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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5100 }
Medical Text: Admission Date: [**2101-2-25**] Discharge Date: [**2101-3-3**] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: An 80-year-old female, with a history of aortic stenosis, had recently had increase in dyspnea on exertion. The patient had a cath today which revealed severe AS with [**Location (un) 109**] 0.59, 1+ AR and a left ventricular ejection fraction of 65%, with normal coronaries. The patient was referred to the cardiac surgery service for AVR. The patient had an echo in [**2100-11-20**] that showed AS, [**Location (un) 109**] of 0.4, 2+ TR, 1+ MR, AV gradual peak at 93. PAST MEDICAL HISTORY: 1. Hospitalized in [**2096**] with ?pneumonia versus CHF, and the patient was intubated at that time. The patient had a question of a history of AFIB at that time, and the patient was on Coumadin for a brief period of time. 2. Status post tonsillectomy. SOCIAL HISTORY: No smoking history. The patient denies drinking alcohol. The patient is married and lives with husband. MEDICATIONS: 1. Atenolol 25 qd. 2. Multivitamins 1 tablet qd. LABS ON ADMISSION: White count 5.9, hematocrit 35.2, platelets 181, INR 1.1, sodium 137, potassium 3.3, chloride 104, bicarb 23, BUN 28, creatinine 0.6, glucose 132. UA was negative. LFTs were normal. REVIEW OF SYSTEMS: The patient denied TIAs, CVA, seizures, no PND, no palpitations, no cough, no wheezes. The patient states that she has occasional heartburn relieved with Tums. The patient has a rare history of diarrhea, some hemorrhoids. The patient denies claudication. Denies diabetes, thyroid disease, or heme issues. PHYSICAL EXAM: The patient is a healthy appearing 80-year-old female. Neurologically, the patient was grossly intact without carotid bruits. Examination of the lungs revealed clear to auscultation bilaterally. Examination of the heart revealed a IV/VI systolic ejection murmur with S1 and S2. Abdomen was soft, nontender, nontender. Examination of the extremities revealed warm with positive peripheral pulses without any edema. HOSPITAL COURSE: The patient was admitted to the cardiac surgery service and underwent aortic valve replacement with a #19 tissue valve. The patient was extubated and transferred to the CSRU. The patient was on perioperative Kefzol, remained afebrile with pulse at 100, and blood pressure 133/56, otherwise doing well. The patient's white count was 21.9, hematocrit 36.9. The patient was put on low dose Lopressor 12.5 [**Hospital1 **], and the patient's Swan was switched to a CVL. On postop day #2, the patient was started on lasix for low urine output. The patient remained afebrile with pulse around 90, blood pressure 130s/40s, otherwise doing well. The patient still had the chest tube, wires and Foley. The chest tubes were removed. Lopressor was increased to 25 mg [**Hospital1 **]. On postop day #3, the patient continued to remain afebrile. Pulse was running around 88, normal sinus, blood pressure 120s/40s, otherwise doing well. Taking in good POs and making good urine. White count was down to 13. The patient was transferred to the floor in stable condition. On postop day #4, the patient had no complaints. The patient's Lopressor was at 50 [**Hospital1 **]. The patient had a low-grade fever of 100.3, otherwise remained stable, pulse around 87, and blood pressure 110s/60s. She was taking good POs and making good urine. White count at 13. The patient's wire was removed and had worked with physical therapist. On postop day #5, the patient remained afebrile with stable vital signs. Pulse still running around 90. The patient worked with physical therapist and passed level 5, and it was safe for the patient to return home. On postop day #6, the patient had no complaints. The patient was on Lopressor 100 [**Hospital1 **] for systemic ventricular tachycardia. The patient's T-max was 100.1, pulse remained at 99, and blood pressure 116/51. The patient was taking good POs and making good urine. The patient was switched to Lopressor 75 mg tid, and the patient was doing well. Pressure and heart rate were better controlled. The patient was discharged home in good condition. CONDITION ON DISCHARGE: Good. DISPOSITION: Home with services. FINAL DIAGNOSES: 1. Status post aortic valve replacement. 2. Severe aortic stenosis. 3. Pneumonia. 4. Status post tonsillectomy. FO[**Last Name (STitle) **]P PLANS: 1. Please follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks; please call his office for follow-up appointment. 2. Please follow-up with Dr. [**Last Name (STitle) 26191**], the PCP, [**Last Name (NamePattern4) **] [**1-21**] weeks; please call for a follow-up appointment. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po bid for 7 days. 2. Potassium 20 mEq po q 12 h for 7 days. 3. Colace 100 mg po bid. 4. Metoprolol 75 mg po tid. 5. Aspirin 325 mg po qd. 6. Percocet 1-2 tabs po q 4 h prn pain. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 26192**] MEDQUIST36 D: [**2101-3-3**] 08:52 T: [**2101-3-3**] 09:37 JOB#: [**Job Number 26193**] ICD9 Codes: 4241, 9971, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5101 }
Medical Text: Admission Date: [**2190-10-4**] Discharge Date: [**2190-10-7**] Date of Birth: [**2112-6-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old gentleman with coronary artery disease, diabetes mellitus, and chronic renal insufficiency who presented with a chief complaint of shortness of breath. The patient presented to the Emergency Department and was found to be bradycardia to the 20s. Per the patient's family, the patient had complained of shortness of breath for the past two days prior to admission. He was becoming dyspneic with walking across the room. On the day of admission, the patient had decreased oral intake and one episode of vomiting. His wife his finger blood sugar level to be 400 and called his primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) who advised the patient to go to the [**Hospital1 69**] Emergency Department. In the Emergency Department, the patient's heart rate was in the 20s with a stable blood pressure. Electrocardiogram showed complete heart block. According to his wife, the patient does not have any recent history of chest pain, orthopnea, or paroxysmal nocturnal dyspnea. The patient did complain of some lightheadedness earlier on the day of presentation. He denies any recent history of fevers or chills. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft in [**2181**] with stents times five in [**2189**]. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. Hypertension. 5. Benign prostatic hypertrophy. 6. Congestive heart failure with left ventricular systolic dysfunction. 7. Chronic renal insufficiency. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg by mouth once per day. 2. Lasix 80 mg by mouth once per day. 3. Hydralazine 25 mg by mouth four times per day. 4. Isordil 20 mg by mouth three times per day 5. Toprol-XL 100 mg by mouth once per day. 6. Zantac 150 mg by mouth twice per day. 7. Zestril 40 mg by mouth once per day. 8. Zocor 80 mg by mouth once per day. 9. Flomax 0.4 mg by mouth once per day. 10. Proscar 5 mg by mouth once per day. 11. Insulin (70/30) 40 units subcutaneously in the morning and 35 units subcutaneously in the evening. 12. Procrit 7500 units subcutaneously every other week. ALLERGIES: An allergy to PENICILLIN. SOCIAL HISTORY: The patient is married. He denies any history of alcohol, tobacco, or drug use. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was afebrile, his blood pressure was 164/58, his heart rate was in the 70s (following temporary pacemaker placement), his respiratory rate was 20, [**Hospital1 **]-level positive airway pressure [**6-22**] with an FIO2 of 60%, and saturating 100%. The physical examination was notable for an irregular rhythm with normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops were appreciated. Extremity examination revealed no lower extremity edema was present on examination. Chest examination revealed crackles in the lungs bilaterally. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission revealed complete heart block with a rate of 30 and possible anterior fascicular block. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories were notable for a creatinine of 4 and a potassium of 6.2. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Coronary Care Unit. In the Emergency Department, prior to transfer to the Coronary Care Unit, a temporary pacemaker was placed. The patient was also placed on [**Hospital1 **]-level positive airway pressure to assist with ventilation. The following morning, the patient was taken for pacemaker placement. The patient received a [**Company 1543**] SDR 303B dual-chamber rate-responsive pacemaker. The patient tolerated the procedure well. Following the procedure, the patient was sent back to the Coronary Care Unit for further monitoring. Following pacemaker placement his heart rate remained stable in the 60s with a systolic blood pressure ranging from the 120s to the 140s. Due to his congestive heart failure and mild left ventricular systolic dysfunction, the patient was diuresed with Lasix. The patient required multiple blood pressure medications to control his hypertension. He was also continued on aspirin, statin, and beta blocker due to his history of coronary artery disease. The patient was not placed on an ACE inhibitor due to his elevated creatinine over his baseline. His creatinine remained stable between 3.7 and 4 throughout his hospitalization. However, his creatinine was elevated from his previous known baseline of 3. Following the pacemaker placement procedure, the patient was restarted on his home insulin scheduled of 70/30. It was found to cause excessive nocturnal hypoglycemia. His evening insulin dose was decreased, and he had no further problems with his blood sugars. On hospital day four, the patient was found to have an episode of shaking chills. He was afebrile, and his white blood cell count was elevated. Blood cultures and urine cultures were obtained but did not grow anything. Due to concern for possible pacemaker pocket infection, the patient was started on intravenous vancomycin; however, there were no signs of infection at pacemaker site. Prior to discharge, the patient was switched to a by mouth antibiotic. Prior to discharge, the patient was given an injection of Epogen 7500 units for anemia of chronic disease and chronic renal insufficiency. