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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3100 }
Medical Text: Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-11**] Date of Birth: [**2124-11-5**] Sex: M Service: [**Hospital Ward Name **] ICU CHIEF COMPLAINT: "Black stools" x one day. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of ischemic cardiomyopathy with an EF of 30 to 35%, status post left anterior descending coronary artery stent [**2182**], history of colonic polyps in [**2177**] status post resection, history of recurrent left lower extremity deep venous thrombosis on chronic anticoagulation who was in his usual state of health until two days prior when he noted onset of fatigue, nausea, loss of appetite. Yesterday one day prior to admission he had one episode of black stool. He denies any abdominal pain. He denies any vomiting or bright red blood per rectum. Of note, he had a light bowel movement on the day prior. He denies any history of heavy alcohol use or non-steroidal anti-inflammatory drugs use. No prior retching. No back pain. He does have a history of abdominal aortic aneurysm repair. He denies any changes in his Coumadin dosing. No lightheadedness. No loss of consciousness. The patient came to the clinic for a scheduled phlebotomy for his hemochromatosis at which time his systolic blood pressure was 88. He reported having black stool and was sent to the Emergency Room. In the Emergency Room he was OB positive. Nasogastric lavage was performed, which returned clear fluid. He was given 2 liters of saline intravenous with no improvement in systolics. His hematocrit was 31 initially and dropped to 24. INR was 2.3. He was given 2 mg of po vitamin K and sent to the [**Hospital Ward Name 332**] Intensive Care Unit. REVIEW OF SYSTEMS: He denies any fevers or chills. He denies any abdominal pain. He does admit to taking Dilantin 200 mg in [**Doctor Last Name 2434**] of his usual 300 dose of one to two weeks. He also admits to persistent reflux symptoms for several years, but it has been untreated. He uses Rolaids prn. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non Q wave myocardial infarction in [**2180**] with left anterior descending coronary artery [**Last Name (un) 2435**]. Status post myocardial infarction in [**2182**] with percutaneous transluminal coronary angioplasty to left anterior descending coronary artery stent. 2. History of congestive heart failure with an EF of 30 to 35%. 3. Hemochromatosis with early cirrhosis requiring q 3 month phlebotomies. 4. Noninsulin dependent diabetes mellitus. 5. Status post abdominal aortic aneurysm repair in [**2178**]. 6. History of recurrent left lower extremity deep venous thrombosis now on anticoagulation. 7. History of seizure disorder. 8. Status post L4-L5 discectomy in [**2181**]. 9. History of benign colonic polyp resection in [**2177**]. MEDICATIONS AT HOME: 1. Aspirin 81. 2. Atenolol 50. 3. Zestril 10. 4. Lipitor 10. 5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday. 6. Metformin 1000 twice a day. 7. Glyburide 20 twice a day. 8. Folate one. 9. Dilantin 300. ALLERGIES: The patient admits to an allergy to intravenous dye many years ago. The reaction was some bumps on his hand. No shortness of breath or choking. SOCIAL HISTORY: The patient lives with his wife in [**Name (NI) 2436**]. He is retired from the furniture upholstery business. He smoked 35 years times half a pack a day. Quit in [**2182**]. Very rare alcohol. No non-steroidal anti-inflammatory drugs or Ibuprofen use. PHYSICAL EXAMINATION: The patient's temperature was 98.4. Heart rate 76 to 79. Blood pressure 90/50. Respirations 15. Sat 94 to 99% on 2 liters. In general, well appearing and in no acute distress. Pupils are equal, round and reactive to light. No scleral icterus. Oropharynx is clear. Conjunctiva were slightly pale. No lymphadenopathy. No bruits. JVP approximately 8 cm. Chest rales at the right base. Cardiac regular. S1 and S2. No murmurs. Abdomen was benign, soft, nontender. Good bowel sounds. He had a midline ventral hernia, which was soft. Liver was palpated 2 cm below the costal margin. The patient was OB positive in the Emergency Department. Extremities revealed 1+ pedal edema with venostasis changes bilaterally. Skin examination had no rashes. The patient s alert and oriented times three with a chronic left foot drop. INITIAL LABORATORIES: White blood cell count 6.3, hematocrit 31.4, which then dropped to 24.3, baseline is 41. Platelets 138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24, BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled, which were negative. The patient's electrocardiogram revealed normal sinus rhythm, PR prolongation at 206. Left axis deviation, inferior Qs, all of which were old. There were some new T wave flattening in V2 to V6. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was admitted with melena likely an upper gastrointestinal bleed given history of abdominal aortic aneurysm, question of enteric fistula. Given history of hemochromatosis and early cirrhosis, question of varices, given history of reflux symptoms, question of esophagitis, gastritis. The patient was again admitted with gastrointestinal bleed and was typed and crossed. He was initially transfused 2 units for a hematocrit of 24. He had two peripheral intravenouses in place. INR was corrected with vitamin K 2 mg and 4 units of fresh frozen platelets and hematocrit revealed a change from 24 up to 26 after 4 units. INR corrected to 1.7. The patient was also started on Protonix 40 intravenous b.i.d. Aspirin and Coumadin were held. The patient underwent an esophagogastroduodenoscopy on the following morning, which revealed grade 1 esophageal varices and mild gastritis esophagitis as well as portal gastropathy. There was no active bleeding at any site. The patient then underwent an abdominal CT, which was negative for aortic enteric fistula. On the following day the patient underwent a colonoscopy, which was normal up until the ascending colon. However, they were not able to go all the way to the cecum and recommended virtual colonoscopy in the future and the patient had then underwent a repeat esophagogastroduodenoscopy with banding times four to the esophageal varices. The patient will need a repeat banding procedure in ten days. After the banding the patient was started on Sucralfate 1 gram q.i.d. and was continued on Protonix. Again aspirin and Coumadin were held throughout. After 4 units hematocrit stabilized from 24 up to 32 and remained stable at 32 upon discharge. 2. Hypotension: The patient was initially in the systolics in the 90s likely hypovolemic in the setting of a gastrointestinal bleed. However, given the history of cardiac disease the patient's enzymes were cycled times three, which were negative. He was resuscitated with fluid, fresh frozen platelets and packed red cells and blood pressure remained stable throughout. After the esophagogastroduodenoscopy the Atenolol was switched to Nadolol given the history of cirrhosis and varices and Zestril was held up until discharge due to low blood pressures. 3. Coronary artery disease: Patient with a history of myocardial infarction in [**2180**] and [**2182**] and is status post stent of the percutaneous transluminal coronary angioplasty in [**2182**]. Enzymes were cycled, which were negative. Aspirin and Coumadin were held due to gastrointestinal bleed. Beta blocker and ace were initially held due to low blood pressures. Lipitor was held secondary to new cirrhosis. The patient was restarted on Nadolol upon discharge, however, aspirin, Coumadin, Zestril and Lipitor were held prior to discharge to be restarted by primary care physician at his or her discretion. 4. Deep venous thrombosis: Patient with recurrent left lower extremity deep venous thrombosis, but admitted with gastrointestinal bleed. INR 2.3, Coumadin was held due to multiple procedures and held upon discharge. The patient will undergo repeat banding in ten days after which time the patient may or may not resume anticoagulation per primary care physician. 5. Hemachromatosis: The patient with hemachromatosis for long standing, now with evidence of cirrhosis on examination. The patient will continue with further phlebotomies as per Dr. [**Last Name (STitle) **] and may need further workup for cirrhosis. 6. History of abdominal aortic aneurysm: Patient ruled out enteric fistula with negative abdominal CT. 7. Seizure disorder: The patient was given additional dose of Dilantin 400 times one and then restarted on his regular does of 300 and will continue on his regular dose. No further seizure activity. 8. Diabetes: The patient was initially held NPO diabetic medications due to NPO status. Was covered with a sliding scale. Sugars remained stable and can restart Glyburide upon discharge. Metformin held secondary to cirrhosis. DISCHARGE DIAGNOSES: 1. Esophageal varices s/p banding. 2. Portal gastropathy. 3. Gastritis esophagitis. 4. Hemachromatosis with early cirrhosis. 5. Coronary disease. 6. Recurrent deep venous thrombosis. 7. Congestive heart failure. 8. Diabetes. 9. s/p abdominal aortic aneurysm repair. 10. Seizure disorder. MEDICATIONS ON DISCHARGE: 1. Nadolol 20 q.d. 2. Sucralfate one q.i.d. times seven days. 3. Protonix 40 po q.d. 4. Dilantin 300. 5. Folate 1. MEDICATIONS HELD: 1. Aspirin. 2. Coumadin. 3. Lipitor. 4. Zestril. 5. Atenolol switched to Nadolol. FOLLOW UP: The patient will follow up with primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]. Follow up with hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and follow up with liver specialist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for repeat banding in ten days. At the time of follow up, the timing for resuming anticoagulation should be addressed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**] Dictated By:[**Name8 (MD) 2439**] MEDQUIST36 D: [**2186-6-12**] 03:36 T: [**2186-6-19**] 08:59 JOB#: [**Job Number 2440**] cc:[**Last Name (NamePattern4) 2441**] ICD9 Codes: 4280, 412
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Medical Text: Admission Date: [**2177-5-15**] Discharge Date: [**2177-5-16**] Date of Birth: [**2135-1-14**] Sex: M Service: . CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a 42 year old man with an anterior myocardial infarction on [**4-30**], status post left anterior descending PCI at [**Hospital6 **], who presented to his primary care physician's office on the morning of admission with complaints of left substernal chest pain. The symptoms began at 9 a.m. with chest pain, diaphoresis, nausea and some dizziness. The pain was slow in onset. It radiated to the left shoulder; no shortness of breath. Similar in location and character to anginal pain but less severe, seven out of ten as opposed to ten out of ten with myocardial infarction, not relieved by sublingual Nitroglycerin. The pain was also different in that it was exacerbated by motion, pleuritic in nature. The patient denies shortness of breath, has two to three pillow orthopnea which is stable. No paroxysmal nocturnal dyspnea. The patient reports loosing weight since discharge from hospitalization on [**5-5**]. He has mild intermittent lower extremity edema but no progressive edema. The patient was transferred to [**Hospital1 69**] and underwent cardiac catheterization. The cardiac catheterization demonstrated a patent left anterior descending stent, serial 40% lesions in obtuse marginal 2, 80% right coronary artery lesion with left to right collaterals from the left anterior descending, PAP pressures 43/20. The patient was transferred to the cardiac care unit for concerns of elevated pulmonary capillary wedge pressures post procedure. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Gastroesophageal reflux disease. 5. History of alcohol. 6. Status post right knee surgery. 7. Status post tummy tuck in [**2173**]. MEDICATIONS: 1. Aspirin. 2. Plavix. 3. Lipitor 80. 4. Warfarin 5. 5. Lisinopril 10. 6. Atenolol 50 p.o. q. day. 7. Mirtazapine 30 p.o. q. day. 8. Zoloft 100 mg q. day. 9. Neurontin 1500 mg p.o. q. day. 10. Protonix 40 mg p.o. q. day. 11. Lorazepam 0.5 mg p.o. three times a day. 12. Azolitmin nasal spray. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Attends [**State 1558**] as a student. Works at [**Doctor First Name 47672**] Pantry. Quit tobacco one week; prior one pack per day times 35 years. History of heavy alcohol use; quit eleven months ago. No illicit drug use. No intravenous drug use. FAMILY HISTORY: No early coronary disease in the family; father with alcohol abuse. PHYSICAL EXAMINATION: Blood pressure 121/66; pulse 56; respirations 15, O2 saturation 98%. PA-pressure 36/16 with mean of 23. In general, a middle aged man in no acute distress. HEENT: Extraocular muscles are intact. Moist mucous membranes. Neck supple. No jugular venous distention. Cardiovascular is regular rate and rhythm, positive S3. Pulmonary clear to auscultation bilaterally. Abdomen soft, notable for ecchymosis across the lower abdomen. Mildly tender around area surrounding bruise. No hematomas, not distended. Positive obesity. Extremities with no edema. Two plus dorsalis pedis pulses bilaterally. Neurological: Alert and oriented, appropriate, non-focal. LABORATORY: White blood cell count 10.8, normal differential. Hematocrit 40.8, platelets 372. Sodium 137, potassium hemolyzed, chloride 100, bicarbonate 25, BUN 21, creatinine 0.6, glucose 88. CK 159, troponin less than 0.3, MB 2.0. Coagulation studies were INR 2.1. EKG normal sinus rhythm at 70, normal axis and intervals. ST elevation in V1 through V4 with Q waves V1 through V3 consistent with evolving old infarction. HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Cardiac Care Unit for monitoring overnight. His hemodynamics remained stable. He was negative approximately two liters post cardiac catheterization and his wedge pressure returned to [**Location 213**]. His arterial and Swan-Ganz catheter were removed by morning. The patient underwent echocardiogram which demonstrated no pericardial effusion. Ejection fraction 30 to 35% on early depressed overall left ventricular systolic function. The patient was started on aspirin 650 mg four times a day times seven days for treatment of post myocardial infarction pericarditis. The patient's Telemetry monitoring demonstrated no arrhythmia and the patient will continue to follow-up for further electrophysiology studies as planned through [**Hospital6 **]. DISCHARGE MEDICATIONS: 1. Aspirin 650 mg p.o. four times a day times seven days, then return to aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. 3. Lipitor 80 mg p.o. q. day. 4. Warfarin 5 mg p.o. q. h.s.; INR measured at 2.6 on [**2177-5-16**]. 5. Lisinopril 10 mg p.o. q. day. 6. Atenolol 50 mg p.o. q. day. 7. Mirtazapine 30 mg p.o. q. day. 8. Zoloft 100 mg p.o. q. a.m. 9. Neurontin 1500 mg p.o. q. day. 10. Protonix 40 mg p.o. q. day. 11. Lorazepam 0.5 mg p.o. three times a day p.r.n. 12. Azolitmin spray 137 micrograms, two sprays q. nostril h.s. 13. Percocet one to two tablets q. six hours p.r.n., dispense twenty. 14. Nicotine transdermal 21 patch q. day. DISCHARGE INSTRUCTIONS: 1. Follow-up as previously planned with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1617**]. 2. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**]. 3. Appointment with Dr. [**Last Name (STitle) **] on [**6-25**] at 03:00 p.m. with appointment with Dr. [**Last Name (STitle) 1617**] to follow. PLEASE SEND CARDIAC CATHETERIZATION REPORT AND ECHOCARDIOGRAM REPORT WITH CARBON COPIES. DISCHARGE DIAGNOSES: Pericarditis. CONDITION ON DISCHARGE: Good. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2177-5-16**] 16:27 T: [**2177-5-16**] 22:20 JOB#: [**Job Number 47673**] CC.: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 **], [**Location **], TELEPHONE NUMBER [**Telephone/Fax (1) 47674**]. DR. [**Last Name (STitle) **], [**Hospital1 2177**] CARDIOLOGY, TELEPHONE NUMBER [**Telephone/Fax (1) 47675**] ICD9 Codes: 4271, 4280, 4019, 2720
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Medical Text: Admission Date: [**2195-12-25**] Discharge Date: [**2195-12-29**] Date of Birth: [**2123-7-8**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old male with a history of ischemic cardiomyopathy with a known EF of 15%, diabetes mellitus, hypertension, hypercholesterolemia, peptic ulcer disease who was admitted to [**Hospital3 417**] Hospital on [**12-19**] for congestive heart failure. The patient reports one week prior to admission he began experiencing increased shortness of breath, dyspnea on exertion, orthopnea and PND. This was also associated with the production of green sputum. The patient was started on Levaquin and admitted for increasing shortness of breath. The patient ruled out for MI by three normal sets of enzymes at the outside hospital. Subsequently a nuclear stress test was obtained which demonstrated a lateral ischemic area with a fixed septal defect and an EF of 14%. The patient was diuresed and treated with antibiotic therapy. However, prior to his discharge, the patient had a run of non sustained V tach and was therefore transferred to [**Hospital1 190**] for catheterization with potential revascularization as well as for consideration of an EP study. Catheterization performed at time of admission demonstrated a wedge of 30, PA sat 50%, right dominant, PA pressure 52/27, no NCA, normal LAD, 90% stenosis of the focal mid region, left circumflex normal, RCA 100% with good collaterals. A stent was placed in the LAD which resulted in dissection of V1 and a stent was also placed in V1. Final result of the catheterization revealed an LAD of 0%, mid LAD 10%, D1 10%. The patient demonstrated a PA sat of 39% towards the end of the procedure and a balloon pump was placed. The patient was then transferred to the cardiac care unit for further management. PAST MEDICAL HISTORY: 1) Ischemic cardiomyopathy with a catheterization in [**2193-3-28**] demonstrating normal LM, normal left circumflex, normal LAD, RCA 100% with an EF of 47%. 2) Congestive heart failure with an EF of 15%. 3) Hypertension. 4) Diabetes mellitus. 5) Hypercholesterolemia. 6) Peptic ulcer disease. MEDICATIONS: Aspirin 325 mg po q d, Lasix 40 mg po q d, Diovan 80 mg po q d, Atenolol 25 mg po q d, Glipizide 5 mg po q d, Prevacid 30 mg po bid, Pravachol 40 mg po q d, Metformin 500 mg po q d, Levaquin 250 mg po q d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives at home with his wife and is able to perform all ADLs. He denies any tobacco or alcohol history. FAMILY HISTORY: The patient reports [**7-8**] siblings suffer from coronary artery disease. PHYSICAL EXAMINATION: Vitals, afebrile, heart rate 80, respiratory rate 20, blood pressure 112/68, PA pressure 58/27, oxygen saturation 100% on non rebreather. General, comfortable. HEENT: Extraocular movements intact, conjunctiva clear, oropharynx clear. Neck, brisk carotid upstrokes. Cardiovascular, regular rate and rhythm, normal S1 and S2, no S3 or S4, no murmurs. Lungs, good aeration bilaterally, minimal crackles at the left base. Abdomen, positive bowel sounds, soft, nontender, non distended, no hepatomegaly. Groin, right groin reveals Swan and intra-aortic balloon pump placement. Extremities, no edema, 2+ DP/PT. LABORATORY DATA: At outside hospital, white blood cell count 7.8, hematocrit 35.8, platelet count 171,000, sodium 136, potassium 4.6, chloride 100, CO2 23, BUN 45, creatinine 1.8, glucose 180, calcium 8.7, albumin 3.2, AST 54, ALT 88. At [**Hospital1 69**], white blood cell count 8.9, hematocrit 34.6, platelet count 174,000, sodium 133, potassium 4.4, chloride 100, CO2 21, BUN 49, creatinine 1.4, glucose 227, ALT 79, AST 62, alkaline phosphatase 106, total bilirubin 0.6, CK 87, albumin 3.3, calcium 8.4, magnesium 2.1, phosphorus 5.2. EKG, normal sinus rhythm, minimal left axis deviation, Q's in leads 3 and AVF, LVH by criteria. HOSPITAL COURSE: The patient is a 72-year-old white male with a history of ischemic cardiomyopathy and an EF of 14% who presented to the [**Hospital3 417**] Hospital with congestive heart failure and pneumonia. The patient was diuresed and entered into non sustained V tach and catheterization showing 90% in LAD with a stent placed complicated by failed V1 and 2 dissections as well as complicated by low cardiac index and hypotension and placement of an intra-aortic balloon pump. 1. Cardiovascular: The patient had one stent placed in his LAD and two stents were placed for dissection. He was treated with initial IV fluid hydration as per post cath protocol. An intra-aortic balloon pump was placed during the procedure secondary to low EF and PA sats of 39%. Following admission to the CCU the patient underwent aggressive diuresis with a Lasix drip, titrated as needed to maintain appropriate urine output. Anti-hypertensive meds were held and a Heparin drip was initiated given the placement of the intra-aortic balloon pump. In addition, the patient was maintained on telemetry with the intent to consult electrophysiology consult after improvement of his basic cardiac status. The patient was continued on Aspirin and Plavix and Integrilin was stopped as per protocol with Heparin being initiated for the intra-aortic balloon pump. Cholesterol profile was checked which demonstrated a total cholesterol of 40, LDL of 79 and HDL of 28. The patient was continued on Pravachol which she was on for hypercholesterolemia as an outpatient. The patient was successfully diuresed with IV Lasix which was titrated down to his usual daily dose of 40 mg po q d. On hospital day #3 the patient was started on Captopril 12.5 mg which he tolerated well and following which the intra-aortic balloon pump was weaned and removed. ACE inhibitor dosing was titrated to Captopril 12.5 mg tid and then switched over to Zestril 5 mg po q d. In addition, prior to discharge the patient was started back on his beta blocker of Atenolol 25 mg po q d. Aspirin and Plavix will also be continued as an outpatient as well as Pravachol. The patient remained hemodynamically stable and was transferred to the floor where he did well. He tolerated his anti-hypertensive medications, maintaining his systolic blood pressure in the 90's. The issue of his non sustained ventricular tachycardia was revisited by electrophysiology who recommended that the patient follow-up with Dr. [**Last Name (STitle) 37577**] within the next 1-2 weeks for initiation of an EPS study. The patient was hemodynamically stable at time of discharge and will follow-up with his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 2. Pulmonary: The patient demonstrated significant congestive heart failure at time of admission which responded well to IV Lasix. The patient was diuresed quickly at the beginning of the hospital stay and his Lasix was titrated down to his usual daily dose of 40 mg po q d. The patient's oxygen requirements were also titrated until he was able to maintain saturations over 96% on room air. At time of discharge the patient had a normal pulmonary exam. He completed a 7 day course of Levaquin for a presumed pneumonia which was started at the outside hospital. 3. Renal: The patient had an initial creatinine of 1.8 which was likely secondary to receiving 500 cc of dye during his catheterization procedure. The patient was treated with two doses of Mucomyst and his creatinine fell to within normal limits by the end of the hospital stay. The patient maintained excellent urine output over the course of the hospital stay and had no further renal issues. 4. Infectious Disease: The patient was diagnosed with a pneumonia at the outside hospital and started on Levaquin. This was continued to complete a 7 day course. The patient remained afebrile with a normal white blood cell count over the course of the hospital stay and did not demonstrate any other signs of infection. 5. Gastrointestinal: The patient was placed on Protonix for GI prophylaxis. He quickly began to tolerate a regular diet and had no further gastrointestinal issues over the course of the hospital stay. 6. Hematological: The patient's hematocrit was followed and remained stable over the course of the hospital stay. He was on a Heparin drip initially with placement of intra-aortic balloon pump which was discontinued after discontinuation of the pump. The patient was not placed on any further anticoagulation. 7. Endocrine: The patient has a history of diabetes mellitus and was placed on a regular insulin sliding scale. His oral hypoglycemics were held during hospital stay secondary to her acute issues. The patient is to resume his usual diabetic regimen at time of discharge. 8. Prophylaxis: The patient was maintained on IV Heparin, subcu Heparin as needed until the patient was fully ambulatory. He was also maintained on Protonix for GI prophylaxis. CONDITION ON DISCHARGE: The patient was discharged to home in stable condition. FOLLOW-UP: The patient is to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office on the morning after discharge at [**Telephone/Fax (1) 3183**] to obtain an appointment within 7 days. He is also to contact Dr. [**Last Name (STitle) 37577**] within the next 1-2 weeks to set up a time for EPS study. DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Plavix 75 mg po q d times 30 days, Zestril 5 mg po q d, Protonix 40 mg po q d, Pravachol 40 mg po q d, Lasix 40 mg po q d, Glipizide 5 mg po q d, Metformin 500 mg po q d, Atenolol 25 mg po q d. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2195-12-29**] 16:39 T: [**2196-1-4**] 21:33 JOB#: [**Job Number 37578**] ICD9 Codes: 4280, 4271, 486, 4019
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Medical Text: Admission Date: [**2195-12-18**] Discharge Date: [**2195-12-23**] Date of Birth: [**2135-12-21**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 19908**] Chief Complaint: bladder cancer Major Surgical or Invasive Procedure: cystectomy with ileal conduit History of Present Illness: 59yM s/p radical cystectomy, ileal conduit IVF: 5.0L EBL:800cc PMH: CAD s/p MI x 3, CABG, CHF with EF 40%, DM diet, HTN, lipid Meds: ASA 81, Atenolol 12.5, Cristor 20, Lopid 600 [**Hospital1 **]; NKDA; +TOB Plan: MSO4 PCA; if UOP good later can give Toradol EKG, Lop 5q4 IS NPO/NGT/Pepcid; KUB for stents D5LR at 150; lytes RISS SCH3 Ancef/Flagyl x48hrs R IJ, L art line, NGT, stoma with labelled stents, JP PT consult Brief Hospital Course: Patient was admitted to the Urology service after undergoing radical cystectomy and ileal conduct. No concerning intraoperative events occurred; please see dictated operative note for details. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. With the passage of flatus, patient's diet was advanced. The patient was ambulating and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Patient is scheduled to follow up in one weeks time with in clinic for wound check. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. 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* 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. Please take Tylenol in addition to oxycodone, and transition to Tylenol as pain improves. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [**6-17**] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of the ileal conduct. Followup Instructions: 1-2 weeks Completed by:[**2195-12-23**] ICD9 Codes: 3051
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Medical Text: Admission Date: [**2125-7-11**] Discharge Date: [**2125-8-29**] Date of Birth: [**2060-8-9**] Sex: F Service: LIVER TRANSPLANT SURGERY CHIEF COMPLAINT: The patient comes in after a fall. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman, status post autologous liver transplant on [**2125-6-27**] for primary sclerosing cholangitis, diabetes type II. She came in for a visit at the [**Hospital 1326**] Clinic Center today, one day after falling on the floor at home landing on her ribs and forehand. The patient reports no loss of consciousness, lightheadedness, chest pain, shortness of breath at this time. She did report that her legs have been feeling very weak lately. The patient was helped to her feet by her brother and the patient resumed her activities for the day without complaint. Today, the patient complained of significant pain in her left lower ribs. The patient also reports having decreased appetite since discharge. No nausea or vomiting, positive flatus, positive bowel movement, describes "not liking the sight of food". The patient has a recent hospital admission on [**2125-6-27**] to [**2125-7-5**]. The patient's diagnosis was end-stage liver disease, status post orthotopic liver transplant followed by duplex ultrasound revealing normal arterial and venous flow, cholangiogram revealing no stricture or lesion of the biliary system. Condition at the time of discharge was stable. She was discharged to home without services. At the time, she was on MMF 1,000 b.i.d., prednisone 15 q d, Inderal 275 b.i.d. PAST MEDICAL HISTORY: Status post autologous liver transplant 06/[**2125**]. Primary sclerosing cholangitis, status post stents. Diabetes type 2. Hyperthyroidism. Gastroesophageal reflux disease. Diverticulosis. Laminectomy. Appendectomy. Cholecystectomy. Ulcerative colitis. BRCA status post mastectomy and chemotherapy. MEDICATIONS ON ADMISSION: 1. Ativan 0.5 mg p.r.n. 2. Fluoxetine 60 mg q d. 3. Levothyroxine 150 mg q d. 4. Multivitamin, one q d. 5. Alendronate 70 mg q week. 6. Bactrim SS, one q d. 7. Fluconazole 400 mg q d. 8. Lispro, one unit q.i.d. SS. 9. Lantus 12 units q p.m. 10. MMF 1,000 [**Hospital1 **] 11. Protonix 40 mg q d. 12. Valcyte 450 b.i.d. 13. Prednisone 15 q d. 14. Neoral 275 b.i.d. 15. Furosemide 20 q d. PHYSICAL EXAMINATION: On admission, she was in no apparent distress. She was alert and oriented times three. Cranial nerves II-XII were intact. Pupils equal, round and reactive to light. Extraocular movements intact. Moist mucous membranes. Regular rate and rhythm with 1-2/6 diastolic rolling murmur. Clear to auscultation bilaterally. Exquisitely tender along the left lateral lower costal margin. Abdomen was nondistended, normal abdominal examination, soft, nontender, well healing incision with staples in place, no erythema or signs of drainage. Extremities: Dorsalis pedis was present, no edema. Vital signs on admission: Temperature 97.1, blood pressure 123/65. LABORATORY DATA: Hematocrit 28.5, white blood cell count 14.9, platelets 419, sodium 131, potassium 6.7, chloride 98, bicarbonate 20, BUN 59, creatinine 2.2, glucose 308, calcium 9.6, phosphate 5.4, magnesium 2.7, ASG 28, ALT 44, alkaline phosphatase 148, total bilirubin 3.5, PT 13.3, PTT 25.5, INR 1.2, fibrinogen 504. Her first cyclosporin level for the next day was 1,330. She was continued on prednisone 15 q d. She was put on 275 b.i.d. for the first two doses and after the level, she was held one dose and then started on 200. The repeated mostly held with occasional dosing with levels slowly declining from 1,000 to 540 by [**2125-7-21**]. HOSPITAL COURSE: Status post fall. The patient came with confusion. She developed respiratory insufficiency and decreasing mental status with changes. She required intubation. She had developed ascites and hydrothorax, which were drained. Despite a normal ultrasound on admission, magnetic resonance imaging showed portal vein thrombosis. She received TPA times three and Wall stenting of the portal vein and flow was reestablished. There was still some clot in the superior mesenteric vein. Her symptoms decreased and she improved clinically. Her ascites resolved as she became ambulatory while requiring tube feeds presently. It is possible that she no longer will require the tube feeds. Pain is well controlled on oral medication. Regarding cultures, on [**2125-7-15**], she had a blood culture that is negative. On [**2125-7-16**], she has a BAL that was negative. She received several methicillin resistant Staphylococcus aureus screenings, which were negative on [**2125-7-23**]. On [**2125-7-24**], cultures through her hospital stay have failed to grow anything or show anything of clinical significance. On [**2125-7-29**], the patient received MR [**First Name (Titles) 151**] [**Last Name (Titles) **] contrast MRCP so she had the MR of the abdomen with and without contrast and reconstruction for indications status post recent liver transplant and elevated alkaline phosphatase. Impression was portal vein thrombosis from confluence of the IMV this point being higher up, mild to moderate intrahepatic biliary ductal dilatation with no fixed filling defect and no strictures seen. The patient was discharged to the [**Hospital1 **] , which is an extended care facility. DISCHARGE INSTRUCTIONS: They are to monitor her for the following: Fevers, chills, nausea, vomiting, inability to tolerate food or drink. If any of these occurs, they are to contact the physician immediately or their in-house physician if they are unable to reach. FINAL DIAGNOSES: Portal vein thrombosis, hydrothorax, thorax respiratory insufficiency requiring intubation. COMORBIDITIES: Diabetes type 2, hypothyroidism, ulcerative colitis, gastroesophageal reflux disease, diverticulitis, cholecystectomy, laminectomy, appendectomy, breast cancer status post chemotherapy and mastectomy. FOLLOW UP: Liver [**Hospital 1326**] Clinic [**2125-9-3**] at 10:20 a.m. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**2125-9-11**] at 2:10 p.m. Liver [**Hospital 1326**] Clinic [**2125-9-17**] at 9:20 a.m. Phone number for the clinic is [**Telephone/Fax (1) 28347**] and the same for Dr. [**Last Name (STitle) 816**]. PROCEDURES PERFORMED: Chest tube and intubation. CONDITION ON DISCHARGE: Afebrile and tolerating a regular diet. Pain well controlled on oral medications. DISCHARGE MEDICATIONS: 1. Levothyroxine sodium 150 mcg tablets, one tablet p.o. q d. 2. Alendronate 70 mg tablets, one tablet p.o. q week Fridays. 3. Bactrim SS tablets, one tablet p.o. q d. 4. Multivitamin. 5. Lansoprazole 30 mg capsules delayed release, one capsule p.o. q d. 6. Artificial tear ointment. 7. Polyvinyl alcohol drops. 8. Albuterol nebs. 9. Fluconazole 200 mg tablets, one tablet p.o. q 24 hours. 10. Visicol 10 suppository h.s. as needed. 11. Ipratropium bromide nebs as needed. 12. Docusate 100 mg, one capsule p.o. b.i.d. 13. Valganciclovir 450 mg tablets, one tablet p.o. q d. 14. Spironolactone 25 mg tablets, one tablet p.o. q d. 15. Acetaminophen. 16. Lorazepam 0.5 mg tablets p.o. b.i.d. as needed for anxiety. 17. Fluoxetine HCL 20 mg capsules, one capsule p.o. q d. 18. Sliding scale insulin. 19. Warfarin. She should take 0.5 mg every day. 20. Mycophenolate mofetil 200 suspension for reconstitution 2.5 p.o. q d four times a day, which is 500 mg four times a day. 21. Prednisone 5 mg tablets. Take two tablets p.o. q d, which is 10 mg every day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 46274**] MEDQUIST36 D: [**2125-8-29**] 14:09:03 T: [**2125-8-29**] 15:19:26 Job#: [**Job Number 52365**] ICD9 Codes: 5119, 5849, 5990
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Medical Text: Unit No: [**Numeric Identifier 76230**] Admission Date: [**2155-10-9**] Discharge Date: [**2155-10-13**] Date of Birth: [**2155-10-9**] Sex: M Service: NB DATE OF TRANSFER TO NEWBORN NURSERY: [**2155-10-12**] HISTORY: This is a full term infant with respiratory distress admitted for NICU management. The infant was born at 38-3/7 weeks to a 36-year-old gravida 4, para 2, blood type is 0 positive, antibody negative, GBS negative, hepatitis B negative, RPR nonreactive woman. PAST MEDICAL AND OBSTETRIC HISTORY: Reportedly unremarkable. ANTEPARTUM HISTORY: Remarkable for advanced maternal age and normal testing. Elective cesarean section under spinal epidural anesthesia. Apgars were 9 and 9. The infant initially did well in the recovery area, breast fed and later had grunting, flaring and retracting noted and was transferred to the NICU. PHYSICAL EXAMINATION AT TRANSFER: The infant was in an open crib and breathing room air. Breath sounds were equal and clear. HEAD, EARS, EYES AND THROAT: Anterior fontanelle was open and level. Sutures opposed. Positive root, positive suck and positive Moro. [**Doctor First Name **] tone. RESPIRATORY: The infant's breath sounds were equal and clear. No retraction. CARDIOVASCULAR: Soft audible murmur on exam. Regular rate and rhythm. The infant was pink and well perfused. GI: The abdomen was soft and round without masses. Positive bowel sounds. Cord on and dry. GU: Normal male genitalia. Testes descended bilaterally. The infant's current weight upon transfer was 2925. Birthweight was 2990. SUMMARY OF COURSE BY SYSTEMS INCLUDING PERTINENT LAB RESULTS: RESPIRATORY: Infant initially on nasal cannula 02 upon admission to the NICU. Chest x-ray was consistent with TTN. The infant transitioned to room air on day of life #2 and has been stable on room air for over 24 hours. CARDIOVASCULAR: The infant has been cardiovascularly stable. Soft audible murmur on exam. Regular rate and rhythm. Blood pressure stable at 74/54 with a mean of 61. FLUIDS, ELECTROLYTES AND NUTRITION: The infant initially was n.p.o. IV fluids of D10W at 60 mL/kg. Full breast feeding began on day of life #2 and IV weaned successfully off with stable D-sticks of 66 to 81. Set of electrolytes were done on day of life #1: Sodium 137, potassium 4.8, chloride 101, and bicarb of 23. Serum calcium was 7.2. Ionized calcium 1.05. GI: Maximum bilirubin on day of life #3 was 8.4/0.4. The infant has not required phototherapy. A repeat bilirubin is ordered for day of life #4. HEMATOLOGY: The infant's blood typing not done. The infant's initial hematocrit upon admission was 44.1 with a platelet count of 405,000. INFECTIOUS DISEASE: Blood culture and CBC were performed upon admission to the NICU. Initial white count was 16.7 with 68 polys and 6 bands. The infant was begun on ampicillin and gentamicin for a 48-hour rule-out and his blood culture has remained negative to date. SENSORY: Passed BAERS b/l. OPHTHALMOLOGY: The infant does not meet criteria for ophthalmology exam. CONDITION AT TRANSFER: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 76231**]. CARE AND RECOMMENDATIONS: Feeds at transfer: The infant is ad lib breast feeding. The infant is currently not on any medication. Car seat positioning screening: The infant does not meet criteria. State screening has been sent [**2155-10-9**] per protocol, results are pending. Immunizations received: Will receive Hep B [**10-13**] prior to d/c. Follow-up appointment schedule recommended with pediatrician, Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) **], 48 hours after discharge from the hospital. DISCHARGE DIAGNOSIS: 1. Transient tachypnea of the newborn. 2. Sepsis evaluation. 3. Term AGA infant [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 71194**] Dictated By:[**Last Name (NamePattern1) 71091**] MEDQUIST36 D: [**2155-10-12**] 17:58:49 T: [**2155-10-12**] 20:07:52 Job#: [**Job Number 76232**] cc:[**Last Name (NamePattern1) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD ICD9 Codes: V053, V290
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Medical Text: Admission Date: [**2103-12-10**] Discharge Date: [**2103-12-16**] Date of Birth: [**2081-4-8**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8257**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 22 year-old Gravida 2 Para 0 at 21 weeks 2 days GA presented to the ED with fever and flank pain. She reported bilateral flank pain, mild nausea and denied any vaginal bleeding, contractions, or leakage of fluid. She was feeling active fetal movement. . Upon arrival to the ED she was found to have fever 101.1, tachycardia to 120 and hypotension with blood pressure 80/50s. Examination revealed CVA tenderness. Labs revealed a white blood count of 18 and urinalysis had >50 WBC. The clinical picture was consistent with pyelonephritis. Ceftriaxone was administered. Given the persistent hypotension despite 4 Liters of IV fluid, the decision was made to admit her to the [**Hospital Unit Name 153**]. . Of note she has hyperthyroidism and had not be taking her PTU for the last 2 weeks. Past Medical History: Prenatal Course: 1. Dating: estimated due date [**2104-4-19**] 2. Labs: A+/RI/HepB S Antigen -/RPRNR/HIV negative 3. Ultrasound: normal full fetal survey 4. Issues: Hyperthyroidism . Past Obstetric History: spontaneous abortion x 1 . Past Gynecologic History: -[**8-28**] Abnormal Pap->Colpo with normal biopsy -h/o GC/chlamydia->negative [**12-30**] . Medical History: Hyperthyroidism ([**Doctor Last Name 933**]) . Surgical History: Right eye surgery Social History: Patient denies any tobacco, alcohol or recreational drug use. Prior to pregnancy, + alcohol Family History: Maternal Great Uncle had [**Name2 (NI) 933**] disease, mother has thyroid dysfunction. No other family history of other autoimmune diseases. Physical Exam: On Presentation: V/S Tm: 100.7, Tc: 98.8, BP 90/44 - 109/33, HR 81-122, RR 22-42, O2 92-96% 2L Gen: Young woman in NAD HEENT: Slight bilateral proptosis with very slight soft tissue swelling in area of epicanthal fold over left eye. OP clear without erythema or exudate. Neck: Thyroid gland small, firm, slightly irregular on left, without tenderness to palpation. Pulm: Good respiratory effort with no audible wheezes, rhonchi, or rales CV: Tachycardic, nl s1/s2 Abd: Gravid, soft, non-tender, +BS Back: No significant CVA tenderness Skin: No acanthosis nigricans, no rashes, left forearm tattoo Ext: Warm and well perfused without lower extremity edema Pertinent Results: [**2103-12-10**] WBC-18.0*# RBC-3.42* Hgb-10.9* Hct-30.1* MCV-88 Plt Ct-268 [**2103-12-10**] Neuts-93.3* Lymphs-4.5* Monos-1.6* Eos-0.5 Baso-0.1 [**2103-12-10**] WBC-14.4* RBC-2.92* Hgb-9.2* Hct-25.9* MCV-89 Plt Ct-209 [**2103-12-11**] WBC-11.7* RBC-2.57* Hgb-8.2* Hct-22.7* MCV-88 Plt Ct-187 [**2103-12-11**] Neuts-85.9* Lymphs-10.1* Monos-3.8 Eos-0.1 Baso-0.1 [**2103-12-11**] Hct-28.9*# [**2103-12-12**] WBC-10.3 RBC-2.88* Hgb-9.3* Hct-25.4* MCV-88 Plt Ct-206 [**2103-12-13**] WBC-6.2 RBC-3.08* Hgb-9.6* Hct-27.3* MCV-89 Plt Ct-207 . [**2103-12-10**] PT-13.3 PTT-30.2 INR(PT)-1.1 [**2103-12-11**] PT-14.0* PTT-36.0* INR(PT)-1.2* . [**2103-12-10**] Glucose-123* UreaN-7 Creat-1.1 Na-136 K-3.1* Cl-102 HCO3-21* [**2103-12-10**] Glucose-96 UreaN-7 Creat-0.7 Na-139 K-3.5 Cl-112* HCO3-15* [**2103-12-11**] Glucose-97 UreaN-6 Creat-0.7 Na-130* K-3.8 Cl-100 HCO3-17* [**2103-12-11**] Glucose-89 UreaN-6 Creat-0.8 Na-140 K-3.4 Cl-110* HCO3-19* [**2103-12-12**] Glucose-76 UreaN-5* Creat-0.8 Na-136 K-4.1 Cl-108 HCO3-19* . [**2103-12-10**] ALT-14 AST-21 AlkPhos-57 TotBili-0.6 [**2103-12-10**] ALT-13 AST-25 LD(LDH)-200 AlkPhos-47 TotBili-0.4 . [**2103-12-10**] Albumin-3.0* Calcium-6.7* Phos-1.6* Mg-1.4* [**2103-12-11**] Calcium-6.4* Phos-2.1* Mg-2.2 Iron-10* [**2103-12-11**] Mg-1.7 [**2103-12-12**] Albumin-2.9* Calcium-8.3* Mg-1.9 . [**2103-12-11**] calTIBC-179* Ferritn-129 TRF-138* . [**2103-12-10**] 11:49AM BLOOD TSH-0.19* [**2103-12-10**] 11:49AM BLOOD T3-146 Free T4-0.86* [**2103-12-10**] 09:17PM BLOOD T4-9.4 calcTBG-1.28 TUptake-0.78 T4Index-7.3 [**2103-12-12**] 04:54AM BLOOD PTH-16 [**2103-12-13**] 07:45AM BLOOD TSH-1.0 [**2103-12-13**] 07:45AM BLOOD T3-129 Free T4-0.96 . [**2103-12-10**] Type-[**Last Name (un) **] Temp-39.1 pH-7.34* Comment-GREEN TOP [**2103-12-12**] Type-[**Last Name (un) **] pH-7.43 . [**2103-12-10**] URINE Blood-NEG Nitrite-POS Protein-30 Glucose-100 Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-MOD [**2103-12-10**] URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-[**1-24**] [**2103-12-11**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . URINE CULTURE (Final [**2103-12-13**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . URINE CULTURE (Final [**2103-12-12**]): <10,000 organisms/ml. . Blood cultures 1/19, [**12-11**]: no growth . Echocardiogram [**12-11**]: IMPRESSION: Normal LV cavity size with normal global and regional biventricular systolic function. No diastolic dysfunction or significant valvular disease seen. Small pericardial effusion located posterior to inferolateral wall without evidence of tamponade. . Chest X-Ray [**12-11**]: Final Report INDICATION: 22-year-old female who is pregnant with pyelonephritis and shortness of breath after fluid. PA AND LATERAL CHEST RADIOGRAPHS: There is bilateral predominantly lower lobe air space opacity with air bronchograms. There is prominent azygos vein. The heart size is normal. There are no pleural effusions on this frontal radiograph. Findings are consistent with pulmonary edema. . Bilateral Lower Extremity Venous Doppler [**12-11**]: CLINICAL HISTORY: Acute onset of shortness of breath, 21 weeks pregnant. Evaluate for deep vein thrombosis. Normal flow and compressibility was present in the common femoral, superficial femoral, and popliteal veins in both the right and left side. No evidence of thrombus in either calf was seen. IMPRESSION: No evidence of deep vein thrombosis. . Renal Ultrasound [**12-11**]: INDICATION: 21 weeks pregnant with pyelonephritis. Please assess for hydronephrosis or perinephric abscesses. FINDINGS: The right kidney measures 11.7 cm. The left kidney measures 10.6 cm. There is moderate bilateral hydronephrosis. No definite stones are identified in either kidney. Renal parenchymal abnormalities are identified to suggest abscess. An intrauterine pregnancy is present with fetal heart rate of 167 beats per minute. IMPRESSION: Moderate bilateral hydronephrosis and small amount of right perinephric fluid with no son[**Name (NI) 493**] evidence for renal abscesses. As no renal stones are identified and the entire course of the ureters is not visualized, it is not possible to determine whether the hydronephrosis present relates to pregnancy or other causes. Brief Hospital Course: MICU COURSE: # Acute pyelonephritis: Treated with ampicillin and gentamicin per OB recommendations. Renal ultrasound did not show perinephric abscess. Continued to have intermittent low grade fevers while in the ICU . # Hypotension: Patient met the criteria for sepsis, howevere per prior OMR notes, blood pressures had been running in 90's, so patient not hypotensive per her parameters. . # Tachycardia: Differential diagnosis includes hyperthyroidism though per endocrine consult, felt that based on her labs, she was likely hypothroid. However, may be a sign of early dilated cardiomyopathy. Echocardiogram was normal. Was minimally fluid responsive. Ruled out deep vein thrombosis with lower extremity venous Dopplers. . # Oxygen desaturation: Oxygen saturation in the mid 80s% on hospital day #2. Patient was approximately 9 liters positive. Chest x-ray was consistent with pulmonary edema . # Pregnancy at 21 weeks: Fetal heart rate was reassuring on admission. Continued prenatal vitamins. Had daily fetal heart rate spot checks that were reassuring. . # [**Doctor Last Name 933**] Disease status post eye surgery: TSH is low at 0.19. Free T4 is also low at 0.86. This may be a result of increased thyroid binding globulin induced by hyper-estrogen state. Also, patient had not been taking PTU for 2 weeks. The importance of taking this medication for fetal well-being was explained to the patient and she understood this conversation. Endocrinology consult placed for recommendations regarding thyroid hormone level normalization. . # Hypokalemia: Etiology unclear, was 3.1 on admission. Resolved with repletion. Only 1 episode of diarrhea ~2 weeks ago. Kidney function normal. Oral intake had been good until 3 days ago. . # Anemia: Likely dilutional and secondary to pregnancy, appears to also have iron deficiency component. Recevied 1 unit packed red blood cells for hematocrit of 22. . # Hypocarbia: Likely a hyperchloremic metabolic alkalosis secondary to fluid resuscitation. [**Month (only) 116**] also be a consequence of tachypnea. . . The patient was called out of the ICU on hospital day #3. Clinically she was stable with no oxygen requirement and stable blood pressure. She continued on IV ampicillin and gentamicin until she was afebrile for 48 hours on the evening of hospital day #5. Her initial urine culture grew pan-sensitive E. Coli and she was transitioned to oral Nitrofuantoin. She remained afebrile and was discharged home on hospital day #6. She will remain on suppression for the remainder of her pregnancy. . While hopsitalized, she was followed by the endocrine service. Her thyroid function tests were normal off medication and they believed her [**Doctor Last Name 933**] to be in remission and that she should remain off the propylthiouracil that she had been taking. She will follow up with endocrine as an outpatient. Medications on Admission: PNV Propylthiouracil 100mg [**Hospital1 **] (has not taken for 2 weeks) Discharge Medications: 1. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for 10 days, then once daily for rest of pregnancy. Disp:*50 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pyelonephritis Discharge Condition: Good Discharge Instructions: Take Antibiotics as prescribed - twice a day for 10 days, then once a day for rest of pregnancy. Call with abdominal pain, pain or burning with urination, vaginal bleeding, or any other problems. Followup Instructions: Dr. [**Last Name (STitle) **] at [**Hospital1 **] on [**12-27**] as scheduled. Endocrine: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2103-12-31**] 2:30 ICD9 Codes: 0389, 2762, 2761, 2768
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Medical Text: Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-9**] Date of Birth: [**2037-8-15**] Sex: M Service: MEDICINE Allergies: Simvastatin / Pravastatin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Delerium and Hypoxia Major Surgical or Invasive Procedure: UF [**Last Name (NamePattern4) 2286**] History of Present Illness: Mr. [**Known lastname 10369**] is an 86 year-old man with wegener's c/b ESRD, DM2, atrial fibrillation and chronic right pleural effusion who was found to be delerious at [**Known lastname 2286**] today with hypoxia to 89% on RA that corrected to 93% on 2L. Patient also complained of loose stools for the past several days while at rehab. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] referred the patient to the ED for further evaluation. Of note, the patient was admitted from [**Date range (1) 10375**] for the treatment of PNA. In the ED, initial vitals were 98.5 120 128/76 24 95% 2L. Labs notable for WBC 4.9 90.6%N, HCT 29.9, INR 2.9, proBNP [**Numeric Identifier 10376**], Lactate 1.9, Vanco 28.2. Blood cultures were sent. CXR showed pulmonary edema with persistence of RLL>RML,RUL opacities (also seen was known R-sided effusion that has been worked up extensively by Interventional Pulmonology). Given concern for HCAP, patient already had a therapeutic Vanco level and received ceftriaxone 1g IV, azithromycin 500mg IV, and flagyl 500mg IV. On arrival to the floor, patient was sleeping but easily aroused and was able to answer questions appropriately. Denied any pain, felt comfortable. Coughing with ronchorous breathing and slightly tachypnic. Past Medical History: - Wegener's Granulomatosis, dx [**12/2121**] c-anca + and bx +, on cytoxan/steroids - DM 2 on insulin since [**2082**], typical A1c around 7.5% - ESRD on HD (M/W/F via LUE AVF) - Monoclonal gammopathy most likely a smoldering multiple myeloma - HTN, well-controlled - Bronchiectasis with baseline grossly abnormal CXR - SSS with intermittent afib and bradycardia - Mitral Regurgitation - Chronic anticoag (indication: AF) on coumadin - Prostate cancer --> radiation therapy [**2118**], normalized PSA - Radiation proctitis with rectal bleeding --> laser rx - GI bleed [**3-9**] radiation proctitis - Malignant melanoma left thigh s/p excision - Anemia attributed to CKD - R ingunal hernia - S/p appy - S/p L inguinal hernia repair - hyperlipidemia - Fe deficiency - TB: latent, Patient had a history of TB with treatment in sanitarium in [**2052**]'s, h/o INH toxicity so no treatment of latent TB - MAC: Bronchoscopy with BAL was performed on [**12-23**], and AFBs found on smear c/w MAC per lab results/ID consult. Patient opted to forego MAC therapy - hx of pericardial effusion, no drainage needed - TIA [**2124-3-8**], no residual deficits Social History: Lives with wife who is his caregiver. [**First Name (Titles) **] [**Last Name (Titles) **] son. Retired, was employed as an international business consultant, has a PhD in industrial engineering. Born in Eastern [**Country 10363**]. Came to the United States in [**2068**]. Very active individual before onset of Wegener's in [**2120**] - former mountain climber, tennis player, and skier. - Tobacco history: during WWII, stopped [**2057**] - ETOH: [**2-7**] glass of wine with dinner nightly - Illicit drugs: none Family History: Grandmother: DM Father: kidney infection Sister: TIA x 2 (80s) Physical Exam: Physical Exam on Admission GENERAL - Elderly man lying in bed, A&Ox3, NAD, AOx3 HEENT - NCAT EOMI MM dry OP clear NECK - supple, JVP flat ~ 10cm H2O HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - decreased breath sounds bilateral bases; rhonchorous left base; breathing unlabored, no apparent respiratory distress ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no CVAT EXTR - cool, 2+ DP pulses; LUE AVF with bruit/thrill SKIN - scattered ecchymoses LYMPH - no cervical LAD NEURO - AOX3 and although some responses are inappropriat Physical Exam on Discharge Expired Pertinent Results: Admission Labs [**2124-6-5**] 07:05PM LACTATE-1.9 [**2124-6-5**] 07:00PM GLUCOSE-151* UREA N-19 CREAT-2.6*# SODIUM-145 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-31 ANION GAP-17 [**2124-6-5**] 07:00PM ALT(SGPT)-20 AST(SGOT)-43* CK(CPK)-158 ALK PHOS-123 TOT BILI-0.6 [**2124-6-5**] 07:00PM LIPASE-42 [**2124-6-5**] 07:00PM CK-MB-6 cTropnT-0.21* proBNP-[**Numeric Identifier 10376**]* [**2124-6-5**] 07:00PM VANCO-28.2* [**2124-6-5**] 07:00PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.7 [**2124-6-5**] 07:00PM WBC-4.9 RBC-2.61* HGB-9.5* HCT-29.9* MCV-114* MCH-36.3* MCHC-31.7 RDW-19.0* [**2124-6-5**] 07:00PM NEUTS-90.6* LYMPHS-4.9* MONOS-4.3 EOS-0.2 BASOS-0 [**2124-6-5**] 07:00PM PLT COUNT-65* [**2124-6-5**] 07:00PM PT-30.1* PTT-46.8* INR(PT)-2.9* [**2124-6-5**] 03:00PM VANCO-13.0 [**2124-6-5**] 01:15AM PT-30.2* INR(PT)-2.9* Pertinent Labs [**2124-6-7**] 04:20AM BLOOD WBC-5.7 RBC-2.77* Hgb-9.5* Hct-31.9* MCV-115* MCH-34.4* MCHC-29.9* RDW-18.3* Plt Ct-66* [**2124-6-6**] 07:30AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-3+ Microcy-OCCASIONAL Polychr-NORMAL Spheroc-OCCASIONAL Ovalocy-3+ Schisto-1+ Burr-1+ Ellipto-OCCASIONAL [**2124-6-7**] 10:18AM BLOOD PT-33.5* PTT-52.4* INR(PT)-3.3* [**2124-6-6**] 07:30AM BLOOD ESR-110* [**2124-6-8**] 04:44AM BLOOD Glucose-328* UreaN-48* Creat-3.6*# Na-137 K-5.3* Cl-94* HCO3-24 AnGap-24* [**2124-6-6**] 04:18AM BLOOD CK-MB-5 cTropnT-0.21* [**2124-6-8**] 04:44AM BLOOD Calcium-8.2* Phos-7.5* Mg-2.1 [**2124-6-6**] 12:14PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2124-6-6**] 05:00PM BLOOD CRP-212.4* EKG [**2124-6-5**] Minimally irregular supraventricular tachycardia, most likely atrial fibrillation. Left axis deviation. Left anterior fascicular block. QS deflection in leads V1-V2 consistent with prior anteroseptal myocardial infarction. 0.5 millimeter ST segment depression in leads V4-V6 with T wave inversion in lead aVL and to a lesser degree in lead I. Compared to the previous tracing of [**2124-5-27**], ventricular rate is much faster. T wave inversion is more pronounced in lead aVL but less pronounced in leads V4-V5, with similar left precordial ST segment depression. An ongoing lateral ischemic process cannot be excluded. Clinical correlation is suggested. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 131 0 96 304/428 0 -55 173 CXR portable [**2124-6-5**] FINDINGS: Single AP upright portable view of the chest was obtained. The right costophrenic angle is not included on the images. Again seen is a large area of right mid-to-lower lung opacity which is better assessed on prior CT from [**2124-5-29**]. There is a moderate right pleural effusion with overlying atelectasis, an underlying consolidation cannot be excluded. Streaky and fibrotic opacities are seen in the right lung involving the upper, mid and lower lung fields, most noted in the left mid lung field, also seen on the prior study. Left apical pleural thickening and calcifications are again seen, consistent with chronic change. No large left pleural effusion is seen. There is no pneumothorax. The cardiac and mediastinal silhouettes are stable. Multiple old right-sided rib deformities/fractures are again seen. A left sided [**Year (4 digits) 1106**] stent is again partially imaged. IMPRESSION: 1. Right costophrenic angle not fully included on the images. Given this, large area of right mid-to-lower lung opacity is again seen, likely representing combination of pleural effusion, atelectasis and possible underlying consolidation. Increased right perihilar opacity. Areas of patchy and fibrotic opacities in the left lung again seen, may be chronic. TTE [**2124-6-6**] The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2124-4-11**], tricuspid regurgitation is now more prominent. UE fistulogram Patent AV fistula in the left upper extremity with areas of aneurysmal dilatations in the upper and mid portion of the left arm. The arteriovenous anastomosis is patent however increased velocities were noted. The peak systolic velocity at the level of the arteriovenous anastomosis is 716 cm/sec. Within the fistula, peak systolic velocities ranged between 120 and 143 cm/sec. In the distal fistula there is a patent stent however increased velocities were noted at the level of the proximal end of the stent. Peak systolic velocities at this level were between 689 and 505 cm/sec. Within the stent, the peak systolic velocities ranged between 58 and 244 cm/sec. Distally to the stent and within the subclavian vein peak systolic velocities ranged between 47 and 360 cm/sec. Peak systolic velocity in the brachial artery proximal to the arteriovenous anastomosis was 47 cm/sec. Distally to the anastomosis, the peak systolic velocity was 69 cm/sec. IMPRESSION: Patent AV fistula in the left upper extremity with increased peak systolic velocities at the level of the arterial anastomosis and within the proximal margin of the stent. Velocities were recorded up to 716 cm/sec in the arteriovenous anastomosis. Brief Hospital Course: 86M w/ wegener's, ESRD, Afib, DM2, recent TIA /w delirium, presenting with delerium and hypoxia admitted for possible PNA, expired on [**2124-6-9**] # Dyspnea/SIRS- Patient was recently admitted from [**5-25**] to [**6-2**] for the treatment of HCAP and was discharged on Vanc/Levofloxacin. At HD today, patient was noted to be hypoxic to 89% on RA and was referred to the ED for further evaluation. In the ED, CXR showed continued evidence of right sided opacities. WBC 4.9 is elevated from 3.5 on recent discharge. Patient was tachycardic to the 110-120s (in the setting of Afib) and tachypnic to the 20s with a concern for PNA confering the diagnosis of sepsis. The patient had a therapeutic Vanc level in the ED and received 1L NS, ceftriaxone, flagyl and azithromycin for possible PNA. The antibiotics were continued overnight, but then d/c'd on HD 2 after repeat CXR showed evidence of pulmonary edema. Despite this finding that patient was relatively euvolemic on exam and did not have elevated JVP or marked periperal edema. It is possible that the patient has pulmonary edema in the setting of AF with RVR. There is also the possibility of worsening of GPA given recent discontinuation of azathioprine and elevated ESR/CRP. Patient was unfortunately unable to tolerate [**Month/Year (2) 2286**] given hypotension down to the 70s at each subsequent session. His prednisone was increased with rheumatology recommendation but respiratory status did not improve significantly over the subsequent days. Midodrine was started as patient's family did not wish to pursue any heroic measures. Stress does steroid was not pursued because the patient's family utlimately decided to transition patient to CMO given his progressively worsening respiratory status and hypotension. # GPA/Wegner's granulomatosis. Patient was initially kept on prednisone 10 mg daily and bactrim prophylaxis. However, given the concern of vasculitis flare with recent discontinuation of azathioprine, it was increased in the setting of his worsening respiratory status as well as elevated CRP/ESR. # Delerium: Patient was found to be delerious at HD on day of admission and continued to have an element of delerium on admission the to the MICU. Delirium improved slightly when seroquel wore off. However, patient continued to have a degree of delirium that is likely [**3-9**] underlying inflammatory process and hypoxia. # Afib. He initially did not require any rate control. He was kept on home warfarin initially. However, he later required low dose metoprolol for rate control. Patient does not require rate control. Warfarin was discontinued given supratherapeutic level. # ESRD, HD-dependent: On HD qMWH, kidneys affected by Wegener's vasculitis. Patient had very limited HD sessions given hypotension. # GOC. Patient and his family were updated daily. His outpatient PCP, [**Name10 (NameIs) 10368**], and nephrologist were updated on a regular basis. Palliative care was consulted. His HCP was clear about no heroic measures for the patient and ultimately decided that patient would transition to CMO given persistent hypoxia and hypotension, inability to tolerate [**Name10 (NameIs) 2286**]. Patient passed away on [**2124-6-9**]. Chronic Issues: # Chronic right pleural effusion. Stable on imaging. # Diabetes. He was on insulin sliding scale. # Elevated TropT, LFTs: Troponins and LFTs were downtrending since recent discharge. # Anemia: Patient with iron studies suggesting anemia of chronic disease with macrocytosis likely multifactorial from ESRD (though on epo), bactrim, MGUS, and aging marrow. #. Hypothyroidism. He was continued on levothyroxine 137 mcg daily & 25 mcg QOD #. MGUS / smoldering myeloma: At baseline patient is pancytopenic with WBC in the 3s and Hct low 30s with macrocytosis (also noted to be on immunosuppression as described above). #. Hyperlipidemia. He was continued on statin and ASA. Medications on Admission: - senna 8.6 mg QHS - docusate sodium 100 mg [**Hospital1 **] - atorvastatin 40 mg daily - pantoprazole 40 mg daily - sulfamethoxazole-trimethoprim 800-160 mg 3X/WEEK (MO,WE,FR) - aspirin 81 mg daily - cholecalciferol 800 unit daily - sevelamer carbonate 400 mg daily - acetaminophen 1000 mg Q8H - levothyroxine 137 mcg daily - levothyroxine 25 mcg QOD - prednisone 10 mg daily - folic acid 1 mg daily - warfarin 1 mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure End Stage Renal Disease Wegner's granulomatosis Delirium Atrial fibrillation Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2124-6-9**] ICD9 Codes: 486, 5856, 2930, 5119, 4589, 4240, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3108 }
Medical Text: Admission Date: [**2113-9-23**] Discharge Date: [**2113-9-28**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2972**] Chief Complaint: nausea/vomiting, s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo F with Alzheimer's and recent admit for GI bleed from gastritis and metaplastic pyloric mass presented with an episode of nausea / vomiting / and a fall from her bed. She is a poor historian, but records from [**Location (un) **] indicate that she had vomited w/o blood x 1 around 2 pm on [**2113-9-23**], and possibly fell/slid from bed. Pt denies F/C/abd pain/diarrhea/melena / BRBPR. In ED, she had episode of vomiting with SBP 60's, bradycardia to 30's --> given atropine.She was transferred to the MICU for further mgmt. Past Medical History: Alzheimer's dementia HTN OCD h/o recent GIB w/ EGD revealing high grade duodenal dysplasia and intestinal metaplasia ([**8-9**]) EGD [**9-9**] with ulcerating pyloric mass increased in size. Social History: She lives at [**Hospital3 **] facility). Has a remote history of tobacco use, quit 40 years ago. No EtOH. Family History: NC Physical Exam: O: V: T96.4 BP 114/84 P74 R20 94% 2L Gen: NAD HEENT: OP clear, NG tube in place Resp: lungs coarse bilaterally CV: distant, RRR Abd: soft NTND +BS Ext: no edema Neuro: A+Ox1 (to person), oriented to season and general place Pertinent Results: [**2113-9-23**] 03:45PM BLOOD WBC-7.7 RBC-2.07*# Hgb-6.4*# Hct-20.5*# MCV-99*# MCH-31.1 MCHC-31.4 RDW-18.9* Plt Ct-371# [**2113-9-24**] 01:16AM BLOOD WBC-12.4*# RBC-3.01*# Hgb-9.5*# Hct-28.7*# MCV-95 MCH-31.4 MCHC-33.0 RDW-18.7* Plt Ct-318 [**2113-9-24**] 05:59AM BLOOD Hct-29.0* [**2113-9-24**] 02:54PM BLOOD Hct-31.7* [**2113-9-24**] 09:05PM BLOOD Hct-35.9* [**2113-9-25**] 05:35AM BLOOD WBC-14.7* RBC-3.63* Hgb-11.2* Hct-34.1* MCV-94 MCH-30.8 MCHC-32.9 RDW-19.5* Plt Ct-264 [**2113-9-25**] 03:15PM BLOOD Hct-35.2* [**2113-9-26**] 06:00AM BLOOD Hct-33.8* [**2113-9-27**] 05:30AM BLOOD Hct-33.3* [**2113-9-24**] 01:16AM BLOOD CK-MB-86* MB Indx-18.5* cTropnT-1.62* [**2113-9-24**] 02:54PM BLOOD CK-MB-135* MB Indx-16.2* cTropnT-3.06* [**2113-9-24**] 09:05PM BLOOD CK-MB-97* MB Indx-13.3* [**9-23**] CT head - negative [**9-23**] CXR - unremarkable Brief Hospital Course: 1. Anemia - on admission her Hct was 20.3 so she received total of 3 units PRBCs with an appropriate Hct bump to around 33-35. She was given 2 L NS in ED. This was felt to be secondary to bleeding from the pre-pyloric mass. GI was consulted and felt that she would benefit from stent placement only if she was nauseated/vomiting, but that it would not control the bleeding, so she was tried on food and tolerated all foods well. Her PPI was continued twice a day. It was discussed with her family that a conservative/palliative approach will be pursued, with symptomatic control with PPI twice a day, biweekly hct checks, and likely no readmission if she has a massive GI bleed. This will be conveyed to her [**Hospital3 **] facility, where she is to return. 2. Cardiac ischemia: Her troponins/CK were elevated during admission, likely secondary to ischemia from low hematocrit. As pt has history of bleeding, anticoagulation with heparing was contraindicated anyway. A betal blocker was added to her regimen instead of her calcium channel blocker. She was monitored on telemetry without any adverse events. As she is DNR/DNI, no further enzymes will be drawn. 3. HTN: A beta blocker was substituted for her calcium channnel blocker for its cardioprotective effects. Her BP was stable. 4. s/p fall: She was noted to have had a fall at the outside hospital, but her head CT was negative for bleed and her mental statyus 5. Nausea/vomiting: She tolerated clears then solid food in the hospital without aspiration or vomiting. She did not need antiemetics. 6. Code status: DNR/DNI - This was discussed with the family and palliative care. Also no invasive procedures (i.e. cath, EGD for massive GI bleed) should be done but will consider EGD/stent as outpatient if gastric outlet obstruction develops. The family will clarify her status further, with possible CMO, as an outpatient, and may fill out a do not hospitalize plan. Medications on Admission: home meds:pantoprazole 40 mg PO BID, B-12 1000 mcg PO QD, ferrous sulfate 5 g PO TID, folic acid 0.4 mg PO BID, diltiazem (Tiazac) 240 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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. B Complex-C Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 6. Multi-Vit 55 Plus Tablet Sig: One (1) Tablet PO once a day. 7. Outpatient Lab Work Please draw HCT every Monday and Thursday and send results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**0-0-**] 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Homecare Solutions Discharge Diagnosis: Pyloric mass with subacute bleeding dementia cardiac ischemia Discharge Condition: Pt was eating and drinking well. She was ambulating, and had no complaints of pain. Discharge Instructions: Please administer her current medications, and give colace and senna if constipated. She may resume a normal diet. Please have the nurse or laboratory draw her blood Monday [**10-2**], and each Thursday and Monday after that, with results sent to Dr. [**Last Name (STitle) **]. If she has vomiting, nausea, bleeding or dark stools, please contact Dr. [**Last Name (STitle) **]. Please do not hospitalize without contacting her daughter first. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] early next week for check of your blood count ([**0-0-**]). Follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3815**] (GI) as needed, ([**Telephone/Fax (1) 8892**]. ICD9 Codes: 5789, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3109 }
Medical Text: Admission Date: [**2152-7-23**] Discharge Date: [**2152-7-29**] Date of Birth: [**2098-3-31**] Sex: M Service: CARDIOTHORACIC Allergies: Motrin / Ibuprofen / Shellfish Derived Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2152-7-23**] Placement of IABP [**2152-7-25**] Urgent CABG x 4 on IABP(LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA) History of Present Illness: Mr. [**Known lastname 79662**] is a 54 year old male with history of coronary artery disease since [**2147**]. Approximately one week prior to admission, he was experiencing intermittent chest pain. He eventually presented to [**Hospital3 **] ED. EKG showed ST elevations in v2-v4. He ruled in for acute MI with elevated troponins. He was urgently taken to the cath lab which revealed critical three vessel coronary artery disease. He was started on intravenous therapy and transferred to the [**Hospital1 18**] for urgent surgical revascularization. Past Medical History: Coronary Artery Disease - s/p PCI/stenting to LAD in [**2147**] Hypertension Dyslipidemia Social History: Active smoker. Occasional ETOH. Currently lives with his wife. Family History: Denies premature coronary disease. Physical Exam: Admission Vitals: 132/80, 85, 16 Slightly obese male in no acute distress Oropharyx benign Neck supple, no JVD Lungs clear to auscultation bilaterally Heart regular rate and rhythm, normal s1s2, no murmur or rub Abdomen benign Extermities warm without edema Neurologically intact, no focal deficits noted Distal pulses 2+, no carotid or femoral bruits noted Discharge VS T98 HR88SR BP 130/84 RR 16 O2sat 100-RA Gen NAD Neuro A&O, nonfocal exam CV RRR, no murmur. Sternum stable incision CDI Pulm dimminished bases bilat Abdm soft, NT/+BS Ext warm, 1+ edema bilat. Left SVG sites w/steris CDI Pertinent Results: [**2152-7-23**] 05:05PM BLOOD WBC-13.2* RBC-4.45* Hgb-13.2* Hct-38.1* MCV-86 MCH-29.7 MCHC-34.7 RDW-12.3 Plt Ct-217 [**2152-7-23**] 05:05PM BLOOD PT-13.2 PTT-37.1* INR(PT)-1.1 [**2152-7-23**] 05:05PM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-133 K-3.7 Cl-97 HCO3-28 AnGap-12 [**2152-7-23**] 05:05PM BLOOD ALT-38 AST-76* CK(CPK)-668* AlkPhos-65 Amylase-30 TotBili-1.5 [**2152-7-23**] 05:05PM BLOOD CK-MB-59* MB Indx-8.8* cTropnT-0.48* [**2152-7-25**] 07:19AM BLOOD %HbA1c-5.3 [**2152-7-27**] 04:15PM BLOOD WBC-10.4 RBC-3.62* Hgb-10.7* Hct-31.7* MCV-88 MCH-29.5 MCHC-33.7 RDW-12.0 Plt Ct-153 [**2152-7-27**] 04:15PM BLOOD Plt Ct-153 [**2152-7-26**] 06:17AM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2* [**2152-7-27**] 04:15PM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-137 K-3.7 Cl-97 HCO3-28 AnGap-16 [**2152-7-23**] EKG: Sinus rhythm. ST segment elevation in the anteroseptal leads suggestive of myocardial infarction. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 154 88 358/391 40 2 52 [**Known lastname **],[**Known firstname **] P [**Medical Record Number 79663**] M 54 [**2098-3-31**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-7-26**] 1:09 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2152-7-26**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79664**] Reason: ?ptx after CT removal [**Hospital 93**] MEDICAL CONDITION: 54 year old man with REASON FOR THIS EXAMINATION: ?ptx after CT removal Final Report CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2152-7-25**]. As compared to the previous examination, the mediastinal and pleural drains have been removed. The patient has also been extubated. The pre-existing small left-sided pleural effusion and the associated retrocardiac atelectasis have slightly increased in extent. Otherwise the chest radiographic appearance is unchanged. The Swan-Ganz catheter is in unchanged position. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: WED [**2152-7-26**] 4:37 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79665**] (Complete) Done [**2152-7-25**] at 8:45:34 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2098-3-31**] Age (years): 54 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0 Test Information Date/Time: [**2152-7-25**] at 08:45 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 #: 2008AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.6 cm Left Ventricle - Fractional Shortening: *-0.15 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: *3.7 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall hypokinesis. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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 PRE-BYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST BYPASS There is preserved left ventricular systolic function. The RV is still moderately enlarged but now with normal 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) **] [**2152-7-25**] 10:58 Brief Hospital Course: Mr. [**Known lastname 79662**] was admitted to the cardiac surgical service. Given his critical coronary artery disease, he was brought to the cardiac cath lab where an IABP was successfully placed without complication. Surgery was delayed for several days given recent Plavix dose, and he continued to remain pain free on intravenous therapy. On [**7-25**], Dr. [**Last Name (STitle) **] performed four vessel coronary artery bypass grafting. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. On postoperative day one, the IABP was weaned and removed without complication. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. The remainder of his postoperative course was uneventful, on POD4 he was discharged home with visiting nurses. Medications on Admission: Transfer meds: IV Heparin, Plavix, IV Nitro, Aspirin, Atenolol, Lescol Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*14 Tablet(s)* Refills:*0* 2. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*15 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:*2* 5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day for 7 days. Disp:*7 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary Artery Disease s/p CABG Preoperative Acute ST Elevation MI Hyperlipidemia HTN History of LAD stent [**2147**] Discharge Condition: good Discharge Instructions: Shower daily, no baths or swimming No creams, lotions, powders to incisions No driving No lifting more than 10 pounds for 10 weeks Take all medications as prescribed report any weight gain of greater than 3 pounds a week Followup Instructions: Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks Dr.[**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] in [**1-9**] weeks Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) 4922**] in [**1-9**] weeks Completed by:[**2152-8-1**] ICD9 Codes: 5180, 2875, 2859, 4019, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3110 }
Medical Text: Admission Date: [**2179-12-25**] Discharge Date: [**2179-12-27**] Date of Birth: [**2120-2-17**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 2160**] Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 59 male with DM2, HTN, schizophrenia was picked up by his brother from [**Last Name (NamePattern1) 66721**]nursing home for a day trip. His brother found him to be confused, and he felt dizzy and sweaty; he called EMS. His finger stick was 13, and he was given IM glucagon in the ambulance. In the ED he was found to still be hypoglycemic and was given D50 and allowed to eat. He was also hypothermic to 92.3. Per nursing home, his last temp on [**2179-12-17**] was 97.4 oral. . He has had no changes in any of his psych meds since [**8-/2179**] when he arrived at nursing home. Per nursing staff at [**First Name4 (NamePattern1) 10378**] [**Last Name (NamePattern1) **], his BS had initially been difficult to control [**3-11**] dietary non-compliance. He had been eating foods which would elevate his BS. His last change in his diabetes management was on [**2179-11-29**], which was an increase in his 70/30 insulin from 44 units to 48 units; and on [**2179-12-6**] metformin was added 500 mg qd. . He indicated that he has had hypoglycemic episodes 4x over the past month; usually it occurs around noon, and he feels similar to how he felt today. His brother indicated that it is always the same nurse/aide that is on when this happens. . ED course: Initially in ED, bs 35 (p glucagon). Then he got 1 amp D5W --> 159. Repeat was 29 on chem 7, so given octreotide out of concern for hypoglycemia related to sulfonylurea. After that, his BS was 55, and he was encouraged to eat. One hour after that his BS was 56, after which he was given another amp of D5 and [**Location (un) 2452**] juice. He remained hypothermic to 92-93, and was given a bair hugger. He was then admitted to MICU for closer monitoring. Of note, his last dose of metformin was at 9am on [**12-25**]. . Review of Systems: He currently denies recent f/c/night sweats. He denies cough, abdominal pain, diarrhea, constipation, excessive thirst or urination, HA, change in vision, dysuria, rash, or known sick contacts. [**Name (NI) **] has not had any orthopnea, DOE, PND. At baseline, he walks independently, feeds himself. He is incontinent of urine. . MICU course: On arrival to MICU, pt had a bld sugar of 203. He was given 6U of regular for a sugar of 245 at 6pm. Over the next 6 hours, his blood sugar dropped into the 100s and then at 2am, it was found to be 58. He was symptomatic with confusion and dizziness. He was given [**2-8**] amp of D50 and it rose to 79 but then at 4am, it was found to be 56. He was given another [**2-8**] amp of D50 and it remained in the 70s-100s. At 10am, after breakfast, it rose to 251 and he was given 6units of regular. [**Last Name (un) **] was consulted. Past Medical History: Diabetes Mellitus type 2, on insulin Scizophrenia Hypertension Scrotal cellulitis (rx with cephalexin in [**11-12**]) s/p hepatic tumor resection? ? Coronary artery disease (based on meds / ecg) Social History: Lives at [**Last Name (NamePattern1) 66721**]Nursing Home in [**Location (un) **]. He smokes 5 ciagarettes per day for the past year; he had quit the 10 years previous to that. He denies EtOH use. He enjoys [**Location (un) 1131**]. Family History: NC Physical Exam: (In ICU at admission) 94.5 169/90 81 20 99% 2L NC Gen- NAD, pleasant, alert and oriented, lying in bed under bairhugger Heent- MMM, EOM intact, sclerae anicteric Neck- JVP flat Cor- RRR, nl S1/S2, no M/R/G Chest- CTAB Abd- soft, obese, nontender/nondistended; scars from chole and hepatic resection Ext- 4 small (<1cm) pressur ulcers around base of both feet; 1+ pitting edema bilaterally Neuro- alert and oriented Skin- no rashes, birthmark over right eyelid; scrotum without erythema Msk- full range of motion; strength 5/5 deltoids, biceps, triceps Pertinent Results: [**2179-12-27**] 06:30AM BLOOD WBC-4.2 RBC-3.98* Hgb-11.6* Hct-33.6* MCV-85 MCH-29.1 MCHC-34.4 RDW-15.0 Plt Ct-194 [**2179-12-25**] 01:00PM BLOOD WBC-5.3 RBC-4.06* Hgb-12.2* Hct-34.2* MCV-84 MCH-30.1 MCHC-35.7* RDW-15.1 Plt Ct-225 [**2179-12-27**] 06:30AM BLOOD Glucose-144* UreaN-21* Creat-0.7 Na-137 K-4.6 Cl-103 HCO3-28 AnGap-11 [**2179-12-25**] 01:00PM BLOOD Glucose-29* UreaN-23* Creat-0.9 Na-134 K-4.4 Cl-97 HCO3-29 AnGap-12 [**2179-12-25**] 01:00PM BLOOD ALT-21 AST-27 CK(CPK)-199* AlkPhos-72 Amylase-45 TotBili-0.2 [**2179-12-25**] 01:00PM BLOOD Lipase-22 [**2179-12-26**] 03:30AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1 Iron-42* [**2179-12-25**] 01:00PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.04* [**2179-12-26**] 03:30AM BLOOD calTIBC-289 Ferritn-57 TRF-222 [**2179-12-26**] 03:30AM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE [**2179-12-25**] 02:35PM BLOOD Lactate-1.1 [**2179-12-25**] 05:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2179-12-25**] 05:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG URINE CULTURE (Final [**2179-12-27**]): <10,000 organisms/ml [**2179-12-25**] 4:15 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [**2179-12-25**] 2:30 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): Brief Hospital Course: Hypoglycemia / hypothermia: His hypoglycemia is most likely due to his medical regimen. He has had 5 episodes this past month of hypoglycemia, and his insulin regimen was increased just prior to that, as well as the addition of metformin. [**Last Name (un) **] diabetic consult swas called for and they changed the insulin regimen, started glargine with an insulin sliding sacle. No further episodes of hypoglycemia were noted. Metformin was stopped as well. He is recommended to follow up with [**Hospital **] clinic for better titration of the sugars. Hypoglycemia can also be accompanied by hypothermia. work-up for infection was all negative at discharge. Blood cultures from admission remained negative to date at the time of discharge. His temp remained within normal range. Hypertension: He has a history of hypertension, and his BP has been adequately controlled. He is on lisinopril and labetolol. There is concern of masking hypoglycemic awareness with labetolol, but there was greater concern for rebound tachycardia so this was continued. This may be readdressed by the PCP in clinic. Schizophrenia/Depression: Meds were continued ? Coronary disease: It is unclear if he has CAD or not - he indicated that he had a cath done at [**Hospital3 **] several years ago, though denies heart disease. His ECG shows q waves. Continued ace inhibitor, bblocker, aspirin. His PCP is at [**Name9 (PRE) **] Medical center. . Anemia: unclear baseline or etiology.Continue ferrous sulfate. GI evaluation should be addressed by PCP. Hyperlipidemia: continued atorvastatin The above information was converyed to the patient's nurse at the NH prior to discharge. Medications on Admission: Insulin 70/30 48 units qam, 22 units qpm Ferrous Sulfate 325 qd ASA 81 qd MVI qd Lisinopril 5mg qd Hytrin 5mg qd Celexa 20mg qd Vit c 500mg [**Hospital1 **] Juven (nutrition) Trazodone 50mg [**Hospital1 **] Labetalol 100mg [**Hospital1 **] Trilialafon 12mg [**Hospital1 **] Lasix 40mg [**Hospital1 **] Depakote 125mg tid Glucophage 500mg qam (~9am) Zyprexa 40mg qhs; prn agitation Lipitor 40mg qhs Zinc sulfate qd Glucagon prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Perphenazine 8 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 14. Olanzapine 10 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 19. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 Subcutaneous at bedtime. 10 20. Insulin sliding scale Please follow the insulin slidin scale (Humolog) as suggested 21. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Last Name (NamePattern1) 66721**]Nursing - [**Location (un) **] Discharge Diagnosis: Hypoglycemia - due to increased insulin dose Hypothermia - possibly related to hypothermia Secondary diagnoses: Diabetes Mellitus type 2, on insulin Scizophrenia Hypertension Scrotal cellulitis (rx with cephalexin in [**11-12**]) s/p hepatic tumor resection? ? Coronary artery disease (based on meds / ecg) Discharge Condition: stable Discharge Instructions: Your had very low sugar levels before admission to the hospital. Your insulin regimen has been changed and is noted below. Metformin was also stopped. Please check your sugars 3-4 times before meals in the next [**3-13**] week to make sure that the are not low (less than 60) return to the emergency room or call you doctor if you notice dizziness, sweating or any other symtoms concerning to you. You are requested to make an appointment in the [**Hospital **] clinic ([**Hospital 982**] clinic). Please call [**Telephone/Fax (1) 2384**] to make an appointment in the next 1 to 2 weeks. You should also follow up with your primary care doctor in the next 1 week. Followup Instructions: Follow up with your primary care doctor, Dr [**First Name (STitle) **] [**Name (STitle) 5404**] [**Telephone/Fax (1) **] in the next 1 week. [**Hospital **] clinic ([**Hospital 982**] clinic) - Please call [**Telephone/Fax (1) 2384**] to make an appointment with Dr [**Last Name (STitle) 978**] in the next 1 to 2 weeks. If an appointment is not available with Dr [**Last Name (STitle) 978**] in the next 2 weeks, you are advised to make an appointment with any available medical provider. ICD9 Codes: 5180, 2859, 4019, 2724
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Medical Text: Admission Date: [**2192-11-6**] Discharge Date: [**2192-11-12**] Date of Birth: [**2124-8-2**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2192-11-8**] Coronary artery bypass graft x 5 (left internal mammary > left anterior descending, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2, saphenous vein graft > distal right coronary artery > posterior descending artery) [**2192-11-6**] cardiac catheterization History of Present Illness: 68 year old male with dyspnea on exertion for past 5 months relieved with rest. Occasional chest tightness (GERD like) symptoms with exertion. He is able to walk [**11-29**] mile before he would experience shortness of breath and relieved almost immediatly with rest. He had stress test at [**Hospital1 **] and was interpreted as positive and was sent for cardiac catheterization. He was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Borderline diabetes Hypercholesterolemia Glaucoma Seborrheic keratosis Social History: Lives with:wife Occupation:[**Name2 (NI) 92151**]/consultant Cigarettes: Smoked no Other Tobacco use:denies ETOH:[**1-2**] drinks/week Illicit drug use: denies Family History: Father MI in 70's Physical Exam: Pulse:71 Resp:18 O2 sat:98/RA B/P 151/92 Height:5'9" Weight:200 lbs General:NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] No Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm []x, well-perfused [] Edema [] _____ Varicosities: None [] well healed wound left lateral lower leg Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]:+2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: Cardiac Catheterization [**2192-11-6**]: 1. Selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. The LMCA had no angiographically-apparent significant stenosis. The LAD had a proximal 99% stenosis, 100% D1 stenosis. Right to left collaterals to LAD and D1. The LCX had a 60% OM1 stenosis, with a long 60% stenosis OM2. The RCA had a mid 70% stenosis, a 50% ostial and mid 90% PDA. 2. Limited resting hemodynamics revealed normal systemic arterial pressures at the central aortic level 105/69 mmHg. 3. Left Ventriculography was deferred. [**2192-11-8**] ECHO Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic pressure. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. [**2192-11-7**] Carotid Ultrasound Impression: Right ICA no stenosis. Left ICA <40% stenosis [**2192-11-11**] 11:22AM BLOOD WBC-12.5* RBC-3.86* Hgb-11.3* Hct-33.8* MCV-88 MCH-29.3 MCHC-33.5 RDW-13.4 Plt Ct-210# [**2192-11-12**] 04:41AM BLOOD UreaN-29* Creat-1.0 Na-140 K-3.9 Cl-102 [**2192-11-6**] 06:45PM BLOOD ALT-25 AST-24 AlkPhos-6* Amylase-58 TotBili-0.6 [**2192-11-12**] 04:41AM BLOOD Mg-2.5 [**2192-11-7**] 12:45PM BLOOD %HbA1c-5.9 eAG-123 [**2192-11-6**] 06:45PM BLOOD Triglyc-84 HDL-45 CHOL/HD-2.7 LDLcalc-58 Brief Hospital Course: Mr. [**Known lastname 92152**] was admitted to the [**Hospital1 18**] on [**2192-11-6**] following a cardiac catheterization which revealed severe three vessel coronary disease. The cardiac surgical service was consulted and he was worked up in the usual preoperative manner. A carotid ultrasound was performed which showed a normal right and less then 40% stenosis of the left internal carotid artery. On [**2192-11-8**], Mr. [**Known lastname 92152**] was taken to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated without complications. On post operative day one he was started on betablockers and lasix for gentle diuresis. He continued to progress and was transferred to the floor. Physical therapy worked with him on strength and mobility.Chest tubes and pacing wires removed per protocol. Continued to make good progress and was cleared for discharge to home with VNA on POD #4. All f/u visits were advised. Medications on Admission: LEVOTHYROXINE 88 mcg daily METFORMIN 850 mg twice daily SIMVASTATIN 40 mg daily ASPIRIN 325 mg daily CHOLECALCIFEROL 1,000 unit daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 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:*1* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever . Disp:*50 Tablet(s)* Refills:*0* 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease s/p CABG Diabetes Mellitus type 2 Hypercholesterolemia Glaucoma Seborrheic keratosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage Edema trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check [**11-20**] at 10:15am - Cardiac surgery office [**Hospital **] medical building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Surgeon: Dr [**Last Name (STitle) 914**] [**Name (STitle) 766**] [**12-18**] at 1:30pm Cardiologist: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 2258**] [**12-6**] at 10:40am Please call to schedule appointments with your: Primary Care Dr. [**Last Name (STitle) 55544**] [**Telephone/Fax (1) 12775**] in [**2-28**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2192-11-12**] ICD9 Codes: 4111, 2724, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3112 }
Medical Text: Admission Date: [**2102-3-7**] Discharge Date: [**2102-3-10**] Service: [**Hospital1 **] CHIEF COMPLAINT: This is a [**Age over 90 **]-year-old female admitted with atrial fibrillation with a rapid ventricular response, hypertension and electrocardiogram changes at Dialysis. HISTORY OF PRESENT ILLNESS: On the day of admission, the patient was at Dialysis and received two hours of treatment when she became hypertensive and confused. She has a history of similar complaints on an admission on [**2101-1-24**]. She was brought to the Emergency Department. Heart rate was in the 140s. Systolic blood pressure was 40. She was found to be in irregular narrow complex rhythm and was given two liters of normal saline. Attempts at cardioversion at 100, 200 and 360 joules failed to convert her to sinus rhythm. Her blood pressure slowly rose to 95/50s with fluids and the patient became increasingly response and interactive. An attempt at a left subclavian line failed in the Emergency Department. She was given 5 mg Lopressor intravenous for persistent tachycardia without any change. Her blood pressure became 70s/50s. She was given another liter of normal saline for a total of 3 and transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. End stage renal disease from nephrolithiasis with obstruction. She is receiving hemodialysis at [**Location (un) 4265**] and has a right AV fistula. She is dialyzed Tuesday, Thursday and Saturday. 2. Ulcerative colitis status post colectomy with ileostomy, remote. 3. Paget's disease. 4. Peptic ulcer disease, status post hemigastrectomy. 5. History of cholecystectomy. 6. Osteoporosis. 7. Admitted [**2101-1-24**] for atrial fibrillation with rapid response and lateral ST depressions with troponin leak attributed to demand ischemia and renal failure. Echocardiogram was done and was normal except for delayed relaxation. She had no stress test or cardiac catheterization because patient and family did not desire revascularization. She was started on aspirin at that time. 8. Severe memory deficit and dementia. 9. Recent fall, [**2102-3-3**] with staples to forehead laceration. MEDICATIONS: Epogen 10,000 units subcutaneously q. hemodialysis, Tums 500 mg po t.i.d. with meals. She was discharged on aspirin [**2101-1-24**] but apparently not taking, Ferrlecit at hemodialysis. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home and has full time [**Last Name (LF) 13222**], [**First Name3 (LF) **], who provides 24 hour care. She has a distant tobacco history. She drinks one vodka tonic every afternoon. Her cardiologist is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient had a son nearby but he died within the last several years. Patient's proxy is her [**Last Name (LF) 802**], [**Name (NI) 5627**] [**Name (NI) **], and she is closely involved in her aunts care and transport. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 98.6. Heart rate 130. Blood pressure 99/70. Respiratory rate 24. 100% on nonrebreather. In general, patient is lying in bed in no acute distress, staples to forehead, laceration clean, dry and intact. Oropharynx is clear. Mucous membranes were dry. Sclerae were anicteric. Neck was supple. Jugular venous distention was 7-8 cm. Lungs were clear to auscultation bilaterally. Cardiovascular: Irregular rhythm, tachycardic, 3/6 systolic ejection murmur blowing loudest at the apex. Abdomen was soft with normal active bowel sounds, was nondistended. There was a colostomy in place draining brown stool, no edema. Extremities are warm. There was a fistula in the right upper extremity. Neurologically, she was alert and oriented times one and grossly nonfocal. LABORATORIES ON [**3-3**]: White blood cell count 4.3, hematocrit 35.3. Chem-7 notable for BUN of 28 and creatinine of 5.7. Admission CK 45 with troponin of 1.1. Arterial blood gases 7.39/35/87, lactate 3.1. CT of the head showed no bleed or acute process. Chest x-ray showed no effusion and no infiltrate. Electrocardiogram showed atrial fibrillation at 150 with 1-[**Street Address(2) 1766**] depression in V4 to V6 which was new compared to [**2102-3-3**] except for the ST depression in V4 which is old. After spontaneous conversion, she was in normal sinus rhythm without ST depressions. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with a diagnosis of hypertension and atrial fibrillation resulting from the stress of hemodialysis. She was given a 250 cc normal saline bolus, 20 mg of intravenous diltiazem and then placed on a drip at 8 mg per hour, spontaneously converted to normal sinus rhythm at a rate of 78 on the evening of the 12th. A right femoral line was attempted but returned arterial blood and was removed without complications. She was transferred to the [**Hospital1 139**] Medicine Floor Team on [**3-8**]. She was seen by her Cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], that evening, who started her on an amiodarone load hopefully to prevent recurrence of atrial fibrillation at her next hemodialysis. Electrocardiogram showed resolution of her ST depression after her atrial fibrillation broke. CKs were elevated because of her cardioversion with negative MB fractions and troponin. She was stable throughout [**3-8**] and on [**3-9**] at hemodialysis, she went back in atrial fibrillation with rapid response, however, this time she held her blood pressure and did not have mental status changes. She actually finished the entire dialysis treatment. Back on the floor, systolic blood pressure then dropped to 70s to 90s with a heart rate in the 120s to 160s. After a long discussion with the patient and her proxy, [**Name (NI) 5627**] [**Name (NI) **], the patient and proxy desired the patient to be made "Do Not Resuscitate, Do Not Intubate" with no CPR. This is in keeping with a decision that she made previously when she was less demented. She is, however, to be full care including shocks if she is not in cardiac arrest. The patient at this point was then treated with a total of 25 mg diltiazem in 5 mg intravenous boluses and then placed back on diltiazem drip and again converted back to normal sinus rhythm overnight. The following morning she was at her baseline and was receiving po diltiazem. She underwent echocardiogram cardiography that morning which revealed new left ventricular hypertrophy and 2+ mitral regurgitation plus ejection fraction of greater than 60% and 2+ tricuspid regurgitation. Prophylaxis throughout her stay was with Zantac and normal diet and subcutaneous heparin, although, patient sometimes refused the heparin despite explanation of its importance. Because of her paroxysmal atrial fibrillation, anticoagulation was considered but heparin was not initiated and full dose aspirin is used instead because she is a frail elderly patient with a history of recent fall with head injury and because according to her proxy, comfort is her primary goal. She is going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's monitor to assess for recurrent atrial fibrillation and monitor her q.d. amiodarone. Her home health aid and proxy were advised that her nightly vodka tonic does place her at risk for recurrent falls as the history is that she may have fallen shortly after the vodka tonic. DISCHARGE STATUS: "Do Not Resuscitate, Do Not Intubate" but full care if not in cardiac arrest. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po b.i.d. times two days, 400 mg q.d. times two weeks and then 200 mg po q.d. 2. Nephrocaps 1 po q.d. 3. Aspirin 325 po q.d. 4. Epogen 10,000 units subcutaneous at hemodialysis. 5. Tums 500 mg po t.i.d. with meals. 6. Diltiazem 30 mg q.i.d. converting to 120 mg extended release on [**3-11**] a.m. DISCHARGE FOLLOW-UP: 1. VNA to do home safety evaluation. Assess for need for PC and hopefully remove the staples from her head laceration in about one week. 2. With [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding Cardiology issues and the results of her [**Doctor Last Name **] of Heart's monitor. 3. Hemodialysis on Tuesday, Thursday and Saturday. At her next dialysis on [**2102-3-11**], she should be monitored closely for recurrence as she has now had atrial fibrillation with two consecutive dialyses. DISCHARGE DIAGNOSES: 1. Paroxysmal atrial fibrillation with rapid response triggered by hemodialysis. 2. Dementia. 3. End stage renal disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2102-3-14**] 14:34 T: [**2102-3-14**] 14:34 JOB#: [**Job Number **] ICD9 Codes: 2765
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Medical Text: Admission Date: [**2184-9-25**] Discharge Date: [**2184-10-18**] Date of Birth: [**2105-12-15**] Sex: F Service: MEDICINE Allergies: Cephalexin / Bactrim / Phenergan / Reglan Attending:[**First Name3 (LF) 2195**] Chief Complaint: syncope Major Surgical or Invasive Procedure: Right arterial line placement [**9-26**] Intubation [**9-27**], [**9-29**] Central line placement (right IJ) [**9-27**] Cardiac cath [**9-29**] Left arterial line placement [**10-2**] Cardiac cath and bare metal stent placement to RCA [**10-3**] Tunneled Dialysis Line placement [**10-12**] History of Present Illness: 78F PMH of type I DM complicated by nephropathy, neuropathy, and retinopathy, osteoporosis, CKD (baseline Cr 2.0) and recent NSTEMI in [**6-/2184**] who is presenting with recurrent syncope [**1-29**] to short episdoes of asystole since this AM. . Patient has h/o of gastroparesis and chronic nausea and abdominal dyscomfort. She was at her baseline state of health until this morning. At noon after taking 2 bites of her sandwiched, she developed sudden nausea and had wretching X1, immediately there after she syncopized per her husband with some irregular limb movements w/o incontinence or tongue bite. Husband caught her she did not fall on the floor and did not hit her head. She reacovered after 30 seconds and came to quickly. She recalls feeling faint but otherwise denies any preceeding palpitaions, chest pain or other symptoms except nausea and wretching. After ~ 10 minutes she had another identical episode at which point her husband call EMS. En route EMS noted episode of 6s of asystole and patient becoming unresponsive. . Upon arrival to the ED VS: 98.2 59 140/53 17 100%RA, transcutaneous pacer pads were placed on patient. During observation in ED patient bradyed down to the 40's, then had about 10 second pause with syncope which ended with junctional beat then sinus took over in the 50's. Half a milligram of atropine was given with HR increasing only to the 60's. Initial Glu 100, but 50 on repeat for which she recieved IV D50% 50cc. EKG showed new T-wave inversions in the inferior leads Trop = 0.08 X1 WBC 3.8, Hct 26, PLT 105 all at recent baseline, cr/BUN 2.3/70 at baseline CXR: (my read), AP film hyperinflation, prominent hili and increased mildly interstitial markings which are not significantly changed from prior. . Of note patient's recent history includes admission [**2097-7-17**] for NSTEMI, at the time presented with chest pain new ST depressions and positive biomarkers and had MIBI showing a moderate fixed inferior wall defect without reversible defects. Echocardiogram showed new inferior wall motion (compared to [**2178**] prior) with LVEF 45%, mild left ventricular hypertrophy, mild mitral regurgitation, and mod PHTN (PASP 52 mm Hg above RA pressure). Given concern for her renal functions and no reversible defects on MIBI she was medically managed with ASA 325mg, [**Year (4 digits) **] 300, atorvastatin 80 and metoprolol tartrate PO. More recently she was admitted [**2087-9-9**] for worsening peripheral tingling which after neg head CT was attributed to natural progression of her peripheral neuropathy. On this admission was also noted to be hypertensive to the 200's and was started on amlodipine which she had been taking in the evenings intermitently only if her SBP's > 130. She has otherwise been stable at home, no other recent med changes. No new complaints beyond fatigue and ongoing chronic complaints as per ROS below. . REVIEW OF SYSTEMS On review of systems: + for chronic dizziness, lightheadedness, word finding difficulties. Also had several recent mechanical falls. - denies cough, hemoptysis, black stools or red stools. denies recent fevers, chills or rigors. No prior h/o syncope. . Denies chest pain since NSTEMI 2 months ago, denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: - Type 1 diabetes with renal insufficiency (Dr. [**Last Name (STitle) 978**] and Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **]), peripheral neuropathy, gastroparesis - Anemia (~29-30), on Procrit BIW - Prepatellar bursitis - Bilateral foot drop - Osteoporosis - Hypothyroidism - Hyperhomocysteinemia - Likely acute interstitial nephritis from cephalexin/bactrim [**11/2182**] - Osteoarthritis - Cholelithiasis without cholecystitis per RUQ US [**2182**]. - CAD: s/p NSTEMI [**6-/2184**] (presented with chest pain, inferior ST depression, positive enzymes, MIBI showed non reversible perf defects, managed medically, no revascularization procedure undertaken.) - Ischemic cardiomyopathy with inf wall hypokinesis and LVEF 45% per echo [**6-/2184**] post NSTEMI, NYHA class I-II. Social History: Patient lives with husband. She denies use of tobacco, alcohol, recreational drugs, or herbal medications. She use bilateral foot braces for neuropathy and foot drop. She reports being independent in ADLs but is having increasing difficulty with ambulation without assistive device. Family History: Mother died at age [**Age over 90 **] of old age. Sister died of ovarian CA in her 50's. Sister still alive at age [**Age over 90 **]. No family history of stomach or esophageal cancer. Physical Exam: Admission exam: GENERAL: thin, NAD. Oriented x3. Mood, affect appropriate. HEENT: mild pallor, PERRL, EOMI. No jaundice NECK: Supple with JVD to ear lobes. There's radiating murmur over bil carotids but no bruits. CARDIAC: RRR, distant heart sounds with faint SM at apex and LSB heard best over carotids. No r/g. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: blacked based ulcer on palmar aspect of lateral left foot unstagable but not deep. stage I-II ulcers on medial left ankle and plantar right mid foot. Abrasion left knee. No ROM limitation, pain or bony tenderness along BLE. No signs of cellulitis or discharge. No c/c/e. Peripheral pulses are palpable but faint. Also has OSA changes in fingers. SKIN: ulcers and abrasion as above, no rash Neuro: reduced sensory preception socks and gloves distribution, mild bil intention tremor, A+O X3, very mild word finding difficulty. otherwise grossly intact. . Discharge exam: 98.2 124/50 89 93%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric there is an ocular hemorrhage noted in the left eye near the lateral canthus, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Chest: she has right tunneled dialysis line which is c/d/i without induration Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Initial labs: [**2184-9-25**] 02:00PM BLOOD WBC-3.8* RBC-2.66* Hgb-8.7* Hct-26.0* MCV-98 MCH-32.7* MCHC-33.5 RDW-13.4 Plt Ct-105* [**2184-9-25**] 02:00PM BLOOD Neuts-69.8 Lymphs-19.1 Monos-6.3 Eos-4.5* Baso-0.3 [**2184-9-25**] 02:00PM BLOOD PT-11.9 PTT-30.2 INR(PT)-1.1 [**2184-9-25**] 02:00PM BLOOD Glucose-101* UreaN-70* Creat-2.3* Na-140 K-4.8 Cl-105 HCO3-29 AnGap-11 [**2184-9-25**] 02:00PM BLOOD ALT-25 AST-28 CK(CPK)-49 TotBili-0.4 [**2184-9-25**] 02:00PM BLOOD Lipase-19 [**2184-9-25**] 02:00PM BLOOD CK-MB-3 [**2184-9-25**] 02:00PM BLOOD cTropnT-0.08* [**2184-9-25**] 09:30PM BLOOD CK-MB-3 cTropnT-0.06* [**2184-9-25**] 02:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2 [**2184-9-25**] 02:00PM BLOOD TSH-11* [**2184-9-25**] 09:30PM BLOOD Free T4-1.3 . Pertinant labs: [**2184-10-18**] 06:15AM BLOOD WBC-4.7 RBC-2.35* Hgb-7.5* Hct-23.2* MCV-99* MCH-31.9 MCHC-32.3 RDW-18.4* Plt Ct-117* [**2184-10-8**] 07:05AM BLOOD PT-10.9 PTT-47.1* INR(PT)-1.0 [**2184-10-18**] 06:15AM BLOOD Glucose-413* UreaN-32* Creat-2.5* Na-132* K-4.2 Cl-95* HCO3-31 AnGap-10 [**2184-9-29**] 05:09AM BLOOD CK-MB-20* MB Indx-6.1* cTropnT-2.06* [**2184-9-29**] 10:30AM BLOOD CK-MB-22* MB Indx-7.5* cTropnT-2.71* [**2184-9-29**] 04:10PM BLOOD CK-MB-39* MB Indx-8.9* cTropnT-3.89* [**2184-9-29**] 10:38PM BLOOD CK-MB-45* MB Indx-11.8* cTropnT-3.78* [**2184-9-30**] 05:58AM BLOOD CK-MB-42* MB Indx-13.9* cTropnT-3.41* [**2184-10-18**] 06:15AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9 [**2184-10-14**] 06:20AM BLOOD calTIBC-222* Ferritn-641* TRF-171* [**2184-9-25**] 02:00PM BLOOD TSH-11* [**2184-10-14**] 06:20AM BLOOD PTH-50 [**2184-10-14**] 06:20AM BLOOD 25VitD-23* [**2184-9-29**] 08:00AM BLOOD Cortsol-40.1* [**2184-10-13**] 06:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE . Imaging: CXR [**2184-9-25**]: mild bibasilar atelectasis . MR of head, MRA of head and neck, [**2184-9-28**] FINDINGS: There is no evidence of infarct or hemorrhage. There are scattered T2/FLAIR hyperintensities in the subcortical and periventricular white matter, which are nonspecific but could be seen as the sequelae of chronic microangiopathy. There is prominence of the ventricles and extra-axial CSF spaces, stable since the prior examination. There is no mass, midline shift, or hydrocephalus. There is mucosal thickening of the frontal, ethmoidal, sphenoid, and maxillary sinuses. A small amount of fluid is visualized in the mastoid air cells. . MRA BRAIN: There is irregularity of the cavernous internal carotid arteries due to atheromatous disease. The right A1 segment is smaller, probably hypoplastic. The anterior cerebral arteries are otherwise patent with normal branching pattern. The left M1 and bilateral M2 segments exhibit narrowing and irregularity likely atheromatous disease. There is narrowing of the V4 segment of the right vertebral artery. The basilar artery appears patent. The posterior cerebral arteries are patent with normal branching pattern. There is no evidence of aneurysm, or arteriovenous malformation. . MRA NECK: The origin of the common carotid and vertebral arteries is not included in the field of view. The cervical vertebral arteries are patent. There is mild narrowing of the proximal right internal carotid artery. Otherwise, both internal carotid arteries are patent. The diameter of the proximal carotid arteries is larger than the distal diameter, therefore, there is no stenosis by NASCET criteria. IMPRESSION: 1. No evidence of infarction or hemorrhage. 2. Mild narrowing of the cavernous carotid arteries, likely related to atherosclerotic disease. No aneurysm or arteriovenous malformation. 3. Unremarkable MRA of the neck. . ECHO [**2184-9-29**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with focal hypokinesis of the inferior wall, basal to mid inferolateral wall, distal septal wall, and apex. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. No mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild left ventricular hypertrophy. Focal regional left ventricular systolic dysfunction consistent with multivessel CAD. Right ventricular dilation and dysfunction. Moderate pulmonary artery hypertension. Moderate functional [**Last Name (un) 22837**] stenosis from MAC. Compared with the prior study (images reviewed) of [**2184-7-19**], more extensive regional dysfunction is present with a decline in ejection fraction. Right ventricular systolic dysfunction is now present. There is a gradient across the mitral valve consistent with functional mitral stenosis. . Cardiac Cath [**2184-9-29**]: Assessment & Recommendations 1. Severe diffuse three vessel coronary artery disease with subtotal occlusion of heavily calcified diffusely diseased RCA 2. Moderate pulmonary arterial hypertension with severe right ventricular diastolic heart failure on pressor. 3. Moderate left ventricular diastolic heart failure. 4. Cardiogenic shock with SBP ranging from 60 mm Hg off pressor to 180 mm Hg (with excellent cardiac index) on pressor(norepinephrine) 5. Monitoring PA line left in place. As this is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 26900**], [**First Name3 (LF) **] NOT advanced to PCW position or inflate balloon without fluoroscopic guidance. 6. CCU team to evaluate the benefits and risks of RCA rotational atherectomy and stenting given echocardiographic and hemodynamic evidence of RV failure, but heavily calcified and diffusely diseased RCA. . Renal US [**10-2**]: IMPRESSION: 1. Findings consistent with bilateral abnormal renal arterial circulation. No evidence of venous thrombosis. No stones or hydronephrosis. 2. Right pleural effusion. . Cardiac Cath [**10-3**]: Interventional details Change for [**Doctor Last Name **]-0.75. Crossed with a ChoICE PT XS wire. Serial dilations with 01.25 mm, 2.0 mm. 2.5 mm. 2.75 mm balloons. Deployed a 2.5 x 18 mm Integriti stent and postdilated to 3.0 mm. Used the 2.75 mm balloon to dilate the mid RCA. Final angiography revealed normal flow, no dissection and 30% residual ostial stent recoil in the RCA and 30% residual stenosis in the mid vessel RCA. The distal RCA had diffuse unchanged disease. Assessment & Recommendations 1.ASA 81 mg PO QD indefinitely 2.[**Doctor Last Name **] 75 mg PO QD x 30 days uninterrupted and preferably x 12 months. 3.Secondary prevention CAD. . VENOUS DUPLEX UPPER EXTREMITY [**2184-10-6**] Duplex evaluation was performed of both upper extremities. Both subclavian veins are patent and phasic. Thrombus is identified in the right cephalic and the antecubital fossa as well as the left cephalic vein. Left basilic vein is patent. Both brachial and radial arteries are patent with calcifications. IMPRESSION: Thrombus in both cephalic veins and antecubital fossa on the right. For diameters of patent veins as well as brachial and radial arteries evaluate scan worksheet. Brief Hospital Course: 78F PMH of type I DM (complicated by nephropathy, neuropathy, and retinopathy), CKD (baseline Cr 2.0) and recent inferior NSTEMI in [**6-/2184**] who presentd with recurrent syncope [**1-29**] to short episdoes of asystole. . Acute issues: # Bradycardia/Asystole/Syncope: Patient admitted following multiple syncopal episodes preceded by nausea and retching. In ambulance, noted to have 6 second asystolic pause. Had additional 10 second pause in the ED and was given 0.5mg of atropine. After admission to CCU, continued to have episodes of bradycardia to the 30s-40s with associated hypotension. These were often but not exclusively related to nausea and vomiting. Concern for recurrent inferior MI but troponins and CK-MB initially stable. Initially thought to be most likely secondary to elevated vagal tone, but patient had progressive hypotension and bradycardia as hospitalization progressed (see below NSTEMI). Episodes of syncope resolved later in hospitalization, with no events of significant symptomatic pauses noted on tele. She did have several episodes of bradycardia to the 30s but was asymptomatic during these events. . # Hypotention/Shock: Shock appeared cardiogenic in nature on cath study but sepsis was highly considered given low SVR. On day 2 of admission, patient became hypotensive to the 60s-80s systolic, associated with bradycardia. She was started on dopamine with good response. Patient also developed intermittant fevers, so concern for sepsis. UA dirty, urine cultures were negative to date except for one sample with staph aureus coag +, pansensitive. [**12-31**] blood cultures grew gram positive cocci on [**8-26**]. Patient given 1 dose vanc/zosyn, then switched to vanc/cefepime. Cefepime was discontinued when urine culture returned with staph and not GNR. Lactate 3.1 on [**9-27**], likely due to hypoperfusion with low blood pressures, and eventually normalized below 2 on repeat measurements. Patient with low temperature and restarted on zosyn. Hemodynamically, pt required pressor support on Hospital Day 8, pt remained on levophed gtt with labile SBPs ranging from 90s to 150s intermittently. On [**2184-10-3**] vanc and zosyn were discontinued as blood cultures were no growth to date, and ID consulting team also recommended discontinuing antibiotics. Patient was on lasix gtt to decrease preload for cardiogenic shock and this was discontinued when CVP goal of [**10-8**] was reached. Patient was weaned from pressors on [**10-5**] and remained off pressors for remainder of hospital course. . # Mental status changes: Patient with intermittant episodes of unresponsiveness associated with hypotension, concerning for seizure vs hypoperfusion. The first of these occurred following dose of Phenergan and was associated with muscle rigidity, attributed to medication reaction. However, patient continued to have similar episodes throughout the day on [**9-27**]. After one unresponsive episode, had sensation of falling. Also had periods of hallucinations, picking at bedclothes, confusion more consistent with acute delirium. Neurology consulted. MRI and MRA of head/neck showed no infarct, just atherosclerotic disease in cavernous carotid arteries. EEG showed no seizure activity. Concern for encephalitis given low grade fevers, so LP done which was unremarkable and viral PCR negative. The patient was electively intubated to preform procedures and get imaging. She remained intubated for some time given on pressors and going to cath lab (see below). She was successfully extubated on [**10-5**]. After which her mental status was improved. . # Anuric Acute on Chronic Kidney Disease: Urine output decreased to <10cc/hr on second day of admission. Cr increased from 2.2 on admission to 3.4 the morning of [**9-27**]. FENa <1%, but no improvement in UOP with fluid boluses or initiation of pressors. Urine sediment suggestive of early ATN. Pt also with anion gap metabolic acidosis which was most likely related to uremia and lactic acidosis. In addition, delta/delta revealed underlying non gap metabolic acidosis which could be related to RTA secondary to diabetes. Renal consult suggested renal U/S, urine lytes and urine eosinophils. Renal u/s showed R renal artery parvus tardus suggestive of renal artery stenosis and poor diastolic flow bilaterally. Cath study on [**10-3**] did not show impressive stenosis of renal arteries and no interventions were done. Urine lytes were consistent with ATN and urine eosinophils were negative and thus made interstitial nephritis related to cephalosporins (history of allergy) less likely. Following PCI on [**10-3**], Cr continued to trend up with declining bicarb which felt to be related to contrast induced injury. The patient's Cr continued to increase and UOP only with diuretics. Per renal recs home Epo was restarted, low phose diet, nephrocaps, and sevelameer 800mg TID with meals started on [**10-12**]. Renal was following and tunneled HD line was placed on [**10-13**]. Patient underwent dialysis initiation once transferred to the floor and will undergo MWF dialysis once discharged. She is largely anuric at this point. . # CAD: Initially inferior wall STD + TWI similar to ECG changes at the time of NSTEMI 2 months ago, but cardiac enzymes stable, no chest pain. Continued home aspirin, [**Month/Year (2) 4532**], statin. Metoprolol initially held due to bradycardia, hypotension, pauses. Pt had troponinemia on [**9-29**] that peaked at 3.89 and cath study showed 3VD - this was concluded to be demand NSTEMI presentation. CAD was later intervened on [**10-3**] with high risk PCI (after multiple family meetings regarding goals of care) where the RCA was stented with BMS. Patient was restarted on increased dose of metoprolol on [**10-7**]. . # Nausea/Vomiting: most likely [**1-29**] to her chronic diabetic gastroparesis but could also be manifestation of inferior myocardial ischemia. Obstructive biliary issue is also on the ddx given RUQ US showed cholelithiasis. LFTs on admission were unremarkable and lipase negative. On day of demand NSTEMI LFTs trended up slightly ALT 41, AST 64, AlkP 229, GGT 98, and TBili normal. The patient continued to have nausea and emesis intermitently throughout course. Low dose ativan was used to control nausea given reactions to other medications as above. This resolved by discharge, at which time the patient was tolerating PO. . # Nutrition: Patient with poor PO intake on admission. Tube feeds were initiated on [**10-2**] but rate could not be advanced given high residual volume due to gastroparesis. A post-pyloric tube was placed on [**10-5**] and tube feeds were resumed. The patient continued to recieve tube feeds until she pulled out tube on [**10-8**]. She resumed oral feeding on [**10-9**]. . # ischemic cardiomyopathy: post NSTEMI echo in [**6-/2184**] showed inf wall hypokinesis and LVEF 45%. No ACE-I were started given CKD. NYHA class I-II. ECHO on this admission showed decreased LVEF to 35-40% likely secondary to additional cardiac insult this admission. The patient was diuresed intermittently during hospital course. Initially with IV lasix bolus. She was then started on torsemide and metolazone with good response. Diuretics were stopped on [**10-11**] secondary to low BPs and dry volume status. Isordil was started for afterload reduction. . # Pancytopenia: this is long standing, unknown if worked up in the past. Pt's thrombocytopenia worsened throughout course but with normal coagulation panel which was not consistent with DIC/TTP. Most likely this could be related to bone marrow suppression related to stress/sepsis/shock/antibiotics. Additionally patient on Epo at home, restarted on [**10-13**]. . # Hypothyroidism: TSH elevated on presentation but with normal FT4. Pt's home Synthroid was continued throughout course. . Transitional issues: # Dialysis follow-up # Cardiology follow-up # Renal follow-up # Patient's goal hematcrit should be >30% given her NSTEMI during this admission. Patient recieved one unit of pRBC on the day of discharge and total of 4unit pRBC during her hospital stay. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**]. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Glargine 8 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Levothyroxine Sodium 50 mcg PO DAILY Start: In am 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY Start: In am 8. Calcium Carbonate 500 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY Start: In am 10. Fish Oil (Omega 3) 1000 mg PO DAILY Start: In am 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Vitamin D 800 UNIT PO BID 13. Amlodipine 2.5 mg PO DAILY patient has been taking this at home QHS:PRN SBP > 130. 14. Epoetin Alfa 0 UNIT IV ONCE Duration: 1 Doses Start: HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Vitamin D 800 UNIT PO BID 9. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 10. Isosorbide Dinitrate 10 mg PO TID RX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth Every 8 hours Disp #*90 Tablet Refills:*0 11. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth Every 8 hours Disp #*90 Tablet Refills:*0 12. Omeprazole 20 mg PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. Nephrocaps 1 CAP PO DAILY RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 15. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 16. Glargine 8 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Hospital1 8**] Discharge Diagnosis: Syncope Non ST Elevation Myocardial Infarction Renal Failure Cardiogenic Shock Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 26898**], It was a pleasure taking care of you during your recent admission to [**Hospital1 18**]. You were admitted with fainting spells. These were felt to be due to vasovagal episodes. These episodes resolved and no pace maker was placed. However, your hospital course was complicated by a heart attack which resulted in organ damage and required you to be supported by a breathing machine and medications to improve your blood pressure. A stent was place in the site of the heart blockage. Unfortunately, the heart attack resulted in significant damage to your kidneys. As a result, you were started on dialysis. You improved once dialysis was started and you were discharged to rehab. The following changes were made to your medications. STOP Amlodipine Iron Supplement START Nephrocaps Multivitamin Sevelamer Folate Isosorbide Dinitrate Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2184-11-2**] at 11:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2184-10-18**] ICD9 Codes: 5845, 5856, 2930, 2762, 3572, 4168, 4280, 2449, 412
