131-10-10**] 8:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-30**] 9:00 Please undergo neurocognitive testing with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2131-10-16**] 8:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] ICD9 Codes: 7907, 4019, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2481 }
Medical Text: Admission Date: [**2200-3-11**] [**Month/Day/Year **] Date: [**2200-3-14**] Date of Birth: [**2149-10-22**] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 465**] Chief Complaint: abd pain, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 50 y.o. man with DM2, HTN, hypercholesterolemia, psoriasis, p/w acute on chronic abd pain. Patient says that he has had about 6 weeks of lower abdominal pain, loose stools, with scant BRBPR. He had a coloscopy done [**3-6**] which showed "mild colitis". He was in his usual state of health, with some improvement in his abdominal pain, good appetite after the colonoscopy until day prior to admission when while driving from NY to [**Location (un) 86**] on business he started to feel unwell with nausea and upper abdominal pain. He pulled over to vomit, unsuccessfully, and continued to drive. He tried to go to work but felt so ill he went back to his hotel, where he vomited 5 times (no blood), the pain worsened to ~[**7-25**], and he decided he needed to seek help. . In the ED he presented with RUQ, LUQ, and epigastric abd pain today with fever to 102.2 and chills, with an initial lactate of 5.0. Rectal exam in the ED showed brown Guaiac + stool. His GI doc in NY was called and faxed reports of the biopsies from his colonoscopy show eosinophils, rectal biopsies show chronic/active colitis. GI doctor [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **] (Dr. [**Last Name (STitle) **], home phone [**Telephone/Fax (1) 71993**]). He was treated with levo and flagyl, followed by Vanco and Zosyn, anzemet, MS for pain, and IVF. CXR was negative for acute processes or free air and a CTA with gastrograffin showed no explantion for the patient's symptoms. UA was negative. . ROS basically negative. No recent travel, camping, changes in routine. Recent sick contact with daughter who has "flu" symptoms and multiple sick contacts at work. Does say that he's had about 1 month of aching joint pains which effects most of his joints, aches daily, and which he associates with a new increase in the size, spread, and severity of his psoriasis. Has not spoken to a doctor about it as he was more concerned about his GI symptoms. Past Medical History: Psoriasis HTN hyperlipidemia OSA (on bipap) DM (on oral meds) tonsilectomy Social History: Married to NP, works in publishing. Has two children 4 & 6. Lives in [**Location **], where he receives his medical care. Quit tobacco 4 years ago, drinks ~ 1x/month on business. No drugs. Family History: Mother alive, well. Father died at age 49 with MI. Brother alive has had multiple MIs. Physical Exam: VS: 102.3 109/53 92 21 94% on RA GEN: middle-aged man, diaphoretic, ill-appearing HEENT: OP clear, MMM, PERRLA, EOMI CV: heart sounds distant PULM: CTAB ABD: obese, firm, NT, +BS, +hepatomegaly EXT: no edema, +2 DP pulses NEURO: alert, oriented, CN grossly intact Pertinent Results: Initial labs: [**2200-3-11**] 04:09PM LACTATE-2.1* [**2200-3-11**] 12:07PM CK(CPK)-524* [**2200-3-11**] 12:07PM CK-MB-3 cTropnT-<0.01 [**2200-3-11**] 12:07PM CK-MB-3 cTropnT-<0.01 [**2200-3-11**] 02:58AM GLUCOSE-214* UREA N-12 CREAT-1.1 SODIUM-137 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18 [**2200-3-11**] 02:58AM ALT(SGPT)-16 AST(SGOT)-23 CK(CPK)-477* ALK PHOS-58 AMYLASE-52 TOT BILI-1.3 [**2200-3-11**] 02:58AM LIPASE-33 [**2200-3-11**] 02:58AM CK-MB-3 cTropnT-<0.01 [**2200-3-11**] 02:58AM CALCIUM-7.0* PHOSPHATE-2.0* MAGNESIUM-1.2* [**2200-3-11**] 02:58AM WBC-5.7 RBC-4.12* HGB-12.6* HCT-35.7* MCV-87 MCH-30.5 MCHC-35.2* RDW-13.7 [**2200-3-11**] 02:58AM NEUTS-88.1* BANDS-0 LYMPHS-7.1* MONOS-3.1 EOS-0.9 BASOS-0.8 [**2200-3-11**] 02:58AM PT-13.6* PTT-24.3 INR(PT)-1.2* [**2200-3-10**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2200-3-10**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2200-3-10**] 08:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2200-3-10**] 05:45PM CK(CPK)-116 [**2200-3-10**] 05:45PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-82 AMYLASE-86 TOT BILI-1.2 [**2200-3-10**] 05:45PM LIPASE-51 [**2200-3-10**] 05:45PM CK-MB-3 cTropnT-<0.01 [**2200-3-10**] 05:45PM CORTISOL-33.7* [**2200-3-10**] 05:45PM CRP-14.6* [**Month/Day/Year **] labs: [**2200-3-14**] 06:02AM BLOOD WBC-4.7 RBC-3.95* Hgb-10.9* Hct-32.7* MCV-83 MCH-27.5 MCHC-33.3 Plt Ct-250 [**2200-3-14**] 06:02AM BLOOD Neuts-71.5* Lymphs-12.7* Monos-5.7 Eos-9.7* Baso-0.2 [**2200-3-14**] 06:02AM BLOOD Plt Ct-250 [**2200-3-14**] 06:02AM BLOOD Glucose-210* UreaN-11 Creat-1.1 Na-140 K-3.9 Cl-103 HCO3-25 AnGap-16 [**2200-3-14**] 06:02AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.5 [**2200-3-12**] 05:03AM BLOOD VitB12-289 Folate-18.8 Ferritn-320 [**2200-3-13**] 07:23AM BLOOD Lactate-1.7 strongyloides negative Imaging: RUQ US [**3-11**] Markedly limited examination due to above described factors. Echogenic liver likely due to fatty infiltration, however other liver diseases such as cirrhosis/fibrosis cannot be excluded. No obvious gallstones or wall thickening is demonstrated. CT [**3-11**] IMPRESSION: 1. No definite acute inflammatory pathology is identified within the abdomen or pelvis to account for the patient's symptoms. The colon is normal in appearance. There is no free air or free fluid. 2. A single celiac lymph node is borderline in terms of size criteria for pathologic enlargement (measuring 10 mm in short axis). The significance of this finding is unclear, and CT followup may be needed to assess for interval change. 3. Fatty infiltration of the liver. 4. Distention of the gallbladder, which may be related to prolonged fasting related to symptoms. . CXR [**3-10**] IMPRESSION: No acute cardiopulmonary process. No evidence of free air. Brief Hospital Course: 50 y.o. man with DM2, HTN, hypercholesterolemia, psoriasis, p/w acute on chronic abd pain. . #Colitis- Patient's recent colonoscopy c/w colitis and positive for eosinophils. The ddx for this is ischemic (unlikely given CT scan distribution although does have risk factors : DM, high cholesterol, fam hx heart disease), inflammatory ( more likely given his history of psoriasis, joint pain and age), allergic (possible given eos) v infectious (possible given fever). GI was consulted. Stool O/P were negative. Strongyloides was negative. Patient was treated with 2 week course of ciprofloxacin and clindamycin. As his symptoms resolved and hematocrit was stable, patient was discharged home with GI follow-up in [**State 531**]. . #Fever: Patient febrile, diaphoretic but never hypotensive. Peak lactate 5.9 and trended down to 1.7. No clear cause on abd CT - no free air to suggest perforation, other possible sources of infection. Ucx did show 10-100,000 colonies of enterococcus but pt has no dysuria or increased frequency and repeat urine culture was negative. RUQ US negative for cholecystitis. Colitis was most likely reason for fever and suggests a more infectious or inflammatory cause for the colitis. . #joint pain: per patient affects multiple joints on an almost daily basis. There may be some association with acute worsening psoriasis. ?new psoriatic arthritis v IBD. Patient does have some slight psoriatic nail changes but no dactylitis. . # HTN- continue losartan and held HCTZ as patient was dehydrated. HCTZ restarted on [**State **]. . # Hypercholesterolemia- continued lipitor . # OSA- continue BIPAP-pt brought his own machine. . # Depression- continued celexa and klonopin qhs with xanax prn . # DM2- held metformin given his elevated lactate and dehydration. Covered with RISS and out on diabetic diet. Metformin was restarted on [**State **] as his lactate was 1.7. . # Friction blisters- Pt developed allergic reaction to pressure of BP cuff. Localized blisters present that began to look infected. Patient was started on clindamycin. Medications on Admission: Glucophage 1000 q hs, 500 q am lipitor 20 hyzaar 20 celexa 20 klonopin xanax PRN [**State **] Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. HYZAAR Oral 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*60 Tablet(s)* Refills:*2* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 6. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 5 days. Disp:*20 Capsule(s)* Refills:*0* 7. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 8. Glucophage 500 mg Tablet Sig: One (1) Tablet PO qam. Disp:*30 Tablet(s)* Refills:*2* [**State **] Disposition: Home [**State **] Diagnosis: colitis [**State **] Condition: stable, afebrile. [**State **] Instructions: You were admitted with vomiting and bloody diarrhea. The cause of your colitis is not clear and you should follow-up with your GI doctor [**First Name (Titles) **] [**Last Name (Titles) **]. You have been started on antibiotics for your bowel and left arm infection. Please take all medications as directed. Please follow-up with all outpatient appointments. Please return to the ED if you experience fever > 101, worsening diarrhea, bleeding, abdominal pain, vomiting, chest pain or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor within the next 1-2 weeks. . You should also follow-up with the gastroenterologist. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] ICD9 Codes: 0389, 2720, 4019
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Medical Text: Unit No: [**Numeric Identifier 73599**] Admission Date: [**2127-6-27**] Discharge Date: [**2127-6-29**] Date of Birth: [**2127-6-27**] Sex: M Service: NB HISTORY: Baby boy [**First Name8 (NamePattern2) **] [**Known lastname 73589**], triplet number 3, delivered at 35-1/7 weeks gestation with a birth weight of 2435 grams, and was admitted to the newborn intensive care nursery for management of prematurity. The mother is a 40-year-old gravida 2, para 0 now 3 woman, with estimated date of delivery [**2127-8-2**]. Prenatal screens included blood type O positive, antibody screen negative, hepatitis B surface antigen negative, rubella immune, RP nonreactive, and Group B strep unknown. This pregnancy was by in [**Last Name (un) 5153**] fertilization which resulted in a dichorionic triamniotic triplet gestation. The mother's maternal history was noted for anemia, asthma treated with albuterol, and GER treated with Protonix. This pregnancy has been followed with the growth of triplet 1 and 2 slowing down which precipitated delivery by cesarean section for intrauterine growth restriction of triplet 1 and 2. This baby emerged with a good cry, just dried and bulb suctioned, did not require oxygen, pinked up nicely on his own. Apgars 9 and 9 at 1 and 5 minutes respectively. PHYSICAL EXAMINATION: At discharge: Weight 2365 grams (50th to 75th percentile). Length 47.5 cm (50th to 75th percentile). Head circumference 35 cm (greater than the 90th percentile). Anterior fontanel: Open, soft, flat. Sutures approximated. No cleft. Red reflex positive in both eyes. Breath sounds clear, equal, with easy work of breathing. No murmur. Normal pulses and perfusion. Abdomen: Soft, no hepatosplenomegaly, no masses. Three-vessel cord. Spine intact. No dimple. Hips stable. Normal male. Testes descended. Normal tone and reflexes for gestational age. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Has always been on room without respiratory distress. Respiratory rate 30s to 60s. No apnea, bradycardia, or desaturations. Cardiovascular: No murmur. Heart rate ranges in the 120s to 130s. Recent blood pressure 64/30 with a mean of 43. Fluids, electrolytes, nutrition: started ad lib feeds following birth, is taking Enfamil 20 calories per ounce ad lib, every 4 hours, taking about an ounce to an ounce and a half, is spitting a little bit, is voiding and stooling appropriately. Discharge weight: 2365 grams. GI: Has mild jaundice. Bilirubin to be drawn tomorrow morning on [**2127-6-30**]. Hematology: No blood work was drawn. Hematocrit unknown. The baby is [**Name2 (NI) **] and well- perfused. Infectious disease: No sepsis risk factors. No labs drawn. Neurology exam is age appropriate. Hearing screening has not been performed, will need to be done prior to discharge. CONDITION ON DISCHARGE: Stable preterm infant. DISCHARGE DISPOSITION: Transfer to newborn nursery. PRIMARY PEDIATRICIAN: Pediatrician has not yet been identified. CARE AND RECOMMENDATIONS: 1. Ad lib feedings: Enfamil 20 with iron, follow weight and feeding volume, may need 24 calorie. 2. Medications: None. 3. Car seat position screening test needs to be done prior to discharge. 4. Newborn screen to be drawn on [**2127-6-30**] with bilirubin. IMMUNIZATIONS: He has not received any immunizations. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age, 35-1/7 weeks preterm infant. 2. Triplet number 3. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2127-6-29**] 00:52:17 T: [**2127-6-29**] 06:14:46 Job#: [**Job Number 73600**] ICD9 Codes: V053
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Medical Text: Admission Date: [**2180-3-28**] Discharge Date: [**2180-3-31**] Date of Birth: [**2127-1-11**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2145**] Chief Complaint: abdominal pain, hypotension, diarrhea, and fever Major Surgical or Invasive Procedure: Central line History of Present Illness: 53yo female with a history of asthma presents with abdominal pain, hypotension, and fever. . Approximately 2 weeks ago, patient developed dysuria and low abdominal pain. She describes her abdominal pain as being sharp in character, located in the right side of her abdomen, without radiations, and without any clear exacerbators or relievers. This was thought secondary to a urinary tract infection, and she was treated wtih a 10 day course of ciprofloxacin. Her dysuria resolved, but her abdominal pain persisted. At the same time, she was diagnosed with bacterial vaginosis for which she was treated with metronidazole. After completing her course of ciprofloxacin, she was subsequently diagnosed with a yeast infection for which she was treated with a topical antifungal medication. Then approximately 2 days ago, she developed fevers and chills with a Tmax of 102.7 on this day of admission. Additional symptoms include right-sided low back pain, nausea, generalized abdominal pain, and watery diarrhea which started on the day of admission. On additional review of systems, she denies recent travel, sick contacts, or dietary changes. She is in a monogamous relationship with her male partner of three years. Has a possible history of chlamydia but no other STDs that she is aware of. Her last menstrual period was in [**Month (only) 958**] [**2179**] and was previously regular. . She initially presented to [**Hospital3 **] Hospital where her vital signs were 90/54, HR 109, RR 22, Pulse ox 98% RA. She received dilaudid .5mg IV x 1, morphine 4mg IV x 2, phenergan 12.5mg IV x 2, tylenol 650mg PO x 1, zofran 4mg IV x 2. She had pelvic US and CT Abd/Pelvis that demonstrated ovarian cyst. She received zosyn x 1. Upon arrival in the [**Hospital1 18**] ED, temp 99.9, HR 80, BP 78/44, RR 20, and pulse ox 98% on room air. Her exam was notable for mild RLQ and LLQ tenderness. Labs were notable for a normal WBC at 8.5, hematocrit at 34, contaminated UA with 11-20 epis. She received 2L NS with improvement in her BP from 70s to 80s. She also received metronidazole 500mg IV x 1 and zofran 2mg IV x 2. OB-gyn was consulted, and she was thought to have likely C. diff colitis and recommended treatment for C. diff. Her ovarian cysts were thought likely benign. Surgery was consulted and recommended broad spectrum coverage with vanc / zosyn / flagyl and consideration of a repeat CT scan with oral and IV contrast. . Upon arrival to the [**Hospital Unit Name 153**], she describes her abdominal pain as [**2181-4-12**] in pain, sharp and crampy in character, located in her lower abdomen. Her primary complaint is her frequent loose and watery stools. Past Medical History: 1. Asthma 2. s/p Choledocalcystectomy 3. s/p Endometrial Ablation 4. G2P2 s/p SVD x 2 with uncomplicated pregnancies and deliveries Social History: Home: lives in [**Hospital3 **], alone Occupation: employed in real estate on [**Hospital2 **] [**Hospital3 **] EtOH: Denies Drugs: Denies Tobacco: Denies Family History: nc Physical Exam: On admission Gen: uncomfortable appearing but no acute distress HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: hypoactive BS, soft, tender to deep palpation in suprapubic area, no guarding EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant GYN EXAM: bimanual exam without cervical motion tenderness or adnexal tenderness Pertinent Results: [**2180-3-28**] 07:25PM BLOOD WBC-8.5 RBC-3.62* Hgb-11.0* Hct-32.0* MCV-88 MCH-30.3 MCHC-34.3 RDW-13.2 Plt Ct-141* [**2180-3-28**] 07:25PM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-138 K-3.6 Cl-112* HCO3-20* AnGap-10 [**2180-3-29**] 04:14AM BLOOD Albumin-2.5* Calcium-6.1* Phos-2.1* Mg-1.4* Iron-5* [**2180-3-28**] 07:25PM BLOOD ALT-20 AST-24 AlkPhos-34* TotBili-1.2 [**2180-3-28**] 09:02PM BLOOD Lactate-1.9 . [**2180-3-28**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-3-29**]): CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . CT abd/pelvis OSH films [**2180-3-28**]: IMPRESSION: 1. No acute pathology to explain patient's symptoms. 2. Liver hypodensities, which are too small to characterize and some of which are incompletely evaluated. 3. 3.7 cm right adnexal cystic lesion. Pelvic ultrasound in six weeks is recommended to ensure resolution. 4. Fibroid uterus. 4. Choledochojejunostomy with expected air within the biliary system. . CXR [**2180-3-28**]: IMPRESSION: Right IJ central line terminating in the mid SVC. Brief Hospital Course: 53yo female with a history of asthma and s/p choledocalcystectomy presents with hypotension, abdominal pain, diarrhea, fever. . 1. Sepsis/hypotension: The pt's hypotension was likely secondary to sepsis or severe volume depletion from C difficile. Of note patient is normally in low 90s systolic. Pt's systolics were in the 80s most of her first evening in the [**Hospital Unit Name 153**] with no changes in mental status. She was bolused with LRs. The next morning she dropped her SBP to 66 but was mentating fine and responded to 2L of LR. After aggressive volume resuscitation, her BP have now been stable on the floor. SBP 100s range (i.e. at her baseline), mentating well and feeling well. 2. C diff: Likely related to antibiotic use, reports she was given recent antibiotic course x 10 days for UTI. Pt was febrile in the ED and had symptoms of sepsis and severe volume depletion. Her WBC was normal at [**Hospital1 **] but elevated at an OSH. Patient stool came back positive for c. diff x2. She was started on IV flagyl and oral vancomycin. She is doing well on oral regimen with decreased bowel movements to 3-4 per day, taking good po's. She will complete 2 week course po vancomycin. She plans to discuss with her local providers her hx of UTIs -- she understandably is wary of future antibiotics for UTIs. I informed her that though I don't have her outpt records, generally uncomplicated bladder infections should be ~3 day course antibiotics, longer if there are symptoms of pyelonephritis. Recommmended that urine cultures be checked when she has dysuria in the future to confirm that she actually has an infection. 3. Asthma Stable and under adequate control. Patient was continued on home regimen. . 4. Anemia: The etiology of her anemia is unclear in our records but is chronic per pt. Her HCT has been stable here and she has not required transfusion. She has known iron deficiency and her iron should be restarted after she completes her course of flagyl. . 5. Ovarian cyst: pt reports she has known cyst and we recommend f/u with her PCP and gynecologist for this. She was given a copy of her abdominal CT report. . 7. CODE: FULL CODE . 8. COMM: [**Name (NI) **]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7111**] [**Telephone/Fax (1) 36501**] Medications on Admission: 1. Zolpidem prn 2. Singulair 3. Combivent 4. s/p cipro x 10 days 5. s/p metronidazole x 4-5 days 6. s/p topical antifungal therapy 7. ? ferrous sulfate Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days: OK to give in different formulation depending on pharmacy availability (such as liquid). Disp:*56 Capsule(s)* Refills:*0* 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Combivent 18-103 mcg/Actuation Aerosol Sig: [**12-10**] Inhalation four times a day. Discharge Disposition: Home Discharge Diagnosis: Sepsis Hypotension (resolved) Clostridium difficile colitis Discharge Condition: stable Discharge Instructions: You had had a severe infection from C. difficile colitis and should continue taking the oral vancomycin for 2 weeks. Please seek medical attention if you develop abdominal pain, fevers, worsened diarrhea. Followup Instructions: Follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) 36502**] in the next 1-2 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2180-4-4**] ICD9 Codes: 4589