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient's discharge status was to home with home physical therapy. DISCHARGE DIAGNOSES: 1. Complete heart block. 2. Status post pacemaker placement. 3. Congestive heart failure. 4. Systolic dysfunction. 5. Coronary artery disease; status post coronary artery bypass graft and stent from prior hospitalization. 6. Hypertension. 7. Insulin-dependent diabetes mellitus. 8. Chronic renal insufficiency. 9. Benign prostatic hypertrophy. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg by mouth once per day. 2. Zantac 150 mg by mouth twice per day 3. Toprol-XL sustained release 100 mg by mouth once per day. 4. Hydralazine 50 mg by mouth q.6h. 5. Amlodipine 5 mg by mouth once per day. 6. Isosorbide dinitrate 20 mg by mouth three times per day. 7. Furosemide 80 mg by mouth twice per day. 8. Docusate 100 mg by mouth twice per day as needed (for constipation). 9. Insulin (70/30) 40 units subcutaneously in the morning and 25 units subcutaneously in the evening. 10. Tamsulosin sustained release 0.4 mg by mouth at hour of sleep. 11. Finasteride 5 mg by mouth once per day. 12. Zocor 80 mg by mouth once per day. 13. Clindamycin 150 mg by mouth q.6h. (times five days). DISCHARGE INSTRUCTIONS/FOLLOWUP: (The patient's was scheduled to follow up as follows) 1. The patient was instructed to follow up with the [**Hospital1 1444**] Cardiology Device Clinic on [**2190-10-12**]. 2. The patient was instructed to follow up with his primary cardiologist (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 32963**]) at the [**Hospital6 4193**] Cardiovascular Division. 3. The patient was instructed to follow up with his primary nephrologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**]) at the [**Hospital6 15291**]. 4. The patient was instructed to follow up with his primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on [**10-12**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Name8 (MD) 32964**] MEDQUIST36 D: [**2190-10-12**] 15:35 T: [**2190-10-14**] 11:39 JOB#: [**Job Number 32965**] ICD9 Codes: 4240, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5102 }
Medical Text: Admission Date: [**2174-8-20**] Discharge Date: [**2174-8-26**] Date of Birth: [**2104-3-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7299**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: s/p EGD and colonoscopy s/p IVC filter placement History of Present Illness: Ms. [**Known lastname 4886**] is a 70 year old female with history of left leg DVT on warfarin who presented with two days of bright red blood per rectum. She complained of weakness and dizziness for the past couple days and when her daughter visited her noticed she was pale and diaphoretic. . In the ED, initial vs were: T 98 HR 155 BP 130/57 RR 18 SaO2 99%RA. Patient was given 2 liters NS IVF, 2 units of FFP to reverse her INR of 2.7, and one unit pRBCs. After a 500cc bolus, her SBP increased from 70s to 130s and HR decreased from 150 to 100s. NG lavage was weakly positive with pink saline and small clots at end of suction. A central line was placed, and she received IV PPI prior to transfer. Vitals at transfer were 130/90, 80, 20, 100% RA. . In the [**Hospital Unit Name 153**], she reports feeling better after being treated in the ED. Patient reports having a week of BRBPR with clots approximately three weeks ago that spontaneously resolved. Her current bleeding episode started yesterday with 6 bloody bowel movements. Afterwards, she had some palpitations with exertion and felt fatigued. She had three episodes of non-bloody, yellow emesis last night without any abdominal pain with some associated cold sweats. Patient has had some intermittent constipation (baseline [**1-27**]/day) with straining occasionally but this does not always occur prior to bloody BM. No known sick contacts, DOE, SOB. No current N/V or abdominal pain. She does complain of discomfort from the NG tube. . Review of systems: (+) Per HPI, 20 pound weight loss over last year. (-) Denies fever or headache. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies current nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: LLE Deep Venous Thrombosis, [**2170**] & [**2173**] Hypertension Type 2 Diabetes Mellitus A1c 6.7% 6/10 Schizoaffective Disorder Hyperlipidemia Social History: Pt is widowed and lives at an [**Hospital3 **] facility. She is a non-smoker and denies alcohol and illicit drug use. . Emergency Contact: [**Name (NI) 1439**] [**Name (NI) 4886**], daughter, ([**Telephone/Fax (1) 108712**], work: ([**Telephone/Fax (1) 108713**], cell: ([**Telephone/Fax (1) 108714**] Case Manager: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79685**], ([**Telephone/Fax (1) 108715**], cell: ([**Telephone/Fax (1) 108716**] Family History: Non-contributory Physical Exam: Vitals: T: 97.6 BP: 144/57 P: 84 R: 22 O2: 100% RA General: Alert, oriented, pale African American female in no acute distress HEENT: EOMI, sclera anicteric with pale conjunctiva, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, R IJ in place Lungs: Clear to auscultation bilaterally with decreased BS at bilateral bases, 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, small reducible umbilical hernia GU: foley in place Ext: cool digits with normal cap refill, well perfused, 2+ pulses, no clubbing, cyanosis or edema, strength 5/5 in BLE extremities Pertinent Results: WBC-9.8# RBC-2.62*# HGB-6.6*# HCT-19.8*# MCV-76* PLT COUNT-368 NEUTS-68.6 LYMPHS-24.4 MONOS-4.8 EOS-1.8 BASOS-0.3 GLUCOSE-195* UREA N-20 CREAT-1.2* SODIUM-141 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-24 PT-27.3* PTT-25.6 INR(PT)-2.7* . [**8-20**] EKG: Sinus tachycardia at 117 with RBBB and LAFB (unchanged from prior) . [**8-20**] CHEST X-RAY:Frontal view of the chest demonstrates cardiomegaly. Right IJ catheter terminates in superior vena cava. There is mild congestive failure. . [**2174-8-22**] Intervential Radiology IMPRESSION: 1. Normal anatomy of the IVC with a maximal caval diameter of 2.2 cm. 2. No evidence of caval thrombus or aberrant caval anatomy. 3. Successful placement of an infrarenal OptEase IVC filter. . [**8-23**] EGD: normal anatomy, no explanation for bleeding. . [**8-23**] [**Last Name (un) **]: Findings: Excavated Lesions, Multiple diverticula were seen in the sigmoid colon. Diverticulosis appeared to be severe. Impression: Diverticulosis of the sigmoid colon Otherwise normal colonoscopy to cecum . [**2174-8-22**] 02:50PM BLOOD WBC-9.7 RBC-3.68* Hgb-9.7* Hct-29.0* MCV-79* MCH-26.4* MCHC-33.5 RDW-15.2 Plt Ct-283 [**2174-8-23**] 05:05AM BLOOD WBC-7.5 RBC-3.28* Hgb-8.7* Hct-26.9* MCV-82 MCH-26.6* MCHC-32.5 RDW-15.7* Plt Ct-284 [**2174-8-24**] 05:55AM BLOOD WBC-7.8 RBC-3.15* Hgb-8.3* Hct-25.0* MCV-80* MCH-26.2* MCHC-33.0 RDW-15.9* Plt Ct-245 [**2174-8-24**] 12:34PM BLOOD Hct-28.1* [**2174-8-23**] 05:05AM BLOOD PT-13.6* PTT-24.4 INR(PT)-1.2* [**2174-8-25**] 12:55PM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-140 K-3.9 Cl-104 HCO3-29 AnGap-11 [**2174-8-22**] 05:00AM BLOOD ALT-11 AST-13 LD(LDH)-180 AlkPhos-65 TotBili-0.7 Brief Hospital Course: # Acute blood loss anemia/GI bleed: Pt was admitted to the ICU, where she remained hemodynamically stable without evidence of ongoing bleeding. Her INR had been reversed with 2units of FFP and 10mg Vitamin K. She was transfused with 2 more units of pRBCs for a total of 3 and her hematocrit bumped appropriately. She was called out to the floor and underwent bowel prep on [**8-22**] followed by EGD/[**Last Name (un) **] on [**8-23**] which did not show any evidence of ongoing bleeding though severe diverticulosis of the colon. Pt was monitored in house and remained hemodynamically stable with stable Hct and no evidence of ongoing bleeding. She was started on Ferrous Sulfate 325mg daily and continue on Omeprazol 20mg daily, she will need follow up with GI following psychiatric admission. . # History of DVT: Pt has had two DVTs, most recent was diagnosed at an OSH in [**2174-5-26**] and has been on warfarin since that time. INR was 2.7 in setting of acute GI bleed and it was reversed as above. She underwent IVC filter placement on [**8-23**] given the risk of anti-coagulation. After discussion with daughter/GI, decision was made to avoid restarting coumadin given her risk to rebleed and her delay in getting care in the setting of this bleed. Pt is scheduled to see her PCP after discharge to further discuss this issue. . # Schizoaffective disorder: Pt had a recent prolonged inpatient psych admission and was seen by psychiatry in house. After discussion with outpatient providers, decision was made to transfer to inpatient psych facility for further care. Pt was continued on Fluoxetine, Donepezil, Lamotrigine and Mirtazapine. Further discussions regarding her ability to care for self at home to be held at that time. . # HTN: stable, continue on home regimen of Lisinopril . # DMII: Stable, will resume home regimen of Metformin 500mg [**Hospital1 **]. Please continue BS checks and pt instructed to stop if not taking regular meals. . Medications on Admission: Aricept 5 mg qHS Fluoxetine 20 mg qday Lamotrigine 50 mg [**Hospital1 **] Lisinopril 20 mg daily GlycoLax 17 gram/dose daily Mirtazapine 45 mg qHS Multivitamin Omeprazole 20 mg daily Seroquel 300 mg qHS Warfarin 6.5mg daily Discharge Medications: 1. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 2. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. Acute blood loss anemia 2. Diverticulosis 3. DVT s/p IVC filter . Secondary: DMII Hypertension Schizoaffective Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with acute blood loss anemia from a lower gastrointestinal bleed in the setting of anti-coagulation for a DVT. You have been transfused with blood and your blood counts have stabilized without any sign of further bleeding. You underwent placement of an IVC filter to treat the DVT. Please note that we have stopped the Coumadin. You should not take this medication again unless you are instructed by a physician. . We have restarted your home regimen including Metformin 500mg twice daily and two new medications 1. Ferrous Sulfate 325mg daily (in place of Multivitamin) 2. Omeprazole 40mg daily . Please continue to monitor your blood sugars at home, you should not take the Metformin if you are not eating regular meals. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Location: [**Hospital1 641**] Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 2115**] Appointment: Thursday [**2174-9-1**] 11:00am . Please call the [**Hospital **] clinic at ([**Telephone/Fax (1) 2233**] after discharge to schedule a follow up appointment with them. ICD9 Codes: 5849, 2851, 4589, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5103 }
Medical Text: Admission Date: [**2170-3-26**] Discharge Date: [**2170-4-16**] Date of Birth: [**2101-3-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45556**] Chief Complaint: GI bleeding, respiratory distress Major Surgical or Invasive Procedure: s/p central line placement History of Present Illness: 68-year-old male with a history of hypertension and gout who is being treated on the biologics service with IL-2 for metastatic melanoma. He began the protocol on Monday and had been tollerating the TID IL-2 infusions, but had a decline in his plts from 200 to 56 as well as a 11# weight gain attributed to capillary leak. He also had significant electrolyte imbalances, tachycardia, and tachypnea expected from this protocol. On the day of [**Hospital Unit Name 153**] transfer, patient had some mild epigastric discomfort and complained to his daughter of heartburn. Of note, he was on daily indocin while on IL-2 therapy. At 10pm, he developed some diarrhea and then had an episode of nausea and vomiting. The covering MD noted 2 very large blood clotts in the emesis. Noted increased RR of 40s, was 84% on RA and then improved to 100% on 4L NC. Biologics attending was not concerned about other parameters, but was worried abt bleeding as patient may be at risk for bleeding given his plts have dropped in the past few days. Brought to [**Hospital Unit Name 153**], GI team asks for FFP, plts. Pt has guiac positive brown stools, but complains of hemorrhoids and some rectal irritation that may be contributing. Holding on NG lavage unless patient becomes unstable. First two hcts are stable. Past Medical History: Onc Hx per OMED notes: Pt was diagnosed with melanoma in [**4-/2167**] when he was found to have a mole on his left abdomen. He underwent wide local excision and sentinel lymph node biopsy at that time which revealed no residual melanoma and the 3 sentinel nodes were negative. Two years later in [**4-18**], he developed a red raised nodule under the scar of the local excision. This was reexcised and he subsequently did well until [**8-/2169**] when he had another satellite recurrence and reexcision. He then had a third satellite recurrence and reexcision in [**10/2169**] and was then started on interferon therapy that was stopped [**2-15**] side effects. Recent PET/CT done revealed a left axillary lymphadenopathy as well as 2 liver lesions. .. .. PmHx: melanoma, Gout, Htn. Reports recent normal EGD and colonoscopy Social History: Married, 4 kids, quit smoking 35 years ago (prior 7pk yr hx), rare EtOH use, retired engineer . Family History: Father with lung cancer Physical Exam: PE: 98.2 133-152/72-75 HR 132 RR 28 100% 4L NC Gen: obese, breathing rapidly, no acute distress, comfortable, alert HEENT: mm dry, op clear, neck supple with tripple lumen in place, eomi CV: distant HS, tachy s1s2 no m/r/g Lungs: crackles noted bilat, L>R, otherwise clear Abd: obsese, multiple metastatic nodules palpable on L side of abdomen, soft, nt/nd, active bs Ext: 1+ edema bilat Rectal: brown guiac positive stools Pertinent Results: CXR PORTABLE [**3-27**] IMPRESSION: Minimal patchy basilar opacities likely due to atelectasis. No evidence of pulmonary edema. . [**2170-3-31**] CXR PORTABLE IMPRESSION: New diffuse bilateral parenchymal opacities compatible with pulmonary edema. . [**2170-3-31**] CHEST XR: A single AP supine view is compared to previous examination earlier from the same day. Again seen extensive bilateral parenchymal opacities suggesting pulmonary edema. There is more dense consolidation in left lower lobe with air bronchogram, compatible with pneumonia. There is a new endotracheal tube with the tip overlying T3. . [**2170-4-2**] BILATERAL LE DOPPLER IMPRESSION: No evidence of lower extremity DVT. . ECHO [**2170-4-2**]: EF>60% Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The right ventricular cavity is moderately dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. There is a trivial pericardial effusion. . [**2170-4-4**] RENAL US IMPRESSION: 1. Multiple left kidney stones, the largest measuring 2.1 cm in the mid pole. No evidence of hydronephrosis. Multiple parapelvic cysts. 2. Right kidney stone. No evidence of hydronephrosis. . [**2170-4-7**] LIVER/GB ULTRASOUND IMPRESSION: 1. No evidence of intra- or extrahepatic biliary ductal dilation. No evidence of cholecystitis. 1.3 cm shadowing gallstone. 2. Two hypoechoic liver lesions likely corresponding to the lesions seen on CT. Metastatic disease to the liver is within the differential. . [**2170-4-9**] CXR IMPRESSION: AP chest compared to [**4-2**] and 24: Left lower lobe consolidation is clearing, probably resolving atelectasis. Pulmonary vascular congestion is present but edema has not returned. Azygous distention indicates volume overload. Heart size is top normal. No pleural effusion or pneumothorax. ET tube and right subclavian line are in standard placements and a nasogastric tube passes through the mid stomach and out of view. . *** CULTURE DATA *** [**4-11**] urine cx neg [**4-10**] blood cx X 6 pending [**4-10**] sputum cx: 2+ GPC in pairs, sparse growth oropharyngeal flora [**4-10**] stool: O&P pending [**4-7**] blood cultures neg [**4-7**] worm macroscopic pending [**4-6**] CMV VL not detected [**4-6**] Crytococcus negative [**4-5**] Rapid resp viral negative [**4-5**] BAL: oropharyngeal flora, no PMN, no microorg, neg fungal, AFB Brief Hospital Course: HOSPITAL COURSE: On the day of [**Hospital Unit Name 153**] transfer, [**2170-3-29**], patient had some mild epigastric discomfort and complained to his daughter of heartburn. Of note, he was on daily indocin while on IL-2 therapy. At 10pm, he developed some diarrhea and then had an episode of nausea and vomiting. The covering MD noted 2 very large blood clots in the emesis. Noted increased RR of 40s, was 84% on RA and then improved to 100% on 4L NC. Biologics attending was not concerned about other parameters, but was worried about bleeding as patient may be at risk for bleeding given his plts have dropped in the past few days. . Brought to [**Hospital Unit Name 153**], GI team requested FFP, plts. Pt has guiac positive brown stools, and complained of hemorrhoids and some rectal irritation that may be contributing. He was not scoped emergently that night, and his vitals were closely followed, along with Hct. His Hct was noted to be stable, with stable VS, and no episodes of melena. GI felt no emergent need for EGD. He is receiving PPI [**Hospital1 **]. On [**4-1**], the pt was intubated for respiratory distress secondary to pulmonary edema thought to be secondary to capillary leak syndrome from HD IL-2. He underwent diuresis and was started on levo/flagyl for ?LLL PNA, started [**3-31**]. On [**4-3**], levo/flagyl d/c'd as all cx negative, pt afebrile. Another reason abx d/c'd was b/c pt developed a rash thought to be a drug hypersensitivity reaction, which improved post d/c abx. ID was consulted [**4-4**] for continued fevers and recommended the initiation of broad spectrum abx incl. Vancomycin, Aztreonam, and Flagyl (stopped [**4-8**]), RUQ US to r/o cholangitis (b/c pt had elev LFTs), and stated would not give steroids, and would do bronchoscopy/BAL for most likely pulm source. Chest CT demonstrated b/l lower lobe infiltrates c/w pulm edema vs. PNA. Pt underwent Bronch [**4-5**], showing limited eval of right sided airways, lavage with RLL post segment, result: no PMN, no microorg, grew OP flora, PCP negative, AFB negative. Vancomycin was continued for ? line infection, and b/c the pt had difficult access, his line was continued for 19 days. He has been on Vanco for 8 days. The pt's LFT elevation was attributed to IL-2 therapy, a known side effect. . Also, he was noted to have renal insufficiency, with Cr to 1.6, and eosinophilia, with presumed AIN. His creatinine continued to rise to 2.6 (baseline 0.9). He was given prednisone, which was subsequently d/c'd. Renal was consulted [**2170-4-5**] and recommended for pt to increase free water intake. They felt he had a number of reasons to have ARF, including: capillary leak syndrome, NSAIDs, infection, contrast on [**4-2**], and drug reaction though no eos or WBC in urine. The pt's creatinine demonstrated slow improvement, was 1.4 [**4-7**], and on transfer from ICU, his Cr was 0.9 (baseline). . Subjectively on transfer from [**Hospital Unit Name 153**] to the medical floor, the pt felt well, is laughing and joking with family, and has no pain complaints. States his breathing if fine. No cough, fever, chills. No N/V. No abd pain. No diarrhea or constipation. No dysuria. No chest pain or shortness of breath. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Impression: A/P: 69 M with metastatic melanoma s/p IL-2 therapy, last dose at 3 pm [**3-29**], now with fevers, resp failure [**2-15**] non-cardiogenic pulm edema; now improving, extubated [**4-12**], and satting well on NC. Resolved ARF. s/p Drug hypersensitivity reaction with discontinuation of all antibiotics and improvement. . #. Pulmonary status s/p respiratory distress: Mr. [**Known lastname 64730**] was intubated initially [**3-31**] for resp distress, thought secondary to non-cardiogenic pulm edema from capillary leak syndrome from Il-2, with possible contribution from PNA. LLL inbfiltrate on CXR, fevers, but sputum never grew anything, so unclear if PNA vs atalectasis. He was intially started on levaquin and flagyl. Chest CT showed lower lobe infiltrates c/w pulm edema vs PNA. Lenis were neg, but he did not have a CTA because of renal failure. He has no h/o CHF, COPD or asthma. No Echo on file. The pt was then taken off all abx on [**4-11**] because all cx data was negative and fevers seemed likely due to acute interstitial nephritis given eosinophilia, ARF, rash versus due to his melanoma and IL'2 treatment. ID was consulted, recommended bronchoscopy and labs, empiric sntibiotics for presumed Hospital acquired PNA vs. line infection, so he was started on vancomycin. Bronchoscopy from [**4-5**] was negative. He remained on vancomycin for 8 days until his central line was pulled. We then discontinued Vancomycin IV. -now on room air, sats stable -nebs prn if needed -chest PT, mobilize secretions -IS to bedside and encourage pt to use . # ARF, resolved: this was thought to be acute interstitial nephritis given fever, rash and ARF with peripheral eosinophilia. However, eos negative in urine. Renal consulted felt to be pre-renal also question contrast induced nephropathy. This fully resolved with hydration, so finally appeared to be most likely pre-renal and contrast related. His creatinine continued to be at his baseline. We ended up restarting his outpatient ACEI. Will see PCP [**Last Name (NamePattern4) **] 1 week. . # Fever: Unclear etiology still, all cultures negative. He has been hemodynamically stable. ID was consulted in the setting of contemplating starting steroids. ID recomended to r/o infection BAL prior to starting empiric antibiotics, multiples serologies histoplasma antigen, EBV viral load, CMV viral load, cryptococal antigen, Strongiloides serology. RUQ u/s. All work up unrevealing to date, and fevers tapered off. Afebrile for 6 days prior to leaving ICU. Initial empiric a/b regimen with flagyl, aztreonam and vanco was D/C'd . He has remained afebrile on the medical floor and has been instructed to report to the ED for fever, chills. . #. Hypernatremia, resolved: Likely due to increase insensible lossess. Free water boluses and D5w was given with normalization of sodium. . #. ?Line infection: Pt was continuing to spike fevers in the ICU with a negative panculture workup and no infiltrate. Other sources excluded, so IV vamco empirically given. His line was pulled, no drainage and erythema at site. His blood cx are negative to date. We stopped IV vancomycin on transfer to medical floor, no evidence to support its use. . #. Metastatic Melanoma: Il-2 therapy on hold for now. Plan per Onc team, attending Dr. [**Last Name (STitle) **] and [**Doctor Last Name **]. His restaging lung CT, head CT showed only mediastinal nodes largest 1.7 cm, could not assess for pulm nodules given pulm edema. The pt has follow up with Dr. [**Last Name (STitle) **]. . #. GI Bleed: The pt had emesis with large clots on [**3-28**]. No further bleeding, hct has since remained stable stable. The pt can continue his PPI. His Hct has remained stable, as well as his vital signs. . #. Elevated LFTs: stable. This is a known side effect of IL-2 therapy. We held his IL-2, and trended his LFTs, which improved over time. . # Confusion/ICU psychosis: Pt had vivid dreams as well as hallucinations while in the ICU, and would often speak inappropriately at times or answer questions with responses unrelated. He was started on low dose haldol. On the medical floor, the pt was appropriate in conversation, but would occasionally state things that he was going to "[**Country 4194**] to herd cattle." On questioning his family, they stated that he has no plans for a trip. He is otherwise appropriate. He has an appointment to follow up with his PCP [**Last Name (NamePattern4) **] 1 week. His haldol was not given while he was on the medical floor. . #. Communication: with pt, wife and daughter [**Telephone/Fax (1) 64731**] . #. Nutrition: The pt initially failed his speech and swallow study, however the study was done a few hours post extubation, when the pt still had copious secretions. At the time of transfer to the medical floor, the pt was swallowing and chewing fine. He did not experience any choking or coughing episodes with eating, and he is tolerating a po diet well. We did not repeat his swallow study. He does not appear to be an aspiration risk now. . #. Access: RSC multi-lumen [**3-26**] discontinued, now with pIV . #. Code: full . #. Proph: PPI, pneumoboots, heparin sq tid . #. Dispo: Home with physical therapy services. Follow up with PCP. [**Name10 (NameIs) **] has a CAT scan scheduled for the last week in [**Month (only) 547**], followed by a Heme/Onc appt on [**5-16**]. Medications on Admission: hctz, atenelol, lisinopril, allopurinol, MVI Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 2. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 6. Atenolol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Primary Diagnoses: 1. Metastatic melanoma status post High dose IL-2 therapy 2. Capillary Leak Syndrome secondary to High dose IL-2 3. Acute Renal Failure 4. Fever 5. Hypernatremia 6. Elevated liver function tests secondary to high dose IL-2 Secondary Diagnoses: 1. Hypertension 2. Gout Discharge Condition: Stable Discharge Instructions: Notify Dr.[**Name (NI) 46582**] office for fever, chills, bleeding, shortness of breath, persistent swelling or inability to take oral fluids. Please take all of your medications as directed. Please follow up with your doctors (see information below). Followup Instructions: You have a follow up appointment with your Primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 64732**], for Thursday, [**2170-4-26**] at 1:30pm. His office number is: [**Telephone/Fax (1) 64733**] if you have any questions. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-5-9**] 10:15 Provider: [**Known firstname **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2170-5-16**] 4:30 Provider: [**Name10 (NameIs) 13145**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2170-5-16**] 4:30 Completed by:[**2170-4-16**] ICD9 Codes: 5849, 486, 2760, 4019, 2749, 2930
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Medical Text: Admission Date: [**2100-11-4**] Discharge Date: [**2100-11-7**] Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a very active 80-year-old female with no prior history of coronary artery disease, who presents with substernal chest pain. The patient states that she was in her usual state of health, taking daily walks around [**Country **] Pond, until day of admission when she developed sudden onset of substernal chest pain. The pain was characterized as pressure like in nature. There was no radiation, no associated nausea or dizziness. The patient was able to ask somebody to call an ambulance. She was brought to the [**Hospital1 69**], where she was noted to have ST segment elevations in II, III, and aVF. She was taken emergently to the Catheterization Laboratory, where she was found to have a total occlusion of her RCA. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Osteoporosis. 3. High cholesterol. 4. History of breast lump status post excision. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Synthroid. 2. Fosamax. 