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Medical Text: Admission Date: [**2114-11-29**] Discharge Date: [**2114-12-10**] Date of Birth: [**2114-11-29**] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [**First Name4 (NamePattern1) 15406**] [**Known lastname 11622**] delivered at 35 weeks gestation, birth weight 2775 grams, was admitted to the Newborn Intensive Care Unit for management of prematurity and respiratory distress. estimated date of delivery [**2115-1-3**]. Prenatal screens included blood type O positive, antibody screen negative, Rubella immune, RPR nonreactive, and hepatitis B surface antigen negative and group B strep positive. Pregnancy was complicated by placenta previa noted on 18 week and 25 week ultrasound and preterm contractions from 28 week gestation managed with bed rest. Had intermittent vaginal bleeding. spontaneous vaginal delivery under epidural anesthesia on [**2114-11-29**] secondary to progressive preterm labor. Rupture of membranes one hour prior to delivery. No maternal fever. Received intrapartum antibiotics five hours prior to delivery. Infant emerged with a weak cry and well maintained heart rate. Received oral and nasal bulb suctioning, tactile stimulation and dried. Subsequently required brief positive pressure ventilation for irregular respiratory effort. Spontaneous regular respirations were established but the infant was still pale with intermittent grunting and was therefore grunting and was therefore transferred to the Intensive Care Nursery from labor and delivery. Apgar scores were 6 and 8 at one and five minutes respectively. Examination of placenta at the delivery showed scattered old clots without calcifications. PHYSICAL EXAMINATION ON ADMISSION: Weight 2775 grams (75th percentile), length 50.5 cm (90th percentile), head circumference 34 cm (90th percentile). A nondysmorphic pale infant, palate intact, anterior fontanelle soft and flat, moderate nasal flaring, moderate intercostal and subcostal retraction, good breath sounds bilaterally with a few scattered rales, well perfused with regular rate and rhythm, femoral pulses present bilaterally, no murmur. Abdomen soft, nondistended, no organomegaly, no masses, three vessel cord, normal female external genitalia. Active alert infant with tone slightly decreased moving all limbs symmetrically. Normal reflexes. Hips stable. SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: Placed on nasal CPAP 6 cm of water on admission for respiratory distress. Highest oxygen requirement on CPAP 45 percent. Weaned to nasal cannula oxygen on day of life two. Required supplemental O2 by nasal cannula until day of life seven. Has remained in room air since with comfortable work of breathing, respiratory rate 30 to 50s. Respiratory: Has had several episodes of apnea and bradycardia or oxygen desaturations since admission. Last oxygen desaturations on [**12-6**], last bradycardia episode on [**12-4**] associated with feeding. Cardiovascular: Received one bolus of normal saline for pallor on admission. Has remained hemodynamically stable throughout hospital stay. A soft murmur was audible through the first few days of life that has subsequently not been heard. Fluids, electrolytes and nutrition: Was n.p.o. on admission and receiving D10W by peripheral intravenous. Started enteral feeds on day of life two, on all breast or bottle feed by day of life four with weight gain. Discharge weight Gastrointestinal: Peak total bilirubin 13.1, direct .4. Did not require phototherapy. Hematology: Hematocrit on admission 41 percent. Infectious disease: Received Ampicillin and Gentamicin for 48 hours for rule out sepsis. Respiratory distress though secondary to mild surfactant deficiency. Initial CBC was benign. Blood culture was negative. Received initial dose of Synagis RSV prophylaxis. Neurology: Examination age appropriate. Sensory: Hearing screening was performed of automated auditory brain stem responses passed both ears. CONDITION AT DISCHARGE: Stable preterm infant. DISCHARGE DISPOSITION: Discharged home with parents. Name of primary pediatrician: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**], [**Hospital 2312**] Pediatrics, telephone number [**Telephone/Fax (1) 37109**]. CARE RECOMMENDATIONS: 1. Ad lib demand breast feeding, follow weight gain. 2. Medication: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d. 3. Car seat test passed. 4. Immunizations received: Received hepatitis B immunization and Synagis on [**2114-12-7**]. Immunizations recommended: Synagis RSV prophylaxis to be considered from [**Month (only) 359**] to [**Month (only) 547**] for infants who meet any of the following three criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household, or with preschool siblings or, 3) with chronic lung disease. FOLLOW UP APPOINTMENTS: 1) Follow up appointment with pediatrician following discharge. 2) [**First Name (Titles) 1587**] [**Last Name (Titles) 28085**] made to [**Location (un) 86**] [**Hospital6 1587**], telephone number [**Telephone/Fax (1) 37525**]. DISCHARGE DIAGNOSES: 1. AGA preterm female. 2. Respiratory distress syndrome resolved. 3. Rule out sepsis. 4. Neonatal jaundice. 5. Apnea of prematurity, resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2114-12-9**] 04:69 T: [**2114-12-9**] 07:05 JOB#: [**Job Number 38966**] ICD9 Codes: 769, 7742, 2765, V290, V053
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Medical Text: Admission Date: [**2128-11-15**] Discharge Date: [**2128-11-24**] Date of Birth: [**2082-1-24**] Sex: M Service: [**Company 191**] MED HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old man with past medical history including hepatitis C (treated with PEG- Interferon, Ribavirin, finished [**10/2127**] with viral load not detected by PCR in [**1-/2128**]), who presented initially to [**Hospital 1263**] Hospital for elective endoscopic retrograde cholangiopancreatography. He complained of two-week history of jaundice associated with intermittent vague abdominal pain with some constipation. Denied recent nausea, vomiting, diarrhea, fever, or chills. At [**Hospital 1263**] Hospital patient underwent EGD on [**2128-11-11**] and was found to have gastritis/gastroesophageal reflux disease. A recent abdominal ultrasound showed a questionable focal lesion (location not reported). On [**2128-11-11**] he also underwent an ERCP that revealed common bile duct stricture which was stented with a plastic stent. Per report patient's bilirubin had been 23.8 on admission to [**Hospital 1263**] Hospital and continued to remain elevated after stenting. The patient underwent laparoscopic cholecystectomy on [**2128-11-13**] at [**Hospital 1263**] Hospital with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain left in place. On [**2128-11-15**] the patient was transferred to the [**Hospital6 256**] for a repeat ERCP. During ERCP procedure on [**2128-11-15**] patient received Versed, Fentanyl, Phenergan and was reportedly very difficult to sedate. The plastic common bile duct stent was removed, and during procedure, patient went into respiratory arrest. He became apneic with heart rates in the 30s, systolic blood pressure to 81, and oxygen saturation to 40% very briefly. A Code Blue was called and patient was given Flumazenil and Narcan. Patient never lost his pulse. The patient's heart rate increased to a rate of 150s with systolic blood pressure to the 150s. Patient was bagged, ventilated, and was witnessed to vomit brown material into the bag mask. He was intubated by Anesthesia for airway protection and brought to the [**Hospital Ward Name 12573**] Intensive Care Unit. He became agitated en route to the Intensive Care Unit and vomited more brown material. He was stabilized in the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Hepatitis C, viral load undetectable in 01/[**2128**]. 2. Gastroesophageal reflux disease. 3. Hiatal hernia. 4. Gastritis. 5. Esophageal ring. 6. Gallstones. 7. Status post laparoscopic cholecystectomy on [**2128-11-13**]. 8. Status post ERCP [**2128-11-11**] and [**2128-11-15**]. 9. Trauma to neck at age 10 with tracheal and esophageal reconstruction done at that time with permanent voice damage. Patient has a permanent whisper. MEDICATIONS UPON ADMISSION: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient quit tobacco smoking 15 years ago; had a 15-pack-year history prior to this. Positive for alcohol abuse; quit 16 years ago. Positive intravenous drug use; quit 16 years ago. PHYSICAL EXAMINATION: Temperature 98.3, heart rate 81, blood pressure 121/61, oxygen saturation was 95% on AC mode, tidal volume 700, respiratory rate 20, FIO2 of 100%, and a PEEP of 5. General: Patient was intubated, sedated, jaundiced profoundly. HEENT: Icteric sclerae; pupils equal, round, reactive to light; endotracheal tube in place; mucous membranes moist. Neck: Supple; jugulovenous pressure at 6 cm at 45 degrees; no bruits; no lymphadenopathy; well healed scar on anterior neck. Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Chest: Bibasilar rhonchi with upper airway congestion, otherwise clear to auscultation. Abdomen: Obese; J-P drain at right upper quadrant with 40 cc of serosanguinous fluid; site is clean, dry, and intact without erythema; liver edge palpable at 4 cm below midclavicular costal margin; no palpable splenomegaly or pulsatile mass; soft, nondistended, good bowel sounds. Extremities: Warm, dry, 1+ pedal pulses bilaterally; no cyanosis, clubbing, or edema. Neuro: Sedated; moving all extremities; good gag reflex. Derm: Warm, dry, with bilateral palmar erythema. LABORATORY DATA UPON ADMISSION: White blood cells 7.5, hematocrit 34.3, platelets 169. Coagulation studies were normal. Chemistry was normal with the exception of a potassium of 2.9. ALT 36, AST 47, LDH 229, alkaline phosphatase 240, total bilirubin 19.6, amylase 28, lipase 60, CK 174, MB 5, troponin less than 0.01, albumin 2.3, calcium 7.7, ammonia 40. Blood gas on arrival to the Intensive Care Unit: pH 7.25, PCO2 55, PO2 250, bicarbonate 25, lactate 3.0. EKG: Sinus tachycardia with a rate of 104, normal axis, no acute ST-T changes, no prior study available for comparison. Portable chest x-ray showed the ETT at carina, diffuse patchy infiltrates bilaterally, and no effusions. HOSPITAL COURSE LISTED BY PROBLEM: 1. Respiratory arrest/respiratory failure: Likely due to heavy sedation needed during ERCP. Patient with likely aspiration pneumonia versus chemical pneumonitis. Patient was started on Ampicillin, Levofloxacin, and Metronidazole empirically. Patient was treated for a seven-day course. On day two of ICU admission patient was extubated without difficulty. He was quickly weaned to a nasal cannula and subsequently was weaned to room air within a day of extubation. Patient's white blood cell count decreased during admission, and an initial fever after intubation to a maximum of 102.2 resolved and patient was afebrile for last eight days of admission. Patient was kept on p.r.n. nebulizer treatments and remained with good saturation 2. Common bile duct stricture: On day two of admission a percutaneous drain was placed by Interventional Radiology with both internal and external draining of bile. The common bile duct stent had been removed on ERCP upon admission. A biopsy of the common bile duct was done at that time and showed chronic inflammation and no evidence of tumor or mass. Both PTC and CT of abdomen and MRCP were unrevealing for extrinsic mass. However, this stricture was concerning for malignancy. Patient's bilirubin continued to decline towards normal during his admission, and on day of discharge bilirubin was at 9. Patient's drain was capped on day prior to discharge to ensure adequate internal drainage. Patient was sent home with drain in place. 3. Gallbladder adenocarcinoma: Pathology from [**Hospital 1263**] Hospital was returned during patient's admission. The final pathology indicated a well differentiated invasive adenocarcinoma of the gallbladder. The tumor invades the muscular wall and extends into adjacent adipose tissue. The cystic duct appeared free of malignancy, but the serosal liver bed showed focal extension of tumor. There were also scattered foci suspicious for lymphvascular invasion per the report. The stage given was at least PT2N1MX. The patient's pathology slides have been requested by the surgeons who consulted on this patient and will be reviewed by our Pathology Department in the coming weeks. An Oncology consult was obtained at the time this report was sent from [**Hospital 1263**] Hospital, and at this time Oncology has requested the MRCP in addition to sending the bile fluid draining for cytology. The cytology report came back negative for malignant cells. Patient was seen by the Surgery team headed by Dr. [**Last Name (STitle) **], who wishes for a wide surgical resection of malignancy that would include a partial liver lobectomy and removal of the ductal system. Dr. [**Last Name (STitle) **] wishes for patient to follow up with him on [**2128-12-10**] to allow his aspiration pneumonia and acute issues to resolve. [**Name (NI) **] PTC drain will be assessed at that time. Patient will also follow up with Dr. [**First Name (STitle) **] from Oncology after his surgical treatment. It is unclear at the time of this discharge whether the common bile duct stricture is related to the adenocarcinoma of the gallbladder or is simply just inflammation as the pathology precludes. All of this will be assessed during the surgical procedure planned by Dr. [**Last Name (STitle) **]. 4. Pain management: Patient complained of abdominal pain related to his drain placement. Patient has a history of narcotic abuse and repeatedly requested minimal narcotics for his pain control; however, these were needed during his admission for relief of pain. Patient was given subcutaneous Dilaudid as needed and was switched to p.o. Oxycodone upon discharge. Patient felt good relief and improvement of his pain throughout his admission. 5. Nutrition: Patient was tolerating p.o. diet with good appetite during admission. He was started on supplemental multivitamins, folate, and thiamine and will continue these upon discharge. 6. Prophylaxis: Patient was started on pantoprazole and was on Heparin during his admission for deep venous thrombosis prophylaxis. Patient was ambulating without difficulty and was cleared to go home with services. Other laboratory values that were checked during admission include a CEA of 2.4, a CA of 19-9 of 58, bile fluid that grew Enterococcus that was sensitive to both Ampicillin and Levofloxacin. Patient's seven-day course of antibiotics, as explained above, was seen to cover for this Enterococcus. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home with [**Location (un) 86**] VNA for drain care and pain management. DISCHARGE DIAGNOSES: 1. Adenocarcinoma of the gallbladder. 2. Common bile duct stricture. 3. Resolving aspiration pneumonia. 4. Hepatitis C. 5. Gastroesophageal reflux disease. 6. Gastritis. 7. Status post laparoscopic cholecystectomy. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg p.o. q.d. 2. Folic acid 1 mg p.o. q.d. 3. Multivitamins, one, p.o. q.d. 4. Thiamine 100 mg tablets p.o. q.d. 5. Colace 100 mg b.i.d. 6. Ursodiol 300 mg q.d. p.r.n. itching. 7. Phenergan 25 mg tablets p.o. q. four to six hours p.r.n. nausea. 8. Albuterol inhaler one to two puffs q. six hours p.r.n. for shortness of breath or wheezing. 9. Oxycodone 5 mg tabs, take one to four tablets p.o. q. four to six hours p.r.n. for pain. Patient given 60 pills, no refills. DISCHARGE INSTRUCTIONS: 1. Patient to see his primary care doctor, Dr. [**First Name (STitle) 5936**], at [**Telephone/Fax (1) 25350**], on Wednesday, [**2128-12-1**], at 5:15 p.m. Patient will have his chemistries and liver function tests checked within two to three days of discharge by home nursing to ensure trending downward of bilirubin. 2. Dr. [**Last Name (STitle) **] from Surgery on [**2128-12-10**] to plan for coming operation. 3. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Hematology/Oncology on [**2128-12-22**] at 1 o'clock. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2128-11-24**] 15:16 T: [**2128-11-25**] 14:27 JOB#: [**Job Number 37705**] ICD9 Codes: 5070
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Medical Text: Admission Date: [**2103-8-13**] Discharge Date: [**2103-8-27**] Date of Birth: [**2024-7-13**] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone Analogues Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: redo sternotomy, aortic valve replacement (25mm St. [**Male First Name (un) 923**] porcine) [**2103-8-14**] History of Present Illness: This 78 year old patient with complex past medical history s/p Coronary Artery Bypass Graft x 4 in [**2090**]. Pt had a cardiac cath at NEBH in [**12-8**]. The aortic area was 1.0 with a mean gradient of 33 and an EF of 58%. Then [**12-9**] he developed chest pain and ruled in for MI with a troponin of 6.5.He had a cardiac cath at [**Hospital1 18**] at that time which showed a valve area of 0.8 with a mean gradient of 34 and an EF of 40%. The study showed significant native CAD but all grafts were patent.He declined intervention at that time because he was going to [**State 108**] for the winter. When he returned this spring he was complaining of increased dyspnea on exertion. He had a cardiac cath [**2103-6-6**] at NEBH which showed severe aortic stenosis and a calculated [**Location (un) 109**] of 0.6 cm2 and a mean gradient of 34-35 mmHg. This catheterization also showed severe 3 vessel native CAD. The LIMA graft to the LAD was patent. The vein graft to the PDA was patent with a significant lesion in the native vessel downstream from the graft. The vein graft to diagonal branch is patent with distal native vessel severe disease and patent saphenous vein graft to the obtuse marginal with diffuse attenuation of native vessels. On [**2103-6-19**] he then underwent stenting of the PDA via the SVG. He now presents for surgical evaluation for Aortic valve replacement. Past Medical History: aortic stenosis s/p redo sternotomy, aortic valve replacement this admission PMH: coronary artery disease, s/p CABG [**2090**] chronic atrial fibrillation non-insulin dependent diabetes mellitus hypertension hyperlipidemia Social History: The patient is a retired salesman and lives with his wife. [**Name (NI) **] has a distant smoking history. He drinks an occassional glass of wine, no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Physical Exam Pulse: 78 Resp: 18 B/P Left: 110/70 Height: 5'[**05**]" Weight: 195lbs General: WD/WN male, NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X], except left eye Neck: Supple [X] Full ROM [X], -JVD Chest: Lungs clear bilaterally [X], Healed midline scar from CABG Heart: RRR [X] Irregular [] Murmur[X] 2/6 SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Healed RLE from groin to anke Neuro: Grossly intact, A&O x 3 Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: none Left: none Pertinent Results: [**2103-8-17**] 01:45AM BLOOD WBC-8.9 RBC-2.83* Hgb-9.6* Hct-27.2* MCV-96 MCH-34.0* MCHC-35.4* RDW-13.3 Plt Ct-129* [**2103-8-17**] 01:45AM BLOOD PT-16.2* INR(PT)-1.4* [**2103-8-17**] 01:45AM BLOOD Glucose-132* UreaN-26* Creat-0.7 Na-136 K-4.2 Cl-104 HCO3-23 AnGap-13 [**2103-8-17**] 01:45AM BLOOD Mg-2.2 PRE-CPB:1. The left atrium is moderately dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. 2. A patent foramen ovale is present. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior hypokinesis. There is mild global left ventricular hypokinesis (LVEF = 40 %). Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). 4. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 5. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild to moderate ([**2-2**]+) mitral regurgitation is seen. 8. There is a moderate right pleural effusion. 9. There is a trivial/physiologic pericardial effusion. Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the results. POST-CPB: On infusions of epinephrine and phenylephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. Trivial AI. No paravalvular leak. Mitral regurgitation is 1+. TR is 1+. There is preserved biventricular systolic function on inotropic support. The aortic contour is normal post decannulation. The size of the left pleural effusion is significantly reduced. [**2103-8-27**] 05:00AM BLOOD WBC-11.0 RBC-3.07* Hgb-10.2* Hct-29.6* MCV-96 MCH-33.1* MCHC-34.4 RDW-13.5 Plt Ct-594* [**2103-8-27**] 05:00AM BLOOD PT-25.4* INR(PT)-2.4* [**2103-8-27**] 05:00AM BLOOD Glucose-52* UreaN-22* Creat-0.8 Na-136 K-4.7 Cl-100 HCO3-23 AnGap-18 Brief Hospital Course: Mr [**Known lastname 41819**] was admitted preoperatively for heparinization while off Coumadin. On [**8-14**] he was brought to the operating room for redo sternotomy and Aortic valve replacement with #25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Porcine valve. Cross clamp time=75 minutes.Cardiopulmonary Bypass time=107 minutes. Please see Dr[**Last Name (STitle) **] operative report for further details. He tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition on Epinephrine and Neosynephrine for optimal hemodynamic support. He was weaned from the ventilator and extubated on POD#1. Upon extubation he was found to be restless and somewhat agitated. This was initially felt to be from the narcotics he had received however these symptoms persisted. The neurology team was consulted and a head CT was done(A preliminary report read "No hemorrhage or large territorial infarct. Ill-defined low attenuation foci in the right frontal centrum semiovale/corona radiata white matter (2:25-28), may represent infarcts, age indeterminate). He was seen by Dr [**Last Name (STitle) 656**] who felt the patient did not have a new infarct. Over the next 48 hours his neurological exam improved dramatically, all lines and drains were discontinued in a timely fashion. Beta-blocker and diuresis was initiated. On POD3 he was transferrred to the stepdown floor for continued post-op care and recovery. Once on the floor he was noted to have a small amount of serous drainage from the inferior aspect of his sternal wound and was prophylactically started on Keflex. The remainder of his hospital course was essentially uneventful. Over the next several days he made slow but continuous progress in his physical activity and on POD #12 he was cleared for discharge by the cardiac surgery covering attendings, to home with VNA. All follow up appointments were advised. Medications on Admission: Digoxin 250 MCG 1 tablet daily Simvastatin 20 mg 1 tablet daily Warfarin 2.5 mg 1 tablet daily, 2 tablets on Sunday Lisinopril 10 mg daily Metoprolol 25 mg twice a day Plavix 75 mg daily Glyburide 5 mg twice a day Aspirin 325 mg daily Nitro Patch PRN Discharge Medications: 1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 1 weeks. Disp:*14 Tablet Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO Q AM. Disp:*60 Tablet(s)* Refills:*2* 5. Warfarin 1 mg Tablet Sig: adjust dose to target INR 2-2.5 Tablets PO DAILY (Daily): Pt to receive 2.5 mg on [**8-21**]. home regime preop was 2.5mg qd with 5mg on Sunday. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain/fever. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO three times a day. Disp:*45 Tablet(s)* Refills:*2* 14. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. 15. Glyburide 5 mg Tablet Sig: One (1) Tablet PO Q PM. Disp:*60 Tablet(s)* Refills:*2* 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: tbd Discharge Diagnosis: aortic stenosis s/p redo sternotomy, aortic valve replacement(25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine) PMH: coronary artery disease, s/p CABG [**2090**] chronic atrial fibrillation non-insulin dependent diabetes mellitus hypertension hyperlipidemia Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **keep a log of your blood sugars and present to your PCP [**Last Name (NamePattern4) **] 1 week visit** Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) **],[**First Name3 (LF) 198**] [**Telephone/Fax (1) 14525**] in 1 week, Please resume Coumadin/INR follow up with DR.[**Last Name (STitle) 7389**] Neurology -Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] -see in [**2-2**] weeks [**Telephone/Fax (1) 1694**] Please call for appointments Have INR drawn by VNA [**8-28**] with results to Dr. [**Last Name (STitle) 7389**] [**Telephone/Fax (1) 14525**] Completed by:[**2103-8-27**] ICD9 Codes: 4241, 4019, 2724, 412
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Medical Text: Unit No: [**Numeric Identifier 72195**] Admission Date: [**2190-4-24**] Discharge Date: [**2190-5-25**] Date of Birth: [**2190-4-24**] Sex: M Service: Neonatology IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 72196**] is a 31 day old former 29 and [**1-24**] week premature infant who is being transferred from the [**Hospital1 69**] Neonatal Intensive Care Unit to the special care nursery at [**Hospital 1474**] Hospital. HISTORY: Baby [**Name (NI) **] [**Known lastname 72196**] was born on [**2190-4-24**], as the 980 gram product of a 29 and [**1-24**] gestation pregnancy to a 23- year-old gravida I, para 0 to I mother with [**Name (NI) 37516**] of [**2190-7-9**]. Prenatal laboratory studies included blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative and group B strep unknown. Pregnancy was notable for 2 vessel cord noted on ultrasound with otherwise normal ultrasound findings and a normal quadruple screen. Pregnancy was complicated by preeclampsia treated with magnesium, as well as a course of betamethasone which was complete on [**2190-4-23**]. On the evening of delivery, mother experienced worsening blood pressures and then was noted to have a nonreassuring fetal heart tracing. This prompted a C-section delivery. Rupture of membranes was at delivery and there was no maternal fever or intrapartum antibiotic prophylaxis given. At delivery, the infant emerged with spontaneous cry requiring facial CPAP but otherwise routine care. Apgars were 8 and 8 and the infant was transferred to the NICU. SOCIAL HISTORY: Notable for mother having fetal alcohol syndrome, and currently living with her adoptive mother. Father of the infant is not involved in this infant's care. HOSPITAL COURSE: By systems: Respiratory: On admission, the infant was noted to have moderate respiratory distress due to hyalin membrane disease. He was intubated and placed on mechanical ventilation and treated with 2 doses of Surfactant. He was on conventional ventilation with settings up to PIP of 25, PEEP 5 and rate of 25 and then gradually weaned over the next 48 hours. He was extubated to CPAP by day of life 2 and subsequently weaned to room air on day of life 7. Since weaning from CPAP, he has required intermittent periods of nasal cannula support for spells or work of breathing. Respiratory status has gradually improved and the infant has been stable in room air since day of life 17. He was treated with caffeine for apnea of prematurity and this was discontinued on day of life 29. The infant was also noted to have nasal congestion and he was treated with several days of nose drops including phenylephrine, dexamethasone and prednisolone from day of life 14 through day of life 18 with improvement. He did complete 4 weeks of vitamin A treatment as well. By the time of discharge, the infant is breathing comfortably in room air with rare spells noted. Cardiovascular: The infant has been hemodynamically stable throughout hospitalization. A murmur was noted on day of life [**3-21**]; echocardiogram on day of life 4 revealed normal anatomy with a moderate patent ductus arteriosus with continuous left to right flow. A patent foramen ovale with left to right flow was noted as well. The infant was begun on a course of indomethacin with resolution of the murmur. No further evidence of a PDA has been noted and no further imaging studies have been performed. Fluid, electrolytes and nutrition: The infant was initially maintained n.p.o. and was given parenteral nutrition. A umbilical venous catheter was placed for the first week of life at which point a PICC line was placed and the umbilical venous catheter was removed. Enteral feedings were begun on day of life 9 following treatment for the PDA with Indocin. Enteral feeds were then advanced without difficulty reaching full volume feedings by day of life 18. PICC line was removed on day of life 19. Caloric density was gradually increased to a maximum of 150 cc/kg/day of 28 calorie breast milk with additional beta protein. At the time of discharge, the infant continues on 150 cc/kg/day of breast milk supplemented to 28 calories with additional beta protein. Feeding is given via gavage with occasional breast feeding attempts. Electrolytes were normal throughout admission. The infant was noted to have hypoglycemia on admission to the NICU but this resolved with initiation of IV fluid and blood sugars have been normal since that time. Electrolytes on day of life 16 included a sodium of 136, potassium of 4.6, chloride of 107 and bicarbonate of 22. Our plan was to check a set of electrolytes along with nutritional laboratory studies of calcium, phosphorus and alkaline phosphatase on day of life 34. The infant has maintained normal urine and stool output throughout. Of note, gavage feedings are given over 1 hour due to a history of small spits; no recent significant spits have been noted. The infant is being treated with vitamin E supplementation. GI: The infant did develop hyperbilirubinemia requiring phototherapy. Peak bilirubin was 6.1 on day of life 3. The infant received phototherapy for approximately 3 days with resolution of hyperbilirubinemia. Heme: Initial hematocrit was 50.8. The infant was begun on iron supplementation following full enteral feedings. Last hematocrit was measured on day of life 17 and this was 40. Of note, initial CBC at the time of delivery revealed a white count of 4.0, with 20% polys, consistent with mild neutropenia. A repeat CBC on day of life 2 showed a white cell count of 5.5 with 40% polys, within normal range. ID: CBC and blood culture were sent on admission. The infant was treated with 48 hours of ampicillin and gentamicin that were then discontinued with negative blood cultures and benign clinical course. The infant did receive 48 hours of oxacillin and gentamicin from day of life 17 to 19 for some mild umbilical erythema for concerns of possible omphalitis. Blood cx was negative and symptoms resolved, and course was not thought consistent with omphalitis. Neurology: The infant has maintained a normal neurologic examination throughout admission. Head ultrasound on day of life 6 and again on day of life 31 was normal. Initial eye exam was performed on day of life 24 and this revealed immature retina in zone 2 bilaterally with follow up recommended in 2 weeks; this would be approximately [**2190-6-1**]. CONDITION ON DISCHARGE: The infant is breathing comfortably in room air with occasional spells. The infant is receiving full volume feedings of 150 cc/kg/day of breast milk supplemented to 28 calories per ounce with additional beta proteins given PG with occasional breast feeding. The infant is being treated with iron and vitamin E. The infant is maintaining stable temperatures in isolette. DISCHARGE DISPOSITION: The infant is being transferred to [**Hospital 1474**] Hospital. PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) **], M.D. in [**Location (un) 1475**]. RHCM: Newborn screens were sent on [**4-27**], and [**5-9**]. First hepatitis B vaccine was given on [**2190-5-24**]. PHYSICAL EXAMINATION: At discharge, weight is 1575 grams. Vital signs are stable in room air. The infant is a small premature infant who is active at exam. Fontanelles are soft and flat. Ears and nares are normal. Palate is intact. Red reflex is present bilaterally. Neck is supple. Chest is clear to auscultation without grunting, flaring or retractions. Cardiac is regular rate and rhythm without murmur. Abdomen is soft with active bowel sounds without hepatosplenomegaly. GU: Normal premature male with testes descended bilaterally. No hernias are palpated. Anus is patent. Femoral pulses are 2+ and symmetric. Hips and back are normal. Extremities are warm and well perfused without lesions. Tone and activity are appropriate. DISCHARGE DIAGNOSES: 1. Prematurity at 29 and 1/7 weeks. 2. Borderline growth restriction with weight percentile of 15th percent. 3. Respiratory distress syndrome. 4. Patent ductus arteriosus. 5. Hyperbilirubinemia. 6. Sepsis evaluation. 7. Apnea of prematurity. 8. Two vessel umbilical cord. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2190-5-25**] 13:20:54 T: [**2190-5-25**] 16:39:16 Job#: [**Job Number 72197**] ICD9 Codes: 769, 7742, V290, V053
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Medical Text: Admission Date: [**2183-10-15**] Discharge Date: [**2183-10-18**] Service: MEDICINE Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 297**] Chief Complaint: Cc:[**CC Contact Info 108953**] Major Surgical or Invasive Procedure: ORIF History of Present Illness: . HPI: 83M with PMH significant for CAD s/p CABG in [**2169**], MVR in [**2178**], CHF, and COPD, presents to the ED after experiencing R hip pain following a fall. He states that he was bending over, and became dizzy with blurred visual after standing up abruptly. He fell on his side. He denies LOC or head trauma. Films taken at his rehab ([**Hospital3 **]) demonstrated R femoral neck fracture, and he was sent to [**Hospital1 **] ED. Of note, CXR at rehab on [**2183-10-10**] suggested evidence of RLL and LUL infiltrate, and was started on Levofloxacin 500mg PO qD x 10 days. . In the ED, initial VS were BP 134/69, HR 71, RR 18, SaO2 95% 2L NC. Hip films confirmed R femoral neck fracture. Initial labs significant for INR 5.4, on coumadin. CT head showed no evidence of hemorrhage. He was seen by orthopedic surgery, who recommended admission to medicine service for medical optimization prior to likely ORIF surgery [**10-16**]. Mr. [**Known lastname **] also complained of mild flank pain. A UA was ordered once he reached the floor. Past Medical History: . PMH: CAD: s/p CABG [**2169**] s/p MVR [**2178**] s/p PPM, placed [**2178**] at time of valve surgery, V-paced CHF - EF 40% on [**2178**] TTE Pulmonary HTN by [**2178**] cath Tracheomalacia following prolonged intubation Restrictive lung disease with PFTs c/w neuromuscular disease, possibly [**3-6**] diaphragmatic damage from previous cardiac surgeries h/o Endocarditis h/o colon CA [**92**] yrs ago, resected BPH h/o GIB Social History: SOCIAL HISTORY: The patient denies history of intravenous drug use or ethanol use. He has greater than 33 pack year history of tobacco use, discontinued [**2178**]. His wife recently died. His daughter died emphysema secondary to alpha I antitrypsin deficiency. The patient retired five years ago as a [**Hospital **]medical Engineer. . Family History: FAMILY HISTORY: Father died of an MI at age 82, mother died of cancer at age 69. He is a carrier of alpha I antitrypsin gene. . Physical Exam: . PE: TL 97.1F BP: 135/60, HR: 79, RR: 30, SaO2: 90% 2L (prior to neb treatment). Gen: Ill appearing gentleman, lying in bed, NAD HEENT: PERRL, sclerae anicteric, OP clear Neck: Supple, no LAD, previous orifice from trach visible CV: RRR, II/VI SEM LUSB, mech valve click, +S3 Chest: Crackles R base, no w/r Abd: Soft, NT/ND, +BS Extr: R leg externally rotated, 2+ DPs bilaterally Neuro: A&Ox3 Pertinent Results: ECG [**2183-10-15**]: V-paced at 84bpm [**2183-10-18**]: Atrial fibrillation. Right axis deviation. Compared to the previous tracing of [**2183-10-15**] there is deep T wave inversion in leads II, III, aVF and V3-V6 consistent with active ischemic process. Rule out infarction. Clinical correlation is suggested. . Imaging: CXR [**2183-10-15**]: Cardiomegaly, s/p CABG and MVR, dual-lead PPM. Elevation of right hemidiaphragm with volume loss and interstitial opacities c/w CHF. Also focal opactiy over R lung zone and fluid in fissure, could be c/w PNA. Small effusions, no PTX. . Head CT [**2183-10-15**]: FINDINGS: There is no evidence of intra- or extra-axial hemorrhage. The ventricles, cisterns and sulci are mildly prominent, consistent with age-related involutional changes. Multiple patchy areas of hypodensity in the white matter consistent with chronic small vessel ischemic disease, and include hypodensity which is more prominent, but unchanged within the left subinsular cortex. A bony protuberance about the ossicle may represent an osteoma which is unchanged or merely a congenital variant. IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Evidence of age related involutional changes and white matter disease, unchanged. . Hip films: There is a comminuted right femoral neck fracture. Subtle angulation is present. No other fracture is identified. IMPRESSION: Right femur fracture. . [**3-9**] PFTs: FVC 1.98L (51% predicted) FEV1 1.25L (51% predicted) FEV1/FVC: 63% (100% predicted) . [**1-2**] TTE: EF 40%. The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed secondary to severe inferior and posterior hypokinesis and mild hypokinesis of the rest of the left ventricle; the ejection fraction is approximately 40 percent. There is moderate global right ventricular free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is no significant aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . [**7-3**] Cath: (prior to MVR) 1. Coronary angiography in this right dominant system revealed three vessel CAD. The left main coronary artery had a 40% distal stenosis. The LAD had an 80% mid-vessel stenosis, and there was competitive flow from the LIMA in the distal LAD. The ramus intermedius branch had a 40% proximal stenosis. The left circumflex artery was totally occluded proximally. The RCA had a diffusely diseased proximal segment and was totally occluded after the first acute marginal branch. 2. Graft arteriography revealed a patent LIMA to the LAD. The SVG to the rPDA was widely patent, and the rPDA distal to the anastamosis had a 70% stenosis. The SVG to the obtuse marginal branch was ectatic but without significant stenosis and the marginal branch distal to the anastamosis supplied collaterals to the right postero-lateral branch. 3. Resting hemodynamic measurements revealed severe pulmonary hypertension witha PA systolic pressure of 92 mmHg. There was increased right and left sided filling pressures with a mean RA pressure of 16 mmHg, a mean PCWP of 28 mmHg and an LVEDP of 22 mmHg. The cardiac index was preserved at 2.3 L/min/m2. 4. Left ventriculography revealed global hypokinesis with posterobasal wall akinesis and moderate-to-severe (3+) mitral regurgitation. The calculated LVEF was 45%. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA and SVGs. 3. Moderate-to-severe (3+) mitral regurgitation. 4. Mild systolic ventricular dysfunction. 5. Severe pulmonary hypertension [**2183-10-15**] 06:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2183-10-15**] 06:05AM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-2.3 [**2183-10-15**] 06:05AM WBC-5.4 RBC-3.18* HGB-10.2* HCT-30.2* MCV-95 MCH-32.2* MCHC-33.9 RDW-16.7* [**2183-10-15**] 06:05AM PT-43.8* PTT-37.1* INR(PT)-5.0* [**2183-10-15**] 01:30AM GLUCOSE-90 UREA N-28* CREAT-1.1 SODIUM-138 POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-35* ANION GAP-12 [**2183-10-15**] 01:30AM CK(CPK)-39 [**2183-10-15**] 01:30AM cTropnT-0.02* [**2183-10-15**] 01:30AM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.2 [**2183-10-15**] 01:30AM WBC-6.3# RBC-3.33* HGB-10.7* HCT-31.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-16.5* [**2183-10-15**] 01:30AM PT-46.7* PTT-37.4* INR(PT)-5.4* Brief Hospital Course: Pt. was admitted for optimization of medical status prior to operation for hip fx. stable until early [**10-17**] around 12:oo am when began desatting to the high 80s on 2L NC. Vital signs o/w at the time: T 97.3 BPs 90s-100s/30s-60s, HR 60s-70s, rr in the high 20s. Pt was also noted to be increasingly somnolent and unresponsive. Pt placed on 100% FM with improvement of sats. He had been given MS contin 45 mg at 11 am the day prior and was therefore given narcan 0.2 mg X1 and narcan 0.4 mg X1 several hours later. He was given lasix 10 mg IV X3 o/n. Mental status improved somewhat with the early dose of narcan. CXR checked at the onset of the pt's change in status demonstrated worsened bibasilar pna. ABG trend o/n was as follows: 12:20 am 7.33/68/70 4:00 am 7.23/90/65 6:00 am 7.27/79/60 At time of MICU eval ABG was checked and demonstrated 7.05/139/125. Given worsening respiratory status pt transferred to the unit. Code status confirmed with family to be DNR/DNI. HCP felt that [**Name (NI) 108954**] would be an in-line with the pt's wishes. Pt. EKG showed new Afib with ST changes worrisome for ischemia and trop leak without elevation of CK in context of rapidly progressive ARF. He was given trial of [**Name (NI) 108954**] overnight without much improvement of MS. In discussion with pt.'s family, it was decided to choose comfort care interventions. He was placed on morphine drip and passed [**10-18**] with family around Medications on Admission: Meds: Lopressor 25mg PO bid Prilosec 20mg PO qD Coumadin 3mg 5d/wk, 2mg 2d/wk Azmacort 2 puffs tid levaquin ([**10-19**] last dose - ?pnemonia) lasix 10mg PO qD lisinopril 5mg PO qD Albuterol neb [**Hospital1 **] Atrovent neb [**Hospital1 **] Combivent 2 puffs qid wellbutrin XL 150mg PO qD Dulcolax 10mg PR prn Remeron 7.5mg PO qHS . Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: hypercarbic respiratory failure CAD: s/p CABG [**2169**] Atrial fibrillation Acute Renal Failure Hip fracture CHF PNA Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none ICD9 Codes: 486, 0389, 4280, 5070, 5849
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Medical Text: Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-30**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve / Codeine / Depakote Attending:[**First Name3 (LF) 613**] Chief Complaint: hypotension after hemodialysis Major Surgical or Invasive Procedure: R IJ central line placement Hemodialysis History of Present Illness: Chief Complaint: Hypotension . History of Present Illness: 72F with a history of type II DM, ESRD on HD, GAVE, HTN, MR, CAD, CHF w/ RV failure and seizure disorder with recent hospitalization from [**5-5**] to [**6-3**] with culture negative sepsis with MS change and c.diff colitis, who presents to the ED on [**6-4**] for HD. Pt was discharged on [**6-3**] and was due for her HD today per her MWF schedule. She was sent from rehab to the [**Hospital1 18**] ED for HD due to her current diarrhea from c.diff colitis and concerns about her volume status. She was seen in the ED then sent for HD with 2.5 fluid removed. Prior to HD, in ED BP 131/76 RR 16 92% 4L. . Following her ultrafiltration, she returned to the ED for likely discharge back to rehab. However, both during HD and on return to the ED, she was noted to be hypotensive, to as low as SBP 60s. She received 2 L total IVF in ED with minimal response. She had a RIJ placed for access. Her BP has since been labile and she has had BP to 67/42 with HR 89 at time of transfer to the floor. The only laboratory sent at the time of admission to floor were CBC and chem 10. . Allergies: Aspirin / Aleve / Codeine / Depakote Past Medical History: * Chronic Gastric Angiodysplasia (GAVE)and consequent chronic low-grade UGIB, and has therefore been advised not to take aspirin or other antiplatelet agents. * DM type II: c/b nephropathy and neuropathy - currently not on diabetic meds, has hypoglyemia [**12-27**] poor nutritional stores * ESRD: HD MWF has fistula L arm * CAD * CHF, R-sided, diastolic EF 50-55% with 4+ TR 2+ MR [**8-/2155**] TTE * Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB) * colon polyps (hyperplastic) [**7-/2153**] colonoscopy * gastritis and duodenitis [**7-/2153**] EGD * gout * pleural effusion s/p thoracentesis [**8-/2153**] negative cytology, . Social History: Pt lives at [**Location **]. No ETOH, tobacco, or drugs. Pt has four children, all involved in her care. There were several family meetings during this admission with all her children. They are very supportive and close family. No health care proxy is assigned at this time ([**2156-5-31**]). She is aware that she needs to choose one. . Family History: [**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother had an MI in her 80s. Physical Exam: VS: T: 95 BP: 78/48 HR: 112 RR: 16 Gen: Elderly woman in apparent distress, intermittently responsive and awake, at times combative and agitated HEENT: NCAT. Mucous membranes slightly dry Neck: Supple, no JVD, RIJ dressing c/d/i CV: RRR normal s1 s2 Chest: Poor air movement Abd: Soft, NT/ND. No HSM or tenderness. +BS, umbilical hernia Pertinent Results: [**2156-6-3**] 05:13AM BLOOD WBC-5.6 RBC-2.63* Hgb-9.5* Hct-30.8* MCV-117* MCH-36.3* MCHC-30.9* RDW-25.9* Plt Ct-76* [**2156-6-24**] 04:16AM BLOOD WBC-6.4 RBC-2.35* Hgb-8.5* Hct-27.3* MCV-116* MCH-36.3* MCHC-31.3 RDW-20.3* Plt Ct-129* [**2156-6-30**] 07:18AM BLOOD WBC-6.1 RBC-2.53* Hgb-8.9* Hct-28.3* MCV-112* MCH-35.3* MCHC-31.5 RDW-18.8* Plt Ct-142* . [**2156-6-3**] 05:13AM BLOOD Glucose-70 UreaN-10 Creat-2.6* Na-141 K-3.9 Cl-102 HCO3-30 AnGap-13 [**2156-6-24**] 04:16AM BLOOD Glucose-161* UreaN-8 Creat-2.2* Na-133 K-3.6 Cl-97 HCO3-30 AnGap-10 [**2156-6-30**] 07:18AM BLOOD Glucose-85 UreaN-11 Creat-3.0* Na-133 K-3.6 Cl-95* HCO3-27 AnGap-15 . [**2156-6-5**] 02:25AM BLOOD ALT-16 AST-32 AlkPhos-147* Amylase-59 TotBili-2.5* [**2156-6-6**] 05:31AM BLOOD ALT-19 AST-44* LD(LDH)-439* AlkPhos-133* TotBili-2.4* [**2156-6-21**] 05:58AM BLOOD ALT-12 AST-29 LD(LDH)-309* TotBili-6.1* DirBili-4.5* IndBili-1.6 . [**2156-6-28**] 06:13AM BLOOD ALT-19 AST-50* AlkPhos-189* TotBili-9.6* . [**2156-6-5**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2156-6-5**] 11:49PM BLOOD CK-MB-NotDone cTropnT-0.18* [**2156-6-6**] 09:06PM BLOOD CK-MB-NotDone cTropnT-0.18* . [**2156-6-16**] 05:11AM BLOOD Ammonia-69* [**2156-6-17**] 05:05AM BLOOD Ammonia-52* [**2156-6-21**] 04:03PM BLOOD Ammonia-16 [**2156-6-23**] 06:12AM BLOOD Ammonia-53* [**2156-6-14**] 04:22AM BLOOD Digoxin-0.9 [**2156-6-15**] 06:53AM BLOOD Digoxin-1.8 . Imaging: Echo - The left atrium is elongated. The right atrium is moderately dilated. A secundum type atrial septal defect is present. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CT abdomen and pelvis - CT OF THE ABDOMEN WITHOUT CONTRAST: There is a moderate-to-large left effusion, simple in attenuation, increased in volume from the prior study. There is a small right pleural effusion, also increased since the prior exam. There is bilateral lower lobe atelectasis versus consolidation. There are coronary artery calcifications and calcifications of the aortic valve. The non-contrast appearance of the liver, gallbladder, spleen, pancreas and adrenal glands is unremarkable. The known enlarged common bile duct is not well assessed on this examination. The kidneys are atrophic. There is no hydronephrosis. A moderate amount of ascites is again seen. There is no free intra-abdominal air. There is circumferential wall thickening of the colon, most marked from the cecum through the hepatic flexure. The transverse, descending, and sigmoid colon is not well distended though it may be thickened to a lesser degree. Small bowel loops are normal in caliber and appearance, without evidence of obstruction. The abdominal aorta is normal in caliber, with atherosclerotic calcifications. Patency of the mesenteric vessels cannot be assessed without IV contrast; no air is seen within them. There is no mesenteric or retroperitoneal lymphadenopathy. There is extensive subcutaneous edema bilaterally, similar to that seen on the prior study. A 2.4 x 1.3 cm nodule is seen in the subcutaneous fat of the left lower abdomen, possibly related to an injection. CT OF THE PELVIS WITHOUT CONTRAST: Oral contrast reaches the rectum, which is normal in appearance. There are calcifications of the uterine vessels. The bladder is likely collapsed and not well assessed. There is a moderate-to- large amount of free pelvic fluid, slightly increased from the prior exam. No enlarged pelvic or inguinal nodes are seen. Again extensive subcutaneous edema is appreciated. No suspicious osseous lesions are detected. Multiplanar reformatted images were essential in delineating the anatomy and pathology in this case. IMPRESSION: 1. Interim development of circumferential wall thickening of the colon, most pronounced in the cecum through the hepatic flexure. The remainder of the colon is likely thickened to a lesser degree. While infectious/inflammatory colitis such as C. Diff remain in the differential, ischemic colitis is of concern, given the vascular distribution of the findings (right sided predominance and elevated lactate) . The patency of the mesenteric vessels was not assessed on this non- contrast exam. No free air, portal venous gas or obstruction. 2. Extensive third spacing of fluid including subcutaneous fluid, pleural effusions and ascites. 3. Known enlargement of the common bile duct is not well assessed on this study. Followup imaging was advised on the prior exam. 4. Atrophic kidneys. 5. Moderate-to-severe atherosclerotic calcification of the abdominal vasculature. 6. Nodule of the subcutaneous fat of the left lower abdomen. This could be related to injections. Attention on followup studies will be helpful. Brief Hospital Course: 71 yo F with DM, ESRD on HD, GAVE, HTN, CHF w/ RV failure, c.diff colitis and persistent diarrhea admitted for hypotension, also noted to be persistently hypoglycemic. Was in the unit on pressors, then was able to be weaned off. Waxing and [**Doctor Last Name 688**] encephalopathy while on floor, contributing to hypoglycemia and aggitation. . # Hypotension: Coagulopathy, thrombocytopenia, hypothermia and hypotension was concerning for sepsis. Her BP was not responsive currently to IVF, she received total of 1.5 L in ED and 1 L on floor, she was started on neo (did not tolerate levophed) and started on broad spectrum antibiotics including vancomycin IV and cefepime IV as well as vancomycin po and flagyl iv for her c.diff. There was also likely component of hypovolemia in setting of diarrhea and poor POs. She as weaned off of neo, but continue to have intermittent low blood pressures to the high 80's and 90's. This is likely secondary to her c.diff infection. She was mentating at her baseline throughout these hypotensive periods. She received her usual dialysis, but did not tolerate much fluid removal. She was eventually weaned off of her pressors. For several dialysis sessions, she was unable to have a high enough BP for adequate fluid removal, but BPs started to improve and patient was tolerated dialysis with approx 2-3L removal per session. When transferred to the floor, patient had moderately low BPs while she was in aflutter/afib. Patient evenutally converted with HRs in 80-100s and BPs improved. Likely due to improved heart function with slower rhythm. BPs on discharge in 120s and stable. . # Atial tachycardia: Intermittent bursts of atrial tachycardia - afib vs. aflutter. HRs in 120s-140s during these epsisodes. Low BPs but had normal perfusion. Electrophysiologists were consulted and started 4 week amiodarone load with 400 mg daily. Then will start 200 mg amiodarone daily indefinitely. Also on digoxin 0.125 mg every other day. Pt was not on beta blocker during this time because blood pressure were unable to tolerate. While on floor, after approx 1-1.5 weeks of amio load, patient's aflutter/fib resolved. Was in NSR and telemetry was discontinued. She was noted to have several runs of asymptomatic NSVT to about 10 beats while on telemetry. Will continue amio 400 mg until [**7-10**], then switch to 200 mg daily. . # Encephalopathy - likely related to toxic metabolite buildup, probably hepatic failure is biggest contributor. Would wax and wane between confusion and lucidness. Would treat aggitation with SL zyprexa. Avoided sedating meds. Pt was refusing narcotics for pain control because she could feel herself not thinking clearly. Upon discharge, patient has appropriate mental status for several days and was able to understand her situation. Likely has depression contributing at some level, too. Often is sad and crying in the morning when family is not around. . # Hypoglycemia: Pt has history of diabetes, but is no longer on any diabetic meds because of these low blood sugars. Is likely due to poor nutritional stores in setting of hepatic failure with poor gluconeogenesis. Endocrinology was consulted during previous admission and did not feel insulinoma was a possibility. C peptide was likely only elevated because it is renally cleared. Pt FS was as low as 15 while in the MICU. Pt was able to resume her diet and then have appropriate blood sugars. She does need encouragement to keep appropriate PO intake. While on the general medicine floor, had a period ofo altered mental status in which she was too somnolent to eat, and to maintain sugars, we had her on a d10W gtt at 500cc/hr for about 3 days. She became hyponatremic at that time. Her mental status improved, we were able to stop the drip and keep her on her normal PO diet and her sugars did much better. Her hyponatremia also resolved. We started her on scheduled glucose tabs, but she does not take them regularly because she does not like the taste. . # ESRD/HD: On HD MWF. Needs to continue this schedule as an outpatient. . # Thrombocytopenia/coagulopathy: Initially ther was concern for DIC. She was given vitamin k initially, however her coagulopathy is likely [**12-27**] to her hepatopathy [**12-27**] to right heart failure. Her coags were followed as well as monitoring for signs of bleeding. No further intervention was necessary. Her INR is high at 2.5. She does not have any active signs of bleeding and has stable anemia with a hemoglobin between 8 and 9. . # Hyperbilirubinimia: Thought to be associated with congestive hepatopathy from RV hypokinesis. We monitored her liver functions were showed increasing bilirubin. She became more jaundiced throughout her stay. Her belly exam remained intermittently tight and distended, worsening at time, but improves often after dialysis. She is asymptomatic. We discussed possibly doing a therapeutic paracentesis, but with her his risk and lack of symptoms, we decided against it. . # Peripheral Vascular Disease - the patient developed what appears to be arterial ulcers on her Bilateral big toes. They do not seem infected, but she has symptoms of pain in her heels, occassionally her hands. We did ultrasounds studies of her ABIs which were 0.4 and 0.6 in R and L respectively. We tried to control her pain with oxycodone, but patient refusing narcotic meds. Tylenol up to 2 gms daily can be used for symptom relief. . # C.diff - was admitted with a c.diff infection. Was treated with appropriate course of PO vanco and PO flagyl. Diarrhea is now only mild and not voluminous like it previously had been. Does not need any more treatment on discharge. . # Hx of siezures - on prior admission, had a seizure while hypotensive and in the MICU. Is now on keppra for siezure prophylaxis. Will continue keppra as outpatient. She has an appointment with neurology is late [**Month (only) 216**] in which they may cchoose to discontinue this med. . # Pleural effusions - patient has a stable pleural effusion, unknown etiology. A thoracentesis was attempted previously, but unsuccessful. There has been a question of possible lymphoma seen on prior imaging studies, but no diagnosis has been made. Her breathing is stable on room air and she is not dyspneic on the mild exertion she is able to do. . # Deconditioning - has been in and out of the hosptial since about [**Month (only) 956**], does not get out of bed much. Needs extensive PT work to improve her strength. . # Code - patient is now DNR/DNI as CPR is not medically indicated in her case. Palliative care knows the patient and the family well. There were many family meetings during the time of her care about the patient's poor prognosis. . # Contact: son [**Name (NI) **], [**Telephone/Fax (1) 13227**] Medications on Admission: Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as needed. Omeprazole 40 mg Capsule PO DAILY Metronidazole 500 mg PO TID for 10 days from [**6-3**] Keppra 100 mg/mL 250 mg PO BID Ergocalciferol (Vitamin D2) 50,000 unit PO 2X/WEEK (MO,TH) for 2 months Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day: Start after 2 months of 50,000u twice weekly is completed. Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 10 days: Please finish taking amiodarone 400 mg daily until [**7-10**]. Then start taking 200 mg daily. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: Do not exceed 2 grams daily. 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 7. Dextrose (Diabetic Use) 300 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: PLEASE DO NOT START THIS DOSAGE UNTIL [**7-11**]. Thanks. Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Discharge Diagnosis: Primary diagnosis: 1. Hypotension 2. C. diff 3. Altered mental status secondary to multiorgan failure 4. ESRD on HD 5. Liver dysfunction 6. Right heart failure 7. Peripheral Vascular disease 8. Hypoglycemia Discharge Condition: vitals signs stable, SBPs in 110s-120s, HR 80s-90s. Afebrile. Somewhat delerious, but waxing and [**Doctor Last Name 688**]. Continues to have mild diarrhea 2-4x a day. Able to get from bed to chair with assistance. Tolerating ground solids. Discharge Instructions: You were admitted for low blood pressures after a dialysis session. You were in the MICU for several days on a vasopressor medicine that kept your blood pressure at a high level. We had a difficult time removing fluids from your body during dialysis while you had this low blood pressure. . Eventually we were able to wean you off the vasopressors. You were treated for a possible infection with strong antibiotics. None of the cultures came back, so we do not know if there was an infection causing you to have these low pressures. . These pressures also affected your mental status. Some days you were very delerious from having low pressures and having toxic metabolic buildup in your blood from your multiorgan failure. We monitored your electrolytes and liver function tests. You started to improve over time but still have some good days and bad days. . You had a bowel infection called c.diff this whole time. It causes chronic diarrhea. We treated you with anitbiotics called vanco and flagyl, both of which are taken by mouth. You stopped taking these medicines on [**6-24**]. . You also had heart problems during this hospitalization. For a while, you were in a rhythm called atrial flutter. It caused your heart rate to go very high, which is unsafe for your body. We were able to start controlling it with medicines called digoxin and amiodarone. The electrophysiologists helped us choose and then further manage these medicines. . You also had some problems keeping you blood sugars high enough, especially on days when you were confused and not eating well. We treated you with IV fluids that had sugar in them. You did well and when your mental status improved, we were able to take that off. You should continue to try and eat as much as possible several times a day to help your nutrition and blood sugars. . You continued dialysis MWFs while an inpatient. . You will be discharged to a rehabilitation facility to start working on your strength. You will need to continue dialysis. You should come back to the hospital for any chest pain, shortness of breath, dizziness, fainting, or other concerns. Followup Instructions: Neurology: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2156-7-19**] 4:30 . PCP: [**Name10 (NameIs) 357**] call [**Known firstname 2048**] [**Last Name (NamePattern1) 4223**] at [**Telephone/Fax (1) 7976**] to make an appointment as needed once at rehabilitation. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2156-6-30**] ICD9 Codes: 0389, 5856, 4240, 2749, 4280, 3572, 2875
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Medical Text: Admission Date: [**2140-2-22**] Discharge Date: [**2140-2-24**] Date of Birth: [**2066-3-12**] Sex: M Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 6075**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: Endotracheal intubation radial arterial line intra-arterial MERCI clot retrieval History of Present Illness: Pt. is a 73 y/o w/ a hx of prior TIA and HTN who was brought to [**Hospital3 **] by EMS for acute onset of unresponsiveness this afternoon, found to have bithalamic infarct on MRI. History is per daughter and wife (daughter interprets for wife, who does not speak English) They report that at 3:30 he was well, and was taking care of his baby granddaughter. At 4:00 his wife heard him grunt and came into the room to check on him. She found him sitting on the couch. His left eye was rolling up, and his right eye was staring forwards and wide open. His neck seemed stiff. His left hand was rubbing his belly, and he was kicking his left leg irregularly. His right hand was curled into his body and stiff, and he was not moving his right leg. He seemed to be grunting and trying to speak, but could not produce any words. He was drooling and both sides of his face seemed to be drooping. He did initially seem to understand his wife, because she went to get an emergency chinese herbal rememdy, and he stuck out his tongue when she asked. She called his daughter, who called EMS. EMS arrived around 4:15. He was transferred to [**Hospital3 **]. On exam there he is described as snoring and unresponsive. His pupils were 5 mm and minimally reactive. He had decorticate posturing, and his toes were upgoing bilaterally. Past Medical History: Hypertension CAD TIA 6 years ago in [**Country 651**], treated with an "IV medicine," no residual Social History: lives with wife, daughter, and son in law, emigrated from [**Name (NI) 651**] last [**Month (only) **], no tobacco, rare EtOH Family History: wife thinks his mother may have had a stroke Physical Exam: T- 97.5 BP- 168/85 HR- 71 RR- 18 O2Sat- 100% on RA Gen: Lying in bed, intubated HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: intubated, sedated, does not respond to voice or sternal rub Cranial Nerves: pupils 7 mm, non-reactive. No EOM with Dolls (horizontal or vertical) No gag with manipulation of ETT, minimal gag with deep suction. No corneals R or L. Motor: Normal bulk bilaterally. Tone flaccid in bilat UE. Trace decerebrate posturing in both arms, triple flexion in both legs with pain. Sensation: no response to pain in any extremity Reflexes: Trace throughout. Toes upgoing bilaterally Coordination: not assessed Gait: not assessed Pertinent Results: Labs: OSH labs: Na 137 K 3.8 Cl 103 HCO3 23 BUN 17 Cr 0.6 Gluc 146 INR 1.0 PT 11.7 Hct 44.8 Plt 155 WBC 3.0 Hgb 15.6 Imaging CTA head and neck: Tip of basilar artery does not opacify consistent with occlusion. The PCAs do opacify however, probably from collaterals given no PCOMs identified. Dominant left vert. Hypodensity of bilateral thalamus possible acute infarcts. No ICH. Old right parietal infarct with ex vacuo dilataton of right occipital [**Doctor Last Name 534**]. old infarct of genu of left internal capsule. Paranasal sinus disease. CT HEAD W/O CONTRAST [**2140-2-23**] 12:26 AM FINDINGS: New hyperdensity is noted throughout the basilar cisterns and layering within the bilateral sylvian fissures. Discrete foci of relatively greater hyperdensity are noted within the interpeduncular cistern and right quadrigeminal cistern which measures 6 and 16 mm in size, respectively. The lateral ventricles have slightly increased in size compared to the prior study at 21:13. There is no shift of midline structures. The cerebral sulci are slightly less well defined. Redemonstrated is the area of old right frontoparietal infarction and ex vacuo dilatation of the occipital [**Doctor Last Name 534**] of the right lateral ventricle. An old small lacunar infarct near the genu of the left internal capsule is again seen. Subtle thalamic hypodensity seen on the prior study is less apparent. There are small fluid levels in the sphenoid sinus air cells. Maxillary sinus mucosal thickening is worse on the right. There is mucosal thickening of the ethmoid air cells. Mastoid air cells remain clear. IMPRESSION: 1. Extravasated contrast and hemorrhage within the subarachnoid space as described. 2. Slight increase in size of the lateral ventricles. 3. Old right frontoparietal infarction. 4. Old lacunar infarct of the genu of the left internal capsule. 5. Possible acute infarct of the thalamus. 6. Paranasal sinus disease as described. Brief Hospital Course: Pt is a 73 w/ a hx of prior TIA and HTN who was brought to [**Hospital1 **] by EMS for acute onset of unresponsiveness this afternoon, found to have bithalamic infarct on MRI. On exam his pupils are 7 mm and unreactive, he has no corneals and a very weak cough with deep suction, and no EOM with Dolls. He has decerebrate posturing in his arms and triple flexion in his legs with pain. His exam is consistent with a top of the basilar syndrome, which is indeed confirmed on CTA here and MRI at [**Hospital3 **]. 1) Top of the basilar artery infarction- He was out of the window for IVtPA at presentation. The patient had bilateral thalamic infarctions at presentation with evidence for lethal injury without emergent intervention. Neurosurgery was cosulted re: the possibility of angiogram and possible clot retreival. He was immediately taken to the interventional neuroradiology suite where MERCI clot retrieval device was used with successful opening of basilar artery, complicated by rupture of the left PCA. The patient had a large subarachnoid hemorrhage. The patient had minimal brainstem reflexes following, and within hours no longer had a gag reflex or any other spontaneous movements. He had fluctuating hyperthermia followed by hypothermia suggestive of hypothalamic injury. A formal braindeath examination was performed on HD #2 and the patient met all clinical criteria for brain death including apnea test. The family wanted family members to arrive from other countries prior to withdrawal of care. The patient expired shortly after extubation. Medications on Admission: Herbal remedy for HTN ASA 81 mg QD Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA ICD9 Codes: 4019
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Medical Text: Admission Date: [**2184-6-20**] Discharge Date: [**2184-6-25**] Date of Birth: [**2107-8-16**] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: sob Major Surgical or Invasive Procedure: none History of Present Illness: 76yo M with h/o nonsmall cell lung cancer, metastatic to chest wall, spinal cord, and brain p/w 2d h/o SOB, fever, and vough productive of yellow sputum. Pt. is s/p a recent right frontal craniotomy and resection of metastatic tumor ([**5-19**]). He is currently on taxotere chemotherapy, most recent dose on [**6-17**]. The patient says that he has been recovering well since the surgery. Over the last two days, he developed the above symptoms, plus intermittent chills. No N/V/CP/dysuria/no abd pain, no headache, no neck pain, no change in mental status. Upon arrival to ED patient was noted to be hypoxic with an O2 sat of 86% on r/a, up to 97% on non rebreather mask. He was febrile to 101.4 and tachycardic with a heart rate of 122. A chest X-ray revealed a persistent opacities in the RUL and RLL (the pt. is s/p XRT to RUL). The RLL infiltrate was noted to be suspicious for pneumonia. Past Medical History: 1) Nonsmall cell lung cancer, dx'd [**2-24**], metastatic to chest wall, also causing cord compression. S/p steroid tx, chemotx, and XRT. S/p right frontal craniotomy on [**5-19**] for metastatectomy. 2) PUD 3) hearing loss (secondary to perforated tympanic membrane) 4) COPD Social History: SHx: tob: 1.5ppd x 65 years, quit two years ago EtOH: retired painter - lives with wife, has three children Physical Exam: PE: V/S: T 99.0, bp 140/52, P 97, spO2 97% on 100% NRB, RR 35 Gen: Elderly male, +temporal wasting, in respiratory distress, taking rapid shallow breaths HEENT: OP dry MM, PERRL, EOMI NECK: no JVD PULM: coarse bronchial breath sounds with expiratory wheezes bilaterally, prolonged I:E ratio COR: tachycardic S1/S2, no murmurs appreciated ABD: S/ND/NT, +BS EXT: no CCE Pertinent Results: [**2184-6-20**] 09:45PM GLUCOSE-155* UREA N-18 CREAT-0.6 SODIUM-138 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 [**2184-6-20**] 03:08PM PO2-67* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0 [**2184-6-20**] 10:40AM WBC-9.4 RBC-4.19* HGB-12.7* HCT-37.6* MCV-90 MCH-30.3 MCHC-33.8 RDW-18.2* Brief Hospital Course: IMP: 76 yo male with h/o NSCLC with clinical pneumonia (shortness of breath, hypoxia, fever, productive cough). Likely postobstructive given lung masses. PLAN: 1) Hypoxia: most likely secondary to combination of poor lung substrate (COPD / lung cancer) + added insult of infection (pneumonia). Will provide supplemental O2 to keep sp)2 > 90, but less than 95% given h/o COPD. Would check ABG. 2) Pneumonia: likely postobstructive. Would treat with levofloxacin as well as provide anaerobic coverage with metronidazole. Obtain sputum for gram stain and culture. Obtain blood cultures to monitor for dissemination. 3) Lung cancer: disseminated. Current plans are for head XRT. Continue steroids. 4) Brain mets: s/p recent surgery. Pt. to be seen by neurosurgery. 5) COPD: underlying lung disease. Would provide nebs prn. Patient already on antibiotics and steroids. 6) PPx: hep sc, PPi (steroids) 7) CODE: DNR/DNI --> had long discussion with the patient, his wife, and his son [**Name (NI) **] (cell# [**Telephone/Fax (1) 38091**]); they do not want his life dependent on a ventilator, should it come to that. Hospital Course: [**6-28**] transferred from ICU, Chest CT showed increased ground glass opacities and interstitial infiltrates bilaterally. [**6-22**]: did well through the day, no issues [**6-23**]-off respiratory precautions [**6-24**]:Improved. Likely D/c to rehab tomorrow Medications on Admission: MEDS (on admission) decadron 2mg po qd (as part of taper) oxycontin 10mg po hs prn percocet prn FeSO4 tab 325mg po qam Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 3. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QPM PRN () as needed for pain. Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Courtyard - [**Location (un) 1468**] Discharge Diagnosis: pneumonia Discharge Condition: stable Discharge Instructions: Rehab facility Followup Instructions: please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5562**] Completed by:[**2184-6-25**] ICD9 Codes: 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3122 }
Medical Text: Admission Date: [**2160-10-22**] Discharge Date: [**2160-10-25**] Date of Birth: [**2092-2-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 68 female with h/o severe COPD on home O2, hypothyroidism who presented to [**Hospital6 4620**] Tuesday with several days of increasing lethargy, confusion, and oxygen requirement. She arrived in [**Location (un) 86**] on Sunday to visit her son, and has been more lethargic and confused than normal, feeling unsteady on her feet, and complaining of shortness of breath. She has not used any inhalers, and her son has been increasing the amount of supplemental oxygen to 5-6L/min. She did not take her regular medications on Monday, and it was noticed that she had 21 lorazepam tabs when she left NY, and now only has about 5 left. Her son called her pulmonologist in NY, who thought this could be due to hypercapnea or too much lorazepam, and recommended going to the ED. . She is a poor historian, though it sounds as though her respiratory status has gotten much worse in the past 6 months, at which time she has been on home O2. There has then been a subacute decline over the past two weeks, which was noted by her daughter in [**Name2 (NI) **] and then her son in [**Name (NI) 86**]. She has not had any other symptoms recently, including cough, sputum production, fever, chills, myalgias, nasal congestion. . She was diagnosed with "severe COPD" several years ago, and has required home oxygen over the past few months. She does not regularly use any inhalers, though notes that when she does use albuterol she gets some relief. She was recently prescribed combivent, but her psychopharmacologist recommended against it b/c it made her agitated. . NWH course: She was found to be hypoxic to the 80s, afebrile, normotensive, confused. Her initial ABG was 7.25/96/130. Once on BiPAP, her SaO2 improved to 95%, and RR was 24-36. She was given solumedrol 125mg, nebs. Repeat ABG was 7.41/60/60. She was less confused. Her pulmonologist was contact[**Name (NI) **] and said she has baseline very severe COPD, and agreed with DNR/DNI status and use of non-invasive ventilation. There were no ICU beds at NWH, so she was transferred to [**Hospital1 18**]. . Review of Systems: As above. No f/c/night sweats. No abdominal complaints, URI sx, urinary sx. No chest pain, orthopnea. Past Medical History: - COPD (unknown PFTs; on home 4 L/min oxygen) - dx 4-5 years ago - Hypothyroidism - Anxiety / panic attacks Social History: Widowed x 2. [**Hospital 8735**] medical interpreter. She has two children. Lives alone in an apartment across the street from her daughter; uses home O2 4L/min, drives, and is independent of ADLs. She is a former smoker (30 pack year, quit in [**2145**]); denies EtOH. Family History: non-contributory Physical Exam: Vs- 98.9 axillary 134/86 22 94% on 30% ventimask, hr 104 Gen- mildly labored breathing, using excessory neck muscles, speaking in three word phrases Heent- PERRL, EOM intact, MMM Neck- JVP flat, no LAD Cor- RRR, nl S1/S2, no M/R/G Chest- poor inspiratory effort, poor air movement, no crackles, wheezes Abd- + BS, soft, NT/ND Ext- cool, poor capillary refill >2 sec Neuro- not oriented to time or place (did not know she was in [**Location (un) 86**]) Skin- no rashes, lesions Msk- no pitting edema Pertinent Results: [**2160-10-22**] 01:48PM TYPE-ART TEMP-37.0 RATES-/12 O2 FLOW-2 PO2-72* PCO2-58* PH-7.48* TOTAL CO2-44* BASE XS-16 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-NASAL [**Last Name (un) 154**] [**2160-10-22**] 04:30AM GLUCOSE-171* UREA N-19 CREAT-0.6 SODIUM-140 POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-39* ANION GAP-13 [**2160-10-22**] 04:30AM estGFR-Using this [**2160-10-22**] 04:30AM CK(CPK)-32 [**2160-10-22**] 04:30AM CK-MB-3 cTropnT-<0.01 [**2160-10-22**] 04:30AM CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-1.9 [**2160-10-22**] 04:30AM TSH-1.0 [**2160-10-22**] 04:30AM WBC-9.2 RBC-4.34 HGB-12.8 HCT-39.2 MCV-91 MCH-29.4 MCHC-32.5 RDW-13.6 [**2160-10-22**] 04:30AM PLT COUNT-264 [**2160-10-22**] 03:38AM TYPE-ART PO2-61* PCO2-65* PH-7.44 TOTAL CO2-46* BASE XS-16 . pCXR: 1. Findings suggesting COPD. 2. Suspected pulmonary hypertension. 3. No evidence of focal consolidation or congestive heart failure. . MRI/A Brain: The ventricles and extraaxial spaces are normal in size. There is no evidence of midline shift, mass effect, or hydrocephalus seen. There is no evidence of significant subcortical white matter ischemic disease or evidence of acute infarct seen on diffusion images. A linear flow void is incidentally noted in the right corona radiata extending to the margin of the right lateral ventricle indicative of a developmental venous normally. There are no chronic microhemorrhages visualized on susceptibility images. Small retention cysts are visualized in both maxillary sinuses. IMPRESSION: No evidence of acute infarct. MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head. Brief Hospital Course: 1. COPD flare: Patient was believed to have COPD exacerbation due to viral URI, though etiology unclear. She was intially treated with IV solumedrol and then switched to PO prednisone. She did not require bipap or antibiotics and her symptoms improved. She had negative cardiac enzymes x2 - 1 set here and 1 set at the OSH. Patient was noted not to be taking any short or long acting bronchodialators or steroids as an outpatient. She was discharged on prednisone 40 mg daily, to complete a 3 week taper. She was discharged on O2 continuos 3L, to be increased to [**3-5**] with walking. 2.word finding difficulty: Complained of having difficulty doing crossword puzzle after admission. MRI/A head was normal with no CVA and normal flow. Seemed to resolve at discharge. 3.hypothyroidism: Continued on levothyroxine 4.hyperglycemia:blood sugar elevated on admit, likely due to IV solumedrol, this resolved as her prednisone was decreased. Follow up blood sugar with PCP. 5. anxiety: Continued on paxil and ativan 6. Code status: DNR/DNI no central lines. Medications on Admission: - paxil 10 mg [**Hospital1 **] - lorazepam 0.5 mg [**Hospital1 **], (and prn) - synthroid 0.125 mg qd - [**Location (un) **] [**Doctor Last Name **] - fish oil 2000mg [**Hospital1 **] - mucinex - albuterol prn Discharge Medications: 1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for excess secretions. 5. Omega-3 Fatty Acids 550 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Prednisone 10 mg Tablet Sig: as dir Tablet PO once a day: Take 4 tabs daily for next week, then take 3 tabs daily for a week, then take 2 tabs daily for a week, then take one tab daily for a week, then stop. Disp:*70 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 14. Home O2 Please wear 3L Continuos O2 via NC at all times, and 4-5L with walking. Keep O2 sat 92-98% Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: COPD Flare Anxiety Hypothyroidism Discharge Condition: stable Discharge Instructions: Take medications as listed below. Follow up with your PCP [**Last Name (NamePattern4) **] [**12-3**] weeks after discharge from rehab. Please also follow up with your pulmonologist in [**12-3**] weeks after discharge from rehab. Followup Instructions: 1. Follow up with your PCP [**Last Name (NamePattern4) **] [**12-3**] weeks after discharge from rehab. 2. Please follow up with your pulmonologist in [**12-3**] weeks after discharge from rehab as well. You may need some follow up PFTs. ICD9 Codes: 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3123 }
Medical Text: Admission Date: [**2106-1-16**] Discharge Date: [**2106-1-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Male First Name (un) 5282**] Chief Complaint: lower gastrointestinal bleeding Major Surgical or Invasive Procedure: flexible sigmoidoscopy x 2 central line placement History of Present Illness: This is an 88 yo Cantonese-speaking female who presented with 2 episodes of BRBPR and called EMS. She was found to have an SBP of 90 in the field and brought to the ED. She was given 1 liter LR, 1500 cc NS, 1 U pRBC and transferred to the ICU. Per the Cantonese interpreter, she denied any abdominal pain, but has had recent weakness. She has a hx of liver disease and hepatocellular carcinoma and has been followed by Dr. [**Last Name (STitle) 79140**] at [**Hospital1 336**] Patient was admitted to the MICU where she was observed to have BM c BRBPR on [**1-17**]. She underwent flexible sigmoidoscopy without any intervention. Patient subsequently had additional episodes of bleeding with BMs on [**1-18**] and became hypotensive. She was transfused packed red blood cells and and was rescoped. This time she had derma-bond to two bleeding lesions. Patient has not had any additional bowel movements since that time. Hct has remained stable and she has remained hemodynamically stable. Past Medical History: -Type II Diabetes Mellitus -Hypertension -Hepatocellular Carcinoma, followed by Dr. [**Last Name (STitle) 79140**] at [**Hospital1 336**]. Per PCP patient not interested in treatment -Cryptogenic Cirrhosis -Knee Osteoarthritis -Asthma Social History: (per PCP): Lives with her husband. [**Name (NI) **] children (unknown how many) who are not involved in her care. No tobacco or ETOH. Family History: Unknown Physical Exam: Exam on Admission To Hepatorenal Floor from MICU Vitals: T 97.1 BP 132/68 HR 85 RR 22 O2 Sat 97% RA Gen: well appearing, no acute distress HEENT: NC/AT, OP clear Lungs: CTAB, no wheezes or crackles Heart: RRR, s1/s2 present, -mrg Abd: +BS, soft, non-tender, non-distended Ext: no edema, cyanosis or clubbing Pertinent Results: ADMISSION LABS: CBC: [**2106-1-16**] 08:45PM BLOOD WBC-4.0 RBC-2.08* Hgb-6.7* Hct-20.0* MCV-96 MCH-32.5* MCHC-33.7 RDW-16.8* Plt Ct-70* [**2106-1-16**] 08:45PM BLOOD Neuts-59.0 Lymphs-26.9 Monos-8.6 Eos-5.1* Baso-0.4 COAGS: [**2106-1-16**] 08:45PM BLOOD PT-22.3* PTT-56.9* INR(PT)-2.1* CHEMISTRIES: [**2106-1-16**] 09:15PM BLOOD Glucose-216* UreaN-19 Creat-1.1 Na-146* K-3.6 Cl-113* HCO3-24 AnGap-13 [**2106-1-18**] 03:24AM BLOOD Calcium-7.3* Phos-3.8 Mg-1.9 LFTs: [**2106-1-16**] 09:15PM BLOOD ALT-12 AST-26 LD(LDH)-212 AlkPhos-75 TotBili-0.6 HEPATITIS PANEL: [**2106-1-16**] 09:15PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE [**2106-1-16**] 09:15PM BLOOD HCV Ab-NEGATIVE ---- ---- DISCHARGE LABS: [**2106-1-21**] 04:49AM BLOOD WBC-12.1* RBC-3.37* Hgb-11.0* Hct-30.8* MCV-91 MCH-32.6* MCHC-35.8* RDW-17.8* Plt Ct-67* [**2106-1-21**] 04:49AM BLOOD Glucose-164* UreaN-30* Creat-0.9 Na-143 K-4.1 Cl-113* HCO3-21* AnGap-13 MICROBIOLOGY: [**2106-1-21**] 3:57 am STOOL CONSISTENCY: SOFT Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Pending at time of discharge) ---- ---- IMAGING STUDIES: ABDOMINAL U/S [**2106-1-17**]: IMPRESSION: 1. Left hepatic mass measuring 2.9 x 2.4 x 2.5 cm is compatible with the reported history of hepatocellular carcinoma. 2. Cholelithiasis without evidence of cholecystitis. 3. Normal hepatic arterial and venous waveforms without evidence of thrombosis. Brief Hospital Course: This is an 88 year old female with a history of cryptogenic cirrhosis, hepatocellular carcinoma who presented with bright red blood per rectum found to be secondary to bleeding rectal varices. # Rectal Variceal Bleed: Patient observed to have bowel movements with bright red blood per rectum on [**1-17**]. She underwent flexible sigmoidoscopy by the liver service which on first flex sig did not observe active bleeding and no interventions performed. On [**1-18**] patient had additional episodes of bright red blood per rectum and had a repeat flex sig. On the second flex sig two large rectal varices with hemocystic spots were observed and injected with dermabond. Patient had no additional episodes of bleeding after this intervention. In total the patient was transfused 6 units of packed red blod cells given she presented with a Hct of 20. Patient was on an octreotide drip and ciprofloxacin for 72 hours. Patient should follow up for repeat flex sigmoidoscopy in [**12-29**] weeks. Team to discuss whether patient will follow up at [**Hospital1 18**] or [**Hospital1 336**] with outpt PCP who is at [**Hospital1 336**] and will contact patient with this information. # Hepatocellular Carcinoma: Patient followed by Dr. [**Last Name (STitle) 79140**] an oncologist at [**Hospital1 336**]. Per patient's PCP patient has not been interested in undergoing treatment for her known cancer. We suggested that the patient make sure she understand all available treatment options and discuss these options with her oncologist and PCP. # History of Hypertension: Diovan and Diltiazem were held initially given blood loss and episode of hypotension while in the MICU. Medications were not restarted given that patient's blood pressure was in a normotensive range. Patient has PCP follow up on [**2106-1-29**] at which time she should have her blood pressure rechecked. # Asthma: Respiratory status remained stable. Patient's atrovent and albuterol inhalers were continued. Theophylline was held given that patient was on cipro. Patient may restart theophylline on discharge. # DM: Blood sugars remained stable. Per patient's PCP, [**Name10 (NameIs) **] is no longer on treatment for her diabetes. Medications on Admission: -Diltiazem 300 mg daily -Loratadine -Diovan 160 mg [**Hospital1 **] -Theophylline 200mg [**Hospital1 **] -Atrovent inhaler [**Hospital1 **] -Albuterol -Hydrocodone-Acet 5-500 -Omeprazole 20mg daily -Diabetic Boost 1 can TID Discharge Medications: 1. 3 in 1 commode 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not take more than 4 per day since this medication takes acetaminophen which could be toxic to your liver. 5. Loratadine Oral 6. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. diabetic boost 1 can TID Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Discharge Diagnosis: Primary: Lower gastrointestinal bleeding secondary to rectal variceal bleed Secondary: Hepatocellular carcinoma, Asthma, Hypertension Discharge Condition: hemodynamically stable Discharge Instructions: You were admitted to the hospital with lower gastrointestinal bleeding. We determined that you have rectal varices, that are related to your chronic liver disease, were responsible for the bleeding. You bleeding resolved after we did a procedure that put applied a material to the varices to make them stop bleeding. Following this procedure you did not have any further bleeding and your red blood cell counts remained stable. You should have this procedure repeated within the next [**11-27**] weeks in order to prevent further rectal bleeding. We will discuss setting up this procedure with your primary care provider to determine whether it would be more convenient for you to have this procedure done at [**Hospital 4415**] versus [**Hospital1 18**]. STOP TAKING: Diltiazem Diovan If you experience any additional episodes of rectal bleeding, not chest pain, shortness of breath or dizziness please contact your primary care physician immediatley or come to the emergency department for evaluation. Followup Instructions: We suggest that you have another flexible sigmoidoscopy in order treat your rectal varices. You should have this within the next 2-3 weeks. We will talk with your doctor and discuss whether you should return to our hospital to have this or go to [**Hospital 58906**], where you receive most of your care. Either us or your doctor's office will contact you with this information. You are scheduled to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**], [**2106-2-2**] at 11:20 am. Completed by:[**2106-1-21**] ICD9 Codes: 5849, 4019, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3124 }
Medical Text: Admission Date: [**2179-7-26**] Discharge Date: [**2179-8-4**] Date of Birth: [**2105-7-27**] Sex: F Service: ORTHOPAEDICS Allergies: seasonal Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior/posterior lumbar fusion with instrumentation L4-S1 History of Present Illness: Ms. [**Known lastname 33813**] has a long history of back and leg pain. She has failed conservative therapy and is electing to proceed with surgical intervention. Past Medical History: HTN, barrett's espophagus, hypothyroid, hyperlipidemia Social History: Denies Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [**2179-7-28**] 05:30AM BLOOD WBC-6.8 RBC-3.00* Hgb-9.5* Hct-26.7*# MCV-89 MCH-31.5 MCHC-35.4* RDW-15.1 Plt Ct-136* [**2179-7-27**] 09:00PM BLOOD Hct-21.1*# [**2179-7-26**] 07:19PM BLOOD WBC-8.4 RBC-3.66* Hgb-11.6* Hct-32.7* MCV-89 MCH-31.6 MCHC-35.3* RDW-12.8 Plt Ct-177 [**2179-7-28**] 05:30AM BLOOD Glucose-118* UreaN-18 Creat-1.4* Na-136 K-4.9 Cl-103 HCO3-25 AnGap-13 [**2179-7-28**] 03:03AM BLOOD Glucose-112* UreaN-18 Creat-1.5* Na-135 K-5.0 Cl-102 HCO3-26 AnGap-12 [**2179-7-26**] 07:19PM BLOOD Glucose-163* UreaN-19 Creat-1.1 Na-137 K-3.3 Cl-99 HCO3-23 AnGap-18 [**2179-7-28**] 03:03AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9 Brief Hospital Course: Ms. [**Known lastname 33813**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2179-7-26**] and taken to the Operating Room for L4-S1 interbody fusion through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. However, she developed new onset of right leg weakness and absent peripheral pulses. CTA showed likely left posterior tibial artery occlusion for which she was started on heparin; she had a spontaneous return of pulse and heparin was stopped. Initial postop pain was controlled with a Dilaudid PCA. . The pt was scheduled for the posterior surgery [**7-28**] but became combative, confused and tried to pull out her lines in the pre-op area. The pt started to desat to the 70s and the anesthesia team decided to intubate. CT of the head was taken to rule out hemmorhage given recent use of heparin. CTA of chest was taken, given pts suspected DVT and recent surgery and wet read was negative for PE. In the PACU she also required norepi pressor support. Her abdomen was noted to be distended, and there was difficultly placing an OGT. She was transferred to the MICU. She was started on Vanc/Zosyn given hypoxia, hypotension, and small pleural effusions on CT chest, although she was afebrile. General surgery was consulted for distended abdomen and elevated bladder pressures, who did not believe she had abdominal compartment syndrome. KUB showed ileus and there was no obstruction on CT. RP hematoma had been seen on L spine CT [**2179-7-28**] (5.8 x 3.5 cm), and was stable on CT [**2179-7-29**] (5.3 x 3.6 cm). Hct was stable. The cause of her acute delerium was uncertain, but felt to be multifactorial given the Dilaudid PCA and pt's regular EtOH use. . On [**2179-7-30**], she went back to the OR for the posterior approach. Please see the operative notes for further details. Post-operatively she developed a pneumonia and was placed on Cipro. She continued to improve and was able to work with physical therapy. She was discharged to rehab in good condition and tolerating a regular diet. Medications on Admission: [**Doctor First Name 130**], atenolol 25, levothyroid 88, nexium 40, simvastatin 20 Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 4. atenolol 25 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. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Began [**8-3**]. 9. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Lumbar stenosis and spondylosis Acute post-op delerium Post-op pneumonia Post-op acute blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Lumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity: Activity as tolerated Thoracic lumbar spine: when OOB Treatments Frequency: Please continue to change the dressing daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2179-8-4**] ICD9 Codes: 486, 5185, 2851, 4019, 2449, 2724
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Medical Text: Admission Date: [**2198-12-8**] Discharge Date: [**2198-12-31**] Date of Birth: [**2198-12-8**] Sex: M Service: NEONATOLOGY HISTORY: Baby [**Name (NI) **] "[**Name2 (NI) 333**]" [**Known lastname 37443**], Twin II, is a 34-2/7 week gestation who was admitted to the NICU for management of prematurity. Mother is a 34-year-old Gravida 1, para 0 woman. Prenatal surface antigen negative, RPR nonreactive, Rubella immune, GBS unknown. Maternal history of infertility from endometriosis. Pregnancy notable for invitro conception with selective reduction of one (Triplets to twins). Mother was being monitored by serial fetal ultrasounds, all reportedly okay. Mother presented on [**2198-12-7**] with spontaneous, premature evidence of chorioamnionitis. She was started on Ampicillin and Erythromycin and allowed to labor. Labor was augmented with Pitocin. Due to failure to progress, infants were delivered by cesarean section. Clear fluid, no maternal fever. This triplet emerged with good color and spontaneous crying. Dried, suctioned and stimulated. Responded well. Apgars were 7 at 1 minute and 8 at 5 minutes. He was shown to his parents and then transported to the Neonatal Intensive Care Unit for management of prematurity. PHYSICAL EXAMINATION ON ADMISSION: Weight 2670 grams (75 to 90 percentile), length 47 cm (75th percentile). Head circumference 33 cm (75 to 90 percentile). Active, alert, tone slightly decreased, anterior fontanel open and flat. Palate intact, positive red reflex both eyes. No respiratory distress. Bilateral breath sounds clear and equal. No grunting, flaring or retracting. No murmur, regular rate and rhythm, pink, pulses +2 and equal. Abdomen: Soft, nondistended. No hepatosplenomegaly. Three vessel cord, anus patent, spine intact, no dimple, hips stable, normal male genitalia. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant did not require supplemental oxygen this hospitalization. Infant has remained in room air with respiratory rates 40 to 50. His last apnea and bradycardia was on [**2198-12-25**]. Infant did not receive methylxanthine therapy (caffeine) this hospitalization. Cardiovascular: Hemodynamically stable throughout this hospitalization. No murmurs. Heart rate 140 to 150. Fluid, Electrolytes and Nutrition: Enteral feedings of premature Enfamil 20 calories per ounce with iron was started on date of delivery and advanced to 150 cc's per kilo per day by day of life five. Infant tolerated feeding advancements without difficulty, initally by gavage, then shifting to oral feedings. Maximum caloric density was premature Enfamil 24 calories per ounce. Infant is currently on Enfamil 20 calories per ounce p.o. taking a minimum of 150 cc's per kg per day. Most recent weight is 3075 grams, head circumference 34.5 cm, length 50.8 cm. Gastrointestinal: Most recent bilirubin from day of life three was 7.2/0.2. Infant did not receive phototherapy this hospitalization. Hematology: Infant did not require blood transfusion this hospitalization. Most recent hematocrit from the day of delivery was 46.5, platelets 281, white blood cell count 10.2. Infectious Disease: Infant received 48 hours of Ampicillin and Gentamicin initially for rule out sepsis, blood cultures have remained negative to date. Neurology: Infant does not meet criteria for head ultrasound. Audiology: Sensory audiology hearing screening was performed with automated auditory brainstem responses. Infant passed both ears. Ophthalmology: Infant does not meet criteria for ophthalmology exam. Psychosocial: [**Hospital1 69**] social work was involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) 8717**]. Parents involved. CONDITION ON DISCHARGE: Former 34-2/7 week twin II now 37-4/7 weeks corrected,stable in room air. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**], [**Telephone/Fax (1) 37440**], Fax #[**Telephone/Fax (1) 37444**]. CARE/RECOMMENDATIONS: Feedings at discharge: Enfamil minimum 150 cc's per kg per day 20 calories per ounce with iron p.o. Medications: Fer-in-[**Male First Name (un) **] 2 mg per kg per day. Car seat position screening: Infant passed car seat test. State newborn screening status: State Newborn screen sent on [**2198-12-11**] showed a slightly elevated 1708HP of 64.5. Repeat newborn screen sent on [**2198-12-24**] was within normal range. Immunizations: Infant received Hepatitis B vaccine on [**2198-12-23**]. Infant does not meet criteria for Synagis RSV prophylaxis. FOLLOW-UP APPOINTMENT: 1. Primary pediatrician appointment on [**2199-1-1**]. 2. Visiting Nurses Association. DISCHARGE DIAGNOSIS: 1. Prematurity, 34-2/7 weeks, twin gestation. 2. Rule out sepsis. 3. Apnea of prematurity, resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**] Dictated By:[**Last Name (NamePattern1) 35945**] MEDQUIST36 D: [**2198-12-31**] 15:23 T: [**2198-12-31**] 15:47 JOB#: [**Job Number 37445**] ICD9 Codes: V290, V053
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Medical Text: Admission Date: [**2103-8-29**] Discharge Date: [**2103-9-25**] Date of Birth: [**2021-5-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Worsening L heel/leg ulcers Major Surgical or Invasive Procedure: [**2103-9-6**] L BKA History of Present Illness: Patient is an 82 year old female who came into vascular clinic for a routine follow up visit. She was examined in clinic today, the bandage was taken down and her left leg wound began bleeding profusely. The bleeding was controlled and the wound was rewrapped and she was admitted to the vascular surgery service. This is an ulcer which has not been healing for many months now, at least 4 months, possibly quite a bit longer. She had 3 months ago, in clinic she was noted to have a 3 x 3 cm ulceration on the lateral aspect of her left tibia. She c/o bilateral foot pain. With the right [**5-20**] and the left [**10-20**]. Both feet throb, non radiating and constant. Pain alleviated with tylenol and aggrivated by foot manipulation. Past Medical History: COPD, DM-2, HTN, CVA, hyperlipidemia, CAD, depression, CHF, uterine prolapse, PVD, osteoarthritis, and had an appendectomy in the distant past. Social History: Currently resides at [**Hospital3 537**]. Family History: Non-contributory Physical Exam: 97.4 72 112/70 15 95% RA NAD RRR CTA B S/NT/ND wounds c/d/i. L BKA, staples intact Right- staples medially, has hematoma all along the incision line Pulses: dopplerable DP and PT signals on right Pertinent Results: [**2103-9-25**] 09:13AM BLOOD WBC-9.6 RBC-3.80* Hgb-10.9* Hct-34.4* MCV-90 MCH-28.6 MCHC-31.6 RDW-16.5* Plt Ct-345 [**2103-9-25**] 09:13AM BLOOD Plt Ct-345 [**2103-9-24**] 08:24AM BLOOD Glucose-92 UreaN-8 Creat-0.5 Na-140 K-4.3 Cl-102 HCO3-32 AnGap-10 Cardiology Report ECG Study Date of [**2103-9-4**] 5:22:40 AM Sinus rhythm. Low QRS voltage is non-specific but clinical correlation is suggested. Since the previous tracing of [**2103-6-6**] right axis deviation and early precordial QRS transition are absent and generalized low QRS voltage is now seen. Radiology Report FOOT AP,LAT & OBL LEFT Study Date of [**2103-8-29**] 5:22 PM FINDINGS: Three views of the left foot demonstrate osteopenia. There is hallux valgus metatarsus and varus with mild degenerative changes of the first MTP. There are mild degenerative changes of the first TMT. There is subchondral sclerosis at both aspects of the TMT joints. There is mild enthesopathy at the dorsal and plantar calcaneal insertions. No frank osteomyelitis is identified in the foot. ART DUP EXT LO UNI;F/U LEFT Study Date of [**2103-8-30**] 9:15 AM IMPRESSION: Patent left femoropopliteal bypass graft with low, resistive flow. The below-knee popliteal artery appears to occlude not far below the terminus of the bypass graft. ART EXT (REST ONLY) Study Date of [**2103-8-30**] 9:15 AM IMPRESSION: Severe bilateral lower extremity occlusive disease without Doppler flow below the knee. PVRs are aphasic in the calf levels distally. CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of [**2103-8-31**] 12:32 PM IMPRESSION: 1. Occlusion of left fem-[**Doctor Last Name **] bypass at its proximal end. Left external iliac stent is patent. Occlusion of the left SFA and portions of the left anterior tibial and left posterior tibial arteries. 2. Occlusion of the right SFA at its mid portion. Areas of occlusion in the mid course of the right anterior tibial and right posterior tibial arteries. 3. Indeterminate bilateral low-attenuation adrenal nodules. Differential diagnosis includes adrenal adenomata, but they should be monitored on follow up imaging. CHEST (PRE-OP PA & LAT) Study Date of [**2103-9-4**] 10:53 AM FINDINGS: Since the previous study,the left lower lobe atelectasis is unchanged. The lungs are clear with no mass, consolidation or pneumothorax. Cardiomediastinal silhouette is normal. IMPRESSION: No acute cardiopulmonary findings Brief Hospital Course: [**2103-8-29**] Patient admitted for worsening LLE ulcers. Started on braod spectrum antibiotics (Vanco, Cipro, Flagyl). NIAS requested for LE's, foot x-ray, routine wound care. [**2103-8-30**] HD1: Patient had episodes of hypoglycemia associated with somnolence, with Metformin on hold, d/c'd Pioglitazone. Continued routine wound care, and broad spectrum antibiotics. Podiatry consulted re: L heel ulcer- will need LBKA if circulation cannot be restored. [**2103-8-31**] HD2: No acute events. Continued routine wound care, and broad spectrum antibiotics. Patient had a CTA bilateral lower extremities- demonstrated 1. Occlusion of left fem-[**Doctor Last Name **] bypass at its proximal end. Left external iliac stent is patent. Occlusion of the left SFA and portions of the left anterior tibial and left posterior tibial arteries. 2. Occlusion of the right SFA at its mid portion. Areas of occlusion in the mid course of the right anterior tibial and right posterior tibial arteries, will need Right femoral-to-dorsalis pedis bypass with in situ saphenous vein graft in the future, to be done after L BKA. 8/22-24/09 HD3-5: No acute events. Continued routine wound care, and broad spectrum antibiotics. Booked for LBKA on [**2103-9-4**]. Made NPO, pre-oped, IV hydrated and consented for L BKA. [**2103-9-4**] HD6: Day of proposed surgery, patient at the last minute is refusing to have surgery (L BKA), procedure was re-booked for [**2103-9-6**]. Family contact[**Name (NI) **] and made arrangements for someone to be in w/ patient prior to going to the OR for her L BKA. Continued routine wound care, and broad spectrum antibiotics. [**2103-9-5**] HD7: No acute events. Continued routine wound care, and broad spectrum antibiotics. Made NPO and IV hydrated for L BKA the next day. [**2103-9-6**] HD8: No acute events. Taken to OR and underwent L BKA. Patient tolerated procedure, recovered in the PACU then transferred back to [**Hospital Ward Name 121**] 5 floor. Diet and PO meds resumed. Pain well controlled w/ current medications. [**2103-9-7**] HD9/POD1: Hct is down to 25.4, transfused w/ 1 unit PRBCs. Placed on BKA pathway. Physical therapy referral placed. Rehab screening requested. Family and patient decided to go ahead w/ plans for Right femoral-to-dorsalis pedis bypass to be done during this admission. Booked for [**2103-9-14**]. [**Date range (1) 89694**]/HD10-16/POD6: Continued BKA pathway. Speech and swallow evaluation to evaluate for aspiration and diet recs- continue ground solids and thin liquids. Poor po intake calorie count x 3 days, started Megase. PICC placed for better access, placement confirmed w/ CXR. Continued IV antibiotics. Lisinopril, Mirtazipine and Furosemide discontinued for low BP. [**9-13**] Pre-oped, consented, made NPO after MN, IV hydarted for Right femoral-to-dorsalis pedis bypass. [**2103-9-14**] HD17/POD7: Taken to OR for Right femoral-to-dorsalis pedis bypass with in situ saphenous vein graft. Patient tolerated procedure, recovered in the PACU then transferred to VICU [**Hospital Ward Name 121**] 5. Routine post BKA care. Restarted Heparin drip post-op. Placed lower extremity bypass pathway. [**2103-9-15**] HD18/POD7/1: Hct down to 27.8 <-31.5, transfused w/ 1 unit PRBC's. Fluid resuscitated. Pain managed w/ IV Morphine prn. Continued IV antibiotics. Resume po meds and diet. Continued LE bypass pathway. [**2103-9-16**] HD19/POD8/2: Patient noted to have right unilateral upper extremity swelling, Ultrasound was done and ruled out for UE DVT. Continued IV antibiotics. Continued w/ Heparin drip. Pain managed w/ IV Morphine prn. Fluid bolus for low urine output. [**2103-9-17**] HD20/POD9/3: Hct down to 24.9 <-30.1, transfused w/ 1 unit PRBC's. Continued on LE bypass and BKA pathways. Continued IV antibiotics and Heparin drip. Diet advanced. [**2103-9-18**] HD21/POD10/4: WBC elevated, pan cultured, CXR taken-possible basilar consilidation. First C-diff came back negative. Urine cultures-negative, blood cultures still pending. Heparin drip d/c'd. Electrolytes repleted. [**2103-9-19**] HD22/POD11/5: WBC coming down. Poor PO intake, reconsulted speech and swallow- recs ground solids and nectar thickened liquids, supplements w/ every meal and calorie counts for 3 days. Hct continue to fall now 24.3, transfused w/ 1 unit PRBCs. Poor urine output since MN, IV fluid bolused after blood transfusion. Urine lytes sent FENa 0.06%, Cr 0.4. [**2103-9-20**] HD23/POD12/6: Continued LE bypass and BKA pathways. Transfused 1 unit of PRBCs. Urine poutput remain marginal, good response to low dose Lasix. Rehab screen requested. [**2103-9-21**] HD24/POD13/7: No acute events. Given low dose lasix again w/ good response. [**Hospital 25403**] rehab bed. [**Date range (1) 95755**]: Patient did well over the weekend. No acute events. Discharged to rehab in good consition on [**2103-9-25**]. Medications on Admission: Meds: Lisinopril 10 mg daily Atorvastatin 10 mg QHS Atenolol 50 mg daily Donepezil 10 mg QHS Mirtazapine 30 mg QHS Pioglitazone 15 mg DAILY Acetaminophen 500 mg (2) Tablet PO Q 8H prn pain Docusate Sodium 100 mg Capsule [**Hospital1 **] Ipratropium Bromide 17 mcg/Actuation Aerosol 1-2 Puffs Inhalation QID Aspirin 325 mg PO DAILY Oxycodone 5 mg 1 Q6H prn pain Senna 8.6 mg Tablet [**Hospital1 **] Bisacodyl 5 mg Tablet, Delayed Release (E.C.) 2 PO DAILY prn constipation. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Inhalation Q4H prn SOB. Lasix 20 mg Tablet daily. Metformin 500 mg Tablet PO twice a day. Namenda 10 mg PO daily. Humalog Insulin SC per Fingerstick Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for prn pain. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation QID (4 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily (). 12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 13. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 16. Ipratropium Bromide 0.02 % Solution Sig: [**1-12**] Inhalation Q6H (every 6 hours) as needed for wheezing. 17. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**] Discharge Diagnosis: PVD w/ ischemic L leg/foot and failed bypass Ischemic right leg Acute anemia-related to operations-required blood transfusions History of: COPD DM-2 HTN CVA hyperlipidemia CAD depression CHF uterine prolapse PVD osteoarthritis PSH: [**2103-6-6**] L femAKpop w/NRSVG, L EIA stent, s/p appy Discharge Condition: Stable Lasix on hold, rehab to determine need to resume Discharge Instructions: Division of Vascular and Endovascular Surgery Amputations Discharge Instructions ACTIVITIES: - no driving till FU - may shower, no tub baths - no stump shrinkers, may ace - no pillows under hip/knee WOUND: - staples will remain till FU - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications - PATIENT WILL NEED LOTS OF ENCOURAGEMENT TO ENSURE ADEQUATE NUTRITIONAL INTAKE MEDICATIONS: - Continue all medications as directed - Take your pain medications conservatively - Your pain will get better over time Followup Instructions: Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone: [**Telephone/Fax (1) 1393**] follow up in [**2-13**] weeks Completed by:[**2103-9-25**] ICD9 Codes: 2851, 4280, 3572, 496, 4019, 2724, 311