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Medical Text: Admission Date: [**2167-2-17**] Discharge Date: [**2167-2-22**] Service: Cardiothoracic Surgery CHIEF COMPLAINT: Progressive shortness of breath and chest pain on exertion for the past two to three years. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 46945**] is a 78 year old male with a two to three year history of shortness of breath and chest pain on exertion, who visited his primary care physician for routine physical examination in [**2166-9-11**], at which time he related to his primary care physician the aforementioned episodes of chest pain and shortness of breath. He was subsequently sent for a stress test, as well as an echocardiogram and cardiac catheterization in [**Month (only) 1096**]. The cardiac catheterization showed a 50% lesion in the left anterior descending as well as subtotal occlusion of the diagonal 1 and diagonal 2 arteries. The right coronary artery was also occluded with no collateral flow to the distal portion from the left system. Based on these cardiac catheterization results, the patient was referred for coronary artery bypass graft surgery. He currently states that he has chest pain and shortness of breath on exertion, which is relieved by nitroglycerin as well as rest. PAST MEDICAL HISTORY: 1. Hypertension; 2. Gastroesophageal reflux disease; 3. Psoriasis; 4. Prostate cancer; 5. History of silent myocardial infarction. PAST SURGICAL HISTORY: 1. Transurethral radical prostatectomy in [**2117**]; 2. Colonoscopy with removal of rectal polyps in the [**2124**]. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg q. day; 2. Atenolol 25 mg q. day; 3. Steroid cream; 4. Sublingual nitroglycerin as needed; 5. Nitrodur patch; 6. Hydrochlorothiazide 50 mg q. day; 7. Avapro 75 mg q. day; 8. Legatrin prn for leg pain. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient denies any history of tobacco use. He states that he has been drinking two to three glasses of liquor per week for approximately 50 years. He lives by himself in [**Hospital1 **], [**State 350**] and was a retired letter carrier. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION: The height was 5 feet 9 inches, weight 183 lb, heartrate 58 in sinus bradycardia and the blood pressure was 133/69. In general, Mr. [**Known lastname 46945**] was a well dressed and well nourished male who had mild shortness of breath but was in no acute distress and appearing his stated age. His skin showed some psoriatic patches on the upper back, no rashes, and good skin turgor. His pupils were equally reactive and reactive to light and accommodation. Extraocular muscles were intact. His buccal mucosa was normal as was his dentition. His neck was supple with no jugulovenous distension. He also had no thyromegaly. He did have some left cerebral lymphadenopathy with some tenderness. His heart showed a regular rate and rhythm with normal S1 and S2 and no murmurs, rubs or gallops. His lungs were clear to auscultation bilaterally with no wheezes, rhonchi or rales. His abdomen was soft, nontender, nondistended without rebound or guarding. His extremities were warm, dry and well perfused with no peripheral edema, cyanosis or calf tenderness. He had no varicosities. Gross neurological examination showed that gross motor and sensory systems were intact and there were no deficits. On pulse examination, the patient had 2+ carotid pulses with no bruits. He had 2+ femoral, dorsalis pedis and radial pulses bilaterally, and a 2+ posterior tibial pulse on the left and 1+ posterior tibial pulse on the right. HOSPITAL COURSE: The patient was admitted to the Operating Room on [**2167-2-17**] where he underwent a coronary artery bypass graft times three. For full details of this procedure please refer to the dictated operative report. In summary, the left internal mammary was anastomosed to the left anterior descending with saphenous vein grafts to the right coronary and diagonal arteries. The patient tolerated the procedure well and was transferred to the Cardiosurgical Intensive Care Unit in normal sinus rhythm with a rate of 85 beats/minute, a nitroglycerin drip of 1.5 mg/kg/min, and a Propofol drip at 30 mcg/kg/min. Later that day, the patient was extubated in the Intensive Care Unit without incident, and was cooperative with deep breathing exercises. Over night the patient required volume and Hespan for low urine outputs to which he responded well. On postoperative day #1 he was off all drips, and deemed stable and ready to transfer to the regular floor. Once on the floor the patient did experience frequent bursts of sinus tachycardia with heartrate to the 120s, which seemed to correlate with incisional discomfort during coughing. The blood pressure remained stable during these episodes and he was asymptomatic other than his incisional pain. He was encouraged to use more pain medication as he had previously been using as he had been refusing multiple doses, and this had good effect when started. By postoperative day #3, the patient had been working with physical therapy, and was deemed safe for discharge to home. Diuresis and beta blockade were continued, and beta blockade was titrated in order to better control his heartrate. By postoperative day #5 the patient was doing quite well, and at this time was deemed stable and ready for discharge home. [**Hospital6 407**] services were arranged in order that they may evaluate the patient for a couple of visits after he first returns home. PHYSICAL EXAMINATION ON DISCHARGE: The patient's temperature was 98.9 F with a heartrate of 80 in sinus rhythm and a blood pressure of 110/70 and a room air oxygen saturation of 96%. His heart showed a regular rate and rhythm. His lungs were clear to auscultation bilaterally. His abdomen was soft, obese, nontender and nondistended. He had continued to have some minimal peripheral edema, however, this had been resolving quite well. MEDICATIONS ON DISCHARGE: 1. Enteric coated Aspirin 325 mg q. day 2. Colace 100 mg b.i.d. 3. Potassium 20 mEq q. day for seven days 4. Lasix 20 mg q. day for seven days 5. Lopressor 75 mg b.i.d. 6. Vicodin 1 to 2 tablets every 4 to 6 hours as needed for pain Of note, the patient was instructed to resume his preoperative Hydrochlorothiazide when his course of Lasix was complete. CONDITION ON DISCHARGE: The patient was stable. DISCHARGE INSTRUCTIONS: Activity was as tolerated. Diet was a cardiac heart healthy diet. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass graft times three on [**2167-2-17**]. 2. Hypertension 3. Gastroesophageal reflux disease 4. Psoriasis 5. Prostate cancer status post transurethral resection of prostate 6. Rectal polyps FOLLOW UP: The patient was instructed to follow up with his cardiologist or primary care physician in approximately one to two weeks time to review his medications and physical condition. His follow up with Dr. [**Last Name (STitle) **] was scheduled in three weeks time. Dictated By:[**Name8 (MD) 11089**] MEDQUIST36 D: [**2167-3-14**] 14:41 T: [**2167-3-14**] 15:10 JOB#: [**Job Number 46946**] ICD9 Codes: 412, 4019
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Medical Text: Admission Date: [**2163-3-13**] Discharge Date: [**2163-3-18**] Date of Birth: [**2101-4-18**] Sex: F Service: MEDICINE Allergies: Shellfish Derived / Peanut Attending:[**First Name3 (LF) 4373**] Chief Complaint: Mental status change Major Surgical or Invasive Procedure: None History of Present Illness: 61yo RH F with known brain metastases who was transferred from [**Hospital 4199**] Hospital after medline was called this morning. She presented there after waking this morning. Her boyfriend reports that she kept saying, "I don't want to go" over and over. He found this odd but she was able to walk and he noted no shaking or facial droop and he just thought she wasn't feeling well. Later in the morning, he went back into her room to tell her that her brother had called. She was unresponsive with her eyes closed and did not respond to shaking. He called lifeline and she was brought to [**Last Name (un) 4199**]. Their documentation reports focal seizure activity en route with right gaze deviation, for which she received valium 5mg IV. This continued there and at 12:50pm and 1:10pm, she was given a total of 260mg IV of phenobarbital, which ceased seizure activity. No exam is documented in the included notes. She also received avalox 400mg IV. Labs showed a leukocytosis to 16 with 97% pmn's. Head CT showed decreased size in the left occipital hyperdensity and decreased edema, compared to her prior scans. There was also a 0.4cm right cerebellar mass with no edema, where there had been prior to whole brain radiation. She had a stable L frontal meningioma. Transferred to [**Hospital1 **] for further managment. In ED, seen by neurology. Patient has been on decadron, but nevertheless elevated WBC (here 22K) was felt to be due to infection. Given cerebellar metastases, no LP was done. Patient was empirically treated for bacterial meningitis with vancomycin and ceftriaxone. She was also loaded with Keppra. Decadron was also continued. She has had no convulsive activity at [**Hospital1 **]. She is awake and alertbut non-verbal. Past Medical History: Known metastatic breast cancer, s/p L mastectomy, s/p chemotherapy and treated 13 cyles of whole brain radiation [**2-8**] HTN Seizure disorder Rhuematoid arthritis Social History: She was smoking 1 pack of cigarettes per week for 4 years. She does not drink alcohol or use illicit drugs. Her brother lives in the city near her and a son lives in [**Name (NI) 4444**], MA. Family History: Her maternal grandfather had [**Name2 (NI) 499**] cancer while her paternal grandfather had stomach cancer. Her mother died of [**Name (NI) 2481**] disease while her father passed away after a stroke. Her brother and sister are healthy, and so are her four children. Physical Exam: Gen Awake, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted Pertinent Results: Labs: WBC 22.5 (94% N), hct 43 134 97 40 92 4.8 26 0.9 lactate: 3.1-> 2.7 UA negative EKG:NSR, NA, NInt, no acute ischemic changes CHEST (PORTABLE AP) [**2163-3-12**] 6:42 PM Single bedside AP examination labeled "up" is compared with recent study dated [**2163-2-10**]. There has been interval removal of the nasogastric tube and left subclavian central venous catheter; the overall appearance is otherwise unchanged. The lung volumes are relatively low, but the lungs are clear. The cardiomediastinal silhouette and pulmonary vessels are within normal limits. There is no pleural effusion. Noted are surgical clips projected over the left upper abdomen and left axilla. MR HEAD W & W/O CONTRAST [**2163-3-13**] 1:35 PM 1. Moderate decrease in the FLAIR hyperintensity and size of the enhancing lesion in the left occipital lobe. 2. No significant change in the size of the enhancing lesions in the pons; mild decrease in the FLAIR hyperintensity in the right cerebellar hemisphere, with no significant change in the size of the enhancement. 3. A small focus of increased signal on the DWI and FLAIR sequences in the left medial occipital lobe with no definite enhancement- can represent another focus of metastasis, a small infarct or T2-shine through artifact. Please see the details above. 4. Unchanged left frontal small extra-axial enhancing lesion, that can represent meningioma or dural metastasis. 5.The study is limited for accurate assessment of any small new lesions, due to patient motion artifacts. EEG Study Date of [**2163-3-13**] Largely normal portable EEG for drowsiness and sleep. No clear normal waking background was evident. The slowing appeared likely to be part of sleep. An excessive drowsiness or medication-related encephalopathy cannot be excluded. There were no areas of prominent focal slowing, and there were no epileptiform features. A tachycardia was noted. TTE (Complete) Done [**2163-3-14**] at 9:35:19 AM FINAL The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**2-2**]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: No cardiac source of embolism identified. Preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation. Brief Hospital Course: 61yo F with known brain mets who presented after focal status [**2163-3-13**] that ceased with phenobarbital, no clear seizure activity since transfer to [**Hospital1 18**]. #) Seizure. Neurology consulted upon admission and followed patient during stay. Started on Keppra per Neurology recommendations. Ativan was ordered PRN seizure activity but was not needed during inpatient stay. EEG was performed and revealed slowing secondary to medication effect but no further eleptiform activity. Discussed whole brain radiation with outside Radiation Oncologist who stated the radiation completed thus far was appropriate and adequate and she did not need further whole brain therapy. Upon discharge will be continued on Keppra, Ativan PRN seizure activity and on a decadron taper. #) Breast Ca: Followed by outside oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]; s/p chemotherapy and chest/supraclavicular radiation. Has also completed 13 or 14 rounds of WBT per Dr. [**Last Name (STitle) 77183**]. He confirmed this was an appropriate amount and will not require further whole brain therapy at this time. Discharged to follow-up with primary oncologist. #) Leucocytosis: Liikly due to steroids. Other considerations included metastatic disease as there was no obvious source of infection at this time. No symptoms or signs of infection during inpatient stay. #) HTN: Continued outpatient Atenolol daily. #) Thrombocytopenia- HIT ab was sent ([**2163-3-13**]) and was negative. [**Month (only) 116**] be drug related or marrow involvement of cancer, but would expect other lines to be down as well. Keppra has been reported to cause thrombocytopenia but incidence has not been fully documented. Stably low during inpatient stay. Would recommend rechecking at follow-up appointment with Dr. [**First Name (STitle) **] on [**2163-3-23**] and to have repeat CBC in one week upon discharge to monitor for stability. [**Month (only) 116**] also follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on this issue. # Outside physicians: Dr. [**Last Name (STitle) **], PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Oncologist, [**Hospital3 **] [**Telephone/Fax (1) 74124**] Dr. [**Last Name (STitle) 77183**], Radiation oncologist, [**Hospital3 **] [**Telephone/Fax (1) 77184**] Medications on Admission: Per Prior Discharge Summary: Keppra 500mg [**Hospital1 **] Dexamethasone 4mg TID Lisinopril 10mg daily Metoprolol 25mg TID Per PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]: Atenolol 25mg po daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP < 100 or HR < 50 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Dexamethasone 2 mg Tablet Sig: 1-3 Tablets PO As directed: Please continue 6mg [**Hospital1 **] for 4 days, then decrease to 4mg [**Hospital1 **]. Dr. [**First Name (STitle) **] (primary oncologist) may want to change this dose 5. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q5MIN PRN () as needed for seizures. 6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 7. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) mL PO three times a day as needed for heartburn. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary: Metastatic breast cancer Secondary: Hypertension, Rheumatoid arthritis Discharge Condition: Hemodynamically stable and afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] after being transferred from an outside hospital after having a seizure. Once your mental status improved, you were discharged to an extended care facility for continued rehabilitation. You should follow-up with your primary oncologist and PCP. Please take all medications as prescribed. Please keep all outpatient appointments. Please seek medical advice if you notice increased confusion, seizure, fever, chills, difficulty breathing, chest pain or other symptoms which are concerning to you. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital3 **] Oncology Wednesday, [**2163-3-23**] at 10:45AM [**Street Address(2) 77185**] [**Location (un) 2199**], MA [**Telephone/Fax (1) 74124**] Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] early next week to schedule a follow-up appointment in the next 2-3 weeks. The facility staff may help you with this. His number is [**Telephone/Fax (1) 77186**] ICD9 Codes: 2761, 2875