3. Simvastatin. SOCIAL HISTORY: The patient denies cigarette use or significant alcohol use. She is very active at baseline. FAMILY HISTORY: No known history of coronary artery disease. PHYSICAL EXAMINATION: Blood pressure 134/70, heart rate 82, respiratory rate 20, and satting 99% on room air. In general, the patient was alert and oriented in no apparent distress. HEENT: Oropharynx was clear. Mucous membranes were moist. Neck was supple with no lymphadenopathy. Normal thyroid. Lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops appreciated on examination. Abdomen was soft, nontender, nondistended. Lower extremities: There was no clubbing, cyanosis, or edema. Neurologic: Cranial nerves II through XII were grossly intact. ADMISSION LABORATORIES: Negative cardiac enzymes with a CK of 49 and a troponin less than 0.01. Glucose was elevated at 222. BUN was mildly elevated at 25, creatinine was normal. EKG: Normal sinus rhythm at 80, ST segment elevations in II, III, and aVF with elevations in III greater than elevations in II. HOSPITAL COURSE: The patient was taken emergently to the Catheterization Laboratory, where she underwent coronary angiography. This demonstrated a right dominant system with single vessel coronary artery disease. The RCA had a total proximal thrombotic occlusion. Resting hemodynamics showed mildly elevated right sided filling pressures with a RVEDP of 15 mm Hg. Cardiac index was normal at 2.3. The proximal RCA thrombotic occlusion was successfully treated with a Hepakote stent. There is no residual stenosis. The patient was noted to have mild systolic and diastolic ventricular dysfunction. She was started on Integrilin, aspirin, and Plavix, and continued on her statin. Blood pressure medications were held until the following day. Patient was admitted to the CCU and remained stable overnight. She did have a short six beat run of V-tach, but remained asymptomatic. The following day the patient was started on an ACE and beta blocker. She had an echocardiogram, which revealed an ejection fraction of 45%. Mild left atrium enlargement. There was mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior and mid inferolateral wall. The right ventricular chamber size and free wall motion were normal. The ascending aorta was mildly dilated. Moderate mitral regurgitation was also noted. Aortic regurgitation was also noted. There is pulmonary artery systolic hypertension. The patient remained stable and was transferred to the Medical floor for further observation. She had no complaints of chest pain. It was consensus of the Cardiology team that the patient was then stable for discharge home. The patient was thus discharged. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Hyperlipidemia. 3. Status post inferior myocardial infarction and stenting to right coronary artery. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Alendronate 10 mg p.o. q.d. 3. Simvastatin 10 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Lisinopril 5 mg p.o. q.d. 6. Timolol malleate ophthalmic drops. 7. Folic acid 1 mg p.o. q.d. 8. Sublingual nitroglycerin prn. 9. Ranitidine 150 mg p.o. b.i.d. 10. Toprol XL 25 mg p.o. q.d. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 9725**] MEDQUIST36 D: [**2100-12-29**] 10:42 T: [**2100-12-29**] 12:07 JOB#: [**Job Number 101863**] ICD9 Codes: 9971, 2449, 2720
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Medical Text: Admission Date: [**2156-3-30**] Discharge Date: [**2156-4-15**] Date of Birth: [**2109-2-1**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: 47 year old female presents with 4 weeks of headaches, dizziness, concentration difficulty, word finding difficulty, and fatigue. She has not had a physical since [**2147**]. She went to a doctor for the headaches last week and was started on Fioricet; however, this did not improve her symptoms. Today, while at work, she had the worst headache of her life and she was brought here by a co-worker. The patient cannot recall all the events of this morning but her co-worker reported that she had word finding difficulty today as well. Currently, after receiving pain medication in the ER, the headache is [**4-8**], down from [**8-9**] upon arrival. The patient has had no gait disturbances, visual changes, weight loss, numbness, or weakness. She does not have any chest pain or SOB. Past Medical History: NONE Social History: lives with her partner, works as a creative director for a medical supply company Family History: Noncontributory Physical Exam: T:98 BP:127/73 HR:72 RR:18 O2Sats:97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact with lateral nystagmus Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria. Occasional word finding difficulty. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with lateral nystagmus noted bilaterally. 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 full power [**4-3**] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2156-3-30**] 02:53PM K+-3.9 [**2156-3-30**] 02:53PM O2 SAT-91 CARBOXYHB-8* [**2156-3-30**] 02:50PM GLUCOSE-119* UREA N-13 CREAT-0.7 SODIUM-136 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 [**2156-3-30**] 02:50PM estGFR-Using this [**2156-3-30**] 02:50PM WBC-9.1 RBC-4.81 HGB-14.7 HCT-43.1 MCV-90 MCH-30.5 MCHC-34.0 RDW-13.7 [**2156-3-30**] 02:50PM CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-2.1 [**2156-3-30**] 02:50PM PLT COUNT-200 [**2156-3-30**] 02:50PM PT-11.9 PTT-24.8 INR(PT)-1.0 [**3-30**] CT HEAD: Large temporal lobe mass with significant associated edema and mass effect including subfalcine, uncal and transtentorial herniation. Appearance is most consistent with metastasis, although at this time, there is no known underlying primary tumor. An MR is recommended to further characterize this mass. [**3-30**] MR HEAD: There is a large, 5.8 x 5.0 x 4.4 cm mass arising from the left sphenoid [**Doctor First Name 362**]. This mass is hypointense on T1-weighted imaging but enhances homogeneously following administration of Gadolinium. Central hypointensity on T1-weighted images and hyperintensity on T2-weighted images is likely secondary to central necrosis. FLAIR images demonstrate significant surrounding edema. There is extensive mass effect with rightward shift of 8 mm and associated subfalcine herniation. There is also uncal herniation secondary to local mass effect. Evaluation of post-contrast images demonstrate enhancement of the [**Doctor First Name 500**] adjacent to the mass suggesting that this mass is infiltrating the [**Doctor First Name 500**] locally. Diffusion-weighted images reveal no associated infarct. No definitive blood supply is identified based on these images. The signal intensity values of brain parenchyma are otherwise normal. The visualized portions of the paranasal sinuses are unremarkable. The major vascular flow patterns are normal. IMPRESSION: Large, enhancing mass arising from the sphenoid [**Doctor First Name 362**] on the left with MR characteristics of a meningioma. Significant associated mass effect including subfalcine herniation, rightward shift and uncal herniation. Brief Hospital Course: The patient is a 47 year old woman with headache of 4 weeks duration associated with word finding difficulties and poor concentration found to have large left temporal mass consistent with meningioma arising from the left sphenoid [**Doctor First Name 362**] on MRI. There was significant mass effect and 8mm shift adjacent to the left temporal mass. The patient was treated with dexamethasone and dilantin in addition to analgaesia, and closely observed in hospital. Symptoms and examination remained stable. Embolization of the left temporal mass occurred on [**2156-4-6**]. She proceeded to resection of left craniotomy and excision of left temporal mass on [**2159-4-8**]. After the skull was removed, the brain was noted to be acutely swollen and a bleed was noted behind the meningioma. It took approximately 30 minutes to get to the tumor and stop the bleeding, the patient was given Mannitol interoperatively. Post operative CT scan showed there has been massive progression of intracranial mass effect with approximately 12 mm of subfalcine herniation with obliteration of most sulci bilaterally. There is massive uncal transtentorial herniation with involvement of the left temporal [**Doctor Last Name 534**]. A large collection of air is noted along the frontal and temporal lobes with fluid and air within the resection bed as well as foci of hemorrhage within the left temporal lobe. She was kept intubated for first 24 hours given high dose Mannitol and steroids. A central line was placed for poor access and unfornatley she suffered a pneumothorax requiring a chest tube placement. On post operative day 1 she was extubated and following commands, no motor deficits with short term memory deficits and expressive partial aphasia. Post Operative MRI showed: No evidence of residual neoplasm on post-gadolinium sequences, though evaluation in the immediate postoperative period is limited due to intrinsic T1 hyperintense blood product and a follow up MRI at a later date, as clinically indicated, would improve sensitivity. She moved to the neurostep down on Post op day 3, she remained hemodynamically intact, with a chest tube in place followed by general surgery. Her speech and ability to reason and follow complex commands improved slowly. On [**4-12**] she was transferred to the floor and the results of her biopsy showed ANAPLASTIC (MALIGNANT) MENINGIOMA.WHO ([**2148**]) grade 3. An immediate radiation therapy consult was obtained. She had her chest tube discontinued on [**2156-4-14**] by the thoracics service. She had a minute ptx after it was discontinued. She was tolerating regular diet and was cleared to go home with PT/OT on [**4-15**]. Medications on Admission: Fioricet Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(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. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Meningioma Grade 3 Right Pneumothorax Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? Have a 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, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? 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, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up in brain tumor clinic on You should follow up with Dr [**Last Name (STitle) 3929**]. His office will call you prior to your appointment on [**2156-4-28**]. Follow up in Dr[**Name (NI) 9034**] office in one week for your staples to be removed. Call office at [**Telephone/Fax (1) 72651**] for your appointment. Provider: [**Last Name (LF) 5302**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Date/Time:[**2156-5-19**] 9:20 Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2156-5-5**] 8:40 Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] OB-GYN Date/Time:[**2156-4-21**] 8:45 Completed by:[**2156-4-15**] ICD9 Codes: 3051