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Medical Text: Admission Date: [**2131-8-12**] Discharge Date: [**2131-8-24**] Date of Birth: [**2061-5-31**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Lisinopril / Ibuprofen / Metoprolol Tartrate Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2131-8-20**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with vein grafts to obtuse marginal and PLV History of Present Illness: Mr. [**Known lastname **] is a 70 year old Russian speaking male with h/o 3 vessel coronary artery disease on cath [**2126**] s/p DES to mid LAD, who presented to PCP [**Name Initial (PRE) 151**] 1 month of exertional angina. Pt sent for stress test and it was stopped d/t fatigue and patient was sent home. Shortly after the stress test, pt was called by a doctor to return to the ED. Past Medical History: Coronary Artery Disease s/p stent mid LAD [**2126**] Hypertension Hyperlipidemia Gastroesophageal reflux disease Bilateral Knee pain Chronic breathing problems/[**Name2 (NI) **] d/t Chernobyl - pt worked close Social History: Lives with: wife [**Name (NI) **]: Caucasian Tobacco: quit [**2108**], 22 pack year hx ETOH: social Family History: denies Physical Exam: Pulse:72 Resp:16 O2 sat: 100% RA B/P Right:180/85 Left: 160/85 Height:5'7" Weight:210 LBS, 95.3 KG General: NAD, alert, cooperative Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] NO Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: NONE Left: NONE Pertinent Results: [**2131-8-13**] Cardiac Cath: 1. Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a distal 20% stenosis. The proximal LAD had 90% ostial in-stent restenosis with mild luminal irregularities. There was 60% stenosis of the mid-LAD. The distal wraparound LAD was 30% stenosed. The proximal LCx had a 90% lesion at the bifurcation of OM1, the mid LCx had 60% stenosis. The OM2 was 90% occluded. The RCA had 50% mid and 60% distal disease. The RPDA was occluded at the origin and supplied by right to right collateral. 2. Limited resting hemodynamics revealed a central aortic pressure of 164/86mmHg. 3. Left ventriculography was deferred. [**2131-8-14**] Carotid Ultrasound: Less than 40% stenosis in the right and left internal carotid arteries. [**2131-8-15**] Echocardiogram: The left atrium is moderately dilated. 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 arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2131-8-23**] CXR: PA and lateral chest radiographs are compared to [**2131-8-21**]. The cardiomediastinal contours are stable. Bilateral pleural effusions are probably unchanged in size. Bibasilar atelectasis and overall lung aeration compared to the examination from two days prior have improved. Median sternotomy wires appear vertically oriented and intact. [**2131-8-12**] 11:30AM BLOOD WBC-8.1 RBC-4.25* Hgb-13.8* Hct-39.6* MCV-93 MCH-32.4* MCHC-34.7 RDW-13.6 Plt Ct-237 [**2131-8-24**] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1* MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193 [**2131-8-12**] 11:30AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1 [**2131-8-20**] 04:54PM BLOOD PT-15.8* PTT-63.8* INR(PT)-1.4* [**2131-8-12**] 11:30AM BLOOD Glucose-105 UreaN-15 Creat-0.9 Na-139 K-4.3 Cl-106 HCO3-24 AnGap-13 [**2131-8-24**] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135 K-3.9 Cl-98 HCO3-28 AnGap-13 [**2131-8-14**] 06:40AM BLOOD ALT-13 AST-15 AlkPhos-81 TotBili-0.9 [**2131-8-13**] 06:30AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0 [**2131-8-23**] 05:46AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 [**2131-8-14**] 10:05AM BLOOD %HbA1c-5.7 [**2131-8-24**] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1* MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193 [**2131-8-24**] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135 K-3.9 Cl-98 HCO3-28 AnGap-13 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent cardiac catheterization which revealed severe three vessel coronary artery disease - see result section for details. Prior to catheterization, he underwent Aspirin desensitization. Following cardiac cath he underwent pre-operative work-up for bypass surgery. Prior to surgery though he required Plavix washout. On [**2131-8-20**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He remained stable during his post-operative course and was seen by physical therapy for strength and mobility. There were no significant post-op events besides a rise in his WBC that trended back down to 7 by discharge. Also, all cultures taken were negative. On post-operative day four he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Medications at home: Nifedipine SR 60mg daily Simvastatin 40mg qHS HCTZ 25 mg qHS Inhouse: ASA (desensitized [**2131-8-13**]) Heparin SC TID Colace PRN Plavix 75 mg daily Plavix - last dose:300mg [**8-12**] + 75 mg [**8-13**] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*1* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease, s/p Coronary Arteyr Bypass Graft x 3 Hypertension Dyslipidemia Gastroesophageal reflux disease s/p Stent placement to LAD [**2126**] Bilateral knee pain Chronic breathing problems/[**Name2 (NI) **] d/t living near Chernobyl s/p Appendectomy Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Call with any additional questions or concerns Followup Instructions: [**Hospital Ward Name 121**] 6 in 2 weeks for wound check Dr. [**Last Name (STitle) **] in [**5-6**] weeks, call for appt Dr. [**Last Name (STitle) 3357**] in [**3-6**] weeks, call for appt Dr. [**Last Name (STitle) 52994**] in [**3-6**] weeks, call for appt Completed by:[**2131-8-24**] ICD9 Codes: 4111, 4019, 2724
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Medical Text: Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-27**] Date of Birth: [**2130-9-30**] Sex: M Service: MEDICINE Allergies: Codeine / Bactrim Ds Attending:[**First Name3 (LF) 759**] Chief Complaint: fevers Major Surgical or Invasive Procedure: right IJ placement History of Present Illness: 40 M with HIV (CD 4=664 in [**2169**] and 189 on [**2170-11-5**]) but no history of opportunistic infections who presents with 2 days of fevers to 102 for which he took tylenol. He had a cough productive of clear sputum and back pain secondary to a deep cutaneous abscess. He presented to the ED on [**2170-11-5**] with fever and abscess. The abscess was I&D'd and he was given fluids for tachycardia and oxacillin for abscess. He then abruptly dropped his BP to 60's, a sepsis protocol was initiated and a total of 5 L fluid were given. A central line was placed, vanc, ceftriaxone and dilaudid were given in the ED. Admitted to the [**Hospital Unit Name 153**] for closer monitoring of hypotension and tachycardia. Blood cultures from [**2170-11-5**] grew MRSA x 2. Surgery following. ID consulted for antibiotic therapy and ?indications for propylaxis given low CD4. Past Medical History: 1. HIV: diagnosed in [**2158**], on ZDV/3TC/nevirapine (per OMR note but patient denies ever being on HAART), currently no meds, followed by Dr [**Last Name (STitle) 4844**] 2. Seasonal allergies 3. Right hand tendonitis 4. s/p T and A 5. Right knee cellulitis (MSSA, [**3-21**]) 6. H/o strep pharyngitis, HSV, skin abscesses (per OMR) Social History: Lives alone, currently single, smokes 1 ppd x 12 years, past ecstacy and Ketamine use Family History: Non-contributory Physical Exam: Tm=102.1 Tc=98.6 P=95 (92-104) BP=110/65 (110/65-124/59) RR=21 100% RA Gen - Alert, no acute distress, lying on R side, unable to move secondary to vac dressing HEENT - PERRL, extraocular motions intact, anicteric, moist mucous membranes, poor dentition Neck - 10 cm JVD, no cervical lymphadenopathy, submandibular lymphadenopathy Chest - Right upper lobe crackles, decreased breath sounds at the bases bilaterally R>L CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tenderness; lower back with vac dressing draining 2 cm incised lesion Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**3-1**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Pertinent Results: MRI [**11-19**]: Essentially stable appearance of soft tissue edema/inflammation without evidence of osteomyelitis or drainable abscess collection. Slightly heterogeneous signal within the dependent portions of the iliac bones is non- specific, and most likely represents hematopoietic marrow. CT abdomen [**11-18**]: No intra-abdominal fluid collections. CT chest [**11-14**]: Multiple nodular and focal patchy opacities bilaterally of different sizes, many of which show evidence of cavitation. The largest of these within the right upper lobe although all lobes are affected. These findings are consistent with septic emboli. 2. Elevation of the right hemidiaphragm. Tiny right-sided pleural effusion which is layering posteriorly. 3. Gastric varices. MRI Pelvis [**2170-11-7**]: No evidence of intraosseous infection. CXR [**2170-11-7**] AP: Increased right pleural effusion with right lower lobe atelectasis vs. PNA. Increased pulmonary edema vs. diffuse infection. CXR [**2170-11-6**] AP: Left upper lobe, right upper lobe infiltrates suggestive of PMA. Diffuse intersitital opacities suggestive of pulmonary edema vs. infxn [**2170-11-5**] 07:35AM WBC-12.9* LYMPH-8* ABS LYMPH-1032 CD3-82 ABS CD3-845 CD4-18 ABS CD4-189* CD8-59 ABS CD8-613 CD4/CD8-0.3* [**2170-11-5**] 07:35AM PLT COUNT-240 [**2170-11-5**] 07:35AM WBC-12.9* RBC-5.24 HGB-14.6 HCT-42.8 MCV-82 MCH-27.9 MCHC-34.1 RDW-12.1 [**2170-11-5**] 07:35AM NEUTS-84.4* LYMPHS-8.3* MONOS-6.6 EOS-0.4 BASOS-0.4 [**2170-11-5**] 07:35AM CORTISOL-25.6* [**2170-11-5**] 07:35AM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-1.5* URIC ACID-3.8 [**2170-11-5**] 07:35AM LIPASE-12 [**2170-11-5**] 07:35AM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-147 ALK PHOS-102 AMYLASE-28 TOT BILI-0.9 [**2170-11-5**] 07:35AM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-132* POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15 [**2170-11-5**] 08:06AM LACTATE-2.3* [**2170-11-26**] 10:31AM BLOOD WBC-4.1 RBC-4.34* Hgb-11.5* Hct-35.3* MCV-81* MCH-26.5* MCHC-32.7 RDW-14.6 Plt Ct-419 [**2170-11-5**] 07:35AM BLOOD WBC-12.9* Lymph-8* Abs [**Last Name (un) **]-1032 CD3%-82 Abs CD3-845 CD4%-18 Abs CD4-189* CD8%-59 Abs CD8-613 CD4/CD8-0.3* [**2170-11-21**] 05:00AM BLOOD WBC-3.7* Lymph-42 Abs [**Last Name (un) **]-1554 CD3%-91 Abs CD3-1408 CD4%-29 Abs CD4-454 CD8%-57 Abs CD8-888* CD4/CD8-0.5* [**2170-11-22**] 05:50AM BLOOD ALT-46* AST-30 CK(CPK)-20* AlkPhos-131* TotBili-0.2 [**2170-11-19**] 10:06AM BLOOD ALT-57* AST-41* LD(LDH)-174 AlkPhos-127* Amylase-39 TotBili-0.2 [**2170-11-25**] 03:28AM BLOOD Vanco-14.5* Brief Hospital Course: 1. sacral abscess - Abscess was incised and drained in the ED. Surgery consult obtained, and this was felt to be subcutaneous abscess rather than pilonidal cyst. Wound cultures grew out MRSA. Pt placed on vancomycin, ultimately for a 4-week course. Wound vac was placed, with surgery following and doing dressing changes. Wound vac discontinued prior to discharge per surgery team; wet-to-dry dressings were performed, and eventually dry gauze dressings. No evidence of further infection, with abscess appearing to be healing well by discharge. Pt will follow up with Dr. [**Last Name (STitle) **] in surgery in 4 weeks. 2. MRSA sepsis - Pt was admitted to the [**Hospital Unit Name 153**] from the ED on a non-rebreather mask, hypotensive on a levophed drip which was weaned off and the patient remained stable, transferred from [**Hospital Unit Name 153**] to the floor on [**2170-11-8**]. On arrival, pt's CVP continued to be low ([**4-23**]), with further fluid resuscitation resulting in adequate BP. Levophed drip was stopped 48 hours later, and BP remained stable throughout rest of course. Pt had multiple further blood cultures for surveillance purposes, which were negative. Last positive blood culture was on [**11-5**]. Pt on vanco for 4 week course after first negative blood culture. Vancomycin trough levels were persistently low, with continual uptitrating of the dose, up to 1750mg IV q12, and then ultimately was 1000mg IV q8h with a therapeutic trough level. 3. pneumonia - Pt noted to have multiple patchy opacities on CXR and chest CT, some of these lesions were noted to be cavitating. ID was involved early in the course of [**Hospital **] hospital stay. 3 AFB smears were negative, PCP via sputum induction was negative, Legionella urinary antigen was negative, Cryptococcus negative. A PPD was placed, which was negative, as well. CXR showed right pleural effusion with right lower lobe atelectasis vs. pneumonia. This was evaluated with U/S probe and it was determined that the fluid collection was too small to be tapped. Findings on CT scan were consistent with septic emboli, so a TTE and then TEE were performed, both of which were negative for any vegetations. Per ID, it is thought that these are septic emboli, likely of MRSA, from some intravascular source but not valvular vegetations. The appearance of these nodules, in their cavitations is consistent with Staph pneumonia, possibly from hematogenous spread. Pt was placed on 4 week course of vanco, and he continued to improve overall, feeling well by the time of discharge. He maintained good O2 sats and showed no respiratory distress. A followup CT scan was arranged prior to discharge, and pt will follow up in [**Hospital **] clinic to determine if the vancomycin may be discontinued. 4. fevers - fevers persisted even with the vancomycin on board. Pt's cultures were consistently negative and no changes noted on repeat chest imaging. Pt clinically was well-appearing in the last week or so before discharge, but was still having fevers. Other sources of fever were searched for: an abdominal CT showed no fluid collections or occult abscesses; an MRI of the sacral area near the abscess ruled out osteomyelitis. It was thought that perhaps his subtherapeutic vanco dose might be responsible for this. However, no further causes of infection were found, and pt was clinically well. Pt remained afebrile for > 4 days prior to discharge. 5. HIV - CD4 count low 189, but pt had an acute infectious process going on. Repeat CD4 count when pt more stable was 454. Bactrim prophylaxis was stopped. Pt will follow up with Dr. [**Last Name (STitle) 4844**] in [**Month (only) 404**] of next year. No HAART while in house. 6. HSV - pt had some oral HSV and completed a 7-day course of famciclovir with resolution of symptoms. 7. gastric varices - varices were found incidentally on CT scan. LFTs were mildly elevated. Pt asymptomatic. Abd CT scan did not comment on any liver abnormalities. An outpatient EGD appointment was arranged to better assess these varices, as well as a subsequent liver clinic appointment. 8. PPX: H2 blocker, SQ heparin 9. FULL CODE. 10. Dispo: Patient will be discharged to home with VNA for PICC care, as well as help with dressing changes. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q12H (every 12 hours) for 11 days: Last day of treatment in [**12-6**]. Patient may need longer duration of therapy to be determined by outpatient infectious disease doctor. [**Last Name (Titles) **]:*22 doses* Refills:*0* 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD () as needed: to PICC. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. saline heparin flushes per VNS protocol 11. PICC line care Discharge Disposition: Home With Service Facility: [**Location (un) **] HOME THERAPIES Discharge Diagnosis: Primary diagnoses: MRSA sacral abscess MRSA bacteremia Septic Pulmonary Emboli HIV Secondary diagnoses: Gastric Varices, seen on CT scan Seasonal allergies Right hand tendonitis s/p T and A Right knee cellulitis (MSSA, [**3-21**]) h/o strep pharyngitis, HSV, skin abscesses (per OMR) Discharge Condition: stable. pain well controlled. wound healing well. Discharge Instructions: Please call your doctor and return to the hospital for fever/chills, increasing warmth, pain, redness, or swelling from the abscess, general malaise, diarrhea, or any other concerns you may have. Please go to all of your appointments. Followup Instructions: You have the following appointments: 1) Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-12-1**] 10:15 This is on the [**Hospital Ward Name 517**]. Please do not eat any solid food 3 hours beforehand. ***Before this appointment, please call ([**Telephone/Fax (1) 26760**] to update your information. 2) MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30 3) Dr. [**Last Name (STitle) **] - surgery - to take a look at your abscess [**2170-12-24**], 1:00PM; in [**Hospital Ward Name 23**] building (Surgical Subspecialties); phone number ([**Telephone/Fax (1) 26761**] 4) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**], Dr.[**Name (NI) 4864**] nurse practitioner Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-12-25**] 11:00 5) Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-2-7**] 9:50 6)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2170-12-20**] 10:00 ***You need to arrive at 9 am. Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS Date/Time:[**2170-12-20**] 10:00 This is for evaluation of your liver 7) Liver Clinic appointment: to follow up with liver scan [**2171-2-26**] at 9 am [**Location (un) **] Dr. [**Last Name (STitle) 10924**] ICD9 Codes: 5119
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Medical Text: Admission Date: [**2164-12-21**] Discharge Date: [**2164-12-23**] Date of Birth: Sex: Service: ADMISSION DIAGNOSES: 1. Status post motor vehicle collision. 2. Anoxic brain injury. 3. Hypernatremia. 4. Cardiac contusion. 5. Subdural hematoma. DISCHARGE DIAGNOSES: 1. Brain death secondary to anoxic brain injury. 2. Status post motor vehicle collision. 3. Anoxic brain injury. 4. Hypernatremia. 5. Cardiac contusion. 6. Subdural hematoma. HISTORY OF PRESENT ILLNESS: [**Known firstname 46**] [**Known lastname 75745**] is a 23 year-old gentleman who was in a high speed motor vehicle collision with rollover and subsequent submersion into water on [**12-21**] of [**2164**]. From the transferring hospital reports, the time of submersion was at least 3 minutes before the patient was extricated. The patient was immediately intubated in the field and transferred via Life Flight from regional hospital for management. The patient arrived to the [**Hospital1 1444**] on [**12-21**] intubated with stable hemodynamics. PAST MEDICAL HISTORY: His past medical history was unknown. Upon the initial trauma survey, the patient was found to be neurologically unresponsive. The only neurologically suppressive medication he had been given prior to transfer was succinylcholine for the intubation. He was found to be unresponsive. Corneal, gag and cough reflexes were all absent. No motor function was present in the extremities. His pupils were fixed and dilated. His examination was otherwise only remarkable for some superficial lacerations without significant bleeding. His lab values upon admission were notable for a hematocrit of 45.3. His sodium was 146. His troponin value was 0.11. His lactate value was 4.1. It should also be noted that the patient was normothermic on admission. In terms of his imaging, review of imaging from the referring hospital demonstrated a subdural hematoma which was not causing significant mass effect or shift but there was significant blurring of the [**Doctor Last Name 352**]-white matter interface. His chest x-ray demonstrated diffuse alveolar opacities with edema, consistent with his prior neurologic injury. HOSPITAL COURSE: Upon initial presentation to the trauma bay, there was significant evidence based on the patient's mechanism of injury, examination and imaging that he had suffered an irreversible injury. A neurosurgical consultation was obtained as well. The neurosurgical service concurred that the patient's major injury was likely anoxic brain injury from his submersion. They felt that the subdural hematoma was likely not contributing to his absence of brain stem reflexes. Given these findings, there was no role for any significant additional intervention. The family arrived shortly after the [**Hospital 228**] transfer to the [**Hospital1 1444**]. Family meeting was held immediately discussing his grave prognosis and the lack of recoverable function. The family understood this and requested some additional time for additional family members to arrive. The patient remained intubated and was transferred to the trauma surgical intensive care unit. The family had been in discussion with the [**Location (un) 511**] organ bank and supportive therapy was provided during the remainder of his 48 hour hospitalization until final decisions regarding organ donation could be made, as well as arrival of additional family members. During the course of his hospitalization, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brain scan was obtained. This showed no evidence of perfusion to the cerebral cortex consistent with brain death. The patient expired on [**2164-12-23**]. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2165-7-1**] 17:23:39 T: [**2165-7-1**] 18:04:55 Job#: [**Job Number 75746**] ICD9 Codes: 5185
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Medical Text: Admission Date: [**2147-12-1**] Discharge Date: [**2147-12-8**] Date of Birth: [**2076-8-5**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 71 year-old male with known coronary artery disease status post myocardial infarction in [**2142**] with stents to left anterior descending coronary artery and tissue plasminogen activator. Since then the patient felt well. Over the past five to six months he began to experience exertional angina. On the [**1-30**] the patient underwent ETT and was positive for ischemic responses. Subsequently a catheterization showed left main normal, left anterior descending coronary artery 80% mid occlusion, left circumflex 80% obtuse marginal one, right coronary artery 80% proximal. PAST MEDICAL HISTORY: Hypertension, diabetes, anterior wall myocardial infarction in [**2142**] and benign prostatic hypertrophy. PAST SURGICAL HISTORY: Polyp removal and a deviated septum. MEDICATIONS AT HOME: Norvasc 5 mg po q.d., Micronase 5 mg po q.d., Ecotrin 325 mg po q.d., Imdur 30 mg po q.d., Lopressor 50 mg po b.i.d. HOSPITAL COURSE: The patient was initially managed on the Medicine Service and then on [**2147-12-4**] the patient underwent coronary artery bypass graft times five, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein to left anterior descending coronary artery, saphenous vein to obtuse marginal, saphenous vein graft to PLV and saphenous vein graft to obtuse marginal one by Dr. [**First Name (STitle) 10102**]. Postoperatively, the patient did well. The patient was extubated and went off all drips in the Intensive Care Unit and was transferred onto the floor on postoperative day number two. Upon transfer to the floor the only complications was that the patient developed atrial fibrillation on [**2147-12-5**]. The rate was controlled and the patient was subsequently started on Amiodarone. Also on postop day number two the patient's Foley was discontinued at midnight, however, the patient was unable to void subsequently and the Foley catheter was reinserted and voided approximately 1 liter of urine was drained out and it was decided to leave the Foley catheter in. Prior to discharge the patient was able to work with physical therapy and was able to achieve a level five. He was able to walk 300 feet and climb stairs. DISCHARGE MEDICATIONS: Lopressor 75 mg po b.i.d., Lasix 20 mg po b.i.d. times ten days, potassium chloride 20 milliequivalents po b.i.d. times ten days, Micronase 5 mg po q.d., Amiodarone 400 mg po t.i.d. times four days and then 400 mg po b.i.d. times a week and then 400 mg po q.d. Percocet one to two tabs po q 4 to 6 hours prn, Colace 200 mg po q.d. CONDITION ON DISCHARGE: The patient was afebrile and vital signs were stable. Chest was clear. Heart was a regular rate and rhythm and in normal sinus. Sternum was stable. Incision was clean, dry and intact. No drainage. The patient will be discharged with a Foley catheter in and the patient's daughter is a nurse and she stated that she can take out the Foley 48 hours later and the patient will be followed up by Dr. [**Last Name (STitle) 39819**], telephone number is [**Telephone/Fax (1) 39820**] the urologist that the patient sees. His office is already contact[**Name (NI) **] and aware of the plan and the patient is also told to follow up with Dr. [**First Name (STitle) 10102**] in three to four weeks. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 02-253 Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2147-12-8**] 09:03 T: [**2147-12-8**] 09:15 JOB#: [**Job Number 39821**] ICD9 Codes: 9971, 4019, 412
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Medical Text: Admission Date: [**2152-9-21**] Discharge Date: [**2152-9-26**] Service: MEDICINE Allergies: Penicillins / Codeine / Sulfonamides / Aspirin / Valium / Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril / Egg / Oxycontin Attending:[**First Name3 (LF) 3151**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F w/ ipf, chf, cad, sjogren's syndrome presenting c/o severe shortness of breath for "many days." Pt reports that she has shortnes of breath at baseline (no home O2). She was in her usual state of health, which consists of chronic shortness of breath and Left sided nonradiating chest pain, for which she uses NTG 1-2 times a day. Pt is status post RCA stenting three years ago, since then with recurrent chest pains but negative nuclear tests, thus suggesting noncardiac origin of the chest pains. Pt went to her cardiologist ([**Doctor Last Name **]) for routine f/u today. She reported worsening shortness of breath, and on exam she "appeared uncomfortable, shivering and tachypneic. The respiratory rate is 40 per minute. Her blood pressure is 95/70 in both arms seated, pulse is 60 and regular." She was sent to ER for respiratory distress and lower than normal pressure. She reports 2 episodes of left sided nonradiating non-pleuritic sharp chest pain with no diaphosesis at rest each lasting 10 minutes and resolving without intervention (once while in the cardiologist's office and once while in the ED). She reports that this chest pain is consistent with recurrent chest pain that she has had at basline. ROS positive for chills and rhinorhea and 2 pillow orthopnea; but no PND or leg edema, no fevers, denies nausea/vommitting/diarrhea, no cough, no dysuria. Per ED discussion with pcp- [**Name10 (NameIs) **] has had multiple episodes of dyspnea with CP which is attributed to anxiety and then resolves after r/o MI. . In the ED: T 97.0 HR 58 BP 106/69 RR 25 SzO2 95%2L. Pt given ativan and rountine labs with CE, EKG, and CXR. EKG with no change, first set of CE negative, and admitted to medicine. Past Medical History: -- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-12**] P-MIBI: Normal pharmacologic stress myocardial perfusion with normal left ventricular cavity size and wall motion. -- CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR, mild PA systolic pressure -- Hypertension -- Diabetes mellitus -- Atrial fibrillation - per history but currently in sinus. Not on coumadin -- Sjogren's syndrome / scleroderma. -- squamous cell carcinoma -- Interstitial lung disease -- osteoporosis, with vertebral compression fractures. -- GERD / esophageal dysmotility / peptic ulcer disease. -- Macular degeneration -- h/o DVT -- s/p colectomy -- s/p CVA x4 -- s/p TAH/RSO -- s/p post appendectomy -- h/o femoral hernia repair Social History: [**Hospital1 18**] employee x 36 years, widowed for 38 years, 2 children (58 and 67). Pt does not see family often as live in [**State **] and [**State 4565**] Smoked for about 5 years 3 packs per day. Gave up about 65 yrs ago. Her husband was a heavy smoker, no alcohol. Walks with a cane, reports not leaving the house often (can walk to [**Location (un) **] Corner, about [**12-7**] mile). Lives alone w/ VNA 2x per week. Family History: One child died at age 60 of CAD/cancer. Father died at 52 of MI. Physical Exam: Vitals - T 98.4 BP 144/68 HR 64 RR 26 SaO2 100% on 3.5L NC General - pt is elderly female in moderate distress, shivering, and tachypnic HEENT - Brige of nose with scabed over lesion, [**Name (NI) 3899**], Pt blind, MMM, OP clear Neck - no thyromegaly, no lad, jvp flat CV - nml s1 s2 rrr no m/r/g Lungs - cta bil no rales/rhonchi/wheeze Abdomen - +bs, soft, ntnd, no hsm Ext - no c/c/e neuro: a&ox3, moving all extremities, nonfocal Pertinent Results: [**2152-9-21**] 02:34PM TYPE-[**Last Name (un) **] PO2-38* PCO2-23* PH-7.64* TOTAL CO2-26 BASE XS-4 COMMENTS-GREEN TOP [**2152-9-21**] 02:34PM LACTATE-3.4* [**2152-9-21**] 02:30PM GLUCOSE-100 UREA N-18 CREAT-1.2* SODIUM-137 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-23 ANION GAP-17 [**2152-9-21**] 02:30PM estGFR-Using this [**2152-9-21**] 02:30PM CK(CPK)-75 [**2152-9-21**] 02:30PM cTropnT-<0.01 [**2152-9-21**] 02:30PM CK-MB-NotDone proBNP-4429* [**2152-9-21**] 02:30PM WBC-14.2* RBC-4.23 HGB-13.7 HCT-38.0 MCV-90 MCH-32.4* MCHC-36.1* RDW-15.0 [**2152-9-21**] 02:30PM NEUTS-62.6 LYMPHS-27.3 MONOS-8.5 EOS-0.8 BASOS-0.6 [**2152-9-21**] 02:30PM PLT COUNT-195 [**2152-9-21**] 02:30PM PT-11.3 PTT-23.8 INR(PT)-1.0 . . Imaging: [**2152-9-21**] CXR - 1. Evidence of pulmonary fibrosis, unchanged. 2. Stable cardiomegaly. 3. Overall no change since [**2152-8-14**]. Brief Hospital Course: [**Age over 90 **] yo F w/ Sjogren's syndrome/Scleroderma, esophageal dysmotility, CAD s/p MI X 2 and s/p RCA stent, "chest pain syndrome" resulting in numerous admisssions and extensive negative work-up, who presents with SOB. . # Shortness of breath/chest pain - Pt has presented with similar symptoms multiple times in the past. Pt does have a hx of coronary artery disease and is status post RCA stenting 3 years ago, but has had recurrent chest pains on multipls occasions since which have been worked up with negative nuclear tests, thus suggesting noncardiac origin of the chest pains. She was ruled out for MI w/ serial EKG's and cardiac enzymes. While on the medical floor the patient became extremely anxious and developed a respiratory alkalosis to 7.84 and transferred to the MICU for observation. Anti-anxiolytics were used with good effect. Geriatrics was consulted to assist in anxiety control and recommended clonazepam 0.25 mg [**Hospital1 **] w/ lorazepam rescue. She was also instructed in the use of a brown paper bag to control anxiety -related SOB. . #Gout Patient experienced an acute episode of gout in her right big toe. This was treated w/ 2 days of PO prednisone 40 mg. She will continue 3 more courses to complete 5 total days of 40 mg daily prednisone. . # CAD Patient was ruled out for MI as stated above. Her home dose of beta blocker, statin, and aspirin were continued. . # HTN Well controlled on home BP meds (valsartan, nifedipine, metoprolol). . # DM Patient is currently diet controlled. However, w/ prednisone will continue sliding scale until she completes prednisone. . # Sjogrens/Scleroderma Pt has history of IPF associated with connective tissue disease. On no current therapy. Medications on Admission: Albuterol 1-2 Puffs Q6H PRN Aspirin 81 mg daily Calcium Carbonate 500 mg TID Valsartan 160 mg daily Nitroglycerin 0.3 mg PRN Nifedipine 60 mg SR daily Hexavitamin daily Metoprolol 100mg [**Hospital1 **] Atorvastatin 80 mg daily Isosorbide Mononitrate 60 mg SR TID Ipratropium inhalations QID Fosamax 70 mg weekly Protonix 20 mg daily Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO TID (3 times a day). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO at bedtime. 13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED) for 3 days: See sliding scale. 15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: Non-cardiac Chest Pain, Gout . Sencondary: - Coronary Artery Disease - Anxiety disorder, NOS - Congestive Heart Failure -- Hypertension -- Diabetes mellitus -- Atrial fibrillation - Not on coumadin -- Sjogren's syndrome / scleroderma. -- squamous cell carcinoma -- Interstitial lung disease -- osteoporosis, with vertebral compression fractures. -- GERD / esophageal dysmotility / peptic ulcer disease. -- Macular degeneration -- h/o Deep Venous Thrombosis -- status post colectomy -- status post CVA x4 -- status post Total Abdominal Hysterectomy /Right Salpingo Ooporectomy -- status post post appendectomy -- status post femoral hernia repair Discharge Condition: Stable, chest pain resolved, SaO2 95% on RA Discharge Instructions: You were admitted to the hospital with shortness of breath and chest pain. You were monitored in the Medical Intensive Care Unit because of your breathing. We think that your breathing difficulty may be related to external stressors. . You also had a gout flare which was treated with prednisone. Please continue to take this for the full course. If you have continued fevers, worse pain in the toe or elsewhere, please let your caretakers know or call your doctor. . If you have any symptoms of worsening shortness of breath, chest pain, abdominal pain, nausea, vommiting, or any other concerning symptoms please go to the emergency room. Followup Instructions: Provider PULMONARY BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-9-27**] 1:30 Provider [**Name9 (PRE) 1570**],INTERPRET [**Name Initial (PRE) **]/LAB NO CHECK-IN PFT INTEPRETATION BILLING Date/Time:[**2152-9-27**] 1:30 Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-9-27**] 2:00 Provider [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 250**] [**2152-10-3**] @ 12:20 ICD9 Codes: 4280, 4019, 2749
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Medical Text: Admission Date: [**2142-10-5**] Discharge Date: [**2142-10-25**] Date of Birth: [**2065-11-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Mental status change/Chest pain Major Surgical or Invasive Procedure: [**2142-10-10**] - CABGx3 History of Present Illness: The patient is 76-year-old man who presented with increasing angina and shortness of breath. Catheterization showed severe left main and left-sided coronary artery disease. Ejection fraction was preserved. He had mild mitral regurgitation. It was elected to proceed with bypass surgery. Past Medical History: Hypercholesterolemia HTN ?Parkinson's disease vs. Alzheimers BPH NPH (hydrocephalus) s/p VP shunt Back surgery Social History: Lives with wife. [**Name (NI) 4084**] smoked and drinks rarely. Physical Exam: GEN: Elderly man in NAD HEENT: NCAT, PERRL, EOMI, OP benign NECK: Supple No JVD HEART: RRR, no murmur LUNGS: Clear ABD: Benign EXT: 2+ pulses, no edema, no varicosities. NEURO: Slowed speech, A+Ox3. Pertinent Results: [**2142-10-5**] 08:52PM PT-12.7 PTT-26.9 INR(PT)-1.1 [**2142-10-5**] 08:52PM PLT COUNT-352 [**2142-10-5**] 08:52PM WBC-14.7* RBC-4.36* HGB-13.5* HCT-37.3* MCV-86 MCH-30.9 MCHC-36.1* RDW-13.3 [**2142-10-5**] 08:52PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2142-10-5**] 08:52PM ALT(SGPT)-57* AST(SGOT)-39 LD(LDH)-282* ALK PHOS-202* TOT BILI-0.4 [**2142-10-5**] 08:52PM GLUCOSE-109* UREA N-18 CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 [**2142-10-24**] 06:30AM BLOOD WBC-17.0* RBC-3.08* Hgb-9.3* Hct-27.0* MCV-88 MCH-30.3 MCHC-34.6 RDW-14.7 Plt Ct-543* [**2142-10-24**] 06:30AM BLOOD Plt Ct-543* [**2142-10-24**] 06:30AM BLOOD Glucose-85 UreaN-22* Creat-1.4* Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 [**2142-10-5**] CXR 1. No evidence of pneumonia or effusions. 2. Calcified pleural plaques bilaterally. [**2142-10-16**] CXR Decreased small left pleural effusion. [**2142-10-22**] HEAD CT 1. Air fluid level in the partially visualized right maxillary sinus which could represent sinusitis. Further evaluation could be obtained with a sinus CT. 2. Possible disruption of the VP shunt catheter as it courses in the posterior scalp. Comparison with prior outside exams is recommended to exclude the possibility of shunt malfunction. 3. Moderate hydrocephalus, possibly related to #2. [**2142-10-18**] Video Swallow 1. One trace aspiration event with nectar-thick liquid was observed under fluoroscopy. Aspiration did not occur with other consistencies. 2. The patient has a significant amount of retained material in the valleculae following swallowing, especially with solids. He is not aware of the retained material, and alternating solid and liquid consistencies seen to be effective at clearing retained material. [**2142-9-20**] Chest CT 1. Bilateral pleural effusions and pericardial effusion. 2. Multiple calcified pleural plaques, consistent with prior asbestos exposure. 3. Minimal soft tissue stranding adjacent to the sternum, reflecting post- surgical change from recent sternotomy wire for CABG. Additionally, there is focal soft tissue thickening at the level of the aortic root, which also likely reflects post-surgical change. No definite fluid collections are identified adjacent to the sternum. [**2142-10-12**] EKG Sinus rhythm. Right bundle-branch block. Compared to the previous tracing of [**2142-10-11**] the rate is slower. [**2142-10-22**] Head CT 1. Air fluid level in the partially visualized right maxillary sinus which could represent sinusitis. Further evaluation could be obtained with a sinus CT. 2. Possible disruption of the VP shunt catheter as it courses in the posterior scalp. Comparison with prior outside exams is recommended to exclude the possibility of shunt malfunction. 3. Moderate hydrocephalus, possibly related to #2. Brief Hospital Course: Mr. [**Known lastname 65399**] was admitted to the [**Hospital1 18**] on [**2142-10-5**] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner by the cardiac surgical service. The date of his case was postponed due to a catheterization lab emergency. On [**2142-10-10**], Mr. [**Known lastname 65399**] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 65399**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, plavix and aspirin were resumed. He developed leukocytosis and was pancultured. He was prophylactically started on vancomycin, levofloxacin and fluconazole. His cultures were negative except for MRSA in the sputum without clinical findings of pneumonia. He developed rapid atrial fibrillation which was treated with beta blockade and amiodarone. Gentle diuresis was initiated. The physical therapy service was consulted for assistance with his postoperative strength and mobility. As Mr. [**Known lastname 65399**] was noted to cough with feedings, a swallow evaluation was performed. As he did not show clinical signs of aspiration when fully awake and alert, a supervised regular diet was recommended. On postoperative day five, Mr. [**Known lastname 65399**] was transferred to the step down unit for further recovery. Given his continued leukocytosis, the infectious disease service was consulted. a C. difficile toxin was negative on several occasions. His fluconazole and levofloxacin were discontinued. Mild serosanguinous drainage was noted from his sternotomy. A chest CT was performed which was not suggestive of mediastinitis. A head CT scan was suggestive of sinusitis as well as possible disruption of the VP shunt catheter as it courses in the posterior scalp (outside film correlation was recommended) and moderate hydrocephalus. A repeat speech and swallow consult was performed as Mr. [**Known lastname 65399**] continued to display signs of difficulty swallowing. A video swallow was obtained which showed functional oral and pharyngeal swallowing ability for moist/ground solids and thin liquids if he takes a sip after each bite. There was significant residual in his throat that he was likely unable to feel thus sipping after each bite was encourage. A diet of ground and pureed foods with this liquids was recommended. A hematology/oncology consult was obtained given his persistent leukocytosis to evaluate for a malignancy. A blood smear was evaluated which suggested no evidence of a hematologic malignancy. Follow-up was recommended after discharge if his white cell count had not normalized. The neurosurgery service was consulted to evaluate his VP shunt. A CT shunt series was performed which showed the shunt to be intact without signs of infection or failure. Over time, Mr. [**Known lastname 65400**] white blood cell count slowly trended towards normal. Stopped [**2142-10-24**] Mr. [**Known lastname 65399**] continued to make steady progress and was discharged to rehabilitation on postoperative day 15. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). Disp:*60 Packet(s)* Refills:*2* 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:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*qs qs for one month* Refills:*2* 7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*2* 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*qs qs 1 month* Refills:*2* 11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days. Disp:*42 Tablet(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: Then one tablet po qd x 7 days. Disp:*21 Tablet(s)* Refills:*0* 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs one month* Refills:*2* 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs one month* Refills:*2* 15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Doctor Last Name 62491**]HealthCare Discharge Diagnosis: CAD HTN Hyperlipidemia Acute MI BPH Hydrocephalus (NPH) with VP shunt Leukocytosis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These innclude redness, drainage or increased pain. 2) Monitor vital signs. Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 3) No creams, lotions or powders to wound until it has healed. 4) No lifting more then 10 pounds for 10 weeks. No driving for 1 month. 5) Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. Follow-up with your cardiologist in 2 weeks. Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks. Completed by:[**2142-10-25**] ICD9 Codes: 2761, 4019, 2720
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Medical Text: Admission Date: [**2168-2-1**] Discharge Date: [**2168-2-17**] Date of Birth: [**2089-4-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: worst headache of life with right sided numbness and weakness. nausea, vomiting, slurred speech Major Surgical or Invasive Procedure: Right Frontal EVD Diagnostic cerebral angiogram Tracheostomy PEG placement History of Present Illness: This is a 78 year old male who at 9pm this evening was ambulating to the bathroom when he "reeled" to the right side and then leaned to his right side. At the same moment he experienced right lateral neck pain and headache associated with numbness on the right side of his body, slurred speech, and nausea and vomiting. The pt denies any visual disturbance, bowel and bladder incontinence, or hearing deficit at the time of the event. The patient was brought to an outside hospital where he had a Head Ct which was consistent with a posterior fossa hemorrhage with hemorrhage in the ventricles as well. The patient was transferred here for further management. The patient denies taking aspirin, Coumadin, Plavix heparin or Lovenox Past Medical History: HTN, asthma, low back surgery, enlarged prostate Social History: lives at home with his wife. The patient has three daughters who are at the bedside and one son who is flying in to see the patient overnight. Family History: noncontributory Physical Exam: PHYSICAL EXAM: O: T:97 BP: 136 / 66 HR:54 R: 18 O2Sats: 97% r/a Gen: pt is lying on stretcher with eyes closed in no apparent distress. HEENT: Pupils:1mm EOMs: lateral bilateral nystagmus Neck: supple Extrem: Warm and well-perfused. Neuro: Mental status: pt lethargic, eyes open to voice, cooperative with exam with much prompting. Orientation: Oriented to person, place, and date. Recall:grossly intact Language: Speech slow with good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils are 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength on right 4- biceps/triceps/delts.left foot drop is reported as patients baseline. dorsiflexors/plantar flexors [**1-21**]. Sensation: Intact to light touch. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements. ON DISCHARGE Exam fluctuates ; at best he will eye open to voice with tactile stim. No tracking, + simple commands (sticks out tongue / wiggle toes), Nods yest to name only (appropirate to challenge of name), + right facial weakness, pupils 1.5mm to pinpoint/ reactive, attempts to localize to sternal rub/ + grimace, triple flexion on lower ext. Pertinent Results: CT Head with and without contrast [**2168-1-31**] 1.Intracranial hemorrhage, centered in the superior vermis of the cerebellum, with extension to involve the subarachnoid and intraventricular spaces. The extent of hemorrhage has increased over the short-interval since the prior examination, with an increase in the size of the ventricles, which is likely related to the hemorrhage within the ventricular system resulting in outflow obstruction. Consideration may be given to external ventricular drainage. 2.Multiple small arterial feeding vessels extending towards the cerebellar vermian hemorrhage, with single prominent collecting vein, draining directly into the vein of [**Male First Name (un) 2096**], concerning for a vascular malformation. Given that there is no principal arterial feeder or typical vascular nidus identified, and that there is a close relationship of these multiple arteries to the tentorial dura, these findings suggest an underlying dural arteriovenous fistula, rather than a true arteriovenous malformation (which would, in any case, be unusual in a patient of this age). CT Head without contrast [**2168-2-2**] 1)New or increased bitemporal subarachnoid hemorrhage, concerning for new or continued bleeding from the cerebellar hemorrhagic focus. 2) Otherwise, stable appearance of cerebellar vermian hemorrhage with unchanged vasogenic edema causing mild supratentorial herniation. No midline shift. No increased mass effect. 3) Interval placement of a right frontal approach ventriculostomy catheter terminating into the third ventricle. No significant change in the degree of ventricular dilatation. Stable appearance of blood products within third, fourth and lateral ventricles, with some redistribution. _ _ _ _ _ ________________________________________________________________ Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2168-2-3**] 12:36 AM Final Report HISTORY: 78-year-old man, with altered mental status, and large cerebellar intraparenchymal hemorrhage, with intraventricular extension to the lateral, third and fourth ventricles. Now status post stent placement. De-saturating in the 70% FIO2 and febrile. Assess for pulmonary source. COMPARISON: Limited comparison from prior chest radiographs with the latest on [**2168-2-2**]. TECHNIQUE: MDCT images were acquired from the thoracic inlet to the lung bases before and after administration of IV contrast. Multiplanar reformatted images were obtained for evaluation. CTA CHEST: The study is moderately limited by suboptimal IV bolus timing as the segmental and subsegmental branches of the pulmonary arterial vasculature are insufficiently opacified. There is no central pulmonary embolism. The study is further limited by patient's inadvertent expiration during the supposedly end-inspiratory phase, evident by posterior tracheal wall bowing (2:16). The tracheobronchial tree remains patent. Respiratory motions limits evaluation of the lower lobes, but no suspicious lung masses or nodules are detected. There is bibasilar dependent atelectasis. Bilateral simple pleural effusions are small on the right and trace on the left. There is no pneumothorax. There are scattered calcified lymph nodes, with representative ones seen in the subcarinal station (2:26) and the right hilum (2:27). None of the central lymph nodes are not pathologically enlarged, ranging up to 6 mm in the right lower paratracheal station (3:52). There is no hilar or axillary lymphadenopathy. The visualized thyroid is normal. Heart size is top normal, with trace physiologic pericardial effusion. The left main coronary artery and the left anterior descending artery are partially calcified. Calcified atherosclerotic plaques scatter along the aortic arch. The aorta is otherwise normal in caliber and course, without acute aortic pathology. The remaining great mediastinal vessels are normal. The study is not designed for subdiaphragmatic diagnosis. A 24 x 21 mm hypodense left hepatic lesion (2:24) is compatible with a liver cyst. The right kidney is not imaged, but in the expected location of the right upper pole, there is a hypodense lesion, likely represents a exophytic renal cyst (2:56). The visualized spleen, adrenal glands and pancreas are grossly unremarkable. There is a small hiatal hernia. BONE WINDOW: No suspicious osteolytic or blastic lesion is noted. There are mild-to-moderate multilevel degenerative changes. IMPRESSION: 1. Suboptimal IV bolus timing limits assessment of subsegmental and segmental pulmonary artery vasculature. No central pulmonary embolism. No acute aortic pathology. 2. Bilateral small pleural effusions, right larger than left. 3. Partially calcified mediastinal and hilar lymph nodes. No lymphadenopathy. The study and the report were reviewed by the staff radiologist. _ _ _ _ _ ________________________________________________________________ [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-3**] 12:36 AM FINDINGS: The size of the cerebellar hemorrhage is similar to the previous study, measuring approximately 2.6 x 2 cm (AP x TRV). In comparison to [**2168-2-2**], there is new/increased bifrontal subarachnoid hemorrhage (2:24, 2:23). The amount and distribution of subarachnoid hemorrhage in the temporal lobe is similar to the most recent prior study. Blood again layers in the occipital horns. The amount of vasogenic edema surrounding the cerebellar hemorrhage is similar to the previous study, with partial effacement of the right ambient cistern. The ventricles have decreased in size. The right frontal approach ventriculostomy catheter is unchanged, terminating at the level of the foramen of [**Last Name (un) 2044**]. There is no shift of normally midline structures. No new parenchymal hemorrhage is identified. The visualized paranasal sinuses demonstrate minimal mucosal thickening of the posterior ethmoid air cells on the right. The paranasal sinuses and mastoid air cells are otherwise normally pneumatized and aerated. A small focus of pneumocephalus overlies the right frontal lobe, unchanged. IMPRESSION: 1. New or increased bifrontal subarachnoid hemorrhage in comparison to the study of roughly 16 hours earlier, concerning for new or continued bleeding, with extension of existing hemorrhage into the subarachnoid spaces. 2. Otherwise unchanged appearance of the cerebellar hemorrhage with surrounding vasogenic edema resulting in mild upward transtentorial herniation. 3. Interval decrease in the size of the lateral and third ventricles in comparison to [**2168-2-2**], s/p EVD. Unchanged blood layering in the occipital horns. COMMENT: Discussed by Dr. [**Last Name (STitle) 20059**] with [**Doctor First Name **] [**Doctor Last Name **] of neurosurgery 5:00am, [**2168-2-3**]. The study and the report were reviewed by the staff radiologist. _____________________________________________________________ [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-8**] 3:54 PM Final Report INDICATION: 78-year-old man with cerebellar bleed. Please evaluate. COMPARISON: Angiogram from [**2168-2-8**]. CT of the head from [**2168-2-6**], [**2-3**] and [**2168-2-5**]. Outside hospital CT from [**2168-1-31**]. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. FINDINGS: CT OF THE HEAD: Again seen is an intraventricular shunt traversing the right frontal lobe and ending in the frontal [**Doctor Last Name 534**] of the right lateral ventricle. In the interval, multiple hyperdense streak artifacts are visualized at the level of the superior vermis consistent with AVM embolization meterial. There is unchanged, predominantly right-sided hemorrhage in the superior vermis and superior cerebellar cistern. There is unchanged trace subarachnoid hemorrhage, predominantly seen in the right parietal lobe. There is significant decrease of the previously described intraventricular hemorrhage of the lateral ventricles and fourth ventricle. Unchanged periventricular and subcortical bilateral white matter hypodensities likely represent mixed small vessel ischemic disease. Unchanged mild mucosal thickening of the ethmoid sinuses. IMPRESSION: 1. Unchanged superior vermis, intraparenchymal and superior cerebellar cistern hemorrhage secondary to AVM. 2. In the interval, multiple hyperdense streak artifacts are visualized at the level of the superior vermis consistent with AVM embolization. 3. Unchanged position of the right lateral ventricle drain. 4. Significant decrease of the intraventricular hemorrhage. Unchanged right parietal lobe subarachnoid hemorrhage. _ _ _ _ _ _ _ _ ________________________________________________________________ [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Radiology Report UNILAT UP EXT VEINS US RIGHT PORT Study Date of [**2168-2-7**] 10:16 AM Final Report INDICATION: 78-year-old man with new right arm swelling. Rule out DVT. COMPARISON: None. FINDINGS: Grayscale, color, and Doppler evaluation of the right internal jugular vein, subclavian vein, brachial, cephalic, and basilic veins were performed. There is normal compressibility, flow, and augmentation. There is no evidence of DVT. IMPRESSION: No evidence of DVT in the right upper extremity. The study and the report were reviewed by the staff radiologist. _ _ _ _ _ _ ________________________________________________________________ [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Radiology Report CT CHEST W/O CONTRAST Study Date of [**2168-2-9**] 10:52 AM Final Report HISTORY: 78-year-old man, with pulmonary edema and possible infiltrate in the left lower lobe. Assess for changes. COMPARISON: CTA chest on [**2168-4-4**] and multiple chest radiographs with the latest on [**2168-2-9**]. TECHNIQUE: Non-contrast MDCT images were acquired from the thoracic inlet to the lung bases. Multiplanar reformatted images were obtained in 5 mm and 1.25 mm slice thickness for evaluation. CT CHEST WITHOUT CONTRAST: Compared to the prior study six days ago, there is interval increase to now small bilateral pleural effusions. There are relaxation atelectasis in the lower lobes, but superimposed infection cannot be excluded. Evaluation of the underlying lung lesions is limited in the setting of atelectasis and pleural effusions but no gross mass or nodule are noted. A calcified granuloma is noted in the right lower lobe (2:21). There is no pneumothorax. The patient is intubated with the endotracheal tube terminating 2.4 cm above the carina. A nasogastric tube traversing the esophagus with the tip terminating in the first/second portion of the duodenum. The heart is mild-to-moderately enlarged but without significant pericardial effusion. The unopacified great mediastinal vessels are grossly within normal limits. Mild coronary artery calcifications are most evident along the LAD. Scattered mediastinal lymph nodes are not pathologically enlarged, and likely reactive. There is no gross hilar or axillary lymphadenopathy. Several partially calcified mediastinal and hilar lymph nodes are indicative of old granulomatous disease. The study is not designed for subdiaphragmatic diagnosis. The 2.7 cm hypodense left hepatic lesion again seen, unchanged, likely represents hepatic cyst (2:38). Bilateral multiple hypodense renal lesions, incompletely evaluated but are likely to be renal cysts. The remaining visualized abdomen is grossly normal. BONE WINDOW: There is no osteolytic or blastic lesions concerning for malignancy. Lumbar spinal fusion hardware is noted in the scout image (1:2). IMPRESSION: 1. Interval increase of now small bilateral pleural effusions. Bibasilar relaxation atelectasis. Superimposed infection cannot be excluded. 2. Stable mild-to-moderate cardiomegaly, without significant pericardial effusion. The study and the report were reviewed by the staff radiologist. _ _ _ _ _ _ _ _ ________________________________________________________________ [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Neurophysiology Report EEG Study Date of [**2168-2-13**] FINDINGS: BACKGROUND: Is diffusely slow and disorganized consisting mostly of delta frequency slowing with occasional theta frequencies. There are fairly frequent generalized and multifocal (R>L) spikes and sharps occurring both in isolation as well as in brief semi-periodic runs with a frequency of around 1 Hz. There were no electrographic seizures noted. HYPERVENTILATION: Could not be performed secondary to patient being intubated. INTERMITTENT PHOTIC STIMULATION: Could not be performed secondary to the portable nature of this study. SLEEP: No normal sleep architecture was seen on this recording. CARDIAC MONITOR: A generally regular rhythm was noted; however, there were two distinct rhythms noted, one with a prolonged QRS complex and another with a narrow QRS complex. IMPRESSION: This is an abnormal extended routine EEG due to a diffusely slow and disorganized background marked by fairly frequent generalized and multifocal R>L spikes and sharps. At times, these occurred in brief semi-periodic runs with a frequency of about 1 Hz. There were no electrographic seizures noted. Overall, this background is suggestive of a sever encephalopathy. Amongst the most common causes of encephalopathy are metabolic derangements, medications, infection, and anoxia. [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**] Radiology Report BILAT LOWER EXT VEINS Study Date of [**2168-2-16**] 7:25 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2168-2-16**] 7:25 AM BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 109377**] Reason: eval for dvt [**Hospital 93**] MEDICAL CONDITION: 78 year old man with cerebellar hemorrhage. prolonged bedrest / low frade temps as of [**2168-2-15**] REASON FOR THIS EXAMINATION: eval for dvt Provisional Findings Impression: DLrc TUE [**2168-2-16**] 11:31 AM PFI: No evidence of bilateral lower extremity DVT. Final Report INDICATION: Patient is a 78-year-old male. With prolonged immobilization. Evaluate for deep venous thrombus. EXAMINATION: Bilateral lower extremity DVT study. COMPARISONS: None available. FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral, and popliteal veins were performed. There is normal flow, compressibility and augmentation. In addition, normal flow is demonstrated within the post-bilateral posterior tibial and peroneal veins. Symmetric respiratory variability is demonstrated in the common femoral veins. IMPRESSION: No evidence of bilateral lower extremity DVT. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] LI DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2168-2-16**] 1:25 PM Imaging Lab CT scan +/- contrast this am - reviewed by Dr. [**First Name (STitle) **] as stable without abcess. Final read pending. Brief Hospital Course: Patient presented to OSH after experiencing the worst headache of his life. on the evening of [**2-1**]. he complained of right sided head and neck pain as well as associated right sided numbness and weakness, nausea, vomiting, and slurred speech. On ehad Ct he was found to have a cerebellar hemorrhage most likely secondary to an AVM. He was transferred to [**Hospital1 18**] for further management and was placed in the ICU. Given his cerebellar bleeding as well as his Head CT which showed that his hemmorhage included both lateral ventricles as well as the third and fourth ventricles, he was taken to the OR semi-urgently on the afternoon of [**2-1**] for palcement of an EVD under anesthesia. This procedure was uneventful and he came out of the OR with the EVD at 20cm and clamped. He was stable overnight into the 16th with the EVD clamped and ICP's ranging from [**3-6**]. His mental status seemed to be slightly better on exam on [**2-2**] and he underwent cerebral angiography for diagnostic purposes. He later had ICP's that were slightly elevated with a headache as well. His EVD was opened at 20cm. He spiked a temp and was hypoxic as well. A fever workup ensued as well as a CTA of the chest. PE workup was negative. Ultimiately CSF grew out gram negative rods. It was re-sent and the gram stain was confirmed. On the 18th the distal collection system was changed out and csf was again sent off of the new system, the results were gram negative rods once again. Patient's EVD was then clamped in attemps to determine if EVD can be removed. ID is involved and recommended that we continue current antibiotic regimen. An echocardiogram was ordered. On the morning of [**2-5**] he was quite lethargic on exam with increased weakness right greater than left. This may be secondary to his fevers. Hhe was mentating appropriately and his EVD, which had been clamped overnight was working effectively when opened to assess. He had minimal ICP issues over night which did not require unclamping of his drain. A Head CT with contrast was obtained as well which was planned. CSF was obtained via the EVD in order to assess for any progression of infection. He was switched to meropenem. He had mental status changes and his EVD stopped working on [**2168-2-6**]. A new catheter was placed by Dr. [**Last Name (STitle) **]. His exam remained stable with the drain open at 20. The patient was brought to the angio suite for emobolization on Monday [**2168-2-8**]. he underwent the procedure without issue. His BP was tightly controlled 90-110 sys for approx. the first 24 hours. He was due to be extubated the am of [**2168-2-9**] but he had upper extremity twitching that was non suppressable, somewhat rhythmic and non responsive to ativan. An EEG was performed and the preliminary results were the he was not having seizures Stroke neurology was also consulted to assist in the assessment of the possible seizure activity. They recommended starting Keppra. He remained intubated in the ICU with no eye opeing or ability to follow commands and was subsequently trach and peged on [**2168-2-13**]. on [**2-14**] the EVD had remained clamped for 48 hours and subsequently removed. He was later weaned off of the ventilator to trach collar. His transfer to step down was hindered x 24 hours only by increased secreations requiring frequent suctioning. He had lower extremity dopplers which were negative. His CT +/- contrast was negative this am. He was deemed safe for d/c to rehab. Medications on Admission: HCTZ 25mg Po daily, Monopril 40mg Po daily, Mevacor 10mg PO daily, Hytrin 5mg Po Daily, Claritin 10mg PO prn, Relafen 750mg PO prn, Ultracet 50mg PO prn Discharge Medications: 1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 2. Metoclopramide 10 mg IV Q6H:PRN TF residual > 200 Hold for elevated QTc 3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 4. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for stop after last dose on [**2168-2-24**] weeks. 5. HydrALAzine 15-25 mg IV Q3H:PRN SBP > 160 do not exceed the dose of 200mg/24hrs 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 10. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing. 15. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours) as needed for back pain. 21. Lovastatin 20 mg Tablet Sig: 0.5 Tablet PO Daily (). 22. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 24. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 25. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: CEREBELLAR AVM respiratory failure dysphagia altered mental status CNS venrticulitis with Gram negative rod CNS infection Discharge Condition: Neuroligically improving. Discharge Instructions: Angiogram with embolization Medications: ?????? Continue all medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call the office at [**Telephone/Fax (1) **] to be seen by Dr. [**First Name (STitle) **] / Neurosurgery in 4 weeks - you will need a CT scan of the brain with contrast at that time. Completed by:[**2168-2-17**] ICD9 Codes: 431, 2760, 4019, 2720
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Medical Text: Admission Date: [**2109-10-8**] Discharge Date: [**2109-10-28**] Date of Birth: [**2066-10-31**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Ceftazidime / Carbamazepine Attending:[**First Name3 (LF) 848**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: -[**Location (un) **] t-tube removed and replaced with regular tracheostomy tube -Tunneled HIckman catheter History of Present Illness: 40-year-old bed-bound, hemiplegic, minimally-to-non-verbal woman with history of [**Doctor Last Name **] encephalitis (Dx at age 8), on 4x AEDs at baseline, s/p Left partial (parietal) hemispherectomy in [**2085**] (age 19) and s/p VNS placement, who now presents with several break-through GTC seizures witnessed at a Neurosurgery appointment for battery replacement surgical planning. She has daily focal seizures at baseline -- primarily causing twitching of her Right eyelind -- which are resistant to hemisphereotomy, VNS placement, and four AEDs. She also has occasional break-through GTC seizures. She also has a h/o episodes of aspiration pneumonia requiring intubation, subsequent tracheal stenosis, and is now s/p tracheostomy, then T-tube placement [**2101**]. Her VNS battery was at 0.55 years of life remaining back in [**Month (only) 116**] of [**2108**], but it could not be replaced at that time because the venous access requested by Neurosurgery could not be established at that time (Dr. [**Last Name (STitle) 739**] insisted on a port-a-cath, placement of which in the OR by Thoracic was unsuccessful). On the DOA [**10-8**], while she was at her Neurosurgery appointment (Dr. [**Name (NI) 14232**] office) for preoperative evaluation for her VNS battery replacement, she had multiple seizures involving eye deviation to the left, drooling, and cyanosis. Each seizure lasted less than one minute. From 12:30 to 4:30pm, there were 15-20 seizures. In the past when she has had these seizures, it was a sign that she had an underlying infection, such as aspiration pneumonia, UTI, or G-tube site infection. In the ED on admission, she received lorazepam 2mg IM and then phenobarbital 60mg IV. Of note, her phenytoin dose was decreased several weeks ago due to an elevated level of unclear cause. Her phenobarbital level was good at that point (mid-30s), but her phenytoin level of 7 was much lower than Dr.[**Name (NI) 3536**] goal of 20-25 in this patient, so she was bolused with 500mg IV phenytoin. ROS: The patient has chronic abdominal pain, which she continues to have today. At baseline she understands speech and is minimally verbal, with phonation (has T-tube since [**2101**], replaced once here since) that is understood only by family, not by her outpatient Neurologist/Epileptologist (Dr. [**First Name (STitle) 437**]. She has a right hemiplegia, with contracted/flexed RUE. Does not take PO (G-tube meal bolus feeds). No recent problems with fever, vision, hearing, cough, vomiting, diarrhea, urination, or new weakness. Past Medical History: 1. [**Doctor Last Name **] encephalitis 2. Epilepsy 3. Partial left hemispherectomy at age 19 complicated by right hemiparesis and partial aphasia 4. Mental retardation 5. Left thoracolumbar scoliosis 6. Vagal nerve stimulator implanted [**12-7**], needs battery change 7. h/o Aspiration pneumonias, now on scopolamine patch 8. S/p PEG placement using T tube 9. S/p tracheostomy 10. MRSA line infection in the past 11. Hx multiple UTIs, Urosepsis (enterococcus, VRE, other) 12. Difficult venous access requiring femoral sticks 13. Constipation 14. Mood disorder, on SSRI; also Zyprexa Social History: No history of tobacco, alcohol, illicit drug use. Lives in a group home. Family History: Unremarkable. No h/o seizures or [**Doctor Last Name **] Physical Exam: On admission in the ED: Gen: Lying in bed, NAD HEENT: NC/AT Neck: Supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Trach site c/d/i. Clear to auscultation bilaterally . Wearing face mask. Abd: +BS soft, nontender. G-tube site c/d/i. Ext: no edema Neurologic examination: Mental status: Awake, alert. Follows commands. Tries to talk and says a few words but dysarthric and difficult to understand. Says her name but when asked where she is she points to her mom and nurse to have them answer the question. Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V1-3: Sensation intact V1-V3. VII: Right facial droop (baseline). VIII: Hearing grossly intact. Motor: Tone is increased in the right arm, with the wrist and fingers flexed on that side. Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 1 3 2 1 1 . Legs withdraw to noxious, no spontaneous movement. The ankles are plantarflexed at rest and do not fully dorsiflex to 90 degrees. . Deep tendon Reflexes: . Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 1 1 1 1 1 MUTE Left 1 1 1 1 1 MUTE . Sensation: Intact to light touch on all extremities. . Coordination: Finger-nose-finger dysmetric on left; unable to test other limbs due to weakness. One seizure witnessed during the exam. The patient had eye deviation to the left, drooling, and arrest of purposeful movement for about 1 minute. She returned to baseline several minutes after the episode. Pertinent Results: Labs on admission ([**2109-10-8**]): [**2109-10-8**] 04:25PM BLOOD WBC-3.0* RBC-3.74* Hgb-11.6* Hct-35.6* MCV-95 MCH-30.9 MCHC-32.5 RDW-15.0 Plt Ct-212 [**2109-10-8**] 04:25PM BLOOD Neuts-40.5* Lymphs-51.6* Monos-4.3 Eos-2.7 Baso-0.8 [**2109-10-8**] 04:25PM BLOOD PT-14.2* PTT-37.3* INR(PT)-1.2* [**2109-10-8**] 04:25PM BLOOD Glucose-87 UreaN-18 Creat-0.6 Na-138 K-4.3 Cl-104 HCO3-26 AnGap-12 [**2109-10-11**] 08:24PM BLOOD ALT-28 AST-21 AlkPhos-175* TotBili-0.3 [**2109-10-10**] 02:09AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.8 Mg-2.0 [**2109-10-9**] 01:54AM BLOOD TSH-4.5* [**2109-10-9**] 01:54AM BLOOD Free T4-0.78* [**2109-10-9**] 01:54AM BLOOD Cortsol-5.3 (AM cortisol morning after admission) [**2109-10-10**] 03:08PM BLOOD Cortsol-22.3* (baseline for Syntropin stim test) [**2109-10-10**] 03:55PM BLOOD Cortsol-29.4* (30min after ACTH) [**2109-10-10**] 05:02PM BLOOD Cortsol-34.9* (60min after ACTH) [**2109-10-8**] 04:25PM BLOOD HCG-<5 [**2109-10-9**] 10:41AM BLOOD Type-ART pO2-73* pCO2-41 pH-7.39 calTCO2-26 Base XS-0 [**2109-10-10**] 03:28PM BLOOD freeCa-1.20 *********** AED levels: -Phenytoin/Phenobarbital: [**2109-10-17**] 01:54AM BLOOD Phenyto-18.4 [**2109-10-16**] 02:11AM BLOOD Phenyto-19.1 [**2109-10-15**] 04:27AM BLOOD Phenyto-20.1* [**2109-10-14**] 01:59AM BLOOD Phenyto-19.9 [**2109-10-13**] 01:12AM BLOOD Phenyto-20.2* [**2109-10-12**] 02:51AM BLOOD Phenoba-31.2 Phenyto-19.4 [**2109-10-11**] 01:26AM BLOOD Phenyto-18.0 [**2109-10-10**] 02:09AM BLOOD Phenyto-17.7 [**2109-10-9**] 01:54AM BLOOD Phenyto-17.4 [**2109-10-8**] 04:25PM BLOOD Phenoba-36.4 Phenyto-7.0* -Keppra: [**2109-10-8**] 11:05PM BLOOD LEVETIRACETAM (KEPPRA)- 78.6 (uln @1500bid=70) -Zonisamide: [**2109-10-8**] 11:05PM BLOOD ZONISAMIDE(ZONEGRAN)- 11.6 (10-40) *********** [**2109-10-28**] 04:22AM BLOOD WBC-7.0 RBC-2.93* Hgb-9.3* Hct-27.5* MCV-94 MCH-31.7 MCHC-33.7 RDW-15.3 Plt Ct-280 [**2109-10-28**] 04:22AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-140 K-4.0 Cl-105 HCO3-29 AnGap-10 [**2109-10-27**] 06:08AM BLOOD ALT-15 AST-15 [**2109-10-28**] 04:22AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8 [**2109-10-27**] 06:08AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.8 Mg-1.9 [**2109-10-13**] 05:23PM BLOOD Osmolal-272* [**2109-10-19**] 09:53AM BLOOD TSH-3.9 [**2109-10-28**] 04:22AM BLOOD Phenoba-28.3 Phenyto-20.0 Brief Hospital Course: Initial hospital/ICU course: 42 year old female with h/o [**Doctor Last Name **] encephalitis s/p left hemispherectomy in [**2085**], presents with increased seizures. At baseline, she has focal seizures involving right eye twitching, but she presented with multiple breakthrough seizures involving eye deviation to the left, drooling, and cyanosis. In the past when she has had these seizures, it was a sign that she had an underlying infection. Given the patient's history, the presentation was concerning for underlying infection versus low AED levels. Also of note, her AED battery was supposed to be changed back in [**2109-4-6**], when it had only 0.55 year's power remaining, so it is probably near-dead now, and this may have contributed her seizures on DOA as well. By system/problem: Neuro/epilepsy: Under Dr.[**Name (NI) 3536**] guidance, Ms. [**Known lastname **] was monitored on LTM-EEG for nearly a week in the ICU, up until transfer to the floor. No clinical or electrographic seizures, beyond the intermittent occurrence of skew-deviation/eye-twitching/nystagmoid eye movements clinically, and on LTM, her typical pattern of left/frontocentral spike/spike-and-slow-wave baseline abnormal EEG. Phenytoin level was subtherapeutic at 7 on admission (had been taking 50mg tid), and came up to 19-20 after a few IV loads of 100-500mg followed by increasing her baseline dose to 75mg tid (albumin low at 3.1, so this corresponds to a dose in Dr. [**Name (NI) 10875**] target range of 20-25 if her albumin were normal). may have Phenobarb remained stable and therapeutic in the mid-30s. Zonegran came back therapeutic (10) on admission but was incrased for better seizure control and Keppra was supratherapeutic (76) c/w her dosing of greater than 3g/d. Regarding her VNS replacement, this procedure was deferred until [**11-7**] for complete replacement because wires were cut/damaged as this was discovered during surgery. A venous mapping study was performed by IR and a Hickman tunneled femoral catheter was placed for her vns change. Pulm/ID, Pneumonia: Ms. [**Known lastname **] arrived with leukopenia, hypotension, and hypothermia. Thus, she was treated for SIRS on clinical grounds. Initially, no definitive infectious source was identified. Blood and urinalysis/urine cultures were negative/no growth on admission and afterwards. A c.diff a/b toxin screen sent later in her stay was negative as well. She did have small bibasilar consolidations, however, so she was started on linezolid (rather than vanc, due to a remote h/o vancomycin-resistant enterococcus) and cefepime and clindamycin was started to add coverage for anerobes, with c/f aspiration pneumonia given her recent breakthrough seizures and already tenuous pulmonary/tracheal anatomy (tracheal stenosis with long-standing T-tube). She was coughing frequently and a bronch was performed by IP due to inability to pass a suction catheter through her [**Location (un) **] T-tube. The bronch showed substantial obstruction from granulation tissue within the T-tube, so it was removed, the trachea was dilated, and the tube was replaced with a regular tracheostomy tube. ID was consulted, and suggested discontinuing first clindamycin and then all abx, and said pt OK for nsgy battery replacement if stable for 24h off abx. Subsequently, however, her first quality sputum cultures (previous attempts were unsuccessful due to her tracheal stenosis pre-dilation/tube-replacement) -- from a mini-BAL [**10-12**] and BAL [**10-13**] -- each grew out pseudomonas (cefepime-sensitive), so she was re-started for another 7d course of cefepime IV. She completed her course of Cefepime but also developed a rash from this. The rash cleared after discontinuation of the drug. Of note she recieved her 7D course. She is deemed a colonizer of pseudomonas. CV/hypotension: Ms. [**Known lastname **] was on a norepinephrine gtt intermittently for moderate hypotension over the first several days of her stay in the ICU. After 3-4d, she developed transient diabetes insipidus with UOP of 3-500mL/h and serum Na of up to 147, which was treated with vasopressin gtt, which incidentally allowed rapid weaning of the norepi gtt. Two bedside TTEs were unremarkable/normal. Endo/thyroid/HPA/DI: An elevated TSH of 4 and slighly low free T4, along with hypothermia and hypotension (in the setting of unclear ID process or not) along with a serum cortisol of 5 (thought to be inappropriately normal even at 2am in a patient thought to be septic) all prompted an Endocrinology consult shortly after admission. They recommended following up the thyroid studies later, as an outpatient given their limited utility in the acute setting. They also recommended an ACTH stim test the following afternoon, which revealed a baseline daytime level of 22 (normal / appropriate), and a 60min post-ACTH stimulation level of 38, also wnl. See above w.r.t. transient episode of DI, treated with vasopressin gtt. GI: Patient fed via G-tube with continuous TFs. After her ICU stay she was transferred to the floor where she had an uncomplicated course. There were seizure breakthrough and she was relaoded with dilantin IV for a level 20-25 uncorrected. The group home was instructed and trained in proper trach and catheter upkeep. Medications on Admission: Zyprexa 5 mg Tab 1 Tablet(s) via GT daily Singulair 5 mg Chewable Tab 2 Tablet(s) via GT once daily Fleet Enema 19 gram-7 gram/118 mL ([**Known lastname 65**] unavailable) Keppra 500 mg Tab 3 Tablet(s) via GT in the am; 2 tabs at noon; and 3 tabs at night Zonisamide 100 mg Cap 3 Capsule(s) via GT q pm DuoNeb 0.5 mg-2.5 mg/3 mL Neb Solution 1 vial vis neb every 4 hours while awake Phenobarbital 30 mg Tab 1 Tablet(s) via GT q pm Phenobarbital 60 mg Tab 1 Tablet(s) via GT in the am and 1 tab at 2p; and 1 tab po prn for seizures per protocol Tylenol 325 mg Tab ([**Known lastname 65**] unavailable) Diazepam 10 mg Tab 1 Tablet(s) via GT 1 hour prior to medical/gyn exam Potassium Chloride SR 20 mEq Tab, Particles/Crystals 1 Tab(s) via GT q am Guaifenesin 100 mg/5 mL Oral Liquid 15cc GT Q6hr as needed for chest congestion Simethicone 60 mg Tab ([**Known lastname 65**] unavailable) Colace 100 mg Cap 1 Capsule(s) GT twice a day Ducodyl 5 mg Tab ([**Known lastname 65**] unavailable) Dilantin Infatabs 50 mg Chewable 1 Tablet(s) by mouth three times per day Acidophilus Cap 1 Capsule(s) GT once a day Scopolamine 1.5 mg 72 hr Transderm Patch 1 patch transdermally with change every 72 hours Prevacid SoluTab 30 mg Rapid Dissolve 1 Tablet(s) via GT once a day Miralax 17 gram/dose Oral Powder 1 tsp GT daily GT with 8oz of water Fluoxetine 20 mg Cap 1 Capsule(s) by gt once daily Feeds: Fibersource HN @50cc/hr, continuous Discharge Medications: 1. montelukast 5 mg Tablet, Chewable [**Known lastname **]: Two (2) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 2. levetiracetam 100 mg/mL Solution [**Known lastname **]: Fifteen (15) ml PO BID (2 times a day): LeVETiracetam 1500 mg NG [**Hospital1 **] Morning and evening dose Order was filled by pharmacy with a dosage form of Solution and a strength of 100 MG/ML . Disp:*qs * Refills:*2* 3. levetiracetam 100 mg/mL Solution [**Hospital1 **]: Ten (10) ml PO DAILY (Daily): LeVETiracetam 1000 mg NG DAILY Afternoon dose Order was filled by pharmacy with a dosage form of Solution and a strength of 100 MG/ML. Disp:*qs * Refills:*2* 4. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO BID (2 times a day): PHENObarbital 60 mg NG [**Hospital1 **] Morning and 2pm doses Order was filled by pharmacy with a dosage form of Elixir and a strength of 20 MG/5 ML . Disp:*qs * Refills:*2* 5. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: 7.5 ml PO QPM (once a day (in the evening)): PHENObarbital 30 mg NG QPM Order was filled by pharmacy with a dosage form of Elixir and a strength of 20 MG/5 ML . Disp:*qs * Refills:*2* 6. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H (every 6 hours) as needed for Fever/Pain. Disp:*qs * Refills:*0* 7. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO DAILY (Daily) as needed for Generalized seizure >5 minutes, or more than 3 generalized seizures in one hour.: PHENObarbital 60 mg NG DAILY:PRN Generalized seizure >5 minutes, or more than 3 generalized seizures in one hour. Do not use for focal seizures. Order was filled by pharmacy with a dosage form of Elixir and a strength of 20 MG/5 ML . Disp:*qs * Refills:*0* 8. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO Q6H (every 6 hours) as needed for Chest congestion. Disp:*qs * Refills:*1* 9. simethicone 40 mg/0.6 mL Drops, Suspension [**Hospital1 **]: One (1) PO QID (4 times a day) as needed for Gas pains. Disp:*qs * Refills:*2* 10. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day) as needed for constipation: Docusate Sodium 100 mg PO BID Give meds by GT only. . 11. scopolamine base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*qs Tablet,Rapid Dissolve, DR(s)* Refills:*2* 13. fluoxetine 20 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO DAILY (Daily): Fluoxetine 20 mg NG/peg DAILY . Disp:*qs * Refills:*2* 14. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. Disp:*qs * Refills:*1* 15. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 16. zonisamide 100 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QPM (once a day (in the evening)). Disp:*120 Capsule(s)* Refills:*2* 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*qs * Refills:*2* 18. phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: 1.5 Tablet, Chewables PO TID (3 times a day) as needed for epilepsy. Disp:*100 Tablet, Chewable(s)* Refills:*2* 19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed for groin itching. Disp:*1 * Refills:*0* 20. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed for rash/itching. Disp:*1 * Refills:*0* 21. triamcinolone acetonide 0.1 % Ointment [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. Disp:*1 * Refills:*0* 22. heparin, porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g.Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. Dispense QS x 30 [**Last Name (un) 32460**] . Disp:*qs ML(s)* Refills:*3* 23. Outpatient Lab Work [**2109-11-5**]: Lab: CBC with Diff. Chem 10. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: 1. Epilepsy 2. Tracheal stenosis 3. Pseudomonas pneumonia 4. Autonomic/neuroendocrine abnormalities (hypothermia, hypotension, and hypothyroidism, and transient diabetes insipidus) of unclear etiology Discharge Condition: x Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Mental Status: Confused. Discharge Instructions: x You were admitted for increase in seizures. You were treated for this in the ICU. You were also treated for a pneumonia with cefepime and ultimately found to have a chronic colonization of the airways. For your seizures we gave you dilantin and increased you zonegran. You were also found to have a broken VNS which will be replaced in 2 weeks by neurosurgery. During your stay you had a hickman catheter placed which should stay in place at least until your surgery. You also had your trach tube replaced for an updated one (#7 cuffed Portex Per-fit trache). You will need a blood test done on [**11-5**]. you are to call Dr [**Last Name (STitle) **] office with the results. YOu are to have your VNS changed by Dr [**Last Name (STitle) **] (neurosurgery) on [**11-7**], his number is [**Telephone/Fax (1) 3231**] Followup Instructions: x -[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**]: Neurology Time/date:Please call to make an appointment in 4 weeks. The Phone#: ([**Telephone/Fax (1) 40691**] -Dr [**Last Name (STitle) **]: Neurosurgery tentative OR appointment for [**11-7**]. Call [**11-5**] with lab results to Dr [**Last Name (STitle) **] office [**Telephone/Fax (1) 3231**]. -Lab slip prescribed for [**2109-11-5**]. CBC w/ diff. Chem 10. PT/PTT/INR. Completed by:[**2109-10-28**] ICD9 Codes: 0389, 5070, 2761
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Medical Text: Admission Date: [**2172-12-8**] Discharge Date: [**2172-12-14**] Date of Birth: [**2095-2-11**] Sex: M Service: CARDIOTHORACIC Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2172-12-8**] 1. Aortic valve replacement with a 27 mm [**Company 1543**] Mosaic Ultra aortic valve bioprosthesis model number 305, serial number [**Serial Number 92202**]. 2. Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the distal right coronary artery. 3. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 77 year old male presented to ED today after found to have abnormal stress test. On day prior to admission, he reported left anterior chest, shoulder and upper arm pain/pressure/numbness for 9 hours. He reports chest pain started while he was working at his computer and persisted until he went to bed that evening. He also says that over last few months he has had occasional dyspnea on exertion. He saw his PCP who recommended that he undergo an ETT. His exercise stress test showed ST depressions in inferior and lateral leads. He was then referred to [**Hospital1 18**] for a cardiac catheterization. He was found to have aortic stenosis and coronary artery disease and is now being referred to cardiac surgery for revascularization and an aortic valve replacement. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: Mild aortic stenosis -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Anemia, vitamin B12 deficiency Erectile Dysfunction seborrheic keratosis ocular hypertension GERD hypothyroidism CKD Social History: Lives with significant other. Previously worked in sales/marketing. -Tobacco history: never smoked -ETOH: occasional -Illicit drugs: denies Family History: Father had pacemaker placed when 60. Mother with hx of HTN and CVA family hx also notable for colon cancer and diabetse No additional family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam Pulse:58 Resp:20 O2 sat:100/RA B/P Right:182/72 Left:201/63 Height:6'2" Weight:170 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [III/VI] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none - muscle bulge on right mid shin (present x 60 years) Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left:transmitted murmur B/L Pertinent Results: [**2172-12-12**] 05:52AM BLOOD WBC-9.4 RBC-2.50* Hgb-7.8* Hct-22.4* MCV-90 MCH-31.2 MCHC-34.9 RDW-13.2 Plt Ct-244 [**2172-12-8**] 02:30PM BLOOD WBC-12.1*# RBC-3.52* Hgb-10.6* Hct-31.3* MCV-89 MCH-30.0 MCHC-33.8 RDW-13.3 Plt Ct-177 [**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0 [**2172-12-8**] 01:30PM BLOOD PT-12.9* PTT-32.9 INR(PT)-1.2* [**2172-12-12**] 05:52AM BLOOD Glucose-108* UreaN-39* Creat-1.7* Na-132* K-5.1 Cl-100 HCO3-27 AnGap-10 [**2172-12-8**] 02:30PM BLOOD UreaN-28* Creat-1.3* Na-139 K-4.9 Cl-110* HCO3-24 [**2172-12-14**] 04:32AM BLOOD Hct-27.2* [**2172-12-13**] 04:57AM BLOOD WBC-7.7 RBC-2.39* Hgb-7.4* Hct-21.8* MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-269 [**2172-12-14**] 04:32AM BLOOD UreaN-36* Creat-1.6* Na-136 K-4.8 Cl-102 [**2172-12-13**] 04:57AM BLOOD Glucose-91 UreaN-38* Creat-1.6* Na-135 K-4.5 Cl-103 HCO3-27 AnGap-10 [**2172-12-14**] 04:32AM BLOOD PT-24.8* INR(PT)-2.4* [**2172-12-13**] 04:57AM BLOOD PT-11.1 INR(PT)-1.0 [**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0 [**2172-12-8**] 02:30PM BLOOD PT-12.6* PTT-33.0 INR(PT)-1.2* Echocardiographic: [**2172-12-10**] Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 77 ml/beat Left Ventricle - Cardiac Output: 4.67 L/min Left Ventricle - Cardiac Index: 2.67 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 7 mm Hg <= 10 mm Hg Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *17 < 15 Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 19 mm Hg Aortic Valve - LVOT VTI: 27 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.09 Mitral Valve - E Wave deceleration time: *291 ms 140-250 ms TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2172-12-1**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. Prolonged (>250ms) transmitral E-wave decel time. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Increased left ventricular filling pressure. Well-seated, normally functioning aortic valve bioprosthesis with borderline-elevated transaortic valvular mean pressure gradients (19 mmHg). Normal pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2172-12-1**], a bioprosthetic aortic valve is now present. The pulmonary artery systolic pressure has normalized. CXR: IMPRESSION: [**2172-12-13**] Right apical pneumothorax is tiny and unchanged. Small bilateral pleural effusions are stable and bibasilar atelectasis has improved. Heart size is normal. Right jugular line ends low in the SVC. No pulmonary edema. Brief Hospital Course: On [**2172-12-8**] Mr.[**Known lastname 23903**] was taken to the operating room and underwent Aortic valve replacement(#27 mm [**Company 1543**] Mosaic Ultra aortic valve bioprosthesis)/Coronary artery bypass grafting x3 (left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the distal right coronary artery) with Dr. [**Last Name (STitle) 914**]. Please see operative report for further details.CARDIOPULMONARY BYPASS TIME: 144 minutes.CROSSCLAMP TIME: 123 minutes. He tolerated the procedure well and transferred to the CVICU intubated and sedated. He awoke neurologically intact and was extubated. He weaned off pressor support and initially Beta-blocker was held due to nodal rhythm. Statin/Aspirin and diuresis were initiatited. All lines and drains were discontinued per protocol. POD#1 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. POD#3 he went into rate controlled atrial fibrillation/flutter. He was placed on Beta-blocker and oral Amiodarone. Anticoagulation with Coumadin was initiated. His INR went from 1.0->2.4->3.2 and he was given 0 mg Coumadin on [**2172-12-14**] with repeat INR on [**2172-12-15**] scheduled. INR goal 2.0-3.0 - [**Hospital 2274**] [**Hospital3 271**] to provide further Coumadin instructions. On [**2172-12-13**] he was transfused with 2 units of PRBC for HCT of 21.8 which increased to Hct of 27.2. He was given Folic acid, iron and Vitamin C for post op anemia. He continue to progress and on POD 6 he was cleared for discharge to home with VNA services. All follow up appintments were advised. Medications on Admission: Lisinopril 20 mg daily Levothyroxine 50mcg po daily Omeprazole 20mg po daily Vitamin B12 1000mcg po daily HCTZ 25mg po daily (sometimes halved dose or did not take) Fish oil Red yeast rice extract Discharge Medications: 1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for PAIN/TEMP. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. 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* 10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200 [**Hospital1 **] x 2 weeks then 200 mg daily x 1 month or seen by cardiologist. Disp:*60 Tablet(s)* Refills:*0* 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months. Disp:*60 Tablet(s)* Refills:*0* 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months. Disp:*60 Tablet(s)* Refills:*0* 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed for goal INR 2.0-3.0 - Take NO Coumadin on [**2172-12-14**]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Severe critical aortic stenosis/Severe 3-vessel coronary disease. s/p AVR/CABG Atrial Flutter Secondary: Dyslipidemia Hypertension Mild aortic stenosis Anemia, vitamin B12 deficiency Erectile Dysfunction seborrheic keratosis ocular hypertension GERD hypothyroidism CKD (baseline Creat 1.3-1.5) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] - the office will call you with an appointment for 1 month [**Location (un) 2274**] office to call with appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**University/College **] [**Location (un) 2274**] Center for the next [**1-16**] weeks WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2172-12-17**] at 10:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 17528**],[**First Name3 (LF) 17529**] [**Telephone/Fax (1) 17530**] in [**3-18**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Coumadin for Atrial Flutter: INR Goal 2.0-3.0 [**Hospital 2274**] [**Hospital3 **] to call with further Coumadin instructions Next INR draw Tuesday [**2172-12-15**] Phone: [**Telephone/Fax (1) 17530**] Fax: [**Telephone/Fax (1) 6808**] Completed by:[**2172-12-14**] ICD9 Codes: 4241, 2761, 9971, 2767, 5859, 2449, 2859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3136 }
Medical Text: Admission Date: [**2111-4-15**] Discharge Date: [**2111-4-25**] Service: CARDIOTHORACIC Allergies: Azithromycin / Oxycodone / Calcitonin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2111-4-16**] Aortic valve replacement with a 21-mm St. [**Hospital 923**] Medical Biocor tissue valve History of Present Illness: 86 year old female has a history of hypertension, hyperlipidemia, PAF, GERD and prior bacterial endocarditis. She has been followed through the years for aortic stenosis which is now severe (Peak gradient of 85mmHG/valve area of 0.82cm2). She has noticed a decline in her activity tolerance over the past year. She easily becomes extremely short of breath and profoundly fatigued with as little as walking a few minutes. Often when she is symptomatic, she feels extremely cold. She also describes intermittent flutterings in her chest and occasional "indigestion" type symptoms that can be felt when lying down in bed or at times during the day, often resolving with relaxation. She was found to have non-significant coronary disease on cardiac catheterization. Past Medical History: Aortic stenosis Hypertension Hyperlipidemia Paroxysmal atrial fibrillation [**2087**] acute bacterial endocarditis/osteomyelitis GERD/hiatal hernia, lower esophageal ring [**2106**] syncope (due to dehydration per patient report) Restless leg syndrome Hx of [**Hospital1 15309**] neuroma of feet Degenerative joint disease Osteoporosis/Arthritis [**2108**] diverticulitis/rectal bleeding Hard of hearing (hearing aids bilaterally) Past Surgical History: s/p laminectomy s/p Tonsillectomy s/p Hysterectomy s/p Appendectomy s/p Hemroidectomy Social History: Race:Caucasain Last Dental Exam:2 months ago, Dental clearance obtained in chart Lives with:is widowed with three children. She lives alone, daughter is staying with her until surgery. She uses a cane Occupation:retired Tobacco:denies ETOH:denies Family History: Mother with "enlarged" heart, Bother had MI Physical Exam: Pulse:57 Resp:18 O2 sat:98/RA B/P Right:181/54 Left:189/76 Height:5' Weight:172 lbs General: awake alert oriented Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Murmur [**3-27**] harsh systolic ejection murmur with radiation to carotid areas. Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] + bowel sounds Extremities: Warm [x], well-perfused [x] Trace Edema, some superficial varicosities on the right calf. Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid: bilateral carotid bruits Pertinent Results: [**2111-4-15**] 06:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2111-4-15**] 06:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2111-4-15**] 06:32PM URINE RBC-1 WBC-26* BACTERIA-FEW YEAST-NONE EPI-3 [**2111-4-15**] 06:32PM URINE HYALINE-1* [**2111-4-15**] 06:32PM URINE MUCOUS-RARE [**2111-4-15**] 05:35PM GLUCOSE-104* UREA N-20 CREAT-1.1 SODIUM-136 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13 [**2111-4-15**] 05:35PM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-74 AMYLASE-45 TOT BILI-0.3 [**2111-4-15**] 05:35PM LIPASE-29 [**2111-4-15**] 05:35PM ALBUMIN-4.3 MAGNESIUM-2.2 [**2111-4-15**] 05:35PM %HbA1c-6.0* eAG-126* [**2111-4-15**] 05:35PM WBC-11.6*# RBC-4.15* HGB-12.2 HCT-35.1* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.6 [**2111-4-15**] 05:35PM PLT COUNT-252 [**2111-4-15**] 05:35PM PT-12.8 PTT-26.2 INR(PT)-1.1 CXR: PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG, elevated white blood count. Comparison is made with prior study, [**4-18**] and [**4-19**]. Pulmonary edema has markedly improved. Cardiomegaly is stable. Widened mediastinum is stable. Left PICC tip is in the cavoatrial junction or upper right atrium. Moderate-to-large bilateral pleural effusions are more conspicuous than before and associated with bibasilar opacities, left greater than right. These opacities could be due to atelectasis, but superimposed infection cannot be excluded. ECG: Probable sinus bradycardia with A-V conduction delay. Unstable baseline makes assessment difficult. Probable left atrial abnormality. Delayed R wave progression is non-diagnostic. Since the previous tracing of [**2111-4-15**] limb lead QRS voltage and delayed R wave progression pattern are both less prominent. Brief Hospital Course: Mrs. [**Known lastname 75001**] was admitted one day before surgery for heparinization prior to aortic valve replacement. She underwent usual lab work-up. On [**4-16**] she was brought to the operating room where she underwent an aortic valve replacement. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Later this day she was weaned from sedation, awoke neurologically intact and extubated. She had atrial fibrillation post-op (history of PAF) and was started on Amiodarone. In addition to atrial fibrillation, she had respiratory issues post-op with severe pulmonary congestion that required aggressive diuresis and pulmonary toilet. Coumadin was started for her atrial fibrillation. Due to these issues she remained in the ICU until post-op day five when she was transferred to the telemetry floor. While here she continued to receive beta blockers and was diuresed towards her pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. She worked with physical therapy for strength and mobility post-op. On POD #9, Mrs. [**Known lastname 75001**] is now ready for discharge to rehabilitation center. Her INR is therapeutic at 2.6. Medications on Admission: AMOXICILLIN prior to dental visits LANSOPRAZOLE 30 mg daily METOPROLOL SUCCINATE ER 50 mg daily PRAVASTATIN 40 mg daily TYLENOL ARTHRITIS PAIN Discharge Medications: 1. docusate sodium 100 mg Capsule [**Known lastname **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. warfarin 1 mg Tablet [**Known lastname **]: 0.5 Tablet PO DAILY (Daily) for 1 doses: 0.5mg x 1 tonight then daily per HO. Disp:*30 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet [**Known lastname **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Disp:*30 Tablet(s)* Refills:*0* 5. magnesium hydroxide 400 mg/5 mL Suspension [**Known lastname **]: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*QS ML(s)* Refills:*0* 6. bisacodyl 10 mg Suppository [**Known lastname **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 7. lisinopril 10 mg Tablet [**Known lastname **]: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. pravastatin 20 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 10. tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 11. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) for 7 days: then decrease to 200mg by mouth [**Hospital1 **] x 1week, then decrease to 200mg by mouth daily. Disp:*28 Tablet(s)* Refills:*1* 12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN flush Peripheral IV - Inspect site every shift 14. Ondansetron 4 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past medical history: Hypertension Hyperlipidemia Paroxysmal atrial fibrillation [**2087**] acute bacterial endocarditis/osteomyelitis GERD/hiatal hernia, lower esophageal ring [**2106**] syncope (due to dehydration per patient report) Restless leg syndrome Hx of [**Hospital1 15309**] neuroma of feet Degenerative joint disease Osteoporosis/Arthritis [**2108**] diverticulitis/rectal bleeding Hard of hearing (hearing aids bilaterally) Past Surgical History: s/p laminectomy s/p Tonsillectomy s/p Hysterectomy s/p Appendectomy s/p Hemroidectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. 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.[**Last Name (STitle) **] PCP:[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] MD Cardiologist:[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] MD **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication:Atrial Fibrillation Goal INR:2-2.5 First draw Results to phone fax Completed by:[**2111-4-25**] ICD9 Codes: 4241, 5990, 2761, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3137 }
Medical Text: Admission Date: [**2168-3-24**] Discharge Date: [**2168-5-26**] Date of Birth: [**2168-3-24**] Sex: M Service: NB HISTORY: [**Known lastname **] [**Known lastname **] is a former 27-4/7 week gestational age infant admitted to the Neonatal Intensive Care Unit for prematurity and respiratory distress. MATERNAL HISTORY: Mom is a 29-year-old gravida 2, para 0 now 1 woman with past OB history notable for TAB x1 approximately 10 years ago. Past medical history unremarkable, with current medications including only acetaminophen and ranitidine. PRENATAL MATERNAL SCREENS: Blood type O positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella status pending, and HIV negative. PREGNANCY HISTORY: Last menstrual period on [**2167-9-13**] for EDC of [**2168-6-19**] and estimated gestational age of 27-4/7 weeks by dates and confirmatory ultrasounds. Ultrasounds at 14, 22, 24, and 27 weeks normal and consistent with dates. Pregnancy was complicated by first trimester bleeding, presented with one week history of abdominal pain with hypertension in obstetrician's office on date of delivery. Subsequent evaluation consistent with HELLP syndrome with maternal platelet count of 60,000. Betamethasone was administered eight hours prior to delivery. Mom proceeded to cesarean section under general anesthesia. Membranes were ruptured at delivery yielding clear amniotic fluid. No maternal fever or other signs of chorioamnionitis. No preterm labor. The infant emerged hypotonic and apneic. Was orally and nasally bulb suction, dried, and tactile stimulation provided with onset of inconsistent respiratory effort, but intermittent bradycardia from 90 to 100 beats per minute. Bag mask ventilation for 3-4 minutes with resolution of cyanosis, but continued poor respiratory drive. Infant was intubated on initial attempt and the procedure was tolerated well without complications. The infant was subsequently pink and 100 percent FIO2 with moderate intercostal retractions with spontaneous breath and well- maintained heart rate. He was transferred uneventfully to the Newborn Intensive Care Unit. PHYSICAL EXAMINATION: Preterm infant with examination consistent with 28 weeks gestation. Birth weight 962 grams (25th to 50th percentile). Length 36 cm (50th percentile). Head circumference 25.25 cm (25th to 50th percentile). Vital signs: Rectal temperature 95.1, heart rate 138, respiratory rate 52, and oxygen saturation in 100 percent FIO2 100, blood pressure 45/18, and a mean arterial pressure of 28. Head, eyes, ears, nose, and throat: Anterior fontanel is soft and flat, nondysmorphic, palate intact, neck and mouth normal, moderate facial bruising. Chest: Moderate retractions with spontaneous breaths, good excursion with ventilated breaths, fair breath sounds bilaterally, scattered coarse crackles. Cardiovascular: Infant well perfused, regular, rate, and rhythm, femoral pulses normal, S1, S2 normal, no murmur auscultated. Abdomen is soft, nondistended, no organomegaly, no masses, bowel sounds active, anus patent, three-vessel umbilical cord. CNS: Active infant, responds to stimulation, tone decreased in symmetric distribution, moving all extremities symmetrically. Skin: Facial bruising, otherwise unremarkable. Musculoskeletal: Normal spine, limbs, hips, clavicles. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] was intubated in the delivery room and transported to the Newborn Intensive Care Unit and placed on conventional mandatory ventilation. He received two doses of Survanta and was subsequently extubated to CPAP by day of life two. He received two bicarb boluses on day of life six for persistent metabolic acidosis. He weaned to nasal cannula oxygen by day of life 22, and then to room air by day of life 40. Caffeine citrate was started on day of life two for apnea of prematurity and discontinued on day of life 46. His last bradycardic episode was on [**5-18**]. He has has several desaturation episodes not associated with apnea or bradycardia durign the weeks since his last apneic spell. These were felt due to reflux and/or oropaharyngeal discoordination. Persistence of these lead to starting od Enfamil AR on [**5-31**]. His last episode occured on [**5-29**]. Cardiovascular: [**Known lastname 49966**] blood pressure has been stable throughout his hospitalization. No fluid boluses or pressors were required. He received a course of indomethacin on day of life three for a patent ductus arteriosus. A followup echocardiogram on day of life five showed a small patent ductus arteriosus felt to be clinically insignificant. A louder murmur on day of life 18 prompted a repeat echocardiogram, which showed a 1.5 mm patent ductus arteriosus with left-to-right flow. He received another course of indomethacin at that time. A followup echocardiogram on day of life 20 showed a small less than 1 mm patent ductus arteriosus with left-to-right flow again felt to be clinically insignificant. He continues to have a soft intermittent murmur. Fluid, electrolytes, and nutrition: Umbilical arterial and umbilical venous catheters were placed shortly after admission to the Newborn Intensive Care Unit. IV fluids of D5W were started at 100 cc/kg/day. Enteral feeds were started on day of life nine after his course of indomethacin and advanced to full volume feeds by day of life 15. He was NPO again on day of life 18 for a second course of indomethacin. He was back to full volume feeds by day of life 25. Caloric density was increased to 30 calorie breast milk with ProMod. Transient hypoglycemia on day of life two and three requiring several boluses of D10W. Last electrolytes on [**4-19**] were a sodium of 137, potassium of 5.3, chloride of 100, and bicarb of 26. On [**5-5**], he had a serum calcium of 10.4, a phosphate of 6.1, and an alkaline phosphatase of 388. He is now ad lib p.o. feeds of Enfamil 26 calories/ounce taking 180-210 cc/kg/day. His discharge weight is 2245 grams, length 45 cm, head circumference 31.5 cm. GI: Phototherapy was started on day of life one for a total bilirubin of 6.2. Peak bilirubin of 8.1 on day of life nine. Phototherapy was discontinued on day of life 26 for a bilirubin of 5.0. Rebound on day of life 27 was 5.0. Hematology: [**Known lastname 49966**] blood type is O positive. His hematocrit on admission to the NICU was 50.8. He did not receive any blood products during his hospitalization. His last hematocrit on [**4-10**] was 26.8 with a reticulocyte count of 20.4. Infectious disease: A CBC and blood culture were drawn upon admission to the Newborn Intensive Care Unit. He had a white count of 2300 with a hematocrit of 50, platelet count of 148,000 with 24 percent neutrophils and 1 percent band. His blood culture was negative. His leukopenia improved on day of life one with a white blood cell count of 6,000. He received 48 hours of ampicillin and gentamicin, and had no further issues with infection. Neurology: Head ultrasounds on day of life 4, day of life 8, and day of life 33 were normal. GU: [**Known lastname **] was circumcised on day of life 54. The circumcision is healing nicely. Sensory: A hearing screen was performed with automated auditory brain stem responses. He passed in both ears. Ophthalmology: [**Known lastname 49966**] eyes were most recently examined on [**Month (only) 116**] 24thth and were found to be immature to zone 3. A follow-up examination should be scheduled three weeks from that exam with Dr. [**Last Name (STitle) **] at [**Hospital3 1810**]. Psychosocial: [**Hospital1 69**] Social Work has been involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) **]. CONDITION AT DISCHARGE: Infant is stable, in room air, and taking all p.o. feeds, stable temperature, and open crib. DISCHARGE DISPOSITION: To home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 19419**] in [**Hospital1 1474**], phone number [**Telephone/Fax (1) 53417**]. [**Known lastname **] will also be followed by [**Hospital1 1474**] VNA, phone number [**Telephone/Fax (1) 36133**]. [**Known lastname **] will be followed by [**Hospital3 **] [**Hospital 4189**] Health Center for early intervention, phone number [**Telephone/Fax (1) 43398**]. [**Known lastname 49966**] first pediatric appointment is scheduled for [**5-27**] at 11:30 a.m. with Dr. [**Last Name (STitle) 19419**]. CARE RECOMMENDATIONS: Feeds at discharge: Ad lib demand feeds of Enfamil enriched to 26 calories/ounce by concentration and 2 calories/ounce corn oil. Follow-up appointment with Dr [**Last Name (STitle) 54603**] for repeat eye exam in three weeks. MEDICATIONS: Ferrous sulfate 0.2 cc every day. CAR SEAT POSITION SCREENING: [**Known lastname **] passed his car seat test. STATE NEWBORN SCREENING STATUS: [**Known lastname 49966**] last newborn screening was sent on [**5-10**]. No abnormal results were reported. IMMUNIZATIONS RECEIVED: [**Known lastname **] received his first hepatitis B vaccine on [**5-1**]. He will receive his two month immunizations at his primary pediatrician. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV 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, 2. Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3. With chronic lung disease. 1. Influenza immunization is recommended 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. DISCHARGE DIAGNOSES: 1. Prematurity at 27-4/7 weeks gestation. 2. Respiratory distress syndrome. 3. Patent ductus arteriosus. 4. Hyperbilirubinemia. 5. Apnea of prematurity. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2168-5-26**] 05:11:15 T: [**2168-5-26**] 07:07:38 Job#: [**Job Number **] ICD9 Codes: 769, 7742
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Medical Text: Admission Date: [**2175-8-6**] Discharge Date: [**2175-8-11**] Date of Birth: [**2175-8-6**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) 4813**] [**Known lastname 4027**] is the former 3.150-kilogram product of a 37-2/7-weeks gestation pregnancy born to a 30-year-old G1, P0 woman. Blood type: O-positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep status unknown. This was an uncomplicated pregnancy except for the twin gestation. The infant was born by elective cesarean section. Apgars were 8 at 1 minute and 8 at 5 minutes. He was admitted to the neonatal intensive care unit from labor and delivery suite for respiratory distress. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight is 3.150 kilograms which is 6 pounds 15 ounces, length 19 inches, head circumference 35 cm. General: Nondysmorphic near term male with grunting, flaring, and retracting. Head, eyes, ears, nose, throat: Anterior fontanel soft and flat, palate intact. Positive red reflexes bilaterally. Chest: Breath sounds equal, slightly barrel- shaped chest. Breath sounds: Clear. Cardiovascular: Regular rate and rhythm, no murmur, normal S1, S2. Femoral pulses +2. Abdomen: Benign. Genitalia: Normal. Testes: Descended. Anus: Patent. Spine: Intact. Hips: Normal. Neuro: Nonfocal, age- appropriate exam. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: A chest x-ray obtained shortly after admission to the neonatal intensive care unit was consistent with retained fetal lung fluid. [**Doctor First Name 4813**] required nasal cannula oxygen and weaned to room air on [**8-9**], [**2174**]. At the time of discharge, he is breathing comfortably on room air with a respiratory rate of 40s- 60s breaths per minute. 2. Cardiovascular: [**Doctor First Name 4813**] has maintained normal heart rates and blood pressures. No murmurs have been noted. 3. Fluid, electrolytes, and nutrition: [**Doctor First Name 4813**] was initially NPO and treated with intravenous fluids. Breast-feeding was initiated on day of life #1. At the time of discharge, he is breast-feeding or taking Similac 20 calorie per ounce formula. Weight on the day of discharge is 2.815 kilograms which is 6 pounds, 3 ounces. Serum electrolytes were checked in the 1st few days of life and were within normal limits. 4. Infectious disease: Due to the unknown etiology of the respiratory distress and the unknown group beta Strep status of the mother, [**Name (NI) 4813**] was evaluated for sepsis upon admission to the neonatal intensive care unit. His initial complete blood count was within normal limits. As he remained in oxygen at 24 hours of life, the complete blood count was repeated and remained within normal limits. A 2nd blood culture was sent, and intravenous ampicillin and gentamicin were started. Blood culture was negative, and antibiotics were discontinued after 48-hour course. 5. Hematological: Hematocrit at birth was 43.6%. 6. Gastrointestinal: Peak serum bilirubin was on day of life 4, a total of 10.6 mg per deciliter. Repeat bilirubin on the day of discharge is 12.2. 7. Neurology: [**Doctor First Name 4813**] has maintained a normal neurological exam during admission, and there were no neurological concerns at the time of discharge. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brainstem responses. [**Doctor First Name 4813**] passed in both ears. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] (Ed) [**Doctor Last Name 60843**], [**Location (un) **], [**Location (un) 55**], [**Numeric Identifier 38804**]. Phone number [**Telephone/Fax (1) 60844**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Breast-feeding or Similac 20. 2. No medications. 3. Car seat position screening was performed. [**Doctor First Name 4813**] was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. State newborn screen was sent on [**2175-8-9**] with no notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [**2175-8-10**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks; 2) born between 32-35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3) with chronic lung 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 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Appointment with Dr. [**First Name (STitle) 60843**], primary pediatrician within 2 days of discharge. DISCHARGE DIAGNOSES: 1. Term gestation at 37-2/7-weeks gestation. 2. Twin #1 of twin gestation. 3. Transitional respiratory distress. 4. Suspicion for sepsis ruled out. 5. Status post circumcision. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2175-8-11**] 03:01:23 T: [**2175-8-11**] 04:32:48 Job#: [**Job Number 69172**] ICD9 Codes: V290, V053