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Medical Text: Admission Date: [**2158-12-26**] Discharge Date: [**2158-12-30**] Date of Birth: [**2109-5-21**] Sex: M Service: MEDICINE Allergies: naproxen / penicillin G Attending:[**First Name3 (LF) 4393**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: 49 yo male w/ EtOH cirrhosis with h/o multiple prior upper GI bleeds from esophageal and gastric ulcers transferred from [**Hospital1 **] with hematemesis. Patient has a history of medication non-compliance and per notes continues to drink EtOH. He was transferred From [**Hospital3 **] after an EGD there did not achieve adequate hemostasis. Patient tells me got up this morning around 8am, had a vitamin shake with ensure, that he usually takes three times a day. Then went to the shower, and after felt a bit "queazy", and thats when he vomited out the milkshake, but no blood, just food. Then got dressed, sat down, and 1/2 hour later stared feeling nauseated, went to the brathroom, and that's when blood came out - not as much as last time, but about [**1-8**] a pint - bright red blood. No diarrhea, had a normal bowel movement last night, muddy dark look to the stool. Since last admission he had several small episodes of emesis, but no new bleeding since EGD. In terms of drinking, had not had a drink in a week in a half. He had episodes of withdrawal when he was drinking in the past. But had no withdrawal episodes lately. He is otherwise complaint-free, thirsty and hungry. At [**Hospital1 **], he was admitted to the MICU, given D5NS, potassium, at 100cc/hr. He was seen by GI - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was started on octreotide drip, protonix IV BID, received FFP and vitamin K. Was deemed hemodynamicallly stable for transfer to [**Hospital1 18**]. Of note, he was recently transferred from [**Hospital1 **] to [**Hospital1 18**] at beginning of [**Month (only) **] for the same indication. At that time he was intubated, with active bleeding, thought to be arterial at GE junction. He had an EGD here. Patient was treated with octreotide drip for 72 hours and [**Hospital1 **] iv pantoprazole. Pt was given cipro 500mg [**Hospital1 **], with plan for 1 week course. Pt had repeat EGD showing 3 grade [**1-8**] esophageal varices. Overlying one of the varices was a linear ulcer with 3 clips distally. No active bleeding. Few other smaller ulcers at GEJ that looked like peptic injury. Stomach filled with food and old blood which obscured view. No active bleeding. There was some evidence of protal HTN gastropathy in body/fundus. There was a 4mm polyp at junction of duodenal sweep. No biopsies taken because of recent significant GI bleed. Patient reports that he was doing well since discharge. Prior to transfer, patient was noted to have some hives on his chest -for this he was given solumedrol, also given ativan 1mg for anxiety. On arrival, the vitals were - afebrile, HR 103, BP 170/85 99% on Room air. Past Medical History: (per OSH chart): - EtOH and Hep C cirrhosis, c/b varices w/ variceal bleeds, ascites - Hypertension - hyperlipidemia - Diabetes - Hemochromatosis - Anxiety - EtOH abuse - ostearthritis - Depression - Peripheral vascular disease Social History: graduated from [**Last Name (un) 90683**] [**Location (un) **], former financial manager, but is currently unemployed. Lives with a roommate. Divorced. Has been to rehab before (Garcenold, [**Doctor Last Name **] Point, [**Hospital1 **]) - Tobacco: No - Alcohol: Currently denies actively drinking. - Illicits: None. Family History: Has a maternal uncle who was an alcoholic. Paternal uncles were also alcoholic. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 96.7, P: 101, BP: 170/85, RR: 16, 100% on RA WD, WN, NAD, mild tremor that gets worse with movement. HEENT: PERRLA, EOMI Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, mildly bulging flanks without a fluid wave. Palpable liver tip and splenomegaly. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities spontaneously, nonfocal grossly. Gross intention tremor in upper extremities and upper body. . PHYSICAL EXAM ON DISCHARGE: General: Alert, oriented, no acute distress HEENT: Scleral icterus, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no spider angiomas GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no asterixis Neuro: CNs2-12 intact, motor function grossly normal; A+O x3 Pertinent Results: ADMISSION LABS: [**2158-12-26**] 10:24PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.4* Hct-28.4* MCV-90 MCH-29.8 MCHC-33.3 RDW-15.9* Plt Ct-34*# [**2158-12-26**] 10:24PM BLOOD PT-15.2* PTT-33.8 INR(PT)-1.4* [**2158-12-26**] 10:24PM BLOOD Glucose-152* UreaN-17 Creat-0.9 Na-137 K-4.2 Cl-97 HCO3-28 AnGap-16 [**2158-12-27**] 02:28AM BLOOD ALT-36 AST-86* AlkPhos-112 TotBili-4.8* [**2158-12-26**] 10:24PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 DISCHARGE LABS: [**2158-12-30**] 07:10AM BLOOD WBC-4.2 RBC-3.12* Hgb-9.5* Hct-28.6* MCV-92 MCH-30.3 MCHC-33.1 RDW-16.6* Plt Ct-60* [**2158-12-30**] 07:10AM BLOOD PT-17.8* PTT-32.8 INR(PT)-1.7* [**2158-12-30**] 07:10AM BLOOD Glucose-96 UreaN-22* Creat-1.2 Na-135 K-3.5 Cl-97 HCO3-28 AnGap-14 [**2158-12-30**] 07:10AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2 [**2158-12-30**] 07:10AM BLOOD ALT-28 AST-72* LD(LDH)-193 AlkPhos-91 TotBili-4.2* EEC [**2158-12-27**] Normal EEG in the waking state. There were no focal abnormalities or epileptiform features. CT HEAD W/O CONTRAST [**2158-12-27**] No acute intracranial process. Chronic atrophy and microvascular disease. Brief Hospital Course: BRIEF HOSPITAL COURSE: 49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI bleeds from esophageal varices and gastric ulcers transferred from [**Hospital3 **] with hematemesis. His Hct was stable and here he did not require further intervention. His course was complicated by grand mal seizure (toxic/metabolic vs EtOH w/d). He was discharged home with Hepatology and PCP [**Last Name (NamePattern4) 702**]. #) Upper GI bleed: due to sequelae of cirrhosis. Had an episode of Upper GI bleed, was scoped at OSH, which showed marked telangiectasia of R cardia, portal hypertension gastropathy, initially increasing bleeding, with spurting of blood. 5 clips were placed. At the end of procedure no active bleeding was noted. Here, his hematocrit remained stable and he had no episodes of further bleeding. H.Pylori was negative. He was treated with pantoprazole and octreotide gtt. He was also given ceftriaxone IV (switched to PO Cipro) for 1 week of post-variceal bleed prophylaxis. Continued on Nadolol and PPI. He was discharged home and will f/u for repeat EGD. #) Seizure: Toxic/metabolic vs. EtOH withdrawal. Patient had a tonic clonic seizure on [**2158-12-28**] at 0200 am. He was given 2 mg IV ativan which resolved the seizure. Etiology was thought to be alcohol withdrawal. He was seen by the neurology service who recommended EEG and CT head which were unremarkable. It was felt that the etiology was possibly EtOH w/d (though per his report his last drink was 10 days prior), vs. electrolyte disturbance (his Mg and K were low). He has no further seizures and Neurology did not feel that he needed further workup/follow-up. #) Cirrhosis: due to EtOH/HCV. He was followed by the Hepatology team while he was in house. His diuretics were held in the setting of Cr above baseline. He had no asterixis ro evidence of ascites at the time of discharge. He was started on Lactulose and Rifaximin this admission. He will have electrolytes checked [**Last Name (un) **] after d/c which will be faxed to his Hepatologist, and he will f/u with Hepatology [**Last Name (un) **] thereafter. #) [**Last Name (un) **]: likely prerenal. Cr at baseline is 0.8 but rose to 1.4. Responded to IV fluid/albumin so hepatorenal syndrome unlikely. His diuretics were held. Cr at discharge was 1.2. he will have electrolytes/Cr checked soon after discharge, which will be faxed to Hepatology. #) Alcoholism: ongoing issue. He does have baseline intentention tremor, without asterixis. He was monitored on CIWA; did have a seizure this admission 9see above). He was given daily thiamine/ folate/ multivitamin. #)Anxiety/Depression: stable. He was continued on home celexa 20 mg po daily. #) Transitional issues -PCP f/u: ten days after d/c (Dr. [**Last Name (STitle) 1693**], [**2158-1-9**]) Instructed to have CHEM10/LFTs/coags checked at that visit and faxed to Dr. [**Last Name (STitle) **]. -next EGD: [**2158-1-16**] -Hepatology f/u: [**2158-1-17**] Dr. [**Last Name (STitle) **] (diuretics may be restarted then) -pending labs/studies: none Medications on Admission: 1. Celexa 20mg PO 2. Furosemide 40mg PO daily 3. Magnesium tablet 1 PO daily 4. Nadolol 40mg PO daily 5. Omeprazole 20mg PO BID 6. Trental 400mg PO TID 7. Aldactone 50mg PO BID 8. Sucralfate 1g PO before each meal and at bedtime Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. magnesium Oral 3. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Trental 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO three times a day. 6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*1 bottle* Refills:*2* 11. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days: total course of antibiotics is 7 days (last day is [**2159-1-2**]). Disp:*14 Tablet(s)* Refills:*0* 12. Outpatient Lab Work [**2158-1-9**] Please check CBC/diff, CHEM10, PT/INR, AST, ALT, AlkPhos, T.bili. Fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (fax [**Telephone/Fax (1) 4400**], phone [**Telephone/Fax (1) 2422**]). Discharge Disposition: Home Discharge Diagnosis: Primary: Upper gastrointestinal bleed Alcoholic cirrhosis complicated by varices Seizure . Secondary: Hypertension Diabetes Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Name13 (STitle) **], . You were transferred to [**Hospital3 **] Medical center from another hospital because you vomited blood. You had an endoscopy where a bleeding ulcer was visualized and the bleeding was stopped. Since admission, your blood counts have been stable and you have not vomited any more blood. . During the hospitalization, you had a seizure. It was due to a number of things including alcohol withdrawal, sleep deprivation and some lab abnormalities. The seizure resolved with medicines and did not happen again. The neurologists evaluated you, and per, their recommendations, you had an EEG and CAT scan of the head both of which were normal. You do not need to see a neurologist as an outpatient. . Please seek emergent help for: -bleeding from te rectum, vomiting blood -confusion, lethargy -chest pain, shortness of breath -fever >100.4, chills -increased abdominal girth, swelling . We also spoke with you about quitting drinking alcohol. You were not interested in help with enrolling in a treatment program. We highly encourage you to stop drinking as alcohol use will cause progression of your liver disease, low blood counts, more bleeds from your intestinal tract and possibly more seizures. We know it is difficult, but we think you should really strongly consider quitting drinking. . We have made the following changes to your medications: -STOP Lasix (this will likely be restarted at your outpatient appointment) -STOP Aldactone (this will likely be restarted at your outpatient appointment) -INCREASE Omeprazole from 20mg daily to 40mg twice per day -START Folic acid 1mg daily -START Thiamine 100mg daily -START Lactulose 30ml three times per day (you need to be moving your bowels 2-3 times per day) -START Rifaximin 550mg twice per day -START Ciprofloxacin twice a day (an antibiotic; last day is [**2159-1-2**]) . On discharge, you will follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1693**]. Please have labs checked at that visit (lab slip has been provided) and make sure these labs are sent to your Liver doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Fax [**Telephone/Fax (1) 4400**], phone [**Telephone/Fax (1) 2422**]. You will see Dr. [**Last Name (STitle) **] as an outpatient as well, because you need to have a repeat EGD (upper endoscopy), see appointment below. . It was a pleasure taking care of you. We wish you all the best and happy holidays! Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] H. Location: [**Hospital1 **] PHYSICIAN SERVICES Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**] Phone: [**Telephone/Fax (1) 49260**] Appointment: Tuesday [**2159-1-9**] 11:15am . [**2159-1-16**] 02:30p [**Doctor Last Name **] [**Doctor Last Name **],EAST PROCEDURES (Endoscopy) [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES You will be called about more information . Department: LIVER CENTER When: WEDNESDAY [**2159-1-17**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] ICD9 Codes: 5849, 5715, 2724, 4019, 311, 4439
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Medical Text: Admission Date: [**2142-10-24**] Discharge Date: [**2142-11-9**] Date of Birth: [**2074-2-21**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 68 year old gentleman who is status post coronary artery bypass graft times three in [**2121**] with a five year history of exertional chest and throat discomfort. The patient underwent cardiac catheterization in [**2137**] which revealed patent bypass graft. The patient underwent a follow up stress test in [**2142-5-22**] which showed ischemic ST changes. The patient had a cardiac catheterization in [**2142-6-22**] which showed occluded vein grafts of the right coronary artery with native three vessel coronary artery disease and an ejection fraction of 33%. The patient was referred to Dr. [**Last Name (STitle) **] for operative treatment. PAST MEDICAL HISTORY: 1. Status post coronary artery bypass graft times three in [**2121**]; 2. Hypercholesterolemia; 3. Noninsulin dependent diabetes mellitus; 4. Arthritis; 5. Depression; 6. Hypertension; 7. Hard of hearing; 8. Gastroesophageal reflux disease; 9. Enlarged prostate; 10. Anxiety; 11. Status post left rotator cuff repair in [**2134**]; 12. Status post left parotidectomy in [**2140**]. MEDICATIONS: 1. Atenolol 25 mg p.o. q. day 2. Glucotrol 5 mg p.o. q.d. 3. Lipitor 20 mg p.o. q.d. 4. Celebrex 100 mg p.o. b.i.d. 5. Enteric coated Aspirin 325 mg p.o. q.d. 6. Vitamin E 7. Vitamin B 8. Multivitamin 9. Norvasc 5 mg p.o. q.d. 10. Cardura 2 mg p.o. q.d. 11. Zoloft 100 mg p.o. q.d. 12. Folate 13. Vitamin B12 14. Fish oil ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**2142-10-24**] and was taken to the Operating Room with Dr. [**Last Name (STitle) **] for a redo sternotomy and redo coronary artery bypass graft times three, left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending artery. The patient tolerated the procedure well and was transferred to the Intensive Care Unit in stable condition. Please see the operative note for further details. The patient initially required Levophed drip for maintenance of the blood pressure. In the Intensive Care Unit the patient had several short runs of nonsustained ventricular tachycardia for which he was started on Amiodarone infusion. She was weaned and extubated from mechanical ventilation on the first postoperative evening and postoperative day #1 the patient was transferred from the Intensive Care Unit to the floor. On the evening of postoperative day #1 into postoperative day #2 the patient became progressively hypoxic without improvement with diuretics, pain control or nebulizer treatment. The morning of postoperative day #2 the patient was transferred from the floor back to the Intensive Care Unit for hypoxia. Prior to transfer the patient was found to be hypotensive and significantly hypoxic and was electively intubated prior to transfer. Intubation was without complications. Upon arrival to the Intensive Care Unit the patient underwent a bronchoscopy which showed normal mucosa, copious thin secretions and a small plug in the left lower lobe. A sputum sample was sent from the bronchoscopy. Chest x-ray after intubation showed diffuse interspace disease, right greater than left. The patient was empirically started on antibiotics, Levofloxacin, Vancomycin and Flagyl. The patient remained significantly hypoxic, requiring paralytics and sedation and pressure control ventilation. The patient underwent a transesophageal echocardiogram which showed severely depressed left ventricular systolic function with ejection fraction of 20 to 25% with inferior akinesis, lateral hypokinesis, moderately depressed right ventricular systolic function, moderate mitral regurgitation and mild tricuspid regurgitation. Paralytics were discontinued on postoperative day #3. On postoperative day #4 pulmonary medicine consult was obtained due to the patient's continued respiratory failure, fevers of unknown origin and diffuse patchy infiltrates on chest x-ray, the Pulmonary Medicine Team's feelings were that the respiratory failure was either due to aspiration pneumonia or Amiodarone toxicity or atypical pneumonia. The Pulmonary Team recommended again using steroids, recommended discontinuing Amiodarone. Considering the present management, the patient was pancultured for his continued fever spikes of 102. All of the cultures from that time were negative with the exception of a sputum sample done during bronchoscopy which was positive for Methicillin-sensitive Coagulase positive Staphylococcus which was minimal growth. All subsequent sputum, blood and urine cultures were negative. On postoperative day #4 the patient had a pulmonary artery catheter placed to rule out cardiogenic pulmonary edema that showed a cardiac output of 7.2 and a cardiac index of 3.17, SVR of 715. The pulmonary artery catheter was removed as it was felt that the patient had adequate cardiac output. On postoperative day #4, the patient was switched from pressure control ventilation to conventional ventilation with assist control and subsequent to SIMV. The patient's sedation was slowly weaned down. The patient continued to have improving oxygenation over the next several days. The patient's positive end-expiratory pressure and sedation were weaned. The patient's fever curve continued to defervesce. The patient had no further atrial or ventricular ectopy. It was thought that the patient did not require any anti-arrhythmic therapy. On postoperative day #6 the patient again spiked a fever to 102.9. Blood cultures were sent which were negative. The patient's central line was removed. The patient continued on triple antibiotic therapy. The patient's white count during this time remained steady in the 13 to 15 range. By postoperative day #8 the patient continued to have fevers. The patient was weaning on the ventilator and had been weaned down to CPAP with pressure support, required Diamox for metabolic alkalosis. Sedation had been