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Medical Text: Admission Date: [**2131-12-2**] Discharge Date: [**2131-12-24**] Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 348**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Peripherally insterted central catheter Nasogastric tube History of Present Illness: 85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presents from [**Hospital1 1501**] with respiratory distress. Although it is not clear from discharge summary, recent hospitalization complicated by SICU stay for PNA vs CHF. Unclear if patient was reintubated but was started on levofloxacin and diamox. Discharged ([**11-28**]) to complete 2 week course of ciprofloxacin. . ROS: denies shortness of breath, fevers, chest pain. reports only feeling worn and not well. + achy, tired, malaise. Denies DOE (walks >1 block prior to previous admission with cane), PND. Stable 2 pillow orthopnea. No ankle edema. . ED Course: In ED, afebrile but briefly hypotension and responded to small fluid bolus. CXR showed likely PNA and the patient was given a dose of vanc/CTx. Requiring non-rebreather to maintain oxygenation. Prior to coming up to the ICU, the patient went into a fib with RVR (HR to 140s). Started on dilt drip. . MICU Course: Treated for HAP with vanc/levo/flagyl. Respiratory status improved with decreasing O2 requirement and afebrile. Weaned off dilt gtt, AFib remained well-controlled on PO beta blocker and spontaneously converted to sinus. One episode OB+ 'black' stool but stable Hct and hemodynamics stable. . [**Hospital1 **] Course: He was called out to the floor on [**12-4**]. On the floor he appeared dyspneic and was diuresed for pulmonary edema, but dyspnea not completely resolved. He had negative LENIs and V/Q scan with intermediate probability PE. He also continued to tell the team that "I want to die". SW was consulted and ritalin was started. Pt was not taking in POs and creatinine also started trending up again. [**2131-12-12**] pt was found to have BP 72/40 and decreased UOP. He was given a 500 cc bouls and Bps initially trended up to 82/50 and then down to 70/40. He then received an additonal 1 L fluid bolus and was transferred to the ICU. . MICU Course: He received 7 liters of IVF with improvement of his blood pressure and subsequent improvement in his mental status. Psychiatry and neurology were consulted; his perseveration on "I want to die. Hurry up." did not seem consistent with a diagnosis of depression, but his behavior did raise concern of frontal release . Neurology Celexa was stopped as it has been reported to cause hypotension and is without immediate benefit to the patient, and at the recommendation of psychiatry, ritalin was stopped as well. Past Medical History: CVA with residual L hemiparesis (R MCA stroke [**2110**]) OA Gout Hypertension Bilateral Carotid stenosis s/p left CEA [**11/2131**] Type II DM, diet controlled Gastritis CKD (2-2.2) Recent PNA on Cipro Right parafalcine late subacute subdural hematoma Social History: Was living with wife and son but currently in rehab. Retired salesman, air force pilot. No current or past tobacco use, no EtOH abuse. No illicit drug use. Family History: No family hx of stroke, CAD, cancer, DM, or other neurologic disease Physical Exam: T 97.8 HR 86 BP 120/58 RR 28 SaO2 93% on 1L General: WDWN, NAD, jovial, very pleasant, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD, left CEA surgery site with sutures but no erythema or drainage Cardiac: RRR, s1s2 normal, no m/r/g, no JVD Pulmonary: crackles at bases (L>R), occ wheeze Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech slurred, CNII-XII intact, residual left arm and leg weakness from prior CVA Pertinent Results: Hematology [**2131-12-2**] 04:00AM WBC-37.4*# RBC-3.83* HGB-11.7* HCT-34.0* MCV-89 MCH-30.5 MCHC-34.3 RDW-15.0 [**2131-12-2**] 04:00AM NEUTS-92* BANDS-1 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2131-12-2**] 04:00AM PLT COUNT-316# [**2131-12-2**] 04:00AM PT-15.6* PTT-29.6 INR(PT)-1.4* . Chemistry: [**2131-12-2**] 04:00AM GLUCOSE-198* UREA N-120* CREAT-3.2*# SODIUM-155* POTASSIUM-3.2* CHLORIDE-117* TOTAL CO2-20* ANION GAP-21* [**2131-12-2**] 04:00AM proBNP-2649* [**2131-12-2**] 04:00AM CALCIUM-8.3* PHOSPHATE-5.9*# MAGNESIUM-2.3 . EKG: sinus, 100bpm, LAD, freq PACs, IVCD similar to prior . CXR, portable ([**12-1**])- Large hiatal hernia. Increasing air space opacities within the left lung and right lower lung zone. There is no pneumothorax. There are no pleural effusions. . TTE ([**12-4**])- The left atrium is normal in size. The left ventricular cavity size 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 valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CXR ([**12-6**])- The right PICC line tip terminates in the SVC. The large hiatal hernia is again demonstrated. There is worsening of bilateral infiltrates, suggesting increased degree of pulmonary edema and also of the underlying pneumonia cannot be excluded, especially in the right lower lobe and left upper lobe. Bilateral pleural effusion is small-to-moderate. . Bilateral LE U/S ([**12-7**]): No evidence of deep venous thrombosis in either lower extremity. . V/Q scan ([**12-7**]): INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate central deposition of the radiopharmaceutical, due to the turbulent flow. There are widespread ventilatory abnormalities in RML, RLL, LUL, LLL, predominantly at lung bases. Perfusion images in the same 8 views show similar pattern of perfusion abnormaliies, also most pronounced at the bases. Chest x-ray shows diffuse bilateral infiltrates with similar distribution pattern. IMPRESSION: Matched perfusion and chest X-ray findings. Intermediate likelihood ratio for pulmonary embolism. . Chest CT, non-contrast ([**12-10**]): 1. Intrathoracic stomach. 2. Multifocal pneumonia, most likely aspiration. Small bilateral pleural effusions and subcarinal mediastinal adenopathy, presumably reactive. 3. Calcific cholelithiasis. No evidence of cholecystitis. . Head CT, non-contrast ([**12-12**]): FINDINGS: The posterior fossa is not well seen on today's examination secondary to patient motion artifact. There is no evidence of intracranial hemorrhage. Old areas of hypodensity seen within the left external capsule are unchanged compared to [**2131-11-24**], consistent with chronic lacunar infarction. A lacunar infarct within the right caudate nucleus is also unchanged in appearance. There is no evidence of intracranial mass lesion, hydrocephalus or shift of normally midline structures. The density values of the brain parenchyma are within normal limits. The surrounding soft tissues and osseous structures are unremarkable. The paranasal sinuses appear clear. IMPRESSION: No new areas of acute infarction identified. The previously reported tiny left parafalcine subdural hematoma seen on MRI is not seen on today's examination, likely secondary to interval resorption. . Brain, Head, Neck MRI/MRA ([**12-15**]): FINDINGS: BRAIN MRI: Comparison was made with the previous MRI examination of [**2131-11-23**]. The previously seen subtle increased signal in the right parafalcine region in the frontal lobe on diffusion images is again visualized and appears to be due to T2 shine through. Mild periventricular changes of small vessel disease are seen. There is no evidence of midline shift, mass effect or hydrocephalus seen. There is moderate brain atrophy seen. On diffusion images no evidence of acute infarct is noted. The previously identified interhemispheric parafalcine subdural hematoma has also resolved since the previous MRI examination with subtle changes remaining in this region. IMPRESSION: No evidence of acute infarct or new finding since the previous MRI study. Resolution of previously noted subdural hematoma. No mass effect or hydrocephalus. MRA OF THE HEAD: MRA demonstrates a normal flow signal in the anterior circulation. The A1 segment of the left anterior cerebral artery is hypoplastic but both A2 segments are well visualized. There is mild irregularity of the flow signal seen in the basilar artery which could indicate mild atherosclerotic disease. The distal right vertebral artery is not visualized which appears to be secondary to the artery ending in posterior inferior cerebellar artery, a normal variation. IMPRESSION: Mild atherosclerotic disease otherwise unremarkable study. MRA OF THE NECK: The 3D time-of-flight MRA of the neck is limited by motion. No evidence of vascular occlusion or stenosis seen. IMPRESSION: Somewhat motion-limited normal MRA of the neck. . Right upper extremity U/S ([**12-16**]): Occlusive thrombus in the right basilic vein surrounding indwelling PICC line. No deep venous thrombus in the right upper extremity is identified. . EEG ([**12-18**]): FINDINGS: BACKGROUND: A 9 Hz disorganized posterior predominant rhythm was noted in the waking state, which attenuated with eye opening. HYPERVENTILATION: Contraindicated due to mental status. INTERMITTENT PHOTIC STIMULATION: Produced no activation of the record. SLEEP: The patient progressed from the waking to drowsy states, but did not attain stage II sleep. CARDIAC MONITOR: A generally regular rhythm was noted, with an average rate of 90 beats per minute. IMPRESSION: This is a normal EEG in the waking and drowsy states. No focal, lateralizing or epileptiform features were noted. . CXR ([**12-19**]): Multifocal opacities consistent with multifocal pneumonia/aspiration are overall stable with slight clearing in the left upper lobe and slight worsening in the right upper lobe. Interval