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Medical Text: Admission Date: [**2117-8-21**] Discharge Date: [**2117-9-6**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female with a history of rheumatoid arthritis and hypertension who was in the process of preoperative evaluation for a right knee replacement. She was found to have a urinary tract infection on routine urinalysis on [**8-11**]. She was therefore started on Bactrim. Since then the patient reports nonspecific complaints including increasing fatigue and occasional lightheadedness but denied any chest pain, shortness of breath, nausea, vomiting, or diaphoresis. She does report that her urine did become [**Location (un) 2452**] in color. She experienced a decrease in urine output times two days prior to admission without any dysuria or hematuria. She had laboratories drawn at an outside hospital on [**8-18**] which demonstrated an increased white blood cell count with 3 bands. In addition, her creatinine had increased from a baseline of 1 to 2.7. While she was at her primary care physician's office getting her laboratories drawn she continued to complain of lightheadedness and dizziness. She was seen in the clinic on [**8-20**] for followup. She was found to have a blood pressure of 110/64 and physical examination revealed no bibasilar crackles. Her electrocardiogram showed no acute changes, and a chest x-ray was negative by report. Her creatine kinase enzymes and creatinine were found to be elevated and she was sent to the Emergency Department to evaluate for acute renal failure and to rule out for myocardial infarction. In the Emergency Department, the patient was afebrile with stable vital signs. Her creatine kinases were cycled, and her troponin was negative. Her second creatine kinase had an elevated MB fraction. The patient was questioned again about chest pain, angina, shortness of breath, nausea, vomiting, diaphoresis; and she denied all. She was noted at that time to have a maculopapular rash. In the Emergency Department, she was given Lasix 20 mg, and aspirin, as well as 1 unit of packed red blood cells. She was admitted for further evaluation of her acute renal failure and to rule out myocardial infarction. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Osteoporosis. 3. Hypertension. 4. History of vertigo. 5. No history of coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o. q.d., Bactrim 1-week total (to be completed on [**10-20**]), Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d., Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d. p.r.n. SOCIAL HISTORY: The patient lives alone is very independent. She walks regularly for exercise. She denies any alcohol or tobacco use. Her daughter is her contact at phone number [**Telephone/Fax (1) 32941**]. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were blood pressure 108/48, heart rate 58, respiratory rate 26, satting 97% on 2 liters oxygen. In general, pleasant, in no acute distress. HEENT revealed extraocular muscles were intact. Pupils were equal, round, and reactive to light. The oropharynx was without lesions. Cardiovascular had a regular rate and rhythm, a 2/6 systolic ejection murmur at the left sternal border radiating to the axilla. No jugular venous distention. Pulmonary revealed crackles appreciated at the lower one-third on the left and lower one-half on the right. Abdomen was distended and tympanitic with positive bowel sounds, soft and nontender. No suprapubic tenderness. No costovertebral angle tenderness. Foley in place with light yellow urine. Extremities had 2+ pitting edema to the feet bilaterally. Skin had maculopapular rash over the chest, arms, legs; nonpruritic. Neurologically, nonfocal. LABORATORY DATA ON PRESENTATION: White blood cell count 6.9, hematocrit 27.5, platelets 154. Sodium 128, potassium 4.2, chloride 95, bicarbonate 22, BUN 57, creatinine 3.5, glucose of 111. ALT 15, AST 30, alkaline phosphatase 79, total bilirubin 0.2. Creatine kinase 263 with an MB fraction of 21, giving an index of 8%. Urinalysis was nitrite negative, protein negative, blood negative, 5 red blood cells, 1 white blood cell, no bacteria, 1 epithelial cell. RADIOLOGY/IMAGING: Electrocardiogram revealed sinus rhythm at 56 beats per minute, primary AV block, normal axis, T wave inversions in leads III and aVF. HOSPITAL COURSE: The patient is an 84-year-old female with rheumatoid arthritis with a recent bump in her creatinine and a new rash following initiation of Bactrim therapy, who was also presenting with a complaint of malaise, positive creatine kinases, negative troponin. Her acute renal failure seemed likely secondary to Bactrim initiation as well as possibly having been contributed by dehydration and Vioxx therapy. The role of her positive creatine kinase enzymes was unclear. She also seemed to be demonstrating a mild congestive heart failure at the time of admission. The patient was ruling in by myocardial enzymes for a myocardial infarction given her elevated enzymes. She was therefore started on an aspirin and Lopressor, and her ACE inhibitor was held. The patient was started on telemetry, and serial electrocardiograms were followed. The patient was also suffering nonoliguric acute renal failure which was thought secondary to Bactrim, possibly exacerbated by dehydration. Therefore, the Bactrim was held. A Renal consultation was obtained, who said that the sediment of the urine did show white cells. They felt like her symptomatology could be consistent with Bactrim-induced renal insufficiency. They recommended gentle hydration and withholding of offending agents with consideration for steroid treatment should her renal function worsen. Over the course of the next few days the patient's creatinine trended downward as the patient diuresed. The patient remained cardiovascularly stable with creatine kinase enzymes trending downward as well. She remained chest pain free over the next few hospital days. Her beta blocker, aspirin, and nitrates were continued. However, the patient's pulmonary function continued to worsen over the next few days. She continued to have low oxygen saturations and required increasing amounts of oxygen to maintain her saturation. In addition, she continued to have rales on examination despite avid diuresis. Therefore, it was felt that congestive heart failure was an unlikely reason for the patient's pulmonary problems. A CT scan was obtained which was not consistent with pulmonary embolus. As her pulmonary situation continued to deteriorate, it was felt that she was likely developing acute respiratory distress syndrome. She was therefore evaluated by the Medical Intensive Care Unit team for possible transfer. By [**8-27**], the patient was requiring 10 liters to 15 liters by face mask to maintain oxygen saturations of greater than 90%. As part of the workup of her hypoxia, an echocardiogram revealed an ejection fraction of 50% with moderate pulmonary hypertension, and her CT angiogram while demonstrating no evidence of pulmonary embolus did demonstrate increased interstitial infiltrates and areas of ground-glass opacifications. She was therefore transferred to the Medical Intensive Care Unit on [**8-27**] for management of what appeared to be a noncardiogenic interstitial infiltrate of unclear etiology. She was continued on levofloxacin 250 mg p.o. q.d. and was started on Solu-Medrol 60 mg intravenously q.8h. A bronchoalveolar lavage was planned to evaluate for infectious etiology of the patient's pulmonary issues as well as to obtain a tissue sample for evaluation of possible hypersensitivity pneumonitis. Pending these results, the patient was continued on empiric antibiotic therapy as well as empiric Pneumocystis carinii pneumonia coverage and empiric steroids. Her saturations remained stable on a nonrebreather over the next few days; however, the patient did not show any improvement in her pulmonary situation. Results from the bronchoalveolar lavage did not demonstrate any etiology of the patient's pulmonary pathology. Therefore, Thoracic Surgery was contact[**Name (NI) **] for evaluation for possible open lung biopsy. Over the course of the next few days the patient's pulmonary situation continued to worsen. On [**8-30**], it was felt that the patient was becoming fatigued and could not longer support her own breathing. Therefore, she was intubated and sedated to decrease her work of breathing. Levofloxacin and Solu-Medrol were continued. The patient has remained hemodynamically stable; however, after initiating sedatives for placement of the endotracheal tube, her pressure dropped and responded well to fluid boluses. On [**9-1**], a central line was placed in preparation for a lung biopsy. This resulted in a subsequent pneumothorax which was treated with chest tube placement. The patient tolerated the procedure without difficulty. A lung biopsy was performed later that afternoon. Results from the lung biopsy demonstrated extensive fibrosis with virtually no pulmonary architecture remaining. Therefore, it was felt that the patient was suffering end-stage fibrosis possibly secondary to a usual interstitial pneumonitis versus an acute interstitial pneumonitis. Over the course of the next few days the patient's oxygen requirements and ventilatory support need increased. A family discussion was held to discuss the patient's poor prognosis given the extent fibrosis found on lung biopsy. It was determined that the only possible course of treatment left was a short course of intensive high-dose steroids. The patient's family agreed to this treatment, and the patient was treated with 1 g of Solu-Medrol intravenously q.d. times three days. Over the course of those three days, the patient remained hemodynamically stable but with decreasing blood pressure and had to be started on pressors. She also required increasing ventilatory support and was kept sedated as well as paralyzed. Serial blood gases demonstrated increasing acidosis. In addition, the patient's peak pressures increased to well over 40. Therefore, at the end of three days of high-dose steroids it was felt that the patient's pulmonary situation had not improved. This was discussed at length with the patient's family who agreed that in this situation the patient would not want to be on a ventilator for the rest of her life. Therefore, the focus of care was switched to comfort measures only. The patient was provided with adequate sedation and pain medication. The patient was found to be unresponsive in the afternoon of [**2117-9-6**]. Telemetry demonstrated no electrocardiac activity. The patient was found to have pupils fixed and dilated with absent reflexes, absent heart sounds, and absent breath sounds. The patient was pronounced dead at 4:30 p.m. on [**2117-9-6**]. The patient's family was in attendance at the time of death. The attending, Dr. [**First Name (STitle) **], and the patient's covering primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], were contact[**Name (NI) **]. The patient deferred an autopsy at the time of death. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2117-10-14**] 17:06 T: [**2117-10-17**] 10:08 JOB#: [**Job Number **] (cclist) ICD9 Codes: 5849, 5990, 2765, 2761
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Medical Text: Admission Date: [**2200-11-11**] Discharge Date: [**2200-11-19**] Service: CSU . HISTORY OF PRESENT ILLNESS: This is a 79-year-old male patient with history of coronary artery bypass graft in [**2191**] and stenting in [**2199-3-23**]. He reports feeling well until four weeks prior to admission, when he began developing exertional angina and increase of episodes of atrial fibrillation. An echo at the end of [**10-2**], showed a new inferior wall abnormality. He was admitted to an outside hospital for catheterization, showing occlusion of his obtuse marginal graft. At that time, he was transferred to the [**Hospital1 69**], on [**2200-11-23**] for valve and possible redo coronary artery bypass graft. He had been on Plavix for the stents he had placed in [**2199-3-23**] and, for that reason, it was decided that he would be discharged home off the Plavix for a week and return to have his coronary artery bypass graft done. However, once home, he again was experiencing some atrial fibrillation on the morning of [**11-9**] and since he wasn't anticoagulated preoperatively, his cardiologist advised that he be readmitted. He was readmitted to [**Hospital1 190**] on [**2200-11-11**] for intravenous heparin and plans for a coronary artery bypass graft/MVR later in the week. PAST MEDICAL HISTORY: Coronary artery bypass graft in [**2191**] with left internal mammary artery to the left anterior descending; saphenous vein graft to obtuse marginal one and obtuse marginal two, right coronary artery and left circumflex. Chronic renal insufficiency. Diabetes type II. Hypertension. Paroxysmal atrial fibrillation. Congestive heart failure. Mitral regurgitation. Status post tonsillectomy. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient lives in [**Hospital1 6930**] with wife, retired. Very active, drives. No assistive devices. Tobacco: Quit 40 years ago with a 20 pack year history. No history of alcohol. FAMILY HISTORY: Mother down with a heart attack at the age of 55. Two brothers with coronary artery disease and myocardial infarction, both deceased at 54 and 56 years of age. One sister deceased of a myocardial infarction in [**2164**]. PHYSICAL EXAMINATION: On presentation, height was 5' 7". Weight 168 pounds. Vital signs: Temperature 97.5; blood pressure 152/78, heart rate 74 and sinus; respiratory rate 16. SP02 on room air 94%. General: The patient is sitting up in bed, in no acute distress. Neurological: Alert and oriented times three, appropriate. Respiratory: Positive rales, bilateral bases, left greater than right. Cardiovascular: Regular rate and rhythm, S1 and S2, 3 out of 6 systolic ejection murmur, loudest at the apex. GI: Soft, round, nontender, nondistended, positive bowel sounds. Extremities are warm, well-perfused, darker in color in the calf area with no edema or varicosities. LABORATORY DATA: Preoperative lab results from [**11-6**] and [**11-7**] reveal white blood cell count of 6.3, hematocrit 35.8, platelets 160, PT 13, INR 1.1, sodium 144, potassium 4.6, chloride 107, CO2 28, BUN 31, creatinine 1.8, glucose 99, ALT 27, AST 19, LDH 168, alkaline phosphatase 79, amylase 53, total bilirubin 0.8. Urinalysis was negative. Chest x-ray on [**11-5**] showed no acute cardiopulmonary processes. He also had carotid ultrasound preoperatively, showing less than 40% bilateral stenosis and lower extremity vein mapping showing the right greater saphenous vein patent throughout and left greater saphenous vein harvested from his previous coronary artery bypass graft. HOSPITAL COURSE: Mr. [**Known lastname **] was brought to the hospital on [**2200-11-11**]. IV heparin was given preop for his coronary artery bypass graft/MVR. He had some renal insufficiency at baseline. His creatinine was monitored here with a creatinine of 1.7 preoperatively. He was taken to the operating room on the morning of [**2200-11-13**] with Dr. [**Last Name (STitle) **] and underwent a coronary artery bypass graft times two with saphenous vein grafts to the obtuse marginal one and obtuse marginal two. He also had a mitral valve repair with a 28 mm [**Location (un) 55269**] Annuloplasty ring. Total cardiopulmonary bypass time of 129 minutes. Cross clamp time was 82 minutes. The patient was transferred to cardiac surgery recovery unit with a mean arterial pressure of 89, CVP of 10, heart rate of 80 on Nitroglycerin, Dobutamine and Propofol drips. He was extubated on the evening of his operation and his IV drip medications were weaned as tolerated. He was transferred to the inpatient floor on postoperative day one in stable condition. His heart rate continued to vary between a normal sinus rhythm and atrial fibrillation, which is the patient's baseline. Chest tubes were discontinued on postoperative day two without incident. His cardiac pacing wires were discontinued on postoperative day number three, also without incident. Mr. [**Known lastname **] was followed by the physical therapy team throughout his hospital stay, with initial evaluation on [**11-15**]. They continued to follow him throughout his stay and on [**11-17**], they found that the patient was safe to return home once medically stable, stating that all goals of the physical therapy team were met. The remainder of Mr. [**Known lastname 1500**] postoperative course was uneventful with a fairly chronic atrial fibrillation postoperatively, that was known preoperatively, treated only with rate control and Coumadin which he was on preoperatively as well. The Coumadin was restarted on [**11-17**] and will be continued at home. On [**11-19**], it was found that the patient is medically stable for home and will be discharged. CONDITION ON DISCHARGE: Good. VITAL SIGNS: Temperature 98.2, pulse 83, sinus rhythm, varying with atrial fibrillation. Respiratory rate of 18; blood pressure 119/54, weight 78.3 kg. LABORATORY FINDINGS: Pertinent laboratory results included white blood cell count of 7.6; hematocrit of 30.0; platelets 112, Sodium 142; potassium of 3.6; chloride 103; C02 33; BUN 52; creatinine 1.6; glucose 88. PHYSICAL EXAMINATION: Neurological: Alert, oriented, nonfocal. Pulmonary: Lungs clear bilaterally. Cardiac regular rate and rhythm, varying with atrial fibrillation. Abdomen is soft, nontender, nondistended, with positive bowel sounds. Extremities: 1+ edema. Sternal incision without drainage or erythema. Leg incision clean and dry, no drainage. DISCHARGE STATUS: Home with visiting nurses. DISCHARGE DIAGNOSES: Coronary artery disease. Mitral stenosis. Chronic renal insufficiency. Diabetes type II. Hypertension. Paroxysmal atrial fibrillation. DISCHARGE MEDICATION: 1. Amiodarone 400 mg p.o. daily for 7 days and then decrease to 200 mg p.o. every day. 2. Colace 100 mg p.o. b.i.d. 3. Percocet 5/325 one to two tablets p.o. q. 4 hours p.r.n. for pain. 4. Aspirin 325 milligrams p.o. every day. 5. Lasix 20 mg p.o. b.i.d. for 7 days. 6. Potassium chloride 20 mEq every day for 7 days. 7. Lopressor 50 mg p.o. b.i.d. 8. Terazosin hydrochloride 5 mg p.o. at bedtime 9. Coumadin 2.5 mg p.o. times one and then as directed by physician. 10. Lentis insulin 100 units per ml 24 units subcutaneously at bedtime and Humilog insulin subcutaneously per sliding scale. FOLLOW-UP: Appointment with Dr. [**Last Name (STitle) **] in four weeks. Make an appointment with patient's primary urologist in one week and appointment with Dr. [**Last Name (STitle) 55270**] in one to two weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 5898**] MEDQUIST36 D: [**2200-11-19**] 17:16:55 T: [**2200-11-20**] 07:24:08 Job#: [**Job Number 55271**] ICD9 Codes: 4240, 4019
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Medical Text: Admission Date: [**2164-10-22**] Discharge Date: [**2164-10-30**] Date of Birth: [**2095-10-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2164-10-22**]: Emergency repair of type-A ascending aortic dissection with ascending aortic and hemiarch replacement with a size-28 Gelweave graft. History of Present Illness: 69 year old male woke up this am with acute epigastic pain, chest pain, shortness of breath and diaphoresis. He called EMS and was brought to ED and was found to have type A dissection and is going emergently to OR with Dr. [**First Name (STitle) **]. Past Medical History: Hyperlipidemia Hypertension BPH right superior cerebellar artery stroke prostate cancer s/p brachytherapy 5 years ago gout Afib Past Surgical History: s/p lumbar laminectomy s/p tonsillectomy Social History: Lives with wife, Ex [**Name (NI) 2570**], quit smoking 25 years ago, drinks a glass of wine on occasions, no drug abuse Family History: Strokes in both parents Physical Exam: Admission: Pulse:58 Resp:18 O2 sat:97 B/P 206/72 Height:6'1" Weight:220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**10-22**] Echo: Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior wall.. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. A mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) to Moderate [2+] aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2164-10-22**] at 1715. Post bypass: Patient is A paced. LVEF= 40%. 2+ aortic insufficiency present. (2 jets seen - one central and the other eccentric. Mild mitral regurgitation present. [**10-22**] Chest CT: 1. Type A aortic dissection with involvement of the entire thoracic aorta and abdominal aprta as well as multiple abdominal aprtic branches, described in detail above. No evidence of aortic rupture. 2. Infrahilar lymphadenopathy, unclear etiology, may be reactive. 3. Multiple pancreatic hypodense lesions. Recommend further evaluation with non-emergent MRCP. 4. Pulmonary, hepatic, and splenic calcifications suggestive of granulomatous disease. 5. Diverticulosis without evidence of diverticulitis. [**10-23**] Renal U/S: 1. No hydronephrosis. Simple bilateral renal cysts. 2. Arterial and venous flow is seen bilaterally within the kidneys. [**2164-10-30**] 03:56AM BLOOD WBC-9.2 RBC-2.97* Hgb-8.9* Hct-26.5* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-313 [**2164-10-29**] 03:43AM BLOOD WBC-10.2 RBC-2.96* Hgb-8.8* Hct-26.4* MCV-89 MCH-29.8 MCHC-33.3 RDW-15.1 Plt Ct-245 [**2164-10-28**] 05:00AM BLOOD WBC-10.2 RBC-2.85* Hgb-8.7* Hct-25.4* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.9 Plt Ct-184 [**2164-10-30**] 03:56AM BLOOD PT-15.2* INR(PT)-1.4* [**2164-10-29**] 03:43AM BLOOD PT-14.8* INR(PT)-1.4* [**2164-10-28**] 05:00AM BLOOD PT-15.5* INR(PT)-1.5* [**2164-10-27**] 05:12AM BLOOD PT-15.3* INR(PT)-1.4* [**2164-10-30**] 03:56AM BLOOD Glucose-109* UreaN-66* Creat-2.2* Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 [**2164-10-29**] 03:43AM BLOOD Glucose-116* UreaN-70* Creat-2.6* Na-136 K-3.8 Cl-98 HCO3-29 AnGap-13 [**2164-10-28**] 05:00AM BLOOD Glucose-105* UreaN-61* Creat-3.1*# Na-135 K-4.0 Cl-97 HCO3-27 AnGap-15 [**2164-10-27**] 05:12AM BLOOD Glucose-131* UreaN-87* Creat-5.2* Na-134 K-4.4 Cl-97 HCO3-25 AnGap-16 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 2572**] was transferred to the ED by EMS presenting with acute epigastric pain, chest pain, shortness of breath and diaphoresis. He was found to have a type A aortic dissection and was emergently transferred to the operating room for repair. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained intubated for several days due to respiratory failure and worsening hypertension during extubation trial. Finally on post-op day two he was weaned from sedation, awoke neurologically intact and extubated. In addition on post-op day two, nephrology was consulted for decreasing urine output and acute kidney injury. He eventually required hemodialysis and was followed closely by nephrology throughout his hospital course. Atrial fibrillation was noted post-operatively (has history of) and he was appropriately treated with beta-blockers and Amiodarone. Chest tubes and epicardial pacing wires were removed per protocol. He had a swallow study performed due to a history of CVA which he passed for a regular diet, thin liquids. On post-op day four he was transferred to the step-down unit for further recovery. Blood pressure medications were titrated to keep SBP<140. Coumadin was eventually started for his atrial fibrillation and history of CVA and his home dose was resumed. He is to be followed by the [**Hospital3 2576**] [**Hospital 197**] Clinic. Over the next several days he remained stable while receiving hemodialysis. Renal continued to follow, urine output slowly increased and renal function was improved to a creatinine of 2.2 at the time of discharge (peak cratinine 5.7.) Renal signed off with the thought that renal function would continue to inprove, although it may not return to baseline (1.5-1.6.) Physicial therapy worked with him for strength and mobility. On POD 8 he was ambulating without difficulty, tolerating a full oral diet and his incisions were healing well. It was felt that he was safe for discharge home at this time with VNA services. Medications on Admission: famotidine 20 mg [**Hospital1 **] labetalol 200 mg- 2 Tablet(s) Twice Daily Benicar 40 mg- 1 Tablet Once Daily methocarbamol 750 mg- 1 Tablet TID warfarin Unknown Strength 1 tablet daily allopurinol 300 mg Daily simvastatin 40 mg Daily prednisone 5 mg Tab Oral PRN- last dose 1 week ago (has only taken a few times for gout) Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed for INR goal 2.0-2.5. Disp:*90 Tablet(s)* Refills:*2* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 12. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Aortic Dissection s/p Emergent repair Past medical history: Hyperlipidemia Hypertension Benign prostatic hypertrophy Right superior cerebellar artery stroke Prostate cancer s/p brachytherapy 5 years ago Gout Atrial fibrillation s/p lumbar laminectomy s/p tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Ultram Sternal Incision - healing well, no erythema or drainage Edema: 1+ LE edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**11-6**] at 10:45 AM in [**Hospital Unit Name **] [**Hospital Unit Name **] Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2164-11-27**] 1:30 Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Cardiologist: Please get referral to cardiologist from Dr. [**Last Name (STitle) 2578**] Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 2578**] [**Telephone/Fax (1) 2579**] in [**2-21**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for Atrial Fibrillation Goal INR: 2.0-3.0 First draw [**2164-10-31**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Mass [**Hospital 2580**] [**Hospital 197**] Clinic Results to phone [**Telephone/Fax (1) 2581**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2164-10-30**] ICD9 Codes: 5845, 2875, 2767, 4241, 2724, 2859, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3142 }
Medical Text: Unit No: [**Numeric Identifier 54913**] Admission Date: [**2200-1-27**] Discharge Date: [**2200-4-18**] Date of Birth: [**2200-1-27**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is a former 1.070 kg product of a 29-2/7 week gestation pregnancy born to a 41- year-old G7, P2, now three woman. Prenatal screens: Blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B Strep status unknown. The pregnancy was notable for in-[**Last Name (un) 5153**] fertilization conception. The mother experienced increased blood pressures and had 2 plus proteinuria. She was admitted on [**2200-1-10**] for management of hypertension with magnesium sulfate. She received betamethasone on [**1-10**] and [**2200-1-11**]. The mother was monitored for ongoing concerns for restricted fetal growth. The estimated fetal weight was at the 10th percentile. Prior obstetrical history is notable for spontaneous vaginal deliveries in [**2183**] and [**2194**]. Also mother treated for hypothyroidism with Synthroid. Delivery was undertaken for concern for fetal heart rate decelerations noted on monitoring. Delivery was by cesarean section for breech positioning. Apgars were 7 at 1 minute and 8 at 5 minutes. Baby required intubation in the delivery room for respiratory distress and apnea. He was transported to the Neonatal Intensive Care Unit for treatment of respiratory distress and prematurity. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 1.070 kg, length 38 cm, head circumference 37 cm, all 25th percentile for gestational age. General: Intubated preterm male, no obvious dysmorphisms. Head, eyes, ears, nose, and throat: Anterior fontanel open and flat, orally intubated, symmetric facial features. Palate intact. Positive red reflex bilaterally. Chest: Equal breath sounds with diffuse crackles, fair aeration. Cardiovascular: Regular, rate, and rhythm without murmur, normal S1, S2, femoral pulses plus 2. Abdomen is soft, nontender, no masses. GU: Preterm male genitalia. Testes undescended. Spine straight with intact sacrum. Moving all extremities. Neurologic: Tone and reflexes consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: [**Known lastname **] was treated with two doses of Surfactant. His maximum ventilatory settings were a peak inspiratory pressure of 24 over a positive end expiratory pressure of 5, intermittent mandatory ventilatory rate of 25, and 40 percent oxygen. He weaned to low settings, and was extubated to continuous positive airway pressure on day of life two. He required reintubation on day of life three for frequent episodes of apnea. He remained on the ventilator through day of life 12. He was extubated to continuous positive airway pressure with supplemental O2 from day of 12 through 32. He was on nasal cannula O2 from day of life 32 to 41, when he weaned to room air. Date of his transition to room air was [**2200-3-9**]. He was treated for apnea of prematurity with caffeine. His caffeine was discontinued on [**2200-3-9**]. His last episode of apnea occurred on [**2200-3-15**]. At the time of discharge, he is breathing comfortably on room air with respiratory rates 40-60x/minute. 1. Cardiovascular: An intermittent murmur was noted from the second week of life of approximately two months of age. [**Known lastname **] was noted to have consistently elevated blood pressures with systolics greater than 100 mm Hg during the middle of [**Month (only) **]. A cardiac echocardiogram was performed on [**2200-4-7**] that showed good biventricular function. A small patent foramen ovale and otherwise structurally normal heart. A renal ultrasound was performed, which was within normal limits. He had a consultation with the Renal service from [**Hospital3 18242**]. He initially received several doses of hydralazine, which was ineffective and he was changed to captopril, which has required titration of is dosing. At the time of discharge, he was on 0.2 mg orally 4x daily. On the day of discharge this was increased to 0.3 mg 4x daily. The goal is to have his systolic blood pressures under 100 mm Hg. The contact person with the Renal team is Dr. [**First Name (STitle) **] [**Name (STitle) 54914**], and he can be reached through [**Hospital3 1810**] paging system, [**Telephone/Fax (1) 54915**], beeper number [**Pager number **] or office number is [**Telephone/Fax (1) 54916**]. VNA will be coming to the house to perform daily BP measurements over the weekend. Dr [**Last Name (STitle) **] has been asked that these be called to him for titration of medication dosing. 1. Fluid, electrolytes, and nutrition: [**Known lastname **] was initially NPO and maintained on intravenous fluids. Enteral feeds were started on day of life number three and gradually advanced to full volume. He had a percutaneously inserted central catheter for parenteral nutrition, which was discontinued when he reached full feeds, which was on day of life 15. He was advanced to a maximum of 30 calories/ounce with additional ProMod protein supplement. At the time of discharge, he is ad lib feeding or breast feeding taking in 400-500 cc daily. Serum electrolytes were checked frequently during admission and were all within normal limits. The most recent set were checked on [**4-14**] and showed NA 141 K 4.8, Cl 104 HCO3 22, BUN 5 and creatinine 0.1. His discharge weight is 3.165 kg with a length of 47.5 cm and a head circumference of 37 cm, which notably is above the 90th percentile. A HUS done on [**4-17**] was normal as were all previous studies. 1. Infectious disease: Due to the unknown group B Strep status and his respiratory distress, [**Known lastname **] was evaluated for sepsis at the time of admission. A white blood cell count was 4,700 with a differential of 22 percent polys, 2 percent bands. A blood culture obtained prior to starting intravenous antibiotics was no growth and initial course of antibiotics was stopped at 48 hours. He was noted to have a reddened periumbilical area and was again recultured on day of life 14. He received a seven day course of oxacillin for presumed omphalitis. The blood culture at that time was also no growth. 1. Hematological: Hematocrit at birth was 51.8 percent. He did not receive any blood products during admission. His low hematocrit was 28 percent on [**2200-3-26**]. Most recent hematocrit was on [**2200-4-6**] at 31.2 percent with a reticulocyte count of 2.4 percent. 1. GI: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. His peak serum bilirubin occurred on day of life three, a total of 7.8/0.3 mg/dl direct. He required phototherapy for approximately one week. His phototherapy was discontinued on day of life 10 with a rebound bilirubin of 3.7, total over 0.4 mg/dl direct. [**Known lastname **] also had bilateral inguinal hernias, which were repaired at [**Hospital3 1810**] on [**2200-4-4**]. He had a circumcision performed at that time also. Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38447**] performed the surgery. 1. Neurology: [**Known lastname **] has had four normal ultrasounds during admission, most recently on [**2200-4-17**]. As noted with his discharge growth parameters, his head circumference is 37 cm, which is greater than the 90th percentile. He has a normal neurological exam at discharge and there are no current neurological concerns. 1. Sensory: Audiology. Hearing screening was performed with automated auditory brain stem responses. [**Known lastname **] passed in both ears. Ophthalmology. Eyes were most recently examined on [**2200-3-12**] and retinas were found to be mature. Recommended followup with Dr. [**Last Name (STitle) 36137**], [**Hospital3 1810**] Ophthalmology is recommended at age eight months. 1. Psychosocial: [**Hospital1 69**] Social Work was involved with this family. The contact person is [**Name (NI) 5036**] [**Name (NI) 4467**], and she can be reached at [**Telephone/Fax (1) 8717**]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. The primary pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54917**], [**Hospital 1411**] Medical Associates, [**Location (un) **] [**Street Address(2) 54918**], [**Location (un) **], [**Numeric Identifier 54919**], phone number [**Telephone/Fax (1) 8506**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Feeding: Ad lib breast feeding or expressed mother's milk ad lib p.o. Medications: Ferrous sulfate 25 mg/mL dilution 0.6 mL p.o. once daily, Poly-Vi-[**Male First Name (un) **] 1 mL p.o. once daily, captopril oral suspension 0.3 mg p.o. 4x daily. Car seat position screening was performed. [**Known lastname **] was observed for 90 minutes in his car seat without any episodes of bradycardia or oxygen desaturation. State newborn screens were sent on [**4-6**], and [**2200-3-20**] with no report of abnormal results. Immunizations received: Hepatitis B vaccine on [**3-17**] and [**2200-4-18**]. Diphtheria, acellular pertussis, Hemophilus influenza B on [**2200-3-29**], and injectable polio vaccine and pneumococcal 7-valiant conjugate vaccine on [**2200-3-30**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the three criteria: 1. Born at less than 32 weeks, 2. Born between 32 and 35 weeks with two of three of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3. With chronic lung disease. Influenza immunization is recommended 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. FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Renal, Dr. [**First Name (STitle) **] [**Name (STitle) 54914**], office [**Telephone/Fax (1) 50498**] or page through [**Hospital3 18242**] [**Telephone/Fax (1) 38834**], beeper number [**Pager number **]. He should be consulted if systolic blood pressure is consistently over 100 mm Hg. Planned followup in one month after discharge with DMSA scan. Serum electrolytes should be checked within one week of discharge. Primary pediatrician within five days of discharge. Pediatric Ophthalmology at eight months of age. [**Hospital6 407**] will be checking blood pressure daily. DISCHARGE DIAGNOSES: Prematurity at 29-1/7 weeks gestation. Respiratory distress syndrome. Suspicion for sepsis ruled out twice. Apnea of prematurity. Anemia of prematurity. Omphalitis. Bacterial conjunctivitis. Unconjugated hyperbilirubinemia. Hypertension of unknown etiology. Macrocephaly. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2200-4-18**] 07:21:03 T: [**2200-4-18**] 08:13:14 Job#: [**Job Number **] ICD9 Codes: 769, 7742, V290
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Medical Text: Admission Date: [**2175-2-11**] Discharge Date: [**2175-2-18**] Date of Birth: [**2131-1-26**] Sex: F Service: EMERGENCY Allergies: Doxycycline / Tetracycline / Augmentin Attending:[**First Name3 (LF) 2565**] Chief Complaint: Shortness of breath, Chest pain Major Surgical or Invasive Procedure: [**2175-2-15**] Right heart catheterization History of Present Illness: Ms. [**Known lastname **] is a 44 year-old Chinese ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] dialect, related to Cantonese, history) speaking female who presents for acute onset of shortness of breath and palpitations. She has a complicated PMH: is s/p L pneumonectomy for TB in [**2160**] that was c/b post-pericardiotomy syndrome; has newly diagnosed pulmonary hypertension, with chronic hypoxia on home 3L O2 and CPAP; and a history of breast cancer s/p R mastectomy and chemo in [**2170**]-[**2171**]. She says that she woke up this morning at 0500-0600 and felt a sharp pain over her heart, shortness of breath, sweatiness, HA and blurry vision. She took hot milk and water, and then felt worse, with a heart rate of 180. She says that she felt like she was in "shock". The pain radiated down her arm and into her shoulder and "liver region". Not associated with taking deep breaths. She was taken to the ED and arrived around 0745. She says this was similar to her symptoms last week when admitted to [**Hospital1 18**], but the intensity of this episode was far greater, especially with regard to her heart rate and SOB. She denies cough, fevers, but + chills. She denies any recent sick contacts. [**Name (NI) **] night sweats but + diaphoresis. Has had 3-4 days of nausea and diarrhea, with 3-4 bowel movements/day (essentially since discharge). She does not feeling generally short of breath for a few months, with decreased appetite over the last 1 month and a 2-lb weight loss. She felt well yesterday. Notably, she did present to the ED on [**2-6**] with again similar complaints which resolved after oxygen and observation. She did not keep her cardiology appointment on [**2-7**]. Upon presentation to the ED, her VS were HR 124, and she was 77% on 4L NC. She was put on a NRB and her O2sat improved to 100%. VS prior to transfer were 98.1, HR 103, BP 107/69, RR 28, O2sat 99% on 4L NC. A CXR was done and showed minimal change from [**2-6**]. EKG with sinus tachycardia, no significant changes. Labs without elevation in WBC, normal lactate, cardiac enzymes normal in ED x 1. . Currently she reports feeling at her baseline with no SOB or chest discomfort. Still feels her heart rate is fast. Past Medical History: - TB S/p extrapleural left pneumectomy with mediastinal repositioning and serrated mediastinal flap [**2160**] c/b myopericarditis treated with ibuprofen, c/b pericardial effusion and tamponade - Pulmonary hypertension - OSA/nocturnal hypoventilation - Right-sided stage I breast cancer ER/PR neg, HER-2/neu negative, diagnosed in [**5-7**] --- s/p lumpectomy and sentinel node biopsy in [**6-6**] and s/p 4 cycles adriamycin and cytoxan on [**2171-10-9**] --- s/p completion mastectomy was done on [**2172-3-12**] as radiation would have compromised pulmonary function further ---s/p weeks of taxol c/b neuropathy Social History: The patient lives at home with her husband and son. She does not work. She immigrated from [**Country 651**] in [**2154**]. She denies any tobacco, alcohol, or illicit drug use. Family History: Her mother's sister was diagnosed with breast cancer at the age of mid-40s. Her grandfather had diabetes. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: VS: T 98.6, BP 95/66, HR 102, RR 24, O2sat 98%4L GENERAL: Thin appearing female in NAD. HEENT: PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, no JVD CHEST: No chest wall tenderness. S/p R mastectomy with well-healed incision. CARDIAC: Tachycardic, normal S1, split S2 with loud P2. LUSB II/VI systolic murmur, LLSB I/VI systolic murmur. No thrills, lifts. No S3 or S4. LUNGS: Transmitted BS in left lung but right lung clear with no crackles, wheezes or rhonchi. ABDOMEN: Soft, mild TTP in epigastric area, otherwise nontender, non-distended, no rebound or guarding. +BS. EXTREMITIES: No LE edema. Pulses equal, [**12-3**]+ in both LEs Pertinent Results: CBC/diff: [**2175-2-11**] 08:25AM BLOOD WBC-4.4 RBC-4.06* Hgb-10.3* Hct-34.9* MCV-86 MCH-25.4* MCHC-29.6* RDW-14.0 Plt Ct-222# [**2175-2-12**] 07:07AM BLOOD WBC-3.5* RBC-4.12* Hgb-10.4* Hct-35.9* MCV-87 MCH-25.2* MCHC-28.8* RDW-13.7 Plt Ct-246 [**2175-2-11**] 08:25AM BLOOD Neuts-80.8* Lymphs-11.1* Monos-7.3 Eos-0.5 Baso-0.2 . Coags: [**2175-2-11**] 08:25AM BLOOD PT-11.4 PTT-25.3 INR(PT)-0.9 [**2175-2-12**] 07:07AM BLOOD PT-11.1 PTT-27.7 INR(PT)-0.9 . Lytes [**2175-2-11**] 08:25AM BLOOD Glucose-125* UreaN-10 Creat-1.0 Na-137 K-4.3 Cl-95* HCO3-36* AnGap-10 [**2175-2-12**] 07:07AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-139 K-4.7 Cl-92* HCO3-42* AnGap-10 [**2175-2-12**] 07:07AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9 . Cardiac enzymes: [**2175-2-11**] 08:25AM BLOOD CK(CPK)-36 [**2175-2-11**] 03:20PM BLOOD CK(CPK)-38 [**2175-2-11**] 08:25AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2175-2-11**] 03:20PM BLOOD CK-MB-NotDone cTropnT-<0.01 . ABG [**2-12**]: [**2175-2-12**] 02:43PM BLOOD Type-ART O2 Flow-4 pO2-116* pCO2-106* pH-7.25* calTCO2-49* Base XS-14 . ECHO [**2-13**]: The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2175-2-3**], the image quality on the current study is suboptimal. Trace aortic regurgitation is now seen. Biventricular cavity size and systolic function are similar. The estimated PA systolic pressure is now lower, but may be related to technical quality rather than a true change. Intravenous saline contrast injection does not suggest right-to-left shunt. . C. CATH [**2175-2-15**]: COMMENTS: 1. Resting hemodynamics revealed moderate pulmonary hypertension, with PA systolic pressure of 70mmHg on room air, with normal to mildly elevated mean PCWP of 13 mmHg. 2. With 100% inhaled oxygen, the PA systolic pressure decreased to 62mmHg from 70mmHg, and mean PA pressure decreased from 45mmHg to 38mmHg, with a decrease in PVR from 730 dynes-s/cm5 to 645 dynes-s/cm5. 3. Inhaled nitric oxide caused no significant change in pulmonary pressures or PVR above 100% oxygen. FINAL DIAGNOSIS: 1. Moderate pulmonary hypertension, responsive to 100% oxygen. .. CXR [**2175-2-17**]: As compared to the previous radiograph, there is no relevant change. Left post-pneumonectomy chest with typical changes. On the right, massive apical post-infectious, potentially post-tuberculous changes are seen with a retraction of the hilar and apical lung parenchymal structures.In the remaining lung, extensive fibrotic scars are seen. These, however, have not increased in extent as compared to the previous examination. No newly appeared focal parenchymal opacities in the right lung. The pre-existing minimal pleural effusion has completely resolved. Brief Hospital Course: This is a 43 yo F with a history of TB s/p L pneumonectomy c/b post-pericardiotomy syndrome, pulmonary hypertension, OSA, and R stage I breast cancer s/p R mastectomy in [**2171**] presenting with acute onset of shortness of breath, chest pain, tachycardia, and hypoxia. Her events during this hospitalization are summarized as below: . # SOB/Chest pain: Patient with long history of hypoxemia and is on home O2 and CPAP, although her compliance with the CPAP is questionable. Her initial O2 sats improved drastically in the ED on the non-rebreather, and she remained stable on 4L by NC on the floor. It was felt that most likely she had some event at home (O2 not on) that led to her presentation. Cardiac events were felt unlikely given normal enzymes, unchanged EKG, symptom resolution. She has a history of pulmonary HTN, with echo during last admission demonstrating significantly worsening pressures and RV dilation. She had a CXR in the ED without PNA although with pleural effusion that has been relatively stable; however she had no cough or clear fevers at home so this was not thought to be a contributing factor. PE was felt to be less likely given a negative CTA during the last admission. On the floor, she was continued on O2 by NC. She had no desaturation events overnight. On HD#2, an ABG was drawn. This demonstrated severe hypercapnea with a pCO2 of 106. Patient was asymptomatic. Because BiPAP could not be done on the floor, the patient was then transferred to the MICU. . Patient was placed on BiPAP in the ICU and pCO2 levels only mildly improved. Patient was counseled extensively regarding the importance of compliance with BiPAP. Her anxiety was a major obstacle in wearing the BiPAP mask. Patient's ability to tolerate BiPAP improved with the introduction of ativan 0.25 mg qhs. She was encouraged to wear her supplemental oxygen at all times and to use BiPAP whenever sleeping or feeling tired. The etiology of patient's significant hypercarbia and hypoxia was unclear. [**Name2 (NI) **] has presumed pHTN in the setting of left pneumonectomy. Her recent CT chest also showed some evidence of pulmonary edema/effusions. Patient reports her symptoms are largely unchanged over the last few months, however, she is requiring frequent hospital admissions. An echo was performed that showed no evidence of shunt. Ultimately the decision was made to undergo right heart catheterization to evaluate pulmonary pressures. The catheterization showed decreased pressures with increased oxygen delivery. As a result of the right heart catheterization she was started on sildenafil 20 mg po tid. Patient had an episode of increased somnolence and hypercarbia (pCO2 132) after starting the sildenafil. It was unclear whether the increased oxygenation decreased respiratory drive or whether use of ativan contributed to this presentation. He ativan dose was decreased, she was placed on BiPAP and her pCO2 returned to her baseline of 115 and her symptoms resolved. After discussion with Ms. [**Known lastname **], her pulmonologist Dr. [**Last Name (STitle) 2168**], and her family the decision was made to transfer her to a pulmonary rehabilitation center that could work with her increase her BiPAP tolerance and increase her mobilty. Patient was counseled extensively regarding the importance of compliance with BiPAP. Her anxiety was a major obstacle in wearing the BiPAP mask. Patient's ability to tolerate BiPAP improved with the introduction of ativan 0.25 mg qhs. She was encouraged to wear her supplemental oxygen at all times and to use BiPAP whenever sleeping or feeling tired. . # Sinus Tachycardia/Palpitations: This was felt to be most likely from hypoxia. Initially dehydration from recent diarrhea was also considered. She was given a 500 cc NS bolus on HD#1. Her HR continued to be elevated. Her TSH was normal. Per medical records the patient's tachycardia is chronic and asymptomatic. Heart rate ranged from 90-110 during majority of hospitalization. # AVNRT: Patient had a brief episode of AVNRT in the evening following right heart catheterization. She was symptomatic with lightheadedness, hypotension (SBP 80s), and neck palpitations. The arrhythmia resolved abruptly with vagal maneuver. Patient's outpatient cardiologist Dr. [**Last Name (STitle) 73**] was notified. The decision was made not to start a low dose beta blocker as patient has problems in the past with orthostasis and this may exacerbate those symptoms. She was monitored on telemetry for the duration of the hospitalization without further episodes. . # DISCHARGE: [**Hospital1 **] PULMONARY REHAB # CODE: FULL Medications on Admission: - Levothyroxine 25 mcg PO DAILY - Ranitidine HCl 150 mg PO BID - Alendronate 70 mg PO once a week: every saturday. - Loratadine 10 mg Tablet PO once a day prn allergy symptoms. - Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet PO twice a day. - Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs QID prn shortness of breath or wheezing. - Multivitamin PO once a day. - Zolpidem 5 mg Tablet PO at bedtime for 5 days. Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for anxiety. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. neb 9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**3-7**] hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Pulmonary Hypertension Pulmonary edema Sinus tachycardia Discharge Condition: Patient has persistent sinus tachycardia (her baseline) and stable blood pressures. She requires 4L supplemental oxygen via nasal cannula and BiPAP during sleep. Discharge Instructions: You were admitted to the hospital after presenting to the emergency department for shortness of breath and chest pain. When you arrived in the emergency room, your blood oxygen level was low. This returned to a better level once we gave placed you on BiPAP. Because of your high oxygen requirements and your need for BiPAP you were transferred to the ICU where you were closely monitored. You underwent several studies to evaluate your heart and lung function. . The following changes were made to your home medications: 1) START Sildenafil 20 mg by mouth three times a day to help your oxygen levels 2) START Lorazepam 0.25 mg by mouth at night to help with anxiety while on BiPAP machine It is very important the you use your supplemental oxygen at ALL TIMES and that you use your BiPAP EVERY NIGHT. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2168**] within two weeks of discharge. ICD9 Codes: 4168, 4019
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Medical Text: Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-16**] Date of Birth: [**2082-5-29**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26543**] was a 76-year-old gentleman with a significant past medical history. He presented to an outside hospital prior to this hospitalization complaining of one month of chest pain and fatigue with exertion. The patient was admitted to that hospital and evaluated for coronary artery disease. He underwent a stress thallium test which was positive. He was transferred to the [**Hospital1 188**] for cardiac catheterization, and this study revealed severe 3-vessel disease. A Cardiology Surgery consultation was performed, and the patient was found to be a suitable candidate to undergo a coronary artery bypass graft. HOSPITAL COURSE: On [**2159-5-10**], Mr. [**Known lastname 26543**] was taken to the operating room at the [**Hospital1 188**] by Dr. [**Last Name (STitle) 1537**] of the Cardiothoracic Surgery Service, and he underwent an on-pump coronary artery bypass graft times two with left internal mammary artery to the left anterior descending artery and a right lesser saphenous to the obtuse marginal. The patient tolerated the procedure well, and he was transferred in a stable condition to the Cardiothoracic Surgery Recovery Unit. Overnight, he was weaned off his pressors and was successfully and uneventfully extubated by the next morning. He required 2 units of packed red blood cells for a low hematocrit. His postoperative course was prolonged and complicated by cardiac arrhythmias requiring amiodarone and diltiazem to control his atrial fibrillation and rapid heart rate. By postoperative day two, his cardiac arrhythmia was not totally controlled, and his creatinine started to rise. He was noted to have labored breathing, and by postoperative day three, the nursing noticed that the patient was more confused than usual and was having problems trying to find words as well as moving his right side. An emergent head CT was obtained, and it revealed an image most consistent with a left posterior cerebral artery infarction. He was evaluated by the Stroke Service and Neurology who recommended to keep his systolic blood pressures at about 140 and to obtain a magnetic resonance imaging with a stroke protocol. By postoperative day five, Mr. [**Known lastname 26543**] continued to be in rapid atrial fibrillation and on intravenous amiodarone drip as well as a maximum diltiazem drip. His neurologic status did not improve, and later that day he became progressively acidotic, and his white blood cell count became elevated. At that point, there was a concern for this patient to be having an ischemic bowel since he developed peritoneal signs. An emergent Surgery consultation was obtained, and the patient was taken to the operating room for an exploratory laparotomy. He was found to have an ischemic bowel, and a small bowel resection times two with an ileocolectomy as well as an aorta to superior mesenteric artery bypass with a Dacron graft was performed since the patient was found to have a thrombosed superior mesenteric artery. The patient received 6 liters of crystalloid and 3 units of packed red blood cells, and after the surgery he was transferred in a critical condition back to the Cardiothoracic Surgery Recovery Unit. These findings were discussed in detail with the family, and there were explained about the seriousness of this patient's condition. Overnight, he was kept on maximum Intensive Care Unit support including amiodarone drip, diltiazem, as well as pressors without significant improvement. His white blood cell count remained elevated, and his acidosis worsened. He was started on continuous venovenous hemofiltration since his creatinine was 2.2. By 6 o'clock in the afternoon, despite the continuous venovenous hemofiltration and the full Intensive Care Unit support, his condition worsened, and General Surgery decided to take him back to the operating room for a second exploratory laparotomy. Once in the operating room, and upon entering the abdominal cavity, the entire bowel was noted to be ischemic. There were no free perforations, and the bypass graft was still patent. The patient's abdomen was closed, and he was transferred back to the Cardiothoracic Surgery Recovery Unit to discuss the prognosis with the family. The operating room findings were discussed with the wife, and after she spoke with Dr. [**Last Name (STitle) **] from the General Surgery Service, she wished to make the patient comfort measures only in light of the global ischemic bowel disease. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] was informed, and all of the pressor support was discontinued. Shortly after the pressor support was stopped, the patient expired in the Cardiothoracic Surgery Recovery Unit. The house officer was called to evaluate the patient and he was found to have no pupil reflex, no corneal, no spontaneous breathing, no gag reflex pulling the ET-tube, no palpable pulse or audible heart sounds. The patient was pronounced dead at 10:06 p.m. on [**2159-5-16**]. His family was notified as well as Dr. [**Last Name (STitle) 1537**]. The Medical Examiner was also notified, and he declined the case. The family did not want a postmortem examination, and the patient will shortly be transferred to the morgue to await further arrangements by the family. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 26544**] MEDQUIST36 D: [**2159-5-17**] 00:35 T: [**2159-5-17**] 10:40 JOB#: [**Job Number **] ICD9 Codes: 9971, 496, 4019
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Medical Text: Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-15**] Service: MEDICINE Allergies: morphine Attending:[**Doctor First Name 3298**] Chief Complaint: transfer from OSH for ERCP for bile leak Major Surgical or Invasive Procedure: ERCP with stent placement History of Present Illness: This is an 86 yo F with CAD s/p CABG, HTN, dyslipidemia, GERD, history of CVA, and tracheobronchomalacia and eosinophilic bronchitis who presented on transfer from [**Hospital3 60338**] for ERCP for a biliary leak. Patient initially presented to OSH on [**10-5**] with RUQ abdominal pain and nausea without vomiting. Her labs were significant for WBC 11.6, Tbili 0.5, Dbili 0.2, amylase 97, lipase 26, ALT 22, AST 22, alk phos 121, UA positive. Patient had a RUQ ultrasound which showed interval development of mild to moderate biliary dilatation (CBD 9mm at level of ampulla). Also with 9 mm gallstone in the fundus of the gallbladder. She underwent a laparoscopic cholecystectomy [**10-6**] which was a difficult procedure and JP drain was left in place. Due to persistently high output and suspicion of bile leak ERCP was attempted [**2199-10-8**] to assess for cystic duct leak however unable to cannulate common bile duct. Decision made to transfer patient to [**Hospital1 18**] for ERCP with biliary stent if there is a cystic duct leak. On presentation here patient reported [**7-24**] RUQ pain, described as sharp. Pain steadily worsening. She denied nausea, vomiting, diarrhea, cp, sob or lightheadedness/dizziness. No fever or chills. No po intake since ERCP. Patient did have a significant amount of epigastric abdominal pain after ERCP on day prior to arrival but that resolved after procedure. She denied hematochezia or melena. Last BM prior to admission. ROS as per HPI otherwise 10 pt ROS negative Past Medical History: CAD s/p CABG in [**2190**] S/p PPM Aortic regurg HTN Dyslipidemia Nephrolithiasis Chronic back pain GERD Hx of CVA with left eye blindness Tracheomalacia Eosinophilic bronchitis Social History: Lives with husband in [**Name (NI) 6691**]; 2 children and 2 grandchildren. Retired from paper company. No history of tobacco, no etoh or illicits. Family History: Mother deceased from CHF Father deceased from unclear causes Physical Exam: ON ADMISSION: VS: 98.1 136/67 76 20 99% 2L NC Appearance: alert, NAD, thin Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 [**2-17**] diastolic murmur at LUSB, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, + RUQ ttp, slight distension, +bs, incisions with small amount of serosanginuous drainage; no rebound/guarding, JP drain with dark bile output Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] ON DISCHARGE: VS: T 98 (afebrile >24 hrs), BP 126/68, P 83, RR 20, O2 Sat 99% on RA Gen: Thin elderly female in NAD HEENT: anicteric, MMM CV: regular rate and rhythm, no periperhal edema, JVP not elevated (at clavicle with patient at 20 degrees) Pulm: Mild crackles at bases resolved with cough and taking deep breaths, good air movement bilaterally, no wheezing or rhonchi Abd: Soft, mildly hypoactive BS, slight tenderness to palpation in right upper quadrant w/o guarding or rebound, JP drain in place with small amount of bilious fluid, no organomegaly or masses appreciated Extrem: W and WP with no clubbing, cyanosis, or edema Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-12.0* RBC-3.43* Hgb-10.8* Hct-30.8* MCV-90 RDW-13.5 Plt Ct-332 --Neuts-78.8* Lymphs-12.1* Monos-4.3 Eos-4.5* Baso-0.4 PT-15.8* PTT-30.5 INR(PT)-1.4* Glucose-67* UreaN-14 Creat-0.7 Na-141 K-4.1 Cl-108 HCO3-24 ALT-52* AST-30 LD(LDH)-170 AlkPhos-86 Amylase-90 TotBili-0.9 Lipase-34 Calcium-8.8 Phos-2.6* Mg-1.6 On Discharge: WBC-10.1 RBC-3.47* Hgb-10.6* Hct-30.8* MCV-89 RDW-14.4 Plt Ct-431 Glucose-95 UreaN-9 Creat-0.7 Na-140 K-4.2 Cl-105 HCO3-29 AnGap-10 ALT-29 AST-27 AlkPhos-76 TotBili-0.6 Other Important Labs [**2199-10-10**] 07:25AM BLOOD CK-MB-5 cTropnT-0.05* [**2199-10-10**] 04:53PM BLOOD CK-MB-9 cTropnT-0.06* [**2199-10-11**] 04:29AM BLOOD CK-MB-6 cTropnT-0.07* ============== MICROBIOLOGY ============== Blood Cultures *2 [**2199-10-9**]: No growth- FINAL Bile Culture [**2199-10-9**]: GRAM STAIN (Final [**2199-10-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2199-10-12**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2199-10-15**]): NO GROWTH. C diff toxin assay [**2199-10-12**]: Negative ============== OTHER RESULTS ============== ECG Study Date of [**2199-10-10**] Atrial fibrillation with ventricular premature beats. Left axis deviation. Diffuse ST-T wave abnormalities. No previous tracing available for comparison. PORTABLE ABDOMEN Study Date of [**2199-10-10**] IMPRESSION: No evidence of obstruction. The evaluation of free air is limited on this supine radiograph. Suggest upright films to better assess for free air. CHEST (PORTABLE AP) Study Date of [**2199-10-10**] IMPRESSION: Free intraperitoneal air. Please see comments above regarding documentation of communication of this finding. CT ABD & PELVIS WITH CONTRAST Study Date of [**2199-10-10**] IMPRESSION: 1. Inflammatory changes and free air but no drainable collection. Free air of uncertain significance in the setting of recent surgery although bowel perforation cannot be excluded. 2. Small focal fluid collection adjacent to the pancreas. 4. Distended fluid-filled loops of bowel suggest an ileus. 5. Bibasilar atelectasis and effusions. 6. Biliary stent and pneumobilia consistent with recent ERCP. Abdominal drain with tip in the surgical bed. ERCP [**2199-10-10**]: Impression: -The major papilla was gaping, but did have the appearance of a fish mouth papilla. -Extravasation was noted at the right intrahepatic duct c/w with a duct of Luschka leak. -Otherwise normal biliary tree. -A sphincterotomy was performed. -A biliary stent was placed. -Otherwise normal ercp to third part of the duodenum Portable TTE (Complete) Done [**2199-10-11**] Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 86 yo F with CAD, s/p PM, HTN, dyslipidemia, GERD, hx of CVA, tacheomalacia and eosinophilic bronchitis who initially presented to OSH on [**2199-10-5**] with cholecystitis now s/p lap chole with complicated surgery requiring JP drain presented in transfer with concern for bile leak. 1) Cholecystitis s/p lap chole: On admission, patient with abdominal pain and increased JP drain output concerning for bile leak. Pt was initially admitted to Medicine, and the ERCP team was consulted. She underwent successful ERCP with placement of a plastic stent, which relieved the biliary leak. Following the procedure, pt developed acute respiratory distress and hypoxia. CXR was concerning for acute pulmonary edema. She was treated with lasix for diuresis and she was transferred to the ICU for further care. In the ICU, patient was noted to have free air under the diaphragm and was evaluated by surgery for urgent OR. However, given stable abdominal exam with no evidence of acute abdomen, and temporal relationship to lap chole, air was attributed to recent surgery and no intervention was necessary. Her breathing rapidly stabilized (see below). Abdominal exam improved with tenderness around JP drain resolving steadily after ERCP and at discharge had only slight tenderness around drain with movement. Surgery consult recommended JP drain removal be performed as an outpatient by her primary surgeon. She was initially treated with vanc/zosyn, though this was changed to cipro/flagyl as exam remained stable. Her diet was gradually advanced, which she tolerated well. She was discharged with plan to complete two more day of ciprofloxacin/metronidazole for a total course of 7 days after biliary stent placement. 2) Acute on chronic diastolic congestive heart failure: Patient was transferred to ICU on [**10-10**] after developing sudden respiratory distress on the floor in the setting of elevated BP (presumed catecholamine surge). Pt was diuresed with lasix IV boluses with significant improvement in her respiratory status. She was weaned off the facemask and maintained her saturation on nasal canula. Home blood pressure medications were restarted and she was euvolemic on transfer out of the ICU. Echocardiogram showed normal EF, mild AS. Furosemide was stopped and she was weaned off supplemental oxygen with no further respiratory distress. 3) Atrial fibrillation: Pt has history of previous AF and was on coumadin but stopped some time prior to admission in the context of severe GI bleed. After discussion with PCP and cardiologist pt is usually in sinus and during hospitalization had a brief episode of well rate controlled AF that converted back to sinus. Given history of severe bleeding coumadin will be discussed further as an outpatient but held for now. This was decided in discussion with PCP and stroke risk was discussed with patient and husband. Aspirin and diltiazem were continued. 4) Diarrhea: Patient had diarrhea after being transferred out of the MICU but this was low volume and not associated with fever, leukocytosis or other symptoms. C diff was negative and this began to improve after solid food was restarted. Likely due to functional hypermotility and liquid diet. 5) GERD: She was continued on her her home PPI 6) Eosinophilic bronchitis: She was continued on her home fluticasone-salmeterol inhaler and albuterol PRN 7) CAD s/p CABG: She never had signs or symptoms of ACS. She was continued on her home ASA and diltiazem. Simvastatin was held at admission then restarted at discharge. 8) HTN, benign: She was hypertensive post procedure but then blood pressures were well controlled on home regimen of diltiazem and amlodipine. 9) History of cerebrovascular disease: Blood pressure control was continued with dilt and amlodipine. Her aspirin was similarly continued. 10) Glaucoma: She was continued on her home cyclosporin drops. The patient tolerated a full diet prior to discharge. She received heparin SC for DVT prophylaxis. She was full code. Transitional Issues: - She will be discharged to acute rehab given deconditioning and poor exercise tolerance for PT - She will follow up with Dr. [**Last Name (STitle) 73823**], her surgeon, regarding removal of her JP drain - She should have an MRCP as an outpatient to evaluate a possible pancreatic cyst seen on in house CT scan - She will follow up with Dr. [**Last Name (STitle) 64453**], her cardiologist, for further management of her diastolic heart failure and CAD - She will follow up with Dr. [**Last Name (STitle) **] in 6 wks for repeat ERCP and evaluation of need for more stents vs stent removal - Doctors [**Name5 (PTitle) 73824**] and [**Name5 (PTitle) 64453**] [**Name5 (PTitle) **] continue to manage patient's atrial fibrillation and discuss/ weigh risks and benefits of anticoagulation with the family Medications on Admission: Outpatient Medications: Diltiazem ER 360mg daily Protonix 20mg [**Hospital1 **] Advair 250/50 [**Hospital1 **] Norvasc 2.5mg daily ASA 81 Vit D3 [**2187**] IU daily MVI Vit C 500mg daily Simvastatin 40mg daily Gelnique Sachets 10% gel q evening Restasis 1 gtt ea eye [**Hospital1 **] Tylenol prn . Transfer Meds: per discharge summary, no doses listed Norvasc Vitamin C ASA Cyclosporin Cardizem Fluticasone Hydrocodone with acetaminophen MVI Protonix Kcl Zocor Genteal to eyes Vit D3 Discharge Medications: 1. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 2. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. multivitamin Capsule Sig: One (1) Capsule PO once a day. 8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Gelnique 10 % (100 mg /gram) Gel in Packet Sig: One (1) packet Transdermal at bedtime. 11. cyclosporine 0.05 % Dropperette Sig: One (1) drop each eye Ophthalmic [**Hospital1 **] (2 times a day). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: last day [**10-17**]. Tablet(s) 16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days: last day [**10-17**]. Discharge Disposition: Extended Care Facility: Mt. Greylock ECF Discharge Diagnosis: # Bile leak s/p cholecystectomy # Cholecystitis # Hypoxic respiratory distress/acute diastolic heart failure # 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: You were admitted in transfer from [**Hospital6 6689**] for complicated cholecystitis and cholecystectomy complicated by bile leakage. You underwent ERCP with stent placement, and the leak stopped. Your hospitalization was complicated by a period of heart failure, but this improved with treatment. Due to weakness you are being discharged to a rehabilitation facility who will help manage your medications. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73823**] [**Hospital1 **] Surgical Associates Friday, [**10-25**] at 1:30 PM [**Apartment Address(1) 73825**] [**Location (un) 6691**], MA Phone: [**Telephone/Fax (1) 73826**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64453**]- Cardiology Monday, [**11-4**] 9:15 am [**Street Address(2) 73827**], [**Apartment Address(1) 36475**] [**Location (un) 6691**], MA Phone [**Telephone/Fax (1) 73828**] Dr. [**First Name (STitle) **] [**Name (STitle) **] Thursday, [**11-21**] Arrive at 7 am for 8 am repeat ERCP [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES Phone [**Telephone/Fax (1) 13246**] (you should not eat on the morning of the procedure) ICD9 Codes: 4280, 4241, 2724
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Medical Text: Admission Date: [**2112-8-17**] Discharge Date: [**2112-8-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: bradycardia and hypotension, transferred from [**Hospital1 **] Major Surgical or Invasive Procedure: R internal jugular central line placement History of Present Illness: 89 yo woman with past medical history signficant for hypertension, atrial fibrillation, hyperlipidemia, hypothyroidism, presents from [**Hospital 100**] Rehab, where she found to have decreased mentation, with associated bradycardia to the 40s, and SBP in the 50s. Her daughter reports that four days ago she was well w/o complaints. Today, however, when she visited the patient, the patient was difficult to arouse and couldn't sit up on her own. The patient was able to recongize her daughter, but was confused and more somulent than usual. At that time she was found to have a SBP of 60 and a pulse in the 40s. . No f/c, n/v, diarrhea, chest pain, or other complaints. The [**Hospital6 459**] reports she has had a 10 pound weight gain over the last several weeks. She was also started on a fentanyl patch in the last week for chronic lower back pain, and neurontin for pain over the last month or two as well. . In the ED, her VS 96.6 HR 45 53/22 18 99RA were, was given atropine 1mg, 2L NS she was started on dopamine with good response, BP increased to 130s. . In addition, she was otherwise afebrile, but had a leukocytosis, with 35% bandemia, CXR with a possible LL infiltrate and was started on vancomycin and ceftazidime. . Pt with recent admission to OSH with falls in [**Month (only) 116**], and decision was made for relocation to Nursing homes. She is wheelchair bound at baseline, although her daughter reports her strength is "pretty good." . Per her daughter and the rehab center, on review of symptoms, 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. He denies exertional buttock or calf pain. All of the other review of systems were negative. She has had some lower extremity edema noted by her daughter last week. The [**Hospital 100**] Rehab reports she has had no antibiotics in the last four months. Past Medical History: Arthritis left knee arthroscopy Atrial Fibrillatin HTN T12 compression fracture with scoliosis Spinal Stenosis GERD Hypothyroidism Hypercholesterolemia Anxiety Cataract Surgery Hysterectomy Social History: lives at Senior Home, no tob/etoh; no regular exercise Family History: Son who died with CAD Physical Exam: VS: T 93.2 , BP 96/69 , HR 67 , RR 18 , 98 O2 % on 3L Gen: Sedated, but arousable elderly, NAD HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, dry MMM, JVD flat, no LAD, supple, no thyromegaly Neck: Supple with JVP of 8cm CV: S1 S2 rrr, SEM III/VI greatest LLSB, apex, also RUSB Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. diffuse rhonchi at bases. Abd: Normoactive BS, soft, TTP lower quadrants, no RT, no [**Doctor Last Name **] sign, no hepatosplenomegaly Skin: b/l escharred heel ulcers, decubitus no obvious ulcers, EXT: 2+ pitting edema, up to mid calves, DP pulses 1+ b/l Pertinent Results: [**2112-8-17**] 04:30PM BLOOD WBC-17.3*# RBC-3.45*# Hgb-9.5*# Hct-29.4*# MCV-85 MCH-27.4 MCHC-32.2 RDW-16.7* Plt Ct-208 [**2112-8-17**] 04:30PM BLOOD Neuts-58 Bands-35* Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [**2112-8-17**] 04:30PM BLOOD Glucose-141* UreaN-25* Creat-1.7* Na-132* K-5.5* Cl-92* HCO3-26 AnGap-20 [**2112-8-17**] 04:30PM BLOOD CK(CPK)-198* [**2112-8-17**] 11:40PM BLOOD CK-MB-22* MB Indx-13.7* cTropnT-0.08* [**2112-8-17**] 11:40PM BLOOD TSH-3.1 [**2112-8-18**] 12:19AM BLOOD Type-ART Temp-36.0 O2 Flow-4 pO2-61* pCO2-70* pH-7.28* calTCO2-34* Base XS-3 Intubat-NOT INTUBA [**2112-8-18**] 08:06AM BLOOD Lactate-4.6* Na-131* K-4.3 . Micro data [**2112-8-17**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT [**2112-8-17**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT [**2112-8-17**] URINE URINE CULTURE-PRELIMINARY {ESCHERICHIA COLI} Brief Hospital Course: 89-year-old woman with PMH HTN, Afib, decubitus ulcers, presenting with bradycardia, shortness of breath, hypotension, and septic shock likely from a) gram positive cocci [**2-19**] decubitus ulcers b) urosepsis c) pneumonia. . The patient initially was resuscitated with IVF's and started on broad antibiotic coverage with vancomycin, ceftazadime, and flagyl. Central venous access was initiated to monitor CVP per sepsis goal directed therapy guidelines. The patient presented with do not resuscitate / do not intubate advanced directives. Patient was supported with oxygen by nasal cannulae. Bradycardia was resolved with atropine and hypotension was treated with dopamine iv infusion. . Family, including son and daughter, were notified and came to the hospital. Discussions were engaged regarding ulimate goals of care. The decision was made to provide comfort measures only and to withdraw active treatment of ultimate pathology. Pressors and antibiotics were discontinued, and within 45 minutes the patient passed secondary to cardiac arrest. . The patient was pronounced dead at 12:51pm and arrangements were made for burial proceedings with the family. Medications on Admission: Caltrate 600+D 2 tabs daily Amiodarone 300mg Daily Cozaar 100mg Daily Levothyroxine 50 mcg daily (50mcg on Sunday) Coumadin 2mg Daily Zocor 40mg daily Trazadone 100mg qhs Lasix 40mg daily Potassium Vitamin B12 Neurontin 100mg TID Celexa 10mg QD Oxycodone 5mg Q4 PRN Fentanyl 50mcg Q3D Xanax 0.125mg [**Hospital1 **] Xanax 0.125 q8PRN Lasix 40mg QD Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: sepsis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none ICD9 Codes: 0389, 5849, 486, 2724, 4019, 2449
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Medical Text: Admission Date: [**2169-10-13**] Discharge Date: [**2169-11-16**] Date of Birth: [**2119-3-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: unsucessful suicide attempt via method of hanging Major Surgical or Invasive Procedure: [**2169-10-23**] - tracheostomy and percutaneous G tube History of Present Illness: Patient is a 50 year old male who was brought to the trauma bay after an unsucessful suicide attempt via the method of hanging. Patient hung himself in the attic and rope reportedly broke and he was found walking down the stairs. The ambulance was called. He was intubated on the scene and transferred to [**Hospital1 18**] - GCS 3T. Past Medical History: hypertension Social History: Patient has a 16 year old daughter. [**Name (NI) **] recently lost a job and was to be evicted from his apartment on the day he attmpted suicide. Has relationships with ex-spouses x2 Family History: non-contributory Physical Exam: Upon presentation: HR:74 BP:173/90 Resp:15 O(2)Sat:100% normal Constitutional: Comfortable HEENT: Pupils equal, round and reactive to light Large amount of neck edema and subcutaneous air, circumferential ligature mark on neck, no expanding hematoma or bruit, intubated, dried blood in nares Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Nondistended, Soft GU/Flank: No costovertebral angle tenderness Extr/Back: No edema Skin: No rash, Warm and dry Neuro: sedated Psych: Sedated Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: INR(PT) [**2169-11-15**] 1.5* WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2169-10-29**] 05:10 10.2 3.30* 9.7* 29.4* 89 29.3 32.9 13.9 531* Imaging: [**2169-10-13**] CT head without contrast No acute intracranial process. Significant soft tissue emphysema in the anterior tissues of the neck and face. [**2169-10-13**] CT c-spine w/o contrast 1. Fracture of the posterior pedicles of C2 vertebral body bilaterally. 2. Question fracture of hyoid bone . 3. Likely fracture of the left lamina of the thyroid cartilage posteriorly. [**2169-10-13**] CT torso 1. Multiple fractures of the left transverse processes of the lumbar spine and left seventh rib as detailed above. 2. Anterior chest wall subcutaneous air. 3. No mediastinal hematoma or evidence of extravasation. 4. Endobronchial debris causes atelectasis of the right upper lobe. [**2169-10-13**] CTA neck 1. Occlusion of the left common carotid and the left internal carotid artery extending up to the level of the cavernous carotid on the left with good flow from collaterals from the circle of [**Location (un) 431**] seen in the supraclinoid carotid and left MCA is felt to be secondary to a dissection given mechanism of injury. 2. Thrombosis left external carotid artery. 3. Irregularity in the wall of the right common carotid artery just inferior to the carotid bulb is likely secondary to a small dissection. 4. C-spine fractures as detailed on the cervical spine CT. 5. Left hyoid bone inferiorly displaced fracture of the greater cornu. 6. Left thyroid cartilage mildly displaced fracture. 7. Significant subcutaneous emphysema in the anterior neck is felt to be secondary to a tracheal injury at the level of the thyroid cartilage. [**2169-10-13**] MR cervical spine Known fracture at C2, better seen on the previous CT scan. Injury to the posterior interspinous ligament at C1-C2 as well as possibly to the ALL and PLL. Increased signal within the C2-C3 disc space, concerning for acute injury to the disc. Small CSF density collection anteriorly in the epidural space extending from C2-C3 to C5-C6 which could represent a hygroma or epidural hematoma without significant compromise of the cord. There is no evidence for cord contusion. [**2169-10-16**] CT torso Compressive atelectasis/comsolidation at both lung bases with no evidence for intra-abdominal abscess identified. [**2169-10-16**] CTA neck 1. Persistent occlusion of the left common carotid near its takeoff from the aortic arch, at the level of the clavicular head with distal reconstitution of the external carotid branch via muscular collaterals, as well as the petrous portion of the internal carotid artery, likely via filling from an ophthalmic artery collateral as well as via the circle of [**Location (un) 431**], which is intact. 2. Interval improvement in irregularity previously seen in the region of the right carotid bulb. 3. Though MRI is more sensitive for this, there is no evidence of territorial cerebral infarct. 4. Previously described soft tissue and bony traumatic changes of the neck and oropharynx including fracture of the bilateral C2 pedicles, subcutaneous emphysema, soft tissue stranding, and mottled density filling the nares and oropharynx. Left hyoid and thyroid fractures are again noted, though subcutaneous emphysema has improved. [**2169-10-18**] CT neck w/o contrast 1. Diffuse edema such that infection cannot be excluded; however, no drainable fluid collection or abscess formation is seen at this time. 2. Small area of enhancement with central hypodensity, which could represent a developing fluid collection in the right oropharynx. This area may be amenable to direct visualization. 3. Similar additional findings including fractures of the pedicles at C2 and left transverse foramen. Fracture of the left hyoid. 4. Stable appearance of occlusion of the left carotid artery with distal reconstitution of the external carotid. 5. Diffuse edema and subcutaneous emphysema, overall slightly decreased from initial examination and similar to the immediate prior examination of [**2169-10-16**]. [**2169-10-20**] neck US Multiple hematomas extending throughout the neck soft tissues, right greater than left. Given the heterogeneous contents, these are not amenable to aspiration. MICROBIOLOGY: [**10-13**] MRSA screen positive [**10-13**] BCx x2: pending [**10-13**] UCx: F-no growth [**10-15**] UCx: F- no growth [**10-15**] sputum cx: GS- >25 PMNs, 3+ GPCs; Cx- moderate growth MRSA [**10-15**] BCx x2: F- no growth [**10-17**] Packing x3: 1. MRSA 2. Strep anginosus sensitive to gent, rifamp, tetra, bactrim, and vanco 11/7 L fem TLC tip cx: No significant growth. Brief Hospital Course: The patient was admitted to the Trauma Surgical Service for evaluation and treatment after unsuccessful suicide attempt. Neuro: A MRI head and C-spine were obtained at neurosurgery's request. His head CT showed no acute intracranial processes. CT cervical spine showed fracture of the posterior pedicles of C2 vertebral body bilaterally; their final recommendation was for a hard cervical collar to be worn for six weeks. He will follow up with Neurosurgery at that time. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Patient was brought in intubated. The tracheostomy was done by the thoracic service on [**10-23**]. He was transitioned to a trach mask and was stable. His tracheostomy was eventually removed and he is on room air with stable oxygen saturations in the high 90% range. GI/GU/FEN: A PEG was placed on HD11 and tube feedings were started and advanced to goal. He underwent video swallow x 2 for which he failed requiring that he remain on tube feedings. The plan is for him to follow up as an outpatient with ENT and Speech for video swallow and electrical stimulation. In the meantime he is NPO except for no more than 8 oz water in 24 hour period for swishing and spitting. He is receiving blous tube feedings; he was provided with teaching by nursing on how to administer the bolus feedings. ID: No active issues. Fever curve and WBC were monitored, his last WBC on [**10-29**] was 10.2 which is within normal range; his T max was 98.4 on [**11-15**] at time of this dictation. Endocrine: Blood sugars were monitored and treated. Hematology: He was treated with a heparin drip for his carotid dissection and transitioned to Coumadin. His goal INR is [**1-18**], on [**11-15**] his INR was 1.5; he received Coumadin 10 mg on [**11-14**] and will need to receive 10 mg on [**11-15**] with an INR check for [**11-16**] to adjust dose if necessary. He will require at least daily INR's until he is therapeutic and then the INR can be checked 1-2x/week. He will remain on the Coumadin for ~6 months, a carotid ultrasound will need to be done prior to stopping the Coumadin. Prophylaxis: He received compression boots and Pepcid. Psychiatry: Psychiatry was consulted who followed patient; he was maintained on a one-to-one sitter and suicide precautions. He has been recommended for inpatient psychiatric stay. He was evaluted by Physical therapy and is independent with transfers, ambulation, feeding himself and personal hygiene. Medications on Admission: None Discharge Medications: 1. Outpatient [**Name (NI) **] Work PT/INR 2-3x/week and prn based on goal INR 2-3 range 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via feeding tube. Disp:*30 Tablet(s)* Refills:*2* 3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day) as needed for constipation: via feeding tube. 4. sodium chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal TID (3 times a day). Disp:*1 * Refills:*2* 5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) Grams PO Q12H (every 12 hours) as needed for constipation. 6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*350 ML(s)* Refills:*0* 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via feeding tube. 8. warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Goal INR [**1-18**]; adjust dose based on INR please. 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN line maintenance Peripheral IV - Inspect site every shift 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for spasms. 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) Ml's PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: s/p Self hanging attempt Injuries: C2 posterior lamina fracture Right 7th rib fracture Bilateral carotid dissection Thrombosis of the left common carotid, w/ ext into left internal & external carotid arteries Hyoid bone fracture L1-L5 mildly displaced transverse process fractures Respiratory failure Dysphagia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a self hanging attempt. Your trauma caused significant bodily injuries. You were required to have an operation which provided you with a protective airway for breathing and a special feeding tube was placed to provide you with nutrition. You underwent swallowing tests in the hospital and it has been determined at this time that your swallowing muscles are still weak. In 4 weeks you will see the Ear, Nose & Throat doctors followed by [**Name5 (PTitle) **] appointment with the Speech Specialist, a repeat video swallow test will be done then. Until that time you will need to continue with your tube feedings as instructed. DO NO eat anything by mouth. The cervical collar will needto remain in palce until told to remove it by the Neurosurgeon, Dr. [**Last Name (STitle) 548**]. It is OK for you to shower. Avoid tub baths for now until your feeding tube is removed. Avoid lifting heavy objects greater than 10 lbs. You will need to continue on the blood thinning medication called Coumadin for at least 6 months because of the injury to the artery in your neck (carotid artery). Blood tests will need to be drawn at least 1-2x/week called an INR to measure how thin your blood is Followup Instructions: Follow up in 4 weeks in [**Hospital **] clinic, call [**Telephone/Fax (1) 41**] for an appointment. After you follow up with ENT you will need to have a repeat Swallow study done in 4 weeks to determine if you can be upgraded to a diet. Please call [**Telephone/Fax (1) 3731**] to request to have a Vital Stim test done. You will also need to have the video swallow test repeated at that time. Follow-up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks with a Non-contrast CT scan of the cervical spine. Call [**Telephone/Fax (1) 1669**] for an appointment. The clinic Our is located in the [**Hospital **] Medical Building, [**Hospital Unit Name 12193**], [**Street Address(2) 87879**], [**Location (un) 86**], [**Numeric Identifier 718**]. Follow up in [**Hospital 2536**] clinic in 4 weeks, call [**Telephone/Fax (1) 600**] for an appointment. It was notedthat you do not have a PCP; there are 2 options for obtaing one: 1. Contact the MD referral line at [**Telephone/Fax (1) 5867**] - patients or their families must call 2. Dr. [**First Name (STitle) 9054**] [**Name (STitle) 6481**] at [**Hospital1 18**] [**Location (un) **] which is closer to the [**Location (un) 15005**]/[**Hospital1 189**] area that you have indicated you will be going to after discharge, is taking new patients, the office number is [**Telephone/Fax (1) 4775**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] ICD9 Codes: 5185, 5180
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Medical Text: Admission Date: [**2103-1-14**] Discharge Date: [**2103-1-17**] Date of Birth: [**2055-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Chest pain and alcohol withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 47 yo M with ETOH abuse c/b dilated cardiomyopathy (EF 49% 9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w etoh withdrawal and chronic reproducible chest pain. He currently drinks [**1-3**] gallon of vodka daily, his last drink was evening of [**2102-1-13**]. He reports that after his recent d/c from the hospital on [**1-6**], he attempted to make multiple follow up appointments with MDs and detox, but "did not hear back"; he became frustrated and again began drinking [**1-3**] gallon of vodka/day. He reports he has also been having chest pain which is chronic in nature which he reports gets worse when he's drinking significant amounts. He reports it "hurts every time my heart pumps". He denies CP with deep inspiration and denies SOB. He has had no cough or hemoptysis. He reports since being in the ED, he feels increasingly tremulous and anxious and is hypertensive "because he's withdrawing." He denies hallucinations. In the ED, initial vitals were 97.3 98 [**Telephone/Fax (2) 23538**]% on 2L NC. Urine tox was positive for benzos and cocaine; serum EtOH level was 249. ECG reportedly with "NSST depressions and J pt elevations". CEs were negative x2 sets. CXR was performed which showed stable radiographic appearance of known cavitary lesions in both lung apices with no new process identified. Plan was initially for d/c from ED given negative CEs, however patient began to withdraw in ED with sx of tremulousness, anxiety, hypertension. He received thiamine, folic acid, MVI. He received a total of 40mg diazepam (30mg IV, 10mg PO). He was hypertensive to the 170s-230s systolic and received his home dose lisinopril and IV hydralazine x2. His home dose beta blocker was held given urine tox positive for cocaine. Of note, he has had multiple past admissions for CP and EtOH withdrawal, most recently from [**Date range (1) 23539**] at which time he required large amounts of benzos for safe detox. He was discharged home with plans to be admitted to inpatient substance abuse program at [**Hospital1 882**], however he did not do this. He is now being admitted to the ICU for EtOH withdrawal for q30min-1h CIWA. ROS: No fevers/chills. No cough/sob, no palpitations. No N/V/diarrhea. No melena/hematochezia. No dysuria/hematuria. No rashes. Wound on back from recent fall is healing well. Past Medical History: Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (EF 25%) - cocaine abuse (last use ~ 3 weeks ago) - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [**2093**] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies) Social History: Smokes < [**1-3**] ppd recently; prior to that he smoked 1 ppd x30 years. Heavy EtOH use (usually >1 gallon vodka per day). Sober x10 years up until ~2 years ago; more recently, reports several months of sobriety. +Cocaine abuse; last use several wks ago. He denies IVDA. Sexually active with his girlfriend. Family History: Mother with CAD. Sister with h/o CVA. Physical Exam: VS: Temp: 97.5 BP: 185/119 HR:102 RR:19 O2sat 97%RA GEN: Appears mildly tremulous, moderate distress [**Month/Day (2) 4459**]: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules, left anterior neck with soft tissue defect s/p surgery for head and neck cancer RESP: CTA b/l CV: rrr, soft II/VI systolic murmur at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice, wound mid low back healing without erythema, induration, warmth, fluctuance NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTRs-patellar and biceps. Pertinent Results: [**2103-1-14**] 01:24AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG* bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2103-1-14**] 08:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG Brief Hospital Course: # Alcohol withdrawal: His last drink was on [**2103-1-13**] and on admission he was tremulous and required increasing CIWA scale. On hospital day #2, he was transferred to the ICU for q30min-1h CIWA. In the ICU on [**1-14**], he received 200 mg total of valium, on CIWA scales for anxiety and tremor. On [**1-15**] he received 140 mg valium in the ICU. He was transferred to the medicine floor on [**1-15**] and was continued on a CIWA scale. Psychatry was consulted due to high [**Month/Year (2) **] requirement. He was started on a standing valium regimen and was tapered, in addition to the CIWA scale. He was also continued on MVI, thiamine and folate. On transfer to [**Hospital1 882**] Level 4 detox program on [**2103-1-17**], his standing valium dose was tapered to 15 mg [**Hospital1 **]. In addition, he was continued on his CIWA scale. . # Polysubstance abuse: In the ED, his toxicology screen was positive for ETOH, benzos, and cocaine. In the setting of cocaine use, his beta blocker was discontinued on admission. . # Chest pain: He reported intermittent chest pain that has been chronic in nature. Per his history, his pain worsens in the setting of withdrawl and bodyaches. Of note, his exercise MIBI is without evidence of ischemia from [**9-9**]. In addition,, his pain is reproducible on exam and thus appears most consistent with musculoskeletal pain. . # Hypertension: He was hypertensive on admission in the setting of withdrawl. His beta blocker was discontinued and he was continued on his home regimen of lisinopril. . # Dilated Cardiomyopathy (EF 25%): He remained euvolemic throughout hospitalization. He was continued on ASA and ACE-I. . Medications on Admission: Aspirin 81 mg PO DAILY Levothyroxine 75 mcg PO DAILY Buspirone 10 mg PO BID Toprol XL 150 mg Tablet PO once a day Lisinopril 30 mg PO DAILY Trazodone 50 mg PO HS Olanzapine 5 mg PO HS B-complex with vitamin C Hexavitamin Folic acid 1mg PO daily Thiamine 100mg PO daily Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO every twenty-four(24) hours. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 11. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Alcohol abuse Secondary Polysubstance abuse Congestive heart failure Hypertension Hypothyrodism Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for alcohol withdrawal. You should continue to abstain from alcohol use. Please take all of your medications as prescribed. If you develop chest pain, shortness of breath, persistent fever > 101, or any other serious concerns, please return to the nearest emergency room. Followup Instructions: Please follow up with your primary care provider at [**Name9 (PRE) **] Community Health Center at [**Telephone/Fax (1) 23520**] in [**3-6**] weeks. You will need further evaluation of your difficulty swallowing. Completed by:[**2103-1-31**] ICD9 Codes: 4019, 2449
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Medical Text: Admission Date: [**2118-8-14**] Discharge Date: [**2118-8-19**] Date of Birth: [**2063-5-16**] Sex: M Service: MEDICINE Allergies: Prochlorperazine / Iodine Attending:[**First Name3 (LF) 3016**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 79353**] is a 55 yo man w/ metastatic melanoma and known mets to brain (incl cerebellum), who presents with one day of headache and altered mental status. History is obtained by the patient's wife due to the patient being sedated from the ED. Over the past few days prior to admission, the pt's wife notes that he had not been sleeping well at night due to increased urinary frequency. However, other than feeling more tired during the day he had been overall doing well. On the morning prior to admission, the patient developed a severe headache, associated with nausea and several episodes of bilious vomiting. He was unable to keep down any POs. Additionally, he had increasing confusion and agitation and so was taken to [**Hospital3 12748**]. In the ED there, head CT revealed hemorrhage of some of his brain mets with 2mm midline shift and mild hydrocephalus. He received 8mg IV dexamethasone, 4mg IV morphine x 2, and zofran. [**Hospital1 18**] oncology fellow was contact[**Name (NI) **] and transfer was arranged. Of note, pt has had 2 recent admissions to [**Hospital1 18**] with nausea, vomiting, dizziness and dehydration. This was felt to be due to combination of Taxol and progression of CNS disease. During admission Mr. [**Known lastname 79353**] was made aware that surgical resection of the cerebellar metastasis may relieve these symptoms, however, he has refused any kind of surgery on more than one occasion on review of the medial record. He was placed on 4 mg every 8 hours of dexamethasone and was discharged with home IV fluids and PICC line on [**2118-7-19**]. In the ED, initial vs were: T 97.5, P 60, BP 166/90, R 15, O2 sat 98% RA. Patient was agitated, but not talking or answering questions. He was given 3mg of ativan for sedation to obtain a repeat CT head. He brady'd to the 30s after receiving sedation, but HR improved up to low 100s spontaneously. Repeat CT head was reviewed by neurosurgery and showed no change from OSH imaging, without hydrocephalus or risk for herniation. Additionally, it was felt there was no significant change since his last imaging 2 months ago. Family declined surgical intervention, per his prior wishes. He was given decadron 10mg IV and transferred to the [**Hospital Unit Name 153**] for close monitoring. On arrival to the [**Hospital Unit Name 153**], the patient is somnolent and unarousable but appears comfortable. His wife is at the bedside. Past Medical History: PMH: 1. Metastatic melanoma: Onc hx adapted from recent onc clinic note by [**Doctor First Name **] [**Location (un) **]: Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] wide local excision and left parotid neck node dissection for a 6 mm thick melanoma of his left parietal scalp in [**2116-7-3**], with 3 of 27 nodes being positive. He received adjuvant interferon, but had a soft tissue recurrence in the left neck a few months into therapy. This was resected and interferon therapy was resumed post surgery until [**Month (only) 404**] of [**2117**], when he developed contralateral neck soft tissue recurrence treated with surgical resection and parotidectomy in [**2117-4-3**]. Pathology revealed 4 of 8 nodes positive, and a large lymph node measuring 1.7 cm in the parotid. His interferon therapy was discontinued at this time. A PET CT scan in [**Month (only) 216**] of [**2117**] revealed lung nodules and a 3.3 cm left inguinal mass. Head MRI revealed a single brain metastasis in the right corona radiata. He [**Year (4 digits) 1834**] CyberKnife radiosurgery to this lesion in [**2117-11-3**]. He began high dose IL2 in [**2117-12-4**], without response. He developed deep vein thrombosis in [**Month (only) 404**] of [**2118**], requiring Lovenox. Followup head MRI revealed disease progression in the CNS. He was begun on CTLA4 antibody protocol on [**2118-3-1**], with 6 week scan showing disease progression, particularly in the CNS, and he [**Year (4 digits) 1834**] whole brain radiation therapy started on [**2118-4-12**]. He completed a 4-week course of radiation on [**2118-4-22**]. Repeat CT scan showed evidence of disease progression, particularly in the left inguinal area. Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] surgical resection of a mass in his left groin area in [**2118-5-4**]. Surgery was able to remove the mass. Ventriculostomy [**2118-6-23**] for occlusive hydrocephalus. Had first dose of taxol [**2118-6-28**]. 2. s/p appendectomy as a child 3. Degenerative joint disease in the L5 area 4. Cervical neck surgery [**2112**] 5. DVT as above . Social History: Married, 2 children. Lives with wife and has pet dog. Formerly worked as a commercial fisherman, a construction worker, and other odd jobs. Quit smoking 15 years ago after 20 pack-year history. Very occasional EtOH. Family History: Mother passed away with metastatic uterine CA. Physical Exam: Vitals: T: 99.8, BP: 149/69, P: 87, R: 15, O2: 97% RA General: Somnolent, moving all extremities spontaneously but is not responsive to painful stimuli, no acute distress HEENT: Well-healed surgical scar on the superior aspect of the head, sclera anicteric, pupils 2mm and minimally responsive, MMM, oropharynx clear Neck: surgical scar in the left neck, supple, JVP not elevated, no LAD Lungs: coarse upper airway sounds, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; 10cm subcutaneous mass in the left axilla, 6-8cm subcutaneous mass in the left groin near his surgical excision site, and 5cm subcutaneous mass at the internal aspect of the right calf Skin: pinpoint echymoses on his abdomen [**3-7**] lovenox injections Pertinent Results: LABS ON ADMISSION: [**2118-8-13**] 07:00PM BLOOD WBC-9.6 RBC-3.97* Hgb-11.8* Hct-34.4* MCV-87 MCH-29.7 MCHC-34.2 RDW-15.8* Plt Ct-326 [**2118-8-13**] 07:00PM BLOOD Plt Ct-326 [**2118-8-13**] 07:00PM BLOOD Glucose-112* UreaN-23* Creat-0.7 Na-137 K-4.2 Cl-101 HCO3-23 AnGap-17 [**2118-8-13**] 07:00PM BLOOD TSH-2.0 LABS ON DISCHARGE: [**2118-8-17**] 12:00AM BLOOD WBC-6.3 RBC-3.41* Hgb-9.9* Hct-29.8* MCV-87 MCH-29.1 MCHC-33.3 RDW-15.9* Plt Ct-232 [**2118-8-17**] 12:00AM BLOOD Plt Ct-232 [**2118-8-17**] 12:00AM BLOOD Glucose-119* UreaN-32* Creat-0.7 Na-144 K-4.0 Cl-111* HCO3-23 AnGap-14 [**2118-8-17**] 12:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.3 CXR [**2118-8-13**]: New opacification at the right lung base accompanied by a greater elevation of the right hemidiaphragm could be atelectasis alone or combination of atelectasis and pneumonia, particularly aspiration. Large nodule in the right mid lung unchanged since [**Month (only) 547**]. Heart size normal. No appreciable pleural effusion. No pneumothorax. EKG [**2118-8-14**]: Sinus tachycardia, rate 140. Vertical axis. Cannot exclude inferior myocardial infarction of indeterminate age. S1-Q3-T3 pattern. Consider acute pulmonary embolism. Compared to the previous tracing of [**2118-8-14**] sinus bradycardia has given way to sinus tachycardia and axis is now vertical. Also, non-specific inferolateral repolarization changes have appeared. HEAD CT [**2118-8-14**]: No new focus of hemorrhage. Overall unchanged picture of hemorrhagic metastases. Brief Hospital Course: 1. ALTERED MENTAL STATUS: Most likely multifactorial but primarily from leptomeningeal involvement and hemorrhagic brain metastases with contributions from over-sedation from home benzodiazepines, PNA and UTI. On admission to the ICU patient was quite sedated and only minimally responsive. Across his stay he became more responsive and was able to follow commands, move all extremities, and at times speak quite coherently, although his mental status continued to wax and wane. During his hospitalization he also developed a left sided facial droop thought likely due to evolving brain metastases and leptomeningeal involvement. 2. GOALS OF CARE/CODE STATUS: The patient code status was made DNR/DNI during this admission and this was confirmed with the patient's wife. A family meeting was held to discuss goals of care, and it was decided to move towards hospice care after discharge. The patient's wife, however, appeared to hold out ongoing hope for the patient's recovery, and the patient himself expressed the desire to attempt one more round of Taxol. Discharged with home VNA and bridge to hospice. 3. METASTATIC MELANOMA WITH HEMORRHAGIC BRAIN METS: Known mets to scalp, neck, groin, brain s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16859**], [**First Name3 (LF) **] mass resection and ventriculostomy for obstructive hydrocephalus. On Taxol at admission, first dose 5/26. In previous discussions, patient has been clear that he did not desire further surgical intervention for control of his brain mets. He repeatedly stated his desire for one more attempt at treatment with Taxol, which was decided against given the patient's disease progression despite taxol therapy. Dexamethasone was continued for cerebral edema and all anticoagulation was held. 4. FEVERS/PNA/UTI: Fever and CXR on admission with consolidation at right base concerning for aspiration pneumonia, as well as WBCs in U/A. No elevation of WBC. Started on Vanc/Zosyn later changed to Vanc/Cefapime after blood cultures remained negative. Urine Cx grew out enterococcus which was sensitive to ampicillin, nitrofurantoin and vancomycin. 5. NAUSEA/VOMITING: Likely related to leptomeningeal involvement and metastatic impingement on fourth ventricle versus recent chemo. No evidence of increased intracranial pressure on head CT but during stay patient did develop left sided facial droop. Could be related to vertigo in setting of additional brain edema as in recent admission. He also has had dizziness and lighthededness with standing and sitting up, and on previous admission patient had orthostatic hypotension. Patient was treated with Ondansetron and Decadron. 6. h/o DVT: Dx in [**2-11**]. Lovenox stopped on admission given hemorrhagic brain mets. Medications on Admission: Dexamethasone 4mg PO q8 Lovenox 80mg SQ [**Hospital1 **] (held since [**8-12**]) Ativan 0.5mg PO TID Vicodin 1-2 tabs q6-8 prn Olanzapine 2.5mg PO BID prn Zofran 8mg PO TID prn Colace 100-200mg PO daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain. Disp:*500 ml* Refills:*4* 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*40 Tablet(s)* Refills:*3* 4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*40 Tablet(s)* Refills:*2* 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). Disp:*300 ml* Refills:*2* 6. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation, hallucinations: Please take 1 tablet up to 3 times per day as needed for agitation or hallucinations. Disp:*90 Tablet(s)* Refills:*2* 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-4**] Tablet, Rapid Dissolves PO every four (4) hours: please take 1-2 tablets up to every 4 hours, as needed, to control nausea and vomiting. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 8. IVF Resumption of hydration and line per critical care systems. Normal saline as needed for hydration. 9. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Dexamethasone Intensol 1 mg/mL Drops Sig: Six (6) ml PO every eight (8) hours. Disp:*qs 2 weeks* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: PRIMARY: 1. Melanoma, metestatic 2. Leptomeningeal invovlement 3. Mental status changes 4. UTI 5. PNA Discharge Condition: clinicall stable, moderately alert, pain controlled, patient and family aware of diagnosis, on comfort measures and IVF only Discharge Instructions: You were admitted for change in mental status thought to be secondary to progression of your cancer. Your symptoms are consistent with tumor involvement of the fluid in your spinal cord (called leptomeningeal invovlement). We had a family meeting with palliative care and Dr. [**Last Name (STitle) 79354**] team and discussed goals of care. You will be discharged home with VNA services with bridge to hospice. You will have a PICC line with IV fluids. . We have made changes to your medication. Please follow the discharge instruction. . Call your doctor if you have worsening pain or agitation or any other questions. Followup Instructions: Call your doctor if you have worsening pain or agitation or any other questions. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**] ICD9 Codes: 431, 5070
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Medical Text: Admission Date: [**2102-1-8**] [**Month/Day/Year **] Date: [**2102-1-20**] Date of Birth: [**2033-8-28**] Sex: F Service: SURGERY Allergies: Codeine / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2534**] Chief Complaint: febrile, bacteremic due to PICC Major Surgical or Invasive Procedure: none History of Present Illness: 68 yo woman w/Hx ventral hernia repair c/b enterocut fistula, abdom wall abscess, more recently w/PICC-associated enterococcus and coag neg staph bacteremia, now admitted on [**2102-1-8**] with GPC bacteremia and Klebs UTI. Past Medical History: SBO s/p surgery complicated by ventral heria repair and wound infection requiring vancomycin and pigtail placement in [**Month (only) **] [**2100**]; s/p hysterectomy, s/p lap chole, s/p LOA, epilepsy, anxiety, tremors, depression, hypothyroid, sz d/o Social History: currently living at NE Siani since [**Year (4 digits) **]. no tobacco or EtOH Family History: Noncontributory Physical Exam: T: 98.2 P: 86 R: 20 BP: 136/84, O2Sat 99% RA General: Alert, oriented, follows commands, watching TV HEENT: NCAT, PERRL, OP clear without exudates/lesions Neck: no LAD/JVD Lungs: CTA B Heart: RRR, 2/6 systolic murmur Abdom: midline 10 x 10cm wound with ostomy bag over top, and J-tube entering the middle of such wound. LLQ mildly tender Extrem: *LUE AC w/3x3cm tender nodule over former site of PICC line *RUE new PICC c/d/i, no erythema GU: Foley intact Neuro: MAE, PERRL Skin: no rash Pertinent Results: [**2102-1-8**] 02:55PM PLT COUNT-222 [**2102-1-8**] 02:55PM NEUTS-68.8 LYMPHS-13.5* MONOS-8.6 EOS-9.0* BASOS-0.1 [**2102-1-8**] 02:55PM WBC-9.3 RBC-3.26* HGB-8.6* HCT-26.7* MCV-82# MCH-26.4* MCHC-32.2 RDW-13.2 [**2102-1-8**] 02:55PM estGFR-Using this [**2102-1-8**] 02:55PM GLUCOSE-103 UREA N-68* CREAT-2.1*# SODIUM-138 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 [**2102-1-8**] 04:23PM LACTATE-1.5 [**2102-1-8**] 03:50PM URINE HOURS-RANDOM [**2102-1-8**] 03:50PM URINE UHOLD-HOLD [**2102-1-8**] 03:50PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2102-1-8**] 03:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2102-1-8**] 03:50PM URINE RBC->50 WBC-21-50* BACTERIA-FEW YEAST-NONE EPI-0 [**2102-1-17**] 06:31AM BLOOD WBC-13.5* RBC-3.25* Hgb-8.7* Hct-26.1* MCV-80* MCH-26.7* MCHC-33.3 RDW-14.2 Plt Ct-358 [**2102-1-16**] 05:44AM BLOOD WBC-11.1* RBC-3.13* Hgb-8.2* Hct-25.3* MCV-81* MCH-26.3* MCHC-32.6 RDW-13.6 Plt Ct-324 [**2102-1-15**] 04:10AM BLOOD WBC-10.6 RBC-3.05* Hgb-8.2* Hct-24.7* MCV-81* MCH-26.8* MCHC-33.1 RDW-13.4 Plt Ct-308 [**2102-1-9**] 09:10PM BLOOD Neuts-80.1* Lymphs-9.8* Monos-5.5 Eos-4.5* Baso-0.1 [**2102-1-17**] 06:31AM BLOOD Plt Ct-358 [**2102-1-17**] 06:31AM BLOOD PT-40.9* INR(PT)-4.5* [**2102-1-16**] 05:44AM BLOOD Plt Ct-324 [**2102-1-16**] 05:44AM BLOOD PT-30.1* PTT-36.5* INR(PT)-3.1* [**2102-1-15**] 04:10AM BLOOD Plt Ct-308 [**2102-1-15**] 04:10AM BLOOD PT-22.6* PTT-38.8* INR(PT)-2.2* [**2102-1-17**] 06:31AM BLOOD Glucose-93 UreaN-48* Creat-3.4* Na-139 K-4.4 Cl-104 HCO3-25 AnGap-14 [**2102-1-16**] 05:44AM BLOOD Glucose-89 UreaN-48* Creat-3.4* Na-140 K-4.1 Cl-106 HCO3-23 AnGap-15 [**2102-1-15**] 04:10AM BLOOD Glucose-96 UreaN-50* Creat-3.4* Na-140 K-3.4 Cl-109* HCO3-21* AnGap-13 [**2102-1-14**] 04:44AM BLOOD Glucose-101 UreaN-59* Creat-3.5* Na-142 K-3.2* Cl-111* HCO3-22 AnGap-12 [**2102-1-10**] 06:19PM BLOOD CK(CPK)-12* [**2102-1-10**] 01:07PM BLOOD CK(CPK)-15* [**2102-1-9**] 09:10PM BLOOD ALT-27 AST-26 CK(CPK)-18* AlkPhos-272* TotBili-0.4 [**2102-1-10**] 06:19PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2102-1-10**] 01:07PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2102-1-9**] 09:10PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2102-1-17**] 06:31AM BLOOD Calcium-8.7 Phos-6.7* Mg-2.2 [**2102-1-16**] 05:44AM BLOOD Calcium-8.5 Phos-6.1* Mg-2.4 [**2102-1-15**] 04:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.8 [**2102-1-14**] 04:44AM BLOOD Calcium-9.0 Phos-4.8*# Mg-1.9 [**2102-1-13**] 01:54AM BLOOD Calcium-9.1 Phos-6.5* Mg-2.2 [**2102-1-12**] 06:52PM BLOOD calTIBC-194* Ferritn-1898* TRF-149* [**2102-1-9**] 10:50AM BLOOD calTIBC-209* Ferritn-GREATER TH TRF-161* [**2102-1-12**] 06:52PM BLOOD Triglyc-90 HDL-26 CHOL/HD-3.3 LDLcalc-41 [**2102-1-16**] 05:44AM BLOOD Vanco-19.0 [**2102-1-13**] 07:56PM BLOOD Vanco-14.9 [**2102-1-12**] 06:52PM BLOOD Vanco-29.3* [**2102-1-8**] 02:55PM BLOOD HoldBLu-HOLD [**2102-1-11**] 02:14AM BLOOD Type-ART pO2-170* pCO2-39 pH-7.41 calTCO2-26 Base XS-0 [**2102-1-10**] 03:04PM BLOOD Type-ART pO2-171* pCO2-31* pH-7.44 calTCO2-22 Base XS--1 [**2102-1-9**] 09:25PM BLOOD Type-ART pO2-160* pCO2-40 pH-7.38 calTCO2-25 Base XS-0 [**2102-1-9**] 06:53PM BLOOD Type-ART pO2-448* pCO2-41 pH-7.38 calTCO2-25 Base XS-0 Intubat-INTUBATED [**2102-1-9**] 06:53PM BLOOD Lactate-1.8 [**2102-1-8**] 04:23PM BLOOD Lactate-1.5 [**2102-1-12**] 06:52PM BLOOD PREALBUMIN-Test [**2102-1-9**] 10:50AM BLOOD PREALBUMIN-Test Brief Hospital Course: Mrs [**Known lastname 107389**] was admitted to the Surgery service with a Klebsiella UTI and coagulase negative staph positive blood cultures at her rehab. She was started on Cefriaxone and Vancomycin and her PICC line was pulled and the tip cultured and blood and urine cultures were also sent. All cultures were negative. On [**1-9**], she became anxious and then developed respiratory distress, hyopoxia, and acidosis that required emergent intubation. She was transfered to the ICU where her respiratory distress was attributed to CHF as a TTE showed a EF of 40% whereas she had previously had a normal EF. She was diuresed and extubated. Renal was consulted for worsening renal funciton that they believed was secondary to ATN. A renul ultrasound showed only mild left pelvocaliectasis and no signs of obstruction or hydronephrosis. Upper extremity ultrasound revealed left IJ occluding thrombus and and left upper extremety non-occlusive thrombus. The patient was started on Heparin drip and bridged to coumadin. A repeat ECHO on [**1-12**] showed improved EF of >55% and no vegetations. Mrs [**Known lastname 107389**] was transferred back to the regular floor and did well. Infectious disease was consulted and recommended continuing the vancomycin and stopping the ceftriaxone as a 10 day course of treatment had been completed. Repeat blood and urine cultures were negative. A new PICC line was placed on [**1-13**] for antibiotics and TPN, but given her recent bacteremia and her tolerating tube feeds well, TPN was not restarted. She remained afebrile and was tolerating her tube feeds well, and was advanced slowly to a regular diet in addition to her tube feeds. A left upper extremity ultrasound of the old PICC site showed findings suggestive of left antecubital thrombosed pseudoaneurysm. Due to the presence of multiple thrombi, infectious disease recommended continuing the IV Vancomycin for 4 weeks and will continue to follow her laboratory and micro data at rehab. Her abdominal wound/ostomy/fistula continued to require daily care by wound/ostomy nurses. Recommendations for wound care and nutrition were included in the page one. . Heme: Pt was found to have left IJ and left upper extremety thrombi. Given her respiratory distress early in her admission a chest ct-angiogram was considered but not performed secondary to her worsening renal function. She was started on therapeutic dosing of heparin and bridged to coumdin. Her INR was therapeutic on [**Month/Year (2) **], but her daily coumdain dose was not stable and will need to be monitored closely at rehab. . Renal: Mrs [**Known lastname 107389**] presented in acute renal failure, which worsened somewhat during her hospital course, despite adequate hydration and consistently good urine output. Renal was consulted and felt was ATN and recommended renal ultrasound and monitoring urine output. The renal ultrasound showed no obstruction or hydronephrosis. Her creatinine and urine output should be followed at rehab. . Cardiac/Respiratory: Pt had episode of respiratory distress/hypoxia as described above, that appeared to be a combination of anxiety and new CHF with reduced EF on ECHO. EKG was unchanged and troponin 0.03, 0.03, 0.04, which was considered to be negative in the context of her worsening renal failure. She was stabilized in the ICU, diuresed and easily extubated. Repeat ECHO was normal and her respiratory status remained stable after returning to the floor. She has had no chest/respiratory complaints and is satting 97-100% on room air. . Infectious disease: Pt presented with Klebsiella UTI and Co-Ag neg staph bacteremia likely secondary to a line infection. For her UTI she completed a 10 day course of Ceftriaxone. For her bacteremia, her PICC was pulled, she was started on IV Vancomycin, and will have a 4 week course given her thrombi. Micro [**2008-1-5**] blood cxr at OSH: GPC ([**1-24**]) [**1-6**] urine cxr at OSH: klebsiella [**Last Name (un) 36**] to bactrim, aztreo, cefaz, ceftaz, ceftriaxone, resistant to cipro amp levo nitrofurantoin [**1-8**] urine cxr: contam final [**1-8**]: blood cxr: ng final [**1-8**]: PICC tip cxr: ng final [**1-10**] urine: ng final [**1-11**]/: MRSA SCREEN NEG Medications on Admission: . nystatin 5ml PO q6 2. ferrous sulfate 300mg PO BID 3. metoprolol 100mg PO TID 4. mirtazapine 15mg PO qhs 5. citalopram 40mg [**Hospital1 **] 6. heparin sodium 50units IV q8 7. primidone 50mg qHS 8. olanzapine 5mg daily 9. lipids 250ml IV Mon/We/Fri 10. esomeprazole 40mg IV BID 11. ascorbic acid 500mg [**Hospital1 **] 12. levetiracetam 500mg IV BID 13. ergocalciferol [**Numeric Identifier 1871**] units PO Mon, Thurs 14. TPN 15. fentanyl patch 75mcg TD q72 hours 16. ceftazidine 1gm IV q8h 17. vancomycin 1gm IV q8h 18. tylenol 650mg PO q4 prn 19. albuterol 2.5mg neb prn 20. zofran 4mg IV prn - last dose 2/14 21. hydromorphone 6mg IV q4h prn - last dose 2/15 22. nutren with replete at 20cc/hr 23. quetiapine 200mg PO BID [**Numeric Identifier **] Medications: 1. Acetaminophen 325 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Insulin Regular Human 100 unit/mL Solution [**Numeric Identifier **]: SSI Injection ASDIR (AS DIRECTED). 3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Numeric Identifier **]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Numeric Identifier **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Fentanyl 100 mcg/hr Patch 72 hr [**Numeric Identifier **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Citalopram 20 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Quetiapine 200 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Primidone 50 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO HS (at bedtime). 9. Mirtazapine 15 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Levothyroxine 100 mcg Tablet [**Numeric Identifier **]: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO TID (3 times a day). 12. Hydralazine 25 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP > 150. 13. Sevelamer HCl 400 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Warfarin 2 mg Tablet [**Numeric Identifier **]: 1.5 Tablets PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA). [**Doctor First Name **] Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] [**Location (un) **] Diagnosis: s/p component release and mesh repair of ventral hernia, enterocutaneous fistula, klebsiella UTI, Acute Renal Failure, bacteremia. [**Location (un) **] Condition: good [**Location (un) **] Instructions: Mrs. [**Known lastname 107389**] will require 4 weeks of vancomycin IV (end date [**2102-2-5**]). She will need weekly labs: CBC/diff, BUN/Cr, LFT, Vanco trough faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 18871**]. Her VANCOMYCIN SHOULD BE HELD UNTIL A VANC LEVEL IS BELOW 20, then restarted at 750mg Q48 hours. VANC TROUGHS SHOULD BE CHECKED AND REVIEWED BEFORE EACH DOSE UNTIL STABLE. IF QUESTIONS PLEASE CALL INFECTIOUS DISEASE. DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 17490**]. Continue tube feeds per nutrition recommendations and wound/ostomy care. Please return to [**Hospital1 18**] if you have increasing pain, drainage, or fever, shaking chills, shortness of breath. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3243**] MD Phone: [**Telephone/Fax (1) 2359**] Date/Time:[**2102-2-7**] 1:30 ICD9 Codes: 5845, 7907, 5990, 2762, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3151 }