weaned off, however, the patient was agitated and not following commands, restless in the bed. A neurological consult was obtained which neurology felt that the majority of his problem was probably due to metabolic and infectious causes, however, felt that it could be due to a stroke and recommended an magnetic resonance imaging scan at a future date to further delineate this. However, by postoperative day #9, the patient's mental status had improved. The patient began to follow commands and move all extremities to command, and their recommendations were changed to consider the magnetic resonance imaging scan if the patient did not continue to progress. The patient continued to progress from a neurologic standpoint. By postoperative day #9, the patient was weaned and extubated from mechanical ventilation and continued to improve from a pulmonary standpoint, was able to tolerate nasal cannula by the morning of postoperative day #10 and required some pulmonary toilet, encouragement with coughing and deep breathing. It was noted about this time that the patient had an area of skin abrasion on his lower coccyx and gluteal cleft. Duoderm was applied and subsequent skin care specialist evaluated the patient and felt that it was a Stage 2 ulcer and recommended continuing Duoderm. The patient continued to improve, neurologically. He was quickly weaned off of oxygen to room air by postoperative day #11. Fever curve decreased by postoperative day #11, temperature maximum was 98. The patient continued to have episodes of confusion and delirium, however, he was following commands and moving all extremities equally. The patient's delirium continued to improve. The patient's antibiotics were weaned. The Vancomycin and the Flagyl were discontinued as the patient had no positive culture, was continued on the Levofloxacin. The patient was tolerating a regular diet without signs or symptoms of aspiration. The patient began walking with physical therapy, ambulating in the Intensive Care Unit. By postoperative day #13, the patient was transferred from the Intensive Care Unit to the regular floor. He remained hemodynamically stable and was able to ambulate with assistance, on room air and by postoperative day #15 the patient was deemed stable for discharge to a rehabilitation facility. The patient will be discharged on postoperative day #16. CONDITION ON DISCHARGE: Temperature maximum 96.5, pulse 78 in sinus rhythm, blood pressure 95/60, respiratory rate 18, room air oxygen saturation 95%, patient's weight on [**11-8**] was 90.1 kg. Preoperatively the patient weighed 100 kg. The patient was awake, alert and oriented times three, moving all extremities equally. Heart regular rate and rhythm without rub or murmur. Respiratory breath sounds are clear bilaterally. Abdomen, positive bowel sounds, soft, nontender, nondistended, tolerating regular diet. Extremities were warm and well perfused, no edema. The pressure ulcer over the gluteal cleft is covered with Duoderm. There is some mild erythema. There is no fluctuance. The sternal incision is clean and dry. The sternum is stable. Staples are intact. Left leg, vein harvest incision is clean and dry. Steri-Strips are intact. LABORATORY DATA: Laboratory data revealed white blood cell count 13.1, sodium 136, potassium 5.0, chloride 98, bicarbonate 29, BUN 27, creatinine 1.1, glucose 104. The patient has a chest x-ray pending for [**11-8**]. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. 3. Enteric coated Aspirin 325 mg p.o. q. day 4. Plavix 75 mg p.o. q. day 5. Percocet 5/325 one to two p.o. q. 4 hours prn 6. Lipitor 20 mg p.o. q. day 7. Prevacid 30 mg p.o. q. day 8. Zoloft 100 mg p.o. q. day 9. Lasix 20 mg p.o. q. day times seven days 10. Glipizide 5 mg p.o. q. day 11. Regular insulin sliding scale for blood sugar 120 to 150, give 1 unit subcutaneously, for blood sugar 150 to 200 give 3 units subcutaneously, for blood sugar 201 to 250 give 5 units subcutaneously, for blood sugar of 251 to 300 give 7 units subcutaneously, for blood sugar of 301 to 350 give 9 units, subcutaneous, for blood sugar greater than 350 give 11 units subcutaneously. DISCHARGE DIAGNOSIS: 1. Coronary artery disease 2. Status post redo coronary artery bypass graft times three 3. Postoperative respiratory failure due to Amiodarone toxicity versus aspiration pneumonia 4. Postoperative atrial fibrillation 5. Postoperative Stage 2 pressure ulcer on gluteal fold CONDITION ON DISCHARGE: The patient is to be discharged to rehabilitation in stable condition. FOLLOW UP: The patient should follow up with the Dr. [**Last Name (STitle) 29480**] in one to two weeks, the patient should follow up with Dr. [**First Name (STitle) **] in one to two weeks. The patient should follow up with Dr. [**Last Name (STitle) **] in one month. The patient should have the staples removed from the sternal incision on postoperative day #21 which is [**11-14**]. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2142-11-8**] 17:13 T: [**2142-11-8**] 20:48 JOB#: [**Job Number 29481**] ICD9 Codes: 5070, 5185, 2767
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Medical Text: Unit No: [**Numeric Identifier 60165**] Admission Date: [**2131-12-19**] Discharge Date: [**2131-12-19**] Date of Birth: [**2060-9-8**] Sex: M Service: TRA HISTORY: Trauma. PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old man who was transferred from an outside hospital after he fell down 4 to 10 stairs at home. He arrived in an intubated condition without a pulse. PHYSICAL EXAMINATION: On arrival, the patient was intubated and pale in appearance. There was no heart beat on palpation or auscultation. The lungs were clear on a ventilator. The abdomen was soft. Extremities were cool and pale. PERTINENT X-RAYS: None. PROCEDURES PERFORMED: 1. Right groin cordis placement. 2. Emergency room thoracotomy. 3. Exploratory laparotomy. 4. Transesophageal echocardiography. CONCISE SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was brought by Med-flight to the [**Hospital1 69**] in an intubated condition after being unstable at an outside hospital for several hours. On arrival, he did not have a palpable pulse and an ACLS protocol was initiated. He did have a narrow complex rhythm; and given that an emergency room thoracotomy was undertaken. After the thoracotomy, and cardiac massage and ACLS protocol a heart beat was obtained. The patient was emergently transferred to the operating room where the patient's heart stopped again. With further resuscitation, the heart beat was regained again. At this time, a small laparotomy was conducted elucidating serosanguineous ascites type of fluid. An exploratory laparotomy was then conducted which was negative for any abdominal source of bleeding. The abdomen was closed with a [**Location (un) 5701**] bag, and the patient was transferred to the intensive care unit in an unstable condition. Within 1 hour of transfer to the intensive care unit the patient had a PEA arrest. ACLS protocol was initiated and was unsuccessful. The patient was declared dead at that time. CONDITION ON DISCHARGE: Death. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Multiple trauma. 2. Emergency room thoracotomy. 3. Exploratory laparotomy. 4. Cardiac arrest. 5. Cirrhosis and ascites. FOLLOW-UP PLANS: None. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 22102**] MEDQUIST36 D: [**2132-1-18**] 13:22:39 T: [**2132-1-19**] 10:55:45 Job#: [**Job Number 60166**] ICD9 Codes: 4275, 4019
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Medical Text: Admission Date: [**2168-8-10**] Discharge Date: [**2168-8-22**] Date of Birth: [**2100-3-21**] Sex: F Service: SURGERY Allergies: Penicillins / Tetracycline / Erythromycin Base / Latex Attending:[**First Name3 (LF) 1481**] Chief Complaint: nausea/vomiting/diaphoresis Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions. History of Present Illness: 68 F presents to [**Hospital1 **] ED with nausea, vomiting, diaphoresis and distended abdomen after recent laparoscopic assisted right colectomy on [**2168-8-2**]. She was discharged from [**Hospital1 18**] on [**2168-8-6**] after in stable condition. She was doing well, tolerating a regular diet until yesterday when she developed the aforementioned symptoms. Past Medical History: Her past medical history is notable for heart disease, status post myocardial infarction in [**2167-8-28**]. She had some stents placed and was on aspirin and Plavix. She was also noted to have pulmonary embolism around this time and has been started on Coumadin and since then, her Plavix has been discontinued. She also has a history of hypertension and diabetes. Past surgeries include a lumbar fusion, tonsillectomy, deviated septum repair, appendectomy, cholecystectomy, hysterectomy and bladder suspension as well as several orthopedic surgeries include rotator cuff surgery and arthroscopies. The patient does not smoke or drink. She is retired and lives with her husband. There is a history of colon cancer in her father. [**Name (NI) **] mother died of a myocardial infarction. Review of systems is notable for a history of interstitial cystitis and arthritis as well as remote history of depression. Social History: Lives with husband Active lifestyle- regularly goes to gym Family History: Non-contributory. Physical Exam: Afebrile, VSS Alert, oriented x 3, NAD RRR CTAB Abdomen soft, appropriately mildly tender, steristrips in place LE warm, no edema Brief Hospital Course: Ms. [**Known lastname 2784**] presented to ED on [**8-10**] with nausea, vomiting, diaphoresis and distended abdomen. She received an exploratory laporatomy with lysis of adhesions for a small bowel obstruction that was found to be the cause of her symptoms. See Dr. [**Name (NI) 45689**] operative note for details. Patient was intubated in the ED d/t inability to protect airway and aspiration. Bronchoscopy was performed after surgery and she was found to have very little aspiration contents in her lower airways. She was admitted to the ICU after surgery d/t intubation and need for neosynephrine for BP control. While in the ICU she was successfull weaned off neosynephrine, and required lopressor for tachycardia. She had a drop in her Hct to 24 and required one unit of blood. She spiked a fever so was given a treatment of cipro, vancomycin, and flagyl. She was successfuly extubated on POD 5 and experienced resp distress that responded with Lasix. She was transferred out of the unit on POD 6. She had episodes of non-responsiveness on the floor for which she received several cardiac work-ups, psychiatry saw her and recommended discontinuing her narcotic pain medicine and her benzodiazepines. She also had a work-up with Neurology which included a 24 hour EEG, MRI and MRA of her head, and several lab tests. All of these were negative. At the time of discharge, she was stable and no longer experiencing these episodes of non-responsiveness. Neurology and her primary team felt that she was able to return to home. Physical therapy saw the patient and recommended home PT. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*20 Suppository(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Codeine Sulfate 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: small bowel obstruction Discharge Condition: stable Discharge Instructions: Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks. Please call [**Telephone/Fax (1) 2981**] to make appointment. Please contact your PCP for [**Name Initial (PRE) **] outpatient MRI of your spine. Neurology recommended this because they feel it is possible that a bulging disc could be contributing to your generalized weakness Completed by:[**2168-8-22**] ICD9 Codes: 0389, 5849, 5070, 4280, 4019, 412
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Medical Text: Admission Date: [**2135-1-16**] Discharge Date: [**2135-1-22**] Date of Birth: [**2084-4-17**] Sex: M Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: 50 year old male diagnosed with a left subdural hematoma on [**2135-1-14**]. Was discharged on [**2135-1-15**]. The patient was found to be unresponsive in his car by his brother. There was an empty ETOH bottle also found in the car. PAST MEDICAL HISTORY: Seizure disorder, hypertension, gastroesophageal reflux disease, depression, hepatitis C and ETOH. PAST SURGICAL HISTORY: Api. MEDICATIONS AT HOME: 1. Dilantin 300/100/100. 2. Atenolol 100 q d. 3. Paxil 20 mg q d. 4. Prilosec. PHYSICAL EXAMINATION: 91, sinus rhythm; blood pressure, 155/94; 100% room air sat. Opens eyes to voice. Follows commands. Oriented to person. Knows he is in the hospital. Pupils are equal, round, and reactive to light. Extraocular movements full. Face, symmetric. Tongue, midline. Tremulous bilateral upper extremities. Positive right pronator drift. Motor strength, [**4-25**] on the right except for + triceps, 4+ grasp and 4+ extensor hallucis longus. Motor strength on the left is 5 throughout. CAT scan shows expanding left subdural hematoma with mass effect causing a midline shift. LABORATORY: Dilantin, 32.3; ETOH, 23; platelet level, 125. All other labs, within normal limits> HOSPITAL COURSE: Taken to Operating Room on [**2135-1-16**] for craniotomy and evacuation of subdural hematoma. No complications. Was monitored in the Intensive Care Unit for close neurological observation and blood pressure control. Was placed on CIWA scale for possibly ETOH withdrawal. Repeat head CT showed well drained hematoma. Postoperative day #3, was transferred to Floor. Neurologically improved. Moved all extremities. No drift noted. Strength, [**4-25**] bilateral. However, the patient had some behavior issues related to withdrawal. At one point, became extremely agitated and combative. Was sedated with additional Ativan with good effect. He was slowly weaned from the CIWA protocol with success. PT was consulted and evaluated the patient and recommended rehabilitation. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Folic Acid 1 mg p.o. q d. 2. Multi Vit one cap p.o. q d. 3. Thiamin 100 mg p.o. q d. 4. Lopressor 25 mg p.o. b.i.d. 5. Protonics 40 mg p.o. q d. 6. Heparin 5,000 units subcutaneous tissue b.i.d. 7. Percocet one to two tabs p.o. q 4 to 6 prn. DISPOSITION: The patient is neurologically stable and will be discharged to rehabilitation. FOLLOW UP: A follow up with Dr. [**First Name (STitle) **] with a repeat head CT in one month and staples to be removed on Monday, [**2135-1-24**]. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2135-1-21**] 14:00 T: [**2135-1-21**] 15:18 JOB#: [**Job Number 46189**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2143-4-3**] Discharge Date: [**2143-4-5**] Date of Birth: [**2093-11-21**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Abdominal Pain, Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 49 year old female with HIV (Last CD4 500's, VL undetect), BLE paralysis, h/o DVT, and h/o rectal cancer with multiple complications with ostomy, nephrostomies, and multiple SBO's/ileus who presented to the ED with vomiting and SOB. She is being transferred the the [**Hospital Unit Name 153**] for hypotension. . She is frequently admitted to OMED for SBO's. She occasionally can manage this at home with bowel rest and IV fluids. Over the past 5 days, she again developed nausea, vomiting, abdominal pain, and liquid output from her ostomy. She therefore stopped eating and took IV fluids at home. She felt slightly better last night and had dinner, but then had recurrence of her abdominal pain. She also had the new onset of shortness of breath. Also reports poor urine output x 1 day. . She was taken to [**Hospital1 **]. She was found to be 92% on room air. She refused an NG tube as it makes her vomiting worse. Labs were notable for creatinine of 3.8 (from baseline of 0.8), hyperkalemia, and hyponatremia. CXR was reportedly clear with possible linear atelectasis. KUB was unremarkable. UA showed WBC and bacteria, but at her baseline. ECG was significant for QTc prolongation to 514. There was concern for PE given her SOB/hypoxia and paralysis, and she was empirically started on a heparin gtt for PE (no CTA given ARF). She was given 2L IVF. She had a large amount of emesis (1L) and her shortness of breath resolved. She was given a dose of ceftriaxone and transferred to our ED. . In our ED, initial vitals were 97.6 90 108/70 18 100% 4L. She had a renal ultrasound that showed no hydronephrosis and nephrostomy tubes in place. LENIs were negative for DVT. She was signed out to OMED, and then became hypotensive to the 80's/40's. She was started on levophed and SBP increased to the 130's. Her HR dropped to the 40's initially but improved to 60-70. She was given vancomycin and zosyn and 1.7 more liters of IVF (for a total of 3.7L). She has had 700cc output from her nephrostomy tubes. She continues on a heparin gtt. She has a 20g PIV and a port. Her current vitals are afebrile, 130/70, 65, 100%3L. . Currently, she has no complaints--she states that her ileostomy output increased shortly after her arrival to the [**Location (un) 620**] ED and that her abdominal pain symptoms began to resolve gradually since then. She states that her abdominal pain is currently at baseline and that she would like to start advancing her diet. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: ONCOLOGIC HISTORY: # Rectal cancer: - late [**2139**]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [**2141-2-20**]: began chemoradiation - [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [**2141-3-13**]: 5-FU was restarted at a reduced dose - [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [**Date range (3) 70844**]: Radiation was also held - [**2141-3-27**]: 5-FU was restarted at a further reduced dose - [**2141-3-31**]: completed radiation - [**2141-4-3**]: completed chemotherapy - [**Date range (3) 70845**]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [**2141-5-31**]: found to be HIV positive and began on HAART - [**Date range (1) 70846**]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [**7-/2141**]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: # HIV. # Short gut syndrome secondary to bowel surgery for CA. # Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes. # Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[**2141**]. # Pancreatic insufficiency. # Anemia. # Chronic pain. # LLE DVT: dx [**3-/2142**], was on warfarin. Social History: Lives with her husband and 4 children in [**Location (un) 17566**], does not smoke or drink alcohol. On long-term disability. Family History: Her father died at 72 of MI. Her mother alive and well. Remote family history of breast, colon cancer. Her daughter has ulcerative colitis. Physical Exam: ADMISSION EXAM: Vitals: 98.8 90 113/75 17 99%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 DISCHARGE EXAM: Vitals 98.4 65 71/49 12 93%RA General Appearance: Well nourished, No acute distress, Thin Head, Ears, Nose, Throat: Normocephalic, moist mucous membranes Cardiovascular: RRR, no murmurs Respiratory / Chest: Clear bilaterally ; port site clean and dry on R chest Abdominal: Soft, Non-tender, Bowel sounds present, ileostomy and nephrostomy c/d/i Extremities: Warm extremities with no LE edema Pertinent Results: Blood Counts [**2143-4-3**] 10:41AM BLOOD WBC-10.9 RBC-3.53* Hgb-10.7* Hct-33.4* MCV-95 MCH-30.4 MCHC-32.2 RDW-15.9* Plt Ct-268 [**2143-4-5**] 04:37AM BLOOD WBC-3.8* RBC-2.90* Hgb-8.9* Hct-27.0* MCV-93 MCH-30.6 MCHC-32.9 RDW-15.8* Plt Ct-240 . Coags [**2143-4-3**] 07:35AM BLOOD PT-14.6* PTT-40.3* INR(PT)-1.3* [**2143-4-5**] 04:37AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1 . Chemistry [**2143-4-3**] 10:41AM BLOOD Glucose-113* UreaN-32* Creat-2.3*# Na-133 K-3.5 Cl-103 HCO3-17* AnGap-17 [**2143-4-4**] 03:47AM BLOOD Glucose-80 UreaN-20 Creat-1.3* Na-138 K-3.4 Cl-110* HCO3-20* AnGap-11 [**2143-4-5**] 04:37AM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-137 K-3.9 Cl-108 HCO3-21* AnGap-12 . Microbiology [**Hospital1 **]-[**Location (un) 620**] URINE CULTURE [**2143-4-2**] >100,000 org/ml KLEBSIELLA PNEUMONIAE AMPICILLIN R >=32 AMP/SULBAM S 4 CEFAZOLIN S <=4 CEFOXITIN S <=4 CEFTAZIDIME S <=1 CEFTRIAXONE S <=1 CIPROFLOXACIN S <=0.25 ERTAPENEM S <=0.5 GENTAMICIN S <=1 IMIPENEM S <=1 LEVOFLOXACIN S <=0.12 PIP/TAZ S <=4 TOBRAMYCIN S <=1 TRIM/SULFA S <=20 . IMAGING: [**4-3**] LENIS: Limited examination, with wall-to-wall flow and augmentation seen in bilateral superficial/deep femoral and popliteal veins. Calf veins not visualized. . [**4-3**] RENAL U/S IMPRESSION: Normal kidneys, with nephrostomy tubes in expected position. . [**4-4**] CT Abd/Pelvis 1. No CT evidence for cystitis; however, evaluation is limited both by underdistension of the bladder as well as significant likely radiation-related changes in the lower pelvis. 2. Unchanged appearance of small bowel loops with focal areas of thickened wall and folds likely related to radiation-related changes without bowel wall dilatation. Brief Hospital Course: HOSPITAL COURSE This is a 49yo F PMHx HIV, rectal CA c/b bilateral nephrostomies & ileostomy, p/w vomitting, admitted to MICU for hypotension, found to have UTI, started on antibiotics w clinical improvement, stable and discharged home. . ACTIVE #. Hypotension / UTI: On admission, patient was found to have SBPs in the 70s with an intact mental status and without signs of ischemia / poor perfusion. Patient was fluid resuscitated and started on levophed given concern for sepsis. On review of chart and discussion w PCP, [**Name10 (NameIs) **] was found that patient baseline pressures were SBP 80s. Patient weaned off pressors and pressures remained in 80s-90s during daytime hours, dipping into 70s at night. Patient was found to have a Klebsiella UTI based on cultures from [**Hospital1 **]-[**Location (un) 620**]. She was was initially treated with Daptomycin and Zosyn given recent VRE and Klebsiella UTIs, once sensitivities returned, abx were narrowed to cefpodoxime. . #. Vomiting: Patient reported vomitting prior to admission, which had resolved by the time of admission w subsequent increase in her ostomy output to baseline. It was uncertain whether this represented a resolved viral gastroenteritis or ileus (as she has a history of ileus). . #. Acute renal failure: Creatinine was elevated to 3.8 on admission from baseline of 0.8. Urine lytes were c/w prerenal state, and Cr trended down w fluid resuscitation. No signs of obstruction on renal ultrasound. Given patient's b/l nephrostomy tubes, case was discussed w urology who did not believe additional management was warranted. At discharge Cr was 0.9. . INACTIVE #. Rectal cancer: No evidence of recurrence by CT [**11/2142**] or CEA [**2143-2-12**]. . # HIV: Last CD4 534, VL <48 copies on [**2143-3-21**]. Continued outpatient antiretrovirals. . TRANSITIONAL 1. Code - Patient remained full code 2. Pending - At discharge, admission blood cultures remained pending. Discharge summary was faxed to PCP to alert that these values would need to be followed up. 3. Transfer of Care - Patient scheduled for follow-up w PCP who was notified of the details of this admission via email. 4. Barriers to Care - Per PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] baseline low SBPs (80s-90s), should be kept in mind when treating future infections so as not to over aggressively treat Medications on Admission: 1. abacavir-lamivudine 600-300 mg once a day. 2. ritonavir 100 mg DAILY 3. darunavir 400 mg Tablet [**Name Initial (NameIs) **]: Two (2) Tablet PO DAILY (Daily). 4. methadone 5 mg Tablet: Alternate two (10mg) and three (15mg) tabs every six hours. 5. hydromorphone 4 mg: Four (4) Tablet PO Q2H prn pain 6. pregabalin 150 mg [**Hospital1 **] 7. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID 8. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Hospital1 **]: 1 Tablet PO three times a day as needed for High ostomy output (>5L). 9. ondansetron 4 mg Tablet q8h prn 10. lansoprazole 30 mg Daily 11. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. pentoxifylline 400 mg Tablet Extended Release [**Hospital1 **]: One (1) Tablet Extended Release PO three times a day: Compounded with vitamin E 100 Units. 13. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn 14. mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn 15. lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO HSprn. 16. cyanocobalamin (vitamin B-12) 1000 mcg (Daily). 17. ergocalciferol (vitamin D2) 50,000 unit once a week. 18. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 19. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID 20. magnesium sulfate 4 % IV infuse 2g if Mg <1.5. Discharge Medications: 1. abacavir-lamivudine 600-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 3. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 4. methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours): Alternate with 15mg for every 6 hour dosing. 5. methadone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q 12H (Every 12 Hours): Alternate with 10mg dose for every 6 hour dosing. 6. Dilaudid 4 mg Tablet [**Hospital1 **]: Four (4) Tablet PO q2. 7. pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day. 8. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a day as needed for diarrhea. 9. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 11. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 12. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO 1X/WEEK (WE). 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 16. magnesium sulfate 4 gram/100 mL Piggyback [**Last Name (STitle) **]: Two (2) gram Intravenous once: if Mg<1.5. 17. zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as needed for insomnia. 18. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as needed for insomnia. 19. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. 20. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 21. cefpodoxime 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Urinary Tract Infection Secondary: HIV Short gut syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Mrs. [**Known lastname 70847**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the ICU with low blood pressure. You were briefly given IV medications to increase your blood pressure, and antibiotics to treat a urinary tract infection. You improved and are now ready for discharge. During this hospitalization the following changes were made to your medications: -STARTED cefpodoxime (to be continued for a total of 14 days) Followup Instructions: Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: FRIDAY [**2143-4-12**] at 11:40 AM With: [**First Name8 (NamePattern2) 3679**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] ICD9 Codes: 5990, 2761, 2768
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Medical Text: Admission Date: [**2129-1-5**] Discharge Date: [**2129-1-23**] Date of Birth: [**2081-6-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Intraventricular hemorrhage Altered Mental Status Major Surgical or Invasive Procedure: Intubation NG tube placement A-line placement Central Line Placement History of Present Illness: Pt is a 47 F h/o stroke, vp shunt in place, mental retardation who is a nursing home patient and ([**Hospital1 **] of state) Pt was in her usual state of health when she was noted to become acutely unresponsive with a concomitant rise in her respiratory rate. Pt was noted to vomit at that time and was brought urgently to OSH. As part of the OSH's workup, pt received head CT revealing a large intraventricular bleed. She was transferred by ALS and arrived at [**Hospital1 18**] hyperthermic to 105, seizing during transfer, and tachycardic to 170's. She was emergently intubated and central access placed. As pt was noted to have hr in the 170s she was given adenosine for ? a.flutter then noted to be sinus tach. To control her seizures, pt was given propofol but continued to seize. She was subsequently loaded on dilantin. Seizures were ultimately controlled with versed. In [**Name (NI) **], pt was hypotensive to 80's. She was transferred to the MICU initially on neo with pressures in the 90s. Initial lactate measured in the ED was 10.4. Pt received 4 liters of IV fluid and follow up lactate improved to 5. Pt covered empirically with ceftriaxone/vanco and tx to the MICU for further evaluation and treatment. Past Medical History: Mental retardation Hydrocephalus Ventricular drain Asthma DM - non insulin dependent CVA(unknown residuals) Social History: Resides at [**Hospital 2251**] Nursing and Rehab center Family History: unknown: Pt is [**Hospital1 **] of the state. Physical Exam: expired Pertinent Results: [**2129-1-5**] 10:14PM LACTATE-5.3* [**2129-1-5**] 10:10PM GLUCOSE-130* UREA N-15 CREAT-1.0 SODIUM-144 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-18 [**2129-1-5**] 10:10PM WBC-16.0* RBC-3.94* HGB-11.4* HCT-33.4* MCV-85 MCH-29.0 MCHC-34.2 RDW-14.8 [**2129-1-5**] 10:10PM NEUTS-67.9 LYMPHS-20.9 MONOS-10.6 EOS-0.1 BASOS-0.5 [**2129-1-5**] 10:10PM PLT COUNT-268 [**2129-1-5**] 07:39PM LACTATE-7.2* [**2129-1-5**] 05:00PM GLUCOSE-171* UREA N-18 CREAT-1.2* SODIUM-145 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-19* ANION GAP-27* [**2129-1-5**] 05:00PM estGFR-Using this [**2129-1-5**] 05:00PM CALCIUM-9.3 PHOSPHATE-1.2* MAGNESIUM-1.7 [**2129-1-5**] 05:00PM WBC-15.6* RBC-4.19* HGB-11.9* HCT-35.7* MCV-85 MCH-28.3 MCHC-33.2 RDW-13.8 [**2129-1-5**] 05:00PM NEUTS-82.4* LYMPHS-13.0* MONOS-4.2 EOS-0.2 BASOS-0.3 [**2129-1-5**] 05:00PM PLT COUNT-336 [**2129-1-5**] 05:00PM PT-13.0 PTT-42.4* INR(PT)-1.1 [**2129-1-5**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2129-1-5**] 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2129-1-5**] 05:00PM URINE RBC-[**5-10**]* WBC->50 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2129-1-5**] 05:00PM URINE HYALINE-0-2 [**2129-1-5**] 04:58PM LACTATE-10.4* Brief Hospital Course: Pt was admitted from the ED to ICU. She was hypertensive, hyperthermic, and tachycardic with rates in the 170 range. Pt exhibited roving eye movements and right sided clonus. She was not responsive. Over the course of her hospitalization, pt experienced intermittent fevers, hypotension, rhabdomyolysis. She was evaluated by neurology and neurosurgery, both services concluding that there was not any meaningful recovery expected. As the patient is a [**Hospital1 **] of the state, affidavits were generated and the patient's case was presented before the courts. The patient was subsequently made CMO and expired shortly thereafter. Medications on Admission: Valproic acid, geodon, prozac, metformin, albuterol, enolase, senna, bisacodyl, MOM (all doses unknown) Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 431
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Medical Text: Admission Date: [**2128-7-31**] Discharge Date: [**2128-8-2**] Date of Birth: [**2128-7-31**] Sex: F Service: NB HISTORY: This infant was born at 34 and 6/7 weeks gestation by Cesarean section after failed induction for IUGR for maternal hypertension. PRENATAL HISTORY: Mother is a 29 year-old, prima gravida, EDC [**2128-9-5**]. Prenatal screens: Blood type A positive, antibody negative. HBSAG negative. RPR nonreactive. Rubella immune. GBS unknown. Maternal history was notable for asthma which was treated with Albuterol and Advair as well as chronic hypertension which required treatment with Nifedipine starting at 16 to 20 weeks gestation. This pregnancy was complicated by intrauterine growth restriction, admitted in early [**Month (only) **] with worsening hypertension and treated with full course of betamethasone and discharged home on bedrest. Mother was readmitted on [**2128-7-30**] for induction of labor due to intrauterine growth restriction and hypertension. The induction prompted fetal heart rate decelerations, therefore, the infant was delivered by Cesarean section. Mother received intrapartum antibiotic prophylaxis times greater than 4 hours, due to premature delivery with unknown GBS status. Artificial rupture of membranes for clear fluid occurred at the time of delivery. There was no maternal fever. There was a nuchal cord x1. The baby emerged with spontaneous cry and required only brief blow-by oxygen and routine care in the operating room. Apgars were 8 and 8 at 1 and 5 minutes. The infant was then transferred to the NICU for continued care for prematurity. PHYSICAL EXAMINATION: Measurements at birth: The weight is 2080 grams which is 25th to 50th percentile. Length 46 cm which is 25th to 50th percentile. Head circumference 32 cm which is 50th percentile. HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant had mild grunting, flaring and retracting on admission to the NICU. This quickly resolved on the newborn day. The infant has remained stable on room air since that time. She had mild apnea of prematurity. Her last episode was [**8-4**]. She has now completed a 5 day countdown. Cardiovascular: The infant has maintained cardiovascular stability while in the NICU. She does not have a murmur and has normal heart rates and blood pressures. Fluids, electrolytes and nutrition: The infant was started on IV fluids on admission to the NICU due to mild respiratory distress. The infant started enteral feedings on the newborn day and weaned off of IV fluids as well. She has always been fully po. She is presently taking ad lib p.o. feeds of breastmilk or Enfamil 20. The most recent weight is 2040 grams. No electrolytes have been measured on this infant. Gastrointestinal: Hyperbilirubinemia treated with phototherapy. Peak bilirubin 12.7/0.3. Rebound bilirubin 7.9/0.3 Infectious disease CBC and blood culture were screened on admission to the NICU due to the transitional respiratory distress. The CBC was benign. There was no left shift. The blood culture remains negative at 48 hours. The infant was not started on any antibiotic therapy. Neurology: The infant has maintained a normal neurologic examination for gestational age. Sensory: Audiology: A hearing screen was passed. Psychosocial: A [**Hospital1 18**] social worker has been in contact with the family. If there are any concerns, the social worker can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Discharge home with parents. PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, telephone number [**Telephone/Fax (1) 37304**]. CARE RECOMMENDATIONS: Ad lib p.o. feedings by breast or supplement with E-20 with iron at discharge. Medications: None. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi- vitamin preparation) daily until 12 months corrected age. Car seat position screening will need to be done prior to discharge. State newborn screen: sent x 2 IMMUNIZATIONS RECEIVED: Hepatitis B vaccine given [**8-7**]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: Dr. [**Last Name (STitle) **] in [**12-27**] days. DISCHARGE DIAGNOSES: 1. Prematurity, born at 34 and 6/7 weeks gestation. 2. Transitional respiratory distress resolved. 3. Sepsis ruled out. 4. Apnea of prematurity, resolved. 5. Hyperbilirubinemia, treated. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**] Dictated By:[**Name8 (MD) 62299**] MEDQUIST36 D: [**2128-8-2**] 02:33:23 T: [**2128-8-2**] 05:30:22 Job#: [**Job Number 75054**] ICD9 Codes: 7742, V053, V290