removal of the nasogastric tube. Left lower lobe atelectasis is unchanged. Brief Hospital Course: 85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presented with hypoxic respiratory distress [**1-4**] PNA and new-onset AFib with RVR. . # Pneumonia: Multifocal PNA, treated for aspiration and HAP given recent intubation / hospital stay with vanc/levo/flagyl x 11 days, vanc/zosyn/flagyl x 2 days, vanc/[**Last Name (un) 2830**]/flagyl x 4 days. LENIs negative, V/Q scan intermediate probability PE. Pulm consulted but rec no bronch as respiratory status improved. He was taken off antibiotics x 2 days and spiked fever, tachypnic, WBC increased from 10 -> 22 (C. diff negative), then decreased 11 after starting linezolid and levofloxacin (to complete 14 day course on [**1-1**]). Respiratory status improved with diminished O2 requirement and resolution of tachypnea. Followup with PCP. . # Personality change: ?depression vs. frontal disinhibition. Patient had been expressing wishes to die intermittently. Occasional sundowning. Psych and neuro consulted. CT head shows resorbed subdural hematoma, MR brain negative for acute CVA. EEG was normal with no seizure activity. Intermittenly uncooperative and somnolent, then spontaneously A&Ox3; likely [**1-4**] delerium from toxic-metabolic cause in setting of significant frontal atrophy noted on head CT. Tried on ritalin (d/c'd [**1-4**] concern for MS change), celexa (d/c'd [**1-4**] concern for hypotension), and remeron (d/c'd [**1-4**] concern for MS change, risk of serotonin syndrome while on linezolid). Occasionally the patient developed non-threatening hallucinations thought to be [**1-4**] toxic-metabolic causes. If he develops agitation, psych recommends considering a trial of haldol 0.5mg prn. . # Paroxysmal AFib: RVR to 140's at presentation, started on dilt drip while in the ED, which was then weaned off in MICU. Remained in sinus rhythm the rest of hospital course. No prior h/o AFib per patient (confirmed with PCP). CHADS score 3, and therefore would probably benefit from anticoagulation, but given fall risk, recent SDH, comorbidites this was deferred (discussed with PCP). Monitored on telemetry with no repeat events. Continued metoprolol with good BP control; occasionally sinus tachy likely [**1-4**] volume depleteion, stress, and infection. . # ARF on CRF: Resolved. Baseline Cre ~2.2; was 2.0 at discharge. Most likely pre-renal azotemia in setting of hypovolemia (poor intake, diarrhea) and responded to IVFs. Medications were renally dosed. . # DM2: Diet-controlled. Hypoglycemic on transfer to MICU in setting of starting NPH for persistant hyperglycemia; NPH was then discontinued. Fingersticks were eventually discontinued as serum glucose was well-controlled. . # CVA: s/p CEA, stable (followed by [**Doctor Last Name 1391**]). MR brain negative for acute event. Vascular surgery made aware patient admitted, no active issues. Cont ASA, Aggrenox. . # Cardiovascular: No documented h/o CAD or CHF but multiple risk factors. Preserved EF on echo, although possible diastolic dysfunction. CXR after MICU transfer with mild to moderate volume overload and the patient was gently diuresed until euvolemic. Cont ASA, statin, BB. . # Anemia: OB +ve stool noted while patient was in MICU, and then intermittent positivity during rest of hospital stay. ?gastritis. Received 1 unit pRBC during admission with appropriate increase in Hct, which remained stable. Started on PPI [**Hospital1 **]. Recent c-scope (2 years ago per patient) negative; denies ever having EGD or h/o GI bleeding. Would consider pursuing outpatient GI followup. . # Coagulopathy: Elevated INR 1.4-1.5 at presentation likely nutritional given poor PO intake. LFTs normal and albumin/prealbumin low supporting nutritional deficiency. Received vitamin K PO with slight improvement. . # Rash: Likely drug reaction [**1-4**] zosyn as this was only new recent medication around the time the rash began. Serum eos normal. The rash resolved after 1 week. Mild pruritis was well-controlled with topical anti-itch cream. . # Hypernatremia: Resolved. Hypovolemic at presentation (~3.5L H2O deficit), serum Na+ normalized with free water boluses but recurred when stopped from poor PO intake and again improved with free water (3L deficit). PO intake encouraged. . # Hypotension: Resolved after 8L of fluids in MICU. Likely [**1-4**] hypovolemia from poor PO intake and diarrhea. Diarrhea also resolved (C. diff neg x 3). Continued to supplement with IV hydration and intermittent hypodermoclysis given poor POs. . # Hyperthyroidism: Mild with slighlty elevated free T4, slightly depressed TSH. No thyroid nodules on exam. Difficult to interpret in acute care setting, and therefore would suggest rechecking as outpatient. . # Activity: PT worked with patient frequently. Goal OOB to chair daily. Will likely need significant rehabilitation and will benefit greatly from increased mobility and independence. . # FEN: Prethickened liquids / ground solids, PO intake encouraged; Briefly with NG tube on tube feeds but d/c'd according to family wishes due to somnolence and mental status changes; Continue aspiration precautions; Repleted 'lytes prn Medications on Admission: 1. Aspirin 81 mg QD 2. Folic Acid 1 mg QD 3. Simvastatin 20 mg QD 4. Metoprolol 25 TID 5. Ciprofloxacin 750mg Q48H for 2 weeks. 6. Dipyridamole-Aspirin 200-25 mg Cap, QD 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Insulin Regular QID PRN Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous membrane PRN (as needed). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to affected areas. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed: apply to affected areas. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1-2H () as needed. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: Please have blood counts (CBC) checked on [**2131-12-31**]. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. 14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 18. CBC Sig: One (1) lab test once for 1 doses: Please have blood counts (CBC) checked on [**2131-12-31**]. Discharge Disposition: Extended Care Facility: [**Hospital 21341**] Rehab Discharge Diagnosis: Primary: [**Hospital 7502**] hospital-acquired Acute renal failure Altered mental status Hypotension Hypernatremia Acute blood loss anemia Atrial fibrillation . Secondary: Cerebrovascular accident with residual left hemiparesis Osteoarthritis Gout Hypertension Bilateral carotid stenosis status post carotid endarterectomy Type II diabetes mellitus Gastritis Chronic renal insufficiency Right parafalcine subacute subdural hematoma Discharge Condition: Good Discharge Instructions: Please take all medications as prescribed. . New medications: levofloxacin, linezolid . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: Please schedule a followup appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 40075**], at [**Telephone/Fax (1) 40076**] in 2 weeks. ICD9 Codes: 486, 5849, 2760, 5990, 2749, 311
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Medical Text: Admission Date: [**2133-7-17**] Discharge Date: [**2133-7-20**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2745**] Chief Complaint: DKA Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms. [**Known lastname 18741**] is a 54 year old F with history of DMI, severe gastroparesis, HTN, Grave's Disease and Hep C, who presents to the ED with altered mental status. Of note, patient has been admitted multiple times within the past year for DKA. Most recent admission was [**Date range (1) 11768**] for DKA. . According to report the patient was brought in by EMS for change in mental status and increased weakness. Glucose per EMS was >800. According to ER notes, patient had spoken to PCP earlier in the day regarding feeling lethargic. She was told to drink lots of fluids. No trauma and no focal weakness. No further history available in medical record. . In the ED, vitals were T 96, BP 171/85, HR 142, RR 18, O2sat 100% on FM. Initial labs showed a glucose of 872, AG 30 with HCO3 3. Lactate was 5.9, K 7.0. She was combative and confused and was intubated for airway protection. Intravenous access was obtained with left femoral line. She received a total of 5L NS, insulin bolus of 10U/hr followed by gtt at 6U/hr. CXR without acute pulmonary process. Head CT was done due to altered mental status and showed no evidence of ICH. Admitted to the [**Hospital Unit Name 153**] for further management . On arrival to the [**Hospital Unit Name 153**] the patient is intubated, sedated. She is tachycardic to the 120s. Past Medical History: 1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**] Several episodes of DKA (last one in [**2129**]), managed on 36U Lantus plus HISS 2. Diabetic polyneuropathy 3. Hypertension 4. Grave's disease s/p RAI [**2129**] 5. Reactive airway disease 6. Seronegative arthritis, followed in rheumatology 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, never been on antiviral therapy, acquired via blood transfusion during surgery in [**2110**] 8. GERD 9. Migraines 10.Bilateral knee arthroscopy in [**5-24**] 11.s/p TAH and pelvic floor surgery with bladder lift 12.Depression 13. Bone spurs in feet Social History: No smoking/EtOH/drugs. Lives at home with 2 daughters. [**Name (NI) **] lives downstairs. She does not work. Family History: Mother: died of colon cancer + for DM-2 Physical Exam: T 97.1 BP 123/87 HR 126 RR 16-18 O2 sat 100% on CPAP+PS 5/5, FiO2 50%, RR 16 Gen: Patient is intubated, sedated. [**Name (NI) 4459**] - CV: Tachycardic, nl s1 s2, no m/r/g Lungs: Clear bilaterally Abd: Soft, NT, ND, +BS Ext: No edema Neuro - Pertinent Results: [**2133-7-17**] 06:15PM