Medical Text: Admission Date: [**2142-9-27**] Discharge Date: [**2142-10-2**] Date of Birth: [**2104-10-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13541**] Chief Complaint: Lower GI bleed in setting of ulcerative colitis flare Major Surgical or Invasive Procedure: Colonoscopy ([**2142-9-29**]) 10 units PRBC's History of Present Illness: The pt is a 37-yo man with ulcerative colitis who presents with 3-4 days of bloody bowel movements. He had been experiencing a flare of his ulcerative colitis, that begain back in [**2141-7-14**]. He was treated with oral steroids for 6 weeks, uptitrated to 40mg Prednisone daily, and is also using cortisone retention enemas. He has also noted swelling in his knees. He is being followed by his gastroenterologist Dr. [**Last Name (STitle) 79460**] at [**Hospital1 2025**]. He had noted improvement in his abdominal symptoms until about 3-4 days PTA, when he noted bloody bowel movements. Since then he has been having [**5-20**] bloody bowel movements daily. On [**Month/Day (3) 766**], he had his Hct checked at [**Hospital 1191**] Hospital, where he works, and noted that it was about 29 (down from baseline ~38). One day PTA, he had profuse bleeding and passed out. His BP at the time was 80/60. He was brought in to the ED for further evaluation. Upon arrival to the ED: VS- afeb, HR 85, SBP 120s-130s, O2-sats 100% RA. Hct on arrival was 20.8. He was given 2L NS and transfused 2units PRBCs. He was started on IV Flagyl given concern for C.diff after it was noted that his WBC was 19. Serial Hcts during transfusion showed little change (final Hct in ED 21.1), although he remained HD stable. He was admitted to the MICU for further care. Past Medical History: -Ulcerative Colitis - dx age 19, had severe lower GI bleeding at age 21, a flare in [**2133**], then no problems until the last couple years when he has had an escalation of his symptoms and most recently required escalating doses of prednisone -Allergic Rhinitis -OSA - uses CPAP of 9 -(+) ppd - after initial steroids in [**2125**], s/p 9 months INH -H/o dysplastic nevi on back s/p resection Social History: Patient is a physchiatrist. Wife is an Oncologist at [**Hospital1 18**]. Denies prior tobacco use. Drinks approximately 1 drink per month with slight increase in alcohol use leading up to UC flair. Family History: Father is Ashkenazi [**Name (NI) **] who had history of IBS and GIST (passed at age 66). Mother is Korean and has h/o HTN and glaucoma. Physical Exam: VS: Tmax: 99.3 (during transfusion), Tcurr: 98.7, HR: 75, BP 112/62, RR: 18, 100% on RA GENERAL: NAD, comfortable, appropriate, somewhat pale HEENT: EOMI, conjunctival pallor, oropharynx benign, mucus membranes are dry LUNGS: CTA bilaterally, no rhonchi or wheezes HEART: RRR, no MRG, nl S1-S2 ABDOMEN: BS+, soft, mildy tender during palpation of LLQ, no guarding, no rebound EXTREMITIES: No peripheral edema, No obvious effusions of knees bilaterally NEURO:AxOx3 Pertinent Results: CBC: [**2142-9-26**] WBC-19.3* RBC-2.32* HGB-6.9* HCT-20.8* MCV-90 MCH-29.9 MCHC-33.3 RDW-14.1 [**2142-9-26**] NEUTS-79.2* LYMPHS-17.6* MONOS-2.7 EOS-0.3 BASOS-0.2 [**2142-9-27**] HGB-7.3* HCT-21.1* [**2142-9-27**] WBC-15.0* RBC-2.76* HGB-8.2* HCT-24.1* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.3 [**2142-9-27**] HCT-24.4* [**2142-9-27**] HCT-26.4* [**2142-10-2**] Hct-37.8 [**2142-9-26**] 09:40PM PT-13.8* PTT-19.6* INR(PT)-1.2* Electrolyes: [**2142-9-26**] 09:40PM GLUCOSE-175* UREA N-24* CREAT-1.0 SODIUM-136 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 [**2142-9-27**] 09:57AM ALBUMIN-2.9* CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-2.0 [**2142-9-27**] 09:57AM ALT(SGPT)-20 AST(SGOT)-14 LD(LDH)-128 ALK PHOS-43 TOT BILI-0.4 [**2142-9-27**] 10:24AM LACTATE-1.1 Iron Studies: [**2142-10-1**] 05:20AM BLOOD calTIBC-217* Ferritn-56 TRF-167* LE U/S:IMPRESSION: No DVT on the right leg CT AB: IMPRESSION: Colitis extending from the mid ascending colon to the distal one-third of the transverse colon. The terminal ileum, rectum, and sigmoid colon are spared. The differential for the etiologies include infectious and inflammatory. Please correlate with laboratory values, for example, for history of C. diff colitis. Brief Hospital Course: # Lower GI bleed: Pt presented with 3-4 days of multiple bloody bowel movements, and hematocrit nadir of 19%. He was initially cared for in the ICU. GI was consulted, and recommended therapy with Solumedrol 20 mg IV every 8 hours, intravenous Cipro and flagyl, and oral mesalamine 2400 mg PO BID and mesalamine enemas. A CT scan of the abd/pelvis on [**2142-9-27**] showed colitis. Colonoscopy on [**9-28**] showed a single lesion in the transverse colon without continuous lesions more consistent with CD than UC. Biopsies are still pending at the time of discharge. He was transfused a total of 10 units of PRBCs during his hospital stay, with subsequent stabilization of his hematocrit. His last transfusion was on [**2142-9-30**]. Of note, C. difficile was sent and returned negative. He was transitioned to oral antibiotics on [**10-1**] and Prednisone on [**2142-10-2**]. He additionally tolerated a regular diet at the time of discharge. He was discharged with out-patient follow-up with GI at [**Hospital1 2025**]. Med changes: Ciprofloxacin and Flagyl for 7 day course (will end on [**2142-10-7**]). Prednisone [**Date Range 15123**] starting at 60mg PO will defer to Primary GI doctor [**First Name (Titles) **] [**Last Name (Titles) 15123**]. Bacrim DS and protonix while on high dose steroids. Mesalamine will be continued at home. An appointment was made with his primary GI doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] [**10-8**] at 1:45. #. Swollen right knee - While in the hospital, the patient additionally reported arthralgia involving his R>L knee, without overlying skin changes. The possibility of extra-intestinal manifestations of IBD was raised. LENI was negative for DVT. Medications on Admission: Hydrocortisone retention enema QHS Asacol 2400 mg [**Hospital1 **] Prednisone 40 mg daily Claritin 10 mg daily Multivitamin Calcium Vitamin C Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR ([**Hospital1 766**] -Wednesday-Friday) as needed for pcp [**Name9 (PRE) 6187**] for 3 weeks. Disp:*9 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) for 3 weeks. Disp:*21 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute flare of inflammatory bowel disease. Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with acute ulcerative colitis flare and 3-4 days bloody bowel movements and low hematocrit. An abdominal CT scan showed colitis, and you were treated with antibiotics (Flagyl and Cipro) for suspected GI infection. After a few days, the cultures did not grow anything. A colonoscopy was also performed and biopsies were taken, the results were pending at the time of discharge. Once you were hemodynamically stabilized, you were transferred from the MICU to the floor. During your time on the floor, your Hct stabilized and there were no signs of acute bleeding. After slowly advancing your diet and following up with the GI recommendations, it was decided to discharge you with antibiotics, and have you follow-up with your GI and primary care doctors. Please take all medications as directed and attend all follow-up appointments. Since you were admitted, we have made some changes to your medication regimen: - Prednisone 60mg [**Hospital1 15123**] as directed by your GI doctor. - Ciprofloxacin and Flagyl 7 day course to be completed on [**2142-10-7**]. - Bactrim DS while on high dose steroids. - Protonix while on steroids. If you have worsening abdominal or back pain, fevers, chills, loss of control of your bowels, numbness/weakness, please seek medical attention or come to the emergency department immediately. Followup Instructions: Please follow-up with your GI specialist at [**Hospital1 2025**], Dr. [**Last Name (STitle) 79460**]. An appointment has been made for 1:45 on [**Last Name (STitle) 766**] ([**2142-10-8**]). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**] ICD9 Codes: 5789, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3152 }
Medical Text: Admission Date: [**2101-1-13**] Discharge Date: [**2101-2-11**] Date of Birth: [**2030-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right hydrothorax, fluid overload, fever Major Surgical or Invasive Procedure: [**2101-1-13**]: right ultrasound-guided thoracentesis [**2101-1-14**]: flexible bronchoscopy [**2101-1-18**]: bronchoscopy, thorascoscopy video-assisted right drainage of effusion, decortication, removal of gortex mesh History of Present Illness: Mr. [**Known lastname 75713**] is a 71 year-old male with history of right upper lobe lung cancer s/p right thoracotomy with right upper lobectomy and en-block chest wall resection with decortication of the middle and lower lobes. The procedure was difficult procedure and complicated by prolonged hospital stay due to bronchopleural fistula. He returned for followup on [**2101-1-13**] with improving postoperative chest discomfort, yet reported shortness of breath, nonproductive cough, and bilateral lower extremity edema, despite being recently placed on lasix by his PCP. [**Name10 (NameIs) **] had a low-grade fever to 100.1 the evening prior to his followup appointment. CXR ([**2101-1-13**]) revealed right hydropneumothorax. He was subsequently admitted to the Thoracic Surgery service for further workup and management. Past Medical History: PMH: Traumatic blindness (left eye) Hypertension Alcohol-induced gastric ulcers (alcohol-free x20yr) Lung CA, R chest wall ([**4-11**]), s/p carboplatin, taxol with avastin h/o serratia marascens VAP PSH: s/p appendectomy, date unknown [**2100-12-22**]: Bronchoscopy, Reoperative right thoracotomy with right upper lobectomy and en bloc right chest wall resection (ribs 3,4 and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication of right middle and right lower lobes. . [**2100-12-25**]: Flexible bronchoscopy with therapeutic aspiration and bronchoalveolar lavage. . [**2100-12-26**], [**2100-12-27**], [**2100-12-28**], [**2101-1-19**]: Flexible bronchoscopy with therapeutic aspiration. . [**2101-1-13**]: Right sided thoracentesis under ultrasound guidance. Social History: Lives with wife EtOH: {x}N { }Y Quit Tobacco: {x}N { }Y Quit 20 years ago Drugs: {x}N { }Y Amount: Married: { } N {x}Y Occupations: Construction worker Exposures: Asbestos, chemical / construction materials Diabetes: N Immunodeficiency: N Cancer: Y Family History: Notable for cerebral hemorrhage. Father with lung cancer. Brother with gastric cancer and another brother with emphysema. Sister with cystic fibrosis. Physical Exam: General: NAD, thin-appearing male, awake, alert HEENT: NC/AT, mucous membranes moist, OP clear, no lesions Neck: Supple, no lymphadenopathy Cardiovascular: RRR no murmurs Respiratory: Significantly decreased right base, slightly decreased on left base. Empyema tubes x3. Back: Well-healed thoracotomy scar Gastrointestinal: soft, nontender, nondistended, normoactive bowel sounds Musculoskeletal: [**2-6**]+ pitting edema LE bilaterally Skin: Right port without erythema, bilateral splinter hemorrhages Pertinent Results: [**2101-1-13**]: CXR (on admit) No evidence of remaining aerated pulmonary tissue in right-sided hemithorax and central right-sided airways only followed 2-3 cm distal to the bifurcation. A hydropneumothorax is present on the right side with an air-fluid level above thoracic arch. Multiple right-sided upper rib defects consistent with chest wall reconstruction. Mild-to-moderate mediastinal shift towards right side indicative of volume loss. The left-sided hemithorax shows grossly normal appearance of the lung without evidence of acute infiltrates or congestive pattern. . [**2101-1-13**]: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS . [**2101-1-25**]: ECHO: Left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy. 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 regurgitation. The mitral valve leaflets are mildly thickened. There is a small pericardial effusion. . [**2101-1-27**]: CT Chest IMPRESSION: 1. New, large hematoma in the right upper chest, predominantly pleural, despite two apical pleural tubes; new submuscular, R chest wall hematoma. 2. Persistent right pleural thickening and worsening atelectasis. 3. New small left pleural effusion. . [**2101-2-3**]: CT Chest IMPRESSION: 1. Resolving large hematoma in the right upper chest with reexpansion of the right upper lobe volume. 2. Persistent right extrathoracic hematoma with less gas. 3. Resolving left pleural effusion. . [**2101-2-9**]: Renal U/S: No evidence of hydronephrosis . [**2101-2-10**]: CXR (prior to discharge) IMPRESSION: No relevant changes in right hemithorax. Minimal increase in a subtle perihilar, but diffuse opacity in the left lung. Brief Hospital Course: Neuro: On admit, the patient was given oral pain medication, on which he reported adequate pain relief. Following right VATS and post-operative intubation, he was placed on propofol gtt and given dilaudid IV until extubated. When able to tolerate po, he was placed on oral pain medication. Prior to discharge, his pain was adequately controlled on tylenol. . Cardiopulmonary: Following admission, the patient underwent a bronchoscopy on [**2101-1-14**] which revealed a small amount of granulation tissue at the base of cords c/w prior intubation trauma, healthy appearing surgical stump, mucous in RLL, and edematous RML/RLL bronchi. Based on the right hydropneumothorax revealed on CXR, a right apical chest tube was inserted (drained ~1000cc serosanginous) at the bedside and pleural fluid cultures were obtained. tPA was placed through the tube prior to obtaining CT Chest on [**2101-1-17**]. On [**2101-1-18**], due to the persistent right effusion, the patient underwent a flexible bronchoscopy, right video-assisted thoracoscopy with drainage, and decortication. Two additional right chest tubes were placed while in the operating room. The patient tolerated the procedure well, yet post-operatively, was electively intubated following right hemithorax whiteout demonstrated on CXR. He was subsequently transferred to the ICU and underwent bronchoscopy which revealed moderate inflammation and edema in the distal trachea and mainstem bronchi with a mucous plug in the bronchus intermedius and right middle lobe takeoff. Repeat bronchoscopy on [**2101-1-19**] revealed a small amount thick mucoid secretions in the LLL, with an intact RUL stump. Following bronchoscopy, he was weaned to extubate without incident. On [**2101-1-20**], he was transferred to [**Hospital Ward Name 121**] 7. He had multiple CT scans during the remainder of the hospitalization, results aforementioned. On [**2101-1-26**] he was transferred to the TICU for hypotension and decreased hemocrit. After stabilization of hemocrit (received 6 units pRBCs) and blood pressure stabilization, he was transferred to [**Hospital Ward Name 121**] 7 on [**2101-1-28**]. Once on the floor, tPA was placed through the chest tubes. He became hypertensive (SBP 180s) intermittently, and was administered hydralazine IV prn in addition to atenolol and lisinopril (home medications). On [**2101-2-7**], all three chest tubes were placed to waterseal. The anterior CT was subsequently converted to an empyema tube. Prior to discharge, the posterior and basilar tubes were converted to empyema tubes. CXR on [**2101-2-11**] revealed no relevant changes in the right hemithorax. . FEN/GI: Following admit, the patient tolerated a regular diet. He was given Ensure supplements and calorie counts were initiated per nutritional recommendations. Over 3 days, calorie were 1403 and protein 47 grams. Lasix 40mg daily was continued for diuresis and electrolytes were repleted as appropriate. On discharge, he was tolerating a regular diet; denied nausea or vomiting. . ID: On admit, patient had temperature of 101.2, WBC=8.5. He was initially placed on vancomycin and levofloxacin IV while awaiting culture results. Diflucan was started on [**2101-1-15**] due to [**Female First Name (un) **] albicans growth in pleural fluid from [**2101-1-13**] and subsequently [**2101-1-18**]. Levofloxacin was discontinued on [**2101-1-24**]. Infectious disease was consulted for antibiotic management. Recommendations included: checking TEE to r/o endocarditis, continuing diflucan from [**Date range (1) 75840**], checking LFTs every 2weeks while on diflucan, and obtaining f/u CT scan at end of treatment course to determine resolution of effusion. On discharge, the patient was afebrile, WBC=9.9. He was discharged on vancomycin, to continue until all empyema tubes removed, and fluconazole, to continue until [**2101-2-28**]. . Renal: On [**2101-2-9**], the patient's creatinine increased to 1.7 (from 1.3 on admit). Fractional excretion of sodium was 0.9. Renal ultrasound revealed right kidney 11.6 cm, left kidney 10.7 cm, with no evidence of hydronephrosis, nephrolithiasis, or renal mass. Urinalysis was negative; no eosinophils. Renal team was consulted and thought acute renal failure was likely drug-related. Renal recommmendations included holding lisinopril and renally dosing antibiotics. Creatinine was closely followed; on discharge, creatinine was 1.9. . Endo: Blood sugars were closely monitored. The patient was placed on an insulin sliding scale. On [**2101-2-4**], the patient was triggered for a blood sugar of 26. He was confused and disoriented, yet improved with 1/2 amp D50 x2 and [**Location (un) 2452**] juice. He subsequently received D10W, insulin was held, and fingersticks were closely monitoring. He did not have any further low blood sugars during the remainder of his hospitalization. . Heme: He was given heparin SQ 5000U TID for DVT prophylaxis. He received 2 units pRBC on [**2101-1-26**] for Hct drop (28.6 to 23.8). Post-tranfusion Hct was 25.9, and he subsequently received 4 more units pRBC, with resulting Hct of 33.0. On discharge, Hct was 26.6. Medications on Admission: Atenolol 100 mg daily Oxycodone-Acetaminophen 5-325 mg, 1-2 tabs po q4-6hr prn pain Docusate Sodium 100 mg [**Hospital1 **] Lisinopril 20 mg [**Hospital1 **] Hydrochlorothiazide 25 mg daily Doxazosin 6mg qhs Lasix 40mg daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 2. Doxazosin 4 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours): Dr. [**Doctor Last Name 75841**] disease will stop this medication. Disp:*30 Tablet(s)* Refills:*1* 7. Atenolol 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day: Hold for SBP<100, HR<60. 8. Diazepam 5 mg Tablet [**Doctor Last Name **]: [**1-5**] to 1 [**1-5**] Tablet PO Q12H (every 12 hours) as needed. 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (2) **]: One (1) gm Intravenous Q 24H (Every 24 Hours). Disp:*30 gm* Refills:*1* 10. Atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO q pm. 11. Outpatient Lab Work check vanco level, liver function tests, and bun/creat on monday [**2101-2-14**] and call to Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] 12. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Telephone/Fax (1) **]: One (1) ML Intravenous DAILY (Daily) as needed. Disp:*qs unit/ml* Refills:*0* 13. Tylenol 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO every four (4) hours. 14. Saline Flush 0.9 % Syringe [**Telephone/Fax (1) **]: One (1) Injection prn. Disp:*qs syringe* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Lung CA, right chest wall s/p carboplatin, taxol with avastin, s/p right thoracotomy with right upper lobectomy and enblock right chest wall resection with [**Doctor Last Name 4726**]-Tex chest wall reconstruction Secondary: Hypertension Gastric Ulcers COPD CRI (baseline Cr 1.5) Traumatic blindness L eye Discharge Condition: Good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops discharge Cover chest tube site with a clean dry dressing daily. The gauze at the end of the chest tubes can changed as often as needed. If the chest tube falls out- cover the site with a gauze and call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] immediately. Complete Diflucan through [**2101-2-28**] LFT's every 2 weeks while on Diflucan: Fax results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 432**] You may only [**Last Name (un) 41829**] bathe until the chest tubes are removed. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on thursday [**2101-2-17**] at 3pm in the [**Hospital Ward Name **] clinical center [**Location (un) **]. Please arrive 45 minutes prior to your follow up appointment and report to the [**Location (un) **] radiology for a chest xray. Follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2101-2-28**] 11:00 in the [**Last Name (un) 2577**] Building basement [**Last Name (NamePattern1) 10357**] ICD9 Codes: 5849, 5859, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3153 }
Medical Text: Admission Date: [**2136-1-12**] Discharge Date: [**2136-1-23**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo male s/p recent hospitalization for colectomy and splenectomy complicated by anastomotic leak and treated with a diverting ileostomy with g-j tube placement and appendectomy. He was discharged to rehab and returned less than 1 week later with fever and acute renal failure. Past Medical History: HTN Hiatal hernia TIA (on Plavix) Asthma Spinal stenosis AR and MR (requires SBE prophylaxis) Social History: Married and lives with wife [**Name (NI) **] in [**Name (NI) 108**] during winter months Family History: Noncontributory Physical Exam: Gen: NAD, AAOx3 CV: RRR Pulm: some coarse BS bilat Abd: soft, NT, wound open and packed, ostomy intact Ext: no c/c/e Pertinent Results: [**2136-1-12**] 06:10PM GLUCOSE-98 UREA N-49* CREAT-1.5* SODIUM-134 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [**2136-1-12**] 06:10PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2 [**2136-1-12**] 06:10PM WBC-13.9* RBC-3.75* HGB-11.9* HCT-35.0* MCV-94 MCH-31.7 MCHC-33.9 RDW-17.1* [**2136-1-12**] 06:10PM PLT COUNT-418 Cardiology Report ECHO Study Date of [**2136-1-13**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Pulmonary embolus. Right ventricular function. Height: (in) 67 Weight (lb): 185 BSA (m2): 1.96 m2 BP (mm Hg): 129/54 HR (bpm): 56 Status: Inpatient Date/Time: [**2136-1-13**] at 10:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W006-0:13 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.44 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: *3.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.89 Mitral Valve - E Wave Deceleration Time: 368 msec TR Gradient (+ RA = PASP): 19 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of [**2134-6-29**]. LEFT ATRIUM: Mild LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The IVC is normal in diameter with >50% decrease collapse during respiration (estimated RAP [**4-12**] mmHg). LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. The patient appears to be in sinus rhythm. Conclusions: The left atrium is mildly dilated. The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. There is moderate 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%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. 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 are moderately thickened with focal calcification of the noncoronary cusp. There is no aortic valve stenosis.Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate symmetric LVH. Normal left ventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [**2134-6-29**], there is no significant change. CTA CHEST W&W/O C&RECONS, NON- Reason: r/o PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 85 year old man with concern for PE. REASON FOR THIS EXAMINATION: r/o PE CONTRAINDICATIONS for IV CONTRAST: None. EXAMINATION: CT of the chest with and without contrast dated [**2136-1-13**]. COMPARISON: CT of the abdomen dated [**2136-1-12**]. INDICATION: Question pulmonary embolism. TECHNIQUE: Axial imaging was obtained through the chest before and after the administration of IV contrast. FINDINGS FOR CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is heavy atherosclerotic calcification of the thoracic aorta and great vessels. There is cardiomegaly and coronary artery calcification. There is no pericardial effusion. After administration of IV contrast there is evidence of thrombus in the right main pulmonary artery as well as segmental and subsegmental branches of the right upper lobe pulmonary arteries. No thrombus is seen within the left pulmonary arteries. Small mediastinal lymph nodes are demonstrated which are numerous but not enlarged by CT criteria. Scattered air space disease is seen within the right middle lobe and right lower lobe which may represent atelectasis, infection, or infarction given evidence of pulmonary embolism. There is bibasilar atelectasis. There is no evidence of pneumothorax or pleural effusion. Limited imaging of the upper abdomen demonstrates evidence of splenectomy with small fluid collection in the left upper quadrant measuring 3 cm which contains gas consistent with post-surgical changes. Small amount of fluid measuring 2.4 cm x 1.6 cm is seen adjacent to the pancreatic tail. IMPRESSION: 1. Evidence of pulmonary embolism on the right as described with air space consolidation within the right middle and right lower lobes which may represent atelectasis, infection, or pulmonary infarction given evidence of pulmonary embolism. 2. Limited evaluation of post-surgical changes in the left upper quadrant as seen on prior CT abdomen and pelvis. Findings were discussed with the resident taking care of the patient at completion of the examination. Reason: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE RADIOPHARMECEUTICAL DATA: 7.1 mCi Tc-[**Age over 90 **]m MAA ([**2136-1-12**]); 44.0 mCi Tc-99m DTPA Aerosol ([**2136-1-12**]); HISTORY: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate marked central clumping consistent with airways disease. There is diffuse irregularity of tracer uptake within the lung parenchyma. Perfusion images in the same 8 views show multiple large peripheral wedge-shaped defects in the right lung. Perfusion irregularity of the left lung is much less pronounced than the right. Chest x-ray shows a left lower lobe opacity. While the above findings may in part be attributed to airways disease, they are concerning for pulmonary embolism and consistent with a moderately high probability for pulmonary embolism. IMPRESSION: Moderate-High Likelihood for pulmonary embolism. Brief Hospital Course: He was admitted to the Surgery Service under the care of Dr. [**Last Name (STitle) **]. He underwent a lung scan which revealed moderate to high probability of pulmonary embolus. CTA of the chest was done following the lung scan which revealed a thrombus in the right pulmonary artery. He was started on a Heparin drip and later started on Coumadin and Lovenox as a bridge until his INR becomes therapeutic. On HD #5 he experienced episode of increased shortness of breath and chest pressure after performing morning ADL's; EKG and CXR were all normal; his CK and troponin were flat. He again experienced a similar episode on HD #7, EKG without change compared to previous one; chest radiograph performed and pending at time of this dictation. This episode was proceeded by a session of chest physiotherapy and resolved shortly after that. His supplemental oxygen was discontinued at that time as his room air saturations were 95%. On HD #8 he was noted to have guaiac positive stool via his ileostomy. His Coumadin was stopped; the Lovenox was changed to Heparin and he remained on the Plavix. His hematocrits were as follows: [**2136-1-20**] 01:20AM 32.6* [**2136-1-19**] 09:00PM 34.6* [**2136-1-19**] 07:14PM 32.6* [**2136-1-19**] 09:30AM 33.5* A GI consult was obtained and recommendations for scoping were made. The scope showed: The first stoma was examined. We reached 50 cm and found no blood and normal ileal mucosa with bile. The second the stoma was examined and initially normal ileal mucosa was seen aprox 15 cm. Following 15 cm, colonic mucosa was observed. Multiple polyps were seen. Polyp in the 25 cm Polyp in the 30 cm Otherwise normal colonoscopy to anastomosis Recommendations: Pt will need a repeat colonscopy once he is off his coumadin Monitor hct Physical therapy was consulted and have recommended rehab stay following his acute hospitalization. The patient has continued to progrss well, tolerating a normal diet and having O2 sats in the high 90's on room air. His HCt has remained stable and he is discharged in stable condition to rehab to followup with Dr. [**Last Name (STitle) **] and with Dr. [**First Name (STitle) 679**] of gastroenterology. He will remain on lovenox until his INR is at a therapeutic range of [**1-7**] at which point the lovenox will be stopped and he will be continued on coumadin only for anticoagulation. Medications on Admission: Plavix 75' Flomax 0.4' Cozaar 50' Lipitor 10' Lopressor 25" Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff Inhalation QID (4 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Date Range **]: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 4. Atorvastatin 10 mg Tablet [**Date Range **]: One (1) Tablet PO at bedtime. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime): Adjust daily dose based on INR. 8. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a day): hold for HR <60; SBP <110. 9. Losartan 50 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Date Range **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 12. Colace 100 mg Capsule [**Date Range **]: One (1) Capsule PO twice a day as needed for constipation. 13. Milk of Magnesia 800 mg/5 mL Suspension [**Date Range **]: Ten (10) ML's PO twice a day as needed for constipation. 14. Enoxaparin 100 mg/mL Syringe [**Date Range **]: Seventy (70) mg Subcutaneous Q12H (every 12 hours): discontinue after therapeutic INR ([**1-7**]) reached on warfarin. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab [**Location (un) 3915**] Discharge Diagnosis: Pulmonary embolus Discharge Condition: Stable Discharge Instructions: Please call or return if you have a fever >101.5, severe pain, inability to pass gas or stool, nausea/vomiting, chest pain, shortness of breath, drainage from the wound, or any other concerns. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 6439**] for an appointment. Please call for a followup with GI, Dr. [**First Name (STitle) 679**], ([**Telephone/Fax (1) 16940**] for a repeat ileoscopy. Completed by:[**2136-1-23**] ICD9 Codes: 5849, 4019
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Medical Text: Admission Date: [**2165-1-6**] Discharge Date: [**2165-2-22**] Date of Birth: [**2116-4-16**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Unresponsive, right hemiparesis Major Surgical or Invasive Procedure: Left Hemicraniectomy Arterial line central venous access Chest tube Intubation Tracheostomy PEG History of Present Illness: The patient is a 48 year old man with a history of atrial fibrillation (not on anti-coagulation), hypertension, right basal ganglia bleed in [**1-4**] now presenting as a transfer from an OSH for unresponsiveness and right-sided weakness. The history as per the wife (through translator) is that she woke up at 6 am and was unable to wake up her husband. [**Name (NI) **] appeared to be moving his the right side less as well (no facial droop appreciated). His last known well state was at 12 am. She activated EMS and he was taken to an OSH. There he was noted to have eyes open but was not following commands. They performed a head CT and discovered that he had hypodensities in the left- MCA distribution with surrounding parenchymal edema. He was transferred here for further management including intensive care services. He arrived in our ER at about 9:30 am. Past Medical History: -atrial fibrillation not on anti-coag -IDDM -HTN -right basal ganglia bleed [**1-4**] that left him with some residual left sided weakness Social History: -lives with wife and daughter -works as a cook -current smoker (since teenage years) -EtOH use -Cantonese speaking Family History: -unknown at this time Physical Exam: Vitals: 98.8 178/90 78 (irreg) 98% room air General: middle-aged man lying still on stretcher Neck: supple Lungs: Clear to auscultation CV: Irregular rate and rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema Neurologic Examination: Patient with minimal response (eye opening to sternal rub); non-verbal; not following commands; weak corneal reflex; weak gag reflex; left eye deviation; no dolls eye response; withdraws to pain on left arm and leg, no response on right; some spontaneousmovement on left arm; absent reflexes on right; brisk on left Pertinent Results: CT (head)[**2165-1-6**]: 1. Large left MCA infarct with loss of the [**Doctor Last Name 352**]/white matter differentiation. 2. There is hyperdensity of the left MCA, suggesting acute thrombosis of this vessel. NCHCT ([**2165-2-7**] - most recent): Status post large left MCA stroke and left craniectomy with interval decreased brain swelling, but persistent herniation of the left hemisphere through the craniectomy defect. Small hemorrhages are present within the infarcted left cerebrum. CBC: 9.2/42/391 Normal LFTs on [**2165-2-17**] Usually needs K and Mg replacement. Brief Hospital Course: Pt was found to have a large left MCA infarction with swelling and impending herniation. After discussion with the family, the decision was made given the patient's young age of 48 to proceed with craniectomy to avoid impendeding brain stem herniation. On [**2165-1-6**] he had left frontal, parietal, temporal, occipital craniectomy with duraplasty and placement of subgaleal drain. He was admitted to the neuro-ICU for continued management. He was transferred to the step-down unit on [**2165-1-24**]. The left MCA stroke was likely due to cardioembolic source (afib not on coumadin). Pt was initially started mannitol, then taken to OR for craniectomy. Initially, he was started on dilantin for seizure ppx. This was later switched to depakote due to concern for drug fever. Head CT remained stable. Started on aspirin 325. He should be continued on depakote for seizure prophylaxis as he will need to go to the OR eventually for skull replacement. Check VPA level q week. ** He will need a repeat Noncontrast head CT in [**4-5**] weeks with scan sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] for review to determine when he should have his skull replaced. ** In the meantime, he has a helmet to wear to protect his brain. Exam upon discharge: awake, alert, looks at examiner when she enters the room, nonverbal, does not follow commands or mimic, tracks money to the right, will turn his head to the right but has a left gaze preference. Left arm/leg is strong. Right face droop. Right pareisis. Will move arm and leg proximally just a little to noxious stimuli. Pt has a hx of Afib. Rate is controlled with diltiazem, metoprolol. He will occasionally go into rapid afib with HR 150's but most of the time he is asymptomatic. HTN was controlled with dilt, betablocker, and captopril. Respiratory wise, he was initially intubated in the ER for airway protection. On [**1-7**], early am noted to have RUL PTX, chest tube was placed. PTX resolved. He developed PNA during his course with pseudomonas in sputum (pan-[**Last Name (un) 36**]). He was treated for PNA. Trach was placed [**1-11**]. He has been stable from a respiratory standpoint. ID: He was initially started on levoflox for presumed aspiration pneumonia and cefazolin post craniectomy. On [**1-7**], sputum Cx was positive for Klebsiella (pan [**Last Name (un) 36**]) and pseudomonas (pan [**Last Name (un) 36**]). On [**1-10**] he was started empiric vancomycin for empiric coverage of CSF vs line infection. On [**1-11**], ID was consulted. He was started on Gent and Zosyn. Vanco was continued. On [**1-15**], Flagyl was started for c.diff infection. Zosyn was changed to Ceftaz on [**1-15**]. On [**1-28**], Gent and Cef d/c'd. WBC decreasing and pt remains afebrile. Last set of cultures ([**2087-1-25**]) shows pansensitive pseudomonas in sputum, blood and urine cx negative. Finished a 14 day course of Flagyl for positive c.diff on [**1-30**]. He then became tachycardic, tachypnic, diaphoretic on [**2165-2-13**] and was sent to the ICU as he met criteria for sepsis. He was called out the next day and he was never hemodyamically unstable. Found to have a pseudomonas UTI. He will complete a 10 day course of cipro for the pseudomonas on [**2165-2-22**]. Diabetes: Pt placed on NPH and RISS for coverage. Please adjust NPH and insulin as needed per finger sticks QID. GI/FEN: Pt had PEG placed. Continued on PPI and tube feeds. PPX: pneumoboots, SC heparin, PPI Medications on Admission: -prazosin 1 [**Hospital1 **] -lipitor 10 qd -verapamil 180 [**Hospital1 **] -toprol xl 50 qd -NPH -clonidine 0.3 [**Hospital1 **] -protonix Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 units Injection TID (3 times a day): for DVT prophylaxis. 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Valproate Sodium 250 mg/5 mL Syrup Sig: 500 mg PO Q6H (every 6 hours): Please check a level each week, goal 50-100. This is for seizure prophylaxis. 6. Docusate Sodium 150 mg/15 mL Liquid Sig: [**2-3**] PO BID (2 times a day). 7. Acetaminophen 160 mg/5 mL Elixir Sig: 325 - 650 mg PO Q4-6H (every 4 to 6 hours) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: 1 neb IH Inhalation Q6H (every 6 hours) as needed. 9. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via peg tube. 10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via peg tube. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed): to reddened skin. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush: swish and suction. 13. Insulin NPH 45 units AM, 10 units PM Regular insulin sliding scale with finger sticks QID. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): to complete a 10 day course, started on [**2165-2-13**], last day will be [**2165-2-22**]. 15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<110. 16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold for SBP<110, HR<55. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for congestion. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Left MCA stroke Atrial fibrillation DM HTN Discharge Condition: Stable - awake, alert, nonverbal, does not follow commands, left gaze preference, right hemiparesis. Discharge Instructions: Please keep follow up appointments. Please call your doctor or return to the emergency room if you experience worsening or new weakness, respiratory distress or other concerning symptoms. Followup Instructions: 1. Follow up with neurosurgery (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**]) to have skull replaced in approximately one month. ([**Telephone/Fax (1) 88**]. You will need a repeat Noncontrast head CT to evaluate your readiness for surgery in [**4-5**] weeks. **PLEASE HAVE THIS CT SENT TO Dr. [**Last Name (STitle) 1132**].** 2. Please call your primary care doctor to arrange an appointment after discharge from rehab. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 56439**] 3. Please call [**Telephone/Fax (1) 1694**] to arrange follow up in stroke clinic after your discharge from rehab. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] ICD9 Codes: 5185, 5990, 4019
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Medical Text: Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-12**] Date of Birth: [**2090-7-16**] Sex: M Service: MEDICINE Allergies: Cefepime / Cipro Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hypotension, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx of PE on coumadin. . He presents to his [**Hospital 3242**] clinic with fatigue for several days, and anorexia, with about 12-16 hours of worsening shortness of breath. . Endorses increased cough with yellow sputum production and chills, but no fever. This morning, he reported an acute episode of dyspnea that did not rapidly improved, and occured with little amounts of activity and somewhat improved with rest. No PND/orthopnea. No hemoptysis. . He has had no new rashes, and has not had documented fevers. He has no diarrhea, but has been nauseated without vomiting. He reports mild epigastric pain. He has a mild headache made somewhat worse with light, but he feels that this is very consistent with flares of GVH and not different (has occured he estimates about 8 times). . In clinic SBP 70's, and he was given saline with improvement, but then the BP decreased down to the 80's. Labs from clinic showed that Cr increased to 2.9 (baseline 1.1). WBC increased somewhat. He was transferred to the ED for further evaluation. . In the ED, initial vs were: 4 97.6 72 105/73 18 99% He was given total of 3L of saline, and recent vital signs were 98.8 129/85 80 16 96% on 2L at time of transfer. A bedside "shock" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG was not significantly changed. Her INR was 3.0. Of note, he was also complaining of left sided shoulder/neck pain associated with shortness of breath and diaphoresis. . For interventions, he received 1 gm vanc and 1gm aztreonam, 40 mg medrol, and 2 L IVF in clinic, and another liter in the ED. Past Medical History: - AML-M7: s/p matched unrelated allogenic transplant on [**2143-6-24**] - Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**] consistent with GVHD, managed with cyclosporine, steroids, periodic CellCept, and has received 1 cycle of Rituxan. - Type 2 DM - Hyperlipidemia - H/o AVN bilateral hips - HTN - H/o nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage - h/o left interpolar renal lesion, followed with MRs - h/o BCC s/p excision - h/o SCC left cheek, s/p Mohs' [**5-/2144**] - h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware) - h/o anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**] - Chronic numbness, neuropathic pain in left upper extremity. - Multilevel compression fractures T11, T12, L1 and mild compression L3 and L4. - h/o pulmonary embolism [**11/2144**] on anticoagulated from [**11/2144**]-present - h/o RSV [**11/2144**] requiring ICU admission - h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**] Social History: Lives with his wife, and one of children, worked as a [**Company 22957**] technician until [**Month (only) 547**] when he took early retirement and he is no longer working. Tob: previously smoked 1ppd for many years but quit 2.5 years ago EtOH: h/o social use; none recently Family History: Mother died suddenly in her 70s. Father died of unknown cancer with tumors visible across body. One sister has thyroid cancer. One brother has diabetes and kidney stones. One sister has [**Name (NI) 5895**]. Physical Exam: Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.7 ??????C (98.1 ??????F) HR: 85 (85 - 85) bpm BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg RR: 11 (11 - 11) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) . General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mild RUQ->mid epigastrium tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . No calf or thigh tenderness. Skin: depigmentation on hands, redness of neck, but no notable skin changes otherwise. No rashes. Pertinent Results: [**9-9**] CT chest without contrast IMPRESSION: 1. Mostly resolved parenchymal opacities, leaving several parenchymal bands which are felt most likely to represent residua of a prior infectious or inflammatory process. 2. Subacute to chronic rib fractures, including along the right posterior seventh rib, where there is faint but suspicious sclerosis extending further laterally than would usually be expected in the setting of an uncomplicated rib fracture. In the setting of prior treated hematological malignancy, the finding of vague sclerosis raises concern for a bone marrow abnormality such as myelofibrosis or potentially a form of disease recurrence. Mostly, however, the bones appear within normal limits. . [**9-9**] PFT's SPIROMETRY Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 3.86 5.05 76 3.83 76 -1 FEV1 2.83 3.60 79 2.69 75 -5 FEV1/FVC 73 71 103 70 98 -4 . [**9-8**] RUQ US IMPRESSION: 1. Polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. This has not changed significantly since prior ultrasound scan, but followup imaging is advised. . [**9-8**] Echo The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) 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 borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . Micro: [**9-8**] CMV VL negative [**9-8**] sputum: oropharyngeal flora [**9-8**] urine cx negative [**9-8**] viral screen and cx negative [**9-7**] blood cx negative . ON ADMISSION: [**2145-9-7**] 01:05PM BLOOD WBC-11.1* RBC-4.39* Hgb-16.0 Hct-49.0 MCV-112* MCH-36.5* MCHC-32.7 RDW-14.9 Plt Ct-264 [**2145-9-7**] 01:05PM BLOOD Neuts-85.1* Lymphs-7.0* Monos-5.2 Eos-2.5 Baso-0.3 [**2145-9-7**] 01:05PM BLOOD PT-30.5* INR(PT)-3.0* [**2145-9-7**] 01:05PM BLOOD UreaN-28* Creat-2.9*# Na-140 K-4.4 Cl-101 HCO3-29 AnGap-14 [**2145-9-7**] 01:05PM BLOOD ALT-24 AST-20 LD(LDH)-201 CK(CPK)-37* AlkPhos-155* TotBili-0.3 [**2145-9-7**] 01:05PM BLOOD cTropnT-0.05* [**2145-9-7**] 01:05PM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.6* Mg-2.4 [**2145-9-7**] 08:13PM BLOOD Lactate-1.9 . ON DISCHARGE: [**2145-9-12**] 05:40AM BLOOD WBC-7.2 RBC-3.45* Hgb-12.5* Hct-38.3* MCV-111* MCH-36.2* MCHC-32.7 RDW-15.0 Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Neuts-68.8 Lymphs-17.2* Monos-7.9 Eos-5.7* Baso-0.4 [**2145-9-12**] 05:40AM BLOOD Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Glucose-80 UreaN-18 Creat-0.9 Na-143 K-3.7 Cl-104 HCO3-30 AnGap-13 [**2145-9-12**] 05:40AM BLOOD ALT-25 AST-18 LD(LDH)-181 AlkPhos-112 TotBili-0.2 [**2145-9-12**] 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 UricAcd-4.6 Brief Hospital Course: 55 y/o male with ?viral syndrome vs. other atypical infection with hypotension that is suspected to be hypovolemia or adrenal insufficiency, with acute renal failure. . # Lethargy: concern for viral syndrome, including activation of CMV, or a respiratory virus. He has been known EBV+ in the past. This could also be related to sensation of dyspnea that he has been having, and warranted further cardiovascular and pulmonary work-up in parallel with the infectious work-up. In the ICU, continued broad spectrum antibiotics of vancomycin and aztreonam (given allergy). Infectious workup largely negative including CMV VL, respiratory panel, EBV VL, fungal markers, blood cultures, urine cultures, CT chest. Pt's lethargy improved with IVFs, antibiotics, and stress dose steroids. Did not ever need pressors. . # Dyspnea/Cough: Concern for infectious process. Regarding VTE, his risk should be reduced with therapeutic INR, though the concern for coumadin failure merits consideration, though would be unlikely and he has no other signs and symptoms of DVT. PFTs completed [**9-9**], with official report pending at time of this summary. CT chest showing resolving parenchymal processes, resolving infectious/inflammatory process. Continued broad spectrum antibiotics initially. When no infiltrate noted on CXR, decreased ABX to 5 days of azithromycin for treatment of bronchitis. . # Hypotension: A bedside "shock" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG unchanged. Patient's hypotension was fluid/stress dose steroids responsive. Initially given stress dose steroids with plans to resume home dose. Also given IVF repletion. BPs normalized. Likely etiology was slight adrenal insufficiency in setting of viral syndrome despite negative infectious workup. Patient discharged with prednisone 7.5 mg daily. . # Acute Renal Failure: Likely pre-renal azotemia. Improved with IVFs. Cr 0.9 on discharge. . # Mild epigastric/RUQ tenderness: No laboratory e/o hepatitis. RUQ US showing polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. No other findings to explain epigastric pain. This pain has resolved on discharge. . # Pulmonary Embolism [**11-23**]: continued coumadin with INR goal [**1-19**]. # Diabetes: Continued NPH 12 units [**Hospital1 **], with close sugar monitoring and diabetic diet. Medications on Admission: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a day BUDESONIDE [ENTOCORT EC] - (Dose adjustment - no new Rx) - 3 mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice a day FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**] hours as needed for pain INSULIN LISPRO [HUMALOG] - SS LISINOPRIL - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a day OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three) Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20 mg) and 3 tablets every evening (60 mg) PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once day PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet - Apply to upper torso once daily WARFARIN [COUMADIN] - (Dose adjustment - no new Rx) - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (Dose adjustment - no new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily) INSULIN NPH HUMAN RECOMB - (Prescribed by Other Provider) - 100 unit/mL Suspension - 12 units twice a day Please take first dose in the morning and the second dose at bedtime Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: QAM and QPM. 6. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO once a day: at 1400 every day. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 9. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): For total 7.5 mg daily. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: On Saturdays. 13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet Transdermal once a day: Apply to upper torso once daily as directed. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous twice a day. 15. Insulin Lispro 100 unit/mL Solution Sig: Varied units Subcutaneous four times a day: As per home sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Hypotension/adrenal insufficiency Bronchitis Acute renal failure . Secondary diagnosis: AML s/p MUD allogeneic SCT [**6-/2143**] Chronic GVHD of skin/liver h/o PE Diabetes mellitus Discharge Condition: Stable, afebrile, BP 113/76, RR 16, sats 96% on RA, INR 1.8. Discharge Instructions: You were admitted with fatigue, shortness of breath, cough, low blood pressure and acute renal failure. We were concerned for early sepsis and you were in the ICU initially. You received broad spectrum antibiotics and stress dose steroids, but a full workup (including viral swabs, cultures, ECHO, and CT chest) were unrevealing. CT chest showed resolving infiltrates and your symptoms improved so the antibiotics were switched to azithromycin for presumed bronchitis. Your prednisone was increased due to presumed mild adrenal insufficiency. . The following medication changes were made: 1) Prednisone increased to 7.5mg daily 2) Azithromycin (antibiotic) started, to be completed as outpatient 3) Your lisinopril (blood pressure medication) and metoprolol were discontinued. Do NOT resume these medications until speaking to Dr. [**Last Name (STitle) **]. . You need to have your INR checked on Tuesday, [**2145-9-14**]. You also need to follow up with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] within the next week. Please call their office tomorrow to make this appointment. . of the following symptoms: fever, chills, shortness of breath, difficulty breathing, abdominal pain, cough, flu symptoms, or any other worrisome symptoms. Followup Instructions: You need to have your INR checked on Tuesday, [**2145-9-14**]. . Please call Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 72254**] office to make an appointment to be seen later this week. They can be reached at [**Telephone/Fax (1) 3241**]. Completed by:[**2145-9-17**] ICD9 Codes: 0389, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3156 }
Medical Text: Admission Date: [**2183-12-15**] Discharge Date: [**2183-12-22**] Date of Birth: [**2116-4-4**] Sex: M Service: ORTHOPAEDICS Allergies: Soma / Fentanyl Attending:[**Doctor Last Name 1350**] Chief Complaint: Low back and more bothersome buttock and radiating right leg pain found to be related to retrolisthesis at L3- L4, lumbar spinal stenosis, adjacent segment disease. He underwent a prolonged and multimodal course of conservative care including injections, physical therapy, medications, and activity modifications. His syndrome was refractory this. Due to the refractory nature of his syndrome, as well as the severity of the symptoms, which did limit his ability to walk, he elected to undergo surgical treatment. Major Surgical or Invasive Procedure: 1. Anterior interbody fusion with correction of spinal deformity L3-L4. 2. Interbody reconstruction with biomechanical device L3-L4 by direct lateral approach. 3. Removal of hardware L4, L5, S1. 4. Inspection of posterolateral fusion. 5. Bilateral L2 laminotomy. 6. Revision laminotomy, bilateral, L3, L4, L5. 7. Laminectomy S1. 8. Posterolateral fusion L3-L4. 9. Posterolateral instrumentation L3-L4. 10.Application of local autograft for fusion augmentation. 11.Application of allograft for fusion augmentation. History of Present Illness: back and more bothersome buttock and radiating right leg pain found to be related to retrolisthesis at L3- L4, lumbar spinal stenosis, adjacent segment disease. He underwent a prolonged and multimodal course of conservative care including injections, physical therapy, medications, and activity modifications. His syndrome was refractory this. Due to the refractory nature of his syndrome, as well as the severity of the symptoms, which did limit his ability to walk, he elected to undergo surgical treatment.weakness in his right leg. He has had right knee buckling on several occasions, particularly with prolonged walking over two minutes Past Medical History: Significant for interstitial lung disease, spine surgeries [**2172**], [**2174**], [**2176**] as described above. Hypertension, bilateral total knee replacement, gallbladder surgery in [**2146**], knee replacement in [**2153**], lung biopsy [**2179**]. Physical Exam: [**2-23**] right iliopsoas and quadriceps. Rest of BLE - hip abductors, left quad and iliopsoas [**3-24**] SILT Reflexes 2 + in knees and ankles. Plantars downgoing. Pertinent Results: [**2183-12-15**] 08:49PM TYPE-ART PO2-452* PCO2-43 PH-7.28* TOTAL CO2-21 BASE XS--6 [**2183-12-15**] 08:44PM GLUCOSE-129* UREA N-21* CREAT-1.0 SODIUM-139 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13 [**2183-12-15**] 08:44PM CALCIUM-7.9* PHOSPHATE-4.0 MAGNESIUM-2.0 [**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86 MCH-29.8 MCHC-34.8 RDW-14.3 [**2183-12-15**] 08:44PM PLT COUNT-227 [**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86 MCH-29.8 MCHC-34.8 RDW-14.3 [**2183-12-15**] 08:44PM PT-12.7 PTT-29.0 INR(PT)-1.1 Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet Medications on Admission: Current medications include Tramadol 50 2 tabs twice a day, Darvocet-N 100 2 tablets q.4 hours, nabumetone 500 mg 1-1/2 tablets twice a dayisosorbide mononitrate, nitroglycerin, verapamil, aspirin 81, L-thyroxine, Senna, Advil p.r.n., Lyrica Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/Wheezing. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Actimmune 2,000,000 unit/0.5 mL Solution Sig: One (1) ML Subcutaneous Monday, Wednesday and Friday HS (). 9. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 16. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous every twelve (12) hours. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: .1. Adjacent segment degeneration, adjacent segment disease L3-L4. 2. Spondylolisthesis L3-L4. 3. Spinal stenosis L3-L4, L4-L5, L5-S1. 4. Prior lumbosacral fusion L4-S1. 5. Healed posterolateral fusion L4-S1. Discharge Condition: Stable, Patient alert orientd and tolerating oral diet. Discharge Instructions: You have undergone the following operation: Lumbar anterior and posterior fusion with instrumentation. Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Ambulation with assitance, Gait training. Stair climbing. Treatments Frequency: Physical therapy every day to make the patient self ambulatory. Steri strips to fall off on their own. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2183-12-31**] 2:15 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2183-12-31**] 1:55 Completed by:[**2183-12-22**] ICD9 Codes: 486, 2930, 2749, 5859, 2449
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Medical Text: Admission Date: [**2196-7-10**] Discharge Date: [**2196-7-13**] Service: MEDICINE Allergies: Namenda Attending:[**First Name3 (LF) 2698**] Chief Complaint: Syncope/Bradycardia Major Surgical or Invasive Procedure: Permanent Pacemaker History of Present Illness: Ms. [**Known lastname 14495**] is an 89 y/oF with hyperlipidemia and mild memory impairment/early alzheimer's being transferred from [**Hospital1 **] with bradycardia/pauses leading to syncope. . Her daughter relates her relevant story today. She was out with her family doing normal daily activities including walking around, having lunch. Then at 130pm her she was buckled into the back seat of the car and her daughter reports she not response, head rolled against the window, eyes rolled back, for about 15-20 seconds. Did not hit her head (she was sitting in the back seat, buckled in), no falls. Daughter denies [**Name2 (NI) **]/clonic movement suggestive of sz activity. She denies dehydration or decreased PO intake ("she eats like a horse"). When she awoke, she was "white as a ghost" and "didn't feel well" but doesn't sound like she was post-ictal. She didn't remember any events of the day which apparently is unusual for her (h/o dementia though). . She was taken to [**Hospital1 18**]-[**Location (un) 620**] where she was 96.9 145/60 18 100% WBC 7.0 (N51, L 37, M8), Hct 38.4, Plts 163. Chem fairly unremarkable including renal fxn 22/0.9, BS 112. CK 166/MB 3.8/MBI 2.3/Trop <0.01. UA with small LE and [**3-25**] WBC's. CXR was clear. She was originally going to be admitted for 24hr telemetry with concern for dysrhythmia. EKG per report NSR @ 65bpm without ST changes. She apparently became agitated and wanted to leave, and received Haldol at 1930pm. . Per OSH records "At 1:46am pt had 36 seconds of no heart beat (asystole), but easily woken up. At 3:09 heart stopped for 20 seconds, was unresponsive and received 1mg Atropine, when awake, has no c/o any discomfort. Stat Trop at 2am is 0.01, CK 125, EKG no changes, gait unsteady." Transfer to [**Hospital1 18**] for further management. . Her ROS is as above, including some memory deficits, but otherwise she appears very functional, gait is steady, able to do her ADL's. No other focal symptoms in any other major systems, including cardiac review of systems. Past Medical History: 1. ? TIA per report, vs total global amnesia in [**2177**], lasted few days, nl EEG 2. Dementia 3. Hyperlipidemia 4. Osteoporosis 5. Vitamin D deficiency 6. Reactive depression [**2186**] after loss of husband 7. S/p cataract extraction [**2188**] 8. Nail avulsion/paronychia Social History: The patient denies tobacco, alcohol, or drug use. She lives in [**Hospital3 **] and has a family nearby with support and has a daughter who presents with her today. Widowed two children, three grandchildren, six great-grandchildren. Does not smoke. Walks daily Family History: No family history of sudden cardiac death Physical Exam: 97.6 110/60 p69 19 100% NC Thin elderly frail female in no distress, pleasant but unable to report history. Conversational. PERRLA, EOMI. Mouth dry appearing. No carotid bruits. JVD not elevated. Carotid pulsations normal. Marked kyphosis, CTAB no w/c/r/r, some decreased BS's at the bases RRR, heart sounds soft, no murmurs appreciated. PMI not palpable. Bilateral radial and DP's are easily palpable. Abd soft, NT ND, Hyperactive BS's. No BLE edema noted AO to person only. CN 2-12 intact, no facial droop, no dysarthria. Spontaneously moving all four extremities with good [**6-22**] age appropriate strength no focal neuro deficits noted. Sensation intact through bod. Cerebellar exam intact. Reflexes hyporeflexic in UE's and not able to comply with exam in lower extrems. Pertinent Results: [**2196-7-10**] CXR FINDINGS: There are no old films available for comparison. No rib fractures are identified and there is no pneumothorax. The cardiac silhouette is normal. The aorta is mildly tortuous. There is no focal infiltrate or effusion. CBC [**2196-7-13**] 05:02AM BLOOD WBC-8.1 RBC-4.76 Hgb-13.2 Hct-40.3 MCV-85 MCH-27.7 MCHC-32.7 RDW-13.3 Plt Ct-151 [**2196-7-12**] 04:30AM BLOOD WBC-7.1 RBC-4.93 Hgb-13.8 Hct-42.1 MCV-85 MCH-28.1 MCHC-32.9 RDW-13.6 Plt Ct-164 [**2196-7-10**] 05:24AM BLOOD WBC-7.3 RBC-4.70 Hgb-13.0 Hct-40.3 MCV-86 MCH-27.6 MCHC-32.2 RDW-13.2 Plt Ct-164 Chemistry [**2196-7-13**] 05:02AM BLOOD Glucose-94 UreaN-28* Creat-1.0 Na-142 K-4.2 Cl-109* HCO3-22 AnGap-15 [**2196-7-12**] 04:30AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-142 K-3.8 Cl-110* HCO3-20* AnGap-16 [**2196-7-11**] 04:18AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-144 K-3.8 Cl-110* HCO3-24 AnGap-14 [**2196-7-10**] 05:24AM BLOOD Glucose-110* UreaN-24* Creat-0.9 Na-142 K-4.4 Cl-109* HCO3-26 AnGap-11 [**2196-7-13**] 05:02AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1 [**2196-7-12**] 04:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 [**2196-7-11**] 04:18AM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.7 Mg-2.2 Cholest-189 [**2196-7-10**] 05:24AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2 HbA1c [**2196-7-11**] 08:14AM BLOOD %HbA1c-5.7 eAG-117 Lipid Panel [**2196-7-11**] 04:18AM BLOOD Triglyc-89 HDL-95 CHOL/HD-2.0 LDLcalc-76 TFT [**2196-7-10**] 05:24AM BLOOD TSH-5.1* [**2196-7-10**] 05:24AM BLOOD T4-6.0 Brief Hospital Course: Patient is an 89 yo F with h/o dementia, hyperlipidemia who is transferred from [**Hospital1 18**]-[**Location (un) 620**] for further evaluation of syncope and found to have sinus pauses of over thirty seconds; transferred to [**Hospital1 18**] for further evaluation. . #SINUS NODAL DISEASE: Patient was transferred to the CCU from [**Location (un) 620**] for further monitoring. Besides hyperlipidemia there was no other clear explanation for sinus exit block that she exhibited as there was no evidence of ischemia, medications, hypothyroidism. The syncopal episodes were likely due to the sinus node dysfunction. She was evaluated by the electrophysiology service and underwent placement of a permanent pacemaker on [**2196-7-11**]. She will follow up closely in device clinic for further management of pacemaker . #DELIRIUM: The pt was noted to be agitated and delirious on admission. Following pacemaker placement, she was very agitated. Patient has baseline dementia, however family noted that this was not her norm. She did poorly with conservative anti-delirium measures. Was very difficult to redirect her even with the assistance from family. In order to protect the newly placed pacemaker, patient had to be placed in soft restraints. Patient continued to fight against the restraints and move her left arm, and so small doses of IV haldol was utilized. A total of 3 mg of IV haldol was administered, following which she fell asleep. The morning following, she was back to her baseline. . #DEMENTIA: patient was continued on home regimen of aricept . #HYPERLIPIDEMIA: patient was continued on home regimen of simvastatin . #HISTORY OF TIA: patient was continued on home regimen of aspirin 81 mg Medications on Admission: 1. Aricept 5mg daily 2. Simvastatin 40 mg daily 3. ASA 81 daily 4. Calcium carbonate Vitamin D Discharge Medications: 1. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for 2 days. Disp:*2 Capsule(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] & Hospice Discharge Diagnosis: Primary Diagnosis: - Sinus arrest, now s/p pacemaker Secondary Diagnosis: - Dementia - Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because of you had a pause in your heart rhythm. You had a pacemaker placed to help in controlling your heart rhythm. During this hospitalization, you were cared for in the cardiac intensive care unit. You will need to follow up with your primary care doctor and the device clinic as an outpatient. You medications have changed. Please make note of the following changes: 1. Start taking cephalexin 500 mg, every 8 hours, for one day 2. Start taking tylenol 650 mg, every 8 hours, as needed for pain The rest of your medications have not changed. Please continue to take them as originally prescribed. Followup Instructions: Please be sure to follow up at the DEVICE CLINIC for follow up on your new pacemaker on [**2196-7-20**] at 3:00 PM. The office number is [**Telephone/Fax (1) 62**]. The office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical Center ([**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**]) Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**], within 3-4 weeks after discharge from the hospital. The office number is [**Telephone/Fax (1) 3070**] ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3158 }
Medical Text: Admission Date: [**2146-8-14**] Discharge Date: [**2146-8-17**] Date of Birth: [**2064-12-9**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1257**] Chief Complaint: abd pain Major Surgical or Invasive Procedure: percutaneous nephrostomy tube placement, [**2146-8-13**] History of Present Illness: 81 yo male with presumed COPD and recently diagnosed metastatic bladder CA with known left hydronephrosis presents from OSH ED after complaining of abd pain. The pt reports that he was in his usual state of health until mid-day on the day PTA. At that point, he noted the onset of RLQ abd pain that was non-radiating and intermittently sharp and dull. He presented to the ED at [**Hospital1 **]-[**Location (un) 620**] where he was afebrile but noted to appear unwell and have an SBP in the 90s with associcated sinus tachycardia. A CT scan there demonstrated left hydronephrosis and a question of gallbladder distention. In the [**Hospital1 18**] ED, initial vitals were 97.2, 103, 24, 98/68 and 90% RA. An abd ultrasound was obtained in the ED. This study did not show gall bladder abdnormalities but did demonstrate extensive hepatic mets. He was given emperic doses of Zosyn and vancomycin as well as 5L NS. A urology consultation was obtained given the pt's hydronephrosis and a positive UA. There was a concern for left sided upper urinary tract infection and urgent percutaneous nephrostomy tube placement was advised; this was performed by IR immediately after the pt's arrival to the MICU. A VQ scan was also obtained given the pt's tachycardia and relative hypoxia; the results of this study are pending. ROS was otherwise essentially negative. The pt endorsed intermittent hemature but denied recent unintended weight loss, fevers, night sweats, chills, headaches, dizziness or vertigo. No changes in hearing or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: multiple papillary bladder tumors --first dx in [**4-18**] --s/p BCG therapy --concern for mets to mid left femur, known extensive liver mets renal stones many years ago s/p left inguinal hernia repair lung nodule concerning for possible malignancy noted on CT scan Social History: Retired clerical worker. Smoked multiple PPD from age 14 to 61. Denies EtOH. Family History: No FH of malignancy or other heritable disease. Both parents lived to advanced age. Physical Exam: General: Awake and alert though mildly sleepy. NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP. Neck: Supple, no significant JVD or carotid bruits appreciated. Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi. Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: Trace edema, 2+ radial and DP pulses b/l Skin: No rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [**2146-8-14**] 01:05AM WBC-16.3* RBC-4.49* HGB-14.2 HCT-41.5 MCV-92 MCH-31.6 MCHC-34.2 RDW-14.0 [**2146-8-14**] 01:05AM NEUTS-91.8* LYMPHS-4.4* MONOS-3.3 EOS-0.3 BASOS-0.1 [**2146-8-14**] 01:05AM GLUCOSE-100 UREA N-68* CREAT-2.4* SODIUM-140 POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-18* ANION GAP-25* . CXR: The cardiomediastinal contour is normal. The heart is not enlarged. There is linear platelike atelectasis at the left lung base. The lungs are otherwise clear. Osseous structures are unremarkable. IMPRESSION: No evidence of focal consolidation on this single view. . Abd US 1. Innumerable hepatic metastases from bladder cancer. 2. Cholelithiasis without evidence of cholecystitis. 3. No evidence of intrahepatic biliary ductal dilatation; normal size of CBD. Brief Hospital Course: 81 yo male presenting with bladder cancer, found to have abd pain, tachycardia and borderline blood pressure, s/p perc nephrostomy tube drainage of left hydronephrosis, became persistently hypotensive and subjectively dyspneic with a refractory metabolic acidosis. It was decided to place the patient via care measures and he was placed on a morphine drip -- the patient subsequently expired. #UTI: Treating with Cipro. Await culture results. WBC slightly decreased. Does not meet SIRS criteria. Pt was agressively volume repleted. . #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH approximately one week ago, further elevated on admission, still further increasing today. Some baseline renal dysfunction expected given pt's obstruction; suspect that acuity of further obstruction resulting in additional failure. Pt s/p perc drainage placement and volume repletion. Developed a refractory metabolic acidosis with resultant tachypnea. . #SOB/question COPD: Pt with extensive smoking history and a question of COPD based on prior imaging. No has crackles on exam after 5L volume resuscitation in MICU. Patient became subjectively dyspneic and tachypneic during exams which was summarily relieved by morphine after CMO status. . #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic mets. . #Abd pain: Has resolved. Likely secondary to worsening hydronephrosis/UTI, although numerous other etiologies were certainly possible. Medications on Admission: oxycontin PRN colace Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2146-8-21**] ICD9 Codes: 0389, 5845, 5990, 3051, 496, 4589
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Medical Text: Admission Date: [**2167-10-28**] Discharge Date: [**2167-11-5**] Date of Birth: [**2096-5-11**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Tricor Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2167-10-30**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to LPDA), Right Carotid Endarterectomy [**2167-10-28**] Cardiac Cath History of Present Illness: Mr. [**Known lastname 1458**] is a 71 y/o male transferred from [**Hospital3 **] after +ETT (had chest pain with EKG changes). Underwent cardiac cath which revealed severe three vessel disease. Past Medical History: Carotid Stenosis s/p Left Carotid Endarterectomy, Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p Hemorrhoidectomy Social History: Quit smoking less than 1 yr ago. Smoked x 30-40 years. Denies ETOH use. Family History: Mother with MI at age 68. Physical Exam: At Discharge: VS:T98 BP150/80 P69 RR20 I&O925/700+ Wt88.5kg 96% 2LNC Gen:NAD Chest:lungs CTA bilaterally Heart:RRR, no M/C/R Abd: S, NT, ND Ext:1+ edema, well perfused Incision: C/D/I, sternum stable Pertinent Results: [**2167-10-30**] Echo: PRE CPB The left atrium is moderately dilated. The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is 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 ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly to moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST CPB Normal biventricular systolic function. Thoracic aorta appears intact. No significant change from the pre bypass study. [**2167-10-29**] Carotid U/S: 70-79% stenosis of the bilateral internal carotid arteries. [**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149* [**2167-11-5**] 05:55AM BLOOD Plt Ct-149* LPlt-3+ [**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137 K-4.2 Cl-98 HCO3-30 AnGap-13 [**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149* [**2167-10-28**] 04:30PM BLOOD WBC-8.1 RBC-3.94* Hgb-12.5* Hct-33.8* MCV-86 MCH-31.7 MCHC-37.0* RDW-12.8 Plt Ct-109* [**2167-11-5**] 05:55AM BLOOD PT-14.5* INR(PT)-1.3* [**2167-10-28**] 04:30PM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2* [**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137 K-4.2 Cl-98 HCO3-30 AnGap-13 [**2167-10-28**] 04:30PM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-139 K-3.5 Cl-102 HCO3-29 AnGap-12 [**2167-11-3**] 04:35AM BLOOD Mg-2.4 [**2167-10-29**] 06:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3 Cholest-129 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 1458**] was transferred from OSH after +ETT. Underwent Cardiac Cath on [**10-28**] which revealed severe three vessel coronary artery disease. Patient underwent pre-operative work-up which included echo and carotid u/s. On [**10-30**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4 and left carotid endarterectomy. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed on post-op day one. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the telemetry floor for further care. HIT panel was drawn as platelets trended down post-operatively and found to be negative. He was also anemic with a HCT at 23.2 on post-op day three, but patient refused transfusion. His HCT rose on its own. He was placed on amiodarone for atrial fibrillation and converted. He remained in normal sinus rhythm for greater than 24 hours so coumadin was discontinued. By post-operative day 6 he was ready for discharge. Medications on Admission: Home: Crestor 40mg qd, Gemfibrozil, Atenolol 50mg qd At Transfer: Aspirin 325mg qd, Lopressor 12.5mg [**Hospital1 **], Nitro gtt, Norvasc 5mg qd, Imdur 30mg qd, Omeprazole 20mg qd, Crestor 40mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*qs ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Lifecare Center of [**Location **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Carotid Stenosis s/p Right Carotid Endarterectomy PMH: Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p Hemorrhoidectomy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 11763**] Dr. [**Last Name (STitle) **] (vascular) in 4 weeks.([**Telephone/Fax (1) 8343**] Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] in [**1-25**] weeks ([**Telephone/Fax (1) 40026**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] in [**12-24**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2167-11-5**] ICD9 Codes: 4111, 2762, 4439, 2724, 4019
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Medical Text: Admission Date: [**2165-8-9**] Discharge Date: [**2165-9-3**] Date of Birth: [**2095-10-11**] Sex: F Service: MEDICINE Allergies: Penicillins / Cipro Cystitis / Aspirin / Nsaids / Dicloxacillin / Aldomet / Motrin / Lisinopril / Vioxx Attending:[**First Name3 (LF) 602**] Chief Complaint: hallucinations Major Surgical or Invasive Procedure: none History of Present Illness: CC:[**CC Contact Info 102866**] HPI: (per patient, who is a poor historian given her altered mental status) Pt is a 69 yo F with PMH schizoaffective disorder, DM2, CAD, dCHF, HTN, restrictive lung disease, discoid lupus, and vascular dementia who presented to [**Hospital1 18**] from her [**Hospital3 **] facility for altered mental status and hallucinations of 3 day duration. Pt states the hallucinations began around the same time that developed sores in her mouth that made it painful/hard for her to eat. Visual hallucinations consist of animals and people. The animals are "sometimes scary." Also admits to auditory hallucinations in which she hears voices. She cannot recall the specific things the voices tell her, but says they are sometimes bad and sometimes good. She knows the hallucinations are not real. She denies suicidal or homicidal ideation. She also c/o fatigue and weakness for past three days, and reports insomnia and racing thoughts over that time as well. She c/o pain in her left leg and has a history of falls, but denies recent fall (confirmed by [**Hospital 4382**] facility). ROS per HPI plus: (+) headache "like my head is going to bust open," feeling cold, shortness of breath, cough productive of yellow sputum, rhinorrhea, urinary incontinence (at baseline), abdominal pain, constipation, left shoulder pain, and left knee pain. (-) She denies chest pain, nausea, vomiting, dysuria. In ED VS were T 98.6 F, HR 110, BP 148/100, RR 20, O2 sat 98% on room air. ED course: Chest x-ray, and head CT without contrast were obtained. No neurologic symptoms were noted. UA was negative. Lactate and CPK were found to be elevated. Final ED Diagnosis: Hallucinations Past Medical History: #. DM2 - oral meds. #. CAD s/p MI '[**46**] - does not tolerate aspirin or ACE -> on Plavix #. diastolic CHF, EF > 55% 7/08 #. HTN #. Restrictive lung disease - not on home O2. FEV/FVC 108%, FVC 45%, FEV1 48% 6/07. #. h/o R LE DVT, many years ago per pt #. discoid lupus erythematosus #. h/o CVA - MRI in [**2156**] w/ moderate microvascular changes in the cerebral white matter #. h/o of SVT #. schizo-affective disorder #. dementia #. GERD c/b short segment [**Last Name (un) 865**] and hiatal hernia #. h/o cellulitis #. h/o seizures, per pt many years ago, not on medications #. s/p total abdominal hysterectomy #. small bowel obstruction s/p ex lap w/ lysis of adhesions and partial small bowel resection ([**2162-7-30**]) #. OSA, does not use CPAP #. OA #. osteopenia Social History: Resides in [**Last Name (un) 4367**] [**Hospital3 400**] Facility where she has meals prepared. She dresses and bathes herself. She is able to see her family members frequently. She smoked 2ppd for 20 yrs, but quit in [**2162-6-29**]. Denies current alcohol. She uses a walker for ambulation. Family History: Father: Died of MI at less than 50 years of age. Mother: History of breast CA. Physical Exam: ADMISSION EXAM: Physical Exam: VS: 99.4 F, BP 155/98, HR 106, RR 18, 96% on 2L GA: AOx3, NAD HEENT: head normocephalic, atraumatic. moist mucous membranes. EOM intact. visual field exam limited by pt's limited attention. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: crackles heard at lung bases bilaterally, diminished lung sounds. Abd: soft, obese, NT, +BS. no g/rt. HSM difficult to assess due to body habitus. neg [**Doctor Last Name 515**] sign. Extremities: no edema. DPs, PTs 2+. Skin: hyperpigmented macule present on forehead, hypopigmented patch of skin on left shin, erythema on left foot, midfoot, medial maleolus, 1st MTP joint. Neuro/Psych: CNs III-XII intact. visual acuity not assessed. [**5-2**] strength in U/L extremities, however, pt. is slow to lift her left arm, and strength testing is also limited by pain in knees. DTRs 2+ BL (biceps, brachioradialis). sensation intact to LT. cerebellar fxn (FTN, HTS) and gait not assessed. MSE findings: flat affect. tangential thought process and content, with perseveration on the topic of her marriage at the age of 17. poor attention (cannot state days of the week in reverse order; gets only from Sat. to Wed.) . Discharge PE: Physical Exam: VS: 98.6 130/72 87 22 98 on RA GEN: AAO x2 (not oriented to date), pleasant and conversational, NAD, breating comfortably CVS: RRR, no m/r/g, normal S1, S2 PULM: lungs clear to auscultation b/l ABD: soft, obese, NT, ND, +BS EXT: slight LE edema b/l. No TTP, 2+ DP pulses neuro: AAOx2, CN 2-12 grossly intact, [**5-2**] UE/LE strength Pertinent Results: [**2165-8-9**] 12:21PM BLOOD WBC-12.8* RBC-5.07 Hgb-13.3 Hct-41.5 MCV-82 MCH-26.3* MCHC-32.1 RDW-16.7* Plt Ct-350 [**2165-8-9**] 12:21PM BLOOD Neuts-74.1* Lymphs-19.9 Monos-3.1 Eos-1.8 Baso-1.0 [**2165-8-9**] 12:21PM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1 [**2165-8-10**] 07:30AM BLOOD ESR-52* [**2165-8-11**] 07:35AM BLOOD ACA IgG-2.2 ACA IgM-3.2 [**2165-8-11**] 07:35AM BLOOD Lupus-NEG [**2165-8-9**] 12:21PM BLOOD Glucose-373* UreaN-28* Creat-1.3* Na-133 K-4.7 Cl-95* HCO3-25 AnGap-18 [**2165-8-9**] 12:21PM BLOOD ALT-31 AST-46* AlkPhos-119* TotBili-0.6 [**2165-8-9**] 04:50PM BLOOD proBNP-248 [**2165-8-10**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01 [**2165-8-9**] 12:21PM BLOOD Calcium-10.2 Phos-4.7*# Mg-2.0 [**2165-8-12**] 11:40AM BLOOD TotProt-7.1 Albumin-3.7 Globuln-3.4 [**2165-8-11**] 07:35AM BLOOD %HbA1c-9.7* eAG-232* [**2165-8-13**] 09:05AM BLOOD VitB12-621 Folate-13.9 [**2165-8-11**] 07:35AM BLOOD TSH-2.6 [**2165-8-19**] 08:00AM BLOOD Ammonia-18 [**2165-8-10**] 07:30AM BLOOD CRP-119.2* [**2165-8-10**] 07:30AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2165-8-11**] 07:35AM BLOOD b2micro-3.4* [**2165-8-12**] 11:40AM BLOOD PEP-NO SPECIFI [**2165-8-9**] 12:29PM BLOOD Lactate-2.7* [**2165-8-20**] 03:28PM BLOOD freeCa-1.23 Images: [**2165-8-9**] CXR: Mild interstitial edema and cardiomegaly. [**2165-8-9**] CT HEAD: No acute intracranial process. [**2165-8-10**] LLE DOPPLER:No left lower extremity deep vein thrombosis. [**2165-8-12**] CALF MRI:1. No signs of muscle edema or myonecrosis in the left calf.2. Subcutaneous soft tissue edema of the left calf may reflect third spacing of fluid and edematous changes or cellulitis in the proper clinical setting. 3. Probable small bone infarcts involving the posterolateral distal tibia and lateral aspect of the talus correlated with [**2165-8-9**] left ankle radiographs 4. Mild thickening of the Achilles tendon at attachment site with associated enthesopathy at the posterior calcaneus. [**2165-8-15**] CTA CHEST: No evidence of PE. Moderate cardiomegaly with moderate coronary calcifications. Small hiatal hernia. No evidence of aortic pathology. [**2165-8-16**] MRI HEAD NON CON:1. No evidence of acute infarct, intracranial hemorrhage, or mass lesion. 2. Changes of chronic small vessel ischemic disease. 3. Generalized cerebral atrophy. 4. Focus of old hemorrhage in right frontal lobe which is unchanged. Brief Hospital Course: 69 yo F with PMH schizoaffective disorder, CAD, HTN, DM, restrictive lung disease, discoid lupus, and h/o CVA, who p/w 3d h/o audio and visual hallucinations, leg pain, and SOB with altered mental status. ACTIVE ISSUES: #Alered Mental Status/Hallucinations: Given pt's history of schizoaffective disorder and vascular dementia, initial presentation was thought to be related to delirium vs. progressive dementia or primary psychiatric condition. Initial work-up for infectious and neurologic causes of delirium were unrevealing. Urine analysis was unremarkable, chest xray showed no infiltrate, blood cultures showed no growth. A head CT was negative for an acute intracranial process. A head MRI was also obtained to further evaluate for neurologic causes,and showed only chronic changes and no new areas of ischemia. An EEG was obtained and was negative for epileptiform activity. Over the course of the work up described above, the pt slowly became more withdrawn, which was different from her initial presentation in which she was talkative and quite labile with religious ideosity and frequent outburts of "hallelujah" and "praise [**Doctor Last Name **]." She began to answer fewer questions, and began to appear somewhat paranoid. Psychiatry saw pt and recommended increasing antipsychotic dosage from short acting seroquel 250mg po qhs, to long-acting seroquel 300mg po qHS and adding on haldol 1mg po BID. This was done, and the next morning ([**2165-8-16**]) the patient seemed withdrawn and stuporous. She was awake but not responsive to questions verbally, answering only with mild head nodding. At this time, she was found to have a urinary tract infection (see below), seroquel and haldol were discontinued and the urinary tract infection was treated and her mental status improved the following day, returning to a level similar to at the time of admission. On [**2165-8-20**], she appeared ill and was again withdrawn. She was febrile and diaphoretic. Antibiotic coverage was broadened to vanc/cefepime/flagyl. Pt then developed recurrent SVT to the 220s, relieved with carotid massage. She appeared rigid and diaphoretic. She was transferred to the ICU for further management. In the unit psychiatry was consulted and atypical presentation for neuroleptic malignant syndrome was considered. She was treated with 2mg cogentin and ativan with mild improvement in her mental status. She was transferred back to the general medicine floor, where her mental status continued to wax and wane but never returned to her initial level of interactiveness on admission. She was responsive to some questions, but refusing to answer others. She did not participate in physical exam commands. She remained stable at this point for several days. Given the extensive negative work up for delirium, this was considered to be her new baseline and placement was found for skilled nursing facility for discharge with permission from her health care proxy. At time of discharge, the patient remains AAO x2 (unchanged from before); she is alert and talkative; still having delusions that her family is outside waiting for her; gets agitated about wanting to leave hospital and often refuses to sit or stay in bed. Throughout hospitalization the patient was convinced that her hallucinations and delusions were real. . # Urinary tract infection: [**2165-8-18**] patient was febrile and urine analysis suggested urinary tract infection. She was treated with ceftriaxone. Urine culture revealed grew out presumptive Strep Bovis and E.coli grow out in her urine. . # Supraventricular Tachycardia: Patient has a remote hx SVT, on metoprolol for rate control. On [**2165-8-19**] she developed SVT to the 220s, which resolved spontaneously. Over the course of the following day, she had 4 more episodes of SVT which responded to carotid massage, she was never hypotensive. SHe was transferred to the MICU for closer monitoring. Cardiology was consulted who identified the rhythm as atrial tachycardia vs. AVNRT. The patient has been stable on Metoprolol 200 mg [**Hospital1 **]. # Hypoxia: On admission, patient was hypoxic with 2LNC O2 requirement. There was no evidence of pulmomary edema or consolidation. She was quickly weaned to room air. As part of a work up, an ABG was performed which showed pO2 of 58, this corrected to 92 with 2LNC. Patient was maintained on supplemental oxygen without improvement in mental status. Given significant a-A gradient, and persistent tachycardia, CTA was performed and showed no evidence of pulmonary embolism. Patient has a 20 pack year history and likely has baseline hypoxia with sufficient compensation to maintain peripheral O2 saturation >92%. At time of discharge, the patient no longer has an oxygen requirement, and is satting mid to high 90s on RA. # Ankle pain: Initial laboratory analysis was remarkable for CK in the 800s and an elevated ESR and CRP. Given her complaints of left leg and ankle pain, orthopedic and rheumatologic causes were considered, as well as PE. Plain films of the left ankle and hip were negative for fracture, but did show an area of possible bone infarct in the distal tibia of unclear significance. Rheumatology was consulted who did not believe the presentation was consistent with SLE, or gout. Amyloidosis was also considered however SPEP and UPEP, total protein and globulin levels were unremarkable. Statin-induced myopathy was considered, and statin was held however CK had already begun to trend down when the statin was stopped, making statin induced myopathy unlikely. A LE doppler was negative for DVT. MRI of the leg MRI was done to evaluate for myositis, skeletal vasculitis or other inflammatory myopathy, and diabetic myonecrosis. It was negative for any muscle inflammation or necrosis, and showed only edema in the subcutaneous tissues, which had been noted on physical exam. Within the first few days of her admission, ankle pain and erythemia resolved, etiology remains unclear. . #Cog-wheel rigidity/masked facies/resting tremor - On admission to the MICU, the patient developed acute presentation of symptoms concerning for extrapyrimidal symptoms related to antipsychotics. Patient had received PRN doses of haldol, home seroquel 250 mg. However, all antipsychotics had been D/C'd 2 days prior to symptom onset. Antipsychotics were held. The patient was given 1 mg cogentin x 2. Psych was consulted, who felt that her symptoms were consistent with EPS. The patient was started on Ativan 1mg q6 hrs PRN agitation. Upon transfer back to the general medicine floor, her rigidity had improved and she continued to be treated with prn ativan for agitation, though this made pt quite somnolent. On [**2165-8-25**] she was restarted on seroquel 50mg po BID prn agitation in an effort to avoid sedation associated with benzos. Then as per Psych recommendation, the patient was restarted on low dose, 25 mg, seroquel [**Hospital1 **]. All other PRN doses of seroquel and Ativan were held. The patient seems to be responding well to this regimen. . # Hypertension - pt had very difficult BP management while in house. She was still measuring in SBP 170s on several occasions despite being on max dose of numerous BP meds, including metoprolol, losartan, furosemide, and clonidine patch. While in house, hydralazine 10mg po TID was added to pt's regimen, and metoprolol was further increased to 200mg po BID for management of SVT. On this regimen, her pressures ranged from SBP 140s - 150s, occassionally in the 170s. # hypercholesterol: Because of elevated CKs (peaked at 819), the patient's Simvastatin was discontinued. CK normalized to 92 by time of discharge. She should have her CK rechecked as outpatient and consider restarting simvastatin as outpatient. INACTIVE ISSUES: # CAD - Chronic. Clopidogrel was continued on admission but simvastatin was discontinued shortly after admission secondary to elevated CK levels. # restrictive lung disease: Chronic. Patient was continued on albuterol, ipratropium, tiotropium. Symbicort was replaced with advair during admission due to formulary. Pt is likely compensated at a lower pO2 secondary to her lung disease. She was repeatedly hypoxic during admission without complaints of shortness of breath. Of note, pulse oximetry measured O2 sats in mid-90s on several occasions in which ABG drawn at same time showed hypoxia, so pulse ox is not reliable measure of oxygen status in this patient. # DM - held glyburide, gave SSI while in house # h/o candidal rash: miconazole powder TRANSITIONAL ISSUES: # schizoaffective disorder: The patient was admitted on Seroquel 250 qhs and because of the possibility of NMS, the patient is being discharged on Seroquel 50 mg [**Hospital1 **]. Her lorazepam was held throughout hospital admission. # please check the patient's CK as an outpatient, as she had elevated CK levels as outpatient. Medications on Admission: - AMLODIPINE 10mg daily - CLOPIDOGREL [PLAVIX] - 75 mg daily - FUROSEMIDE - 40 mg daily - GLYBURIDE - 5 mg daily - IPRATROPIUM-ALBUTEROL [COMBIVENT] - 2.5-0.5/3mL one vial neb q6H prn - LORAZEPAM - 0.5mg qHS - LOSARTAN [COZAAR] - 100 mg daily - METOPROLOL ER - 200 mg daily - PANTOPRAZOLE - 40 mg [**Hospital1 **] - QUETIAPINE [SEROQUEL] - 250 mg qHS - SIMVASTATIN - 20 mg daily - CALCIUM CARBONATE - 500 mg (1,250 mg) TID with meals - ERGOCALCIFEROL (VITAMIN D2) - 1000 unit daily - FERROUS SULFATE - 325 mg (65 mg Iron) daily - MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily - SENNA - 8.6 mg two tabs daily prn constipation - CLONIDINE patch 0.3mg apply every wednesday - saline nasal spray 1 spray each nostril [**Hospital1 **] - spiriva 18mcg cap 1 puff daily - symbicort 160/4.5 mcg HFA two puffs [**Hospital1 **] - ibuprofen 400mg po TID prn - nystatin 100,000U powder apply to affected area TID prn - proair HFA inh 90mcg 1-2 puffs q4-6h prn - acetaminophen 650mg po TID Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) INH Inhalation every six (6) hours as needed for shortness of breath or wheezing. 5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for constipation. 9. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 10. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal twice a day. 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 13. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 14. nystatin 100,000 unit/g Powder Sig: One (1) APPL Topical three times a day as needed: to affected area. 15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-30**] puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day as needed for fever or pain. 17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO TID with meals. 19. ergocalciferol (vitamin D2) 400 unit Tablet Sig: 2.5 Tablets PO once a day. 20. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 21. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 22. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 23. Outpatient Lab Work Please check CK on [**2165-9-9**] and fax results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] at [**Telephone/Fax (1) 23926**] 24. Seroquel 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: altered mental status, NOS extra-pyramidal adverse effect, anti-pyschotics hypertension supraventricular tachycardia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. You were given a diuretic that removed fluid from your lungs and your breathing improved. You had an extensive work up to identify the cause of your altered mental status and no cause could be found. While you were in the hospital, you developed muscular side effects from your anti-psychotic medications. These were stopped temporarily and your symptoms improved. We restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. Your blood pressure and heart rate were elevated during your admission. You were started on two new medications to manage this. The following changes were made to your medications: STARTED: hydralazine 10mg by mouth three times a day CHANGED: metoprolol 200mg by mouth twice a day seroquel 50 mg by mouth twice a day STOPPED: lorazepam simvastatin Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. You were given a diuretic that removed fluid from your lungs and your breathing improved. You had an extensive work up to identify the cause of your altered mental status and no cause could be found. While you were in the hospital, you developed muscular side effects from your anti-psychotic medications. These were stopped temporarily and your symptoms improved. We restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. Your blood pressure and heart rate were elevated during your admission. You were started on two new medications to manage this. The following changes were made to your medications: STARTED: hydralazine 10mg by mouth three times a day CHANGED: metoprolol 200mg by mouth twice a day seroquel 25 mg by mouth twice a day STOPPED: lorazepam simvastatin: please discuss with your primary care doctor when you can restart simvastatin Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. You were given a diuretic that removed fluid from your lungs and your breathing improved. You had an extensive work up to identify the cause of your altered mental status and no cause could be found. While you were in the hospital, you developed muscular side effects from your anti-psychotic medications. These were stopped temporarily and your symptoms improved. We restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. Your blood pressure and heart rate were elevated during your admission. You were started on two new medications to manage this. The following changes were made to your medications: STARTED: hydralazine 10mg by mouth three times a day CHANGED: metoprolol tartrate 200mg by mouth twice a day seroquel 50 mg by mouth twice a day STOPPED: lorazepam simvastatin: please discuss with your primary care doctor when you can restart simvastatin Followup Instructions: Your doctor, Dr. [**Last Name (STitle) 1266**], [**First Name3 (LF) **] see you at [**Location (un) 583**] House. Below is his contact information. Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 608**] Department: [**Hospital3 1935**] CENTER When: TUESDAY [**2165-9-24**] at 10:15 AM With: [**Location (un) 394**]/[**Name8 (MD) **] MD [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2165-9-4**] ICD9 Codes: 5990, 5849, 2760, 4280, 4019, 2720, 412
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Medical Text: Admission Date: [**2102-10-10**] Discharge Date: [**2102-10-18**] Date of Birth: [**2041-11-27**] Sex: M Service: [**Hospital Unit Name 196**] HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with no medical care for the last ten years, who had sudden onset of dyspnea while riding his bike. He had positive palpitations, no chest pain, no nausea or vomiting or diaphoresis. He stopped and rested, with no relief. He entered the [**Hospital1 69**] Emergency Department and was found to have an oxygen saturation of 70%. Electrocardiogram showed no complex tachycardia, with an elevated blood pressure. Adenosine was given with no effect. It was given again, and he was broken to normal sinus rhythm with a rate of 80s. Chest x-ray showed congestive heart failure at that time, and he was started on a nitro drip, given aspirin and lasix, and the patient improved. PAST MEDICAL HISTORY: Questionable hypertension, which was untreated, arthritis, essential tremor. MEDICATIONS: Ibuprofen as needed. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs on admission: Afebrile, heart rate in the 80s, blood pressure normal, oxygen saturation 98% on 3 liters. He was alert and oriented, no jugular venous distention was noted. Pupils equal, round and reactive to light. He had crackles halfway up the lung fields. His cardiovascular examination showed distant heart sounds, regular rate and rhythm, with no murmurs, gallops or rubs. His abdomen was soft, nontender, nondistended, bowel sounds present. The extremities were warm and well perfused, with no cyanosis, clubbing or edema. LABORATORY DATA: White count 16.5, hematocrit 46.0, platelet count 362. Sodium 141, potassium 3.2, chloride 101, bicarbonate 20, BUN 12, creatinine 0.9, glucose 101. HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**] service and begun workup of congestive heart failure. The patient was taken to the cardiac catheterization laboratory, which showed three vessel disease and was planned for coronary artery bypass graft at that time. EP studies were also done at that time due to his narrow complex supraventricular tachycardia requiring adenosine. During the catheterization, it was found that the patient had moderate aortic insufficiency and it was planned that he would have an AVR at the same time. On [**2102-10-12**], the patient was taken to the operating room, where a coronary artery bypass graft x 3 and AVR was performed. The patient was transferred to the CSRU postoperatively. He did well. The patient was weaned from his ventilator and was extubated and continued to improve. His Foley was removed. His chest tube was removed. The patient was noted to have supraventricular tachycardia postoperatively, which was broken with adenosine. Lopressor was started in order to control his supraventricular tachycardia, however, the patient continued to have repeat episodes of supraventricular tachycardia. He was kept in the Intensive Care Unit for monitoring and for administration of adenosine. EP was following at this time, and it was planned for a workup. His Lopressor was increased, but again had no effect. The patient was taken to the EP laboratory on [**2102-10-17**], where he was studied and found to have a pathway which was successfully ablated. Physical Therapy was consulted for ambulation, and the patient did well, and it was felt that the patient would be safe to be discharged home. After his ablation, the patient was transferred to the floor, where he did well. On postoperative day number six, the patient had no further episodes of supraventricular tachycardia, and his heart rate was stable. The patient was able to clear stairs with physical therapy, and the patient was discharged home in stable condition. The patient is instructed to follow up with Dr. [**Last Name (STitle) 70**] in four weeks, and with Dr. [**Last Name (STitle) 284**] of Cardiology in two to four weeks, and his primary care physician in one to two weeks. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg by mouth twice a day 2. Lasix 20 mg by mouth twice a day 3. Potassium chloride 20 mEq by mouth twice a day 4. Colace 100 mg by mouth twice a day 5. Zantac 150 mg by mouth twice a day 6. Aspirin 325 mg by mouth once daily 7 Percocet one to two tablets by mouth every four hours as needed The patient is discharged in stable condition. DISCHARGE DIAGNOSIS: 1. Supraventricular tachycardia status post ablation 2. Coronary artery disease status post coronary artery bypass graft x 3 The patient is discharged in stable condition to home, and is instructed to follow up with Dr. [**Last Name (STitle) 70**] in four weeks, Dr. [**Last Name (STitle) 284**] in two to four weeks, and his primary care physician in one to two weeks. [**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern4) 10459**] MEDQUIST36 D: [**2102-10-17**] 23:26 T: [**2102-10-18**] 00:41 JOB#: [**Job Number **] ICD9 Codes: 4241, 4271, 4280, 4019
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Medical Text: Admission Date: [**2132-8-11**] Discharge Date: [**2132-8-12**] Date of Birth: [**2066-11-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: inability to replace trach at home Major Surgical or Invasive Procedure: Tracheostomy replacement History of Present Illness: Pt is a 65 y.o male with h.o severe OSA (central and peripheral), who is usually trached with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] cannula who presents after trach had not been in place for a few days. Pt ordinarily changes his trach by himself q3months. However, on this occasion, it was too difficult to replace and now the trach has been off for a few days. Pt did go to local ER yesterday ([**Location (un) 8117**]), but he was unable to have the trach replaced and was noted to have significant granulation tissue at the stoma site. . In the ED, initial vs were: T P BP R O2 sat. + 17:15 0 98.4 68 146/94 20 96 IP was consulted and observed that ordinarily pt needs to close the stoma to talk and now can talk without closing the stoma. IP suggests bipap overnight. If pt required intubation, the cuff would have to be placed below the stoma. IP is planning to do a rigid bronch tomorrow to either revise the stoma vs. place a T-tube. . Pt states that over the last few months, he has noticed increased difficulty when changing his trach every 4-6months. This week, pt noticed increased difficulty when changing his trach, a few days ago, he also noticed that something did not feel right after he coughed and eventually the tube feel out and pt was unable to replace it. In addition, pt states he has had a multiple revisions and was told there is a great deal of scar tissue at the site. He has not tolerated bypap in the past and states he uses 4L at tM at night at baseline. . On the floor, pt feels well. He denies SOB/PND, fever/chills, CP/palp, URI/cough, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria, skin rash, +chronic b/l ankle pain. However, pt reports that he has been unable to sleep for the last 3 days [**2-11**] trach malfunction, he has been sleeping upright and did awake with an am headache yesterday. In addition, he reports palp ~1months ago, with a reportedly negative w/u. Past Medical History: -obstructive and central sleep apnea-dx 20 years ago s/p uvulopalatopharyngoplasty, multiple attempts with CPAP,tracheostomy eight years ago. -hypothyroid -OA -asthma Social History: works in sales, selling sheet metal. He lives with his wife, drinks 1 ETOH drink daily, denies any w/d symptoms or seizures, denies drug use. Family History: sister with DM Physical Exam: PE on admission: Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA General: Alert, oriented, no acute distress, occasional sounds of air from trach. HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, +trach site with granulation tissue, pink mucosa, no drainage/C/D/I. Lungs: b/l ae +crackles at bases, no w/r CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2132-8-11**] 08:34PM BLOOD WBC-7.1 RBC-5.27 Hgb-15.8 Hct-48.3 MCV-92 MCH-30.0 MCHC-32.8 RDW-13.5 Plt Ct-219 [**2132-8-11**] 08:34PM BLOOD Neuts-52.9 Lymphs-34.9 Monos-7.2 Eos-4.1* Baso-0.9 [**2132-8-11**] 08:34PM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0 [**2132-8-11**] 08:34PM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-140 K-4.1 Cl-105 HCO3-27 AnGap-12 [**2132-8-12**] 04:12AM BLOOD ALT-34 AST-32 LD(LDH)-184 AlkPhos-58 TotBili-0.9 [**2132-8-12**] 04:12AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.6 Mg-2.1 . CXR: Lateral aspect of the left lower chest is excluded from the examination. Other pleural surfaces and the imaged portions of the lungs are clear. Heart size is normal. Trachea is grossly intact, but not fully imaged by this type of examination. Pending upon clinical circumstances, chest CT should be considered. Brief Hospital Course: Pt is a 65 y.o male with h.o severe OSA (central/peripheral) s/p trach who now presents s/p trach dislodgement. . # Airway management - Pt with h.o severe OSA who failed trials of cpap in the past. Pt with trach x15+ yrs per history. Now, has been a few days w/o trach in place and with evidence of granulation tissue and healing stoma. IP consulted and recommended MICU observation o/n. Rigid bronch was performed and they were able to balloon dilate the stoma and replace the trach. They used the same type as before. See OMR for procedure note. He tolerated the procedure well and came back to the MICU with his new trach in place and capped. He was talking and without pain. His oxygenation was normal. IP saw patient on the floor and cleared him for home with follow up in two weeks to have the stitch in his trach removed. He will now have it exchanged in office visits rather than at home. . #OSA-with management as above. Pt with h.o central and peripheral sleep apnea. Did fine overnight with humidified air over stoma. Trach now back in place. . #asthma-home advair, albuterol, ipratropium were continued. . #hypothyroidism-continued home levoxyl. Discharged home in good condition post-op. Patient was advised not to drive for 24 hrs after getting sedation. Medications on Admission: Glucosamine-Chondroitin 250 mg-200 mg Cap Advair Diskus 500 mcg-50 mcg/Dose for Inhalation 1 puff Twice a day Salmon Oil-1000 1,000 mg-200 mg Cap Multivitamins Chewable Tab Ventolin 5 mg/mL (0.5 %) Neb Solution 1 Puff As neded Levothyroxine 125 mcg Tab 1 Tablet(s) by mouth Rhinocort Aqua 32 mcg/Actuation Nasal Spray 1 Puff Twice a day Ipratropium Bromide 0.03 % Nasal Spray Aerosol 1 As needed Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One (1) puff Nasal twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Obstructive sleep apnea . Secondary: Asthma Hypothyroidism Osteoarthritis Discharge Condition: Good. Discharge Instructions: You were admitted because your trach fell out and you were unable to replace it. The interventional pulmonary physicians replaced your trach site and sutured it. You will need to have the sutures removed in 2 weeks. . Please resume taking all medications as you were previously taking prior to admission. . Please call Dr. [**Last Name (STitle) **] if you develop significant pain at the trach site, increased redness or drainage from from the site, difficult breathing, or any other concerns. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks for removal of the sutures. They will call you to schedule this appointment. His phone number is [**Telephone/Fax (1) 3020**]. Completed by:[**2132-8-13**] ICD9 Codes: 2449
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Medical Text: Admission Date: [**2173-3-20**] Discharge Date: [**2173-3-24**] Date of Birth: [**2139-3-28**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2836**] Chief Complaint: Right leg pain, transfer from OSH r/o necrotizing fascitis Major Surgical or Invasive Procedure: none History of Present Illness: 33M with no significant PMH who punctured his leg two days ago with barbed wire after tripping and falling, later burning his legs and arms bilaterally on a space heater. The patient reports pain in his right leg that is [**11-10**] with little relief from narcotics (patient took 15 tablets of oxycodone 30mg at home). The pain is pulsatile and extends from his upper right shin to his foot. Patient is unable to bear weight on right leg. He was initially seen at [**Hospital1 **] [**Location (un) 620**], where he received vancomycin and clindamycin overnight and was given a tetanus shot. He was transferred to [**Hospital1 18**] after threatening to sign out AMA. In the [**Location (un) 620**] ED, the patient received vancomycin and clinda, he then received Zosyn at [**Hospital1 18**]. He has received Dilaudid for pain control with little effect. Past Medical History: Past Medical History: - Attention deficit disorder - Substance abuse Past Surgical History: - None Social History: Current smoker. Social alcohol use. History of snorting heroin, but no IVDU. Family History: Paternal grandmother with DM Physical Exam: On admission: Vitals: Tm/Tc 97.8, HR 81, BP 148/65, RR 18, O2 100% on RA GEN: A&O (per nurse was difficult to arouse earlier), wincing in pain HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: LLE with 2 cm healing, non-draining second-degree burn on anterior shin. RLE with circumferential edema of crus, 1+ pitting edema of foot. Poorly-demarcated erythema now extending beyond border marked earlier, extending from just below knee to ankle. Multiple 1cm x 1cm scabs and 4cm x 3cm healing, non-draining second-degree burn on upper shin. Dorsalis pedis pulses intact bilaterally. Full ROM and strength in both LE and feet. On discharge: VS: 98.1 52 (ranging 50's to low 60's) 127/62 18 98%A GEN: A&O, NAD CHEST: Lung sounds CTAB, bradycardic normal S1S2, no murmurs/rubs/gallops ABD: Soft, nontender, nondistended, +BS EXTR: LLE with multiple healing scabs 1cm x 1cm, 4cm x 3cm healing, nondraining. Very minimal errythema, inside previously outlined area. Minimal edema LLLE, +DP and TP pulses, full ROM and strength in bilateral LE. Pertinent Results: [**2173-3-20**] RLE CT: Extensive soft tissue thickening and edema consistent with cellulitis. No evidence of necrotizing fasciitis. No abscess formation. [**2173-3-22**] RLE US: No evidence of deep vein thrombosis in the right leg. Superficial thrombophlebitis is seen in the greater saphenous vein in the right calf. [**2173-3-22**] LUE US: No evidence of deep vein thrombosis in the left arm. [**2173-3-20**] 08:01AM WBC-6.6 RBC-4.02* HGB-12.1*# HCT-34.8*# MCV-87 MCH-30.1 MCHC-34.8 RDW-12.7 [**2173-3-20**] 08:01AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2173-3-20**] 08:01AM PLT SMR-NORMAL PLT COUNT-223 [**2173-3-20**] 08:01AM SED RATE-20* [**2173-3-20**] 08:01AM CRP-20.7* [**2173-3-20**] 08:01AM GLUCOSE-102* UREA N-10 CREAT-0.6 SODIUM-137 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 [**2173-3-20**] 08:05AM LACTATE-1.3 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2173-3-20**] under the acute care service for monitoring and management of his RLE cellulitis. A CT scan was obtained in the ED (see pertinent results for details) which showed no evidence of necrotizing fascitis. He was hemodynamically stable and was admitted to the surgical floor for monitoring and IV antibiotics. He was started on IV antibiotics empirically. The wound was monitored closely and showed significant evidence of improvement in errythema. He remained afebrile. Given his history of substance abuse, his pain level was routinely assessed and he was administered appropriate amounts of pain medications as needed. He was started on a clonidine patch as well. However, on HD#3 he ingested his clonidine patch because he reports he was in severe pain and his heart was racing. He became bradycardic to the 20's and 30's without hypotension and was given activated charcoal with NG tube lavage and transferred to the trauma ICU for monitoring. While observed in the trauma ICU, Mr [**Known lastname 105674**] bradycardia slowly resolved. By the afternoon his heartrate was in the low 50's and it had been 24 hours since the clonidine ingestion so he was deemed appropriate for floor transfer. During his stay there, a palpable cord in his RLE was identified, as well as an indurated/cord-like area of his LUE, so doppler exams were performed on each which showed no evidence of DVT. Chronic pain and psychiatry consults were both obtained. At that time, Chronic Pain recommended oxycodone 15mg TID based on his reported outpatient usage of 45-60mg TID. He was given one dose of methadone 20mg on [**2173-3-23**] with the understanding it would not be continued. After it was determined his cardiovascular measures were stable and he was tolerating PO intake, he was transferred back to the floor. On the floor he remained afebrile and hemodynamically stable with a HR in the 50's. He remained alert and oriented. His RLE cellulitis continued to improve. On [**2173-3-24**] he is afebrile, hemodynamically stable without leukocytosis. He is out of bed ambulating independently as tolerated. He is being discharged with a 2 week course of Bactrim for MRSA coverage for his cellulutis and a limited prescription for oxycodone until he follows up with his primary care provided on [**2173-3-30**]. Medications on Admission: Adderall 30 mg PO BID Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): do not exceed > 4 gm of aceaminophen in 24 hours. 3. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*19 Tablet(s)* Refills:*0* 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 6. Adderall 30 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1. Cellulitis of the right lower extremity 2. Clonidine ingestion 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 an infection in your skin of your right leg. You have been treated with antibiotics and the infection is stable. You are being discharged home with a presciption for two more weeks of antibiotics. Please take the entire course of antibiotics as prescribed. You are being discharged on narcotic pain medication to control your pain. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Constipation is a common side effect of narcotics. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. Do not drink alcohol or drive/operate heavy machinery while taking narcotics. 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. *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. Followup Instructions: Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER When: TUESDAY [**2173-3-30**] at 12:00 PM With: [**First Name8 (NamePattern2) 247**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2173-3-26**] ICD9 Codes: 3051