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Medical Text: Admission Date: [**2139-7-8**] Discharge Date: [**2139-7-14**] Service: CSU HISTORY OF PRESENT ILLNESS: This is a very pleasant 81 year old white male with a history of coronary artery disease, status post coronary artery bypass graft times one in [**2127**], who has been followed by his cardiologist for heart murmur over the past several years. On a routine physical examination two weeks prior to admission, echocardiogram revealed severe mitral regurgitation with flail leaflet. He was referred for cardiac catheterization and then for redo sternotomy, mitral valve replacement, with Dr. [**Last Name (STitle) **]. He was complaining of increased fatigue and shortness of breath on exertion over a several month period. He denied chest pain or pressure. Cardiac echocardiogram on [**2139-6-8**], showed posterior mitral valve prolapse with four plus mitral regurgitation, moderate tricuspid regurgitation, moderate biatrial enlargement, flail mitral valve prolapse posterior leaflet. Cardiac catheterization on [**2139-6-15**], showed left main 50 percent, left anterior descending coronary artery 40 percent, right coronary artery 40 percent, widely patent functioning left internal mammary artery to the left anterior descending coronary artery, dilated left ventricular cardiomyopathy with an ejection fraction of 49 percent, significant mitral regurgitation, mild to moderate pulmonary hypertension. PAST MEDICAL HISTORY: Coronary artery disease, status post coronary artery bypass graft times one on [**2128-11-8**], with left internal mammary artery to left anterior descending coronary artery. Hyperlipidemia. Mitral regurgitation. Diverticulitis. Dilated cardiomyopathy. Congestive heart failure. Gastroesophageal reflux disease. History of myocardial infarction. Hard of hearing, left greater than right. Prostate cancer, status post radiation treatment. PAST SURGICAL HISTORY: Implantation of a dual chamber permanent pacemaker four years ago. Coronary artery bypass graft times one in [**2127**]. Left fourth finger surgery eight years ago. MEDICATIONS ON ADMISSION: 1. Digoxin 0.125 mg once daily. 2. Monopril 20 mg once daily. 3. Atenolol 25 mg once daily. 4. Zocor 10 mg once daily. 5. Multivitamin once daily. 6. Nitroglycerin sublingual p.r.n. 7. Maalox p.r.n. PHYSICAL EXAMINATION: Vital signs revealed heart rate 61, normal sinus rhythm, blood pressure 98/55, height six feet four inches tall, weight 175 pounds. In general, an 81 year old male in no acute distress, appearing stated age. Skin well hydrated, no rashes or lesions. Head, eyes, ears, nose and throat examination - The pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Normal buccal mucosa. Full upper and lower dentures. Neck is supple with no jugular venous distention, question thyromegaly. Chest clear to auscultation bilaterally. Sternum stable. Sternal incision is well healed. The heart is regular rate and rhythm, S1 and S2, positive III/VI murmur heard best at the apex radiating to the left axilla. The abdomen is soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm, no edema or cyanosis, varicosities on the right thigh and right calf with some on the left calf as well. Neurologically, cranial nerves II through XII are grossly intact. HOSPITAL COURSE: The patient was admitted on [**2139-7-8**], with diagnosis of coronary artery disease, mitral regurgitation, elevated cholesterol, congestive heart failure, dilated cardiomyopathy. He underwent a redo sternotomy with mitral valve replacement, number 31 porcine tissue valve, under general anesthesia. Operating room course was uneventful with cardiopulmonary bypass time of 76 minutes, cross clamp time of 48 minutes, MAP up on transfer out of the operating room, MAP was 67 and CVP 12, PAD 17. He was AV paced at a rate of 88 per minute. He was transferred to the Intensive Care Unit on a Dobutamine drip and Neo-Synephrine drip. The underlying heart rhythm on transfer was a complete heart block with junctional escape beats. He was extubated on the evening of his operative day. Postoperative day number one was significant for a 16 beat run of ventricular tachycardia treated with Lidocaine and Magnesium. He continued to be AV paced with an internal pacer with a rate of 87. Both his Dobutamine and Neo-Synephrine have been weaned and his vital signs are stable on no intravenous drip medications. On postoperative day number two, there were no significant events. The patient was seen by the electrophysiology doctors [**First Name (Titles) **] [**Last Name (Titles) 28067**] of his pacemaker which showed that he does need a new generator but his current pacer is appropriate with occasional AV pacing at 61 necessary. He was also on a small Neo-Synephrine drip at 0.5 for blood pressure support which was weaned throughout the day on postoperative day number two and off completely by postoperative day number three. On postoperative day number three, the patient was transferred to the inpatient floor for recovery in stable condition. He continues to be AV paced at times with an internal pacemaker with some occasional ectopy and premature ventricular contractions. He was followed by physical therapy throughout his hospital course and was found to be safe for home by physical therapy on postoperative day number five. On [**2139-7-13**], postoperative day number five, he was transfused with one unit of packed red blood cells for a hematocrit of 24.8. On postoperative day number six, the patient was stable, ambulating independently in the hallways and was discharged home with visiting nurses. CONDITION ON DISCHARGE: On discharge, physical examination revealed lungs were clear. Cardiovascular regular rate and rhythm with no murmurs, rubs or gallops, occasional AV paced with underlying sinus rhythm. Incision is clean, dry and intact. Sternum is stable. Abdomen positive bowel sounds, positive bowel movement. Laboratories on discharge revealed white blood cell count 4.7, hematocrit 27.9, platelet count 119,000. Sodium 137, potassium 4.7, chloride 103, bicarbonate 26, blood urea nitrogen 20, creatinine 0.9, glucose 99. Chest x-ray on the day of discharge shows small bilateral pleural effusions with atelectasis at bilateral bases, no evidence of pneumothorax seen. DISCHARGE STATUS: Home with visiting nurse. DISCHARGE DIAGNOSES: Status post mitral valve replacement on [**2139-7-8**]. Coronary artery disease, status post coronary artery bypass graft in [**2127**]. Elevated cholesterol. Congestive heart failure. Dilated cardiomyopathy. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. twice a day times seven days. 2. Potassium Chloride 20 mEq twice a day for seven days. 3. Colace 100 mg p.o. twice a day. 4. Aspirin 325 mg once daily. 5. Vitamin C 500 mg twice a day. 6. Atenolol 25 mg once daily. 7. Percocet one to two tablets q4-6hours p.r.n. 8. Ferrous Sulfate 150 mg once daily. FOLLOW UP: Appointment with Dr. [**First Name (STitle) 1356**] in one to two weeks. Appointment with Dr. [**Last Name (STitle) 14522**] in two to three weeks, cardiologist, for evaluation and plans for new battery in pacemaker within one month. Follow-up also with Dr. [**Last Name (STitle) **] in approximately four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 28068**] MEDQUIST36 D: [**2139-7-14**] 17:00:18 T: [**2139-7-14**] 18:47:58 Job#: [**Job Number 28069**] ICD9 Codes: 4240, 4280, 4254, 9971, 4271, 2859, 2720, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2495 }
Medical Text: Admission Date: [**2155-7-23**] Discharge Date: [**2155-7-24**] Date of Birth: [**2101-10-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Chief complaint: acute renal failure, hyperkalemia Reason for ICU admission: Hypotension not responsive to 4L NS . Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 1356**] is a 53 year old male with CAD s/p MI, HTN, type 2 DM, PVD, who [**Known lastname 1834**] right groin exploration and femoral patch redo last week who presented to clinic today with fatigue for one week. He denies fevers, chills, nausea, vomiting, shortness of breath, diarrhea, constipation, abdominal pain. He does report significant surgical incision pain at right groin without significant drainage. In addition, he reported one hour of chest pressure several days ago while at rest which resolved and has not recurred. . In the ED, vitals were T 98.1, 74/47, 69, 18, 100% on RA. He was given 4LNS with only transient improvements of his blood pressure. In the ED, his blood pressure 70s-90s/ 50s-60s. A fast exam was performed in the ED and was negative. His bedside echo was unremarkable. He was not given antibiotics. . Upon arrival to the MICU, patient denied chest pain, lightheadedness, thirst, fevers, chills, dysuria, cough, shortness of breath, diarrhea, or any other concerning symptoms. Past Medical History: CAD s/p MI HTN DM, Type 2 Hyperlipidemia Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**] Arthritis Spinal spenosis Chronic back pain Bilateral knee surgery S/p liver orthotopic liver [**Month/Year (2) **] for ETOH cirrhosis Social History: Patient is a retired cook. He smoked 2 PPD for 40 years, but has since quit. He is a former alcoholic, but has been sober for 6 years Family History: Father died 42 years old from MI. Physical Exam: VS: HR 68, BP 118/60, RR 19, 96% on RA Gen: NAD, well appearing HEENT: EOMI, moist mucous membranes CV: RRR, no m/r/g, distant heart sounds Pulm: CTA b/l, no crackles, wheezes Abd: obese, soft, NT, ND Ext: severe right groin tenderness along the upper aspect of the surgical incision, +warm, but no visible drainage, right sided 2+pitting edema Neuro: AxOx3, moving all extremities Pertinent Results: [**2155-7-24**] 05:00AM BLOOD WBC-5.1 RBC-2.80* Hgb-8.3* Hct-25.6* MCV-91 MCH-29.6 MCHC-32.5 RDW-14.8 Plt Ct-217 [**2155-7-23**] 02:35PM BLOOD WBC-5.8 RBC-2.97* Hgb-8.9* Hct-26.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.4 Plt Ct-266 [**2155-7-23**] 09:45AM BLOOD WBC-8.1 RBC-2.69* Hgb-8.3* Hct-24.6* MCV-92 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-265 [**2155-7-24**] 05:00AM BLOOD Neuts-66.2 Lymphs-26.2 Monos-5.3 Eos-1.8 Baso-0.5 [**2155-7-23**] 02:35PM BLOOD Neuts-69.0 Lymphs-24.2 Monos-4.9 Eos-1.6 Baso-0.4 [**2155-7-24**] 05:00AM BLOOD Plt Ct-217 [**2155-7-24**] 05:00AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1 [**2155-7-23**] 02:35PM BLOOD Plt Ct-266 [**2155-7-23**] 02:35PM BLOOD Plt Ct-266 [**2155-7-23**] 02:35PM BLOOD PT-13.0 PTT-28.4 INR(PT)-1.1 [**2155-7-23**] 09:45AM BLOOD Plt Ct-265 [**2155-7-24**] 03:46PM BLOOD UreaN-28* Creat-2.1* Na-137 K-5.3* Cl-109* HCO3-21* AnGap-12 [**2155-7-24**] 05:00AM BLOOD Glucose-56* UreaN-30* Creat-2.1* Na-138 K-5.3* Cl-107 HCO3-21* AnGap-15 [**2155-7-23**] 10:44PM BLOOD Glucose-199* UreaN-34* Creat-2.2* Na-136 K-5.3* Cl-108 HCO3-20* AnGap-13 [**2155-7-23**] 07:31PM BLOOD Glucose-181* UreaN-36* Creat-2.2* Na-136 K-5.9* Cl-109* HCO3-20* AnGap-13 [**2155-7-23**] 02:35PM BLOOD Glucose-147* UreaN-43* Creat-2.8* Na-135 K-5.5* Cl-103 HCO3-24 AnGap-14 [**2155-7-23**] 09:45AM BLOOD UreaN-40* Creat-2.7* Na-132* K-6.2* Cl-99 HCO3-24 AnGap-15 [**2155-7-24**] 05:00AM BLOOD ALT-17 AST-17 LD(LDH)-195 CK(CPK)-41 AlkPhos-36* TotBili-0.2 [**2155-7-23**] 02:35PM BLOOD ALT-19 AST-17 AlkPhos-45 TotBili-0.2 [**2155-7-23**] 09:45AM BLOOD ALT-20 AST-19 AlkPhos-43 TotBili-0.2 [**2155-7-23**] 02:35PM BLOOD Lipase-11 [**2155-7-24**] 05:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2155-7-24**] 05:00AM BLOOD Albumin-3.4 Calcium-8.6 Phos-3.2 Mg-2.2 [**2155-7-23**] 10:44PM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6 [**2155-7-23**] 07:31PM BLOOD Calcium-7.5* Phos-2.9 Mg-1.6 [**2155-7-23**] 02:35PM BLOOD Albumin-3.8 [**2155-7-23**] 09:45AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-1.8 [**2155-7-23**] 09:45AM BLOOD tacroFK-5.4 [**2155-7-23**] 02:35PM BLOOD LtGrnHD-HOLD [**2155-7-23**] 10:48PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP [**2155-7-23**] 02:36PM BLOOD Comment-GREEN TOP [**2155-7-23**] 10:48PM BLOOD Lactate-1.2 [**2155-7-23**] 02:36PM BLOOD K-5.2 . CXR-IMPRESSION: Normal chest radiograph . u/s groin-IMPRESSION: Hematoma without evidence for pseudoaneurysm. Brief Hospital Course: Mr. [**Known lastname 1356**] is a 53 yo male with PVD, HTN, HL, CAD s/p MI, s/p liver [**Known lastname **] for alcoholic cirrhosis, admitted to the MICU for hypotension. . Hypotension. Patient had significant hypotension in the ED that required 4L of NS to normalize, and patient is now normotensive in the MICU. Perhaps hypotension is related to overdiruesis with home lasix dose, and med effect from several antihypertensives, however there is concern for early sepsis in this patient who is immunosuppressed with cellcept and prograf. Patient has significant right groin pain, making the surgical site the most likely source of infection. Normal lactate is reassuring. Significant blood loss is less likely given Hct is stable over the past week. Another possibility is cardiac etiology of hypotension given transient chest pressure several days ago, but this seems less likely in the setting of unchanged EKG. PT covered with vanco/zosyn overnight. He was switched to bactrim/cipro in am. U/S showing hematoma but no sign of abscess. Pt given IVF and home diuretics and anti-hypertensives held with good effect. Home BP meds except ACEI and diuretic were resumed upon discharge. . Acute Renal failure. Patient has baseline creatinine between 1.8 and 2, now with rising Creatinine to 2.8. He likely has pre-renal ARF as it responded to 4LNS bolus, though it remains above baseline. Prograf may be causing the elevated Cr as well, but dose was lowered today. Cr returned to near baseline. Prograf and cellcept continued. . Hyperkalemia. Likely secondary to renal failure and groin hematoma resorption. No EKG changes. Pt got 2 doses of kayexylate. He will have labs drawn in a few days and results will be sent to his hepatologist. In addition, his baseline K is around 5. . Right groin wound. Patient is s/p femoral graft removal and replacement due to infection last week. Now with significant wound tenderness. No clear evidence of drainage. U/S showing small hematoma, no sign of abscess. Cilostazol 50mg [**Hospital1 **]. Per vascular, pt may stop the cipro and resume his normally scheduled dosing of bactrim. . S/p Liver [**Hospital1 **]. Patient is s/p liver [**Hospital1 **] in [**2150**] for alcoholic cirrhosis. Currently on prograf and cellcept. Prograf dose reduced today from 5 mg [**Hospital1 **] to 4 mg [**Hospital1 **]. Immunosuppressants continued. Bactrim ppx continued. . CAD s/p MI. Patient has EKG without ischemic change. S/p chest pressure 4 days ago. - consider echo if not clear source of hypotension . HTN. - hold home antihypertensives (Lisinopril, atenolol, nifedepine) . DM, Type 2. - NPH and ISS - follow fingersticks . Hyperlipidemia. - continue lipitor . Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**] Cilostazol 50 mb [**Hospital1 **] - vascular following . Medications on Admission: Fosamax 70 mg weekly Atenolol 50 mg daily Lipitor 40 mg daily Cilostazol 50 mb [**Hospital1 **] Cipro 500 q 12 hours Nexium 40 mg daily Tricor 145 mg daily Lasix 20 mg every other daily Hydromorphone 2-4 mg q 4-6 hours NPH 48 q am, 28 qpm with HISS Lisinopril 5 mg daily Cellcept [**Pager number **] mg [**Hospital1 **] Nifedipine 30 mg daily Viagra prn Tacrolimus 4 mg [**Hospital1 **] Detrol LA 4 mg [**Hospital1 **] Trazodone 100 mg prn insomnia Bactrim [**Hospital1 **] Aspirin 325 daily Calcium Carbonate 1500 [**Hospital1 **] Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for PVD. 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours. 14. Nifedipine 30 mg Tablet Extended Rel 24 hr (2) Sig: One (1) Tablet Extended Rel 24 hr (2) PO once a day. 15. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: see below Subcutaneous twice a day: 48 units qam 28 units qpm. 17. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed. 18. Outpatient Lab Work chemistry panel, including potassium. to be done [**7-26**]. Fax results to Patient Phone: ([**Telephone/Fax (1) 1582**] Patient Fax: ([**Telephone/Fax (1) 12173**] Discharge Disposition: Home Discharge Diagnosis: Major: hypotension due to hypovolemia acute renal failure hyperkalemia . s/p R.femoral vascular surgery s/p liver [**Telephone/Fax (1) **] Discharge Condition: stable Discharge Instructions: You were admitted for low blood pressure and fatigue. For the low blood pressure you were given IVF and your home diuretics were stopped. Your low blood pressure resolved. You also were evaluated by the vascular surgery team and [**Telephone/Fax (1) 1834**] a groin ultrasound that showed a small hematoma but no evidence of infection or aneurysm. In addition, you had mild renal failure that resolved with the above treatments. . You should not take your lasix or lisinopril until you see your liver doctor. However your other blood pressure medications, atenolol and nifedipine should be resumed upon discharge. . You should see your liver doctor within 1 week of discharge. . Please continue to take you medications as prescribed and follow up with the appointments below. . You also had elevated blood potassium. For this you were given a dose of kayexylate. You should be sure to have this blood level checked either at your PCP or liver doctor's office within 2 days. . Followup Instructions: Please make sure you follow up the liver service within 1 week of discharge. . Please also be sure to follow up with your PCP. . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2155-7-31**] 4:00 . Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2155-8-19**] 10:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2155-8-19**] 10:00 ICD9 Codes: 5849, 2767, 4019, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2496 }
Medical Text: Admission Date: [**2150-8-10**] Discharge Date: [**2150-8-21**] Date of Birth: [**2095-9-11**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Optiray 350 Attending:[**First Name3 (LF) 5141**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: None History of Present Illness: 54F with metastatic melanoma presenting with fatigue. Pt reports she was seeing her [**First Name3 (LF) 3390**] yesterday and felt extremely fatigue and generally unwell. Pt referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for IVF. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], stool guiac positive. Hct found to be 25. Pt transferred to [**Hospital1 18**] for further mgmt. Pt denies pain. Recently admitted [**Date range (1) 62150**] with pleuritic chest pain and also had issues with n/v during that admission. Pt discharged on regimen of PO reglan and zofran. She reports nausea pretty well controlled. Reports last emesis >1wk ago. Reports relatively poor PO intake with liquids > solid foods. Denies CP, SOB, lightheadedness. Denies urinary symptoms. Reports baseline constipation, last BM 3 days ago which was loose. Pt denies evidence of blood in stool or with BMs. This morning, pt reports feeling relatively better. Denies pain. Past Medical History: PAST MEDICAL HISTORY: Metastatic melanoma with known lung metastases Hypopituitarism secondary to ipilimumab tx Diabetes Mellitus Type 2 Hypertension Atrial fibrillation s/p ablation [**2149-2-5**] h/o DVT &PE s/p IVC filter [**2144**] h/o catheter-associated IJ thrombus [**2150-2-11**] s/p Cholecystectomy s/p tonsillectomy s/p C-section Thyroid nodule Osteoporosis Vitamin D deficiency PAST ONCOLOGIC HISTORY: - [**2140**]: diagnosed with right shoulder melanoma - [**2145-3-21**]: presented with hemoptysis, bilateral DVT, PE, lung mass biopsy revealed metastatic melanomam. IVC filter placement. - [**2145-5-21**]: underwent chemotherapy. Disease progression noted. - [**2145-9-20**]: enrolled in MDX-010/ipilimumab study - [**2146-5-22**]: CT evidence of disease progression with enlarging right paratracheal and retrocaval nodes - [**2146-6-21**]: restarted MDX-010, completing 3 cycles of therapy. Follow-up CTs showed minimal interval progression - [**2147-9-21**]: began ipilimumab on compassionate access trial, found to have autoimmune hypophysitis [**1-22**] ipilimumab and protocol was subsequently discontinued. She was found not to have the specific BRAF mutation. - [**2148-3-21**]: started phase 1 RAF265 clinical trial with dose reduction x2 for nausea, vomiting and neuropathy. - [**2149-2-5**]: therapy held due to atrial flutter unrelated to study drug, requiring cardiac ablation on [**2149-2-11**]. Drug could not be restarted. She was taken off study on [**2149-2-19**]. - [**2149-3-12**]: started trial of sorafenib and bortezomib. Completed 6 cycles of therapy. - [**2149-12-1**]: CT showed disease progression with peritracheal pleural-based and retroperitoneal metastatic foci with several new right pleural and diaphragmatic foci. Treatment options were discussed and high-dose IL-2 was chosen given the small chance of a durable complete response. She passed eligibility testing with PFTs notable for FEV-1 1.66 or 71% predicted. - [**0-0-0**]: Admitted for first cycle of IL-2. She received [**8-4**] doses on week 1, complicated by tachycardia and pulmonary edema. - [**2150-2-11**] - [**2150-2-14**]: Admitted with left neck pain, found to have catheter-associated IJ thrombus, treated with Lovenox Social History: Married, lives in [**Hospital1 392**]. She has 3 adult children. She used to do clerical work but has not recently been employed. Remote smoking history. No history of EtOH abuse, no drug use. Family History: Mother had breast cancer and died of PE at age 62. Father died of an MI at 61. One brother with a dx of melanoma, which was completely excised. Physical Exam: Admission PE: Vitals: 98.1, 100-110s, 120s/50-60s, 18, 95-99% RA GENERAL: pleasant obese woman, lying in bed, in NAD HEENT: PERRLA, anicteric sclera, dry membranes CARDIAC: regular rhythm, tachycardic to 100s LUNG: bibasilar inspiratory rales, otherwise CTAB, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese, soft, nondistended, +BS, nontender EXTREMITIES: moving all extremities well, no LE edema, no obvious deformities NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge PE: Physical Exam: Vitals: Tmax 98.3, 102/70, P101 96% RA BS 117-190 GENERAL: pleasant obese woman, lying in bed, in NAD CARDIAC: regular rhythm, tachycardic to 117s LUNG: Good air movement bilaterally, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese, soft, nondistended, +BS, mild RUQ tenderness. RLQ superficial firmness that is tender. normoactive BS. EXTREMITIES: moving all extremities well, trace symmetric LE edema, no obvious deformities NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission Labs: [**2150-8-10**] 06:40PM WBC-9.9 RBC-3.28* HGB-9.3* HCT-29.2* MCV-89 MCH-28.2 MCHC-31.7 RDW-14.4 [**2150-8-10**] 06:40PM NEUTS-74.5* LYMPHS-19.9 MONOS-4.5 EOS-0.8 BASOS-0.4 [**2150-8-10**] 06:40PM PLT COUNT-477* [**2150-8-10**] 06:40PM PT-12.3 PTT-33.7 INR(PT)-1.1 ENDOCRINE [**2150-8-18**] 07:00AM BLOOD TSH-1.3 [**2150-8-18**] 07:00AM BLOOD Free T4-1.3 [**2150-8-18**] 07:00AM BLOOD Cortsol-7.2 Discharge Labs: [**2150-8-18**] 07:00AM BLOOD WBC-8.8 RBC-3.03* Hgb-8.5* Hct-26.3* MCV-87 MCH-28.1 MCHC-32.3 RDW-15.3 Plt Ct-311 [**2150-8-18**] 07:00AM BLOOD Glucose-60* UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-96 HCO3-26 AnGap-19 IMAGING: MRI Head [**2150-8-18**]: No findings to suggest metastatic disease to the brain. CT Abd/Pelv [**2150-8-19**]: 1. Overall, worsening disease burden with increase in right lower lung pleural lesion with multiple new mesenteric nodules as well as metastatic lesions within the ascending colon and small bowel. No evidence of bowel obstruction. 