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Medical Text: Admission Date: [**2192-9-23**] Discharge Date: [**2192-9-28**] Date of Birth: [**2140-7-8**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 689**] Chief Complaint: Diarrhea for 6 weeks, anuric x3 days. Major Surgical or Invasive Procedure: None History of Present Illness: Pt's history and hospital course reviewed. Briefly, this is a 52M w/ h/o HIV who p/w 3 days of anuria and general malaise. He had been having diarrhea for the past 6 weeks and on presentation to the ED for his anuria, he was found to be hypotensive to 84/60 and in ARF with Cr 5.7 (baseline 1.0). He also complained of left-sided chest discomfort, a substernal pressure radiating across his chest that had been ongoing for 2-3 weeks. Sepsis protocol was initiated and RSC CVL was placed. BP improved to SBP of 100 with 4L IVF and IV heparin was started for troponin leak of 0.11. He was transferred to the MICU. . While in the MICU, the patient's ARF responded well to IVF, with his Cr decreasing to 1.8 on transfer to the floor. TnT decreased from 0.11 to 0.02. However, TTE showed a markedly dilated RV cavity and moderate global RV free wall hypokinesis consistent with RV pressure/volume overload. The patient's pretest probability for PE was considered high given his HIV status, chest pain, and TTE results, but a V/Q scan showed low probability. Given his post-test estimated probability of PE was 20%, he was continued on anticoagulation. Hct drop from 33.8 on admission to 26.1 after fluid resuscitation with guaiac positive stool, hypovolemia, likely demand ischemia, and h/o abnormal EGD raised strong suspicion for GIB, but his Hct returned to 33.3 by time of transfer to floor. His platelets dropped from 160 on admission to 97, and HIT antibody test was positive [**9-25**], so he was switched to argatroban. On the day of transfer, the pt spiked a low-grade temperature to 100.7. He was pan-cultured but no antibiotics were started as there was no clear infectious source. Past Medical History: HIV - dx [**2179**], CD4 <100 on [**2192-9-11**], on HAART HIV neuropathy Vacuolar Myelopathy - impaired sensation from neck down Spastic Bladder Muscle Spasticity of Leg CAD s/p cypher times 3 (mid-RCA, prox-RCA, and mid-LAD) +PPD but negative CXR and sputum s/p Appy Social History: Lives with wife, son, and father, smokes 1.5 ppd x 35 years, occ etoh, no drugs, previously worked as manager, now on disability Family History: Father alive at 86 and healthy, mother deceased at age 85 from breast cancer, one sister and one brother both healthy Physical Exam: VS: 100.6, 139/95, 85, 20, 100% RA, 83.3kg Gen - sitting comfortably in bed, NAD HEENT - PERRL, EOMI, sl thrush, MMM NECK - supple, LAD (old), no JVD Lungs: CTAB CV - RRR, nl S1S2, no m/r/g Abd - soft, ND, NT, no reb/gaurd, NABS Ext - no c/c/e, dry skin over lower extremities Neuro - CN II-XII intact, spastic lower extremities with 3/5 weakness, nl strength in upper ext. AAO X3, no focal deficits Pertinent Results: [**2192-9-23**] 12:35PM GLUCOSE-98 UREA N-41* CREAT-5.7*# SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20 [**2192-9-23**] 12:35PM WBC-8.1# RBC-3.91* HGB-11.9* HCT-33.8* MCV-87 MCH-30.3 MCHC-35.1* RDW-17.9* [**2192-9-23**] 12:35PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-264* ALK PHOS-115 TOT BILI-0.5 [**2192-9-23**] 12:35PM LIPASE-180* [**2192-9-23**] 08:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2192-9-23**] 08:13PM URINE RBC-[**5-12**]* WBC-[**2-5**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2192-9-23**] 10:58PM CORTISOL-3.6 [**2192-9-23**] 10:58PM CORTISOL-24.5* [**2192-9-23**] 10:58PM CALCIUM-6.4* PHOSPHATE-3.7 MAGNESIUM-1.9 URIC ACID-7.4* . [**9-23**] CXR: PORTABLE AP CHEST RADIOGRAPH: The right subclavian venous line is terminating in mid SVC. There is no evidence of pneumothorax. Cardiac and mediastinal contours are within normal limits, and there is no consolidation or effusion. . [**9-23**] CT OF THE ABDOMEN WITHOUT IV CONTRAST. Dependent changes are seen at the lung bases. Allowing for limitations of a non-contrast study, the liver, gallbladder, pancreas, spleen, and kidneys appear unremarkable. Again seen is a rounded hypodensity in the right adrenal likely representing adrenal adenoma, not significantly changed in appearance from prior study. Visualized portions of bowel appear unremarkable. There is no evidence of free air or free fluid within the abdomen. Scattered lymph nodes are seenthroughout the mesentery and retroperitoneum, however, none appear to meet CT criteria for pathological enlargement. . -CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid appear unremarkable. Air is seen within the bladder, likely secondary to Foley catheterization. No evidence of free air or free fluid within the pelvis. . -ECHO ([**5-8**]): EF 55% , no regional wall abnormaliites, mild pulmonary HTN. . -ECHO [**2192-9-24**]: 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. The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is minimal mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**2192-9-24**] LENIs: no DVT . [**2192-9-24**] V/Q scan: low probability for PE Brief Hospital Course: This is a 52 y.o. HIV positive male ([**2192-9-11**]: CD4 72, VL>100,000) with a 6 week history of diarrhea and low-grade temp who was initially admitted to the MICU for hypotension and ARF, improved after volume resuscitation. . # Diarrhea. Likely the patient was hypotensive and in renal failure secondary to hypovolemia precipitating ARF. The patient had a small amount of outpatient work-up for this, negative to date, including: Stool C. Diff, culture and CMV viral load undetectable. The patient was given symptomatic treatment, including imodium and his diarrhea improved dramatically. He was unable to provide a stool sample while on the floor. The patient was given a prescription for an outpatient stool sample for repeat stool culture (including viral and bacterial), DFA for crytosporidium and giardia, ova & parasites, microsporidium. The GI team was consulted on the patient. It was their recommendation that the patient have an infectious work-up. If negative and diarrhea persists, the patient should have a colonoscopy at a later date when aspirin and plavix can be held (at least 9 months from the time of drug eluting stent placement. At the time of discharge, the patient's diarrhea was well-controlled with loperamide and the patient was tolerating fluids PO. He was encouraged to have aggressive PO fluid intake whenever diarrhea occurs. . # Fevers. The patient had a low-grade (100) fever after coming to the floor from the MICU. This may be secondary to the same process as the diarrhea. However, the patient has poorly controlled HIV and therefore is at risk for numerous sources. Empiric antibiotics were deferred as no source of infection was found. . # Hypotension. Likely secondary to persistent diarrhea. The patient was aggressively hydrated with IV NS in the MICU. He came to the floor normotensive and maintained this volume status for the remainder of his time in the hospital. . # Acute renal failure. Likely pre-renal secondary to persistent diarrhea and volume depletion. The patient's Cr improved to normal range after volume resuscitation. . # Chest pain. The patient had a CTA that was negative for PE. He had a slight troponin elevation thought consistent with demand ischemia in the setting of hypotension and poor troponin excretion in the setting of renal failure. The patient's troponin trended downward throughout his admission and he never showed CK elevations. . # CAD. No signs of acute ischemia. Troponin leak with normal CK likely secondary to demand ischemia and ARF. The patient was continued on ASA, plavix, beta blocker, statin. His ACEi was held for renal failure and then restarted prior to discharge. On echo, the patient had new mechanical dysfunction. The patient should have outpatient p-MIBI to assess for perfusion deficits. . # HIV. On [**2192-9-11**], CD4 72, VL>100,000. The patient's HAART has been held while in the MICU for renal failure. These medications were restarted prior to discharge. The patient's PCP will consider initiating prophylactic antibiotics as an outpatient. . # Anemia. Patient's baseline appears 29-30. Patient with drop in Hct likely in part secondary to dilution. The patient had guaiac positive stool with known abnormal colonoscopy and EGD in past is concerning for GI bleed. The patient had multiple units of blood transfusion while in the MICU. His Hct normalized prior to discharge. . # Thrombocytopenia. The patient's platelets declined to 90 while in the MICU and he was found to be HIT antibody positive. Heparin products were held and the patient's platelet count stabilized. Medications on Admission: Ritonavir 100 qd 3TC 300 mg qd DDI 400 mg qd Atazanavir 300 mg qd Lisinopril 5 mg qd ASA 325 qd Plavix 75 qd Atenolol 25 mg qd Lipitor 20 qd Famotidine 20 mg [**Hospital1 **] Gabapentin 300 mg qhs Sucralfate 1 g qid Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Didanosine 400 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Atazanavir 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:*90 Capsule(s)* Refills:*2* 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Capsule(s)* Refills:*1* 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Stool sample: Please send for C. Diff toxin assay, DFA for Cryptosporidium/Giardia, routine stool cx, Microsporidium, Yersinia, Vibrio, Ova and Parasites. Give this sample at Dr. [**Last Name (STitle) 12103**] office. Discharge Disposition: Home Discharge Diagnosis: Primary: Diarrhea . Secondary: HIV Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. . Attend all follow-up appointment. . You must give a stool sample for analysis at your primary care physician's office. . It is recommmended that you have an outpatient colonoscopy. Please have your primary care physician help you schedule this study. . If you have recurrent diarrhea you must drink a large amount of water to replace what is lost in your stool. . If you develop nausea, vomiting, fevers, chest pain, shortness of breath or decreased urine output please call your doctor or return to the hospital. Followup Instructions: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3308**]), Monday [**2192-10-8**] 10:30AM. Give a stool sample at this office visit to look for possible causes of your diarrhea. Please make Dr. [**Last Name (STitle) **] aware that it is recommended for you to have a colonoscopy when it is safe to hold your aspirin plavix (9 months after your coronary stent was placed). ICD9 Codes: 5849, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3165 }
Medical Text: Admission Date: [**2174-9-15**] Discharge Date: [**2174-9-29**] Date of Birth: [**2099-1-29**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Allopurinol / Levaquin / Keflex / Zosyn / tamsulosin / Tipranavir / Probenecid / Ambien Attending:[**First Name3 (LF) 4854**] Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: 75yo F PMHx ESRD s/p LR Renal tx, w multiple recent admissions [**Date range (1) 105532**] E. coli UTI and bacteremia, AMS [**Date range (1) 16006**], AMS discharged [**9-1**] for UTI w AMS re-presents w persistent fatigue since previous discharge and AMS x 2d. Per patient's family, pt has been disoriented and displaying erratic behavior; no associated fever/chills/dysuria, N/V/D, chest pain, cough, HA. Family brought her to ED for further evaluation. She completed a course of cefpodoxime on [**9-7**] Of note patient has a hsitory of resistant hypertension with blood pressures at baseline in the 180s despite multi-antihypertensives. On recent admission her BP was elevated at 200s during her admission, and was 150-190s at the time of discharge. In ED, initial vital signs were 98.3 64 187/72 16 97%RA. Labs notable for WBC 15.1 (N83), Hct 31 (baseline), Cr 4.3 (baseline high 2s, low 3s), lactate 1.0, Trop .04, UA <1wbc, few bacteria. Patient had unremarkable CXR, transplant kidney u/s grossly unchanged. Her blood pressure went up to 230s and was staying in the 200s despite getting her home medications. She received .2mg clonidine, 20 furosedmide,100mg hydralazine and 100mg of labetalol at 10pm. She made urine but the volume was not recorded. Given that her blood pressures were still elevated in the 200s she was started on a labetalol drip and transferred to the MICU. At the time of transfer her sBP was 186. On arrival to the MICU she was on the labetalol drip at 2mg/min with a BP of 170/110 and she was A+ox3 and aware of why she was in the hospital. She had no complaints specifically no headache, blurred vision, abd pain n/v. Review of systems: She denies any dysuira, fevers, chills, changes in urine output or abdominal pain. She denies headache, changes in vision, dizziness. She denies any recent falls or unsteadyness on her feet. Denies any changes in bowel mvoements or hematochezia. Past Medical History: s/p LR Renal Tx [**2160**] secondary to Chronic recurrent UTIs, analgesic nephropathy and nephrocalcinosis HTN - uncontrolled Isolated Seizure episode - thought to be secondary to Zosyn administration Anemia of Chronic Disease Thrombocytopenia Diverticulosis and Dieulafoy Lesions Osteoporosis Squamous Cell Cancer s/p Mohs Lower back pain due to lumar spinal stenosis Herpes Encephalitis Hyperlipidemia Hypothyroidism h/o TIA Peptic ulcer disease Chronic Tophaceous Gout h/o right rectus sheath hematoma s/p cataract surgery h/o colonic polyps Social History: She is married and lives with her husband. Retired [**Name2 (NI) **]. They winter in [**State 108**], and she enjoys golfing. Remote history of smoking tobacco- quit 40 yrs ago, smoked x20yrs. Old outside hospital records indicate prior ETOH use, though she denies any current use. Family History: Mother died from melanoma. No h/o colon cancer in family. Physical Exam: ADMISSION EXAM Vitals: 98.7, 170/110, 68, 13 98RA General: Alert, somulent nodding off, ill and cachectic but in NAD. HEENT: Sclera cloudy yellow. Ptosis bilaterally, MMM, oropharynx clear with own dentition in place, unable to cooperate with EOM exam Neck: supple, JVP elevated to earlobe while at 15deg recumbency no LAD CV: Regular rate and rhythm, normal S1 + S2,systolic murmur, rubs, gallops Lungs: Faint crackles bilaterally throughout Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, dusky and echomotic on circumfrential lower extremities and lower arms bilaterally. One sore on mid back. 2+DP/PT pulses bilaterally. No peripheral edema. Neuro: CNII-XII intact, movign all extremities without problems, following commands. Tremulous with astreixis when attempting sustained grip Discharge Exam: Vitals; T-97.6 BP-155/85 HR-70 RR-20 O2-97%RA PE: Gen: No acute distress. Laying in bed with covers pulled around her. HEENT: MMM. EOMI. NCAT Neck: Supple. No JVD CV: RRR. NS1&S2. 3/6 SEM heard best at LUSB. Resp: Poor inspiratory effort. b/l crackles consistent with atelectasisGI: BS+4. Soft. Non-tender. Non-distended. no organomegaly Ext: 2+ pitting edema. Dark, dusky skin on all extremities. Pertinent Results: ADMISSION LABS [**2174-9-15**] 03:10PM PT-11.0 PTT-41.7* INR(PT)-1.0 [**2174-9-15**] 03:10PM PLT COUNT-194 [**2174-9-15**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2174-9-15**] 03:10PM NEUTS-83* BANDS-1 LYMPHS-7* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2174-9-15**] 03:10PM WBC-15.1*# RBC-3.26* HGB-9.8* HCT-31.0* MCV-95 MCH-30.2 MCHC-31.7 RDW-13.9 [**2174-9-15**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2174-9-15**] 03:10PM ALBUMIN-3.8 [**2174-9-15**] 03:10PM CK-MB-2 cTropnT-0.04* [**2174-9-15**] 03:10PM ALT(SGPT)-39 AST(SGOT)-41* CK(CPK)-20* ALK PHOS-125* TOT BILI-0.8 [**2174-9-15**] 03:10PM estGFR-Using this [**2174-9-15**] 03:10PM GLUCOSE-112* UREA N-97* CREAT-4.3*# SODIUM-137 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-18* ANION GAP-17 [**2174-9-15**] 03:20PM LACTATE-1.0 [**2174-9-15**] 03:20PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2174-9-15**] 05:00PM URINE MUCOUS-RARE [**2174-9-15**] 05:00PM URINE HYALINE-1* [**2174-9-15**] 05:00PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 [**2174-9-15**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2174-9-15**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.009 [**2174-9-15**] 05:00PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2174-9-15**] 05:00PM URINE HOURS-RANDOM UREA N-467 CREAT-45 SODIUM-33 POTASSIUM-31 CHLORIDE-31 Urine lytes [**2174-9-15**]: UreaN:467 Creat:45 Na:33 K:31 Cl:31 FeUrea calculated at 46% . U/A [**9-15**]: Yellow Hazy 1.009 pH 5.5 UrobilNeg BiliNeg LeukNeg BldNeg NitrNeg Prot100 GluNeg KetNeg RBC2 WBC<1 BactFew YeastNone Epi<1 . Discharge Labs: [**2174-9-28**] 05:58AM BLOOD WBC-10.9 RBC-2.17* Hgb-6.5* Hct-20.6* MCV-95 MCH-30.1 MCHC-31.8 RDW-14.6 Plt Ct-181 [**2174-9-28**] 05:58AM BLOOD Neuts-72.4* Lymphs-19.7 Monos-4.4 Eos-3.2 Baso-0.3 [**2174-9-28**] 05:58AM BLOOD PT-11.5 PTT-33.3 INR(PT)-1.1 [**2174-9-28**] 05:58AM BLOOD Glucose-99 UreaN-42* Creat-2.8* Na-141 K-4.1 Cl-106 HCO3-27 AnGap-12 [**2174-9-28**] 05:58AM BLOOD ALT-26 AST-17 AlkPhos-92 TotBili-0.7 [**2174-9-28**] 05:58AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.3 [**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 . Pertinent Labs: [**2174-9-22**] 02:27AM BLOOD CK-MB-1 cTropnT-0.04* [**2174-9-21**] 05:45PM BLOOD CK-MB-1 cTropnT-0.04* [**2174-9-16**] 01:32AM BLOOD cTropnT-0.04* [**2174-9-15**] 03:10PM BLOOD CK-MB-2 cTropnT-0.04* [**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 [**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2174-9-23**] 02:46PM BLOOD HCV Ab-NEGATIVE . PPD: Negative . Micro: [**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT [**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT [**2174-9-26**] URINE CULTURE-Neg [**2174-9-22**] URINE CULTURE-Neg [**2174-9-22**] Blood Culture, Routine-Neg [**2174-9-22**] Blood Culture, Routine-Neg [**2174-9-21**] Blood Culture, Routine-Neg [**2174-9-16**] URINE CULTURE-Neg [**2174-9-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2174-9-15**] URINE CULTURE-FINAL ESBL {ESCHERICHIA COLI} [**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] . Images: Head CT [**2174-9-15**] - no infarct nor intracranial hemorrhage RUQ U/S [**2174-9-16**]- Unremarkable appearance of the liver and gallbladder. No biliary dilatation. No hydronephrosis seen in the transplanted kidney. Elevated resistive indices again noted as were reported on the prior transplant kidney ultrasound. R shoulder XR [**2174-9-17**]: There is some AC joint arthropathy. This is stable since the [**2171-6-6**] study. The glenohumeral joint is within normal limits. There are some cystic changes at the humeral head. There is also degenerative change of the glenohumeral joint with spurring anteriorly, new since [**2171**] study. The visualized right lung apex is clear. No acute bony injury is noted KUB Portable [**2174-9-18**]: Nonspecific bowel gas pattern. No findings to suggest ileus or obstruction. Limited assessment for free air. Status post laminectomy and fusion at L4-5, with findings suggestive of hardware loosening. Clinical correlation is requested. CXR portable [**2174-9-22**]: In comparison with the study of [**9-21**], cardiac silhouette is within normal limits and there is no definite pulmonary vascular congestion. Hazy opacification at the bases, more prominent on the right, suggests small pleural effusions with compressive atelectasis. No discrete pneumonia is appreciated. Central catheter tip again extends to the mid-to-lower portion of the SVC. EKG [**2174-9-23**]: Sinus rhythm. Within normal limits. Compared to the previous tracing of [**2174-9-22**] no interval change. U/S RUE [**2174-9-27**]: Brief Hospital Course: 75 year old female with a past medical history of end stage renal disease and transplant with chronic kidney disease and resistant hypertension with baseline blood pressure in the 180s who presented for altered mental status to the ED and developed hypertensive urgency with blood pressures in the 200s requiring labetalol drip for control. Admitted to the ICU for management of her blood pressure. Diagnosed with ESBL E.coli UTI in ED and started on IV meropenem. Transferred to floor after BP stabilized. Pt became very lethargic and hypotensive on floor, and transferred back to MICU. Started HD and improved. Some AMS after transfer back to the floor, but clear on discharge. . Active Issues: #Hypertensive urgency - Patient has baseline resistant hypertension with SBPs often in the 180s. Per patient, she manages all of her medications herself, however, was missing her clonidine patch per ED. Her hypertension could have been due to missing medications. There was concern that her altered mental status was related, however no evidence on CT head of hemorrhage. Her renal function was also worsening, concerning for decreased perfusion to the kidneys leading to acute on chronic renal failure however a renal ultrasound of her transplanted kidney was normal. Given her worsening renal function, losartan was held in the MICU. She responded well to the labetalol, and her systolic blood pressure remained stable in the 150s-180s, which seems to be her baseline. She was transferred to the general medicine service once her blood pressure stabilized. Unfortunately, as her home meds were restarted by the general medicine team, she developed relative hypotension to the 130s and altered mental status. She was transferred back to the MICU, where her home verapamil and clonidine were withheld and she was bolused with IVF. Low-dose verapamil and clonidine patch were slowly reintroduced, and SBP was again stabilized. Transferred back to the floor. SBP ranged between 120's-170's on floor. . #Altered mental status - There was concern that the patient was not acting like herself at home. She has a history of AMS in the setting of UTI and with her recent hospitalization for UTI. Initial concern for underlying infection. Her urine was found to have a resistant strain of E.Coli. Meropenem was started and AMS began to clear. After transfer to the floor she was oriented x3. AMS developed again on the floor and pt became relatively hypotensive. See above. Antibiotics were then broadened include vancomycin in the MICU due to concern that her AMS represented a worsening or new infection. She was pancultured, which found no infection. Both meropenem and vancomycin were d/c'ed as they were thought to be contributing to confusion. After being transferred back to the floor, she was again pan-cultured and fever/WBC were trended. She had no signs/symptoms of active infection, so PICC line was pulled. Thought that AMS likely secondary to uremia. After hemodialysis, patient lethargy and disorientation improved dramatically. AMS may have also had a component of ICU delirium. At time of discharge she was alert, responsive, and oriented x3. . #ESBL E. coli UTI: See above. History of multiple UTIs in the past requiring hospital admission. Found to have ESBL E. coli UTI on this admission. Started on 14 day course of IV meropenem, but only received 8 days total. Thought that abx may be contributing to AMS. She was recultured multiple times with no growth. Her PICC line was discontinued on day of discharge. ID was consulted for prophylactic therapy and recommended that she not have prophylaxis at this time, and recommend urology follow-up. She had no fever or leukocytosis. . #Diarrhea: Pt developed watery diarrhea on day of discharge. C. diff pending. . Chronic Issues: #Acute on chronic renal failure s/p transplant - She has chronic kidney disease with a baseline creatinine of ~3.1 over the past few months. Repeat renal ultra sound in the ED was unremarkable. This acute worsening of renal function could be due to hypertension. Urine lytes with FeUrea of 46% which is not clearly prerenal or ATN. During her MICU stay a foley was placed monitored urine output, we renally dosed medications, creatinine was trended daily, renal transplant was consulted, her immunosuppresive agents prednisone and cyclosporine were continued. The renal transplant team felt that her [**Last Name (un) **] may be a result of [**Last Name (un) **] failure. The hope was to prolong time to hemodialysis, and undergo AV [**Last Name (un) **]. However, her delirious state on the floor, compunded with hyperkalemia prompted initiation of HD via tunneled HD catheter. Her AMS improved quite dramatically and Cr trended down to ~2. Her HD schedule is MWF. Transplant surgery has completed the work-up for AV [**Last Name (un) **]. They will contact the rehab facility with time and date for surgery . #Hx Gout/foot pain: Currently pain free. Extensive h/o gouty flares and allergic to allopurinol. After discussion with pharmacy, decided to restart low dose uloric at 20mg daily. . # Hypothyroidism - This is a chronic issue. Her thyroid function tests were checked and she was continued on her home levothyroxine. . #Anemia of chronic disease- Her hematocrit was higher on admission than her previous discharge hematocrit at 31.0, given that all of her hematologic cell lines are elevated she was likely hemoconcentrated at admission. She remained stbale during this admission with hct ~27-30% . #H/o seizure disorder: On Keppra. In setting of zosyn use previous seizure ,and then again at OSH earlier in [**Month (only) 205**] when received another dose of zosyn. Was followed by neurology on previous admission who recommended continuing keppra and will follow-up with them. . #H/o GI bleed: No GIB during this admission. On protonix 40mg qday . TRANSITIONAL ISSUES: - Was very obstinate to care (refused any blood draws or medications multiple times), per transplant this is her pattern when infected. - outpatient ID for consideration of suppressive therapy for recurrent UTIs - Hemodialysis MWF - Will be called Re: Surgery appt for AV [**Month (only) **] - F/u C. diff - Please continue uloric in this pt with extensive h/o gout - downtrending HCT, check CBC tomorrow, may continue to monitor twice weekly until ensure stability - h/ multiple UTI's. No ppx recommended Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Calcitriol 0.25 mcg PO EVERY OTHER DAY 4. CloniDINE 0.2 mg PO BID hold for sbp<100 or hr<60 5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON hold for sbp<100 or hr<60 6. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H 7. Febuxostat 40 mg PO DAILY 8. HydrALAzine 100 mg PO TID hold for sbp<100 or hr<60 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Losartan Potassium 100 mg PO DAILY hold for sbp<100 or hr<60 11. PredniSONE 5 mg PO EVERY OTHER DAY 12. Propranolol 120 mg PO BID hold for sbp<100 or hr<60 13. Sodium Bicarbonate 1300 mg PO TID 14. Verapamil 120 mg PO Q8H hold for sbp<100 or hr<60 15. LeVETiracetam 500 mg PO BID 16. Acetaminophen-Caff-Butalbital Dose is Unknown PO BID:PRN headache 17. Mirtazapine 15 mg PO HS 18. Furosemide 20 mg PO PRN edema 19. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. CloniDINE 0.2 mg PO TID Hold for SBP <120 mmHg 3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 4. Febuxostat 20 mg PO DAILY 5. HydrALAzine 100 mg PO TID hold for sbp<100 or hr<60 6. LeVETiracetam 500 mg PO BID 7. Levothyroxine Sodium 88 mcg PO DAILY 8. PredniSONE 5 mg PO EVERY OTHER DAY 9. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H 10. Verapamil 20 mg PO Q8H hold for sbp<140 or hr<60 11. Propranolol 120 mg PO BID hold for sbp<100 or hr<60 12. Bengay 1 Appl TP [**Hospital1 **]:PRN back muscle pain 13. Lidocaine 5% Patch 1 PTCH TD DAILY back pain apply to back 14. Nephrocaps 1 CAP PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Calcitriol 0.25 mcg PO EVERY OTHER DAY 17. Atorvastatin 20 mg PO DAILY 18. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON hold for sbp<100 or hr<60 Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: Primary diagnosis: End stage renal disease E.coli urinary tract infection Altered mental status Resistant hypertension hypertensive urgency 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 were admitted because you were confused and had very high blood pressure. You were admitted to the intensive care unit and started on medication through your veins to bring your blood pressure down. Once it was down you were transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service and your home blood pressure medications were slowly added back. Your blood pressure dropped too low on this service and you were transferred back to the intensive care unit. Your blood pressure medications were added back slowly, and you came back to [**Doctor Last Name 3271**] [**Doctor Last Name 679**]. Here your blood pressure remained stable and you were discharged. On most of your home BP medications. Because your kidney function is not as good as it should be, your furosemide and losartan were stopped. Please stop taking these medications for now. They may need to be added back on at a later date depending on your BP. You had another infection of your urinary tract on this admission. You were started on antibiotics through your veins, but was stopped because the antbiotics might have been making you confused. You do not currently have an infection, but let your doctor know if you have any burning, difficulty urinating, or worsening confusion. Your kidney function was decreased at time of admission. We thought this might be causing some confusion for you. You were started on hemodialysis, and your confusion got better. You will need hemodialysis on Monday, Wednesday, and Friday. You will be scheduled with surgery to implant a [**Last Name (LF) **], [**First Name3 (LF) **] that you won't need a HD catheter. They will call you with this appointment. Medications to CHANGE: Clonidine 0.2mg twice a day to 0.2mg three times a day Verapamil 120mg three times a day to 20mg three times a day Uloric 40mg daily to 20mg daily Cyclosporine 100mg twice a day to 75mg twice a day Medications to START: Pantoprazole 40mg daily Nephrocaps daily Bengay apply to back daily lidocaine patch apply to back daily Medications to STOP: STOP losartan STOP furosemide STOP sodium bicarbonate STOP butalbital STOP mirtazipine Followup Instructions: Department: NEUROLOGY When: MONDAY [**2174-12-19**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD [**Telephone/Fax (1) 2928**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ****We realize you have dialysis on this day but the appt is earlier in the morning in hopes that you could go before your dialysis. If this appt still does not work for you, please feel free to call the office to reschedule. Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2174-10-12**] at 4:00 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2174-11-8**] at 3:00 PM With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: Transplant Name: Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] When: Dr. [**Last Name (STitle) 105535**] office is working on a follow up appointment for you in [**5-22**] days after your hospital discharge. You will be called with the appointment date and time. If you have not heard from the office in 2 business days please call the number listed below. Location: [**Hospital1 **] Address: [**Doctor First Name **], 7TH FL, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 673**] [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**] ICD9 Codes: 5856, 5990, 5849, 2449, 2749, 2724, 2767
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Medical Text: Admission Date: [**2127-9-25**] Discharge Date: [**2127-10-8**] Date of Birth: [**2057-7-6**] Sex: F Service: MEDICINE Allergies: Percocet / Codeine Attending:[**First Name3 (LF) 30**] Chief Complaint: Found Unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN, COPD, and CKD w/ a baseline Cr of 2.0 who presents with not being "quite her self" x 1 days and found unresponsive at home by husband. FS was 20 given glucose and FS normal in ER. Initially upon presentation to ER was obtunded and since has been improving. Non cooperative to questioning. . In the ED, rectal temp 104. BP and HR had been normal as well as O2 sats normal. Lactate 7. CVP was initially 13. Given Vanc and Ceftriaxone (at meningitis doses) and flagyl. CT of abd / pelvis was s/p 3 liters IVF in ED. INR was 5.6. EKG J point elevation in V3, ST depressions in V5-V6 which are not new. Most recent set of vitals 36.7, 67, 107/68, 17, 100% on nasal cannula but now on non rebreather because SvO2 is low. Past Medical History: PMH: 1. Diabetes Mellitus type II on orals 2. CAD 3vd 3. Chronic systolic heart failure , EF 20% 4. Multinodular goiter 5. Hypertension 5. Spinal stenosis 6. PVD s/p aortobifemoral bypass, left toe amputations 7. Peripheral neuropathy 8. Hyperlipidemia 9. Depression 10. Anemia 11. CKD Stage III with neuropathy, nephropathy 12. Frequent falls/gait instability 13. Cervical spondylosis s/p C4-7 laminectomy and fusion in [**2-4**] 14. s/p choly 15. h/o SBOs 16. COPD Social History: Level of function prior to [**5-8**] admission was ambulate household distances, wheelchair for community. Lives in senior housing/elevator building with husband. Used bedside commode in home. Pack per day smoker for >40 yrs, denies EtOH, denies illicit drug use. Worked as salesclerk and for the turnpike. Has five children, two living. Family History: Five children, three living. One from HIV, one shot, one drugs. Husband reports both her parents died from "cancer I think, trouble breathing." One son has seizures. Physical Exam: Vitals: T: 104.8 in ER (axillary 95 in ICU) BP: 125/70 HR: 64 RR: 15 w/ periods of apnea O2Sat: 99-100% RA GEN: patient is responsive to verbal stimuli, she is able to follow with her eyes the interviewer but unable to follow any other commands, she is unable to answer any questions. HEENT: PEERL (3-4mm bilat), EOMI, sclera anicteric, no epistaxis or rhinorrhea NECK: JVP 14cm, no thyromegaly or cervical lymphadenopathy, trachea midline COR: RRR, [**2-5**] HSM at LLSB and at apex PULM: Lungs CTAB, no W/R/R, however patient not following commands so poor inspiratory effort ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: Pitting 1+ edema to knees, darkening of skin on lower extremities. NEURO: 1+ reflexes biceps, triceps, achilles, patellar reflexes all bilaterally symmetric, muscle tone is increased in the upper and lower extremities Pertinent Results: [**2127-9-25**] 07:19PM POTASSIUM-5.1 [**2127-9-25**] 07:19PM CK(CPK)-85 [**2127-9-25**] 07:19PM CK-MB-4 cTropnT-0.18* [**2127-9-25**] 04:36PM URINE HOURS-RANDOM UREA N-251 CREAT-87 SODIUM-56 [**2127-9-25**] 04:36PM URINE bnzodzpn-NEGATIVE barbitrt-NEGATIVE opiates-NEGATIVE cocaine-NEGATIVE amphetmn-NEGATIVE mthdone-NEGATIVE [**2127-9-25**] 01:49PM LACTATE-3.3* [**2127-9-25**] 01:49PM HGB-11.1* calcHCT-33 O2 SAT-83 [**2127-9-25**] 12:33PM LACTATE-3.2* [**2127-9-25**] 11:32AM LACTATE-3.8* [**2127-9-25**] 11:25AM CK(CPK)-75 [**2127-9-25**] 11:25AM CK-MB-3 cTropnT-0.16* [**2127-9-25**] 11:25AM VIT B12-GREATER TH FOLATE-GREATER TH [**2127-9-25**] 11:25AM FREE T4-0.79* [**2127-9-25**] 11:25AM ASA-NEG ACETMNPHN-6.0 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2127-9-25**] 10:37AM TYPE-MIX INTUBATED-NOT INTUBA COMMENTS-GREEN TOP [**2127-9-25**] 10:37AM LACTATE-4.5* K+-5.5* [**2127-9-25**] 10:37AM O2 SAT-84 [**2127-9-25**] 08:44AM COMMENTS-GREEN TOP [**2127-9-25**] 08:44AM GLUCOSE-122* LACTATE-7.6* NA+-142 K+-6.3* CL--102 [**2127-9-25**] 08:30AM GLUCOSE-126* UREA N-59* CREAT-3.9*# SODIUM-140 POTASSIUM-6.3* CHLORIDE-101 TOTAL CO2-23 ANION GAP-22* [**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK PHOS-103 TOT BILI-1.5 [**2127-9-25**] 08:30AM LIPASE-28 [**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21* [**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*# MAGNESIUM-2.0 [**2127-9-25**] 08:30AM TSH-36* [**2127-9-25**] 08:30AM T4-4.4* T3-41* [**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5* MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5* [**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1 BASOS-0 [**2127-9-25**] 08:30AM PLT COUNT-197 [**2127-9-25**] 08:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2127-9-25**] 08:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG [**2127-9-25**] 08:30AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2127-9-25**] 08:30AM PT-49.2* PTT-33.9 INR(PT)-5.6* [**2127-9-25**] 08:30AM PLT COUNT-197 [**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1 BASOS-0 [**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5* MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5* [**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2127-9-25**] 08:30AM T4-4.4* T3-41* [**2127-9-25**] 08:30AM TSH-36* [**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*# MAGNESIUM-2.0 [**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21* [**2127-9-25**] 08:30AM LIPASE-28 [**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK PHOS-103 TOT BILI-1.5 , CT abdomen/pelvis:IMPRESSION: 1. Limited study without oral or intravenous contrast. Sensitivity for detecting abscess or bowel ischemia is markedly diminished. 2. Umbilical hernia is seen containing non-obstructed bowel loops. 3. Multiple bilateral non-obstructing renal stones without evidence of hydronephrosis. 4. Cardiomegaly and bilateral pleural effusions. 5. Ascites. 6. Diffuse atherosclerotic disease. , TTE:The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with severe global free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CXR [**9-29**]:IMPRESSION: Likely slight increase in right pleural effusion compared to [**2127-9-26**] with difficult comparison to [**2127-9-27**] because of differences in position. Persistent CHF and left lower lobe atelectasis. . RUQ US: IMPRESSION: Very limited examination secondary to patient cooperation. Patent hepatic veins and IVC. To-and-fro flow within the main portal vein may indicate underlying hepatic congestion or an underlying primary hepatic process. , CT head;FINDINGS: There is no evidence of hemorrhage, recent infarction, hydrocephalus or edema. There is an old lacune in the extreme capsule on the left. There is cerebral atrophy and small vessel ischemic change. The included paranasal sinuses and mastoid air cells are clear. There are no fractures. IMPRESSION: No acute intracranial processes. Old lacune. . CXR [**10-1**]: IMPRESSION: 1. Low lung volumes and interval increase in bilateral pleural effusions and pulmonary vascular congestion. 2. Paucity of abdominal gas suggesting ascites. Brief Hospital Course: This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN, COPD, and CKD w/ a baseline Cr of 2.0 found unresponsive by her husband. [**Name (NI) **] initial presentation was felt to be due to acute liver failure. Her course was complicated by acute renal failue, liver failure, coagulopathy, and DIC. Below is her course by system. She was in the ICU from [**Date range (1) 23681**], and then on the general medical floor. . # Delerium/Altered mental status/Dementia: The patients acute change in mental status was ultimately thought to be due to The patient initially was found to be unresponsive by husband- seems as though she had been lethargic for at least 10 days. She also has been profoundly hypothyroid in the past and also has a ? of underlying alzheimers dementia with fluctuating mental status in the past as well. In the presence of fever, it was thought that patient was infected. Given mental status was altered and no other localizing source,there was initial concern for meningitis. LP was not attempted because of elevated INR and thrombocytopenia. The patient was covered for several days with Vanc/CTX/Amp for empiric meningitis coverage (2 days) and then just CTX/flagyl for 3 days to cover for SBP. She ruled out for pneumonia with a negative CXR, head CT was negative, CT abd/pelvis negative, there was no clot in IVC on RUQ US, and minimal ascites on ultrasound. The pt did have elevated TSH levels, but thyroid function is unreliable in this setting of acute illness. Her TSH prior to admission was similar, and her levothyroxine had recently been increased to 88 mcg daily as an outpatient. The patient was started on lactulose as per below, and her mental status gradually improved. Of note, recent MRI showed changes most consistent with Alzheimer's dementia. She had been seen by behavioral neurology by Dr. [**Last Name (STitle) 724**], and it is felt she suffers from a mixed etiology disorder involving microvascular and probable Alzheimer's disease encephalopathy. She was noted to have some rigidity and cogwheeling on exam, [**First Name8 (NamePattern2) **] [**Last Name (un) 309**] body dementia and Parkinsons' need to be evaluated as an outpatient. She will follow up with neurology (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]) . # Lactic Acidosis: Initial lactate of 7.6 on admission resolved with fluid resuscitation. . # Renal failure: Her creatinine was 3.9 on admission, with baseline of 2.0. Thought to be prerenal, trended down with IVF. No hydronephrosis on ct scan. Her HCTZ, lisinopril, and lasix were all held. After her renal failure was resolving with Cr down to 2.3 and pt was in acute CHF, lisinopril and lasix were restarted. . # Acute Hepatitis: The patient presented with picture c/w acute hepatitis, of unclear etiology. Her ALT was 412 and AST 1161 on admission. Tox screen was negative. The patient was seen by hepatology and it was felt that perhaps her hepatitis was drug induced. She has known hepatitis C, but this was felt unlikely to cause her acute liver failure. Liver US was negative for portal vein thrombosis. She was started on rifaximin and lactulose with improvement in her encephalopathy. Hep B serologies, Hep A serologies were negative. Hep C viral load was greater than 1,000,000. She will need outpatient hepatology follow up (has follow up at the end of [**Month (only) 359**]). -Hepatitis E Ab ordered and pending . # Coagulopathy: Felt to be due to DIC and worsening liver failure. Schisotcytes were seen on initial smear, which improved. Hematology/oncology was consulted and felt pt likely had DIC. Her platelets dropped to the 30s and then began to recover. Her INR rose to 11.3 and then improved. She did receive some vitamin K. Heparin dependent Ab was negative. Antithrombin (AT), protein C, and protein S, Factor V and VIII levels were all low. Hematology felt.... . # Acute on Chronic systolic heart failure: EF 15-20%. Appeared stable on repeat echo this admission. Pt also has mod-severe TR/MR. [**Name13 (STitle) **] last stress test had shown no defect, but this was on rest imaging. Per her cardiologist, Dr. [**First Name (STitle) 437**], the patient's heart failure is not likely ischemic in nature. This cardiomyopathy has been new since [**2122**]. The etiology of her chronic systolic heart failure is unclear. [**Name2 (NI) **] lasix, lisinopril, and hctz were held on admission for acute renal failure, hypernatremia, and dehydration. She was treated with several days of IV D5W. She was noted to have increasing pleural effusions, O2 requirement, and BNP of >70,000. Her lisinopril was restarted once her creatinine was 2.3 and she was given IV Lasix. Her metoprolol was changed to carvedilol per Dr. [**First Name (STitle) 437**] to give better afterload reduction. Dr. [**First Name (STitle) 437**] advised against aladactone given her CRF and predisposition to hyperkalemia. . # Macrocytic Anemia: B12 and folate were normal, Her hct remained stable around 34 despite DIC. . # Fever: The patient had a fever of 104 on presentation. Ultimately this was felt to be due to hepatitis. Her initial work up was negative for any other acute infectious source. As per above, she was covered with antibiotics initially for concern of meningitis or SBP. Her fever had resolved by HD #3. Urine cultures grew yeast. Her foley was removed. . # HTN: The pt is on metoprolol, lisinopril and hctz at home. Her hctz and lisinopril were held given her acute renal failure. Her metoprolol was increased and she was started on norvasc. Lisinopril was restarted after her acute renal failure resolved. , # ? CAD: No history of recent stents in our system but on aspirin and plavix on admission. In fact, there is no evidence the patient has CAD, but this keeps being written in her notes. She was cotinued on metoprolol and aspirin, but her plavix was held in the setting of DIC/thrombocytopenia. Per Dr. [**First Name (STitle) 437**], her cardiologist, the plavix does not need to be restarted as we have no evidence the pt has CAD. . . # Elevated D-dimer/FDP: The patient had a D dimer trending up to 7000, but no further evidence of DVT. LENI of the BL LE were negative for DVT. It is possible the pt has a PE which has been brought up before, but she could not have a CTA due to her renal failure, no VQ scan due to pulmonary edema, and no heparin given her thrombocytopenia and elevated INR. She had no DVT in either the L or R lower extremity and no portal vein clot on US. . Thrombocytopenia: Due to DIC, the pts plts decreased to the 30s but gradually trended back up to ____ at the time of discharge. . #. LLE DVT: Diagnosed [**5-8**]. Was on coumadin as an outpatient. Her coumadin was stopped given her DIC and coagulopathy. Repeat LE US showed no DVT. In discussion with hematology oncology, it was felt further anticoagulation is not necessary. . .#. Hypernatremia: Thought to be due to poor po intake. The patient had a sodium up to 149, improved with D5W. . #. Hypoglycemia/Diabetes Mellitus Type II, controlled, no complications: Hypoglycemia on admission was thought to be in setting of liver failure. This was treated with several days of D5W infusion. She was maintained on sliding scale insulin. , # Pleural Effusions: [**Month (only) 116**] be related to 3rd spacing in setting of acute illness, chronic CHF. Her CHF was treated as per above. . #. Hypothyroidism: Labs unreliable in setting of acute illness. Most recently pts levothyroxine had been increased to 88 mcg as outpatient due to elevated TSH. She was continued on this dose. . #. COPD: No evidence of flare. She was continued on albuterol/ipratropium nebs prn . # Depression: holding wellbutrin in setting of hepatic failure . #. FEN. Thin liquids, Ground consistency solids; w Medications on Admission: colace coumadin 2 mg daily omeprzole 20 mg daily Lasix 20 mg in AM and 80 mg in PM Vit D 400 Plavix 75 mg daily metoprolol 25 mg daily lisinopril 40 mg daily HCTZ 25 mg daily Buproprion 150 mg daily ASA 81 mg daily Neurontin 100 mg at night Levothyroxine 75 mcg daily Imdur 30 mg daily Ultram MS [**First Name (Titles) **] [**Last Name (Titles) 8910**] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Last Name (Titles) **]: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 2. Lactulose 10 gram/15 mL Syrup [**Last Name (Titles) **]: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 3. Furosemide 20 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Levothyroxine 88 mcg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet [**Last Name (Titles) **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Carvedilol 25 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Norvasc 5 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 1* Refills:*2* 10. Tramadol 50 mg Tablet [**Last Name (STitle) **]: [**1-1**] pill Tablet PO Q12H (every 12 hours) as needed for PRN PAIN. Disp:*30 Tablet(s)* Refills:*0* 11. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Bupropion 150 mg Tablet Sustained Release [**Month/Day (2) **]: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 13. Vitamin D 1,000 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Plavix 75 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Day (2) **]: Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute liver failure Acute renal failure Diffuse intravascular coagulation Hypoglycemia Acute on chronic systolic heart failure Delirium Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with acute liver failure, acute renal failure, hypoglycemia, and delerium. You were treated supportively. You also developed acute heart failure, which was treated with diuretics. Followup Instructions: 1. Neurology: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]; appointment on [**11-12**] at 1 PM; [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Hospital1 18**], Phone:[**Telephone/Fax (1) 657**] . 2. Hepatology (Liver doctor): Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2127-10-27**] 12:00 PM, at [**Hospital1 18**] [**Hospital Unit Name 3269**], [**Hospital Ward Name 517**], [**Location (un) **], Liver Center . 3. Needs appt with Dr. [**Last Name (STitle) 23537**] (a resident at [**Company 191**]) [**Telephone/Fax (1) 250**] 4. Needs appt with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**3-4**] weeks ICD9 Codes: 0389, 5849, 4254, 2762, 2760, 4280, 496, 3572, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3167 }
Medical Text: Admission Date: [**2200-8-1**] Discharge Date: [**2200-8-3**] Date of Birth: [**2132-6-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: cardiac arrest at home this AM Major Surgical or Invasive Procedure: s/p cabg x3/MV repair [**2200-7-21**] History of Present Illness: 68 yo male who was discharged home on [**7-29**] after cabg x3/MV repair with Dr. [**Last Name (STitle) **]. Had cardiac arrest at home this AM and was resuscitated from apparent asystole to a junctional rhythm. Had decreased level of responsiveness since his arrest this morning and hyperkalemia with worsening renal function.He was transferred into [**Hospital1 18**] for further management. Past Medical History: Ischemic Cardiomyopathy, Systolic Congestive Heart Failure, Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**] complicated by cardiac arrest, Chronic Renal Insufficiency, COPD, History of Upper GI Bleed secondary to esophogeal varices - s/p cauterization, History of ETOH abuse [**2200-7-21**] cabg x3/MV repair Social History: Former smoker, 50 pack year history of tobacco. Former heavy alcohol abuse, none since [**2198**]. He is a former carpenter and Marine Corp Veteran. Lives in [**State 4565**] and is here visiting for the summer. Currently living with his daughter. Family History: Denies premature coronary artery disease. Physical Exam: eyes open with decorticate posturing when being suctioned occasional twitching of eyes and mouth no spontaneous movement of extremities noted lungs coarse bilat. RRR with holosystolic murmur abd softly distended, no BS noted extrems cool,no edema;knees mottled Pertinent Results: [**2200-8-3**] 07:55AM BLOOD WBC-24.5* RBC-3.10* Hgb-9.8* Hct-29.0* MCV-94 MCH-31.6 MCHC-33.8 RDW-18.1* Plt Ct-284 [**2200-8-3**] 07:55AM BLOOD PT-24.6* PTT-83.1* INR(PT)-2.5* [**2200-8-3**] 07:55AM BLOOD Plt Ct-284 [**2200-8-3**] 07:55AM BLOOD UreaN-41* Creat-2.2* Na-132* Cl-105 HCO3-15* [**2200-8-3**] 02:11AM BLOOD Glucose-77 UreaN-54* Creat-3.2* Na-131* K-5.1 Cl-97 HCO3-20* AnGap-19 [**2200-8-3**] 02:11AM BLOOD ALT-491* AST-694* LD(LDH)-1216* AlkPhos-111 Amylase-286* TotBili-1.8* [**2200-8-3**] 02:11AM BLOOD Lipase-14 [**2200-8-3**] 02:11AM BLOOD CK-MB-20* cTropnT-1.06* [**2200-8-3**] 07:55AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 Cardiology Report ECG Study Date of [**2200-8-2**] 1:08:56 AM Sinus tachycardia. Poor R wave progression with loss of R waves in lead V4. Possible prior anterior myocardial infarction. Compared to tracing of [**2200-7-17**] no significant change is seen except heart rate is now faster. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F. RADIOLOGY Final Report MR HEAD W/O CONTRAST [**2200-8-3**] 11:59 MR HEAD W/O CONTRAST Reason: Anoxic injury of brain? [**Hospital 93**] MEDICAL CONDITION: 68 year old man with post CPR stroke REASON FOR THIS EXAMINATION: Anoxic injury of brain? CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post CPR stroke. Evaluate for anoxic injury to the brain. Routine MRI of the brain without gadolinium was performed. There are no comparison studies. FINDINGS: There is abnormal signal throughout the supra- and infratentorial brain specifically, in the frontal and parietal cortex, bilateral thalami and caudate nucleus and in the cerebellum. The deep [**Doctor Last Name 352**] and cortical abnormalities likely represent sequela of hypoxic ischemic injury. The cerebellar diffusion abnormalities could represent watershed or embolic ischemia. Abnormal signal is also seen in the right putamen. There are also probable scattered small vessel ischemic sequela in the subcortical white matter. Intracranial flow voids appear to be maintained. Bilateral mastoid opacification is seen. There is fluid pooling in the nasopharynx and the nasal cavities, which may be related to intubation. IMPRESSION: Findings likely relating to hypoxic ischemic injury and watershed ischemia. DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: SUN [**2200-8-3**] 6:01 PM Brief Hospital Course: Admitted [**2200-8-1**] to CSRU intubated and unresponsive with a poor neurological status. Renal and neuro consults done as prognosis was poor on triple pressor support. Dr. [**Last Name (STitle) **] discussed the prognosis with the family and CVVHD was started initially for continued support. On [**8-2**], he showed signs of anoxic brain injury with possible ischemia. Cardioverted on the morning of [**8-3**] for rapid AFib. MRI of the head on [**8-3**] showed diffuse areas of infarct. He remained hypotensive despite pressor therapy, and a family discussion was held with neurology and Dr. [**Last Name (STitle) **]. Family decided to make the pt. DNR and he expired at 14:17 on [**8-3**]. Medications on Admission: at home: lasix 20 mg daily KCl 20 mEq daily colace 100 mg [**Hospital1 **] ASA 81 mg daily lipitor 40 mg daily paroxetine 20 mg daily toprol XL 12.5 mg [**Hospital1 **] at transfer: dopamine drip heparin drip ( for ? PE) combivent MDIs protonix 40 mg IV daily rocephin one gram IV daily ASA 325 mg daily Discharge Disposition: Expired Discharge Diagnosis: s/p cardiac arrest [**8-1**] s/p cabg x3/MVrepair [**7-21**] multi-organ system failure Discharge Condition: expired Completed by:[**2200-10-20**] ICD9 Codes: 5845, 2767, 4280, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3168 }
Medical Text: Admission Date: [**2186-3-20**] Discharge Date: [**2186-3-25**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: altered mental status. Major Surgical or Invasive Procedure: none History of Present Illness: 37 y/o male patient with Type I DM, HTN, gastroparesis, ESRD on HD who presents to ED with hypertensive urgency. The patient came to the ED with his usual nausea, vomiting, abdominal pain and was found to be hypertensive to 267/171, HR 102. History is difficult to obtain from patient d/t somnolence and lack of desire to participate in interview. He was given ativan a total of 2 mg of Ativan, 4 mg of dilaudid, labetolol 20 mg IV x 3 and hydralazine 20 mg IV x 1 with good response (BP at one point down to 83/58). He recieved 2L NS, Clonidine 0.2mg, Metoprolol 25mg, and Nifedipine XL 30mg. He also received Anzamet. His BP stabalized and his nausea and abd pain improved. . Of note, the patient is admitted to hospital ~3 times every month for similar complaints with last admission [**Date range (1) 92782**]. In the past, he has eloped prior to formal discharge Past Medical History: 1. DM type I 2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension. 4. History of esophageal erosion, MW tear 5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal stress [**11/2182**] 6. hx of Foot Ulcer 7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**]) Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Lives with his [**Hospital1 **] mother and their three children. Family History: His father recently died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: per Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 916**] Vitals: 97.5, 157/82, 83, 16, 96% 2L General: sleepy, arouses to voice but limited participation with physical exam HEENT: PERRL, left pupil smaller than right, pt will not participate in EOMI, sclera anicteric, MM dry, No OP lesions Neck: Supple, no JVD CV: RRR, nl S1, S2, 2/6 systolic murmur at LUSB Lungs: CTAB post Chest: HD line in place without erythema Abd: Soft, ND, nontender, + BS, no guarding, no rebound, multiple well healed scars Ext: no c/c/e, left arm with fistula with good thrill Skin: no rashes Pertinent Results: admit EKG: Sinus rhythm. Early repolarization, no other change from prev Admission labs: 137 97 47 --------------< 287 4.2 23 8.3 Ca: 9.2 Mg: 2.0 P: 2.3 D . 13.1 11.3 >----< 166 40.2 N:90.9 Band:0 L:5.3 M:3.4 E:0.2 Bas:0.2 PT: 21.4 PTT: 32.8 INR: 2.1 . Trends: WBC: 11.3 - 7.6 INR: 2.1 - 2.3 - 2.4 - 3.0 - 3.7 - 1.3 CK: [**Telephone/Fax (3) 92783**] CKMB: 4 - 7 - 8 Trop: 0.21 - 0.33 - 0.36 Urine tox neg Serum tox neg . Micro: NGTD . Rads: [**3-21**]: Head CT: No definite intracranial hemorrhage or mass effect. [**3-22**]: Head MRI: FINDINGS: No intracranial mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct is apparent. The signal intensities of the brain parenchyma are normal. Specifically, no increased T2 signal is seen in the parietal or occipital regions to suggest posterior reversible encephalopathy. The surrounding osseous and soft tissue structures are unremarkable. Major vascular flow patterns are normal. IMPRESSION: Unremarkable MRI of the brain. Brief Hospital Course: 37 yo M with Type I DM, HTN, gastroparesis, ESRD on HD who presented to ED with hypertensive urgency. Upon presentation it was unclear when last time was that patient took meds, but hypertension likely d/t inability to take meds in setting of N/V. Also contribution of autonomic dysfunction. No evidence of active end organ damage. His outpt meds were restarted and his BP improved. Remainder of hospital course by problem: . # Mental Status Change - On day following admission, the patient was found to be diaphoretic, confused, and had repetition of speach saying only "dilaudid." A trigger was called and given the acuteness of this change, he was transferred to the ICU. DDx included possible toxic metabolic vs. HTN/hypotension. Electrolytes and CBC were unchanged. There were no signs of infection. CE were cycled and there was no acute EKG changes. CT of head without bleed or mass. MRI brain was negative. His mental status improved over the following three days and he was at his reported baseline for at least 24h prior to discharge. . # AV fistula/Access - patient with h/o clotted fistula and with very difficult peripheral access. His [**Month/Day (4) **] was held for two nights in anticipation of possible portacath placement. He also received vit k 1mg IV x1 on [**3-23**]. However, the procedure was delayed and it was determined to be done as an outpatient. His [**Month/Day (4) **] was held at discharge until after his port placement scheduled for the following week. During his stay he had a right femoral line placed, which was removed prior to discharge. . # Hypertension - patient with wild swings in BP. As above, was hypertensive initially. We treated with his home meds. . # DM - We continued his home regimen of NPH 5u [**Hospital1 **] and HISS. He had wild swings in his blood glucose with the lowest recorded in the 20s. He was aware, and he improved with an amp of D50. . # Cards Vasc: After altered ms, EKG with unchanged ant ST elev (likely J point elevation). Trop were mildly elevated. No chest pain at this time. CK/MB stable. - cont asa, bblocker . # ESRD - on HD and followed by renal. We continued calcium acetate and HD as scheduled. . # Access - As above. He had a femoral line which was removed prior to dispo. He is in need of a portacath given his frequent admissions and difficult access. . FEN - DM/Renal diet . PPx - [**Hospital1 **], PPI, ambulating . Full Code Medications on Admission: 1. Metoclopramide 10 mg q6hrs 2. Metoprolol 75tid 3. Calcium Acetate 667 mg Capsule PO TID 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO q6h prn. 5. Dilaudid 4 mg PO q3-4hr prn. 6. Clonidine 0.3 mg/24 hr Patch Weekly 7. Clonidine 0.2 mg Tablet PO TID 8. Warfarin 1.5 mg PO DAILY 9. Nifedipine 30 mg Tablet Sustained Release PO daily 10. Pantoprazole 40 mg Tablet, Delayed Release 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Humalog SS 13. Insulin NPH 2 UNITS Subcutaneous twice a day. Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for agitation. 5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Humalog 100 unit/mL Solution Sig: variable units Subcutaneous four times a day: use sliding scale as directed. 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Two (2) units Subcutaneous twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - hypertensive urgency - altered mental status - DMI - ESRD on HD Secondary: - autonomic dysfunction - s/p esophageal erosion - hx of CAD - hx of foot ulcerations - h/o clot in AV graft x2 Discharge Condition: fair Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You developed altered mental status and were monitored in the ICU. You had a head CT and MRI which were negative. You remained on hemodialysis. . Please take your medications as instructed. Please contact your PCP if you experience shortness of breath, chest pain, worsening abdominal pain, fevers, or chills. . We are holding your [**Hospital1 **] for your surgery. Do not take your [**Hospital1 **] until you discuss when to restart it with your primary care physician or nephrologist. . Please return on Tuesday [**2186-3-28**] at 12:30 to have your portacath placed by surgery. It is very important for you to keep this appointment. Followup Instructions: please return on Tuesday [**2186-3-28**] at 12:30pm for your portacath placement. Please have nothing to eat since midnight the night prior. . Please contact your PCP for an appointment within the next two weeks. Please followup with your nephrologist as scheduled. Completed by:[**2186-3-25**] ICD9 Codes: 5856
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3169 }
Medical Text: Admission Date: [**2137-6-6**] Discharge Date: [**2137-6-19**] Date of Birth: [**2071-5-11**] Sex: M Service: CARDIOTHORACIC Allergies: Oxacillin / Ciprofloxacin Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest Pain/Dyspnea on Exertion Major Surgical or Invasive Procedure: [**2137-6-6**] Cardiac Cath [**2137-6-10**] Aortic Valve Replacement with 23mm St. [**Male First Name (un) 923**] Regent Mechanical Valve History of Present Illness: 66-year-old male with aortic stenosis, atrial fibrillation, coronary artery disease and type II diabetes who was admitted for cardiac catheterization following an abnormal stress test. He had been doing well until [**2137-5-1**] at which time he developed chest burning and dypnea on exertion. He was admitted and underwent nuclear stress test on [**2137-5-2**] where he was able to exercise 6 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and stopped due to fatigue. Nuclear images revealed a new partially reversible inferolateral wall perfusion defect and a fixed inferior wall defect. He was referred for cardiac catheterization. In the cath lab he was found to have single vessel coronary disease as previously but his aortic valve area was 0.68 cm2. He is being admitted for aortic valve replacement. Past Medical History: Aortic Stenosis, Diabetes Mellitus, Atrial Fibrillation, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Chronic back pain, Gout, s/p Tonsillectomy Social History: He is married and works as a French and Spanish teacher in a high school. He does not smoke or drink. He has two daughters. Family History: His mother had CABG @ age 80. Father died of Lung ca (smoker). HTN and DM in family. Physical Exam: T: 97.9 BP: 117/73 HR: 83 RR: 18 O2: 97% on RA General: Well appearing male, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear CV: RRR, s1 + s2, II/VI SEM radiating throughout Resp: clear to ausculation bilaterally, no wheezes, rales, ronchi GI: obese, soft, non-tender, non-distended, +BS GU: no foley Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes Pulses: DP and PT pulses palpable bilaterally Pertinent Results: ECG ([**6-6**]): Atrial fibrillation at a rate of 82. ST-T wave abnormalities. Cardiac Catheterization ([**6-6**]): 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The left main demonstrated no angiographically apparent flow limiting disease. The left anterior descending artery demonstrated mild diffuse disease throughout without any significant stenosis. The left circumflex demonstrated a totally occluded obtuse marginal filling via right to left collaterals. The right coronary artery demonstrated no angiographically apparent disease. 2. LV ventriculography was deferred. 3. Limited resting hemodynamics demonstrated normal right (RVEDP 7 mm hg) and left (LVEDP 7 mm Hg) heart filling pressures. The cardiac index calculated via the Fick method was preserved at 2.0 L/min/m2. 4. The mean pressure gradient across the aortic valve was 47 mm Hg and a peak of 60 mm Hg. The calculated aortic valve area of 0.68 cm2. The aortic valve was heavily calcified. Echo ([**6-10**]): PRE-BYPASS: 1. The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. The left atrial appendage emptying velocity is depressed (<0.2m/s). 2. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is lateral wall hypokinesis of the mid to the apical segments ). Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. Due to co-existing aortic regurgitation, the pressure half-time estimate of mitral valve area may be an OVERestimation of true mitral valve area. 8. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced. 1. A well-seated bileaflet valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 15 mmHg). No aortic regurgitation is seen. 2. Left ventricular systolic function is low normal (LVEF 45%). 3. Right ventricular systolic function is normal. 4. Aortic contours are intact post decannulation. Brief Hospital Course: As mentioned in the HPI Mr. [**Known lastname **] was admitted following his cardiac cath which revealed Aortic Stenosis and single vessel coronary artery disease. He received medical management for several days and underwent pre-operative work-up while awaiting for surgery. On [**6-10**] he was brought to the operating where he underwent a aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one his chest tubes were removed. He was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Also on this day he was started on Coumadin with Heparin bridge for mechanical valve. Coumadin was titrated. On post-op day two his epicardial pacing wires were removed and his was transferred to the telemetry floor for further care. Cleared for discharge to rehab on POD #11 Target INR is 2.5-3.0 for mechanical valve. INR in uptrend on DC 2.1. Medications on Admission: Medications at Home: Niacin 1000 mg daily, KCL 10 mEq [**Hospital1 **], Lasix 80 mg 1-2 tabs daily prn, Zocor 20 mg 1 tab daily, Coumadin 2.5 mg 1 tab for 6 days and 3.75 every Saturday LD [**2137-6-2**], Ativan 1 mg qhs prn, Xanax 0.25 mg [**Hospital1 **] prn, Aldactone 25 mg daily, ASA 81 mg, 2 tablets daily, Lisinopril 10 mg daily, Metoprolol tartrate 100 mg [**Hospital1 **], Nitroglycerin 0.4 mg 1 tab sl q 5 min prn chest pain, Novolog 70/30 40 Units [**Hospital1 **], Magnesium Oxide 400 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. 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* 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days: 7 days. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once): goal is 2.5 - 3. 11. INSULIN Insulin SC Fixed Dose Orders Breakfast Dinner 70 / 30 40 Units 70 / 30 40 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 0 Units 141-200 mg/dL 4 Units 4 Units 4 Units 2 Units 201-240 mg/dL 6 Units 6 Units 6 Units 4 Units 241-280 mg/dL 8 Units 8 Units 8 Units 6 Units 12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): until gouty flare up resolves then DC. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Diabetes Mellitus, Atrial Fibrillation, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Chronic back pain, Gout, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Dr. [**First Name (STitle) **] will be following your INR and adjusting your Coumadin for a goal INR of 2.5-3 when you are discharged from rehab. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 73**] in [**2-24**] weeks Dr. [**First Name (STitle) **] in [**1-23**] weeks Dr. [**First Name (STitle) **] will be following your INR and adjusting your Coumadin for a goal INR of 2.5-3. Rehab: please contact Dr. [**First Name (STitle) **] prior to his discharge from rehab. Daily INRs while at rehab. Completed by:[**2137-6-16**] ICD9 Codes: 4241, 4280, 2724, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3170 }
Medical Text: Admission Date: [**2154-10-25**] Discharge Date: [**2154-10-28**] Date of Birth: [**2084-6-29**] Sex: M Service: MEDICINE Allergies: lisinopril / amlodipine Attending:[**Last Name (NamePattern1) 15287**] Chief Complaint: dizziness with standing Major Surgical or Invasive Procedure: EGD (upper endoscopy) History of Present Illness: 70 y/o M with h/o diverticulosis of the entire colon c/b LGIB in the past, PAF on Coumadin c/b CVA when off Coumadin (no residual deficits), CKD (baseline Cr 1.5) and HTN presenting from [**Hospital 197**] clinic hypotensive with SBP 80s. Previously, he required transfusion with 9U pRBCs and colectomy was recommended; pt refused colectomy and his Couamdin was held. He subsequently had an ischemic posterior CVA and his Coumadin was restarted. In [**Hospital 197**] clinic he endorsed lightheadedness and orthostasis and was sent to the ED. Denies BRBPR, hematemesis or melena. He states that he is orthostatic most mornings, which improves throughout the day, usually after eating breakfast. . In the ED, HCT was 25 (baseline 27-35) INR 3.8. Rectal exam was negative for BRBPR, though stool was faintly guiac positive. He was given 2L NS and GI was consulted; felt EGD could wait until Monday. NG tube/lavage were not performed. 18G and 16G PIV were placed at the PT was admitted to the MICU. VS at time of MICU transfer: T 98 BP 130/60 HR 77 RR 18 Sat 99% RA. . MICU VS: T 98 BP 121/66 HR 68 RR 18 O2 Sat 100% RA States he feels back at baseline, no complaints. Past Medical History: Diverticulosis, entire colon, c/b recurrent GIB, last [**2152**] HTN PAF on Coumadin BPH CKD, stage II Renal cysts CVA Social History: Works as cook at [**Last Name (un) **] College. Single, lives alone. Has three grown children. Quit smoking >40 years ago. Prior history of alcohol abuse, but has been sober x13 years. Family History: No significant CV disease including strokes in family. +HTN and HLD in several members. No notable DM2 history. Physical Exam: Admission Exam: T 98 BP 121/66 HR 68 RR 18 O2 Sat 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7cm above the RA at 45 degrees, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Discharge Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7cm above the RA at 45 degrees, no LAD CV: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: ADMISSION LABS [**2154-10-25**] 03:00PM BLOOD WBC-6.9 RBC-3.20* Hgb-7.9* Hct-25.7* MCV-80* MCH-24.7* MCHC-30.7* RDW-17.9* Plt Ct-261 [**2154-10-25**] 03:00PM BLOOD Neuts-47.9* Lymphs-38.5 Monos-7.9 Eos-1.0 Baso-0.6 [**2154-10-25**] 02:26PM BLOOD PT-39.1* PTT-50.2* INR(PT)-3.8* [**2154-10-25**] 02:26PM BLOOD Glucose-87 UreaN-24* Creat-1.5* Na-140 K-3.8 Cl-105 HCO3-24 AnGap-15 [**2154-10-25**] 02:26PM BLOOD ALT-24 AST-20 AlkPhos-84 TotBili-0.4 [**2154-10-25**] 02:26PM BLOOD Albumin-4.2 [**2154-10-26**] 02:13AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7 [**2154-10-25**] 02:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2154-10-25**] 02:34PM BLOOD Lactate-1.0 . Discharge Labs: [**2154-10-28**] 07:05AM BLOOD WBC-8.3 RBC-3.59* Hgb-8.8* Hct-28.8* MCV-80* MCH-24.6* MCHC-30.7* RDW-18.2* Plt Ct-248 [**2154-10-28**] 07:05AM BLOOD PT-23.9* PTT-42.0* INR(PT)-2.3* [**2154-10-28**] 07:05AM BLOOD Glucose-105* UreaN-18 Creat-1.3* Na-139 K-3.9 Cl-104 HCO3-28 AnGap-11 [**2154-10-28**] 07:05AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.7 . Micro: [**2154-10-25**] 02:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2154-10-25**] URINE CULTURE-Neg . Studies: [**2154-10-28**] EGD: Small hiatal hernia. Schatzki's ring. Normal mucosa in the third part of the duodenum (biopsy). Otherwise normal EGD to third part of the duodenum . Path: [**2154-10-28**] Duodenal BIpsy: Pending Brief Hospital Course: 70 y/o M with h/o diverticulosis of the entire colon c/b LGIB in the past, PAF on Coumadin c/b CVA when off Coumadin (no residual deficits), CKD (Cr 1.5) and HTN admitted to the MICU for GIB and hypotension. Transfused 1U PRBC and remained HD stable, so transferred to the floor. On the floor denied dizziness, lightheadedness, fatigue, or other pre-syncopal symptoms. Had EGD with normal appearing mucosa and no sign of stigmata of bleed. Discharged with plan for capsule endoscopy. . Active Issues # GIB: INR was supratherapeutic at 3.8 on admission. Coumadin intially held. HD stable and Hct stable following 1U PRBC in ED. Guiac positive, so thought this may represent slow GIB. Initially treated in MICU, but quickly transferred to medicine floor. Warfarin restarted at lower dose. Denied any melena/BRBPR during stay. Has full colonic diverticula, but presentation not consistent with diverticular bleed. Pt with iron deficiency anemia and no EGD since [**2152**], so EGD performed to work up anemia. No signs of active bleed or stigmata of prior bleed. Was discharged with plans for capsule endoscopy as an outpatient. Continued on PO omeprazole 20mg [**Hospital1 **]. . #Paroxysmal A. fib: Pt was in and out of a. fib during this admission. Coumadin initially held with supratherapeutic INR, but was restarted when INR <3. The last time his INR was subtherapeutic, he had a CVA. Was rate controlled without medical intervention. . # Hypotension: Slightly hypotensive on presentation. Resolved s/p 2L NS in the ED. Normotensive during stay on floor. Likely related to hypovolemia; possibilities include GIB vs hypovolemia from diuretic use. No fevers or localizing s/sx to suggest sepsis. Patient reports chronic problem with orthostasis. Could be possible med side effect from anti-hypertensive medications vs. terazosin. . Chronic Issues: # Hyperlipidemia: Continued aspirin and statin . # CKD: Cr 1.5 on admission, which is baseline. Discharged with Cr of 1.3 . # BPH: Continued Finasteride and Terazosin . Transitional Issues: #Will need INR check on [**2154-10-30**] to determine if further adjustment is necessary #Will need to follow-up duodenal biopsy results #Will get capsule endoscopy with GI for further work-up of ?GIB . Medications on Admission: 1. Aspirin 325 mg PO DAILY 2. Simvastatin 20 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. Warfarin 5 mg PO DAILY16 6. Terazosin 10 mg PO HS 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Ferrous Sulfate 325 mg PO TID 10. Cyclobenzaprine 5 mg PO TID:PRN msucle spasm . Discharge Medications: 1. Atenolol 100 mg PO DAILY hold for sbp < 100, HR < 55 2. Finasteride 5 mg PO DAILY 3. Hydrochlorothiazide 12.5 mg PO DAILY hold for SBP < 90, HR < 55 4. Omeprazole 20 mg PO BID 5. Simvastatin 20 mg PO DAILY 6. Terazosin 10 mg PO HS 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 8. Warfarin 5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: gastrointestinal bleed Hypotension iron deficiency anemia SECONDARY: Diverticulosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 805**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for several days of weakness and fatigue, low blood pressure, and blood in your stool. Your blood count (hematocrit) was very low and you were transfused 1 unit of red blood cells. Because your blood pressure was low, you spent the night in the intensive care unit. You were then transferred to the medicine floor. We wanted to make sure there was no slow bleed in your stomach you we looked at it with a camera (endoscopy). This was normal and did not show any signs of bleeding. You had biopsies taken and will be contact[**Name (NI) **] with the results of the biopsy. You should follow up with the GI doctors as [**Name5 (PTitle) **] outpatient for further workup to determine what if you are bleeding. They will want you to swallow a capsule that can take pictures of the portion of your GI tract not seen with EGD. Medications to CHANGE: DECREASE warfarin from 6.25mg daily to 5mg daily (have INR checked on [**2154-10-31**]) Followup Instructions: Name: PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] Appointment: Monday [**2154-11-4**] 11:30am *This is a follow up appointment of your hospitalization. You will be reconnected with your primary care provider after this visit. Please have your hematocrit (blood count) checked at this appointment. We are working on a follow up appointment for your hospitalization in [**Location (un) 2274**] Gastroenterology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85321**]. It is recommended you be seen within 1 month of discharge. The office will contact you at home with the appointment. If you have not heard within a few business days please contact the office at [**Telephone/Fax (1) 2296**]. Department: NEUROLOGY When: TUESDAY [**2154-12-10**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ICD9 Codes: 4589, 2768, 2724
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Medical Text: Admission Date: [**2160-6-17**] Discharge Date: [**2160-6-30**] Date of Birth: [**2160-6-17**] Sex: M Service: NB HISTORY: A 39-2/7 week's gestational age infant admitted to the Neonatal Intensive Care Unit with respiratory distress. MATERNAL HISTORY: A 29-year-old, gravida 2, para 0, now 1, woman with the following antenatal screens: O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS negative. PREGNANCY HISTORY: EDC [**2160-6-22**]. Antepartum course benign. Spontaneous onset of labor progressing to vacuum- assisted vaginal delivery under epidural anesthesia. Maternal interpartum fever to 99.3. No other clinical evidence of chorioamnionitis. Rupture of membranes 10 hours prior to delivery, initially yielding clear amniotic fluid, but with terminal meconium noted at delivery. Triple nuchal cord noted at delivery. NEONATAL COURSE: Infant initially hypotonic, with meconium noted on trunk only. Bulb suctioned, dried, brief CPAP provided, but no bag mask ventilation. Infant developed grunting respirations and retractions. Apgar scores were 6 at 1 minute and 7 at 5 minutes. [**Hospital **] transferred to the Neonatal Intensive Care Unit in 100 percent oxygen. PHYSICAL EXAM ON ADMISSION: Birthweight 3,240 gm, length 52 cm, head circumference 32.5 cm. Term-appearing infant in mild respiratory distress. Anterior fontanelle soft and flat, moderate caput, nondysmorphic, palate intact, moderate nasal flaring. Mild retractions, fair breath sounds bilaterally, a few scattered, coarse crackles. Well-perfused, regular rate and rhythm, femoral pulses normal, normal S1, S2, no murmur. Abdomen soft, nondistended, no organomegaly, no masses, bowel sounds active, anus patent, three-vessel cord. Normal male genitalia, testes descended bilaterally. Active, tone normal and symmetric, moving all extremities, normal grasp/suck/gag/Moro. Skin intact. Normal spine, limbs, hips, clavicles. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: [**Hospital **] transferred to the Neonatal Intensive Care Unit for respiratory distress and was initially placed on nasal CPAP. Initial chest x-ray showed [**8-29**] ribs expanded, left lower lobe opacification, possible atelectasis, otherwise normal parenchyma. Small right pneumothorax without mediastinal shift. Infant changed from CPAP to an Oxyhood at 100 percent for nitrogen washout. Initial arterial blood gas on admission showed a pH of 7.32, CO2 37, PAO2 115, bicarb 20, base excess minus 6. Infant weaned on the oxygen [**Doctor Last Name **], and respiratory symptoms subsided spontaneously. A repeat chest x-ray on day of life 1 showed improvement of the right pneumothorax, and the infant weaned to room air by day of life 2. The infant did not require needle aspiration or chest tube placement. The pneumothorax resolved spontaneously. Respiratory rates have been in the 30's-50's. Infant noted to have desaturations to as low as 60 percent, requiring blow-by oxygen at times which improved over time. The last desaturation requiring mild stimulation was on [**6-25**]. CARDIOVASCULAR: The infant required 2 normal saline boluses of 10 cc/kg each on admission for poor perfusion. Perfusion improved, and the infant has remained hemodynamically stable this hospitalization. Heart rate 130's-150's, no murmur. FLUID, ELECTROLYTES AND NUTRITION: The infant was initially receiving nothing by mouth but 60 cc/kg/D of D10W. Enteral feedings were started on day of life 2 of Enfamil 20 cal/oz or breast milk 20 cal/oz. Infant has been feeding ad lib breast milk 20 cal/oz or breastfeeding po, and taking 120-160 cc/kg/D. Voiding and stooling qs. Infant has tolerated feedings without difficulty. The most recent weight was 3,270 gm. GI: The most recent bilirubin level drawn on day of life 2 showed a total bili of 1.7 with a direct of 0.5. The infant has not received phototherapy this hospitalization. HEMATOLOGY: CBC on admission a white blood cell count of 41.2, hematocrit 51.2 percent, platelets 269,000, 52 neutrophils, 4 bands, 37 lymphocytes. A repeat CBC on day of life 2 showed a white blood cell count of 21.3, hematocrit 53.3 percent, platelets 283,000, 59 neutrophils, 0 bands. The infant has not received any blood transfusions this hospitalization. INFECTIOUS DISEASE: The infant received 48 hours of ampicillin and gentamicin for respiratory distress. Blood cultures remain negative. NEUROLOGY: Due to frequent desaturations and vacuum-assisted delivery, a head ultrasound was done on day of life 10 which was within normal limits. No intraventricular or intracranial hemorrhages noted. Infant has had a normal neurological exam, no seizure activity. SENSORY: Hearing screening was performed with automated auditory brain stem responses. Infant passed both ears. PSYCHOSOCIAL: Parents very involved. CONDITION AT DISCHARGE: Full-term infant, stable on room air. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36246**], phone number [**Telephone/Fax (1) 36247**], fax number [**Telephone/Fax (1) 58423**]. CARE RECOMMENDATIONS: 1. Feedings at discharge: Breastfeeding or breast milk 20 cal/oz, po ad lib. 2. Discharge medications: Vi-Daylin 1 ml po qd. 3. Car seat position screen: Infant passed car seat test prior to discharge. 4. State newborn screens: Sent on day of life 2 and day of life 13, results are pending. 5. Immunizations: Infant received hepatitis B vaccine on [**2160-6-23**]. 6. Follow-up appointment: Primary pediatrician and VNA to visit on Wednesday, [**7-2**]. DISCHARGE DIAGNOSES: Status post respiratory distress secondary to pneumothorax. Status post rule out sepsis, ruled out. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2160-6-30**] 14:10:16 T: [**2160-6-30**] 14:56:01 Job#: [**Job Number **] ICD9 Codes: V290, V053
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Medical Text: Admission Date: [**2151-1-25**] Discharge Date: [**2151-1-27**] Date of Birth: [**2077-10-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: chest pain, hypotension Major Surgical or Invasive Procedure: Stress MIBI test History of Present Illness: 73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on coumadin), hypertension who has a history of vague chest pain. She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out. Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a heart rate of 98. She experienced no chest pain and had no significant ST-T wave changes. Nuclear images did show a posterolateral reversible defect in addition to a small anterior apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office for evaluation of near syncope and given an event monitor. Today she went to the [**Location (un) **] ER due to increasing chest pain over the past week with associated weakness. No significant findings on event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of left shoulder pain radiating down her left arm and up left jaw for many years and all previous work-up has been negative. However, in past month, she has developed a new type of chest discomfort over entire chest and associated with nausea and feeling fatigued and lightheaded. No palps, no SOB, no LOC, no association with any activity. She has 4 episodes a day lasting about 5 minutes. Nothing make it better or worse and they occur irregardless of activity. . Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings of ischemia. She received SLNTG X3 with no effect. Nitro gtt started and CP free after 30 min. Then, 45 min later developed hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500 of NS, then 1L NS bolus. SBP in mid80's and she was transferred to [**Hospital1 18**]. . On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP rose to 110-130s within 5 minutes. NO chest pain, palps, SOB during this, but did feel more fatigued. . In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling fatigued, but no other symptoms of CP, palp, SOB, LHD, dizzyness. At baseline, she can climb 2 flights of stairs and now feels slightly more fatigued than usual. . ROS remarkable for intermittent right eye loss of vision "like blind pulled down" for past month, occasional tingling and numbess of right face for at least 6 years (prior to stroke). +PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP, recent illnesses, bladder/bowel changes. Past Medical History: - HTN - hyperlipidemia - PAF: on coumadin, started propafenone 2 years ago which has kept her in sinus - Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no significant valvular disease - GERD - Stroke: 6 years ago with recovery of right hand function - thyroidectomy due to goiter - colon cancer s/p surgery and chemotherapy Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is family history of premature coronary artery disease or sudden death in brother who died of MI age 51. Father: stroke, lung ca, HTN, MI Physical Exam: VS 96.0 104/56 62 17 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 8 cm; no carotid bruits CV: RR, normal S1, S2. I/VI systolic murmur at apex. 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 or tenderness. Ext: trace pitting edema; faint DP pulses bilaterally Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG demonstrated sinus rhythm, 60bpm, nl axis, PR 200 msec, no ST or TW changes compared to earlier in day. PR from OSH EKG TELEMETRY demonstrated: normal rhythm, 2D-ECHOCARDIOGRAM: Per patient, she had an echo 1 week prior which was reportedly normal ETT: Per Dr. [**Last Name (STitle) 11493**] notes: [**2150-11-9**]. 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a heart rate of 98. She experienced no chest pain and had no significant ST-T wave changes. Nuclear images did show a posterolateral reversible defect in addition to a small anterior apical defect. CXR: In comparison with the study of [**1-25**], the patient has taken a better inspiration. The cardiac silhouette is within normal limits with mild prominence of the ascending aorta that would reflect aortic stenosis or hypertension. Pertinent labs on discharge: [**2151-1-27**] WBC-3.9* RBC-3.93* Hgb-12.1 Hct-36.0 MCV-92 MCH-30.8 MCHC-33.6 RDW-13.7 Plt Ct-149* [**2151-1-27**] PT-16.9* PTT-31.5 INR(PT)-1.5* [**2151-1-26**] PT-32.5* PTT-38.3* INR(PT)-3.4* [**2151-1-25**] PT-31.8* PTT-37.7* INR(PT)-3.3* ->given 5mg PO vit K [**2151-1-26**] TSH-2.9 Free T4-1.3 [**2151-1-26**] %HbA1c-6.1* [**2151-1-26**] Triglyc-107 HDL-40 CHOL/HD-3.3 LDLcalc-70 Brief Hospital Course: Patient is a 73 y/o F hx PAF on coumadin, HTN, bradycardia and first degree AVB now presents with chest pressure and lightheadedness CAD: Patient has no known diagnosis of CAD, and cardiac cath from [**2148**] from [**Hospital3 2568**] had clean coronary arteries. She ruled out for an MI here and had a stress stress P - MIBI which revealed no perfusion defects and an LVEF of 65%. Recent stress test per OSH cardiologist notes echo done last week per Dr. [**Last Name (STitle) 11493**] no valve abnormalites. Prior report of MS/MR incorrect. She has been having these symptoms for the past month and her cardiologist felt that there may be a component of near syncope [**3-13**] bradycardia as opposed to CAD. However, her symptoms were relieved with nitro. NO EKG changes. [**Hospital3 **] cath report from [**2148**] show clean coronary arteries. Given negative stress, recent cath that was negative, reportedly normal echo a decision was made not to cath the patient. Beta blocker, aspirin, statin were continued. Her coumadin was held as an inpatient as she was supratherapeutic, this drifted down to INR 1.5 upon discharge, she was discharged with a lovenox bridge. A1C 6.1%. LDL 70, HDL 40, Total 131, Trig 107. Chest Pain: 2 weeks at most 30 min at a time, no assoc w/ exerction, not reproduced w/ palpation dull in nature, several times per day. Supratherapeutic on couadmin and not pleurtic making PE less likely, no tenderness on exam so costochondritis is less likely, cannot rule out coronary vasospasm. Patient should also have a workup for GERD as an outpatient. Rhythm: Hx of paroxsysmal afib, continue anticoagulation and propafenone. INR 1.4 on discharge, discharged with lovenox bridge with close follow up with her primary cardiologist. Hypotension: patient was hypotensive in the setting of nitro gtt, transiently on a dopamine drip for a SBP in the 40s although the patient was mentating at the time and there is a question as to whether the pressure was actually as low as recorded. Hypotension did not return and the patient was normotensive with the addition of her home antihypertensive regimen. Loss of vision/curtain like loss of vision in R eye on waking for the past month. temporal arteritis given ESR of 7 and normal physical exam. Normal carotids on exam, possibly TIA, the patient should have carotid ultrasounds as an outpatient at an early date if she has not already had them. She is on aspirin and anticoagulated. Medications on Admission: propafenone 150 mg b.i.d. aspirin 325 mg Cozaar 50 mg Levoxyl 112 mcg daily Prilosec 20 mg Zocor 20 mg metoprolol 50 mg b.i.d. Coumadin 3 mg daily Discharge Medications: 1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Propafenone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16). 9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day): Continue taking lovenox injections until INR is between [**3-14**] on coumadin as directed by your primary care physician. [**Name Initial (NameIs) **]:*14 syringes* Refills:*1* 10. Outpatient Lab Work Please check PT/INR on [**2151-1-29**] at Dr.[**Name (NI) 62094**] Office and every week thereafter. Please follow up results with him to decide on coumadin dosing and how long to continue with the lovenox injections Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Atypical chest pain Secondary diagnoses: Paroxysmal atrial fibrillation on coumadin Hypertension Hyperlipidemia History of rheumatic fever Discharge Condition: Good, chest pain free, ambulating Discharge Instructions: You were admitted for workup of chest pain, lightheadness. You had a full workup of your heart which was negative for any problems with your heart as the reason for your symptoms. This was including a stress test that was negative for any significant cardiac abnormalities. While you were here, your coumadin level (INR) was found to be low. We have started you on a medication, Lovenox, to be injected twice daily. This should be continued until your INR becomes therapeutic at a level of [**3-14**]. You should follow up with your primary care doctor this week for regular checks of your INR to determine when you can stop this medication. Your first lab check for this will be in 2 days from discharge on [**2151-1-29**] where you should get your INR checked before your annual physical exam with Dr. [**Last Name (STitle) 27542**]. Please take all your medications as prescribed and keep all follow up appointments. We made no changes to your medications except the addition of the lovenox injections twice a day until your INR is within the 2-3 range on your coumadin and Dr. [**Last Name (STitle) 27542**] gives the okay for you to stop the lovenox injections. If you develop chest pain, increased shortness of breath, severe weakness or any other symptom that concerns you, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room as soon as possible. Followup Instructions: Please keep the following appointment: Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2151-2-15**] 9:40 It is very important that you follow up with your primary care doctor, Dr. [**Last Name (STitle) 27542**], this week to check your coumadin level (INR). Please keep your follow up appointment on [**2151-1-29**] with Dr. [**Last Name (STitle) 27542**]. At this visit, and weekly afterwards, he will need to follow up on your INR level to decide how long you should continue on the lovenox injections. ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2133-6-18**] Discharge Date: [**2133-6-22**] Date of Birth: [**2099-9-28**] Sex: F Service: MEDICINE Allergies: Unasyn / Vancomycin Attending:[**First Name3 (LF) 898**] Chief Complaint: periorbital swelling and erythema Major Surgical or Invasive Procedure: none History of Present Illness: 33F without significant PMHx admitted with one day h/o progressively worsening pain and swelling around her right eye. She reports that her symptoms started on the evening prior to admission with a raised painful bump in the corner of her right eye. She reports touching it freqently but denies trying to open in up or drain it. The swelling progressed and by the next morning it was significantly more swollen. She presented to her PCP who immediately referred her to the ED. In the, she was noted to have temp 102, HR in the 100s, BP was stable. She was given 3L IVF and a dose of vanc and unasyn. She was admitted to the medical floor. Soon after arrival to medical floor she was noted to have BP 80s and lactate 3.3. She was given an additional 3L of IVF on the floor though remained hypotensive for roughly 1 1/2 hours while awaiting an ICU bed, however on arrival to ICU bp was 108/62. Past Medical History: none Social History: lives with roomates, denies tobacco use, drinks [**5-2**] alcoholic beverages per week, denies any past or present drug use, no sexual contacts in past 6 months. Family History: denied any significant family history Physical Exam: VS: Tm 102 HR 106 108/62 32 97RA General: awake, alert, in no distress, pleasant and conversant HEENT: R eye periorbital swelling and erythema involving lids as well as conjunctiva itself. She is able to move eyes with full ROM and no pain. PERRL Chest: CTAB CV: RRR, no m/r/g Abd: soft, NT/ND Ext: warm, dry no edema Pertinent Results: [**2133-6-18**] CT Orbits: 1. Significant soft tissue swelling, centered on the eyelid, involving the right side of the face from the level of the mandible to the right frontal region. 2. Extensive right preseptal swelling about the orbit, without a discrete abscess. No evidence of post-septal involvement. 3. Slight hyperenhancement of the superficial aspect of the right lacrimal gland, may reflect secondary inflammation from the overlying facial cellulitis rather than true lacrimal cellulitis. [**2133-6-19**] CXR: There are low lung volumes that accentuate the cardiac silhouette. The lungs are clear. There is no pneumothorax or pleural effusion Notable Admission Labs: [**2133-6-18**] 01:45PM WBC-32.5*# RBC-4.25 HGB-11.9* HCT-35.3* MCV-83 MCH-28.1# MCHC-33.8 RDW-14.8 [**2133-6-18**] 01:52PM LACTATE-3.3* [**2133-6-18**] 02:00PM GLUCOSE-131* UREA N-9 CREAT-0.9 SODIUM-133 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12 Discharge Labs: [**2133-6-22**] 04:45AM BLOOD WBC-8.8 RBC-3.60* Hgb-10.2* Hct-29.9* MCV-83 MCH-28.4 MCHC-34.2 RDW-14.8 Plt Ct-291 [**2133-6-22**] 04:45AM BLOOD Glucose-111* UreaN-5* Creat-0.6 Na-139 K-4.0 Cl-105 HCO3-27 AnGap-11 [**2133-6-19**] 11:45AM BLOOD Lactate-1.9 Brief Hospital Course: In the ED, she was noted to have temp 102, HR in the 100s, BP was stable. She was given 3L IVF and a dose of vanc and unasyn. CT orbits showed significant soft tissue swelling involving the right side of the face from the level of the mandible to the right frontal region, extensive right preseptal swelling without a discrete abscess, slight hyperenhancement of the right lacrimal gland, may reflect secondary inflammation from the facial cellulitis rather than a dacryocystitis. She was evaluated by ENT and opthomalogy. She was admitted to the medical floor for management of orbital/periorbital cellulitis and presumed sepsis. Soon after arrival to medical floor she was noted to have BP 80s and lactate 3.3. She was given an additional 3L of IVF on the floor though remained hypotensive for roughly 1 1/2 hours while awaiting an ICU bed, however on arrival to ICU bp was 108/62. In the ICU her BP was stable, she was continued on her IV antibiotics. The pain in her face improved and her swelling objectively improved over night. She was considered stable for discharge to the medical floor. A two week course of abx are planned with a PICC line after blood cultures remain negative. Ms. [**Known lastname 30533**] is a 33 yo generally healthy female admitted with one day h/o progressively worsening pain and swelling c/w early pre-septal orbital cellulitis and SIRS/Sepsis. 1)Early orbital cellulitis - She presents with rapidly progressing right periorbital soft tissue swelling and erythema c/w periorbital cellulitis (pre-septal), likely originating from cutaneous source. Also with findings on exam concerning for early orbital cellulitis including conjunctival erythema and edema as well as lacrimal gland swelling. She was followed by opthamology throughout her admission. She improved on IV antibiotics initially vancomycin and unasyn. There was no evidence of deeper post septal spread of infection on CT scan. Wound cultures were positive for Group A strep and she was changed to Augmentin on discharge to complete a two week course. Blood cultures were all negative. 2)SIRS/Sepsis - On admission she had high fevers, hypotension with SBP in the 80's, tachycardia, and markedly elevated WBC count c/w SIRS/early sepsis. She was [**Hospital 30534**] transferred to the ICU for overnight monitoring given the severity of her infection. She responded to 3L IVF and did not require pressors. She was treated with vancomycin and unasyn while in the ICU and blood pressure stabilized by the following day and she was called out to the floor. She remained hemodynamically stable throughout the remainder of her admission. Medications on Admission: MTV ferrous sulfate B vitamin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days: Last day of antibiotics [**2133-7-3**]. Disp:*36 Tablet(s)* Refills:*0* 3. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. Ferrous Sulfate Oral Discharge Disposition: Home Discharge Diagnosis: Orbital Cellulitis SIRS Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you had a serious infection around your eye. You were treated with IV antibiotics and monitored initially in the ICU. You improved on antibiotic and you were changed to oral antibiotics prior to discharge. Medications: 1) You were discharged on Augmentin to complete a 2 week course of antibiotics. No other medications were added. Please follow up as below. Please call your doctor or return to the hospital if you experience any concerning symptoms including worsening of the swelling, redness or pain around your eye, fevers, change in your vision or any other worrisome symptoms. Followup Instructions: Please call Dr. [**First Name (STitle) 1395**] at [**Telephone/Fax (1) 2205**] and schedule an appointment to follow up within 2 weeks of discharge. You will need to follow up with opthamology in the next week. Please call the clinic tomorrow at [**Telephone/Fax (1) 253**] to schedule an appointment. ICD9 Codes: 0389
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Medical Text: Admission Date: [**2194-11-26**] Discharge Date: [**2194-12-2**] Date of Birth: [**2117-7-19**] Sex: F Service: CARDIOTHORACIC Allergies: Pravachol / Lipitor / Zocor / Vytorin / Crestor / Boniva / Fosamax / Niaspan / Latex Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2194-11-28**] Coronary Artery Bypass Graft x 3 (Left internal mammary artery to left anterior descending, Saphenous vein graft to obtuse marginal, Saphenous vein graft to posterior descending artery) History of Present Illness: 77 year old female with history of hypertension, hyperlipidemia, and carotid artery stenosis with complaints of exertional chest pain and episodes of shortness of breath at rest. She had an abnormal stress test yesterday and was referred for cardiac catheterization. Now asked to evaluate for surgical revascularization given 3VD. Past Medical History: Hypertension Hyperlipidemia Carotid artery stenosis Osteoporosis Degenerative joint disease-Right knee Right hip trochanter bursistis Basal Cell CA Left cheeck Irritable bowel syndrome ?Right nostril hemangioma- (in chart, pt unsure) s/p Mohs surgery x2 Left cheek s/p Tonsillectomy s/p cholecystectomy Social History: Race:Caucasian Lives with:husband Occupation:Retired Tobacco:denies ETOH:occasional Family History: Father died of CAD in 50s; mother died of CAD in her 70s; son with MI, CAD, and stents Physical Exam: Pulse:57 Resp: 18 O2 sat: 100%RA B/P Right:162/61 Left: 173/59 Height:5'5" Weight:125 lbs General: comfortable 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 negative Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact. moves 4 ext Pulses: Femoral Right: drsg c/I/D Left:palp DP Right: palp Left: palp PT [**Name (NI) 167**]: Left: Radial Right: palp Left: palp Carotid Bruit Right: (-) Left: (-) Pertinent Results: [**2194-11-28**] 01:39PM BLOOD WBC-9.8 RBC-3.71* Hgb-10.9*# Hct-31.5* MCV-85 MCH-29.5 MCHC-34.7 RDW-13.7 Plt Ct-203 [**2194-11-27**] 04:59PM BLOOD PT-13.0 PTT-58.6* INR(PT)-1.1 [**2194-11-26**] 09:10PM BLOOD PT-13.0 PTT-22.2 INR(PT)-1.1 [**2194-11-26**] 09:10PM BLOOD Glucose-113* UreaN-37* Creat-1.3* Na-141 K-3.7 Cl-101 HCO3-28 AnGap-16 [**2194-11-26**] 09:10PM BLOOD ALT-14 AST-21 LD(LDH)-222 CK(CPK)-36 AlkPhos-50 TotBili-0.4 [**2194-11-26**] 09:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2194-11-26**] 09:10PM BLOOD Albumin-4.6 [**2194-11-26**] 09:10PM BLOOD %HbA1c-5.8 ======================================================== [**2194-12-1**] 05:55AM BLOOD WBC-9.8 RBC-4.02*# Hgb-11.5*# Hct-33.1* MCV-82 MCH-28.6 MCHC-34.8 RDW-15.7* Plt Ct-158 [**2194-12-1**] 05:55AM BLOOD Plt Ct-158 [**2194-12-1**] 05:55AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-141 K-4.2 Cl-103 HCO3-29 AnGap-13 ========================================================= Radiology Report CHEST (PA & LAT) Study Date of [**2194-12-2**] 9:38 AM [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p CABG FINDINGS: In comparison with the study of [**12-1**], there is persistence of a small right apical pneumothorax. Continued bilateral pleural effusions with relatively mild engorgement of pulmonary vessels. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: TUE [**2194-12-2**] 10:21 AM = = = = = ================================================================ Brief Hospital Course: Mrs [**Known lastname 24224**] was admitted to [**Hospital1 18**] preoperatively after having several episodes of chest pain at home while awaiting coronary bypass surgery. On day of admission she was ruled out for myocardial infarction and started on heparin infusion. She had no further episodes of chest pain. On [**11-28**] she was brought to the operating room where she underwent a coronary artery bypass graft x3. Please see operative report for surgical details. I summary she had Left internal mamary to left anterior descending artery, reverse saphenous vein graft to obtuse marginal artery and reverse saphenous vein graft to posterior diagonal artery. her bypass time was 63 minutes with a crossclamp of 56 minutes. She tolerated the operation well and following surgery she was transferred to the CVICU for continued monitoring. She did well in the immediate post-op period was weaned from sedation, awoke neurologically intact and extubated. She was hemodynamically stable and weaned off of all vasoactive medications on the operative night. Her chest tubes and pacing wires were removed per cardiac surgery protocol. She was started on Bblockers and these were titrated up. She was transferred to the floor on POD#2. She did experience some nausea and indigestion on transfer to the floor and this was treated with zofran and reglan with good effect. She was very anxious and had to have several family members present at times to help calm her down. Her activity level was advanced with the assistance of physical therapy. The remainder of her hospital course was uneventful and on POD 4 it was decided she was ready for transfer to rehabilitation at Lifecare in [**Location (un) 5165**]. Medications on Admission: ASA 81mg po daily Atenolol 50mg po daily HCTZ 25mg po daily Vitamin D 1000 units po BID Fluocinonide topical 0.025% PRN:rash Discharge Medications: 1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for throat discomfort. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR<60 SBP<100. 11. Fluocinonide 0.1 % Cream Sig: as directed Topical once a day as needed for rash. 12. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x3 with LIMA-LAD, SVG-OM, SVG-PDA PMH: Hypertension Hyperlipidemia Carotid artery stenosis Osteoporosis Degenerative joint disease-Right knee Right hip trochanter bursistis Basal Cell CA Left cheeck Irritable bowel syndrome ? Right nostril hemangioma- (in chart, pt unsure) s/p Mohs surgery x2 Left cheek s/p Tonsillectomy s/p cholecystectomy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact you [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues. 2) Report any fever of greater then 100.5 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) Please shower daily. Wash wound with soap and water. No lotions, creams or pwoders to incision until it has healed. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month from date of surgery. 7) Please call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**2-25**] weeks Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] in [**1-24**] weeks Completed by:[**2194-12-2**] ICD9 Codes: 4111, 4019, 2724