2. Right paraaortic lesion is stable. 3. Soft tissue nodules in the anterior abdominal wall appear smaller. Brief Hospital Course: HOSPITAL COURSE 54F with metastatic melanoma s/p treatment with ipilimumab with complicating hypophysitis presenting with fatigue, nausea, abdominal pain. Initially thought due likely secondary to combination of anemia and dehydration from poor PO intake. Pt recieved IVF and 1unit PRBC, but to minimal relief of symptoms of nausea and fatigue. Patient also had intermittent low grade fevers around 100.5 during admission initially thought to be from atelectasis. Given hx of hypophysitis [**1-22**] previous treatment with ipilimumab, AM Cortisol was drawn. It was found to be low-normal. After consultation with outpatient endocrinology it was agreed that cortisol response was inadequate. Patient's prednisone was increased from 5mg to 10mg to improvement of fatigue and nausea. During admission patient was noted to have LLE DVT and started on subQ Lovenox. Anti-Xa level was drawn after 3rd dose and found to be within range for dosing. Patient was discharged on day 12 of hospitalization with followup with Heme-Onc ([**2150-8-26**]), Endocrine ([**2150-8-25**]) and GI ([**2150-8-26**]). ACTIVE ISSUES: # FATIGUE/NAUSEA: Initially thought to be from combination of dehydration and anemia. Did not improve markedly after IVF and PRBC. MRI negative for brain metastases. Nausea was treated with Zofran and Reglan. Patient has hypophysitis [**1-22**] previous treatment with ipilimumab for metastatic melanoma. AM Cortisol was drawn and found to be low normal. After consultation with outpatient endocrinology it was agreed that cortisol response was inadequate. Patient's prednisone was increased from 5mg to 10mg to improvement of fatigue and nausea. # ABDOMINAL PAIN: Likely combination of progression of disease and adrenal insufficiency. CT Abd/Pelv demonstrated multiple new mesenteric nodules as well as metastatic lesions within the ascending colon and small bowel with no evidence of bowel obstruction. At discharge, patient's pain was controlled on morphine. # LOW GRADE FEVERS: Initially thought to be be related to atelectasis; Had been unlikely that pt had PNA in setting of no leukocytosis and no coughing. Pt was at high risk for PE, but recent scans had been negative. No source of infection had ever been found. After increase in prednisone dosage, intermittent fevers resolved. # LLE DVT: Found on LENI due to leg swelling. Initially treated with Heparin gtt and then transitioned to Lovenox. Due to patient obesity, Anti-Xa level was sent after third dose of Lovenox and found to be within acceptable limits. Patient sent out on twice daily Lovenox SubQ. # DM: Patient came in on Levemir, which was changed over to Lantus. However, BS were noted to be persistently low likely due to decreased PO intake so Lantus was titrated downwards. After resolution of nausea and lethargy, patient began to take POs again and Lantus was again titrated. Patient was discharged with followup with [**Hospital **] Clinic on [**2150-8-25**]. # SINUS TACH: Chronic baseline in 100-110s, with bursts to 140s with minimal exertion during admission. Pt with h/o aflutter s/p ablation seen by cardiology with persistent sinus tach on diltiazem. Unclear origin but chronic tachy in 100-110s documented >6months. Not much improvement after 1u pRBC transfusion [**8-13**], so does not seem to be related to anemia. EKG sinus without change from prior. No evidence of DVT and holding off on CTA to r/o PE as pt had CTA a little over a week ago negative for PE. Converted Diltiazem to PO metop tartrate with somewhat better HR control, which was then transitioned to succinate. Pt continued with HR in 100-110s on metop succinate 100mg QD. # HYPOTENSION: One episode of SBPs down to 80s on [**8-13**], improved to SBPs 90s-120s with better HR control and s/p small IVF boluses. # R PLEURAL EFFUSION: on CXR, likely in some part related to known melanoma mets to the R lung. Seems most likely to have atelectasis as well and seems less likely underlying infiltrate. Pt was intermittently with small O2 requirements (up to 2L NC), but easily weaned to RA with sats in mid to high 90s. # CONSTIPATION: Despite bowel regimen of docusate, senna, and miralax, patient was intermittently constipated throughout admission. Patient sent home with prescriptions for docusate, senna, miralax and lactulose. # ANEMIA: Pt with new anemia since 6/[**2149**]. Prior Hb 10-12 range without any evidence of anemia prior to 1/[**2149**]. Pt with Hb of 12 in [**5-/2150**], now with Hb stable in [**7-30**] range. Pt with guiac positive stool per OSH report. Pt without hematochezia or melena. Recent iron studies [**2150-7-28**] more c/w anemia of chronic disease: iron mildly low with normal ferritin and low TIBC. Unclear that this normocytic normochromic anemia would be from blood loss via GI tract. Hemolysis labs unremarkable. Retic count not elevated and seems more c/w anemia of inflammation. Spoke with GI regarding scope for workup of possible melanomatous mets to bowel as cause of guiac + stool and they said that in setting of hemodynamic stability and stable H/H, will set up with OP f/u with GI first in clinic and then to get scope. S/p 1u pRBCs [**8-13**]. H/H stable after transfusion. INACTIVE ISSUES: # Metastatic melanoma: no current treatment. Communicated with OP onc team and discharged with followup with Heme/Onc on [**2150-8-26**]. # Neuropathy: chronic likely [**1-22**] chemotherapy, continued neurontin # GERD: continued ranitidine TRANSITIONAL ISSUES: # [**Month/Day (2) 269**] to visit patient for Lovenox teaching # f/u with GI for clinic evaluation in order to set up scope to evaluate of intestinal mets from melanoma as cause of guiac + stool ([**2150-8-26**]). # f/u with OP oncologist, Dr. [**Last Name (STitle) **] ([**2150-8-26**]) # f/u with endocrine re: hypophysitis with adrenal insufficiency ([**2150-8-25**]) # f/u with [**Last Name (un) **] re: insulin dosage. # Pt's iron supplementation discontinued on discharge as it was contributing to significant constipation and pt's anemia workup seems most c/w anemia of chronic disease so iron supplementation unlikely to help. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain 2. Calcium Carbonate 500 mg PO DAILY 3. Diltiazem 60 mg PO TID plesae hold for HR<60 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 900 mg PO TID 6. Metoclopramide 10 mg PO QAC/HS PRN nausea 7. Mirtazapine 45 mg PO HS 8. Multivitamins W/minerals 1 TAB PO DAILY 9. PredniSONE 5 mg PO DAILY 10. Pyridoxine 50 mg PO DAILY 11. Ranitidine 150 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Senna 1 TAB PO BID constipation hold if has loose bowel movement 14. Polyethylene Glycol 17 g PO DAILY hold if has loose bowel movement 15. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting 16. Morphine SR (MS Contin) 15 mg PO Q12H for pain not taking 17. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain not taking, but has 18. Ferrous Sulfate 325 mg PO DAILY 19. detemir 34 Units Bedtime Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 900 mg PO TID 4. Metoclopramide 10 mg PO QAC/HS PRN nausea 5. Mirtazapine 45 mg PO HS 6. Polyethylene Glycol 17 g PO DAILY hold if has loose bowel movement 7. Pyridoxine 50 mg PO DAILY 8. Ranitidine 150 mg PO BID 9. Senna 1 TAB PO BID constipation hold if has loose bowel movement 10. Vitamin D 1000 UNIT PO DAILY 11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting 14. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Enoxaparin Sodium 120 mg SC Q12H RX *enoxaparin 120 mg/0.8 mL Inject one syringe subcutaneous every twelve (12) hours Disp #*60 Syringe Refills:*2 16. detemir 20 Units Bedtime 17. Lactulose 30 mL PO BID:PRN constipation RX *lactulose 10 gram/15 mL 30 mL by mouth [**Hospital1 **]:PRN Disp #*30 Container Refills:*0 18. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain RX *morphine 15 mg 0.5-1 tablet(s) by mouth q6h:PRN Disp #*60 Tablet Refills:*0 19. PredniSONE 10 mg PO DAILY RX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Adrenal insufficiency Secondary diagnosis: Metastatic melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 4886**], It was a pleasure taking care of you in the hospital. You were admitted with fatigue. Initially, we had thought this was partially from dehydration and in part from your anemia. We gave you one unit of blood and fluids. You had issues with a fast heart rate during your hospital stay, although this seems to be a chronic issue. We changed your diltiazem to metoprolol to better control this. Despite these treatments, you continued to feel vague symptoms of nausea, abdominal pain and fatigue. We did a test to measure a hormone called cortisol and found it to be relatively low. When we increased your prednisone (which acts in a similar way to cortisol), your symptoms seemed to dramatically improve. During your stay, you also developed a blood clot in your left leg. We are treating this with the blood thinner Lovenox, which is the injection you are receiving in your abdomen. Your blood sugars were running low while you were here, so we decreased your Levemir dosing to 20u at night (instead of 34u). Please check your blood sugars three times a day and bring these numbers to your [**Last Name (un) **] provider at your [**Name9 (PRE) 702**] appointment. If your sugars are >200 but <300, you can increase your levemir to 24u, if they're >300 but <400 you can increase to 28u, and if they're >400 you should return to 34u. If your sugars are lower than 80 you should decrease your dose to 18. With improvement of your fatigue, abdominal pain and nausea, we discharged you on day 12 of your hospital stay. Please follow-up at the appointments listed below. You should see your endocrinologist ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) to adjust your prednisone as needed. We would like you to see the GI doctors to possibly get a colonoscopy because of the positive test for blood in your stool. Please see the attached list for any changes to your home medications. Followup Instructions: Department: Endocrinology, [**Last Name (un) **] Diabetes Center Name: Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] When: Tuesday [**2150-8-25**] at 3:30 PM Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2150-8-26**] at 9:00 AM With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2150-9-4**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2150-8-26**] at 2:30 PM With: [**Year (4 digits) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2150-8-26**] at 2:30 PM With: [**Name6 (MD) **] [**Name8 (MD) 7880**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Cardiology Appt: [**2150-8-31**] 11:20a With: [**Doctor Last Name **] Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Completed by:[**2150-8-21**] ICD9 Codes: 5789, 2851, 4589, 5180, 4019, 2859, 311
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Medical Text: Admission Date: [**2133-7-13**] Discharge Date: [**2133-7-16**] Date of Birth: [**2114-11-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: motorcycle accident Major Surgical or Invasive Procedure: none History of Present Illness: 18M s/p motorcycle collision. Pt was accelerating, "popped a wheelie" and was thrown from m/c. Pt was wearing full face helmet. GCS 15 on arrival. CT scans showed extensive left sided pulmonary contusions, grade 5 splenic laceration, left clavicular/scapular fx, and mild hemoperitoneum. Past Medical History: PMH: none PSH: none [**Last Name (un) 1724**]: none Social History: Smokes ~1ppd, rare EtOH Family History: non-contributory Physical Exam: On admission in the trauma bay: T 99.2, HR 100, BP 145/86, RR 18, O2Sat 98%RA GEN - NAD, A&O HEENT - pupils 2mm and PERRL CVS - tachy, regular PULM - CTAB, chest symmetric, no crepitus ABD - soft, nondistended, +LUQ tenderness; FAST exam negative EXTREM - warm/dry, no edema, no deformities; L shoulder pain and decreased ROM but 5/5 strength and sensation in all extremities On discharge: T 97.8, HR 92, BP 140/70, RR 18, O2Sat 97%RA GEN - NAD, A&Ox3 CVS - RRR, no M/R/G PULM - coarse breath sounds b/l with rhonchi in bilateral lower lung fields bilaterally ABD - minimal LUQ tenderness, soft, nondistended EXTREM - warm/dry, no C/C/E; LUE in sling; 5/5 strength & sensation in all extremities Pertinent Results: [**2133-7-13**] 02:20AM BLOOD WBC-25.8* RBC-5.17 Hgb-15.2 Hct-43.6 MCV-84 MCH-29.4 MCHC-34.8 RDW-13.1 Plt Ct-212 [**2133-7-13**] 04:56AM BLOOD Hct-41.1 [**2133-7-13**] 09:59AM BLOOD Hct-37.7* [**2133-7-13**] 04:31PM BLOOD Hct-37.1* [**2133-7-13**] 10:20PM BLOOD Hct-36.5* [**2133-7-14**] 03:47AM BLOOD WBC-11.5*# RBC-4.24* Hgb-12.4* Hct-35.8* MCV-85 MCH-29.3 MCHC-34.6 RDW-12.9 Plt Ct-162 [**2133-7-14**] 09:40PM BLOOD Hct-35.2* [**2133-7-15**] 09:15AM BLOOD WBC-10.9 RBC-4.24* Hgb-12.3* Hct-36.4* MCV-86 MCH-28.9 MCHC-33.7 RDW-12.9 Plt Ct-184 [**2133-7-13**] 02:20AM BLOOD PT-14.2* PTT-24.3 INR(PT)-1.2* [**2133-7-14**] 03:47AM BLOOD Glucose-105* UreaN-10 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-24 AnGap-14 [**2133-7-14**] 03:47AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 IMAGING: CXR [**2133-7-13**]: Overlying trauma board limits evaluation. Lung volumes are low. Diffuse nodular and hazy opacity of the left lung is most consistent with pulmonary contusions. There is no pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. A left clavicular fracture is noted, partially obscured by the trauma board. There is marked gaseous distension of the stomach. CT Torso [**2133-7-13**]: IMPRESSION: 1. Shattered spleen extending to the hilum, consistent with grade V splenic injury with surrounding small amount of hemoperitoneum which is also seen within the right and left paracolic gutters. 2. Extensive pulmonary contusion of the left lung with multiple pneumatoceles. 3. Areas of ground-glass density within the right lower lobe, which may also represent contusion versus aspiration. 4. Large distended fluid-filled stomach for which NG tube placement is recommended. 5. Left clavicular and left scapular fracture. XR L clavicle & scapula [**2133-7-13**]: IMPRESSION: 1. Left mid clavicle displaced fracture. 2. Incompletely evaluated left lung opacities, as above. Brief Hospital Course: The patient was admitted to the ACS surgery service under Dr. [**Last Name (STitle) **]. His hospital course is as follows by systems: NEURO - The patient's pain was initially difficult to control. He received IV narcotics but still had significant pain and splinting. The Acute Pain Service was consulted by the ICU team and they placed an epidural a started a PCA. Later when tolerating good POs, his epidural was discontinued and he was transitioned to oral pain medications with adequate pain control. CVS - Due to the patient's extensive splenic laceration, his hemodynamics were monitored closely in the ICU for 2 days. He remained hemodynamically stable during his hospital stay. There were no other issues. PULM - Because the patient sustained extensive bilateral pulmonary contusions, his respiratory status was monitored closely. Aggressive pulmonary toilet and IS use was encouraged/implemented and he was gradually weaned off of supplemental oxygen. He had no further respiratory problems. FEN/GI - Because of the severity of the patient's splenic lac, he was admitted to the ICU and made NPO and maintained on IV fluids. His activity level was restricted to bedrest. He was allowed to eat on HD2 and he tolerated his diet well. He stayed on bedrest in the TSICU until HD2 and was then transferred to the floor. His activity level was then liberalized on HD3 and he was able to ambulate independently without problems. GI prophylaxis with famotidine was implemented until the patient was tolerating good POs, upon which it was discontinued. GU - The patient's urine output was monitored closely with a Foley catheter. His urine output remained adequate and the foley was discontinued on HD3 after the epidural was discontinued. He was able to void without problems. HEME - Serial hcts were stable and the patient did not require transfusions. ID - The patient's initial WBC on admission was 25.8. This normalized to 10.9 by HD3. He remained afebrile and there was no evidence of any infectious problems. ENDO - no issues MUSCULOSKELETAL - The orthopedics service was consulted for the patient's clavicular fracture. Their recommendations were to apply a sling for comfort for 2 weeks and follow up as an outpatient in [**2-17**] weeks. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: splenic laceration left clavicle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**3-23**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Continue to wear your sling for at least 2 weeks. Continue to take stool softeners and drink plenty of fluids while on narcotics to prevent constipation AVOID VIGOROUS ACTIVITY, ESPECIALLY CONTACT SPORTS UNTIL YOU ARE SEEN IN [**Hospital **] CLINIC! Followup Instructions: Please call ([**Telephone/Fax (1) 2537**] to schedule a follow-up appointment in [**12-17**] weeks the Acute Care Surgery clinic. Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 1228**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) 1005**] (orthopedics) in [**2-19**] weeks. ICD9 Codes: 3051