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Medical Text: Admission Date: [**2114-2-14**] Discharge Date: [**2114-2-23**] Date of Birth: [**2067-3-6**] Sex: F Service: MEDICINE Allergies: Latex / Penicillins Attending:[**First Name3 (LF) 2195**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation Central venous catheterization History of Present Illness: Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced interstitial lung disease, likely NSIP, chronic diastolic CHF, DM, and chronic pain s/p MVA who presents with respiratory failure. Patient unable to provide history, so HPI gathered from OMR and sign-out. Patient was presumably in USOH on home O2 and began to feel unwell over the past 7 days, with increased home O2 requirement, fever, cough and sputum production. She saw her PCP who treated her for presumed asthma exacerbation and started the patient on a steroid taper (unclear dose). The patient did not improve with this treatment regimen. At home, patient's respiratory distress worsened and she called EMS who took her to OSH ED. At OSH she was found to be hypoxic to 60-70's on RA, she was treated with 750 mg levaquin, 125 mg solumedrol, 4 mg morphine, duonebs and 12.5 mg benadryl, and transfered to [**Hospital1 18**] for further care. . In the ED, initial vs were: T AFeb P 116 BP 118/69 R 30 O2 sat. 85% 7L. Patient was given etomidate, succinylcholine and vecuronium for intubation and sedated with propofol. She was [**Last Name (un) **] given 1g IV ceftriaxone, 100 ucg fentanyl, and albuterol nebs. Even on the ventilator, her O2 Sats were still in the 80's with ABG 7.07/91/78 on 100% FiO2. After optimization of her ventilator settings with low RR and high Vt, the patient's O2 sats improved to 90's. On the floor, the patient was intbuated and sedated. IV access was challenging to obtain and a central line was placed. Her vitals were HR 121 BP 128/59 RR 20 O2 Sat 98% on 100% FiO2. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Non-specific interstitial pneumonitis (possibly idiopathic pulmonary hemosiderosis?) - s/p lung biopsy by VATS [**2109**] at [**Hospital1 **], lost to follow-up until [**2112**] - followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], perhaps started prednisone course [**2114-1-30**] - Home O2 requirement of ~4L - [**2114-1-2**] PFTs: DLCO 40% predicted, TLC 58% predicted, FEV1 54% - Overall consistent with restrictive lung disease CHF with recent hospitalization (per OMR) Diabetes Depression Chronic pain status post MVA ?Cardiomegaly TTE with ?rheumatic MV disease CAD s/p MI (normal MIBI in [**2109**]) Cervical dysplasia Colonic polyps s/p multiple polypectomies Hiatal hernia Migraines PSH: TAH-BSO Cervical cone bx Mediastinoscopy & L VATS [**2109**] Social History: She lives in [**Location **]. She is currently widowed. She has been disabled after a motor vehicle accident which happened several years ago. - Tobacco: ~25 pack year history - Alcohol: denies - Illicits: h/o illicit drug use in youth Family History: She has two children. She has several relatives who have had lung problems and has died from complications related lung disease. Her mother had COPD, died of respiratory failure, father with cardiovascular disease. She had a sister who died after a lung biopsy was performed. She states that several of her family members may have had asbestos exposure including the patient. Physical Exam: ON ADMISSION: Vitals: AFeb HR 121 BP 128/59 RR 20 O2 Sat 98% on 100% FiO2 General: Intubated, mildly sedated, in mild distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, difficult to assess JVP due to short, thick neck Lungs: Tubular, coarse breath sounds anteriorly with occasional expiratory squeaks 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 ON DISCHARGE: Vitals: 97.5 HR 58 BP 100/66 RR 20 O2 Sat 98% on 6L NC General: NAD, comfortable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no JVP Lungs: Symmetric chest rise, no increased resp effort, dew scattered crackles. 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. Pertinent Results: ADMISSION LABS: [**2114-2-13**] 11:40PM WBC-10.6 RBC-4.06* HGB-11.3* HCT-32.9* MCV-81* MCH-27.9 MCHC-34.5 RDW-15.1 [**2114-2-13**] 11:40PM NEUTS-89.4* LYMPHS-7.4* MONOS-2.3 EOS-0.5 BASOS-0.3 [**2114-2-13**] 11:40PM PLT COUNT-198 [**2114-2-13**] 11:40PM GLUCOSE-227* UREA N-10 CREAT-0.9 SODIUM-133 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18 [**2114-2-13**] 11:54PM LACTATE-2.3* K+-4.0 [**2114-2-13**] 11:40PM PT-14.8* PTT-35.6* INR(PT)-1.3* [**2114-2-13**] 11:40PM proBNP-1023* [**2114-2-13**] 11:40PM cTropnT-<0.01 MICRO: [**2114-2-13**] BLOOD CULTURE X2 - NGTD (PENDING) [**2114-2-14**] 10:30 am Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST (Final [**2114-2-14**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2114-2-14**]): Negative for Influenza B. [**2114-2-14**] 11:07 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2114-2-14**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2114-2-16**]): Commensal Respiratory Flora Absent. YEAST. RARE GROWTH. [**2114-2-15**] 10:37 am URINE Source: Catheter. URINE CULTURE (Final [**2114-2-16**]): NO GROWTH. [**2114-2-15**] 12:05 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2114-2-15**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. [**2114-2-15**] BLOOD CULTURE - NGTD (PENDING) STUDIES: [**2114-2-13**] CXR: Interval recurrence or progression of diffuse alveolar opacification in setting of known chronic interstitial lung disease (NSIP/ILD leading diagnostic considerations per OMR). This could be pulmonary edema or widespread pneumonia or hemorrhage. Given the course consideration should also be given to drug or toxin exposure exacerbating a preexisting reaction. [**2114-2-14**] TTE: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis. Normal left ventricular cavity size and regional/global systolic function. Mild mitral stenosis. Compared with the prior study (images reviewed) of [**2110-4-9**], the right ventricular findings are new and suggestive of myocardial contusion. The severity of mitral stenosis has increased. The severity of mitral regurgitation has declined (may be due to tachycardia and suboptimal image quality). [**2114-2-15**] EKG: Sinus rhythm and increase in rate as compared to the previous tracing of [**2110-4-9**]. There is right axis deviation and low limb lead voltage. There is now ST segment elevation in leads V1-V3 with biphasic to inverted T waves in leads V1-V5, more prominent as compared to the previous tracing of [**2110-4-9**]. The rate is increased. These findings are consistent with active anterolateral ischemic process. Followup and clinical correlation are suggested. CTA Wet read [**2114-2-23**]: No PE. Some consolidations/septal thickening suggestive of fluid vs infection. Enlarged pulm artery suggestive of pulmonary HTN. Brief Hospital Course: Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced interstitial lung disease, likely NSIP, CHF, DM, and chronic pain s/p MVA who presents with respiratory failure. ICU Course: Patient was intubated in the ED secondary to respiratory distress and oxygen saturations in the 80s. She was admitted to the MICU were a CVL was placed. She was treated initially empirically with levofloxacin and broadened to vancomycin/cefepime/azithromycin for empiric coverage of HCAP. She was also given IV steroids, then transitioned to prednisone 40 mg daily, for an ILD flare per her outpatient pulmonologist, Dr. [**Last Name (STitle) **]. Influenza swab was sent and returned negative. Sputum cultures grew commensal respiratory flora and yeast. She was also diuresed with IV lasix given an elevated BNP of 1023 over her baseline of 363 from [**10-1**] and overload on CXR. IV Lasix 40mg IV was effective and diuresis. Echocardiogram showed findings of RV free wall hypokinesis c/w contusion related to MVA as well as mild MS and MR. [**Name14 (STitle) 2287**] cardiology recommended further evaluation with TEE as this valvular disease may be contributing to her heart failure. She was extubated on [**2-16**] with return to her baseline home oxygen requirement. Just prior to transfer to the floor patient was started on morphine 60mg/30mg/60mg PO TID for her chronic fibromyalgia neck and shoulder pain. *ACTIVE ISSUES* # Acute on chronic diastolic heart failure: The patient is on daily lasix 60 mg at home and has a history of chronic diastolic heart failure secondary to rheumatic heart disease (echo in [**2109**] showed EF>55%, mild-mod MV regurg). Her dyspnea was thought to be due to volume retention in the setting of starting steroids for baseline lung disease. In the MICU she was started on IV lasix 40 mg with good response. On the floor her lung exam was notable for bibasilar crackles and high-pitched inspiratory squeaks, as well as bipedal pitting edema. She was therefore continued on IV lasix with resolution of dyspnea and improved lung exam. Her oxgen requirement was lowered to her baseline of 6L NC. A repeat CXR on [**2-21**] showed substantial improvement in pulmonary edema compared to the prior study of [**2-17**]. To evaluate the role of mitral valve dysfunction on CHF exacerbation, she also underwent a repeat echo given poor window of bedside TTE in the MICU. The echo was largely unchanged from her prior in [**2109**], with preserved EF 70% and mild resting left ventricular outflow tract obstruction. Rheumatic mitral valve deformity was noted along with mild MV stenosis. Cardiology recommended starting the patient on low-dose metoprolol due to concern for CHF exacerbation from tachycardia/decreased filling time in the setting of the patient's MR/MS. [**First Name (Titles) **] [**Last Name (Titles) 8337**] metoprolol succinate 12.5mg daily well. The patient was transitioned to po lasix 40 mg, and on this low dose continued to produce output 3-4L daily. She appeared consistently euvolemic on this dose. Her Cr remained stable throughout this period. On discharge her weight was 100.2 kg, compared to her baseline weight of 101.2 kg ([**2114-1-2**]). The CTA on day of discharge revealed signs of some fluid overload and decision was made to send her home on 60mg daily (her usual home dose) and to likely taper down to 40mg daily if appropriate when she sees her primary care physician. [**Name10 (NameIs) **] was discharged on lasix 60mg daily and metoprolol 12.5 mg daily. Pt was satting in the mid-high 90s on 6L at time of discharge. # ILD: The patient has advanced interstitial lung disease with tissue diagnosis of fibrotic NSIP in [**2109**]. She is on baseline 6L O2 at home and is followed closely by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. While inhouse it was thought that her lung disease was contributing to her dyspnea and acute presentation. She was therefore continued on prednisone 40 mg po daily. The patient was seen by Dr. [**Last Name (STitle) **] who recommended a slow steroid taper over 1-2 months with possible outpatient transition to azathioprine. Given her continuation of steroids, she was started on a PPI. She was also started on PCP prophylaxis with bactrim and discharged on Cal/VitD. # Diabetes mellitus: The patient had poor glycemic control during her stay, with post-meal FSBG levels consistently >400. A HgA1c was 9.2. Her lantus was increased to 24 from baseline 20 with good effect. She was started on a novolog sliding scale with frequent adjustment. [**Last Name (un) **] saw the patient while inhouse for elevated sugars. The decision was made to STOP metformin given her CHF, and the patient was instructed not to resume this outpatient. She was discharged on lantus 24 U qhs and novolog sliding scale (Starting breakfast and lunch at 12 for BG 100-150, increase by 2; dinner at 8 Units for BG 100-150, increase by 2; bedtime at 4 for BG 151-200, increase by 2). # Chronic pain s/p MVA: Baseline chronic back pain was controlled with her home morphine dose 60mg/30mg/60mg PO TID which was started in the MICU. She had adequate pain control during her hospitalization. *INACTIVE ISSUES:* # Anemia: The patient is chronically anemic and remained so with Hcts ranging from 27.9-31.9. This is consistent with her baseline. # Hypertension: Patient's aldactone was held given diuresis and relatively low BPs on the floor. Because she was started on metoprolol, her aldactone was discontinued. # Depression/anxiety: The patient was continued on her home doses of sertraline 200 mg daily and diazepam 5 mg q6 prn. Labs/Studies Pending at Discharge: - CTA final read ([**2114-2-23**]) Transitional Care Issues: - Patient will need electrolytes checked on Friday [**3-2**]. VNA has been arranged and PCP [**Name Initial (PRE) 13109**]. -Aldactone was held during admission. [**Month (only) 116**] be resumed outpatient if patient tolerates metoprolol. -Started metoprolol 12.5mg succinate daily. Reccomend continued monitoring outpatient as she might benefit from higher dose. Medications on Admission: Diazepam 5mg q6-8h PRN anxiety Lasix 60mg daily Lantus 20u daily Metformin 1000mg [**Hospital1 **] Morphine 60/30/60 mg PO qAM/afternoon/PM Oxycodone 5mg PO BID (between morphine doses) Sertraline 200mg daily Diovan 80mg daily Various vitamins: D2, B6, B12, fish oil (per [**Location (un) 2274**] records, additionally) Fioricet 2 tablets q4h PRN severe HA Spironolactone 25mg daily Hydroxyzine 50mg qAM/PM Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Continue until you see Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*1* 3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. 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:*2* 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every 4-6 hours as needed for wheeze. Disp:*1 inh* Refills:*0* 6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*40 ML(s)* Refills:*0* 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 9. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) as needed for neck/shoulder pain. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 11. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO NOON (At Noon). 12. diazepam 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for anxiety. 13. Outpatient Lab Work Please draw chem 7 on [**2114-2-27**] and fax to:[**Telephone/Fax (1) 6808**] attn: Dr [**First Name8 (NamePattern2) 4320**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 14. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24) Subcutaneous at bedtime. Disp:*1 month's supply* Refills:*2* 15. insulin Novolog Sig: One (1) four times a day: Follow Sliding Scale. Disp:*1 month's supply* Refills:*2* 16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-24**] Syringe Sig: One (1) Miscellaneous four times a day. Disp:*1 month's supply* Refills:*2* 17. Lasix 40 mg Tablet Sig: 1 and [**12-24**] Tablet PO once a day: take total of 60mg (1.5 tablets) a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] [**Location (un) **] Discharge Diagnosis: Primary diagnoses: Acute on Chronic Diastolic Congestive Heart Failure Interstitial Lung Disease Congestive Heart Failure Secondary diagnoses: Diabetes Mellitus Coronary Artery Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 60258**], You were admitted to the hospital for shortness of breath. We believe this was most likely due to extra fluid in your lungs. When you first arrived to our Emergency Department, a tube was placed in your throat to help you breathe (intubation). You were admitted to the intensive care unit, where you were given a medication (Lasix) to help decrease the fluid in your lungs. You were treated with steroids to decrease possible inflammation in your lungs. You also received antibiotics to cover the bacteria that cause lung infections. You responded well to these treatments and your breathing tube was eventually removed. In the ICU, you had an ultrasound of your heart (Echo) which showed slightly worsened disease of one of your heart valves (from rheumatic heart disease). Your heart function is otherwise unchanged from your last echo in [**2109**]. You were then transferred to the medicine floor, where you completed the course of antibiotics. You were continued on steroids. Your IV Lasix was transitioned to Lasix by mouth, and you continued to put out a considerable amount of extra fluid which helped your oxygenation. Your oxygen requirements decreased to your home oxygen of 6 Liters. You were able to ambulate on your own without issue. You will go home on lasix 60mg daily. This dose might be lowered to 40mg daily after you see your primary care doctor next week if she feels it is appropriate. Your sugars were found to be elevated, especially after starting prednisone. We had diabetes specialists see you who helped to titrate your insulin. You will go home on Insulin Sliding Scale regimen that was reviewed with you in the hospital. Please follow the attached Sliding Scale regimen. On the day of discharge you had some chest pain with breathing. We obtained a CT scan of your lungs and it showed there is no clot in your lungs, this is good news. Remember to check daily weights. If your weight goes up by 3 pounds, please call Dr [**Last Name (STitle) **], you might need a higher dose of your lasix. This is VERY important. If you can not get through to Dr [**Last Name (STitle) **], please call your primary care doctor. The following changes were made to your medications: STOP Metformin. Do not take this medication any more. It should not be taken by patients with heart failure. STOP Aldactone. You may resume this if your PCP agrees and if your blood pressure tolerates. We started you on metoprolol and decided to stop the aldactone for now. START insulin sliding scale with Novolog, see the attached form for an explanation. CHANGED lantus from 20->24 U every evening START: Bactrim, take 1 tab daily to prevent pneumonia while on steroids. START: Pantoprazole 40mg daily, take this while on steroids START Prednisone 40 mg daily. You will be on this medication until further discussion with your pulmonologist Dr. [**Last Name (STitle) **]. START Metoprolol 12.5mg daily. Please take [**12-24**] pill of the 25mg daily. This will protect your heart from future heart failure episodes. CONTINUE: Lasix 60mg daily to help remove fluid from your lungs No other medication changes were made. Please continue to take them as you have been doing. Follow-up appointments have been made for you. Please see the details below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Location (un) 2274**]-[**Location (un) **] Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 105541**] Appointment: Friday [**3-2**] at 1:45PM Department: PULMONARY FUNCTION LAB When: MONDAY [**2114-3-12**] at 8:10 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: MONDAY [**2114-3-12**] at 8:30 AM Department: MEDICAL SPECIALTIES When: MONDAY [**2114-3-12**] at 8:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2114-3-22**] at 1 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ICD9 Codes: 4280, 4019, 4240, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3176 }
Medical Text: Admission Date: [**2148-8-11**] Discharge Date: [**2148-9-5**] Date of Birth: [**2100-8-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: i was in a car accident Major Surgical or Invasive Procedure: Lumbar fusion L 345 on [**2148-8-14**] . Blood transfusion . Multiple intubations History of Present Illness: This is a 48 /o white male with non significant pmhx who was involved in a MVA. Pt states he was belted driver who was leaving friends house and then remembers seeing a car that he thought was parked and next thing he recalls his friend was banging on his window. Pt was transferred to [**Hospital1 18**] from a new [**Hospital **] hospital after w/u revealed L4 burst fracture. Pt currently admits to low back pain and tingling in LLE when he everts his L foot. Denies nausea, vomiting, headache, double or blurred vision, loss of control of bowel or bladder. Past Medical History: testicular cancer s/p orchiectomy and radical lymph node dissection Social History: He drinks at least one bottle of wine a day, and on the weekends drinks more hard liquor (whiskey), occasional cocaine use, most recently on the day of his accident. He has had 2 [**Last Name (un) 20934**] prior to this one. Prior to that he hadn't used any cocaine for "years." He denies tobacco use, has girlfriend of 12 years who he lives with at home. He works as a [**Doctor Last Name **] musician. Family History: NC Physical Exam: PHYSICAL EXAM: O: 162/82, 88, 18, 100% 99.6 Gen: WD/WN, comfortable, NAD. HEENT: NCAT, no hemotympanum, no battles or raccoons, no CSF rhinorrhea or otorrhea. Neck: without point tenderness from occiput to C7 Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. . Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: exam full throughout, slight breaking of strength to LLE KE and HF to pain. . Sensation: Intact to light touch. No sensory levels noted sensation intact distal to proximal as well reflexes: upper extremity brisk, B/l knee jerks 2+, ankle jerks absent/pt unable to participate. Toes downgoing bilaterally Rectal exam slightly increased rectal tone, normal sphincter control, no priapism at present.no clonus, no spasticity. Pertinent Results: [**2148-8-11**] 03:54PM HCT-24.0* [**2148-8-11**] 09:10AM HCT-25.4* [**2148-8-11**] 04:31AM GLUCOSE-111* UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [**2148-8-11**] 04:31AM ALT(SGPT)-28 AST(SGOT)-67* ALK PHOS-96 AMYLASE-30 TOT BILI-1.8* [**2148-8-11**] 04:31AM LIPASE-19 [**2148-8-11**] 04:31AM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-2.3 [**2148-8-11**] 04:31AM WBC-8.1 RBC-3.51* HGB-7.9* HCT-25.9* MCV-74* MCH-22.6* MCHC-30.6* RDW-18.5* [**2148-8-11**] 04:31AM PLT COUNT-121* [**2148-8-11**] 04:31AM PT-18.4* PTT-31.4 INR(PT)-1.7* [**2148-8-11**] 12:04AM COMMENTS-GREEN TOP [**2148-8-11**] 12:04AM GLUCOSE-122* LACTATE-2.8* NA+-138 K+-4.6 CL--101 TCO2-25 . [**8-11**]: MRI of Lumbar spine FINDINGS: There is minimal increased T2 signal within the L4 vertebral body in the location of the burst fracture. There is mild retropulsion of few of the fracture fragments. There is a large degree of loss of the vertebral body height. There is no evidence of neural foraminal narrowing at any level. Just posterior to the burst fracture, the retropulsed fragments cause mild-to- moderate spinal canal stenosis. They may impinge upon the traversing L4 nerve roots in the lateral recesses. Again the study is moderately limited due to patient motion artifact. There is no high-degree compression of the cauda equina. The remaining vertebral bodies are normal in alignment and marrow signal. IMPRESSION: Burst fracture of L4 with mild edema. There is moderate retropulsion of few of the fracture fragments. While these do not cause high- grade spinal canal stenosis, they may impinge upon the L4 nerve roots in the lateral recesses. Please correlate with patient's physical examination. . CT of the chest, abdomen, and pelvis after contrast. ([**2148-8-16**]) 1. Bilateral pleural effusions with associated atelectasis. 2. Ascites. 3. No evidence of metastatic disease. . CT Chest without contrast ([**2148-8-23**]) IMPRESSION: 1. No significant interval change compared to [**2148-8-16**]. Redemonstrated are bilateral dependent atelectatic changes with small pleural effusions, stable. 2. No evidence of pulmonary consolidations to suggest a presence of pneumonia. Fine detail in the lungs is obscured by motion artifact. 3. Abdominal ascites. . CT HEAD +/- CONTRAST:Negative CT of the brain without evidence of enhancing mass, particularly within the cerebellopontine angle. However, MRI is more sensitive for the detection of a mass and MRI with gadolinium should be considered if there remains clinical concern. . RUQ ultrasound [**2148-8-27**] LIVER ULTRASOUND STUDY WITH DOPPLER: Both grayscale and color Doppler ultrasound examination of the liver was performed. No focal liver lesions are seen. Coarsened echotexture of the liver consistent with cirrhosis. There is no intrahepatic or extrahepatic biliary ductal dilatation. There is no ascites. The common bile duct measures 5 mm in diameter. The gallbladder is relatively contracted. The right kidney measures 11.7 cm in length, and there are no renal stones or hydronephrosis seen. The main portal vein, anterior, and posterior branches of the right portal vein, and left portal vein are patent with appropriate directionality. The hepatic vein and its branches are patent. IMPRESSION: No focal liver lesions or ascites. Patent vessels as described above. Coarsened echotexture of the liver consistent with cirrhosis. . [**2148-8-21**] EEG IMPRESSION: Largely normal portable EEG. Plentiful movement artifact and the faster beta rhythm (possibly due to benzodiazepine medication) obscured much of the background, but no focal abnormalities or epileptiform features were evident. Brief Hospital Course: Impression/Plan: 47 y/o man with pmhx s/f testicular cancer, etoh and cocaine abuse, admitted after MVC with L4 burst fracture s/p L3-5 fusion on [**2148-8-14**]. He had a prolonged ICU course complicated by respiratory failure with multiple intubations, altered mental status and likely alcohol withdrawl/dt's. . MICU course: Pt was admitted through the emergency department after an MVA. He was admitted to the ICU and placed on log roll precautions for his spine. He was intubated on hospital day number 2 for his safety as he was experiencing the DT's and was being non compliant with his bedrest status. He was taken to the OR later that day for a lumbar fusion L 345. The operation was without complication. He did receive blood transfuion and transfusion of platelets for a HCT <25 and an INR of 1.5. He later than trended up again on his INR to 1.4 however we did not continue to treat as he was now post-op. He had a drain placed in the lumbar region in the OR which was removed on [**Doctor Last Name **] #2. A TLSO was ordered pre-operatively and is in use while pt is OOB. He also had a head CT and a CT of the Torso with and without contrast for two reasons. One, on his original head CT he had what appeared to be a right sided CPA possible meningioma. This was unfounded on the contrasted image. The CT of the torso was performed because the outside tramua images were "wet read" as having spots on the liver. The Torso CT here is negative however there is a hypodensity noted in one of the lobes of the liver that is too small to characterize that should be follwed by the PCP. [**Name10 (NameIs) **] was placed in the D/C instructions. On POD#4 (hosp day 6)he had altered mental status and possible aspiration and required reintubation. He was started on broad coverage antibiotics (ceftaz and flagyl) for pneumonia. Although the patient transiently improved on [**8-18**] and was weaned to [**4-12**], he was noted to have fluctuations in MS [**First Name (Titles) **] [**Last Name (Titles) 17577**] copious secretions on [**8-19**]. Extubated [**8-20**], but continued to have copious secretions which he could not clear. Approximately 12h later the patient became extremely anxious due to inability to clear secretions and req'd re-intubation. . On [**8-21**] the patient was transferred to the MICU service for [**Month/Year (2) 17577**] management of his requirement for mechanical ventilation. On transfer the patient was started on lactulose for presumed hepatic encephalopathy. His antibiotic coverage was expanded to include vancomycin for a presumed VAP. A repeat CT of the chest did not show any evidence of pneumonia and his antibiotics were held. Since the patient was out of the window for [**Month/Year (2) 17577**] etoh w/d, his agitation was managed w/ haldol standing and prn. On [**8-25**] the patient was extubated (following commands, good cough, minimal secretions). . Course on the floor: transferred on [**8-27**] . 1. Respiratory failure: Patient had multiple failed extubations likely secondary to untreated liver failure causing encephalopathy. He responded to lactulose and now has been extubated since [**8-25**], satting well on room air. Although patient was febrile during his MICU course he didnt have pneumonia on CXR or on CT scan. d/c all antibiotics. He had an incentive spirometer at bedside for use. . 2. Altered mental status: Probably secondary to liver disease with encephalopathy, in combination with alcohol withdrawl. No evidence of head trauma, and his EEG was non-focal. Patient likely out of alcohol withdrawl at this point, more than two weeks into hospital stay. His mental status has improved slightly, but because of continued slowing, an MRI/MRA of the brain was obtained to assess for diffuse axonal injury. Neurology followed throughout hospital course. His standing haldol was discontinued to prevent confusion, and he did not require any during his stay on the floor. MRI/MRA of brain showed no evidence of diffuse axonal injury as was suspected due to his generalized slowed cognitive function. At discharge, he had some residual deficits, thought to be secondary to resolving encephalopathy, likely with some underlying retardation due to chronic alcohol abuse. He was scheduled for follow-up Behavioral Neurology evaluation as an outpatient. . 3. Liver disease: Likely secondary to alcoholic cirrhosis. Hepatitis serologies are negative, except for prior infection/vaccination for Hepatitis B. Iron not significantly elevated, indicating that hemochromatosis is not a likley cause of his liver dysfunction. He does have evidence of impaired liver function with increased INR. MELD score is 4, indicating low 90 day mortality. RUQ ultrasound shows evidence of cirrhosis, no ascites. Outpatient follow up with hepatology in [**Month (only) 1096**], to assess his ESLD. He should continue lactulose and metoprolol for variceal prophylaxis. Addictions consult provided patient with places to go for alcohol rehabilitation. Patient states intent to first return home to assess his capacity to be in his native environment. He has a follow up appointment with Hepatology in [**Month (only) 1096**]. . 4. L4 burst fracture s/p fusion on [**8-14**]: He should continue TLSO brace when out of bed, should continue using it until he sees neurosurgery 6 weeks after fusion. He will need standing thoracic and lumbar spine films with his TLSO brace on that neurosurgery will follow up with at their appointment. At the time of discharge, he was unable to stand on his own, and we were not able to do these in house. They will need to be done by the rehab facility or by his PCP. [**Name10 (NameIs) **] well on oxycodone for pain control . 5. Fever: This was never an issue while on the medical floor. SBP r/o with paracentesis. [**Month (only) 116**] have been related to alcohol withdrawl. He was been afebrile on admission to the floor and did not continue to spike fevers. . 6. Anemia: Likely secondary to combo of malnutrition, anemia chronic disease, given low MCV and low iron with normal TIBC. Transfuse for Hct < 25. Continue MVI, folate, thiamine, and iron supplementation. . 7. FEN: S/S done on [**8-27**]. Advance diet to soft solids and thin liquids with supervised feedings. Alternate bites and sips. Pills crushed in puree. Monitor for aspiration. Added ensure to lunch and dinner per nutrition recs. . 8. Prophylaxis: Heparin SQ, pneumoboots, ppi as an inpatient. DVT prophylaxis was discontinued at discharge, as patient was ambulating with his walker. . 9. Code: Full . 10. Dispo: Given patient's deconditioned state as a consequence of the protracted hospital course, and previously fully functional status, he was discharged to [**Hospital **] Rehabilitation. Prior to discharge, he was provided with a self help face sheet with resources for AA and other addiction services. Medications on Admission: none Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*3 L* Refills:*2* 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:*4 Patch Weekly(s)* Refills:*2* 9. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) teaspoon PO DAILY (Daily). Disp:*150 mL* Refills:*2* 10. Ranitidine HCl 15 mg/mL Syrup Sig: Two (2) teaspoons PO BID (2 times a day). Disp:*1 L* Refills:*2* 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*1 L* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: s/p lumbar fusion L345 Discharge Condition: neurologically stable Discharge Instructions: 1) Please call the neurosurgery office at [**Telephone/Fax (1) **] if you have any questions or concerns, Please call immediately if you have any fever 101.5 or greater, any redness swelling or drainage from or around your incision. Please call if your pain is not controlled by your pain meds or if you have any new numbness tingling or weakness. . 2) Call your primary care doctor at [**Telephone/Fax (1) 250**] if you have worsening swelling of your abdomen, legs, shortness of breath, vomiting up blood, dark, tarry stools, or mental status changes. . 3) You have been provided with information about addiction rehabilitation options. You should give serious consideration to the resources that are available. Please make every effort to abstain from alcohol and drug use after you are discharged. Followup Instructions: You are scheduled to follow-up with Neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**] on next Monday, [**9-9**] at 10:30 a.m. Her office is in [**Apartment Address(1) **] of the [**Hospital Ward Name 860**] Building at [**Hospital1 18**] located at [**Location (un) 3387**]. Her office number is [**Telephone/Fax (1) 1690**] should you need to reschedule or cancel. . Please follow up with your Neurosurgeon Dr. [**Last Name (STitle) 548**] on [**Last Name (STitle) 20212**], [**10-2**] at 10:45. Around 9:30 on that same morning, you should go to [**Hospital Ward Name 517**] [**Hospital **] Care Center, Department of Radiology on the [**Location (un) **] to have x-rays of your spine. His office number is [**Telephone/Fax (1) 2992**]. After your x-rays, you will go to Dr.[**Name (NI) 2845**] office in The [**Hospital Unit Name **] located at [**Hospital Unit Name 69616**]. . You have an appointment to see your new primary care doctor, [**Doctor First Name 714**] [**Doctor Last Name **], MD [**First Name (Titles) **] [**Last Name (Titles) 20212**], [**10-2**] at 3 p.m. Her office is in the [**Hospital Ward Name 23**] building on the [**Location (un) **], Central Suite. ([**Telephone/Fax (1) 1300**]. Please call to confirm your address, information. . You have been scheduled to follow up with a hepatologist regarding your liver cirrhosis. You have an appointment scheduled for [**Telephone/Fax (1) 20212**], [**11-13**] @ 1:50, with Dr. [**First Name (STitle) **] [**Name (STitle) 69617**], [**Hospital Unit Name **], [**Location (un) **], ([**Telephone/Fax (1) 1582**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] ICD9 Codes: 5180, 5070
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Medical Text: Admission Date: [**2158-10-11**] Discharge Date: [**2158-10-15**] Date of Birth: [**2135-4-9**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 9160**] Chief Complaint: polyuria, diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 2152**] is a 23 year-old man with diabetes mellitus type 2, depression, and alcohol abuse, who presented to the ED yesterday with generalized weakness, fatigue, polyuria, and polydipsia in the last two weeks, as well as nausea and vomiting. He had URI symptoms two weeks ago. He had been diagnosed with DM about 5 years ago; he had been treated with insulin for some time, and then transitioned to metformin when his glucose control improved. He stopped metformin about two years ago, due to depression. . In the ED he was tachycardic, with blood sugar in 600s, and found to have anion gap metabolic acidosis and ketonuria, consistent with DKA. He was treated with insulin drip and IVF, and admitted to the ICU. . In the ICU, his sugars improved, and his anion gap closed. He was transitioned to Lantus. [**Last Name (un) **] was consulted. He reported chest pain in the ICU which has since resolved (and cardiac biomarkers negative x3). . Currently, he feels much better. His only complaint is of frequent urination. . Review of systems: (+) Per HPI (-) Denies fever or chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria. Denies arthralgias or myalgias. Past Medical History: Diabetes mellitus type 2 Depression Alcohol abuse Social History: Lives in group home in [**Hospital1 8**]. Born in [**Location (un) 7349**], has lived in [**State 350**] for many years. Smokes [**1-26**] cigarettes per day. Drinks alcohol about 3-4 times per week, 6-7 bottles of beer each time. No history of IVDU. Has used marijuana. He has "disowned" his family. Unemployed. Family History: Mother: heart disease, breast cancer Physical Exam: Vitals 96.6 82 152/94 18 99% RA Gen - comfortable, pleasant, obese HEENT - sclerae anicteric, moist mucous membranes Neck - supple, no LAD Pulm - CTAB, good air movement CV - RRR, no murmur Abd - soft, nontender, nondistended Ext - warm, no edema Neuro - alert, interactive, 5/5 strength in bilateral UEs and LEs, normal sensation to light touch (including in feet) Pertinent Results: [**2158-10-12**] 02:49AM BLOOD WBC-12.2* RBC-3.82* Hgb-12.1* Hct-32.6* MCV-85 MCH-31.6 MCHC-37.1* RDW-13.1 Plt Ct-203 [**2158-10-12**] 08:55AM BLOOD Glucose-247* UreaN-6 Creat-0.7 Na-134 K-4.0 Cl-106 HCO3-22 AnGap-10 [**2158-10-11**] 05:30PM BLOOD ALT-75* AST-29 AlkPhos-169* TotBili-1.1 [**2158-10-12**] 08:55AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.9 [**2158-10-11**] 05:52PM BLOOD %HbA1c-10.9* eAG-266* CXR - FINDINGS: AP upright and lateral views of the chest were obtained demonstrating clear well-expanded lungs without focal consolidation, effusion, pneumothorax. Cardiomediastinal silhouette is normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No signs of pneumonia or other acute intrathoracic process. Brief Hospital Course: ## Diabetic ketoacidosis: Mr. [**Known lastname 2152**] was admitted to the ICU for management of mild diabetic ketoacidosis. His presentation was likely precipitated by medication nonadherence and recent URI. He was treated with an Insulin drip, IV fluids, and electrolyte repletion. He was transferred to the floor the following day. Insulin drip was transitioned to Lantus, which was titrated to 30U daily in addition to an aggressive meal-time sliding scale, which was printed out for the patient on discharge. He was on Metformin, but this was stopped due to transaminitis. He was sent home with VNA services to assist with glycemic control. . ## Transaminitis: Patient developed acute worsening transaminitis during this admission. RUQ ultrasound showed evidence of fatty infiltration. Liver service was curbsided and recommended sending off [**Doctor First Name **], anti-mitochondrial Ab, anti-smooth muscle Ab, ferritin, and ceruloplasmin, which are pending at the time of discharge. . ## Alcohol abuse: He was counseled on the risks of excessive alcohol abuse and the risk of liver damage. Social Work met with him. He was not interested in cutting back at this point, stating that alcohol enabled him to be more creative. He displayed no signs or symptoms of alcohol withdrawal. . ## Smoking: Also counseled on smoking cessation. Offered a nicotine patch. . ## Depression: Home Psych meds were continued. Medications on Admission: Topamax Wellbutrin Prozac Vistaril Patient does not know doses. Meds prescibed by his psychiatrist, whose number/contact info he does not recall. Meds are provided by his group home in [**Hospital1 8**] [**Telephone/Fax (1) 91310**]. I called the home - they said patient takes Depakote 1000mg qhs and Risperdal 5 mg qhs. Patient said he will clarify. Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*0* 2. topiramate 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 4. Vistaril 50 mg Capsule Sig: One (1) Capsule PO once a day. 5. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 6. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO at bedtime. 7. Risperdal 1 mg Tablet Sig: Five (5) Tablet PO at bedtime. 8. Lantus 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day. Disp:*2 vials* Refills:*1* 9. syringe (disposable) 3 mL Syringe Sig: One (1) syringe Miscellaneous once a day. Disp:*100 syringes* Refills:*1* 10. glucometer Sig: One (1) glucometer use as directed. Disp:*1 glucometer* Refills:*0* 11. Alcohol Prep Swabs Pads, Medicated Sig: One (1) box Topical use as directed. Disp:*1 box* Refills:*0* 12. glucometer test strips Sig: One (1) strip four times a day. Disp:*100 0* Refills:*1* 13. Lancets,Ultra Thin Misc Sig: One (1) lancet Miscellaneous use as directed for checking fingersticks. Disp:*100 lancets* Refills:*1* 14. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous once a day: use sliding scale as directed. Disp:*2 vials* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Diabetes mellitus type 2, uncontrolled, w/ complications Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 2152**], you were admitted for diabetic ketoacidosis (very high blood sugars). It is important to keep your blood sugars under control through medications, regular follow-ups with your primary care doctor, and being mindful of your diet. We strongly recommend that you stop smoking to avoid complications such as heart and lung disease. We also strongly recommend that you stop drinking alcohol. It appears that alcohol is damaging your liver. You should take Lantus 30 units every morning and use the sliding scale that you have been given. Call your doctor if your blood sugars are above 300. Your liver function tests were abnormal. More labs tests were ordered to evaluate this, but the results are not available yet. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2158-10-23**] at 3:25 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**] Completed by:[**2158-10-16**] ICD9 Codes: 311, 3051
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Medical Text: Admission Date: [**2138-6-5**] Discharge Date: [**2138-6-8**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: bilateral chest tube placement Endotracheal tube placement History of Present Illness: 88 yo male s/p mvc, partially ejected, [**Last Name (un) 60537**] car, initially disoriented with agonal respirations, no BP through transfer. Unresponsive in trauma bay. Past Medical History: unknown Social History: unknown Family History: NC Physical Exam: 98.4 100% ETT General GCS 3 HENT: occipital lac. PERRL 2 mm, reactive TM clear Chest: CTAb, RRR; no e/o injury Neck: trachea midline Abd: soft, ?tender, ND, fast neg Pelvis: stable Rectal: decreased tone, guaiac neg Ext: w/wp no obvious fracture Back: no deformity; ?tenderness Pertinent Results: [**2138-6-5**] 11:58PM TYPE-ART TEMP-37.1 RATES-18/ TIDAL VOL-550 PEEP-10 O2-80 PO2-125* PCO2-44 PH-7.28* TOTAL CO2-22 BASE XS--5 AADO2-411 REQ O2-70 INTUBATED-INTUBATED VENT-CONTROLLED [**2138-6-5**] 10:30PM TYPE-ART PO2-103 PCO2-40 PH-7.30* TOTAL CO2-20* BASE XS--5 [**2138-6-5**] 10:30PM LACTATE-1.4 [**2138-6-5**] 10:00PM CK(CPK)-255* [**2138-6-5**] 10:00PM CK-MB-12* MB INDX-4.7 cTropnT-0.06* [**2138-6-5**] 02:59PM GLUCOSE-149* UREA N-27* CREAT-1.2 SODIUM-144 POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-22 ANION GAP-14 [**2138-6-5**] 02:59PM CK(CPK)-241* [**2138-6-5**] 02:59PM CK-MB-10 MB INDX-4.1 cTropnT-0.06* [**2138-6-5**] 02:59PM WBC-8.4 HCT-29.5* [**2138-6-5**] 02:59PM PLT COUNT-155 [**2138-6-5**] 02:59PM PT-13.7* PTT-29.9 INR(PT)-1.2 [**2138-6-5**] 02:43PM LACTATE-1.7 [**2138-6-5**] 12:50PM CK(CPK)-213* AMYLASE-46 [**2138-6-5**] 12:50PM CK-MB-9 cTropnT-0.09* [**2138-6-5**] 12:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2138-6-5**] 12:50PM WBC-7.8 RBC-2.93* HGB-9.1* HCT-27.7* MCV-94 MCH-30.9 MCHC-32.7 RDW-14.7 [**2138-6-5**] 12:50PM PLT COUNT-170 CXR: bilateral chest tube deep Pelvis: neg CT head: right depressed temporal fracture; right temporal [**Doctor Last Name 534**] bleed; Right orbital fracture CT neck: C1, C2 fracture CT torso: left complete PTX; trace free fluid in abd and pelvis; no HS injury Brief Hospital Course: Was admitted to Trauma SICU where pt was further evaluated by neurosurgery, ophthamology and orthopedic services. Pt was thought to have serious brain injry and likely was thought to have residual, permanent deficits if patient were to regain consciousness, and was given a very poor prognosis. TSICU stay was complicated by acidosis and hemodynamic instability requiring multiple pressors. Family was made aware of any progress or lack thereof, on a daily basis, and on HD#4, pt was made comfort care only. Pt never regained mental status function and passed at 1656 on [**2138-6-9**]. Pupils were dilated and fixed. No signs of spontaneous respirations or cardiac activity was noted. Admitting and ME were notified. Family made aware. Medications on Admission: ? Discharge Medications: Expired Discharge Disposition: Expired Facility: [**Hospital1 **] Hospital Discharge Diagnosis: Pt expired on [**2138-6-9**] of cardiac arrest after being made CMO. Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 2762, 4275, 4019, 2749
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Medical Text: Admission Date: [**2147-11-11**] Discharge Date: [**2147-11-24**] Date of Birth: [**2091-5-22**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Intracranial Hemorrhage Major Surgical or Invasive Procedure: [**11-11**]: Left Hemicraniotomy for Temporal resection for bleed [**11-18**]: Left Craniotomy for Lt Temporal Mass resection History of Present Illness: Pt is a 56 y.o. male who had a fall to the ground while making his bed this afternoon. The fall was not witnessed, but was heard from the next room. He was found by his mother and was reportedly "thrashing around" on the floor and non-responsive. Pt was brought to [**Hospital 11694**] Hospital in [**Location (un) 2251**], MA and found to have an acute LEFT temporal mass and ICH on CT. Pt was transferred to the ED at [**Hospital1 18**] for further evaluation and treatment. Per his mother, wife, and sister, he has been more irritable over the past few weeks and has also had some recent memory loss. Past Medical History: OSAS Social History: Works at the [**Hospital **] hospital in JP as a programming clerk. Lives in [**Location **], MA with his wife and son. Is retired Army. Quit smoking 5 years ago. Does not use ETOH or illicit drugs. Family History: Father died of MI. No known family h/o of intracranial hemorrhages or cancers. Physical Exam: T: afebrile BP:154/88 HR:96 RR: 18 O2Sats: 100% 3LNC Gen: non-verbal. eyes are closed. Appears uncomfortable. Groaning. HEENT: Pupils: 1-2mm, minimally reactive. EOMs: Pt not moving eyes. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: non-verbal. Orientation: unable to assess. Recall: unable to assess. Language: Making incomprehensible groans. Cranial Nerves: I: Not tested II: Pupils are 1-2 mm and minimally reactive to light. III, IV, VI: Unable to respond to commands. Eyes are midline and conjugate. V, VII: Facial droop on right side VIII: Hearing intact to voice. IX, X: unable to assess. [**Doctor First Name 81**]: unable to assess. XII: unable to assess. Motor: RUE: not moving, RLE: +clonus. LUE: Grip-[**5-20**], LLE: Gastroc - [**5-20**]. No tremors. Sensation: intact on left. Toes downgoing on right, upgoing on left. Coordination: could not assess. On Discharge: XXXXXXXXXXXXXXXX Pertinent Results: Labs on Admission: [**2147-11-11**] 05:55PM BLOOD WBC-20.4* RBC-4.59* Hgb-13.6* Hct-40.2 MCV-88 MCH-29.7 MCHC-33.9 RDW-13.1 Plt Ct-195 [**2147-11-11**] 05:55PM BLOOD Neuts-90.6* Lymphs-6.4* Monos-2.6 Eos-0.2 Baso-0.1 [**2147-11-11**] 05:55PM BLOOD PT-13.8* PTT-22.7 INR(PT)-1.2* [**2147-11-11**] 05:55PM BLOOD Glucose-148* UreaN-12 Creat-1.1 Na-138 K-3.7 Cl-103 HCO3-22 AnGap-17 [**2147-11-11**] 05:55PM BLOOD Albumin-4.3 Calcium-8.8 Phos-3.0 Mg-1.9 [**2147-11-11**] 05:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: XXXXXXXXXXXXXXX Imaging: Head CT([**11-11**]): MPRESSION: Extensive left hemispheric hemorrhage with surrounding vasogenic edema and mass effect, including rightward uncal and subfalcine herniation, as described. The differential includes hypertensive and amyloid related intraparenchymal hemorrhage, though other underlying pathologies (i.e. mass) cannot be excluded. CTA Head([**11-12**]): IMPRESSION: 1. Large left-sided temporal lobe hematoma with surrounding edema and mass effect with subfalcine and uncal herniation with midline shift. 2. Displacement of the vascular structures secondary to hematoma without intrinsic vascular abnormality such as an aneurysm, stenosis or occlusion. No abnormal vascular structure seen to suggest arteriovenous malformation. MRI Head([**11-12**]): IMPRESSION: Left temporal hematoma partially evacuated following craniotomy. Mass effect and midline shift is identified. No distinct enhancement seen within the hematoma or in the other parts of the brain to indicate an underlying lesion. Patchy enhancement at the margin posteriorly appear to be due to vascular enhancement. Pathology Results([**11-11**]): I. Left temporal dura (A, B): Dura and mildly hypercellular cortex with scattered atypical cells. II. Left temporal lobe tissue (C-E): Oligodendroglioma, WHO grade II. See note. III. Blood clot (F): Blood and fibrin. MRI Head([**11-16**]): IMPRESSION: 1. New areas of enhancement in the periphery of the hematoma with irregular and nodular appearance as well as a few vague areas of enhancement in the right basal ganglia, in the right thalamus, in the left parasagittal brain parenchyma adjacent to the thalamus. The cause of enhancement is unclear and this may relate to postsurgical changes at the site of the surgery. However, given the vague areas of enhancement in the right thalamus and superior to the left thalamus, associated inflammatory or infective etiology cannot be excluded. Correlate clinically. 2. Mild increase in the size of the left subdural fluid collection as well as the subcutaneous fluid collection in the left frontotemporal region. 3. No significant change in the significant mass effect on the left lateral ventricle, subfalcine and uncal herniation with mass effect on the left posterior cerebral artery and the posterior communicating artery. In the left posterior cerebral artery in the left side of the midbrain. Close followup can be considered, to assess the stability or progression of the enhancing areas. MRI Head ([**11-18**]): IMPRESSION: Left-sided temporal and subinsular rim-enhancing mass with mass effect on the left lateral ventricle, midline shift, and uncal herniation with deformity of the brainstem. The appearances are unchanged compared with [**2147-11-16**]. Left-sided frontoparietal craniotomy with subgaleal fluid collection. MRI Head ([**11-19**]): IMPRESSION: 1. Increased T2 signal, slow diffusion and increased fractional anisotropy within the left posterior temporal lobe is suggestive of new infarct in the left posterior cerebral artery distribution. 2. Persistent shift of midline structures and left uncal herniation with compression of midbrain and pons. 3. Post-operative changes as described above. Head CT([**11-22**]): No evidence of new hemorrhage or mass effect. Persistent, significant rightward shift of midline structures and left uncal herniation. Further evolution of left posterior cerebral artery distribution infarct. Head CT ([**11-23**]): Unchanged mass effect, postsurgical changes and evolving left posterior cerebral artery distribution infarct. Brief Hospital Course: The patient arrived at the [**Hospital1 18**] ED on [**2147-11-11**] with EMS and was found to be hemi-paretic on the right side. He was clinically assessed and immediately taken for non-contrast head CT and head CTA. He was found to have an intracranial hemorrhage vs mass, which was determined to be a surgical emergency. He was taken to the OR for left craniotomy and exploration. The patient tolerated the procedure, and was taken to the TSICU, where he remained intubated and sedated. The patient underwent serial physical exams and radiographic imaging for progressive assessment. As his clniical status improved, he was transferred to the step-down neurosurgical unit on POD 4. Pathology taken from the intracerebral mass was consistent with Oligodendroglioma, WHO grade II and the patient was taken back to the OR on [**2147-11-18**] for resection of this mass and temporal lobectomy. He tolerated this procedure well and recovered in the PACU for a period of 24 hrs. He was transferred back to the neurosurgical floor on [**2147-11-20**]. Secondary to new onset of headaches, the patient had repeat head CTs on [**11-22**] and [**11-23**], which were considered normal and stable. Throughout his post-surgical hospitalization, Mr. [**Known lastname **] has had several incidents of low grade temperature elevations(101.3) which are atelactic in nature as his CBC has been stable, and not evidence of infection was noted at the incision site. On his day of discharge, he had complained of mild "numbness" in the right hand. Upon examination, he was full in strength, and it was secondary to ulnar nerve compression based on how he was sitting, or likely residual from perioperative positioning. He was then discharge to rehab on [**2147-11-24**] Medications on Admission: Occasional NSAID use Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. 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:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 99 doses. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-15**] PO BID (2 times a day). 11. Regular Insulin Regular Insulin per Sliding scale on nursing handout Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Grade II Oligodendroglioma Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**11-28**] days for removal of your staples or sutures. Please call ([**Telephone/Fax (1) 88**] to schedule this appointment. You also have an appointment scheduled in the Brain [**Hospital 341**] Clinic for Provider:[**Name10 (NameIs) **] [**Name11 (NameIs) 4253**] MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2147-12-4**] 4:00. You can also call to schedule your appointment to be seen by Dr. [**Last Name (STitle) **] on this same day. Completed by:[**2147-11-24**] ICD9 Codes: 431
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Medical Text: Admission Date: [**2162-4-27**] Discharge Date: [**2162-5-7**] Service: NEUROLOGY Allergies: Codeine / Erythromycin Base Attending:[**First Name3 (LF) 6075**] Chief Complaint: Change in mental status Major Surgical or Invasive Procedure: Placement of PEG-J tube History of Present Illness: This is a [**Age over 90 **] yo F with h/o afib off coumadin x 1 week for cystoscopy today to evaluate hematuria, who returned from cystoscopy with her family today at about 5:30-6pm. At approximately 6:30pm patient became unresponsive all of a sudden. She was brought back to [**Hospital3 2568**] where she was found to be aphasic with right face droop. She had emesis en route to [**Hospital3 26611**] and was intubated with lido/etom/succ/vec. Given ativan 2mg IV x 1 as well. [**Hospital3 2568**] discussed case with Dr. [**First Name (STitle) **] and it was decided she was not a t-PA candidate as she was out of the 3 hr window. She was transferred to [**Hospital1 18**] for evaluation of intra- arterial tPA (after discussion with stroke fellow Dr. [**First Name (STitle) **], but this was not given as she already had evidence of infarct on her head CT. CTA at OSH showed a left MCA cut off (films not available for review). BP at OSH 151/58. Past Medical History: right eye cataract surgery HTN afib and valve repair, on coumadin hypothyroidism hematuria hemicolectomy for diverticulitis "vein occlusion of the left eye" - ? Social History: : never married, no kids, lives with sister, fully functional and independent in all ADLs. No tob/etoh/drugs. Retired executive secretary. FULL CODE. Family History: : not obtained Physical Exam: Vitals: 96 88 afib 168/107 16 100% on vent GEN: elderly woman, pale, intubated, laying on stretcher, pulling at sheets with left hand, appears uncomfortable HEENT: NC/AT, anicteric sclera, dry mm NECK: supple, no carotid bruits CHEST: CTA bilat CV: irreg irreg without murmurs ABD: soft, NT/ND, +BS EXTREM: no edema, radial and DP pulses 2+ NEURO: MENTAL STATUS: (ativan given approximately 3 hours before exam), does not open eyes to voice, does not follow commands CRANIAL NERVES: Pupil exam: irreg pupil on right, minimally reactive. Left pupil 2mm and reactive. FUNDUS on right appears normal, no papilledema, no hemorrhage. EOM exam: + dolls. Upon repeat exam, eyes deviated to the left, but not fixed. Follows fingers to right but not past midline. Corneal reflex: present bilaterally Facial symmetry: limited by ETT, upper face appears symmetric with grimace to pain Gag reflex: + present MOTOR: spontaneous movements of left arm and leg, picking at sheet and antigravity arm, bending of the left knee. Right arm is flacid and falls when you pick it up. Left foot has some spontaneous movement, minimal and distal. SENSORY: withdrawls vigorously on the left arm/leg and right foot, sluggish withdrawl right arm. REFLEXES: 2+ and symmetric with upgoing toe on the right, down on the left. Pertinent Results: [**2162-4-27**] 12:37AM BLOOD WBC-13.0* RBC-3.48* Hgb-10.3* Hct-31.0* MCV-89 MCH-29.7 MCHC-33.4 RDW-13.6 Plt Ct-266 [**2162-4-28**] 08:33PM BLOOD Hct-29.3* [**2162-5-3**] 09:55AM BLOOD WBC-4.9 RBC-3.36* Hgb-10.0* Hct-30.4* MCV-90 MCH-29.8 MCHC-32.9 RDW-13.9 Plt Ct-277 [**2162-5-4**] 08:05AM BLOOD WBC-7.5# RBC-3.84* Hgb-11.4* Hct-34.5* MCV-90 MCH-29.7 MCHC-33.0 RDW-13.8 Plt Ct-368 [**2162-5-5**] 04:40PM BLOOD WBC-12.8* RBC-3.93* Hgb-11.8* Hct-35.5* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.6 Plt Ct-419# [**2162-5-5**] 08:15PM BLOOD WBC-14.8* RBC-3.89* Hgb-11.8* Hct-36.0 MCV-92 MCH-30.2 MCHC-32.7 RDW-13.8 Plt Ct-381 [**2162-5-6**] 07:25AM BLOOD WBC-15.1* RBC-3.50* Hgb-10.4* Hct-31.0* MCV-89 MCH-29.8 MCHC-33.7 RDW-13.6 Plt Ct-410 [**2162-5-5**] 08:15PM BLOOD Neuts-86* Bands-11* Lymphs-3* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2162-4-27**] 12:37AM BLOOD PT-13.2 PTT-23.2 INR(PT)-1.2 [**2162-4-27**] 12:37AM BLOOD Plt Ct-266 [**2162-4-27**] 06:59AM BLOOD PT-12.6 PTT-25.3 INR(PT)-1.1 [**2162-4-27**] 06:59AM BLOOD Plt Ct-262 [**2162-5-5**] 10:20AM BLOOD PT-12.9 PTT-22.8 INR(PT)-1.1 [**2162-5-6**] 07:25AM BLOOD PT-13.7* PTT-25.6 INR(PT)-1.3 [**2162-5-6**] 07:25AM BLOOD Plt Ct-410 [**2162-5-5**] 08:15PM BLOOD Plt Ct-381 [**2162-5-6**] 07:25AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-140 K-3.5 Cl-107 HCO3-22 AnGap-15 [**2162-4-27**] 12:37AM BLOOD Glucose-165* UreaN-14 Creat-1.0 Na-139 K-3.1* Cl-102 HCO3-22 AnGap-18 [**2162-4-30**] 09:10AM BLOOD Glucose-161* UreaN-27* Creat-1.0 Na-136 K-3.3 Cl-103 HCO3-22 AnGap-14 [**2162-5-6**] 07:25AM BLOOD Amylase-104* [**2162-5-6**] 07:25AM BLOOD Lipase-22 [**2162-5-6**] 07:25AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.6 [**2162-4-27**] 12:37AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-4-27**] 06:59AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-4-27**] 06:59AM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE [**2162-4-27**] 06:59AM BLOOD Triglyc-78 HDL-35 CHOL/HD-4.1 LDLcalc-92 [**2162-4-27**] 06:59AM BLOOD TSH-3.1 [**4-27**] CT head-Left middle cerebral artery territory acute infarction, which is quite extensive, with suggestion of a left middle cerebral artery occlusion. The results were immediately relayed to the ED dashboard at the time of the interpretation and discussed with the attending physician in the emergency room. [**5-5**] Head CT Evolving left MCA territory infarction producing slight mass effect on the left lateral ventricle and slight left to right shift more prominent compared to the prior study. [**5-5**] CT Abd-) Nonspecific 4-mm nodular opacity at the right lung base. 2) Multiple foci of intra-abdominal free air located anterior to the liver and other multiple foci of extraluminal air near the distal duodenum/proximal jejunum with stranding and free fluid present in the anterior pararenal space and left paracolic gutter. Although no extravasated oral contrast is identified, this constellation of findings in this patient status post recent GJ- tube placement is worrisome for perforated viscus. The presence of stranding in the left anterior pararenal space near the pancreas also raises the possibility of pancreatitis. Correlation with laboratory values is recommended. The findings worrisome for perforated viscus were relayed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at approximately 7:30 on [**2162-5-5**] and later discussed with the covering surgical house staff. 3) Dilated pancreatic duct in the tail region of the pancreas with several smaller adjacent cystic lesions that may represent separate small cysts or dilated side branches. 4) Large exophytic left renal cyst with multiple small low-attenuation lesions in the kidneys bilaterally that may represent cysts. 5) 4.1 x 4.6 cm right adnexal cyst. 6) Slight nodular enlargement of the right adrenal gland, incompletely characterized on this single-phase study. Brief Hospital Course: A/P: [**Age over 90 **] yo F with afib, off coumadin x 1 week for cystoscopy to eval hematuria, who presented 6 hrs after sudden onset of unresponsiveness. On exam has right arm hemiplegia and flacidity, and right leg appeared weaker than left. Eyes deviated to the left although do follow fingers to the midline. She was intubated on admission thus exam was limited. CT showed evidence of left MCA infarction. 1. Neuro -She was initially admitted to neuro ICU for q 1 hr neuro checks. Heparin and tPA were held for fear of hemorhagic transformation. Antihypertensives were held with only metoprolol being used for rate control with afib. She continued to have rt sided flacid paralysis with both expressive and receptive aphasia. It was unclear if the pt would protect her airway so NGT was placed in the ICU for enteral nutrition. Due to no improvement in exam, we discussed with the family the need for percutaneous feeding tube if her mental status did not improve. The Health Care Proxy who is the patient's daughter decided that she would have wanted a feeding tube, although per heresay of the rest of the family the patient had documented not wanted a feeding tube should she be unable to eat. Ethics service was consulted and recommended that we should obey the HCP who we hope is acting in the patients best interest and a PEG tube was placed on [**5-4**]. After PEG tube placement the patient deveolped an acute abdomen so Levofloxacin and Flagyl were started and surgery was consulted. Abdominal CT revealed free air and mild hematoma to be the likely cause of the patient's pain, but the family refused surgical exploration. Her NGT was placed to low wall suction and PEG left to gravity for 2 days at which point tube feeds were started per nutrition recs. Prior to discharge she was also started on baby aspirin. [**Name2 (NI) **] abdominal pain resolved and all medications were changed over to PO. Blood cultures remained negative but plan was made for an empiric 10 day course post discharge of the above antibiotics. She will also need the T fasteners on the PEG tube to be removed by cutting them below the tube on [**5-11**] or 7-10 days after J tube placement. 2. GU-Pt had undergone cystoscopic BCG therapy with bx for bladder CIS at outside hospital. She developed uliguria with continued hematuria so urology was consulted on [**4-28**] and recommended CBI. Her urine slowly cleared over the next 2 days but the foley was left in since we wanted to control for recurrent hematuria while coumadin is restarted. 3. Afib - She was rate controlled with with standing IV metoprolol with prn and also required intermitted IV hydralazine for blood pressure control. The restart of coumadin was initially held for placement of PEG but plan was made to restart coumadin with therapeutic INR range of [**12-24**]. She was changed over to PO metoprolol on [**5-7**] but will need to be monitored on telemetry until she is better rate controlled. 4. Hyperthyroidism-Synthroid was held on admission and TSH was WNL. It was unclear what her outpatient dose of synthroid dose so this was held initially but restarted at low dose with plan to recheck a TSH in one month. 5. Pulm-The patient had large amounts of secretions post extubation but chest xr was clear. She cont to have episodes of apnea without hypoxia thought to be due to cerebral edema as seen on follow-up CT. 6. Px-Patient was continued on a PPI and SC heparin Medications on Admission: coumadin PPI Toprol synthroid Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs qs* Refills:*2* 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed for fever/pain. 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8 Hours). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 10. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: Please titrat to INR [**12-24**]. 11. Promote with Fiber Liquid Sig: One (1) PO once a day: Continuous as per page 1. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Large left MCA stroke Discharge Condition: Stable Discharge Instructions: If the patient develops any increasing abdominal pain, inability to move her bowels, vomiting, loss of spontaneous movement on avaialable she should return to the emergency room. Followup Instructions: ICD9 Codes: 2859, 4019, 2449
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Medical Text: Admission Date: [**2175-1-11**] Discharge Date: [**2175-1-20**] Date of Birth: [**2132-1-28**] Sex: F Service: SURGERY Allergies: Amoxicillin / Erythromycin Base / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 301**] Chief Complaint: Patient presented with abdominal pain at [**Hospital6 1597**], CT scan revealed free air. Patient was transferred to [**Hospital1 18**]. Major Surgical or Invasive Procedure: Status Post Marginal ulcer repair History of Present Illness: This patient is a 42 year old female who complains of ABD PAIN. Went to [**Hospital3 **] ED this am for abd pain ,has free air to abd per CT at bypass site.rec,d Fentanyl 50 per amb enroute. Had Flagyl IV Appears uncomfortable MY HPI: transfer from [**Hospital3 2568**]. Presnted there w/ diffuse abdominal pain that started this AM. At OSH, CT demonstrated free air. Pt is s/p gastric bypass in [**2171**] here by Dr. [**Last Name (STitle) **]. Per OSH CT, increased air at anastamosis, suggestive of perforation. Received abx, IVF, analgesia at OSH. En route & at OSH had decreased SBP to 60, now improved w/ IVF. Past Medical History: Hypertension, dyslipidemia, asthma, and obstructive sleep apnea on CPAP. Social History: She denies any alcohol, drug or tobacco abuse. She states she quit smoking three weeks ago. Family History: Non-contributory Physical Exam: Temp:97.5 HR:88 BP:98/65 Resp:20 O(2)Sat:98 normal Constitutional: uncomfortable Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Oropharynx within normal limits Chest/Resp: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds GI / Abdominal: Soft, Nondistended, diffusely tender, + rebound, + guarding GU/Flank: No costovertebral angle tenderness Musc/Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: [**2175-1-11**] 12:25PM BLOOD WBC-19.7*# RBC-5.07 Hgb-9.7*# Hct-33.7* MCV-67*# MCH-19.1*# MCHC-28.6*# RDW-17.3* Plt Ct-452*# [**2175-1-13**] 12:23PM BLOOD WBC-12.3* RBC-3.82* Hgb-7.4* Hct-25.2* MCV-66* MCH-19.4* MCHC-29.5* RDW-17.5* Plt Ct-381 [**2175-1-18**] 06:10AM BLOOD WBC-5.1 RBC-4.24 Hgb-8.2* Hct-27.7* MCV-65* MCH-19.2* MCHC-29.4* RDW-18.4* Plt Ct-355 [**2175-1-11**] 12:25PM BLOOD Plt Smr-HIGH Plt Ct-452*# [**2175-1-13**] 02:07AM BLOOD PT-13.5* PTT-26.1 INR(PT)-1.2* [**2175-1-18**] 06:10AM BLOOD Plt Ct-355 [**2175-1-11**] 12:25PM BLOOD Glucose-76 UreaN-18 Creat-0.8 Na-141 K-4.6 Cl-108 HCO3-21* AnGap-17 [**2175-1-13**] 02:07AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-140 K-4.1 Cl-107 HCO3-26 AnGap-11 [**2175-1-16**] 06:20AM BLOOD Glucose-99 UreaN-4* Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [**2175-1-11**] 12:25PM BLOOD Lipase-35 [**2175-1-14**] 03:34AM BLOOD Lipase-12 [**2175-1-11**] 12:39PM BLOOD Lactate-3.0* [**2175-1-11**] 05:01PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.5* [**2175-1-14**] 01:43PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 [**2175-1-18**] 06:10AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1 Brief Hospital Course: Patient transferred from [**Hospital3 **] with abdominal pain and free air noted on CT scan. Patient went to the operating room where a Closure of marginal ulcer,Omental patch, Gastrostomy and Takedown of gastroenteric fistula was performed. Initially postop patient was monitored very closely in the intensive care unit. Pain control was difficult to achieve with use of ketamine. On postoperative day 3 patient was transferred to the floor. PPI and antibiotics were continued intravenously and patient's labs were closely monitored. On postoperative day 5 patient was started on a bariatric diet. R arm cellulitis was noted and patient started on warm packs and vancomycin. On postoperative day 6 R arm celluilitis improved and patient progressed to a bariatric stage 3 diet. We will discharge her to home today with oral protonix, keflex for cellulitis and follow up with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: lisinopril 10 QD, symbicort Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day: Please take for one week. Disp:*28 Capsule(s)* Refills:*0* 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*300 ML(s)* Refills:*0* 4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:*500 ml* Refills:*0* 5. Multivitamin Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Perforated marginal ulcer Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-22**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 49**] in one week at [**Hospital Ward Name **] [**Hospital Ward Name 23**] building [**Location (un) 470**]. Please call [**Telephone/Fax (1) 2723**] to make an appointment. Completed by:[**2175-1-20**] ICD9 Codes: 2724, 4019
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Medical Text: Admission Date: [**2183-11-20**] Discharge Date: [**2183-12-3**] Date of Birth: [**2129-9-14**] Sex: F Service: SURGERY Allergies: Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal Distention Vomiting Anorexia Major Surgical or Invasive Procedure: Exploratory laparotomy, abdominal colectomy, sigmoid mucous fistula and end ileostomy, transgastric gastrojejunostomy tube placement and splenic flexure takedown History of Present Illness: 54F with h/o recurrent metastatic ovarian cancer s/p TAH/BSO [**4-/2180**], on Taxol (last RX [**11-12**]), who presents to oncology clinic with a 2 day history of progressive abdominal distention, anorexia, vomiting and decreased bowel function. Past Medical History: Recurrent Ovarian cancer Asthma Obesity Social History: She has one son who is 28 years old. She works as a financier and is self employed. She lives in the [**Location (un) 5583**] area. She does not drink or smoke. Family History: She had a grandmother who at the age of 83 developed colon cancer. There is no other cancer in her family. She is not of Ashkenazi [**Hospital1 **] descent. Physical Exam: Admission Physical Exam - [**2183-11-20**] 97.6 100 159/89 18 100%RA AOx3, nontoxic RRR, CTAB Obese, markedly distended/tympanitic +BS, mild right sided abdominal tenderness Rectal- normal brown guaic (-) stool, no strictures 1+ edema Pertinent Results: Admission Labs ------------------- [**2183-11-20**] 01:34PM BLOOD WBC-8.3# RBC-4.32 Hgb-11.5* Hct-35.3* MCV-82 MCH-26.6* MCHC-32.6 RDW-20.6* Plt Ct-429 [**2183-11-20**] 02:20PM BLOOD Neuts-72.2* Lymphs-21.5 Monos-5.5 Eos-0.4 Baso-0.3 [**2183-11-20**] 02:20PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Microcy-2+ [**2183-11-20**] 01:34PM BLOOD Plt Ct-429 [**2183-11-20**] 01:34PM BLOOD Gran Ct-6080 [**2183-11-20**] 02:20PM BLOOD Glucose-159* UreaN-16 Creat-0.7 Na-134 K-3.2* Cl-96 HCO3-27 AnGap-14 [**2183-11-20**] 02:20PM BLOOD estGFR-Using this [**2183-11-20**] 02:20PM BLOOD ALT-67* AST-39 AlkPhos-99 TotBili-0.5 DirBili-0.2 IndBili-0.3 [**2183-11-20**] 02:20PM BLOOD Albumin-4.2 Phos-2.9 Mg-1.9 Discharge Labs ------------------- [**2183-11-27**] 09:55AM BLOOD WBC-10.5 RBC-3.47* Hgb-9.8* Hct-29.4* MCV-85 MCH-28.2 MCHC-33.3 RDW-18.2* Plt Ct-356 [**2183-11-27**] 09:55AM BLOOD Plt Ct-356 [**2183-12-1**] 05:10AM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-139 K-3.8 Cl-108 HCO3-23 AnGap-12 [**2183-11-23**] 03:05AM BLOOD ALT-19 AST-21 AlkPhos-47 Amylase-28 TotBili-0.6 [**2183-12-1**] 05:10AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9 [**2183-11-26**] 06:32AM BLOOD Triglyc-218* CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: CT with RECTAL contrast to rule out distal obstructive proce Field of view: 46 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 54F with large bowel obstruction REASON FOR THIS EXAMINATION: CT with RECTAL contrast to rule out distal obstructive process CONTRAINDICATIONS for IV CONTRAST: IV dye allergy INDICATION: Plain film concerning for large bowel obstruction. COMPARISON: CT scan dated [**2183-10-30**] and plain films dated [**2183-11-20**]. TECHNIQUE: MDCT acquired images of the abdomen and pelvis were obtained after the administration of IV, oral, and rectal contrast. Multiplanar reformatted images were also obtained. CT OF THE ABDOMEN WITH IV CONTRAST The imaged portions of the lung bases are clear. There is diffuse fatty infiltration of the liver. There is a gallstone within the gallbladder. The pancreas and spleen are unremarkable. The adrenal glands are normal. There are multiple left renal cysts and a right renal lesion that is too small to characterize, that probably represents a cyst. There is dilatation of the cecum with diameter measuring up to 12.3 cm. Oral contrast is present within the cecum. No dilated loops of small bowel are seen. Note is made of subtle pneumatosis of the cecum with no wall edema. The transverse colon measures up to 7.8 cm, only mildly dilated by size criteria with no wall edema or pneumatosis. There is a focal narrowing of the lumen of the sigmoid flexure with adjacent peritoneal metastasis producing a low-grade obstruction at this location. The descending colon is of normal size. There is an inflammatory mass located at the mid-upper pelvis (series 5, image 69). Rectal contrast material passes freely through the rectum and sigmoid colon to the level of this inflammatory mass (series 7, image 24). Approximately 1 liter of contrast was given. There is no intra-abdominal free air. There is no mesenteric or portal venous gas. The superior mesenteric artery, celiac artery, and inferior mesenteric arteries all appear patent. CT OF THE PELVIS WITH IV CONTRAST: The bladder is unremarkable. The patient is status post TAHBSO. There is no pelvic free fluid. Rectum is unremarkable with rectal tube in place. Bone windows reveal no suspicious lytic or sclerotic lesions. There are degenerative changes. IMPRESSION: 1) Dilatation of the cecum with measurement up to 12.3 cm, and only mild dilatation of the transverse colon, with the descending colon being of normal diameter. There is a focal area of mild luminal narrowing at the splenic flexure with adjacent mesenteric/serosal metastasis. More inferiorly, in the mid pelvis there is an ill-defined mesenteric metastatic lesion, with rectal contrast noted to clearly pass from the rectum through the sigmoid colon up to the level of this mass. No rectal contrast could be passed through this level. Notably, there is residual stool present within the rectum and sigmoid colon. Taken together, findings are suggestive of at least a partial large bowel obstruction. Complete or high-grade obstruction cannot be excluded as rectal contrast material was not noted to pass through the level of this inflammatory mass. Further evaluation could be performed with a barium enema to assess for passage of contrast through this level. 2) Pneumatosis is noted of the cecum, without associated wall edema. The significance of this finding is not certain. It is not felt to be likely due to ischemia. Correlate clinically. KUB ------- Compared to CT torso of [**2183-10-30**]. There is diffuse distention of the large bowel to the level of the distal sigmoid colon, at which point there appears to be an abrupt cut off which corresponds to an area of serosal implant seen on the prior CT of [**2183-10-30**]. Overall, the findings are highly concerning for distal large bowel obstruction. The large bowel measures up to 10 cm in maximum diameter involving the transverse and hepatic flexure. No evidence of free intraperitoneal air. IMPRESSION: Findings highly suspicious for distal large bowel obstruction. Findings discussed with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] after the study. Portable TTE --------------- Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W057-1:08 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.0 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: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.5 cm Left Ventricle - Fractional Shortening: 0.46 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 65% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 0.90 Mitral Valve - E Wave Deceleration Time: 210 msec TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality - body habitus. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a prominent anterior fat pad. IMPRESSION: Preserved global and regional biventricular systolic function. CLINICAL IMPLICATIONS: Based on [**2173**] 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. Chest Xray -------------- Admission [**2183-11-21**] Portable AP chest radiograph compared to [**2183-3-2**]. The heart size is mildly enlarged but stable. The mediastinal contours are unchanged. The lungs are clear. There is no sizeable pleural effusion. The left subclavian line tip is in mid SVC. IMPRESSION: No evidence of acute cardiopulmonary process. [**2183-11-30**] Chest Xray FINDINGS: Compared with [**2183-11-22**], there has been partial interval clearing of the left lower lobe atelectasis/infiltrate/effusion. No infiltrates are seen in the left mid/upper and right lung fields. Brief Hospital Course: [**Known firstname 636**] [**Known lastname **] was admitted to the surgery service under the care of Dr. [**First Name (STitle) 2819**] on [**2183-11-20**]. CT scan and KUB showed evidence of large bowel obstruction. She was taken to the operating room on HD 1 where she underwent an exploratory laparotomy, abdominal colectomy, sigmoid mucous fistula and ileostomy, transgastric gastrojejunostomy, tube placement and splenic flexure takedown. She was transferred to the ICU intubated postoperatively. At POD 1 she was tachycardic and with low urine output. She was treated with fluid resuscitation and 1 unit PRBCs. She was on day 2 of Kefzol/Flagyl. At POD 2 she was extubated. Urine output was improved and she was afebrile. Her antibiotics were discontinued. Hct was stable at 29.6. Tube feeds were started at jejunostomy. Lasix was started for diuresis. Blood glucose was evaluated and treated with RSSI. At POD 3 an ECHO was performed which was WNL with LVEF>55%. She was transferred to the floor. Blood pressure was elevated and continued to be controlled with IV metoprolol. At POD 4 tube feedings continued with reports of high residuals. A KUB was completed without evidence of obstruction. NGT remained in place. Blood pressure was elevated. Diuresis continued. Physical therapy was consulted. At POD 5 there was return of bowel function. NGT was removed. Diet was advanced to sips. She was febrile to 101.4 Urinalysis was negative. Urine and blood cultures were sent. RIJ was removed and tip sent for culture. CXR was negative. At POD 6 she complained of nausea. Reglan was started and her diet was advanced as tolerated. She was started on PO medications. At POD 7 she had high ostomy output. C. difficile was sent and was negative. Fluid placement was provided to accommodate output. Tube feeds were held to decrease output. She was afebrile. At POD 8 the ostomy output continued to be high at >4000cc. Imodium and Metamucil were started. IV fluids were provided to accommodate output. Blood, urine and line tip cultures from POD5 were negative. Tube feeds were restarted. At POD 11 she was doing well. Ostomy output remained high at 1575cc but was certainly improved from initial post operative bowel function recovery. Metamucil and Imodium dosing was increased. The tube feeds were at goal at 60cc/hr. She was discharged in good condition to an acute rehabilitation center. She was to follow up with Dr. [**First Name (STitle) 2819**] in clinic in [**12-23**] weeks. Medications on Admission: Taxol Effexor XR 37.5 Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 2. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for slow ostomy output. 3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 4. Erythromycin 5 mg/g Ointment Sig: One (1) 1cm ribbon Ophthalmic TID (3 times a day) for 5 days: Left eye. 5. Psyllium 1.7 g Wafer Sig: [**12-23**] Wafer PO TID (3 times a day). 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): 40mg SC daily. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for htn: Please hold for SBP <110 and HR <65. 8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Ovarian Cancer Large Bowel Obstruction Postoperative Fever Discharge Condition: Good Discharge Instructions: Please return or contact for: * Fever (>101 F) or chills * Persistent or worsening abdominal pain * Increased or decreased output from ostomy * Inability to urinate or dark urine * Nausea or vomiting * Redness or drainage at incision * Any other concerns Followup Instructions: Please follow up with Dr. [**First Name (STitle) 2819**] in clinic on [**2183-12-11**] 1:00pm. The clinic is located on the [**Location (un) 470**] of the [**Hospital Unit Name **] near the [**Hospital Ward Name 517**]. You may call ([**Telephone/Fax (1) 6347**] for any questions for concerns. Completed by:[**2183-12-3**] ICD9 Codes: 4019, 2859
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Medical Text: Admission Date: [**2126-1-21**] Discharge Date: [**2126-1-28**] Date of Birth: [**2052-8-6**] Sex: Service: CHIEF COMPLAINT: This man came in with a chief complaint of chest and neck pain and shortness of breath. HISTORY OF PRESENT ILLNESS: A 73-year-old man with past medical history significant for CAD, status post three-vessel CABG, AVR, and pacer, who presented with chest pain which started approximately 1 week prior to admission. Described it as soreness which comes at rest and activity. The patient also complained of shortness of breath, beginning in [**Month (only) **] or [**Month (only) 205**] which previously is his main complaint. The patient also has neck pain with exertion, which abates at rest. Last week prior to admission, the patient had increasing shortness of breath and "neck pain" which escalated and prompted his visit to his PCP. [**Name10 (NameIs) **] patient did lie flat and denies PND. Chest pain started over the prior week but increased shortness of breath prompted an ETT, which showed a large mild reversible defect. Because of this result, the patient escalating systems the primary care doctor referred the patient to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for possible intervention. REVIEW OF SYSTEMS: Negative for cough and fever. Negative for overindulgence in food and alcohol over the holidays. Positive rash. Fair appetite, which is approximately stable. No abdominal pain, nausea, vomiting or diarrhea. Positive occasional monocular loss of vision in the left eye, maybe the right eye too. Carotid ultrasound "okay" per the patient. PAST MEDICAL HISTORY: CAD (CABG three-vessel and AVR [**2124-7-17**], reason positive ETT). Status post pacer placement in the context of unclear disorder ? heart block for AAA repair, [**2123-6-18**]. Status post cardioversion [**Month (only) 116**] or [**2125-6-17**] but felt return of neck pain in [**2125-9-17**]. Hypothyroidism. AAA repair 4 to 5 years prior to admission. Borderline hypertension. Chronic renal insufficiency. Kyphosis. ALLERGIES: NKDA. MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Synthroid 75 mg p.o. q.d. 3. Lotrel 510 mg q.d. SOCIAL HISTORY: The patient was an electric technician, retired, and lives with his wife and son who is 39 years old. The patient has 1 to 2 drinks a day. Former smoker, quit in [**2090**]. FAMILY HISTORY: Mother died at 97 of unclear causes. Father died at 65 with ? CAD but the father is a World War I veteran with many exposures. He has three children who are alive and well and he is the only child himself. PHYSICAL EXAMINATION: VITAL SIGNS: The patient had a heart rate of 107, blood pressure 138/74, saturating 96 percent on room air, and respiratory rate is 21. GENERAL: He is an elderly man, alert, and mildly tachypneic in no apparent distress. HEENT: Bilateral ear lobe creases, mottled nose, and anicteric sclerae. NECK: JVP approximately 6 cm. HEART: A 2/6 systolic murmur at the left sternal border and apex. Regular rhythm and tachycardic. No gallops or rubs appreciated. LUNGS: Clear bilaterally. CHEST: Soft 3 to 4 cm mass above the left nipple. ABDOMEN: Soft, nontender, and nondistended. No hepatosplenomegaly. Multiple surgical scars. EXTREMITIES: Same with no CCE and 2 plus DP pulses bilaterally. NEUROLOGIC: Cranial nerves II through XII intact. Moves all extremities well. LABORATORY DATA: Admission labs are notable for eosinophil percentage of 10.9 percent and creatinine of 2.9. CK on admission was 77 with a troponin of less than 0.01. The patient's recent stress SPECT showed a large valvular reversible defect in the inferior lateral apex, EF of 67 percent (positive for large inferolateral and inferoapical ischemia with normal EF.) Echo on [**2126-1-11**] outside hospital showed mild LVH, EF 55 percent, mild thickened MV with trace MR, dilated ascending aorta, normal aortic valve, normal right ventricular size and function but with mild-to- moderate tricuspid regurgitation, and no pericardial effusion. Chest x-ray on admission also showed no acute cardiopulmonary process or change from [**2124-8-10**]. BRIEF SUMMARY OF HOSPITAL COURSE: A 73-year-old man with history significant for coronary artery disease status post three-vessel CABG, AVR, and pacer, who had 6 months' history of increasing shortness of breath and neck pain. It is angina equivalent. The patient presented in the context of positive stress and escalating pain over the last 1-1/2 weeks. The patient was catheterized and found to have diffuse disease. Given chronic renal insufficiency on dialysis, the patient was reassessed on the second catheterization to avoid giving him too much contrast with one procedure per his attending, Dr. [**Last Name (STitle) **]. However, the patient had a vagal episode and vague UTI at the outside of the second catheterization with anginal chest pain. The patient had a short stay in the CCU as a result. The patient no longer considered to be a catheterization candidate and remaining options include medical management and ? of repeat CABG. The plan therefore changed to send the patient home for outpatient evaluation after carotid ultrasound read. Given that the carotid ultrasound showed complete occlusion of the right ICA and 40 percent of the left ICA, the patient was sent home. This will be detailed below. PROBLEM LIST: Cardiovascular rhythm, no changed tachycardiac event as before. Continue beta-blocker. The patient will also have a pacemaker interrogated by EP which showed normal pacemaker function. It should be slowed only with beta blockade to control the underlying cause of sinus tachycardia, which was performed during the course of his admission. CAD, the patient underwent cardiac catheterization as discussed above. He was continued on beta blockade, statin, and aspirin and thus consideration given to Isordil treatment as an outpatient will be decided on followup. The patient has decreased EF to 40 percent. The patient was continued on beta blockade but never had symptoms of clinical CHF on exam. Renal failure. The patient had improved creatinine over the course of the admission. The patient only had a small bump in his creatinine to 3.0 from baseline in mid to high 2s with his cardiac catheterization. However given that his chronic renal insufficiency had never been adequately explained, renal ultrasound was performed. These results were as follows: Normal appearance of the left kidney and urinary bladder. Right kidney which appeared atrophic and 1 to 2 cm cystic stricture present in the right renal bed. Functionally, the patient has unilateral kidney and ACE inhibitor was therefore held. Hypercholesterolemia. There is no significant increase in LDL but the patient had reduced HDL, so statin was continued given his known coronary artery disease. Hypothyroidism, outpatient Synthroid regimen was continued. Rash, the patient developed a maculopapular rash over the face and torso, which improved with steroid cream. Is to question as to whether this rash is related to metoprolol, there is a question of discontinuing this drug but Cardiology input was to continue this protective drug given his coronary artery disease unless the symptoms became terribly bothersome. Question TIA during cardiac catheterization. The patient developed right hand numbness and weakness, speech slurring, and hypotension during cardiac catheterization. The symptoms resolved with the administration of atropine. The patient had positive amaurosis in the left eye in the past. He also has nausea and vomiting with these episodes. Vascular and Neurology consults were called in regards to this and as a result the patient had a CT head which showed no acute hemorrhage or infarct, chronic small vessel disease. Ultrasound of the carotids were also performed, which showed complete occlusion of the right ICA and 40 percent of the left ICA. The Vascular consults recommended MRA but given that the patient has the pacemaker, he cannot have an MRI. The other alternative would be CT angiograms with the carotids but given his high creatinine, this was also rejected as an option. Given the patient's comorbidities and asymptomatic state, the Vascular Service recommended starting Plavix and follow up with Dr. [**Last Name (STitle) **]. In light of this result, the patient was discharged to home in stable condition. DISCHARGE INSTRUCTIONS: To return to the ER. Call his cardiologist for any chest or neck pain, increasing shortness of breath, dizziness or unusual sweating. DIAGNOSES: Coronary artery disease. Renal insufficiency. Heart failure. Hypothyroidism. Carotid stenosis. FOLLOW UP: Follow up with primary care physician [**Name Initial (PRE) 176**] 1 to 2 weeks. Follow up with Dr. [**Last Name (STitle) **] within 1 to 2 weeks. Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery, within next 4 weeks. CONDITION ON DISCHARGE: The patient was discharged home in stable condition. DISCHARGE MEDICATIONS: 1. Synthroid 75 mcg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Metoprolol 12.5 mg p.o. b.i.d. 5. Fluocinolone cream b.i.d. p.r.n. rash. 6. Plavix 75 mg p.o. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8158**], [**MD Number(1) 8159**] Dictated By:[**Last Name (NamePattern1) 25972**] MEDQUIST36 D: [**2126-6-20**] 13:22:30 T: [**2126-6-21**] 09:23:09 Job#: [**Job Number **] ICD9 Codes: 4111, 5849, 2449
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Medical Text: Admission Date: [**2109-10-28**] Discharge Date: [**2109-11-7**] Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman admitted to [**Hospital1 69**] from [**Hospital6 **] where she presented with lethargy and decreased p.o. intake. Husband states she fell out of bed because of weakness. CT of the head showed subarachnoid hemorrhage. Of note, she was admitted to [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Hospital a week ago with headache, refused magnetic resonance scan at that time. PAST MEDICAL HISTORY: Significant for hypertension, increased cholesterol, carotid stenosis, question Alzheimer's disease with short term memory loss. Hypothyroidism, status post stroke in the past. MEDICATIONS: Plavix, Accupril, Synthroid, Hydrochlorothiazide, Lipitor and Toprol. The patient was admitted to the Surgical Intensive Care Unit for close monitoring and blood pressure control. She had a cerebral arteriogram which showed no aneurysm or arteriovascular malformation as a cause of the subarachnoid hemorrhage. She was monitored closely in the surgical Intensive Care Unit with tight blood pressure control and followed by Cardiology service. The patient had CTA which was grossly negative for any aneurysm, also had magnetic resonance scan and MRA which also was negative. The patient had severe hypertension and was treated with Lopressor 100 mg p.o. b.i.d., Procardia XL 30 mg p.o. q day and Accupril 40 mg q day with intermittent intravenous Hydralazine and Lopressor for systolics greater than 160. The patient was transferred to the regular floor on [**2109-10-31**] in stable condition. On [**2109-11-1**] in the late evening the patient had hypertensive crisis with blood pressure into the 224/90 range and complained of increased headache and confusion. She was started on Nipride and was subsequently switched to p.o. medications as mentioned previously. She currently is on the regular floor in stable condition neurologically oriented times one to two, moving all extremities with no weakness. She has been followed by the physical therapy, occupational therapy, found to require rehabilitation prior to discharge home. She is currently without fever. She is on Lipitor 10 mg p.o. q day, Synthroid 100 mg p.o. q day, Accupril 40 mg q day, Procardia XL 30 mg p.o. q day, Lopressor 100 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., Procardia XL has been increased to 60 mg p.o. q day, hold for systolic pressure less than 110. Levaquin 500 mg p.o. q day for five days which will be discontinued today for urinary tract infection. Hydrochlorothiazide 25 mg p.o. q day and Hydralazine 40 mg p.o. q 6 hours hold for systolic blood pressure less than 160. The patient's vital signs stable, she is afebrile, she will be discharged to rehabilitation with follow-up with Dr. [**Last Name (STitle) 1132**] in one months time. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2109-11-7**] 11:35 T: [**2109-11-7**] 12:45 JOB#: [**Job Number 35840**] ICD9 Codes: 431, 5990, 2761, 2720, 4019, 2449
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Medical Text: Admission Date: [**2116-3-2**] Discharge Date: [**2116-3-4**] Service: CARDIOLOGY CHIEF COMPLAINT: Atrial flutter. HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male with coronary artery disease, status post porcine mitral valve replacement and aortic valve replacement, now with atrial flutter. He presented to an outpatient urology appointment for bladder stones and was noted to have a rapid heart rate in the 150's. An electrocardiogram showed borderline wide complex tachycardia at 150. The patient was sent to his cardiologist, Dr. [**Last Name (STitle) 696**], who was not available. He was sent to Dr. [**Last Name (STitle) 73**], who performed carotid sinus massage and found that the patient was in atrial flutter with 2:1 block. The patient denied palpitations. He had no chest pain, shortness of breath, lightheadedness, headache, visual changes, numbness, tingling or weakness. PAST MEDICAL HISTORY: 1. Coronary artery disease with a left internal mammary artery graft to the left anterior descending artery in [**2106**]: A cardiac catheterization on [**2116-1-6**] showed significant restenosis of the left anterior descending artery that was status post percutaneous transluminal coronary angioplasty, moderate in-stent restenosis of the circumflex coronary artery. Re-intervention of the left anterior descending artery was deferred due to gross hematuria. More specifically, the proximal left anterior descending artery had a discreet 70% stenosis. The right coronary artery was large with discreet moderate 40-50% proximal stenosis. The posterior descending artery was diffusely diseased with a 30% maximal stenosis. The left main coronary artery was at most 20%. The second diagonal artery had been dilated in [**2115-8-10**] and showed mild stenosis, at most 30-40%. There was moderate diffuse in-stent restenosis of the proximal circumflex coronary artery up to 50%. Initially, it appeared that an left anterior descending artery intervention was planned. However, on heparin and Integrelin, the patient had gross hematuria and this was deferred. In discussion with his primary care physician, [**Name10 (NameIs) **] was decided, given that no stenoses were greater than 70%, that plans be for medical management. An echocardiogram in [**2115-9-10**] showed the left atrium to be moderately dilated. The left ventricular cavity size was normal. There was severe regional left ventricular systolic dysfunction, right ventricular chamber size and systolic function were normal. A bioprosthetic aortic valve as well as a bioprosthetic mitral valve were seen without evidence of aortic regurgitation. The motion of the mitral valve appeared normal with mild mitral regurgitation and an ejection fraction of 25%. The patient had a history of paroxysmal atrial fibrillation following valve surgery in [**2106**]. He also had a recurrence in [**2115-2-9**]. He had symptomatic treatment in the past with beta blockers, which caused sinus pauses and severe bradycardia. The patient was status post aortic valve replacement with porcine on [**2106-5-31**] for aortic stenosis, questionably rheumatic. He developed congestive heart failure at that time. He was status post mitral valve replacement with porcine in [**2106-5-10**]. 2. Chronic obstructive pulmonary disease. 3. Prostate nodule, status post biopsy in [**2111**] which was negative. 4. Adult onset diabetes. 5. Hematuria in [**2115-12-11**] with heparin and Integrelin. This was found to be secondary to bladder stones. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d. Digoxin 0.125 mg p.o. q.o.d. Glyburide 2.5 mg p.o. q.d. Isordil 10 mg p.o. t.i.d. Lipitor 5 mg p.o. q.d. Norvasc 5 mg p.o. q.d. Zantac 150 mg p.o. q.d. ALLERGIES: The patient had an allergy to shellfish. PHYSICAL EXAMINATION: The patient had a temperature of 96.9??????F, a heart rate of 120, a blood pressure of 120/70 and a respiratory rate of 18. In general, the patient was in no acute distress. On head, eyes, ears, nose and throat examination, the pupils were 2 cm and symmetric. The the extraocular movements were intact with sustained nystagmus on the right and lateral gaze. There was left facial droop. The neck was supple with no lymphadenopathy. The carotids were without bruits. There were respiratory crackles one third of the way posteriorly bilaterally. The cardiovascular examination was a slightly irregular with a I/VI systolic murmur at the apex. The abdomen was soft, nontender and nondistended with positive bowel sounds. The extremities had no edema. There were 1+ dorsalis pedis pulses bilaterally. On neurologic examination, the patient was alert and conversant. Strength was [**6-13**] with 2+ biceps symmetrically. Touch was intact. LABORATORY: The patient had a white blood cell count of 8,700, hematocrit of 42.3 and platelet count of 229,000. Prothrombin time was 13.8, partial thromboplastin time was 25.7 and INR was 1.3. There was a sodium of 141, potassium of 3.8, chloride of 103, bicarbonate of 25, BUN of 20, creatinine of 0.9. Digoxin level was 0.3. Glucose was 149. Calcium was 9.3. Phosphate was 3.4. Magnesium was 2.1. RADIOLOGY: A chest x-ray showed possible mild upper zone redistribution consistent with, if at all, mild congestive heart failure. ELECTROCARDIOGRAM: The electrocardiogram had a wide complex tachycardia at 150 with a left axis and a left bundle branch block. HOSPITAL COURSE: The patient is an 81-year-old male with coronary artery disease, status post porcine mitral valve replacement and aortic valve replacement, who presented in atrial flutter. Initially, his rate was about the 150's with 2:1 conduction. The patient had a history of severe bradycardia with beta blockers, however cautiously he was given 5 mg of intravenous Lopressor upon presentation and his heart rate slowed to the 80's and 90's. He was started on 12.5 mg p.o. t.i.d. of Lopressor, which he tolerated well. The patient had heart rates well controlled in the 70's to 80's and remained in atrial flutter. The patient had a Digoxin level checked, which was 0.3. He was on a very low dose of Digoxin, 0.125 mg p.o. q.o.d., which was continued. Apparently, he had digitalis toxicity in the past, hence his very low dose. The patient was also started on heparin and, once he was therapeutic, he was loaded on Coumadin. It was anticipated that in one month he would need to undergo cardioversion, probably with amiodarone, given his low ejection fraction. Liver function tests and thyroid functions were pending at the time of this dictation and his chest x-ray did not show evidence of interstitial disease. The patient's INR was 1.3 at the time of this dictation. The patient ruled out for a myocardial infarction on this admission. 2. ISCHEMIA: The patient was status post cardiac catheterization on [**2116-1-6**] with restenosis of the left anterior descending artery and circumflex coronary artery, not intervened upon secondary to hematuria with his anticoagulants. Again, the greatest stenosis was 70% of the left anterior descending artery and this had been medically managed. There were no plans for intervention on this admission. He was continued on his aspirin and Lipitor and ruled out for a myocardial infarction. 3. PUMP: The patient had an ejection fraction of 25%. His blood pressure upon presentation was 120/70 however, given his low ejection fraction, his Norvasc was discontinued and he was started on a low dose ACE inhibitor. He tolerated the Captopril at 6.25 mg and then 12.5 mg. He was continued on his Isordil and switched over to Lisinopril on the day of discharge. Please note that prior to starting anticoagulation, Dr. [**Last Name (STitle) **], his urologist, was contact[**Name (NI) **] and said that it was okay to heparinize the patient and he did not exhibit any evidence of hematuria. The hospital course was also remarkable for a symptomatic multifocal ventricular tachycardia of five beats on two consecutive nights. The plans were for an electrophysiologic study, which was to be done in-house. NOTE: The remainder of this dictation will be done in the addendum. DISCHARGE DIAGNOSES: Atrial flutter. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Last Name (NamePattern1) 104014**] MEDQUIST36 D: [**2116-3-4**] 11:10 T: [**2116-3-5**] 06:37 JOB#: [**Job Number **] ICD9 Codes: 4280, 496
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Medical Text: Admission Date: [**2176-5-9**] Discharge Date: [**2176-5-19**] Date of Birth: [**2112-12-30**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 6169**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 63F h/o Mantle cell lymphoma s/p Part B hyper CVAD [**2176-4-29**] to [**2176-5-3**] presents with fever and neutropenia and only localizing infectious symptoms to the right labia. She noted excoriation of this area secondary to frequent urination post chemotherapy and mild swelling and erythema that developed on the day of admission. On presentation to the emergency department her vital signs were HR to the 150s, BP dropped from 157/63 to 90/50, Hco3 19, lactate 3.7. Due to rapid extension of the right labial erythema and edema, consults to Surgery and Gynecology were obtained. CT scan of the abdomen and pelvis were significant for no air in the soft tissues and both consult services agreed with medical management and close observation. The patient was aggressively hydrated with 2L NS with improvement in her BP and Vancomycin 1 gram, Cefepime 2grams and Clindamycin 600mg were administered intravenously in the ED. The patient was admitted to the MICU for close monitoring and her sepsis. Past Medical History: Mantle Cell Lymphoma diagnosed in [**10-29**] s/p 2 cycles of hyper-CVAD s/p cholecystectomy [**1-31**] Tonsillectomy (age 8) via XRT Recurrent ENT Infections as child TAH/BSO - [**Hospital1 112**] [**2170**] SCC Lower Lip s/p Resection [**2172**] Social History: Patient lives with her husband and has one son. She is [**Name8 (MD) **] RN and currently works as a NH administrator. Tob: quit smoking 39 years ago; used to smoke 5cig/day x 5 years. EtOH: used to drink less than 3x/week, currently no alcohol intake. No recreational drug use Family History: No known leukemias or lymphomas. Father died at 42 from rectal cancer. Paternal aunt died at 68 from BRCA. Paternal uncle and brother have DM. Maternal aunt died at 97 from MI. No FHx of early MI's. Physical Exam: T=103.9, HR 118, BP 92/43, RR 18, O2 sat 100% on RA Gen- non-toxic appearing HEENT-PERRLA, EOMI, sclera anicteric, OP clear Neck- no LAD, JVP est < 5 cm H2O Chest- slight decreased breath sounds at the left base. L port C/D/I CV- tachycardic, regular, normal s1 and s2, no s3 or s4. no murmur or rub. No rv heave Ab- soft/nontender/nondistended, normoactive bowel sounds. No masses or hepatosplenomegaly Ext- no clubbing, cyanosis, or edmea. 2+DP/PT pulses. warm/dry. Genital- right labial swolling with erythema and induration over the inferior aspect. No extension to perianal area. No flocculence. Pertinent Results: Admission labs: LACTATE-3.7* (the following day: [**2176-5-10**] 04:45AM BLOOD Lactate-1.9) GLUCOSE-173* UREA N-19 CREAT-1.3* SODIUM-135 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-17 ALT(SGPT)-94* AST(SGOT)-49* ALK PHOS-106 AMYLASE-30 TOT BILI-1.3 WBC-0.1*# RBC-2.89* HGB-9.1* HCT-25.3* MCV-88 MCH-31.4 MCHC-35.9* RDW-15.4 PLT COUNT-36*# PT-13.3 PTT-24.3 INR(PT)-1.1 Discharge labs: WBC-3.3* RBC-3.49* Hgb-10.8* Hct-30.7* MCV-88 MCH-30.9 MCHC-35.2* RDW-15.2 Plt Ct-120* BLOOD ALT-14 AST-11 LD(LDH)-152 AlkPhos-81 TotBili-0.5 BLOOD Calcium-8.1* Phos-2.7 Mg-2.0 Micro: [**5-9**]: blood cultures 1/2 bottles positive with E coli AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R subsequent negative blood cultures: [**5-11**] x2, [**5-12**] x2, [**5-13**] x2 UCx negative [**5-10**], [**5-12**] Imaging: CT abdomen/pelvis [**5-10**]: IMPRESSION: Vulvitis of the right labia majora, with involvement of the clitoris. No focal gas collections to suggest the presence of necrotizing fasciitis. The right adductor fascia is preserved. No radiographic evidence of osteomyelitis within the pubic symphysis. MRI pelvis [**5-13**]: 1. Asymmetric enlargement of the right labia majora, with edema and asymmetric thickening of the medial aspect of the right labia. This may be secondary to an infectious or inflammatory process, but direct involvement by lymphoma should be considered. 2. No evidence of abscess or fasciitis. 3. Superficial subcutaneous edema involving the anterior aspect of both thighs. 4. Bilateral iliac lymphadenopathy, left greater than the right. 5. Heterogeneous bone marrow signal within the proximal portions of both proximal femurs, likely related to the patient's history of lymphoma. 6. Small free fluid in the pelvis. Brief Hospital Course: 1. vulvitis - Pt was initially admitted to the intensive care unit, and the sepsis protocol was activated. She was volume resucitated with 5LNS with improvement in tachycardia and blood pressure. Two out of four blood cultures (both from the P-AC) were positive for E. coli, and pt was placed on broad antibiotics. She continued to appear clinically well despite continued fevers to 102. Despite broad antibiotic coverage the infection spread to the perianal area and more superiorly. The infectious disease service was consulted and recommended continuing clindamycin despite increasing hyperbilirubinemia to provide optimal coverage for toxin producing bacteria. The Surgery and Gynecology Consult services continued to follow the patient, beginning while in the MICU, and medical therapy was recommended, particularly given concern for introducing infection in the setting of her neutropenia. Pt continued to do well and was transferred to the floor. CT scan showed no evidence of fasciitis or abscess. As there was further concern per surgery team to rule out abscess or fasciitis, an MRI was also performed, which showed neither of these processes. Pt was maintained on meropenem IV, and the erythema of her R thigh and mons continued to improve daily, as did her pain. The wound care nurse showed the pt how to apply duoderm to the area of tissue necrosis/ulceration. Swabs of the area sent for VZV cultures are thus far negative. Pt was concerned about having an IV infusion pump at home due to the multiple animals living in her home; she was therefore switched to ceftriaxone/flagyl to finish out a 2-week total antibiotics course. After the switch, pt was afebrile for the next 48 hours and showed continued signs of improvement. She will return to clinic for daily ceftriaxone until [**5-23**], which is her last dose. On discharge, there was complete resolution of erythema on her thigh and mons; persistent induration along the R labia, with a round, ~1cm area of ulceration on the posterior R labia with an intact eschar overlying the ulceration. Of note, pt's pain was controlled with Tylenol. She attempted oxycodone but did not like the effects on her mental status. She reported that her pain was tolerable with Tylenol. 2. mantle cell lymphoma - pt was status post her second cycle of hyperCVAD. She was neutropenic initially, but her counts recovered, and her G-CSF was stopped. She continued to do well. She was transfused for anemia and thrombocytopenia as needed. It was thought unlikely that the area of necrosis/ulceration was due to lymphoma, given the results of the imaging studies, as above. 3. supraventricular tachycardia - While in the MICU, pt's course was complicated by runs of SVT consistent with AVNRT, requiring adenosine to terminate the rhythm and initiation of metoprolol. 4. hypertension - Pt's BP was in the 130s-140s, even with metoprolol. This was uptitrated, and pt was discharged on Toprol XL 25mg po daily. This should be followed for further blood pressure control. 5. FEN/GI - Pt was ultimately able to take po and was no longer neutropenic on discharge, making her diet unrestricted. Electrolytes were repleted as needed, notably potassium. This should be checked as an outpatient to ensure that she does not require potassium supplementation at home. 6. Code - full Medications on Admission: fluconazole 100mg po daily estradiol 1mg po daily tylenol prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days: return to clinic for infusion daily, end date [**3-25**]. 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Toprol XL 25 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* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. vulvar cellulitis 2. mantle cell lyphoma 3. Eschericia coli sepsis, resolved 4. hypertension Discharge Condition: stable, tolerating po, ambulating Discharge Instructions: Please return daily for ceftriaxone intravenous infusion for the next few days; your last day of treatment will be [**5-23**], to complete a 14-day course. If you notice fevers, chills, worsening pain, or increased redness of your vulva or leg, please go to the emergency room. Followup Instructions: Please return to 7Feldberg for infusion of intravenous ceftriaxone daily until [**5-23**]. ICD9 Codes: 5849, 2875, 4019, 2859
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Medical Text: Admission Date: [**2168-8-11**] Discharge Date: [**2168-8-11**] Date of Birth: [**2093-1-7**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 330**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: none History of Present Illness: 75yoW with salivary cancer metastatic to lungs, bone, liver, kidneys brought to [**Hospital1 18**] ED after cardiac arrest. Patient reportedly found down for 30minutes and intubated in the field for airway protection. On arrival to [**Hospital1 18**] no BP or HR, K 6.8, lactate 17.9. She was treated with epinephrine/atropine x2, pronounced dead, but then regained HR and pulse. BP 58/31, right femoral line placed, and she was started on dopamine. She received calcium gluconate and insulin/D50 for hyperkalemia. Currently HR 128, BP 113/99. ABG 7.08/45/432. She is not responsive to pain or verbal stimuli. Past Medical History: previous care at [**Hospital3 **] - metastatic cancer, thought to be salivary gland primary Social History: patient lives with her daughter. two daughters involved in her care. Family History: non-contibutory Physical Exam: T 92.4 HR 128 BP 113/99 RR 16 A/C TV 400 RR 16 FiO2 100% PEEP 5 ABG 7.08/45/432 Gen: comatose HEENT: pupils fixed 5mm, anicteric, ETT, OG tube with bloody output CV: tachycardic, regular, no mrg Resp: coarse bilaterally Abd: thin, no bowel sounds, soft, large palpable masses RLQ/RUQ/LLQ Ext: muscle wasting, 1+ radial pulses B, decreased DP pulses Neuro: nonresponsive to pain, pupils nonreactive, doll's eyes Pertinent Results: [**2168-8-11**] 12:56PM TYPE-ART PO2-432* PCO2-45 PH-7.08* TOTAL CO2-14* BASE XS--16 [**2168-8-11**] 12:56PM K+-3.8 [**2168-8-11**] 12:25PM GLUCOSE-571* LACTATE-17.9* NA+-139 K+-3.9 CL--100 TCO2-15* [**2168-8-11**] 12:05PM UREA N-23* CREAT-0.9 [**2168-8-11**] 12:05PM CK(CPK)-36 [**2168-8-11**] 12:05PM AMYLASE-125* [**2168-8-11**] 12:05PM CK-MB-NotDone cTropnT-0.02* [**2168-8-11**] 12:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2168-8-11**] 12:05PM URINE HOURS-RANDOM [**2168-8-11**] 12:05PM URINE HOURS-RANDOM [**2168-8-11**] 12:05PM URINE GR HOLD-HOLD [**2168-8-11**] 12:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2168-8-11**] 12:05PM WBC-21.0* RBC-4.02* HGB-8.7* HCT-30.3* MCV-75* MCH-21.6* MCHC-28.7* RDW-16.3* [**2168-8-11**] 12:05PM PLT COUNT-404 [**2168-8-11**] 12:05PM PT-15.6* PTT-58.4* INR(PT)-1.6 [**2168-8-11**] 12:05PM FIBRINOGE-432* [**2168-8-11**] 12:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2168-8-11**] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2168-8-11**] 12:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2168-8-11**] 12:05PM URINE AMORPH-FEW [**2168-8-11**] 11:44AM TYPE-[**Last Name (un) **] PO2-32* PCO2-69* PH-7.15* TOTAL CO2-25 BASE XS--7 [**2168-8-11**] 11:44AM K+-6.8* Brief Hospital Course: 75yo woman with history of metastatic cancer, primary thought to be salivary, presented after cardiac arrest, intubated in the field, rescuscitated in the ED by PEA ACLS protocol. CT head revealed a large posterior fossa intracranial hemorrhage. Neurologic exam demonstrated brain death. Neurosurgery and Neurology consults were called for confirmation. Initial exam was done with the patient hypothermic. She was warmed with a warming blanket, and repeat exam again demonstrated brain death. The family was notified that patient was brain dead. The organ donation team was notified. The family declined organ donation. The ventilator was withdrawn. The medical examiner was called and declined evaluation. Medications on Admission: percocet prn Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased ICD9 Codes: 431, 2767, 2762