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Medical Text: Admission Date: [**2139-2-26**] Discharge Date: [**2139-3-17**] Service: SURGERY Allergies: Sulfonamides / E-Mycin Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal pain: The patient was admitted to [**Hospital1 18**] for acute-on-chronic cholecystitis with cholelithiasis. Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy [**2139-2-27**]. [**Last Name (un) 1372**]-intestinal tube (dobhoff) placement [**2139-3-3**]. [**Last Name (un) 1372**]-intestinal tube (dobhoff) repositioning [**2139-3-16**]. History of Present Illness: The patient is an 86 yo F with a history of MRSA cholecystitis s/p cholecystostomy tube on [**2-1**] which subsequently "fell out" while inhouse but was not replaced as the patient's clinical status had improved. The patient was discharged to a rehabilitation facility on vancomycin via a PICC Line complicated by a (L)UE DVT now on anticoagulation therapy. She was brought to [**Hospital1 18**] on [**2-26**] with a two-day history of nausea and vomiting of stomach contents of food and fluids. Past Medical History: Hypertension, diverticulitis, lactose intolerance, glaucoma, right L5 radiculopathy, DJD, C. difficile colitis, Atrial fibrillation, MRSA cholecystitis. Social History: Lives in [**Location (un) **] alone, her daughters live in the same building. [**Doctor First Name 5464**], contact number [**Telephone/Fax (1) 102135**]. [**Name2 (NI) 4084**] smoked, denies any EtOH use. Has VNA who comes in 2 days/week. Family History: Brothers with diabetes Physical Exam: Upon discharge: VS: T: 98.0 PO, BP: 184/94, HR: 88, RR: 20, SaO2: 96% RA GEN: Elderly female very sleepy today but easily arousable. In NAD. HEENT: Dubhoff in place in (R) nare. Sclerae anicteric. O-P intact. NECK: Supple. No lymphadenopathy. CV: Irregularly, irregular no m/r/g Resp: CTA b/l anteriorly Abd: soft NT/ND EXT: Anasarcic upper and lower extremities but improving, patient has Ace wraps in place for her LE edema Neuro: sleepy today but able to answer questions appropiately. Pertinent Results: [**2139-3-16**] 05:10AM BLOOD WBC-10.6 Hct-26.1* [**2139-3-15**] 04:53AM BLOOD WBC-11.2* RBC-3.17*# Hgb-8.8*# Hct-27.0* MCV-85 MCH-27.8 MCHC-32.5 RDW-15.7* Plt Ct-1031* [**2139-3-2**] 06:52AM BLOOD WBC-15.0* RBC-2.88* Hgb-8.0* Hct-24.7* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.6 Plt Ct-431 [**2139-2-26**] 01:00AM BLOOD WBC-9.3 RBC-3.62* Hgb-10.0* Hct-30.7* MCV-85 MCH-27.5 MCHC-32.4 RDW-14.7 Plt Ct-644* [**2139-3-16**] 05:10AM BLOOD PT-22.6* PTT-26.3 INR(PT)-2.2* [**2139-2-26**] 01:00AM BLOOD PT-33.8* PTT-32.2 INR(PT)-3.5* [**2139-3-16**] 05:10AM BLOOD Glucose-115* UreaN-23* Creat-1.4* Na-142 K-3.5 Cl-99 HCO3-37* AnGap-10 [**2139-2-26**] 01:00AM BLOOD Glucose-102 UreaN-10 Creat-0.6 Na-141 K-3.5 Cl-104 HCO3-26 AnGap-15 [**2139-3-16**] 05:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.5* [**2139-2-28**] 04:19AM BLOOD Calcium-7.8* Phos-3.2 Mg-0.9* [**2139-3-11**] 05:50AM BLOOD calTIBC-153* VitB12-1035* Folate-11.5 Ferritn-297* TRF-118* . ECHO [**3-10**] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion Brief Hospital Course: OPERATIONS DURING ADMISSION [**2-27**] Laparoscopic Cholecystectomy CONSULTATIONS DURING ADMISSION Geriatrics Neurosurgery Speech/swallow Infectious Disease BRIEF HOSPITAL COURSE BY PROBLEM 1. Acute on chronic cholecystitis: The patient was admitted to [**Hospital1 18**] as mentioned above with concerns for acute-on-chronic cholecystitis. She underwent a RUQ Ultrasound and a HIDA Scan, both of which had results concerning for acute-on-chronic cholecystitis. She thus had PICC line placed on [**2-27**] and was started on IV antibiotics. On [**2-27**] she was taken to the operating room where she underwent a laparoscopic cholecystectomy. The procedure was uneventful, she was extubated in the OR, and brought to the floor after an uneventful stay in the PACU. On [**3-1**] she triggered for poor UOP; she was started on diuresis and thought to be in acute renal failure. her JP drain was removed. Infectious disease was consulted for antibiotic advice; they recommended either discontinuing antibiotics, monitoring clinically and checking blood cultures off vancomycin, or continuing empiric antibiotic therapy, but re-scan abdomen and follow labs. The later course was followed ultimately with IV Vanco and Zosyn continued until [**2139-3-10**], when all antibiotics were finally discontinued. 2. Post-operative Delerium: Unfortunately, the patient's postoperative recovery was complicated by prolonged delerium. Geriatrics was consulted on 3/22to help manage her delerium. This most likely occurred in the setting of acute renal failure. They recommended to hold her gabapentin, hold her prozac, give PRN haldol for delirium, f/u nutrition labs and amylase/lipase. 3. Acute renal failure: In the setting of postoperative period; resolved. 4. Aspiration: The patient was seen multiple times by speech and swallow for concerns with aspiration. On [**3-12**] they advanced her diet to soft diet, 1:1 supervision, alternate sips w/food. Unfortunately, the patient has very little appetite. She had a dophoff feeding tube placed and was advanced to goal tube feeds of 45 cc/hr and is tolerating that rate, though with some diarrhea from the tube feeds and initially with nausea and vomiting that required decreasing or holding her tube feeds initially, and then restarting them back. Patient went to IR to have dobhoff repositioned post-pyloric. She tolerated the tube feeds without nausea or vomiting since dobhoff repositioned. 5. T12/L1 fracture: The patient had a known T12/L1/ compression fracture. She was seen by neurosurgery for help in management; initially on [**3-10**] they recommended a TLSO brace, but then when they saw the patient again on [**3-12**] they decided that she did not need the TLSO brace as the compression factures were stable on XR. 6. DVT: The patient was admitted with a known DVT of her LUE. Her INR was initially supratherapeutic, and so her coumadin was dosed daily until her INR became therapeutic once again. 7. Anasarca: The patient developed increasing anasarca throughout her hospital stay; this is most likely secondary to poor nutritional status in the setting of illness, though she does have some valvular heart disease on Echo, documented on [**3-10**]. She was placed in [**Male First Name (un) **] hose, which she did not tolerate, then her legs were wrapped with ACE bandage, and she was started on a gentle dose of diuresis. ACE bandages applied alternating Q8Hours on with Q4Hours off. 8. Anemia: The patient was noted to be anemic throughout her hospital stay. This is likely a combination of chronic disease, acute blood loss anemia. She received a transfusion of 1 UPRBC on [**2139-3-14**] with appropriate increase in HCT. Her stools were guaiaced; a single hemocult was positive on [**3-16**]. 9. Thrombocytosis: The patient also developed a worsening thrombocytosis of unclear etiology. 10. Throughout her stay, the patient was followed by both physical therapy and Speech/Language Pathology. 11. Code Status: DNR/DNI confirmed by daughter [**2139-2-28**]. On [**2139-3-17**], the patient was doing well, afebrile with stable viral signs. The patient was tolerating dobhoff tube feeds at goal with minimal PO intake, voiding with assistance, and pain was well controlled. A standard PIV was placed, and the CVL discontinued. The patient was discharged to the skilled nursing facility East Point in [**Location (un) **], Mass. Medications on Admission: Zantac 20 Po daily, Gabapent 100 PO TID, HCTZ 12.5 PO QAM, Latanoprost 0.005% 1 gtt to each eye [**Last Name (LF) **], [**First Name3 (LF) **] 81 PO daily, Coumadin 2.5 PO daily, Lopressor 25 Po BID, Prozac 10 PO daily, Colace, Senna, Dulcolax Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q4-6 HOURS PRN. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever or pain. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QSUNMONWEDFRI (). 15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QTUETHUSAT (). 16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Zofran 4 mg Tablet Sig: One (1) Tablet PO TID PRN. 18. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): As directed per Humalog Insulin Sliding Scale. Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: 1. MRSA Enterococcus acute on chronic cholecystitis 2. Post-op delerium 3. History of (L)UE DVT on Coumadin 4. Anemia 5. Ansarca Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day with assistance, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-19**] lbs until you follow-up with your surgeon. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment with Dr. [**First Name (STitle) 2819**] (Surgery) in [**1-13**] weeks. Please call ([**Telephone/Fax (1) 17909**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) 172**] (PCP) in 2 weeks. Completed by:[**2139-3-17**] ICD9 Codes: 2930, 2851, 4019
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Medical Text: Admission Date: [**2132-3-17**] Discharge Date: [**2132-4-1**] Service: CARDIOTHORACIC Allergies: Aspirin Attending:[**First Name3 (LF) 1267**] Chief Complaint: coming for aspirin desensitization prior to cath, found to have LMand 3VD referred for CABG Major Surgical or Invasive Procedure: [**3-17**] Cardiac catheterization [**3-20**] CABG x 4 (LIMA->LAD, SVG->OM, SVG->L PLV, SVG->PDA) History of Present Illness: This is a 83 y/o M with h/o BPH, HTN, carotid stenosis who presents for aspirin desensitization prior to cardiac cath after positive MIBI. Of note patient was referred to Dr [**First Name (STitle) **] for evaluation of peripheral vascular disease. [**2131-11-19**] he was going up stairs to pick up his mail, then he had a flash of light and fell. He may have lost consciousness for a short period of time. During this fall he dislocated his right shoulder and fx his left shoulder. He denied any chest pain, palpitations, headaches, shortness of breath or any other symptoms associated with the episode. After being seen by Dr [**First Name (STitle) **], stress MIBI was performed that showed Moderate, reversible defects of the distal anterior and septal walls respectively in addition to left ventricular cavity dilatation consistent with subendocardial ischemia consistent with LAD territory. He also had a carotid ultrasound that reported carotid stenosis with velocities >200 specially on the left side. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. At cath patient was found to have 60% LM, occluded LAD, 80% LCx, 60-70% RCA. Pt also found to have L renal artery stenosis Past Medical History: PAST MEDICAL HISTORY: Bilateral hernias BPH Hypertension Recent syncopal episode with fall resulting in bilateral shoulder and arm fractures. [**2131-10-31**] Peripheral vascular disease, Carotid artery stenosis. Social History: Married. Lives with his wife. Distant history of smoking chewing tobacco. Alcohol occasionally. Initially work in construction. He has 5 children Family History: Mother with DM. No history of premature heart disease or sudden death. Physical Exam: Admission BP 159/64 HR 56 RR 16 Sats 96 % on RA General: well developed, pleasant, well nourished. Oriented to person, place and time. HEENT: pupils equal and reactive to light. External ocular movements preserved. No JVD appreciated. no thyromegaly. Moist oral mucosa. + Left side carotid bruit. Lungs: occasional crackles in both bases. Cardiovascular. Palpation of PMI showed to be located in the 5th intercostal space, mid clavicular line. Regular rate and rhythm, s1-s2 normal. Soft holosystolic murmur in the apex radiated to the axilla. No S3 or S4 appreciated. No rubs. Abdomen: BS+, soft non tender, non distended. obese. no hepatomegaly appreciated. Extremities: no clubbing, no cyanosis. 1+ lower extremity edema. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge VS 97.8 HR 52SR BP150/56 RR 18 O2sat 92% RA Gen NAD Neuro A&Ox3 nonfocal exam Pulm Clear but dim throughout CV RRR no murmur. Sternum stable, incision CDI Abdm soft, NT/ND/+BS Ext warm 2+pedal edema bilat Skin multiple tears from tape Pertinent Results: [**2132-3-17**] 09:52PM WBC-9.8# RBC-3.44* HGB-10.9* HCT-32.0* MCV-93 MCH-31.8 MCHC-34.2 RDW-13.4 [**2132-3-17**] 09:52PM PLT COUNT-206 [**2132-3-17**] 09:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2132-3-17**] 06:00PM GLUCOSE-136* UREA N-21* CREAT-1.0 SODIUM-139 POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-32 ANION GAP-8 [**2132-3-17**] 06:00PM ALT(SGPT)-11 AST(SGOT)-15 CK(CPK)-39 ALK PHOS-59 AMYLASE-49 TOT BILI-0.5 [**2132-3-17**] 06:00PM ALBUMIN-3.4 CALCIUM-8.4 CHOLEST-146 [**2132-3-17**] 06:00PM PT-13.2* PTT-31.9 INR(PT)-1.1 [**2132-3-28**] 06:40AM BLOOD WBC-9.5 RBC-3.05* Hgb-9.1* Hct-28.8* MCV-95 MCH-29.9 MCHC-31.7 RDW-13.7 Plt Ct-398 [**2132-3-28**] 06:40AM BLOOD Plt Ct-398 [**2132-3-25**] 02:55AM BLOOD PT-13.0 PTT-28.0 INR(PT)-1.1 [**2132-3-28**] 06:40AM BLOOD Glucose-104 UreaN-46* Creat-2.0* Na-141 K-4.6 Cl-103 HCO3-32 AnGap-11 CHEST (PA & LAT) [**2132-3-26**] 5:15 PM CHEST (PA & LAT) Reason: evaluate pleural effusion [**Hospital 93**] MEDICAL CONDITION: 83 year old man s/p CABGx4 REASON FOR THIS EXAMINATION: evaluate pleural effusion PA AND LATERAL CHEST RADIOGRAPHS INDICATION: Status post CABG, evaluate pleural effusion. COMPARISON: Series of radiographs, most recent dated [**2132-3-22**]. FINDINGS: Again noted right internal jugular approach central venous catheter device with the distal tip projected over the right atrium. Cardiac silhouette is enlarged and mediastinum is mildly widened, consistent with post-operative state, not overtly changed from previous examination. Lung volumes are improved on this study, however, still evident a left lower lung atelectasis with moderate-sized left pleural effusion. Pulmonary vascularity is normal. IMPRESSION: Not significantly changed degree of left lower lobe atelectasis and moderate-sized pleural effusion. Improved lung volumes bilaterally. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] RENAL U.S. [**2132-3-24**] 10:08 AM RENAL U.S. Reason: Assess kidney's [**Hospital 93**] MEDICAL CONDITION: 83 year old man with ATN REASON FOR THIS EXAMINATION: Assess kidney's INDICATION: 83-year-old with ATN assess kidneys. RENAL ULTRASOUND: No prior studies for comparison. The right and left kidneys measure 9.5 and 10.1 cm respectively. There is an approximately 2cm exopohytic, hypoechoic mass off the mid to lower pole of the right kidney, concerning for a neoplasm. No other solid or cystic lesions. No hydronephrosis. IMPRESSION: 1) 2-cm exophytic hypoechoic mass off the mid to lower pole of the right kidney, concerning for malignancy; MRI is recommended for further characterization. 2) No hydronephrosis. Cortical echogenicity is somewhat difficult to evaluate but appears likely within normal limits. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] PATIENT/TEST INFORMATION: Echo Indication: Intraoperative TEE for CABG procedure Height: (in) 65 Weight (lb): 167 BSA (m2): 1.83 m2 BP (mm Hg): 145/78 HR (bpm): 56 Status: Inpatient Date/Time: [**2132-3-20**] at 09:47 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *2.8 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 7 mm Hg Tricuspid Valve - Peak TS Velocity: 2.0 m/sec TR Gradient (+ RA = PASP): >= 17 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2.Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post Bypass 1.Patient is being AV paced. 2. Biventricular systolic function is unchanged. 3. Mild mitral regurgitation persists. 4. Aorta intact post decannulation. 5. On arrival to the CRSU acute ST elevation seen in the inferior leads. TEE examination did not show any new wall motion abnormalities in either the right or left ventricle. No evidence of aortic dissection. Mild mitral regurgitation seen. Dr [**Last Name (STitle) **] aware of findings. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2132-3-20**] 14:01. Brief Hospital Course: Mr. [**Name13 (STitle) 72457**] was admitted for aspirin desensitization which he tolerated. Cardiac catheterization on [**3-17**] showed LM and 3VD and he was referred for CABG. He awaited plavix wash out. He had a history of a syncopal episode for which he was seen by cardiology with no indication for pacer found. He was taken to the operating room on [**3-20**] where he underwent a CABGx4(LIMA->LAD, SVG->OM, LPLV, PDA). He was transferred to the cardiac surgery ICU in critical but stable condition. He was extubated later that same day. He was seen by nephrology for a rising creatinine. The patient did well in the immediate post-op period, he remained in the ICU for several days to monitor his renal function. On POD 4 he was transferred to the floors after his creatinine plateaued at 3.5. Over the next several days his renal function improved, his activity level was advanced with nursing and PT help. And on POD8 it was decided he was stable and ready to discharge to rehabilitation. Medications on Admission: Plavix 75 Diovan 80 terazosin 5, hydrochlorothiazide 25 finasteride 5 iron 65 multivitamin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: CAD HTN BPH Infrarenal AAA melanoma syncopal episode [**11-4**] with bilat shoulder and arm fractures SBO s/p repair s/p excision of melanoma on face bilat hernia s/p repair Discharge Condition: Good. Discharge Instructions: Call with fever, rednes or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**First Name (STitle) **] 2-3 weeks Dr. [**Last Name (STitle) 8430**] 2-3 weeks Dr. [**First Name (STitle) **] 4 weeks Patient will need an MRI of his kidneys as an outpatient when her creatinine has improved secondary to an inconclusive finding on a renal ultrasound during her stay. Completed by:[**2132-3-28**] ICD9 Codes: 9971, 2767, 5845, 5180, 5119, 4019