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Medical Text: Admission Date: [**2107-11-12**] Discharge Date: [**2107-12-21**] Date of Birth: [**2045-12-2**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 2763**] Chief Complaint: renal failure s/p CRT Major Surgical or Invasive Procedure: HD line placement History of Present Illness: 61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes, diastolic CHF, admitted on [**2107-11-12**] with acute on chronic dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of worsening dyspnea, cough, and fever/chills. Also with orthopnea, PND, and worsening edema in all 4 extremities. . Labs showed ARF with creatinine of 5.8 (up from 2.9). During hospital course on the floor, renal function continued to worsen and urine output was low even with furosemide (unclear etiology of ARF). Also noted to have intermittent somnolence but arousable and fully oriented. ABGs repeatedly with partially compensated respiratory acidosis (has also had this in the recent past), team unsure how reliable ABGs were given bilateral UE fistulas. . Patient was in angio having hemodialysis line placed when his arrest event occurred. He was placed in a lateral decubitus position due to difficulty lying flat due to shortness of breath. Towards the end of his line placement, he became more agitated and was pushing his facemask away. O2 sats were unable to be obtained. He was then placed in supine position for line suturing. He was then noted to be nonresponsive, code blue call. Then noted to be pulseless. CPR initiated and initial rhythm asystole/very slow PEA, subsequently faster PEA. Total pulseless time 13 minutes. Received total 2 mg epinephrine, 2 amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line. Regained pulses with first SBP >180. Intubated. . In the MICU, patient seemed to be waking up some but with also evidence of extensor posturing in upper and lower extremities. Neuro consulted. Aline and CVL placed. . Review of systems: unable to obtain Past Medical History: - Renal cell carcinoma s/p resection [**2093**] - Severe obstructive sleep apnea,(not wearing CPAP at home) - ESRD s/p CRT [**2101**], complicated by transplant renal artery stenosis necessitating stent placement in [**2103**] - Resistant HTN - Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate diastolic LV dysfunction with elevated LVEDP. Mild pulmonary hypertension - Diabetes, type 2, on insulin - GERD - Barrett's Esophagus - s/p patella avulsion repair - history of hypercalcemia - hyperparathyroidism Social History: Married with seven children Employment: Employed as a chef at [**Hospital1 18**] Tobacco: No h/o Alcohol: No h/o Family History: Mother with kidney disease. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Intubated; initially not sedated. Not opening eyes but moving all extremities to pain and initally spontaneously. ?myoclonic and posturing as below. HEENT: Sclera anicteric, pupils equal at 2 mm though minimal reactive. ETT in place. Neck: HD line in place. Obese neck, difficult to appreciate JVD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, loud systolic murmur best at RUSB and LUSB. Abdomen: soft, distended, appears non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. [**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right slightly greater than left Neuro: Moving some spontaneously and responsive to pain in the UEs, not much pain response in the LEs. Seems to be intermittently with extensor posturing (lasts 2-3 seconds at a time), sometimes associated with ?myoclonic movements of ankles. + significant bilateral ankle clonus. Pertinent Results: [**2107-11-12**] 8:10p . Other Urine Chemistry: UreaN:549 Creat:199 Na:<10 TotProt:53 Prot/Cr:0.3 Osmolal:347 . Color Yellow Appear Clear SpecGr 1.013 pH 5.0 Urobil Neg Bili Neg Leuk Tr Bld Neg Nitr Neg Prot 75 Glu Neg Ket Neg RBC 0-2 WBC [**6-15**] Bact None Yeast None Epi 0-2 Other Urine Counts RenalEp: 0-2 CastHy: 0-2 . [**2107-11-12**] 4:10p 138 103 72 ------------- 178 5.0 27 5.8 &#8710; . Ca: 9.6 Mg: 2.6 P: 4.3 &#8710; CK: 315 MB: 5 Trop-T: 0.08 . Alb: 2.9 proBNP: 1817 . .....8.4 5.5 ----- 212 .....26.8 N:68.5 L:21.8 M:6.9 E:2.4 Bas:0.5 . CXR [**2107-11-14**]: In comparison with the study of [**11-12**], there are lower lung volumes. Enlargement of the cardiac silhouette persists with mild vascular congestion suggested. . EKG: NSR at 94, NANI, low limb lead voltage, poor RWP (old); no significant change from prior. . TTE [**2107-11-14**]: The left atrium is moderately dilated. mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There is mild pulmonary artery systolic hypertension. There is a very small circumferenital pericardial effusion. . Renal ultrasound [**11-13**]: No new findings. . CT Chest [**11-15**]: On CT, there is no evidence of air embolism. Cardiomegaly, mild axillary and mediastinal lymphadenopathy. Bilateral pleural effusions with areas of subsequent atelectasis, patchy lower lobe predominant parenchymal opacity is potentially suggestive of a combination of pneumonia and atelectasis. No pathologic air collection in the mediastinum and the lung interstitium. . CT Head [**11-15**]: 1. No acute intracranial hemorrhage or acute vascular territorial infarction. There is no hydrocephalus. 2. Opacification of sphenoid sinus, maxillary, ethmoid air cells and nasopharynx, most likely related to recent intubation. . CT Head [**11-17**]: 1. No acute intracranial hemorrhage or obvious major territorial acute infarct, mass effect, or hydrocephalus. If there is continued concern, MR of the head with diffusion-weighted imaging sequence is more sensitive in the detection of acute stroke. 2. Diffuse opacification of the sphenoid sinus, nasopharynx, the maxillary and the ethmoid air cells partly related to mucosal thickening, secretions from intubation. However, patient also had a left antrochoanal polyp in the past, which is incompletely assessed on the present study. 3. Discontinuous foci in the left parietal bone may relate to thinning of the bone, from arachnoid granulations or other etiology, to correlate with any history of surgery. However, this appearance is unchanged compared to the prior CT sinus study done on [**2102-10-19**]. . RUE US [**11-20**]: Although subclavian vein not evaluated, remainder of right upper extremity venous system appears normal with no evidence of DVT, and DVT would be likely in the subclavian vein given respiratory variation and normal appearance of remainder of the study. . MR [**Name13 (STitle) 430**] [**11-21**]: 1. Severely limited examination demonstrates changes of chronic microvascular white matter ischemic disease with old left frontal encephalomalacia without evidence for acute infarct. 2. Extensive paranasal sinus and mastoid air cell disease. . KUB [**11-25**]: 1. Severely limited examination demonstrates changes of chronic microvascular white matter ischemic disease with old left frontal encephalomalacia without evidence for acute infarct. 2. Extensive paranasal sinus and mastoid air cell disease. . KUB [**11-26**]: There is no evidence of free air. NG tube tip is in the stomach. Right femoral catheter remains in place. There is no evidence of bowel obstruction. There is nonspecific bowel gas pattern. . Portable Abdomen XR [**11-29**]: There is no evidence of ileus, small or large bowel obstruction. . Abdominal US [**12-6**]: Normal right upper quadrant ultrasound with no findings to suggest the cause of the patient's pain. . CT Abd/Pelvis [**12-6**]: 1. Small thrombus within the IVC and at the junction of the right common iliac vein and transplanted renal vein. 2. Diffuse mesenteric stranding with no small or large bowel pathology identified. . CT Head [**12-11**]: 1. . No acute intracranial abnormality. 2. Partial opacification of mastoid air cells bilaterally, maxillary, ethmoid and sphenoid sinuses, partly polypoidal. . CT Abd/Pelvis [**12-11**]: 1. Very large spontaneous hematoma involving a majority of the left hepatic lobe. A small amount of perihepatic hematoma and scattered areas of blood within the mesentery and along the left pericolic gutters tracking into the pelvis. No definite site of active extravasation identified. 2. Branches of left portal vein are attenuated and not well visualized in the midst of the hematoma but are patent. 3. No change in small 1.5 cm thrombus within the infrarenal IVC. Second separate smaller thrombus in the right common iliac vein near the transplant renal vein anastomosis on the prior study not definitely visualized and may have cleared with anticoagulation. 4. Atelectasis of both dependent lower lobes. 5. More confluent consolidative opacity of the superior right lower lobe could be explained with atelectasis but is concerning for possible area of aspiration or pneumonia. . CT Abdomen [**12-16**]: Limited study but no gross evidence of obstruction. . CXR [**12-19**]: There is interval development of vascular engorgement, perihilar opacities, and bibasilar opacities, left more than right, findings which might be consistent with interval progression of pulmonary edema. Evaluation after diuresis is recommended to exclude the possibility of underlying infectious process. Brief Hospital Course: 61M with ESRD s/p CRT, HTN, DM, admitted with dyspnea and ARF. During IR placement of an HD catheter he suffered a PEA arrest x 2. He was cooled using artic sun protocol. He slowly recovered, but his hospitalization was complicated by prolonged intubation leading to tacheostomy placement, Psuedomonas UTI, HAP, Stenotrophomonas PNA, aspiration PNA, acute on chronic kidney injury leading to loss of fuction of his transplanted kidney, IVC thombosis, spontaneous intrahepatic hemorrage during heparinization for his thrombus, gout flair, and altered mental status which has slowly improved. After more than a month in the hospital he has stabilized, is ambulating with assistance, speaking through a Passe Muir valve, and tolerating tube feeds. . # Aspiration: Patient had emesis [**2107-12-13**] and aspirated tube feeds. Developed aspiration pneumonitis vs. aspiration PNA. CXR showed no clear evidence of PNA but CT showed confluent consolidative opacity of superior RLL. Pt was febrile following aspiration event and ended up re-intubated. Now s/p 7-day course of vanc/zosyn for aspiration that ended on [**2107-12-18**]. Respiratory status has dramatically improved and he is now on trach mask only. He had a video swallow evaluation on [**2107-12-20**] which showed silent aspiration. It was suggested that he have a diet of nectar thick liquids and soft consistency solids. meds must be crushed in purees with Q6 hour oral care. He should have follow up with speech therapy at rehab with repeat video swallow if diet is to be advanced. . # Stenotrophomonas PNA: Diagnosed from repeated sputum cultures. On Bactrim x14 day course, day 1=[**12-16**] to d/c [**12-30**]. Note that Bactrim must be give FOLLOWING HD as it is dialyzed off. Intially diagnosed [**12-2**], but was inadquately treated as Bactrim was given prior to HD rather than after. . # Pseudomonas UTI: Had a long course of Cefepime for UCx positive for Pseudomonas x 2. . # Line infection: S/p Cefepime initially for UTI. Then Linezolid was added for purulent appearing CVL. His lines were exchanged and complicated by PEA arrest during procedure. His CVL grew out Micrococcus. According to ID, the Cefepime should have covered it. He received a 14d course of Cefepime and 9d course of Linezolid. A PICC line and new HD line were placed and have had no further complications. . # Labile blood pressures: Pt had been intermittently hypotensive (infectious source vs hypovolemia vs adrenal insufficiency). His infections were treated. He was given stress dose steroids. He was on pressors for hypotension. Ultimately this resolved and he became persistently hypertensive to the 190s to 220s. He was started on a labetalol drip as well as PRN hydralazine. He has been transitioned from Labetalol drip to PO Labetalol on [**12-9**], then switched to Labetalol PRN. On [**12-14**], Labetalol was d/c??????ed. Continue atenolol at 50mg daily. Continue lisinopril 10mg daily. . # Foot Pain: Likely gout, particularly given resolving hematoma and renal failure. Receiveing pulse steroids with Prednisone 40mg daily x5 days starting on [**2107-12-20**]. Will resume chronic Prednisone 5mg PO daily for maintenance of transplanted kidney thereafter. [**Month (only) 116**] need suppressive allopurinol in the future for his gout. . # DVT: Patient found to have venous thrombi in several vessels including his IVC. He was on a heparin drip, being bridged with coumadin. However, all anticoagulation stopped when liver hematoma developed (see helow). Hematology was consulted regarding whether it is appropriate to resume anticoagulation given the risk of bleed, and recommended SC Heparin tid until he follows up with Hematology and possibly vascular surgery regarding possible benefits vs. risks of an IVC filter placement. The patient should not be anti-coagulated with agents other than SC Heparin given his high risk of bleed. . # Abdominal Distension: Patient??????s abdomen became distended and tympanitic during this hospitalization. CT abdomen [**12-11**] showed large liver hematoma with scattered areas of perihepatic hematoma and scattered blood within the mesentery but without definite sites of active extravasation. Distension likely [**2-7**] chemical peritonitis which is resolving following reversal of anticoagulation vs. functional ileus/[**Last Name (un) **]??????s syndrome from infection/sepsis, intra-abdominal bleed, narcotic use, or respiratory failure. This is consistent with the patient??????s continued +bowel sounds and leukocytosis, but CT abdomen did not show dilated R side of colon and loops of bowel were read as WNL. Currently improved abdominal pain and minimally improved distension. Abd is much less tense than prior. Continue Reglan 2.5mg TID standing for treatment of presumed diabetic gastroparesis. Advancing diet as tolerated with tube feeds. . # Liver Hematoma: As above, CT showed hematoma of liver while on heparin drip for IVC thombus. IR consulted re: possible embolization, did not feel the bleed was acute (felt >48 hours old) and wished to preserve hepatic artery and liver function if possible, so recommended monitoring Hct. General surgery consulted re: possible relation to PEG placement, but did not believe this was [**2-7**] procedure based on the location of the hematoma. Recommended montoring q6h Hct and coags, transfusing as needed and keeping Hct >20. Received total of 3 unit pRBC after reversal of PTT with FFP. Awaiting hematology recommendation for long term anticoagulation given presence of IVC thombus but complication of hemorrhage. (Ultimately decided to hold all anticoagulation given severity of liver bleed.) . # Respiratory failure. Originally intubated in setting of arrest with hypoxia beforehand. Was very difficult to wean from vent due to persistent hypoxia, recurrent PNA, and altered mental status. Trach and PEG placed on [**12-2**]. Now stable on trach. Had aspiration even as above leading to short tern re-intubation. Now tolerating trach mask. Speaking with Passe Muir valve. . # Altered mental status s/p PEA arrest: S/p PEA arrest x 2. Underwent Artic Sun cooling protocol. Suring weaning of sedation was severely agitated. Ultimately was transitioned from fentanyl to methadone and then weaned on seroquel. He had a significant set back from his liver hematoma and aspiration PNA. Neuro was consulted and noted a staring spell that was concerning for seizures. He was monitored with continuous EEG, which showed epileptiform spikes but not outright seizure activity. Neuro recommended startingKeppra, with Keppra 500mg qday and an extra 250mg after HD. The patient has slowly improved and is not conversant, [**Location (un) 1131**], walking with assistance, and no longer agitated. He is alert and oriented. . # Acute on chronic renal failure. He is s/p CRT in [**2101**]. Etiology of ARF likely multifactorial due to hypotension from PEA, sepsis, contrast loads, and nephrotoxic drugs. Her the Renal Service, he will not recover renal function of his kidney. He will require HD henceforth. Continue prednisone 5mg PO daily for rejection as well as Renagel 800 tid, Sevelemer 800 tid. . # FEN: Speech and Swallow Recs - video swallow: silent aspiration seen on s/s for thin liquids. Recs: 1. Suggest a PO diet of nectar thick liquids and soft consistency solids. 2. PMV on for all POs. 3. Meds crushed with purees. 4. Monitor for nutritional intake. 5. Q6 oral care. 6. Follow up speech therapy in rehab s/p d/c Medications on Admission: -Amlodipine 10 mg [**Hospital1 **] -Calcitriol 0.25mcg QD -Cinacalcet 90 mg QD -Clonidine 0.1 mg [**Hospital1 **] -Lasix 120mg PO BID -Labetalol 600mg [**Hospital1 **] Lisinopril 10mg QHS -Minoxidil 10mg [**Hospital1 **] -Mycophenolate Mofetil 500mg [**Hospital1 **] -Prednisone 5mg QD Vardenafil 10mg PRN -Aspirin 81mg QD Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM. Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] units Injection PRN (as needed) as needed for line flush. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H (every 6 hours) as needed for fever, pain. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**] Drops Ophthalmic PRN (as needed) as needed for irritation. 8. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for renal transplant. 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four (4) Tablet PO QHD (each hemodialysis): DC on [**12-29**].09. Give AFTER HD. 12. Metoclopramide 10 mg Tablet Sig: 2.5 mg PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Increase as needed for persistent HTN. 14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea, wheeze. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath, dyspnea. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: DC on [**2107-12-24**]. Please give IN ADDITION to standing prednisone 5mg PO daily for rejection. 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 20. Keppra 250 mg Tablet Sig: One (1) Tablet PO after HD: in addition to daily dose of Keppra 500mg PO BID. 21. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): For IVC thrombi until further evaluated by vascular surgery as outpatient. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Primary: - Renal failure - Volume overload / acute on chronic CHF - PEA arrest - Altered mental status - Bacterial pneumonia - Ventilator associated pneumonia - Aspiration pneumonia - Urinary tract infection - Hypertensive urgency - Repiratory failure . Seconary: - Renal cell carcinoma s/p resection [**2093**] - Severe obstructive sleep apnea,(not wearing CPAP at home) - ESRD s/p CRT [**2101**], complicated by transplant renal artery stenosis necessitating stent placement in [**2103**] - Resistant HTN - Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate diastolic LV dysfunction with elevated LVEDP. Mild pulmonary hypertension - Diabetes, type 2, on insulin - GERD - Barrett's Esophagus - s/p patella avulsion repair - history of hypercalcemia - hyperparathyroidism Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted initially for volume overload and shortness of breath. You had a long and complicated hospitalization for treatment of this and various complications. You suffered a severe type of heart attack called a PEA arrest. You required life support from this event and were dependent on a breathing machine for several weeks. Due to this a tracheostomy (breathing tube in your neck) and feeding tube were placed. You had several infections including a urinary tract infection, blood infection, and pneumonias. You developed a clot in your veins and was placed on blood thinners. Unfortunately, you bled while on the blood thinners and these were stopped. Your kidney function worsened and your transplanted kidney stopped functioning. You were restarted on dialysis. . Please continue to take your medications as ordered. . Please attend your follow up appointments. . Followup Instructions: Appointment #1 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Neurology Date/ Time: Wednesday, [**1-4**] at 1pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **] Phone number: [**Telephone/Fax (1) 44**] Appointment #2 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Transplant Date/ Time: [**Last Name (LF) 766**], [**1-9**] at 3:20pm Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] Bldg, [**Last Name (NamePattern1) 439**], [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 673**] Appointment #3 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**] Specialty: Hematology Date/ Time: Wednesday, [**1-25**] at 1:40pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 6946**] During your appointment with Dr. [**Last Name (STitle) 6944**] (Hematology), please discuss whether you will need to be evaluated by vascular surgery regarding possible placement of an Inferior Vena Cava filter, and whether the benefits outweigh the risks, given your blood clots. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2107-12-21**] ICD9 Codes: 5849, 4275, 5070, 9971, 5990, 4280, 5856, 4168, 2749
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Medical Text: Admission Date: [**2178-11-10**] Discharge Date: [**2178-11-12**] Date of Birth: [**2111-9-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: brain hemorrhage Major Surgical or Invasive Procedure: intubated History of Present Illness: Patient with 1 week of severe headaches, fell down stairs at her house and found unresponsive and hypertensive at the scene. Transferred to [**Hospital1 18**] for further evaluation. Past Medical History: ? hypertension Social History: lived with husband, no smoking, no alcohol, no drug use Family History: noncontributory Physical Exam: T 98.4 P85 BP 209/104 RR10 sat 100%bagged mask head:pupils fixed and dilated bilaterally, R parietal hematoma Pulm: poor respiratory effort - intubated with good breath sounds bilaterally CV: RRR, -MRG GI: no trauma visible, plevis stable, rectal lax tone with no blood GU: WNL Neuro: GCS 3, upgoing toes Pertinent Results: [**11-10**] CT head: Large intraparenchymal hemorrhage centered within the right basal ganglia , pons and midbrain, with blood dissecting into the lateral, third and fourth ventricles. Given location of hemorrhage most likely etiology include hypertensive hemorrhage. There is extensive edema surrounding the hemorrhage site with subfalcine and uncal herniation. CT c-spine: No fracture or subluxation is identified involving the cervical spine. Multilevel degenerative changes are seen, notably disc space narrowing at C5-C6 and vertebral height loss and sclerosis of C6. ET tube is present. Dystrophic calcification noted within the right lobe of the thyroid. Mild emphysematous change within the lung apices. The prevertebral soft tissues are normal. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs show mild dependent atelectasis without focal consolidation. 7.2 x 5.8 mm ground-glass nodule is seen within the superior segment of the right lower lobe which is likely inflammatory. No pleural or pericardial effusion identified. The heart and great vessels are within normal limits. The aorta maintains a normal contour without evidence of dissection. ET tube is present with the tip just above the carina. No axillary or mediastinal lymphadenopathy is identified. Note is made of a dilated fluid- filled esophagus. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Liver demonstrates a 7 mm low- density lesion within the right lobe, incompletely characterized. The gallbladder, adrenal glands, spleen, and pancreas are within normal limits. The kidneys enhance and excrete contrast symmetrically. Note is made of a fluid- filled stomach and proximal small bowel, although no evidence of obstruction. No intra- abdominal free air, free fluid or lymphadenopathy is identified. The abdominal aorta maintains a normal contour. The celiac, SMA and [**Female First Name (un) 899**] are normally opacified. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, uterus, and intrapelvic small bowel are within normal limits. No free fluid or lymphadenopathy is identified. The bladder contains a Foley catheter Brief Hospital Course: Patient with herniation and large intraparenchymal bleed on CT, intubated and transferred to ICU. Pupils fixed and dilated, neurosurgery evaluated patient and reported no available intervention. Family was contact[**Name (NI) **] and the decision was made to withdraw care on [**2178-11-12**]. Patient taken off of the ventilator at 21:00, and the patient was pronounced dead at 21:17. Medications on Admission: none Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: intraparenchymal hemorrahage/death Discharge Condition: death [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] ICD9 Codes: 431
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Medical Text: Admission Date: [**2158-7-2**] Discharge Date: [**2158-8-2**] Date of Birth: [**2074-6-4**] Sex: M Service: MEDICINE Allergies: Codeine / Ceftazidime Attending:[**First Name3 (LF) 2817**] Chief Complaint: Ileus and altered mental status Major Surgical or Invasive Procedure: PICC line insertion History of Present Illness: Mr. [**Known lastname 656**] is an 84 year old gentleman recently readmitted after a prolonged hospital course for ileus. He initally presented to an outside Emergency Room on [**6-5**] after a fall, found to have hemothorax with an INR of 11. His hospital course was complicated by continued intractable pain, nerve blocks and transfers to and from the surgical floor. He developed atrial fib with RVR and increased work of breathing and was found to have a loculated R pleural effusion. He underwent VATS converted to thoracotomy for decortication. He grew out MRSA and MSSA with ID recommending Vancomycin until [**7-31**]. He had difficulty weaning form the vent and was put in for a trach/PEG. He was discharged to rehab with a PICC in place to treat the infection above, still with what may have been hypoactive delirium. . The patient was readmitted on [**7-2**] with AMS, ileus and concern for a bowel obstruction. He was found to have + blood cultures from his PICC (with associated clot, PICC changed), and found to have Klebsiella & Pseudomonas VAP for which he is on a 21 day course of Ceftaz/Cipro to end [**7-24**]; TEE negative. He has also developed Afib with RVR for which he has been started on Amiodarone; hypertension intermittently controlled with Nitro gtt; worsening renal function and agitated delirium for which geriatics is following. . At the time of transfer, the patient is not easily arousable and cannot answer questions. A discussion with his primary TSICU team and Geriatrics consultant yields the concerns above. . Review of systems: Unable to obtain, patient not easily arousable/oriented Past Medical History: Past Medical History: 1. s/p fall with hemothorax ([**2158-6-8**]) 2. DVT, right leg in 11/[**2156**]. 3. Hypertension 4. COPD 5. elevated cholesterol 6. Osteoarthritis of the hip 7. BPH Past Surgical History: [**2158-6-18**] Right video-assisted thoracoscopy converted to right thoracotomy, decortication of lung and evacuation of retained hemothorax/empyema. [**2158-6-22**] Percutaneous tracheostomy placement and gastroesophagoscopy with percutaneous gastrostomy tube placement. Social History: No drug abuse Married, former smoker Family History: Positive for cancer in brother, heart disease, mother, father, kidney disease, aunt. Physical Exam: On Admission: 101.6 F 71 133/61 25 100% CMV 1 350x23 +5 GEN: sedated, NAD HEENT: trach in place, No scleral icterus, mucus membranes moist Skin: no rash, wounds. PICC in LUE- no edema, erythema, drainage CV: irreg, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: obese, firm, distended, appears tender-max RUQ, no rebound or guarding, no palpable masses Ext: No LE edema, LE warm and well perfused On discharge: Afebrile, VSS GEN: awake, alert, appropriate, NAD HEENT: trach in place, moist mucous membranes Pulm: Clear to auscultation bilaterally anteriorly CV: irregular, no m/r/g noted Abd: soft, NT, ND, +BS Ext: 1+ pitting edema in the LE bilaterally to the knees Rash: Diffuse erythematous morbilliform eruption worse from the waist down Pertinent Results: Imaging: [**7-2**] pCXR - Moderate right pleural effusion with bibasilar opacity. Overall, this may represent cardiac congestion with associated volume loss. Other less likely considerations include aspiration or bilateral infectious consolidation. [**7-2**] CT torso - new dilated loops of small bowel concerning for early SBO, possible closed loop obstruction. transition point somewhere in LLQ with distortion of mesentery ?rotation of bowel. new free fluid within abdomen. scattered areas of bowel wall thickening. +gallstones, unchanged. b/l basilar consolidations. (preliminary) [**7-3**]- UE US- Grayscale and Doppler son[**Name (NI) 1417**] of the left internal jugular, subclavian, axillary, brachial, and basilic veins demonstrate normal flow, compressibility, augmentation, and waveforms. At the site of the bandage and prior PICC at the left cephalic vein there is intraluminal distention and thrombus with no flow present. [**7-4**]- ECHO No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There are simple atheroma and focal nonmobile (>4mm) plaque in the descending thoracic aorta and aortic arch. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. [**7-13**]- ct HEAD: No acute intracranial hemorrhage, large mass or mass effect is identified. There is no large hypodense area to suggest an acute infarct. There is a small hypodense focus in the right posteroinferior frontal lobe which is more conspicuous than a recent head CT performed [**2158-6-17**]. This may represent volume averaging or a small area of intraparenchymal change (2:15). Note is made of bilateral tortuous ophthalmic veins, which are unchanged from prior study. There is no increased density in the cavernous sinuses to suggest thrombus. There is diffuse opacification at the bilateral mastoid air cells, which is new since prior study. There are air-fluid levels in the left sphenoid sinus. There is diffuse osteopenia. No other bony abnormalities are identified. [**7-17**]- MRI: IMPRESSION: 1. No evidence of acute cerebral infarction. 2. Minimal if any small vessel ischemic disease. 3. Symmetric prominent bilateral superior ophthalmic veins raise question of carotid-cavenous fistla. This is similar as compared to [**2158-6-17**]. Clinical correlation to symptoms is recommended. 4. Paranasal sinus disease. [**7-19**] - RUQ US: Sludge-filled gallbladder, as seen previously, not suggestive of cholecystitis [**7-28**] - Upper extremity dopplers: No new DVT (old dvt in left cephalic vein remains) ADMISSION LABS: [**2158-7-2**] 12:45AM BLOOD WBC-14.8* RBC-3.00* Hgb-8.9* Hct-27.2* MCV-91 MCH-29.8 MCHC-32.9 RDW-16.3* Plt Ct-557* [**2158-7-2**] 12:45AM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.2 Eos-0.2 Baso-0.3 [**2158-7-19**] 02:59AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ [**2158-7-2**] 12:45AM BLOOD Plt Ct-557* [**2158-7-2**] 12:45AM BLOOD PT-14.4* PTT-24.2 INR(PT)-1.2* [**2158-7-2**] 12:45AM BLOOD Glucose-150* UreaN-45* Creat-2.0* Na-146* K-3.9 Cl-103 HCO3-30 AnGap-17 [**2158-7-2**] 12:45AM BLOOD ALT-28 AST-33 LD(LDH)-301* AlkPhos-322* Amylase-38 TotBili-1.9* DirBili-1.1* IndBili-0.8 [**2158-7-2**] 12:45AM BLOOD Albumin-2.9* Iron-80 [**2158-7-3**] 12:21AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.9* [**2158-7-2**] 12:45AM BLOOD calTIBC-203* Ferritn-1196* TRF-156* [**2158-7-2**] 02:35AM BLOOD Type-ART Rates-14/15 Tidal V-450 FiO2-40 pO2-318* pCO2-43 pH-7.47* calTCO2-32* Base XS-7 Intubat-INTUBATED DISCHARGE LABS: [**2158-8-2**] 03:25AM BLOOD WBC-10.6 RBC-3.16* Hgb-9.6* Hct-28.3* MCV-90 MCH-30.4 MCHC-33.9 RDW-17.7* Plt Ct-292 [**2158-8-2**] 03:25AM BLOOD Neuts-82.5* Lymphs-10.9* Monos-4.1 Eos-2.3 Baso-0.1 [**2158-8-2**] 03:25AM BLOOD Glucose-112* UreaN-58* Creat-1.3* Na-140 K-3.8 Cl-97 HCO3-36* AnGap-11 [**2158-8-2**] 03:25AM BLOOD ALT-33 AST-34 LD(LDH)-265* AlkPhos-239* TotBili-0.6 [**2158-8-2**] 03:25AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.0 Mg-2.1 Brief Hospital Course: #) Agitated Delirium: While the patient was originally admitted to [**Hospital1 18**] to the surgical service for management of his SBO vs. ileus, the reason for his extended stay was his agitated delirium. While in the surgical ICU, he was started on precedex, and as per geriatrics consult, he was started on standing seroquel and his sleep wake cycle was re-established. However, his precedex was stopped as this isn't a long term solution, and his delirium worsened. Organic causes of the agitated delirium were ruled out. He was transferred to the medical ICU for continued care of his agitated delirium. While in the medical ICU, we tried a multitude of medications, including a change in his antipsychotics, as well as a variety of benzodiazepines. Geriatrics and psychiatry continued to consult, however all prn and standing medications tried were unsuccessful. Ultimately, we restarted precedex drip in an effort to wash out all other psychoactive medications. Over the course of 5 days, we were able to wean off the precedex while starting clonidine. While the clonidine is for his blood pressure, it was thought that since it works on the same receptor as the precedex, it would also assist in the control of his agitated delirium. After weaning off the precedex, he remains on 0.1 mg of clonidine POBID and has been clear in terms of his sensorium for over 3 days now. He has also been started on depakote as per our geriatrics team. . #) DRESS (drug rash with eosinophilia and systemic symptoms): The patient developed a morbilliform rash that was through secondary to the ceftazidime that was started for his pseudomonas and klebsiella from the sputum. His eosinophils increased to a peak of 15%, and associated with this was an increase in his LFTs as well as progression of his renal failure. A derm consult agreed and they suggested three days of IV solumedrol. Afterward, he was started on a prednisone taper (120 mg x 3 days, 80 mg x 3 days, and 40 mg x 3 days). For symptomatic control, we used barrier creams. On the day of discharge, his rash seems to be a little worse, so rather than continuing with the taper, we have decided to continue him on 40 mg of prednisone and to slow the taper. Now, he should receive three more days of the 40 mg dose (until the [**7-5**]), and then transitioned to 20 mg daily. He should also NOT receive ceftazidime, nor should he receive any lasix (the sulfa groups thought to be contributing to the DRESS). . #) Renal failure: The patient's creatinine continued to rise throughout his hospitalizations. Urine electrolytes and eosinophils were sent which were consistent with ATN rather than AIN. Given the DRESS (see above), we felt that this was the likely reason for the renal failure. His Cr has returned to baseline prior to transfer to rehabilitation. While he had ATN, we kept him even in terms of ins and outs. He was refractory to lasix when he was acutely in renal failure. Also, given the thought that the sulfa group in lasix may worsen DRESS, he instead was placed on 100 mg of ethacrynic acid POBID which has worked well for him. . #) Respiratory distress: The patient required being placed on the ventilator via his trach in what was thought to be volume overload and ventilator associated pneumonia. His sputum grew pseudomonas, and as above, ceftazidime was not helpful as it caused the DRESS syndrome. He was ultimately treated for his VAP with 8 days of cipro and meropenem, as well as an earlier course of cefepime. For gram positive coverage, the patient was continued on his vancomycin (see below). Also, during his hospitalization, his trach was changed x 1 as he had a cuff leak upon arriving to the MICU. In terms of the volume overload, he was started on 100 mg of ethacrynic acid POBID to help him slowly diurese some of the fluid off. His volume status is much improved from when his Cr peaked at 3.0. He was ultimately weaned from the ventilator approximately 1.5 weeks prior to discharge. . #) Staph bacteremia: The patient had GPCs in the blood early in his hospitalization. The patient's vancomycin (originally started for MRSA in the pleural cavity) was continued and an ID consult was done. They felt the course should continue until [**7-31**], and vancomycin was stopped on that date. Future blood cultures have been negative. A TEE was done and was negative for endocarditis. #) Ileus vs SBO: Pt was initially admitted to the surgical team for management of this issue. After multiple scans, it was thought that this was an ileus secondary to narcotic usage. Also, with the renal failure, the level of bowel edema likely contributed to the inability to take tube feeds. After his creatinine normalized, he was able to take tube feeds more consistently and has been at goal. This has largely resolved, and we are continuing to diurese him for his bowel edema. . #) Atrial fibrillation: Anticoagulation was not initiated for him as his risk of stroke while in house was considered to be low, and given the recent surgical procedure, we held off in the setting of his other medical issues. He is maintained on metoprolol tartrate 25 mg POTID for his rate control and this has not been an issue in the few days leading up to discharge. . #) Hypertension: The patient's blood pressure would acutely increase with his agitated delirium, however he was also found to be hypertensive at baseline. His blood pressure medications were titrated, and a nitro gtt was used intermittently while titration was attempted. Ultimately, his pressures and regimen stabilized and clonidine was started in an effort to also help with his mental status. Please see his medication list for his current regimen. . #) Anemia: The patient has worsening anemia with no new suggested bleeding sites, could represent underproduction, bone marrow suppression from infection, abx, renal disease or nutritional deficiency. His Hct stabilized and was checked daily. . #) Elevated blood glucose: No history of diabetes. SSI for glucose control, goal <200 We continued him on 12 units of lantus QHS. He has been doing well on this regimen, however, it will likely need to be titrated in the future once his prednisone taper continues. #) h/o DVT: not currently candidate for anticoag. LENIs negative, UENI?????? no new DVT Will consider anticoagulation at a later date #) Code Status: The patient was originally full code, however during his hospitalization, his family decided to change him to DNR. This will have to be an ongoing discussion with the patient and his family. Medications on Admission: Vancomycin 1 gram q24 (last trough [**7-1**]- 32) Finasteride 5 mg Tab Oral 1 Tablet(s) Once Daily Combivent 1 Aerosol(s) Four times daily nebulizer Docusate Sodium 50 mg/5 mL Oral 2 Liquid(s) Twice Daily Esomeprazole Magnesium 40 mg Once Daily Heparin (Porcine) 5,000 unit/mL TID Losartan 100 mg Tab Oral 1 Tablet(s) Once Daily Methadone 10 mg/5 mL Oral Soln Oral 1 Solution(s) every 8 hours Metoprolol Tartrate 25 mg Tab Oral 1 Tablet Twice Daily 8AM & 2PM Quetiapine 50 mg Tab Oral [**12-12**] Tablet(s) Twice Daily 8AM & 2PM Senna 187 mg Tab Oral 2 Tablet(s) Once Daily, at bedtime Simvastatin 10 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime Tamsulosin SR 0.4 mg 24 hr Cap Oral 1 Capsule, Sust. Release 24 hr(s) Once Daily Tramadol 50 mg Tab Oral [**12-10**] Tablet(s) every 6 hours Insulin Regular Human 100 unit/mL Cartridge Injection sliding scale Cartridge(s) Four times daily Erythromycin Ethylsuccinate 250mg/6.25ml Suspension(s) every 6 hours Miconazole Powder Misc.(Non-Drug; Combo Route) to sacral wound Powder(s) every 8 hours Metoclopramide 10 mg Tab Oral 1 Tablet(s) every 6 hours Bumetanide 0.25 mg/mL Injection Injection 0.5mg Solution(s) Once Daily at 8PM Acetaminophen 650 mg/20.3 mL Oral Soln Oral 1 Solution(s) every 4 hours, as needed Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Tablet,Rapid Dissolve, DR(s) 2. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 3. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: One (1) Capsule, Sprinkle PO QID (4 times a day). 4. Ammonium Lactate 12 % Lotion [**Last Name (STitle) **]: One (1) application Topical twice a day as needed for rash. 5. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 6. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily): Continue with 2 tabs daily for 3 days, then taper to 1 tab daily for 3 days. 7. Ethacrynic Acid 25 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO BID (2 times a day). 8. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours). 9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed for scrotum erythema. 11. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO BID (2 times a day). 14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Delirium, ventilator associated pneumonia, bacteremia and renal failure, ileus now resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please follow your rash closely. You are currently on prednisone which will be decreased over the next few days. Currently you are on 40 mg of prednisone daily for 3 more days followed by 20 mg for 3 more days. Please contact your PCP for any concerning changes in mental status or if your urine output drops off. Followup Instructions: You will be following up with the physician at the rehab center. Completed by:[**2158-8-2**] ICD9 Codes: 5845, 2930, 2760, 7907, 5859
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Medical Text: Admission Date: [**2169-6-2**] [**Month/Day/Year **] Date: [**2169-6-10**] Date of Birth: [**2088-3-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Malaise Major Surgical or Invasive Procedure: Placement of Left SC central catheter Placement of PICC line, removed by patient Replacement of PICC line Transesophageal Echocardiogram History of Present Illness: HPI: 81 year old female with medical history significant for HTN and LE edema p/w lethargy, malaise. Her grandson forced her to go to the [**Name (NI) **]. She states that for days she states that she has had decreased appetite and feeling not "her normal self" over the past few days. She states that she has also noted diarrhea over the past few days but not watery. Grandson called EMS. Pt was found to be hypotensive in the ED with vitals in ED T 97.2 p 72 bp 62/31. Later had fever to 100.8 in ED, with a lactate, 3.5. She was treated per sepsis protocol. L subclavian was placed, she received 4L NS, vanc, levo, flagyl. She has only made 10 cc of UOP in the past hour and transferred ot the ICU on neosynephrine. Cr also noted to increase from baseline 1.1 to 3.1. Her UA was positive. Transferred to MICU for further evaluation and code sepsis protocol. Past Medical History: 1. HTN 2. LE edema 3. Atrophic dermatitis Social History: SOCIAL HISTORY: Patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3064**] survivor who lives by herself. She lives near her grandson who is involved in her care. The patient is noted to have poor compliance with hygiene, she has not bathed within weeks. The patient likely needs assistance at home with either home VNA or home health aides. Family History: FAMILY HISTORY: No history of DVT, does note a family history of breast cancer. Physical Exam: Vitals: 100.1 107/65, 82, 17, 100% on 2L NC, CVP 7 . General - elderly appearing female lying flat in bed in NAD HEENT- PERRL, EOMI CHEST- CTAB, breast ulcerations CV - RR, no M Abd - midline abdominal scar with ulcerations, soft, NT/ND, +BS Ext - trace le edema Skin - no cellulitis Pertinent Results: Admission Labs: . [**2169-6-1**] 07:30PM PLT COUNT-317 [**2169-6-1**] 07:30PM HYPOCHROM-1+ [**2169-6-1**] 07:30PM NEUTS-74.7* LYMPHS-19.6 MONOS-3.5 EOS-2.0 BASOS-0.3 [**2169-6-1**] 07:30PM WBC-15.9* RBC-4.52# HGB-13.1# HCT-39.4 MCV-87 MCH-29.0 MCHC-33.3 RDW-14.5 [**2169-6-1**] 07:30PM LIPASE-22 [**2169-6-1**] 07:30PM ALT(SGPT)-24 AST(SGOT)-41* ALK PHOS-146* AMYLASE-22 TOT BILI-0.5 [**2169-6-1**] 07:30PM GLUCOSE-171* UREA N-38* CREAT-3.1*# SODIUM-144 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-20 [**2169-6-1**] 08:46PM LACTATE-3.5* [**2169-6-1**] 08:46PM TYPE-ART PO2-137* PCO2-33* PH-7.51* TOTAL CO2-27 BASE XS-4 [**2169-6-1**] 09:15PM URINE TRICH-OCC [**2169-6-1**] 09:15PM URINE HYALINE-[**6-17**]* [**2169-6-1**] 09:15PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2169-6-1**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2169-6-1**] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2169-6-1**] 09:15PM PT-13.9* PTT-24.4 INR(PT)-1.2* [**2169-6-1**] 09:15PM URINE UHOLD-HOLD [**2169-6-1**] 09:15PM URINE HOURS-RANDOM [**2169-6-1**] 09:15PM TOT PROT-5.9* ALBUMIN-2.0* GLOBULIN-3.9 [**2169-6-1**] 09:15PM TOT BILI-0.5 [**2169-6-1**] 09:15PM GLUCOSE-133* UREA N-37* CREAT-2.8* SODIUM-149* POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-26 ANION GAP-17 [**2169-6-2**] 03:11AM HCT-30.7* [**2169-6-2**] 03:11AM CORTISOL-13.4 [**2169-6-2**] 03:11AM CORTISOL-22.1* [**2169-6-2**] 03:11AM CORTISOL-25.5* [**2169-6-2**] 03:11AM CALCIUM-6.3* PHOSPHATE-2.8 MAGNESIUM-1.6 [**2169-6-2**] 03:11AM LD(LDH)-292* [**2169-6-2**] 03:11AM GLUCOSE-75 UREA N-30* CREAT-2.2* SODIUM-147* POTASSIUM-2.8* CHLORIDE-116* TOTAL CO2-22 ANION GAP-12 [**2169-6-2**] 03:40AM LACTATE-2.0 [**2169-6-2**] 03:40AM TYPE-MIX TEMP-36.6 O2 FLOW-2 PO2-129* PCO2-42 PH-7.35 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA [**2169-6-2**] 07:52AM PLT COUNT-258 [**2169-6-2**] 07:52AM WBC-16.7* RBC-3.70* HGB-10.6* HCT-32.7* MCV-89 MCH-28.8 MCHC-32.6 RDW-14.5 [**2169-6-2**] 07:52AM CALCIUM-6.6* MAGNESIUM-1.6 [**2169-6-2**] 07:52AM POTASSIUM-4.4 [**2169-6-2**] 08:13AM freeCa-1.05* [**2169-6-2**] 08:13AM LACTATE-1.3 [**2169-6-2**] 08:13AM TYPE-[**Last Name (un) **] TEMP-35.6 PO2-44* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 [**2169-6-2**] 03:38PM URINE RBC-[**11-27**]* WBC-[**6-17**]* BACTERIA-FEW YEAST-NONE EPI-[**3-12**] [**2169-6-2**] 03:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2169-6-2**] 03:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2169-6-2**] 03:38PM URINE HOURS-RANDOM CREAT-117 SODIUM-77 [**2169-6-2**] 03:39PM CALCIUM-7.3* PHOSPHATE-2.7 MAGNESIUM-2.4 [**2169-6-2**] 03:39PM GLUCOSE-220* UREA N-25* CREAT-1.8* SODIUM-143 POTASSIUM-4.2 CHLORIDE-118* TOTAL CO2-18* ANION GAP-11 Pertinent Labs/Studies: . ECG: Sinus tach at 110 bpm. nl axis, borderline QT prolongation. QT 360. No ST/T changes. . Imaging: [**2169-6-2**] - Portable Chest The left subclavian line tip is in the level of the junction of brachiocephalic vein and superior vena cava. There is no pneumothorax or apical hematoma. The heart size is normal. Mediastinal widening seen on the current chest x-ray is most probably due to supine position and relatively low lung volumes. To exclude hematoma, an erect chest PA and Lat films should be obtained. The lungs are clear. There is no pleural effusion. . [**2169-6-2**]: Portable Chest - IMPRESSION: No acute cardiopulmonary process. . [**2169-6-6**]: Transesophageal Echocardiogram: Intravenous sedation was administered as described above. The patient developed asymptomatic hypotension with a systolic blood pressure of 70 mm Hg. The patient remained alert and interactive and did not appear to be sedated. Blood pressure normalized quickly with intravenous fluids. The patient requested that we try to complete the test. One attempt was made at passing the TEE probe, however, the patient was unable to swallow it. The test was terminated. If a TEE is still clinically necessary, an anesthesiologist will be needed to provide deeper sedation and blood pressure support. . [**2169-6-6**] - Echocardiogram (TTE) Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. No evidence of endocarditis seen. 7. Compared with the prior study (images reviewed) of [**2169-5-3**], there is no significant change. . [**2169-6-7**]: IMPRESSION: Successful placement of a 40cm single lumen left brachial vein PICC line. The tip is in the SVC. The line is ready for use. . [**2169-6-7**]: Chest Pa/Lat - IMPRESSION: Small right pleural effusion. Prominent mediastinum likely due to mediastinal fat. . [**2169-6-8**]: IMPRESSION: Successful placement of a 46 cm single-lumen PICC through the left brachial vein with the tip in the superior vena cava. The line is ready for use. . . Microbiology: Blood cultures: [**2169-6-1**]: 4/4 Bottles growing MRSA [**2169-6-3**]: NGTD [**2169-6-4**]: NGTD [**2169-6-5**]: NGTD [**2169-6-6**]: NGTD [**2169-6-6**]: (central line tip) - Coag Pos Staph . Urine: [**2169-6-1**]: 10K-100K STREPTOCOCCUS MILLERI [**2169-6-2**]: No growth [**2169-6-3**]: No growth [**2169-6-6**]: No growth . Relevant Labs: [**2169-6-1**] 08:46PM BLOOD Lactate-3.5* [**2169-6-2**] 03:40AM BLOOD Lactate-2.0 [**2169-6-2**] 08:13AM BLOOD Lactate-1.3 . [**2169-6-2**] 03:11AM BLOOD Cortsol-25.5* [**2169-6-2**] 03:11AM BLOOD Cortsol-22.1* [**2169-6-2**] 03:11AM BLOOD Cortsol-13.4 . [**2169-6-6**] 06:42AM BLOOD TSH-5.8* [**2169-6-7**] 02:06PM BLOOD Free T4-0.8* . [**2169-6-6**] 06:42AM BLOOD calTIBC-83* Ferritn-425* TRF-64* [**2169-6-6**] 06:42AM BLOOD Triglyc-77 HDL-40 CHOL/HD-2.1 LDLcalc-28 [**Month/Day/Year **] Labs: . [**2169-6-9**] 09:45AM BLOOD WBC-15.2* RBC-3.14* Hgb-8.9* Hct-27.5* MCV-88 MCH-28.4 MCHC-32.4 RDW-17.1* Plt Ct-398 [**2169-6-9**] 05:46AM BLOOD WBC-13.7* RBC-2.79* Hgb-8.2* Hct-24.7* MCV-88 MCH-29.3 MCHC-33.1 RDW-16.6* Plt Ct-371 [**2169-6-9**] 05:46AM BLOOD Glucose-104 UreaN-6 Creat-0.9 Na-142 K-4.6 Cl-113* HCO3-21* AnGap-13 [**2169-6-9**] 05:46AM BLOOD Mg-1.8 [**2169-6-10**] 06:00AM BLOOD WBC-13.3* RBC-2.91* Hgb-8.4* Hct-25.7* MCV-88 MCH-29.1 MCHC-32.9 RDW-17.1* Plt Ct-441* [**2169-6-10**] 06:00AM BLOOD Glucose-82 UreaN-6 Creat-0.8 Na-142 K-4.5 Cl-114* HCO3-22 AnGap-11 Brief Hospital Course: The patient is an 81 year old female with medical history significant for LE edema and HTN who was admitted to the MICU with lethargy and hypotension, eventually discovered to have MRSA sepsis from unknown source. . # Sepsis/MRSA bacteremia - As per H+P, the patient presented with lethargy and hypotension found to be febrile with elevated lactate. A central line was placed, the patient was started on broad-spectrum antibiotics with vancomycin, levofloxacin, and Flagyl and volume resuscitation was initiated. The patient was transferred to the ICU on Neosynephrine and was rapidly weaned off pressors within 24 hours. The patient's MICU course was complicated by ARF likely secondary to ATN in the setting of hypotension with eventual complete recovery of renal function with adequate treatment of infection and volume resuscitation. The patient was Blood cultures revealed 4/4 bottles from admission growing MRSA. Initally it was thought that the source of infection may have been from the urine as the patient had a positive UA on admission, however, subsequent cultures revealed Streptococci Milleri rather than MRSA. The patient's antibiotics regimen was tailored to IV Vancomycin, dosed per renal function, as monotherapy. Given that urine did not grow MRSA, it was not clear what the patient's source of infection was. Of note, the patient is noted to have many cutaneous wounds and excoriations. Although no area of frank cellulitis or fluctuance was idenitified, it is suspected this to be the most likely source currently. However, given high grade bacteremia on admission with MRSA, there was clinical concern that the patient may have seeded her cardiac valves. The patient underwent attempted TEE but was unable to tolerate the procedure. The patient developed hypotension in the setting of sedation with rapid resolution with fluid bolus and trendelenberg. Subsequent attempt with less sedation was not tolerated by the patient secondary to discomfort. It was recommended that if TEE were necessary the patient would require anesthesia to be involved. Given that the patient rapidly cleared her cultures with therapy, it was thought that a TTE should first be attempted. TTE demonstrated a hyperdynamic LV with EF > 75% but no vegetations or evidence for endocarditis. The patient remained afebrile for the remainder of her hospital course with decrease in leukocytosis since admission from 16 to 12. On [**Month/Day/Year **] the patient continues to have a mild leukocytosis, ranging between [**12-21**] generally but clinically appears quite well. Despite negative blood cultures, tip culture from the patient's central line has since grown MRSA. Blood surveillance cultures drawn the same day are negative however, signifying the patient was not experiencing significant bactermia from the central line. Subsequent surveillance cultures continue to be culture negative and additional surveillance culture was drawn on morning of [**Month/Year (2) **] given positive CL tip. This will continue to be monitored and facility would be made aware if any cultures turn positive. Given documented bacteremia the patient will require IV antibiotics with Vancomycin, with plans for total duration of 4 weeks given no definite source was identified. The patient started antibiotic therapy with Vancomycin on [**2169-6-4**]. Because of hypotension, the patient's home medications of Valsartan and Lasix were held. The patient is currently normotensive but not hypertensive. The patient therefore is being discharged without these medications, with instructions to follow up with her PCP upon [**Date Range **] from extended care facility to determine when or if she should restart these medications. . # ARF: As above, the patient developed acute renal failure during the ICU course, likely secondary to hypotension with subsequent ATN. The patient's creatinine returned to [**Location 213**] with normalization of blood pressure with volume support, antibiotics, and treatment as above. The patient continues to produce good urine and is currently at her baseline creatinine on [**Location **]. . #. Wounds/ Skin ulcerations - The patient on presentation was wound to have a number of cutansous wounds over her extremities and trunk, mostly healed and scabbing, with some more recent excoriations. The patient had been prescribed protopic cream and petroleum jelly as an outpatient but was not using these regularly per family report. The patient overall was admitted with generally poor hygiene and suspicion that the patient's MRSA may have been introduced via cutaneous injury. The patient continued to receive wound care throughout her hosptialzation with daily cleansing and Aloe Vesta. The patient should continue to receive wound care at the extended care facility as detailed in page 1. . #. LE Edema - The patient on admission was reported to have a history of CHF. However, review of OMR notes reveals echocardiogram was ordered to rule out CHF with plan for ongoing work-up of LE edema given lack of evidence for CHF by recent echocardiogram. Prior to admission, the most recent echocardiogram reveale an EF > 55% without comment on evidence of diastolic dysfunction. Repeat echocardiogram this admission revealed a hyperdynamic LV with EF 75%. The patient was treated with volume as above initially given evidence of sepsis. With normalization of pressures fluid balance was allowed to equilibrate. Physical exam was remarkable for mild LE edema as has been previously documented, but the patient otherwise appears relatively euvolemic. The patient maintained good oxygen saturation on room air. As an outpatient the patient was on a medical regimen including Diovan 160 mg po qd as well as lasix 40mg po qd. These medications have been held throughout the [**Hospital 228**] hospital course as her pressures have generally ranged from 100-120. On further exam the patient was noted to have mild diffuse edema. The patient's Albumin was noted to have fallen from 3.0 one month prior to 1.6. This was thought likely to be secondary to geenrally poor po intake and previous sepsis. The patient was written for boosts and nutritional support was continued. Urine dip revealed no proteinurea and the patient had a normal cholesterol. TSH was mildy elevated and free T4 was just below the lower limit of normal. Given the patient's recent illness however decision was made not to initiate thryroid replacement at this time as this more likely represents sick euthyroid than true hypothyroidism. . #. Anemia - the patient was noted to have an anemia on admission. Iron binding studies were consistent with anemia of chronic disease. The patient had a single OB positive stool on transfer with all subsequent negative. The patient's Hct remained stable throughout the course with some expected fluctuation within lab error and volume status. . #. Tachycardia - On [**Hospital **] the patient is known to have mild persistent sinus tachycardia with HR ranging from 70 to 120. THe etiology is not clear but the patient is doing clinically well, afebrile, not in pain, and hemodynamically stable. As above, the patient's labs trend towards hypo rather than hyperthyroidism. The patient is with excellent O2 sats. The patient was taking [**Doctor First Name **] daily previously. This was discontinued recently given thought that anti-cholinergic effect may be contributing to tachycardia. If the patient's tachycardia persists after [**Doctor First Name **] from extended care facility she should have ongoing evaluation with PCP. . # CODE status - As per discussion with ICU team, the patient was maintained as DNR/DNI Medications on Admission: Diovan 160 mg a day, Aspirin 81 mg a day, [**Doctor First Name **] 180 mg a day Lasix 40 mg a day [**Doctor First Name **] Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection every eight (8) hours: please continue while patient is generally bed bound. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours): First dose [**2169-6-4**]. Patient should complete a 4 week course until [**2169-7-5**]. Patient will require monitoring of Vanc trough q week as per instructions. 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): 2ml IV daily:PRN 10ml NS followed by 2ml of 100U/ml Heparin each lumen daily and PRN. [**Month/Day/Year **] Disposition: Extended Care Facility: [**Location (un) 11729**] Home - [**Location (un) 686**] [**Location (un) **] Diagnosis: MRSA Bacteremia/Sepsis [**Location (un) **] Condition: Stable. Patient hemodynamically stable, afebrile. Upon [**Location (un) **], patient has known sinus tachycardia, with rates 100-125 without obvious cause with basic workup. Patient should receive ongoing outpatient evaluation upon [**Location (un) **]. Patient has known persistent mild leukocytosis with white count [**12-21**]. Patient is receiving antibiotics x 4 weeks for her infection. [**Month/Year (2) **] Instructions: 1. Please take all medications as prescribed from this [**Month/Year (2) **]. You were previously taking Diovan and Lasix. These medications were stopped during this admission because of low blood pressure. Your blood pressure is currently normal, but not elevated. Because of this, you should not take these medications again until you see your primary care doctor. [**First Name (Titles) 616**] [**Last Name (Titles) **] from rehab, please see your PCP to discuss when or if you should restart these medications. . 2. Please keep all outpatient appointments . 3. Please return to the hospital or seek medical attention for any symptoms of chest pain, shortness of breath, fever/chills, nausea/vomiting, or any other concerning symptoms. Followup Instructions: You should continue to receive care at your extended care facility. . After [**Last Name (Titles) **], it is very important you have follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. After [**Last Name (NamePattern1) **] from the extended care facility you should make an appointment to be seen within one to two weeks with Dr. [**Last Name (STitle) **]. If he is not available please ask to be seen by any available physician at [**Name9 (PRE) 191**]. PLease call [**Telephone/Fax (1) 250**] to make this appointment . The following medications have been held this admission: Diovan and Lasix. You should discuss with your primary care doctor during your visit whether or not you should restart these medications. Until then, do not take these medications ICD9 Codes: 5849, 5990, 4280, 2859
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Medical Text: Admission Date: [**2178-6-29**] Discharge Date: [**2178-6-30**] Date of Birth: [**2133-6-10**] Sex: M Service: MEDICINE Allergies: Fish Product Derivatives / Shellfish Derived / Peanut / Grass Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 45yo M with PMHx of refractory asthma with > 100 hospitalization and 17 past intubations now presenting with wheezing, SOB, worsening over the past 2 days. Patient developed cough and shortness of breath for the past week that he attributes to the hot weather. Over the past 2 days, patient has had worsening SOB and wheezing, not managed with home nebulizers. Prior to presentation in the ED, the patient used his nebulizers 6 times on the AM of presentation with no changes in symptoms. He reports that he increased his prednisone dose from 30mg daily to 80mg daily 3 days ago. His cough is productive of sputum, described as clear, thick and yellow. He reports that he had fever of 99.2 1 week ago. He has also noticed DOE, which the patient does not experience at baseline. Of note, he reports that his wife has been ill with coughing and runny nose. Initial vitals upon arrival to the ED: 98.0 103 153/98 22 97% RA. In the [**Last Name (LF) **], [**First Name3 (LF) **] verbal report, the patient is speaking in full sentences though having difficulty completing full sentences, but with no accessory muscle use and no tachypnea. The patient had a CXR which showed no effusions or consolidations concerning for PNA. The patient was given 2 Duo-Neb treatments, IV magnesium, and IV solumedrol 125mg ONCE. On arrival to the MICU, the patient is feeling tired, but denies chest pain, chest tightness, shortness of breath, abdominal pain, nausea, or vomiting. Past Medical History: - Severe asthma with greater than 100 hospitalizations, multiple intubations (17), followed by Dr. [**Last Name (STitle) **] in pulm, plan to refer to Dr. [**First Name (STitle) **] at [**Hospital1 112**] - OSA on CPAP at night - Avascular necrosis of the hip and shoulder from prolonged steroid use, status post hip replacement ([**2173**]) - GERD - H/o L Achilles tendon rupture s/p repair Social History: Works as school bus driver. Lives with wife and one of his three children. Still smoking 1ppd. Has on average a bottle of wine/week when he can afford it. Denies ilicits. Family History: Two children with asthma as well as mother with asthma. Physical Exam: Admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: bilateral wheezes, no rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge: same as above except: VS: 97% RA with ambulation Lungs: CTAB Pertinent Results: [**2178-6-29**] 12:00PM BLOOD WBC-12.9*# RBC-5.20 Hgb-15.6 Hct-47.5 MCV-91 MCH-30.1 MCHC-32.9 RDW-13.5 Plt Ct-310 [**2178-6-29**] 12:00PM BLOOD Neuts-66.4 Lymphs-23.8 Monos-7.9 Eos-1.4 Baso-0.6 [**2178-6-29**] 12:00PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-140 K-5.1 Cl-109* HCO3-21* AnGap-15 [**2178-6-29**] 01:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.027 [**2178-6-29**] 01:40PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2178-6-29**] 01:40PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2178-6-29**] 01:40PM URINE CastHy-5* [**2178-6-29**] 01:40PM URINE Mucous-MANY07/02/12 1:40 pm URINE **FINAL REPORT [**2178-6-30**]** URINE CULTURE (Final [**2178-6-30**]): NO GROWTH. CXR: FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. Bilateral streaky linear perihilar opacities are compatible with reactive airway disease, progressed since [**2175**] and similar to [**2178-5-16**]. The lungs are otherwise clear. No lobar consolidation, pleural effusion, or pneumothorax. The osseous structures are unremarkable. No radiopaque foreign bodies. IMPRESSION: Bilateral streaky perihilar opacities, compatible with reactive airway disease, similar to [**2178-5-16**] though progressed since [**2176-9-13**]. Brief Hospital Course: Mr. [**Known lastname **] was admitted to [**Hospital1 18**] with an exacerbation of his reactive airway disease, asthma vs COPD vs bronchiectasis. He was started on standing bronchodilator nebs and prednisone 60mg daily and admitted to the ICU. His CXR showed no PNA. His respiratory status improved dramatically in the next 24h and his oxygen sat was 97% RA with ambulation. He was encouraged to quit smoking again and provided script for nicotine lozenges. He was discharged with a plan to taper prednisone in the following manner: take 60mg x 4 days, 50mg x 4 days, 40mg x 4 days, then return to usual dose of 30mg daily. He should likely have a high res CT chest as an outpatient to eval for bronchiectasis. He may also have an element of COPD contributing to this picture. He will follow up with PCP in next few days, pulmonary next month. Medications on Admission: 1. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q4H:PRN shortness of breath or wheezing 2. fluticasone 220 mcg/actuation Inhalation [**Hospital1 **] 6 puffs twice a day 3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 4. Montelukast Sodium 10 mg PO DAILY 5. Loratadine 10 mg Oral Daily 6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 7. Omeprazole 20 mg PO BID 8. Tiotropium Bromide 1 CAP IH DAILY RX *Spiriva with HandiHaler 18 mcg 1 cap IH daily 9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation Inhalation Q4H:PRN shortness of breath or wheezing 10. Nicotine Lozenge 4 mg PO Q1H:PRN craving 11. PredniSONE 30mg PO daily Discharge Medications: 1. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q4H:PRN shortness of breath or wheezing RX *DuoNeb 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer IH every four (4) hours Disp #*60 Vial Refills:*0 2. fluticasone *NF* 220 mcg/actuation Inhalation [**Hospital1 **] 6 puffs twice a day RX *Flovent HFA 220 mcg 6 puffs IH twice a day Disp #*1 Inhaler Refills:*0 3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 4. Montelukast Sodium 10 mg PO DAILY RX *Singulair 10 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Loratadine *NF* 10 mg Oral Daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H RX *Serevent Diskus 50 mcg 1 discus IH every twelve (12) hours Disp #*1 Inhaler Refills:*0 7. Omeprazole 20 mg PO BID 8. Tiotropium Bromide 1 CAP IH DAILY RX *Spiriva with HandiHaler 18 mcg 1 cap IH daily Disp #*1 Inhaler Refills:*0 9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation Inhalation Q4H:PRN shortness of breath or wheezing RX *albuterol sulfate 90 mcg 2 puffs IH every four (4) hours Disp #*1 Inhaler Refills:*0 10. Nicotine Lozenge 4 mg PO Q1H:PRN craving RX *nicotine (polacrilex) 4 mg 1 lozenge by mouth every hour Disp #*120 Lozenge Refills:*0 11. PredniSONE 60 mg PO DAILY RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*91 Tablet Refills:*0 RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*100 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Asthma/COPD exacerbation 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 difficulty breathing. This was likely due to an exacerbation of your asthma. You may also have COPD, another chronic lung disease. It is important you take all of your breathing medications every day. You should stop smoking to avoid having more of these episodes. . Some of your medications were changed during this admission: START prednisone taper, take 60mg daily for one week, then 40mg daily for one week, then 20mg daily for one week, then 10mg daily for one week. . You should continue to take all of your other medications as prescribed. Followup Instructions: You should have a follow up appointment with Dr. [**Last Name (STitle) **] within the next 3 days. Please call [**Telephone/Fax (1) 2010**] to schedule this appointment when you get home today. Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2178-8-5**] at 10:20 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2178-8-5**] at 10:40 AM With: [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2178-8-5**] at 10:40 AM [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3193 }
Medical Text: Admission Date: [**2112-3-26**] Discharge Date: [**2112-3-29**] Date of Birth: [**2058-9-15**] Sex: F Service: MEDICINE Allergies: Optiray 350 Attending:[**First Name3 (LF) 602**] Chief Complaint: weakness, hyponatremia Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: 53F with panhypopituitary, HTN, HL who presented today from the ED with 3 days of nausea, vomiting, weakness and dizziness. This began while she was at work on Thursday, with multiple episodes of non-bloody emesis as well as dizziness. She reports she may have had some abdominal pain that preceded these symptoms by a couple days. She continued to take all of her home medications including prednisone throughout these symptoms. . In the ED, her initial vitals were 98 70 92/57 18 100%. She was found to have a sodium of 110 and was given 2L of normal saline. Transferred to the [**Hospital Unit Name 153**] for sodium correction. . On arrival to the ICU, she continues to feel dizzy with some abdominal pain, but overall feels improved. Past Medical History: hypertension hyperlipidemia panhypopituitarism due to [**Doctor Last Name 30762**] syndrome gastritis positive PPD (finished INH, [**2103**]) Social History: Lives with husband and 3 children. Works on an electronics assembly line - Tobacco: none - Alcohol: none - Drugs: none Family History: Mother: hypertension Physical Exam: ADMISSION EXAM: . Vitals: 98.2 75 95/50 13 96% 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, mildly tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: . [**2112-3-26**] 12:30PM BLOOD WBC-6.4 RBC-4.13* Hgb-12.2 Hct-32.9* MCV-80*# MCH-29.5 MCHC-37.0*# RDW-11.8 Plt Ct-344 [**2112-3-26**] 12:30PM BLOOD Neuts-78.5* Lymphs-13.1* Monos-4.4 Eos-1.4 Baso-2.7* [**2112-3-26**] 12:30PM BLOOD Glucose-81 UreaN-8 Creat-0.6 Na-110* K-4.8 Cl-75* HCO3-21* AnGap-19 [**2112-3-26**] 05:04PM BLOOD Calcium-7.3* Phos-3.1 Mg-1.4* [**2112-3-26**] 12:30PM BLOOD Osmolal-238* [**2112-3-26**] 05:04PM BLOOD TSH-<0.02* [**2112-3-26**] 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15 T4Index-13.1* Free T4-2.1* [**2112-3-26**] 05:04PM BLOOD Cortsol-4.0 [**2112-3-27**] 05:00PM BLOOD freeCa-1.06* [**2112-3-28**] 01:05AM BLOOD freeCa-1.11* [**2112-3-26**] 02:11PM BLOOD Lactate-1.4 . . IMAGING STUDIES: [**2112-3-26**] CT HEAD W/O CONTRAST - There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. Ventricles, sulci, and basilar cisterns are unremarkable and stable in configuration compared to prior. Note is made of a lipoma within the quadrigeminal plate cistern on the right. Orbits are symmetric and unremarkable. Paranasal sinuses included on this exam are clear. Skull and extracranial soft tissues are unremarkable. . [**2112-3-26**] CHEST (PA & LAT) - Right basilar opacity is probably atelectasis, but could represent early or developing pneumonia in the appropriate clinical setting. . Cardiovascular Report ECG Study Date of [**2112-3-26**] 12:38:32 PM Normal sinus rhythm with Q-T interval prolongation. Compared to the previous tracing of [**2107-11-25**] the Q-T interval is significantly longer. Clinical correlation is suggested. . MICROBIOLOGIC DATA: [**2112-3-26**] Blood culture - ngtd [**2112-3-26**] MRSA screen - no MRSA DISCHARGE LABS: [**2112-3-28**] 11:30AM BLOOD WBC-5.5# RBC-4.24 Hgb-12.5 Hct-34.8* MCV-82 MCH-29.4 MCHC-35.9* RDW-12.7 Plt Ct-402 [**2112-3-29**] 06:15AM BLOOD Glucose-70 UreaN-16 Creat-0.6 Na-144 K-4.6 Cl-108 HCO3-28 AnGap-13 [**2112-3-28**] 11:30AM BLOOD Calcium-8.9 Phos-1.5*# Mg-2.2 [**2112-3-26**] 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15 T4Index-13.1* Free T4-2.1* Studies pending at discharge: None Brief Hospital Course: 53 yo female with PMH significant for panhypopituitarism in the setting of postpartum hemorrhage ([**Doctor Last Name 1349**] syndrome), hypertension, hyperlipidemia admitted with viral gastroenteritis and adrenal crisis associated with hyponatremia to 110 and hypotension. #Adrenal crisis/Hyponatremia: Patient presented with hyponatremia and hyponatremia to 110 in the setting of an acute illness. It was felt that the patient was relatively [**Name2 (NI) 34512**] insufficent given his acute illness and was treated with IVF and stress dose hydrocortisone. Sodium rapidly improved and GI symptoms resolved quickly as well. Endocrine was consulted and recommended D5W in addition to DDAVP 0.1mcg IV x1 to promote free water reabsorption and prevent too rapid of correction of sodium. HOwever, they did note that rapid correction of sodium in the setting of steroid repletion was okay and expected. Patient was transitioned from stress dose steroids to a rapid prednisone taper and was discharged on a rapid taper to return to his previous maintenance prednisone regimen of 5mg po daily as his acute illness had resolved. Patient will follow with endocrine as an outpatient. #HYPOTHYROIDISM - Patient has known diagnosis of postpartum hemorrhage leading to panhypopituitarism. Admission TSH < 0.02 with TFTs demonstrating T4 11.4, T3 95, free T4 2.1. Initially IV Levothyroxine was used for replacement but was switched to PO Levothyroxine dosing when GI issues resolved. Patient will follow with endocrine as an outpatient. . CHRONIC CARE #GASTRITIS - Patient was continued on omeprazole 20 mg PO daily #HYPERLIPIDEMIA - Pastient was continued on Simvastatin 5 mg PO daily . #Contact: [**Name (NI) **] (daughter) - [**Telephone/Fax (1) 34513**] #Code: FULL #Disposition: Patient was discharged to follow up with Endocrinology in one week and PCP [**Last Name (NamePattern4) **] 3 weeks. She will have labs prior to her Endocrine follow up appointment. Patient was counseled on symptoms of adrenal insufficiency and told to call her doctor if she experiences any neurologic symptoms. Medications on Admission: HCTZ 12.5mg daily Levothyroxine 125 mcg daily Losartan 50mg daily Omeprazole 20mg daily Prednisone 5mg daily Simvastatin 5mg daily Calcium carbonate 500mg / Vitamin D 200 unit [**Hospital1 **] Discharge Medications: 1. prednisone 5 mg Tablet Sig: as directed Tablet PO as directed: Please take: 4 tablets on Wed [**3-/2029**] 2 tablets on [**Doctor First Name **] [**3-31**] 1 tablet/daily thereafter. Disp:*35 Tablet(s)* Refills:*2* 2. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day: Please do not restart until [**2112-3-31**]. 7. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day: Please do not start until [**2112-3-30**]. 8. Outpatient Lab Work Please draw 1) CBC 2) Chem 7 and send labs STAT. Thanks Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Adrenal insufficiency Viral gastroenteritis Panhypopituitarism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a viral gastroenteritis and adrenal insufficiency causing very low sodium levels. Your viral gastroenteritis improved and your symptoms improved with appropriate steroid replacement. You are being discharged on a prednisone taper. You should take 20mg of prednisone on Wed [**3-/2029**], 10mg of prednisone on Thursday [**2112-3-31**] and resume your usual 5mg daily of prednisone on Friday [**2112-4-1**]. You should also follow up with both your PCP and Endocrinology in the next few weeks as detailed below. You are being given a prescription to have your labs drawn on the morning Monday [**2112-4-4**]. Please arrive a few hours before your appointment to have your labs drawn in the [**Hospital Ward Name 23**] or [**Hospital3 **] laboratory. Please call your doctor if you experience any fevers, chills, low energy, malaise, abdominal pain, feel as if you are going to pass out, or notice any focal weakness, difficulties moving, or changes in sensation. Followup Instructions: Department: MEDICAL SPECIALTIES When: MONDAY [**2112-4-4**] at 2:30 PM With: DR. [**Last Name (STitle) **] & ZHIHENG [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: MONDAY [**2112-4-18**] at 11:20 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ICD9 Codes: 2761, 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3194 }
Medical Text: Admission Date: [**2189-12-8**] Discharge Date: [**2189-12-13**] Date of Birth: [**2118-10-6**] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / Fish Oil Attending:[**First Name3 (LF) 1505**] Chief Complaint: Patient complains of worsening chest pain. Major Surgical or Invasive Procedure: CABG x3 LIMA to LAD, SVG to OM, SVG to PDA History of Present Illness: [**Known lastname 7474**] is a 71-year-old male with worsening anginal symptoms who underwent cardiac catheterization that showed a proximal LAD stenosis involving and diagonal, not thought to be a good candidate for percutaneous intervention, presenting for surgical revascularization. Past Medical History: Hypertension Elevated triglycerides Several inguinal hernia repairs [**2187**] TURP Mohs surgery of left ear for skin cancer Squamous cell cancer removed from arm Intermittent back pain (treated with chiropractic therapy) Removal of colon polyps Social History: Patient is married with three children. He previously worked as a specifications writer for an engineering firm. Family History: Mother died of CAD in her 80's. Father died of pneumonia at age 37. Physical Exam: HEENT:PERRLA, FROM, no LAD CV: RRR, no M/R/G Pulm: CTA-B ABD:soft NT, ND, no HSP Ext: trace edema, 2+femoral, DP and PT pulses Neuro: AAOx3, CN II-XII grossly intact Pertinent Results: [**2189-12-8**] 12:20PM freeCa-1.19 [**2189-12-8**] 12:20PM HGB-15.3 calcHCT-46 [**2189-12-8**] 12:20PM TYPE-ART PO2-426* PCO2-41 PH-7.44 TOTAL CO2-29 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED [**2189-12-8**] 11:14PM TYPE-ART PH-7.41 [**2189-12-8**] 11:14PM GLUCOSE-154* K+-3.4* Brief Hospital Course: On [**2189-12-8**] the patient was taken to the OR for a 3 vessel CABG (LIMA to LAD, SVG to OM, SVG to PDA). The patient tolerated surgery well, was extubated the night of surgery and was transferred from the CSRU on postop day one to the regular cardiac hospital floor. On post op day two the patient's foley was removed as were his chest tubes. On post op day three the patient's pacing wires were removed. The patient tolerated a cardiac heart healthy diet, diuresed well after surgery while his pain was controlled throughout his hospital stay. The patient was discharged on post op day five. He will follow up with his PCP [**Name Initial (PRE) 176**] 10 days for medication adjustment if needed and routine blood work. Additionally, the patient was cleared by physical therapy and he will be going home with visiting nursing services to monitor his wounds, assure medication compliance and check vital signs. Medications on Admission: ASPIRIN 81MG--One by mouth every day DYAZIDE 37.5-25MG--One by mouth every day LISINOPRIL 40MG--2 by mouth every day NITROSTAT 0.4MG--One under the tongue as needed for cp; may repeat q5 minutes x 2, then as directed. TOPROL XL 200MG--One by mouth every day VITAMIN B COMPLEX --One by mouth twice a day VITAMIN C 500MG--One by mouth every day VITAMIN E 400U--One by mouth every day Discharge Medications: 1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). Disp:*20 Packet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: HTN CAD dyslipidemia Discharge Condition: Stable 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. Particularly your left upper extremity. Please call with any concerns or questions. You must follow up with a primary care physician [**Name Initial (PRE) 176**] 10 days for medication adjustment and rountine laboratories. Followup Instructions: Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-1-25**] 10:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] [**Telephone/Fax (1) 250**] Follow-up appointment should be in 2 weeks Provider: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5003**] Follow-up appointment should be in 3 weeks ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3195 }
Medical Text: Admission Date: [**2195-4-6**] Discharge Date: [**2195-4-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo F h/o CVA p/w SOB, tachypnea. Patient was recently hospitalized [**2-7**] - [**2-10**] for SOB, tachypnea which was ultimately diagnosed as URI and treated with azithromycin x 5 days. Since that time patient has been at baseline, living in [**Hospital 7137**]. However, this AM she developed fever to 101.5, respiratory congestion, diaphoresis, hypoxia (82% RA, 93% 2L) and tachypnea, and was referred to [**Hospital1 18**] ED. Although she has a reported history of aspiration and is on a pureed diet at baseline, there was no witnessed aspiration event. . In the ED, patient was found to be afebrile with T 97.9, HR 119 BP 134/89, RR 35, O2 sat 98% NRB. ABG 7.30 / 57 / 285 / 29. Patient looked to be in visible respiratory distress at this time and was transitioned to BiPap. After several hours, the patient looked more comfortable and was admitted to the ICU on nasal cannula for further workup and management. Repeat ABG before transfer was 7.34 / 54 / 108 / 30. . On arrival to the unit, the patient had VS T 98.7, HR 109, BP 134/89, RR 52, Sats 100% 4L NC. She was breathing shallowly but comfortably and did not appear to be in any visible distress. Patient is nonverbal at baseline but did not endorse any specific complaints other than feeling uncomfortable. Review of sytems: Limited assessment given poor cooperation second to non-verbal patient. Patient actively denied chest pain, SOB, but endorsed "discomfort" with breathing. Past Medical History: 1. Head trauma in [**2184**]. 2. History of subarachnoid hemorrhage. 3. History of dementia. 4. Anemia of chronic disease 5. Depression. 6. History of urinary tract infections. 7. Contracture of Left upper extremity. 8. mostly non-verbal. can state her name and say a few other things and shake her head yes and no. Social History: lives at [**Hospital3 2558**]. HCP is daughter [**Name (NI) **] [**Name (NI) 46**] in [**Location (un) 686**], phone # [**Telephone/Fax (1) 38634**]. [**Doctor First Name 38635**] daughter is [**Name (NI) **] 1-[**Telephone/Fax (1) 38636**]. Family History: NC Physical Exam: Vitals: T 98.7, HR 109, BP 134/89, RR 52, Sats 100% 4L NC\ GEN: alert, no acute distress HEENT: Patient refused to open mouth for exam. R eye ptosis. No visible facial droop. Neck: Supple. CV: tachycardic, reg rhythm, no mrg RESP: Transmitted upper airway sounds on shallow breathing throughout in all lung fields. ABD: S, NT/ND, +BS EXT: Contractures of upper and lower extremities. WWP. DISCHARGE EXAM: Vitals: T97.7, BP 144/91, HR 81, RR 20, Sat 100%RA Lungs: Occasional rhonchi, but otherwise normal breath sounds Heart: RRR, no m/r/g Abd: + bowel sounds Ext: diffuse muscle atrophy, no edema Pertinent Results: [**2195-4-6**] 02:47PM BLOOD WBC-7.6# RBC-3.23* Hgb-10.8* Hct-32.4* MCV-100* MCH-33.5* MCHC-33.4 RDW-13.8 Plt Ct-208 [**2195-4-7**] 04:39AM BLOOD WBC-9.7 RBC-3.30* Hgb-10.8* Hct-32.7* MCV-99* MCH-32.8* MCHC-33.1 RDW-13.6 Plt Ct-162 [**2195-4-6**] 02:47PM BLOOD Neuts-86.0* Lymphs-10.5* Monos-2.3 Eos-1.0 Baso-0.2 [**2195-4-7**] 04:39AM BLOOD Neuts-83.3* Lymphs-11.9* Monos-2.7 Eos-2.0 Baso-0.1 [**2195-4-6**] 02:47PM BLOOD PT-12.3 PTT-24.7 INR(PT)-1.0 [**2195-4-7**] 04:39AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1 [**2195-4-6**] 02:47PM BLOOD Glucose-230* UreaN-16 Creat-0.6 Na-144 K-4.2 Cl-109* HCO3-28 AnGap-11 [**2195-4-7**] 04:39AM BLOOD Glucose-90 UreaN-10 Creat-0.5 Na-140 K-3.9 Cl-108 HCO3-25 AnGap-11 [**2195-4-7**] 04:39AM BLOOD ALT-9 AST-19 LD(LDH)-188 AlkPhos-70 TotBili-1.4 [**2195-4-7**] 04:39AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.7 Mg-2.2 [**2195-4-6**] 02:52PM BLOOD Rates-/37 FiO2-100 pO2-285* pCO2-57* pH-7.30* calTCO2-29 Base XS-0 AADO2-385 REQ O2-67 Intubat-NOT INTUBA Comment-GREEN TOP [**2195-4-6**] 06:16PM BLOOD pO2-108* pCO2-54* pH-7.34* calTCO2-30 Base XS-2 Intubat-NOT INTUBA [**2195-4-6**] CXR: IMPRESSION: Patient rotation and respiratory motion make the exam suboptimal. Given this, no definite acute cardiopulmonary process is seen. If clinical concern persists, suggest repeat chest radiograph. [**2195-4-7**] CXR: FINDINGS: In comparison with the study of [**4-6**], there is little overall change. Scoliosis of the thoracic spine convex to the right is again seen. Cardiac silhouette remains at the upper limits of normal or slightly enlarged. Some indistinctness of pulmonary vessels again could reflect respiratory motion, though the possibility of mild elevation of pulmonary venous pressure should be considered. Some tortuosity of the aorta persists. URINE CULTURE (Final [**2195-4-8**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. [**Known lastname 38637**] is a [**Age over 90 **] year old woman with history of dementia and recent aspiration who presented with tachypnea, hypoxia, and fever, likely secondary to aspiration pneumonitis. # tachypnea, hypoxia - Initially, thought to be due to HAP vs. mucous plugging vs. aspiration vs. bronchitis vs. URI. History and physical exam limited by patient cooperativity and communicability. No appreciable infiltrate seen on CXR, but imaging suboptimal secondary to contractures and patient respiratory motion. Given patient's fevers, initial hypoxia, and recent cough, she was initially treated empirically for healthcare-associated PNA (with vancomycin and Zosyn). The first night of admission, her oxygenation improved dramatically, and the following morning, she was satting 97% on room air. Antibiotics were discontinued; the etiology of her hypoxia was felt to be aspiration, and her tachypnea/fevers aspiration pneumonitis. She was seen by speech and swallow, who recommended a trial of pureed solids and nectar-thick liquids. # UTI, bacterial - growing E. coli sensitive to cefazolin. Initially treated with Bactrim, but when sensitivities demonstrated that it is resistant to Bactrim, switched to Keflex. Should be treated for total of 7 days with Keflex. # [**1-12**] positive blood cultures. One out of 4 bottles grew GPC's in pairs/chains. Given stable hemodynamics and lack of fever, felt to be contaminant. # dementia - Patient minimally verbal and with limited interactivity at baseline. Per daughter, patient's mental status at baseline throughout the admission. # nutrition - Pureed solids and nectar-thick liquids as above. I addressed the idea of tube feeding with Ms. [**Known lastname 38638**] daughter, including the data that shows that such tubes do not improve mortality or prolong life, and that I did not recommend it. Her daughter believes that her mother eats enough orally to maintain nutrition, and she wants her mother to continue to eat; she is not interested in tube feeds at this time. Conversations regarding her poor nutritional status should continue. # code status - A long discussion was held with the patient's daughter with regard to the irreversibility of her dementia and the likelihood of future aspiration. She understands that her mother may continue to aspirate. I emphasized that she may aspirate to the extent that intubation would be required, and that once intubated, Ms. [**Known lastname 38638**] nutritional status is so poor that she would not likely be able to be extubated. However, her daughter did not wish to change her mother's code status at this time. Further conversations should be had with Ms. [**Known lastname 38638**] daughter regarding her code status and the low likelihood that resuscitation would be successful. Medications on Admission: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two Hundred (200) mg PO BID (2 times a day): Hold loose stools. 2. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily): Hold loose stools. 3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: last dose should be on [**2195-2-13**]. Tablet(s) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. 3. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day. 4. Colace 50 mg/5 mL Liquid Sig: Fifteen (15) mL PO twice a day. 5. Multivitamin Liquid Sig: One (1) dose PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aspiration pneumonitis Bacterial UTI Dementia Poor nutritional status Discharge Condition: Per daughter, patient is at baseline. A&O x 0, answers are one word. Denies pain. Not ambulatory. Discharge Instructions: You were admitted with fever, low oxygen levels, and problems breathing; this was caused by an aspiration event. You were seen by our swallowing experts, and they have recommended that you take only pureed solids and nectar-thickened liquids. Your oxygen levels improved with minimal intervention, and you returned to baseline. You were also found to have a urinary tract infection, which is being treated with antibiotics. Followup Instructions: Please follow up with your primary care doctor at the nursing home within 1 week. ICD9 Codes: 5070, 5990, 2859
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Medical Text: Admission Date: [**2115-6-18**] Discharge Date: [**2115-6-23**] Date of Birth: [**2115-6-18**] Sex: M Service: NB HISTORY: Baby [**Name (NI) **] [**Known lastname 4886**] is a former 36 [**4-15**] week infant admitted to the Neonatal Intensive Care Unit with neonatal depression. He was born at 7:36 a.m. at 36-3/7 weeks, 2570 grams, to a 35 year old G7 P3-4 mother with expected date of confinement of [**2115-7-12**]. Expected date of confinement was determined by third trimester ultrasound, as LMP dating was uncertain. Prenatal labs include blood type O negative, antibody negative, hepatitis B surface antigen negative, HIV negative, RPR nonreactive, rubella immune, GBS positive. Pregnancy complicated by late prenatal care, concerns for mild hypertension, and concerns for fetal growth restriction and oligohydramnios. Mother was admitted [**6-17**] for induction of labor and for worsening blood pressures and oligohydramnios. Perinatal course was complicated by spontaneous rupture of membranes on the morning of delivery at 7:22, with acute fetal deceleration and cord prolapse noted. The mother was brought for an emergency cesarean section. Until rupture of membranes, fetal heart rate had been reassuring. Following rupture of membranes, fetal heart rate was difficult to determine. Mother received perioperative antibiotics, but did not receive GBS prophylaxis. At delivery the infant emerged limp and dusky, without respiratory effort or spontaneous movements. He was dried, warmed, and vigorously stimulated without effect. Positive pressure ventilation was begun, with improvement in color. Initial heart rate was greater than 100, and heart rate remained greater than 100 throughout. By 4-5 minutes of life, intermittent gasps and grimaces were noted. At 9-10 minutes of life, the infant began having regular respiratory effort, with a weak cry, and positive pressure ventilation was discontinued. He was brought to the newborn intensive care unit in oxygen. Apgar scores were 2 (+2 for heart rate), 4 (+2 heart rate, +1 color, +1 grimace), and 7 (-1 for color, - 1 tone, -1 grimace). In the NICU, he was continued in supplemental oxygen and an IV was placed. He was given 20 cc/kg of normal saline bolus. PHYSICAL EXAMINATION: Birth weight - 2570 grams, 25-50th percentile. Discharge weight 2575 grams, 25-50th percentile. Admission length 48 cm, 50-75th percentile. Discharge length 48 cm, 50-75th percentile. Admission head circumference 32 cm, 25-50th percentile. Discharge head circumference 32 cm, 25-50th percentile. Vital signs on admission: Temperature 97, heart rate 140-170, respiratory rate 40-60's, admission blood pressure 61/35 with a mean of 48. Oxygen saturation 90-92 percent in room air. General- A well developed infant in no acute distress, responsive to painful stimuli, but overall decreased activity, decreased tone and decreased responsiveness. Approximately 35 weeks. HEENT - Normocephalic, atraumatic. Fontanel soft and flat. Pupils equal, round, reactive to light. Closes eyes in response to light. Nares and ears normal. Palate intact. Neck is supple, no lesions. Chest is moderately aerated, clear. No grunting, flaring or retracting. Cardiac - Regular rate and rhythm. No murmur. Normal S1 and S2. Femoral pulses are 2+. Abdomen - There is a 3-vessel cord. No masses, no hepatosplenomegaly. Quiet bowel sounds. Genitourinary - Normal male. Testes palpable high in scrotum bilaterally. Patent anus. Extremities are warm. Capillary refill is approximately 1 second. Extra postaxial digits of hands bilaterally, with rudimentary stalk. Small bruising and swelling over proximal left forearm. No obvious deformity. Skin has no rash, no petechiae. Warm. Neurologic at rest - Diminished tone and activity. Lies with arms and legs flexed and extended. Responsive to exam. Intact grasp. Weak suck and Moro. Deep tendon reflexes 1+. No clonus. Admission D stick 114. ABG approximately 30 minutes of life was 7.24, 41, 66, 18 on blow-by O2. Cord venous pH 7.32. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY. The baby transitioned to room air by day of life 1. He remained in room air. He has had no apnea, bradycardia or desaturations. 2. CARDIOVASCULAR. The baby initially had 1 normal saline IV bolus, 20 cc/kg, for perfusion, but did not require any pressor support. Blood pressures have been with systolics in the 50's to 80's, diastolics in the 35-40's, with means in the 50's. The baby has had no murmur, no cardiovascular instability. 3. FLUID, ELECTROLYTES AND NUTRITION. The baby initially was NPO. Had a peripheral IV inserted and received maintenance IV D10W. Subsequent D sticks were greater than 60. Enteral feedings were introduced on day of life 2. He is currently feeding Similac 20 cal/oz ad lib, taking in greater than 60 cc/kg/day, voiding and stooling. Electrolytes at 12 hours were sodium 138, potassium 5 (hemolyzed), chloride 105, CO2 25. BUN 5, creatinine 0.6, calcium 7.9, ionized calcium 1.18. AST 10, ALT 57. Phosphorus was 218. At 24 hours, electrolytes were 140, potassium 4, chloride 104, CO2 25. See weight, length and head circumference above. 4. GASTROINTESTINAL. The baby had a peak bilirubin on [**6-21**] of 14.5/0.4. He was treated with phototherapy for approximately 24 hours. Lights were discontinued on [**6-22**], and the bilirubin was 11.5/0.5. Rebound bilirubin was 10.2/0.3. 5. HEMATOLOGY. The blood type was O negative, Coombs negative. The baby did not require any blood products during this admission. He had an admission hematocrit of 49.7. 6. INFECTIOUS DISEASE. The baby initially had a blood culture and a CBC sent. He had a white count of 19.1 with 21 polys, 1 band, platelet count 219, hematocrit 49.7. He was started on prophylactic ampicillin and gentamicin for 48 hours. Antibiotics were then discontinued, as the baby was clinically well and cultures remained negative. He has had no further issues with infection. 7. NEUROLOGY. The baby was noted to have a few episodes of back arching with mild tonic posturing of upper and possibly lower extremities. No overt seizure activity was observed. He was breathing efficiently at the time, with no apnea. A neurology consultation was obtained. At the time of their exam, he had slightly decreased muscle tone, but responded to tactile and painful stimuli with good recoil. No clonus. Deep tendon reflexes zero to one plus. He had an EEG performed, and a head ultrasound. The EEG was essentially normal, as was the head ultrasound, which was performed on [**6-20**]. Dr. [**First Name (STitle) 57006**] was the neurologist from [**Hospital3 1810**] who consulted on this case and felt that at this point in time, no further follow up by Neurology was indicated. 8. Plastic surgery removed the bilateral extra-axial digits on [**6-20**] using absorbable sutures. The area is healing nicely, with a plan to follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**] one month after discharge at [**Hospital3 1810**] ([**0-0-**]). 9. SENSORY. Audiology - Hearing screen was performed with automated auditory brain stem response. Baby passed this screening. Ophthalmology - Eye exam not indicated based on gestational age greater than 32 weeks. 10.PSYCHOSOCIAL. The parents look forward to [**Known lastname 449**] [**Last Name (NamePattern1) **] transitioning home and are pleased with his progress. CONDITION ON DISCHARGE: Stable. DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: [**Location (un) 669**] Comprehensive Care, [**Telephone/Fax (1) 61888**], FAX [**Telephone/Fax (1) 38261**]. CARE RECOMMENDATIONS: 1. Continue ad lib feedings, Similac 20 with iron. 2. Medications - None at time of discharge. 3. Car seat position screening - Passed. 4. State newborn screen - Sent on [**6-21**], day of life 3, results pending. 5. Immunizations received - Hepatitis B vaccine on [**2115-6-22**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks. 2) Born between 32-35 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) With chronic lung disease. Influenza immunization is recommended 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. Follow up appointments scheduled with [**Location (un) 669**] Comprehensive Care within 1 week. Mother will make appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], plastic surgery, at [**Hospital3 1810**] in 1 month. DISCHARGE DIAGNOSES: Former 36 [**4-15**] week male status post perinatal depression, status post rule out sepsis with antibiotics, status post rule out seizure activity, polydactyly bilaterally. [**Known lastname 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2115-6-22**] 22:20:13 T: [**2115-6-22**] 23:47:16 Job#: [**Job Number 61889**] ICD9 Codes: 7742, V290, V053
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Medical Text: Admission Date: [**2171-8-1**] Discharge Date: [**2171-8-9**] Date of Birth: [**2107-3-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1973**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 64yo man with advanced colon cancer on chemo/radiation (dx 1.5 yrs ago), s/p repeat surgery 6 months ago, presented to the ED with one week of progressive N/V/D, weakness, coffee ground emesis and black stools. He has been unable to tolerate POs for 1 week and has been getting IV fluids at home. Also with weakness, exertional dyspnea, intermittent chest pain approximately 2 days ago, which has since resolved. The patient states that he has a tumor pushing on his stomach and another on his abdominal wall. His most recent EGD in [**Month (only) 116**] showed esophagitis, semi-solid food material, and extrinsic compression of antrum. His previous colonoscopy in [**Month (only) 958**] showed noduar mucosa at anastamosis, and a biopsy showed adenoCa. He underwent a laporotomy in [**Month (only) 116**] with diffuse metastatic disease, Bx of abdominal wall mass showed metastatic adenoCa. In the ED, he was tachycardic with HR 100 to 110s, hypotensive BP 90s/70s, which responded to SBP 120 with IV fluids. Exam was notable for a frail patient with dry MM, abdominal tenderness at scar on abdomen, bilateral edema. Labs were significant for Hct 27.9 (baseline mid-20 to mid 30s), WBC 20.0 (91% PMNs), BUN 34, Cr 1.0, HCO3 42, K 2.3, lactate 2.9, normal LFTs, positive UA. He was admitted to the OMED medicine service, where he had a drop in hematocrit from 27.9 to 23.8. Plt 365. He threw up 400cc of maroon colored / coffee ground emesis. GI assessed, and recommended transfer to the [**Hospital Unit Name 153**] for EGD in the AM. The patient received 2 units pRBCs before transfer to the [**Hospital Unit Name 153**]. Upon transfer to the [**Hospital Unit Name 153**], his vitals were T 97.3, BP 119/86, HR 07, RR 18, O2 95% /RA Past Medical History: PAST ONCOLOGIC HISTORY: - [**6-/2169**] developed nausea, vomiting diarrhea - saw GI and decided on watchful waiting - [**8-/2169**] developed worsening abdominal pain, N/V intermittently - [**9-/2169**] KUB consistent with SBO, CT scan showing poa[**Name (NI) 28210**] large bowel obstruction with concern for mass - [**2169-10-2**] exploratory laparotomy with right hemicolectomy and ileocolic anastomosis. Tumor in proximal transverse colon with no intra-abdominal findings to suggest metastatic disease; pathology showed that tumor invaded through muscularis propria Specifically, the tumor was invading through into the subserosa or the non-peritonealized pericolic or perirectal soft tissues and so it was pathologically stage T3. 21 lymph nodes were examined and 2 out of the 21 were positive for malignancy and so he had a pathologic N1B disease. - Received 3 cycles of FOLFOX that was changed to 5FU/LEUCOVORIN due to allergic reaction to the oxaliplatin. Complete 6 cycles of chemotherapy on [**4-24**]. Last cycle was incomplete. - [**3-/2171**]: CT: disease recurrence at prior surgical site - [**2171-5-20**]: operation:unresectable tumor, peritoneal spread and carcinomatosis - [**2171-6-19**]: start on irinotecan 125mg/m2 3 wks on/1 wk off PAST MEDICAL HISTORY: HTN Rosacea erectile dysfunction Social History: Retired school teacher. Former smoker, quit in [**2169**]. Also quit EtOH in [**2170**]. Denies illicits. Two grown children in the area. Wife is his HCP. Family History: Denies history of malignancy or bleeding diathesis Physical Exam: Vitals: T 97.3, BP 119/86, HR 07, RR 18, O2 95% /RA General: Alert, oriented, pleasant man, appears chronically ill but in in NAD. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, 3/6 systolic murmur heard best over RUSB Lungs: Appears nonlabored on RA. Good air movement with coarse expiratory rhonci which clear with cough. Abdomen: soft, non-distended, tender irregular mass palapated just right of midline in epigastrum. bowel sounds present, no organomegaly, no rebound or guarding GU: no foley Ext: Warm, well perfused, left leg markedly more swollen than right. Neuro: AAOx3. CNII-XII intact, moving all extremities with equal strength against gravity, grossly normal sensation. Pertinent Results: [**2171-8-9**] 08:20AM BLOOD WBC-9.4 RBC-2.90* Hgb-8.2* Hct-25.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-18.2* Plt Ct-318 [**2171-8-6**] 06:38AM BLOOD WBC-14.6* RBC-3.01* Hgb-8.4* Hct-26.2* MCV-87 MCH-27.8 MCHC-32.0 RDW-18.4* Plt Ct-254 [**2171-8-2**] 09:50PM BLOOD WBC-13.8* RBC-3.33* Hgb-9.3* Hct-28.6* MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-279 [**2171-8-2**] 12:09PM BLOOD WBC-12.1* RBC-3.12* Hgb-8.9* Hct-26.9* MCV-86 MCH-28.4 MCHC-33.0 RDW-17.8* Plt Ct-270 [**2171-8-2**] 07:39AM BLOOD WBC-15.0* RBC-3.29* Hgb-9.2* Hct-28.3* MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-295 [**2171-8-2**] 01:20AM BLOOD WBC-17.6* RBC-2.71* Hgb-7.4* Hct-23.8* MCV-88 MCH-27.1 MCHC-30.9* RDW-19.2* Plt Ct-365 [**2171-8-1**] 04:20PM BLOOD WBC-20.0*# RBC-3.19* Hgb-8.7* Hct-27.9* MCV-87 MCH-27.2 MCHC-31.2 RDW-18.8* Plt Ct-487* [**2171-8-1**] 04:20PM BLOOD Neuts-90.6* Lymphs-6.6* Monos-2.6 Eos-0.1 Baso-0.1 [**2171-8-9**] 08:20AM BLOOD PT-12.2 PTT-40.4* INR(PT)-1.1 [**2171-8-6**] 06:38AM BLOOD PT-12.0 PTT-28.8 INR(PT)-1.1 [**2171-8-2**] 12:09PM BLOOD PT-15.7* INR(PT)-1.5* [**2171-8-2**] 07:39AM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.5* [**2171-8-9**] 08:20AM BLOOD Glucose-85 UreaN-23* Creat-0.7 Na-141 K-3.3 Cl-108 HCO3-26 AnGap-10 [**2171-8-8**] 05:56AM BLOOD Glucose-103* UreaN-24* Creat-0.8 Na-138 K-3.4 Cl-103 HCO3-26 AnGap-12 [**2171-8-6**] 06:38AM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-137 K-3.1* Cl-100 HCO3-33* AnGap-7* [**2171-8-3**] 04:26AM BLOOD Glucose-125* UreaN-19 Creat-0.8 Na-143 K-3.6 Cl-104 HCO3-36* AnGap-7* [**2171-8-2**] 12:09PM BLOOD Glucose-127* UreaN-27* Creat-0.7 Na-146* K-3.2* Cl-104 HCO3-38* AnGap-7* [**2171-8-2**] 07:39AM BLOOD Glucose-126* UreaN-30* Creat-0.7 Na-149* K-3.1* Cl-102 HCO3-42* AnGap-8 [**2171-8-2**] 01:20AM BLOOD Glucose-105* UreaN-34* Creat-0.9 Na-150* K-2.3* Cl-102 HCO3-40* AnGap-10 [**2171-8-1**] 04:20PM BLOOD Glucose-109* UreaN-34* Creat-1.0 Na-146* K-2.3* Cl-92* HCO3-42* AnGap-14 [**2171-8-1**] 04:20PM BLOOD ALT-11 AST-24 AlkPhos-95 TotBili-0.7 [**2171-8-6**] 06:38AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9 [**2171-8-3**] 04:26AM BLOOD Calcium-7.2* Phos-2.7 Mg-1.8 [**2171-8-1**] 04:20PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.0 Mg-1.9 [**2171-8-1**] 04:29PM BLOOD Lactate-2.9* [**2171-8-1**] 05:10PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.023 [**2171-8-1**] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG [**2171-8-1**] 05:10PM URINE RBC-1 WBC-11* Bacteri-FEW Yeast-NONE Epi-<1 [**2171-8-1**] 05:10PM URINE CastGr-2* CastHy-98* [**2171-8-9**] 09:10AM PLEURAL WBC-50* RBC-77* Polys-65* Lymphs-19* Monos-9* Plasma-1* Meso-2* Macro-3* Other-1* [**2171-8-9**] 09:10AM PLEURAL TotProt-2.1 Glucose-96 LD(LDH)-67 Cholest-36 Triglyc-22 [**2171-8-1**] 4:20 pm BLOOD CULTURE **FINAL REPORT [**2171-8-7**]** Blood Culture, Routine (Final [**2171-8-7**]): PSEUDOMONAS PUTIDA . FINAL SENSITIVITIES. sensitivity testing performed by Microscan. MEROPENEM <= 1 MCG/ML. SULFA X TRIMETH > 2/38 MCG/ML. AMIKACIN <= 4 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS PUTIDA | AMIKACIN-------------- S CEFEPIME-------------- 4 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- <=0.5 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 2 S MEROPENEM------------- S PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- R [**2171-8-1**] 4:20 pm BLOOD CULTURE **FINAL REPORT [**2171-8-7**]** Blood Culture, Routine (Final [**2171-8-7**]): PSEUDOMONAS PUTIDA . IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 351 0199M [**2171-8-1**]. Aerobic Bottle Gram Stain (Final [**2171-8-2**]): GRAM NEGATIVE ROD(S). [**2171-8-1**] 5:21 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2171-8-3**]** URINE CULTURE (Final [**2171-8-3**]): NO GROWTH. [**2171-8-3**] 1:08 am URINE Source: CVS. **FINAL REPORT [**2171-8-3**]** Legionella Urinary Antigen (Final [**2171-8-3**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2171-8-9**] 6:40 am BLOOD CULTURE PORT #1. Blood Culture, Routine (Pending): [**2171-8-9**] 9:10 am PLEURAL FLUID GRAM STAIN (Final [**2171-8-9**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): Brief Hospital Course: 1. Pseudomonal Bacteremia - The most likely source was his probiotics shakes, which do contain this bacteria, although not on the bottle. - ID was consulted, and the patient was changed from zosyn to ceftazidime to complete a 14 day course - Given the indwelling port, surveillance cultures of the port were obtained, and will followed up in [**Hospital **] clinic 2. Acute blood loss anemia due to esophagitis with GI Bleeding - He present with maroon emesis and decreasing hematocrit. Likely due to recent XRT to abdomen (gastritis) although also likely a major component of regurgitation from the gastric obstruction from the cancer - EGD in [**Month (only) 116**] showed only extrinsic compression of the antrum of the stomach and some mild reflux changes with no vacies or ulcers. He was transferred to MICU and received 2 units of PRBC with appropriate response in his hematocrit. He was started on protonix gtt. GI was consulted and performed an EGD on [**8-2**] showed esophagitis, but unable to fully visualize stomach as there was some food in it. After EGD, he was placed on sucralfate QID and pantoprazole 40mg [**Hospital1 **]. His hct was stable and was transferred out of MICU. - The gastric obstruction was treated with reglan with moderate effect, and he was able to eat a fair amount of pureed diet 3. Pleural Effusion - The precense of the effusion is concerning given the bacteremia, so he underwent thoracentesis with 700cc removed. Cytology was sent given concern for malignant effusion 4. Bacterial UTI: He has positive UA with 11 WBC and few bacteria with an elevated WBC of 20, which most likely is due to the pseudomonas. The antibiotics for pseudomonas bacteremia should cover the bacteria for UTI even if it is a different organism. 5. Bilateral Leg edema: - LE edemas has been present for the past two months since his ex lap for colon resection. B/L LENIs showed no evidence of thrombosis. 6. Chest pain: transient bilateral chest pain on [**7-30**] evening in the setting of XRT/UGIB. His pain lasted 1/2 hour and has since resolved. Tropnin was negative and EKG showed no ST elevations. 7. Colon cancer: he has completed a 10-day course of XRT, as well as [**2-15**] doses of chemotherapy which is likely how he got immunosuppressed causing the bacteremia from the probiotic. 8. Benign Hypertension: Transitional Issues ============================ Follow up with ID on the surveillanc cultures Follow up with PCP about ability to eat (as reglan takes effect) Follow up with IP regarding his pleural effusion Full Code Medications on Admission: - AZELAIC ACID [FINACEA] 15% Gel apply to face twice a day. - CITALOPRAM 10 mg - DOXYCYCLINE 100 mg twice a day - ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit capsule - weekly - LORAZEPAM - 0.5 mg tablet - [**1-14**] Tablet(s) Q4H PRN - OMEPRAZOLE - 20 mg capsule daily - ONDANSETRON HCL - 4 mg tablet daily - POTASSIUM CHLORIDE - 20 mEq tablet daily - PROCHLORPERAZINE MALEATE - 10 mg tablet Q6H PRN nausea - TADALAFIL [CIALIS] - 20 mg tablet Q36H hours prn - TRETINOIN [ATRALIN] - 0.05 % Gel - Pea sized amount at bedtime Discharge Medications: 1. CefTAZidime 1 g IV Q8H RX *Fortaz in D5W 2 gram/50 mL 2 grams IV every eight (8) hours Disp #*22 Each Refills:*0 2. Citalopram 10 mg PO DAILY 3. Doxycycline Hyclate 100 mg PO Q12H 4. Loperamide 2 mg PO QID:PRN diarhea 5. Tretinoin 0.05% Cream 1 Appl TP QHS 6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 8. Sucralfate 1 gm PO QID cannot be given with any other medications or two hours following. RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #*28 Tablet Refills:*0 9. Lorazepam 0.5 mg PO Q4H:PRN anxiety 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. tadalafil *NF* 20 mg Oral Q8H:PRN Sexual Intercourse Discharge Disposition: Home With Service Facility: Steward Home Care Discharge Diagnosis: Pseudomonal Bacteremia Acute Blood Loss Anemia GI Bleeding Esophagitis Moderate Malnutrition Colon Cancer metastatic to bowel/retroperitoneum 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 have been started on Reglan which should make your stomach move food more easily. This takes some time to fully work, so do not be suprised that you may have some intermittant nausea You had a thoracentesis to remove fluid from your chest. If you epxerience sudden difficulty breathing, please go directly to the ED. You should not take your probiotic supplement anymore as this may have been the source of the infection Followup Instructions: Department: [**State **]When: MONDAY [**2171-8-19**] at 2:40 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: INFECTIOUS DISEASE When: TUESDAY [**2171-8-20**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage We are working on a follow up appointment for your hospitalization in Interventional Pulmonary with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. You need to be seen in 1 month of discharge. The office will contact you at home with an appointment. If you have not heard within a few business days please call the office at [**Telephone/Fax (1) 3020**]. ICD9 Codes: 7907, 2851, 5990, 5119, 2760, 2768, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3198 }
Medical Text: Admission Date: [**2193-3-28**] Discharge Date: [**2193-4-4**] Service: NEUROLOGY Allergies: Darvon Attending:[**First Name3 (LF) 5018**] Chief Complaint: right putaminal hemorrhage Major Surgical or Invasive Procedure: MRI History of Present Illness: Mr. [**Known lastname **] is an 88year old right handed male with h/o hypertension, hyperlipidemia, CAD s/p CABG now presenting with sudden onset headache, left arm weakness found to have a right putaminal hemorrhage. Pt was well until this afternoon around 2pm when at lunch with his son developed the above symptoms. Taken to [**Hospital1 **] where his exam was notable for "right sided weakness." Patient was apparently fully alert and conversant. He vomited in the CT scan at the OSH and was intubated. Head CT revealed right putaminal hemorrhage. Following intubation his blood pressures dropped requiring two pressors. He was transferred to [**Hospital1 18**] via [**Location (un) **] for further care. Pt was unable to offer a ROS. According to his son he was seen at [**Hospital1 **] ~2 weeks ago for nephrolithiasis. He is somewhat sedentary at baseline, but independent of all ADL's. Past Medical History: CAD- s/p CABG in [**2174**] Pulmonary HTN systolic HF- EF 35% Hypertension hyperlipidemia nephrolithiasis Social History: pt is a car enthusiast, on the board of the [**First Name8 (NamePattern2) 4304**] [**Location (un) 4223**] Auto museum in [**Location (un) **]. never smoker, no ETOH, no illicits. Family History: NC Physical Exam: Vitals: T 98, BP 125/54 (on levophed), HR 59, R 14, 100% CMV Gen- ill appearing, intubated and sedation (recently rec'd fentanyl from [**Location (un) **]) HEENT- NCAT, anicteric sclera, MMM Neck- no carotid bruits CV- RRR Pulm- CTA B Abd- soft, nt, nd, BS+ Extrem- no CCE Neurologic exam: MS- opens eyes to voice, does not follow commands. localizes sternal rub with right hand. CN- PERRL 4-->3mm, blinks to visual threat bilat, intact corneals bilat, intact gag. Motor/sensory- moving right arm and leg spontaneously, purposefully withdraws right arm, leg and left leg to noxious. no withdrawal or left arm to noxoious stim. Reflexes: left patellar 3+, [**Hospital1 **], brachiorad 3+ on left, right with 2+ patell, [**Hospital1 **], tri. absent ankles. Plantar response was upgoing bilaterally. Pertinent Results: [**2193-4-4**] 05:48AM BLOOD WBC-10.9 RBC-4.22* Hgb-13.7* Hct-38.4* MCV-91 MCH-32.3* MCHC-35.6* RDW-13.4 Plt Ct-244 [**2193-4-3**] 06:28AM BLOOD WBC-8.9 RBC-4.53* Hgb-13.9* Hct-41.1 MCV-91 MCH-30.7 MCHC-33.8 RDW-13.9 Plt Ct-230 [**2193-4-2**] 05:55AM BLOOD WBC-8.0 RBC-4.41* Hgb-13.9* Hct-39.7* MCV-90 MCH-31.6 MCHC-35.1* RDW-13.8 Plt Ct-212 [**2193-3-30**] 12:53AM BLOOD WBC-12.6* RBC-4.30* Hgb-13.7* Hct-38.9* MCV-91 MCH-31.9 MCHC-35.2* RDW-14.1 Plt Ct-183 [**2193-3-29**] 03:55AM BLOOD WBC-11.0 RBC-4.16* Hgb-13.4* Hct-38.8* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.5 Plt Ct-177 [**2193-3-28**] 06:15PM BLOOD WBC-11.8* RBC-4.68 Hgb-14.7 Hct-43.4 MCV-93 MCH-31.4 MCHC-33.9 RDW-13.7 Plt Ct-228 [**2193-4-1**] 06:20AM BLOOD PT-14.1* PTT-24.2 INR(PT)-1.2* [**2193-3-30**] 12:53AM BLOOD PT-14.1* PTT-25.3 INR(PT)-1.2* [**2193-4-4**] 05:48AM BLOOD Glucose-149* UreaN-17 Creat-0.9 Na-147* K-3.2* Cl-115* HCO3-25 AnGap-10 [**2193-4-3**] 06:28AM BLOOD Glucose-122* UreaN-16 Creat-0.9 Na-148* K-3.4 Cl-113* HCO3-23 AnGap-15 [**2193-4-2**] 05:55AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-143 K-3.4 Cl-110* HCO3-23 AnGap-13 [**2193-4-1**] 06:20AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-144 K-3.8 Cl-107 HCO3-25 AnGap-16 [**2193-3-31**] 08:26AM BLOOD Glucose-147* UreaN-19 Creat-0.9 Na-141 K-3.7 Cl-108 HCO3-25 AnGap-12 [**2193-3-30**] 12:53AM BLOOD Glucose-98 UreaN-16 Creat-1.1 Na-142 K-3.7 Cl-109* HCO3-25 AnGap-12 [**2193-3-29**] 03:55AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-140 K-4.4 Cl-109* HCO3-22 AnGap-13 [**2193-4-4**] 05:48AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1 [**2193-3-29**] 03:55AM BLOOD %HbA1c-6.0* [**2193-3-29**] 03:55AM BLOOD Triglyc-48 HDL-44 CHOL/HD-2.9 LDLcalc-75 CT Head [**3-29**]:Right basal ganglia hemorrhage with mild surrounding edema. No herniation or hydrocephalus. CT ABD: 1. Three nonobstructing left renal calculi ranging in size between 4 mm and 2 cm. Multiple bladder diverticula. 2. Cholelithiasis. 3. Findings consistent with prior myocardial infarction at the aex of the left ventricle. 4. Small hiatal hernia. CT HEAD [**4-4**]: Unchanged size and appearance of right basal ganglia intraparenchymal hemorrhage. No new blood or intraventricular extension. No subfalcine herniation. Brief Hospital Course: Pt was admitted to the ICU initially for close monitoring. His hemorrahge is thought to be due to hypertension. He had serial imaging with no change in size of hemorrage. He was monitored with frequnet neuro-checks and cardiac telemtery. He was stable and sent to the neurology floor. He developed hematuria and an CT-abd revieled non-occlusive renal stones. He failed multiple speech evaluations and a PEG was placed in IR without difficulty. PT/OT were consulted. He was noted to have an UA suspicious for UTI despite 3 days of IV cipro and was thus changed to IV ceftriazone for 5 day course. Repeat urine cx is pending at discharge. He will follow-up with Dr. [**Last Name (STitle) **] as an outpt. Medications on Admission: Proscar daily Folic acid 1mg daily Folguard ? strength Atorvastatin 20mg daily Metoprolol 75mg QAM, 50mg qnoon, 50mg QHS Persantine 150mg daily Imdur 60mg daily QHS Lisinopril 10m gdaily Aspirin 325mg daily Amlodipine 5mg daily Discharge Medications: 1. Letter To whom it may concern, [**Known firstname 2174**] [**Known lastname **] is under my medical care at [**Hospital1 827**]. Due to his current condition, he is unable to sign his name or write, or otherwise communicate. Sincerely, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], MD 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Docusate Sodium Oral 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 11. CeftriaXONE 1 g IV Q24H Duration: 5 Days Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Cerebral Hemorrhage R Putamen Discharge Condition: Left upper extremity paresis, left neglect Discharge Instructions: You were admitted because of a bleed in your brain. It was likely due to high blood pressure. If you have any new weakness or numbness you should return to the ER. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2193-6-5**] 1:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] ICD9 Codes: 431, 4019, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 3199 }
Medical Text: Admission Date: [**2147-6-5**] Discharge Date: [**2147-6-9**] Date of Birth: [**2090-4-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Emergent CABG X 3 ([**2147-6-5**]) History of Present Illness: 57 y/o male w/no previous cardiac history, presented to [**Hospital 1474**] Hospital with sudden onset chest pain, ruled in for acute MI, placed on heparin/Plavix/Aggrastat, transferred emergently to [**Hospital1 18**] Cath lab. This revealed 90% LM with extensive thrombus, as well as 80% prox. LAD disease. An IABP was placed, and he was takebn to the OR emergently for CABG. Past Medical History: DM-2 HTN s/p bilat hip replacements s/p gunshot injury to abdomen s/p spinal fusion GERD hx. [**Doctor Last Name 360**] [**Location (un) 2452**] exposure Social History: works as substance abuse counsellor denies ETOH denies tobacco married Family History: non-contributory Physical Exam: Pre-op: unremarkable Today: Neuro: grossly intact Lungs CTAB Cor: RRR Abd: benign Ext: 1+ bilat edema Sternal incison clean, dry, no erythema Left leg EVH sites C/D/I Pertinent Results: [**2147-6-8**] 06:45AM BLOOD WBC-7.5 RBC-3.46* Hgb-10.2* Hct-29.6* MCV-86 MCH-29.4 MCHC-34.4 RDW-13.3 Plt Ct-124* [**2147-6-7**] 03:42AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.0 [**2147-6-8**] 06:45AM BLOOD Glucose-44* UreaN-20 Creat-0.9 Na-138 K-3.7 Cl-97 HCO3-33* AnGap-12 [**2147-6-7**] 03:42AM BLOOD Glucose-70 UreaN-14 Creat-0.8 Na-134 K-4.1 Cl-100 HCO3-28 AnGap-10 [**2147-6-5**] 03:00PM BLOOD ALT-22 AST-23 AlkPhos-122* Amylase-19 TotBili-0.4 Brief Hospital Course: Taken to OR emergently from the Cath Lab due to significant LM disease w/extensive thrombus. Underwent CABG X 3 (LIMA > LAD, SVG > distal LAD, SVG > Ramus). Intra-op TEE revealed normal RV function (mild global & apical hypokinesis), trace MR, trace AI, EF 50%. Post-op to CSRU, extubated day of surgery, hemodynamically stable, IABP d/c'd on POD #1, transferred to telemetry floor on POD # 2, chest tubes removed on POD # 3, he was cleared by physical therapy and discharged to home on POD#4 Medications on Admission: Glyburide 2.5 mg [**Hospital1 **] MS Contin 60mg po BID (am & HS) and 30mg QD (midday) Lisinopril 5mg QD Tenormin 25mg [**Hospital1 **] Zantac 300 mg HS Trazadone 100 mg HS ASA 81 mg Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 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:*2* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 7. Morphine 15 mg Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO every twelve (12) hours: 4 tablets Q AM & Q HS, 2 tablets midday. Disp:*70 Tablet Sustained Release(s)* Refills:*1* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: South [**State 1727**] VNA Discharge Diagnosis: CAD MI DM HTN Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions Followup Instructions: with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11907**] (cardiologist) [**7-6**] at 3:20 pm ([**Telephone/Fax (1) 63797**] with Dr. [**Last Name (STitle) 10273**] (PCP) in [**1-19**] weeks with Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2147-6-13**] ICD9 Codes: 4019