GLUCOSE-872* LACTATE-5.9* NA+-130* K+-7.0* CL--97* TCO2-3* [**2133-7-17**] 06:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2133-7-17**] 06:42PM GLUCOSE-937* UREA N-34* CREAT-2.0*# SODIUM-128* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-LESS THAN [**2133-7-17**] 07:07PM GLUCOSE-747* LACTATE-5.4* NA+-136 K+-4.2 CL--106 TCO2-4* [**2133-7-17**] 08:05PM GLUCOSE-664* LACTATE-3.7* NA+-138 K+-3.9 CL--111 TCO2-5* [**2133-7-17**] 09:06PM GLUCOSE-588* LACTATE-2.7* NA+-140 K+-4.4 CL--112 TCO2-6* [**2133-7-17**] 10:02PM GLUCOSE-526* LACTATE-2.2* NA+-140 K+-4.4 CL--115* TCO2-7* [**2133-7-17**] 11:03PM GLUCOSE-468* LACTATE-1.9 NA+-139 K+-4.4 CL--114* TCO2-7* Brief Hospital Course: The patient was admitted to the ICU intubated due to DKA and altered mental status. She was placed on an insulin drip and her glucose steadily decreased from the 900's to the 200's, and her anion gap closed from 20's to 10. She had a transient decrease to blood glc of 33, but was given [**3-24**] an amp of D50 and placed on D5W. Her glucose subsequently increased to 150, stabilized throughout the next day, and was extubated. She then was placed on Lantus [**Hospital1 **] with an insulin sliding scale which was titrated to 20 units glargine [**Hospital1 **] by the [**Last Name (un) **] service with plans for close outpt f/u. Of note, the patient's ARF, severe electrolyte abnormalities and acidosis had completely resolved at time of discharge. The pt had low grade fevers and a mildly positive U/A (although asymtomatic) and given her prior hx and DM, was discharged on a 7 day course of cipro. Pt to f/u closely with [**Hospital **] clinic. Medications on Admission: Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg Tablet PO BID Simvastatin 10 mg Tablet DAILY Methimazole 15 mg Tablet PO BID Amitriptyline 25 mg Tablet PO HS Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device INH [**Hospital1 **] Aspirin 81 mg Tablet, Delayed Release daily Montelukast 10 mg Tablet PO DAILY Pantoprazole 40 mg Tablet, daily Sulfasalazine 500 mg Tablet PO TID Albuterol 90 mcg 1-2 Puffs INH q6H PRN Hyoscyamine Sulfate 0.125 mg Tablet, SL [**Hospital1 **] Gabapentin 300 mg PO Q12H Metoclopramide 10 mg Tablet PO QIDACHS Metoprolol Tartrate 25 mg Tablet PO BID Oxycodone-Acetaminophen 5-325 mg Tablet PO Q4H PRN Insulin Glargine 20U [**Hospital1 **] Humalog Insulin Per sliding scale. 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 for constipation. 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: [**1-21**] Tablet, Delayed Release (E.C.)s PO once a day. 10. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-21**] inh Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Hyoscyamine Sulfate 0.125 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day. 13. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: take per oupt rx. 17. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous twice a day. 18. Humalog 100 unit/mL Cartridge Sig: per scale Subcutaneous QACHS: Take QACHS per sliding scale given to pt at d/c. 19. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Diabetic Ketoacidosis DM 1 uncontrolled with Complications (neuropathy) Diabetic Gastroparesis HTN Hep C [**Doctor Last Name 933**] Disease s/p RAI Discharge Condition: Vital Signs Stable Discharge Instructions: Return to ED if having FS>500, SOB, light-headedness, chest pain, fevers. Followup Instructions: Patient to f/u at [**Hospital **] Clinic with Dr. [**Last Name (STitle) 61114**] in 1 week. Patient to schedule f/u PCP appt in 2 weeks. ICD9 Codes: 5849, 2761, 4019, 2767, 2720, 3572
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Medical Text: Admission Date: [**2193-7-28**] Discharge Date: [**2193-8-4**] Date of Birth: [**2140-11-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: endotracheal intubation femoral line placement bronchoscopy right bronchial artery embolization History of Present Illness: 52M w/ hx of treated TB (3 years ago, in [**Country 651**], 3 meds, cannot recall names, treated for 9 mos) w/ 1 episode of hemoptysis earlier this evening. Reports coughing up a handful of blood, all blood, no sputum. Over last week or so, has had a cough productive of whitish sputum. No sick contacts. [**Name (NI) **] fevers, no night sweats, no weight loss. Approx 1 mo ago, had a URI. IN ER: Had repeat episode. hemodynamically stable. CT chest was performed noting abnormal findings possibly consistant with reactivated TB. Pulm c/s service notified. ROS: -Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever []Chills/Rigors []Nightweats []Anorexia -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: see HPI -Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Skin: [x]WNL []Rash []Pruritus -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: [x ]WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache Past Medical History: other than TB, no medical history. TB was found on routine screening prior to migrating to US. He has never experienced respiratory symptoms. He received nine months of therapy. Social History: now living in US, son is HCP and primary contact [**Telephone/Fax (1) 80531**]. patient is a non-smoker. Family History: no sick contacts. [**Name (NI) **] family members with active TB. Physical Exam: Exam: VS: T 97.2 P 60 BP 101/56 O2 98%RA Gen: Well, no acute distress, awake, alert, appropriate, and oriented x 3 Skin: warm to touch, no apparent rashes. HEENT: No conjunctival pallor, no scleral jaundice,OP clear, no cervical LAD CV: RRR no audible m/r/g Lungs: clear to auscultation Abd: soft, NT, normal BS Ext: No C/C/E Neuro: strength and sensation intact bilaterally. Exam on discharge: 97.1 HR 72 BP 115/68 RR 20 99% RA Gen: Well, no acute distress, awake, alert, appropriate, and oriented x 3 Skin: warm to touch, no apparent rashes HEENT: No conjunctival pallor, no scleral jaundice,OP clear, no cervical LAD CV: RRR no audible m/r/g Lungs: clear to auscultation Abd: soft, NT, normal BS Ext: No C/C/E Neuro: strength and sensation intact bilaterally Pertinent Results: [**2193-7-28**] LACTATE-1.4 GLUCOSE-116* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14 estGFR-Using this WBC-6.8 RBC-4.95 HGB-14.1 HCT-42.6 MCV-86 MCH-28.5 MCHC-33.1 RDW-13.2 NEUTS-64.3 LYMPHS-27.6 MONOS-4.6 EOS-2.9 BASOS-0.6 PLT COUNT-267 PT-12.1 PTT-29.7 INR(PT)-1.0 Labs on discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 10.7 3.83* 11.0* 32.8* 86 28.7 33.5 13.0 230 Glucose UreaN Creat Na K Cl HCO3 AnGap 106* 13 1.2 139 4.1 107 26 10 Calcium Phos Mg 9.0 2.7 2.4 HIV Ab NEGATIVE ASPERGILLUS GALACTOMANNAN ANTIGEN B-GLUCAN pending urine histoplasma Ag pending CXR [**2193-7-27**] IMPRESSION: Multifocal airspace opacities in the right upper and lower lobes, concerning for active infection. With evidence suggestive of prior TB, current active TB infection is not excluded. CT CHEST [**2193-7-28**] IMPRESSIONS: 1. Peribronchovascular opacities in the right upper and middle lobes most suggestive of bronchopneumonia. Given history of TB and a partly calcified mass in the right upper lobe which could represent a large granuloma, active tuberculosis is an important differential consideration. Hemorrhage is another consideration. 2. Calcified nodule in the right lung (20 x 10 mm), probably sequela of prior infection versus a tumor. CT follow-up is recommended to resolution of opacities and surveillance of the lung nodule within three months. If available, comparison to prior studies could also be helpful. PET scanning could also be considered once the more acute process has resolved. [**2193-8-2**] urine culture - no growth [**2193-8-1**] blood culture pending on discharge Brochoalveolar lavage results: GRAM STAIN (Final [**2193-8-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). ~3000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. STAPH AUREUS COAG +. ~[**2183**]/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S ACID FAST SMEAR (Final [**2193-8-2**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED Respiratory Viral Culture (Final [**2193-8-4**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus. Legionella Urinary Antigen (Final [**2193-7-31**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative SPUTUM Source: Expectorated. GRAM STAIN (Final [**2193-7-30**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. ACID FAST SMEAR (Final [**2193-7-31**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR x 3 [**7-27**] and [**7-28**] blood culture showed no growth Brief Hospital Course: Mr. [**Known lastname **] presented to the ED with a chief complaint of hemoptysis # Hemoptysis - Chest film demonstrated multifocal opacities in the RUL and RLL. Given the patient's prior history of TB and the inability to exclude this on presentation, he was admitted to a negative-pressure room. On the floor, he remained hemodynamically stable. He had three negative AFBs and was removed from respiratory precautions. He had a CT scan on [**7-28**] which showed peribronchovascular opacities and a 1cm x 2cm right lung nodule felt to be chronic granuloma/prior infection sequelae vs. malignancy. On [**7-29**], he again had moderate hemoptysis and reportedly vomited blood and had black stools. Pulmonary was consulted, and he was started on Ceftriaxone/Azithromycin empirically for CAP on [**2193-7-31**]. Durnig his course, he had a recurrence of massive hemoptysis. He was bronched on [**8-1**] and found to have substantial bleeding from the posterior segment of right upper lobe. He then went to IR and had embolization of the right bronchial artery and right upper intercostal arterial branch. After the procedure, he was intubated with a dual-lumen endotracheal tube to prevent extravasation of blood into the left lung if bleeding recurred. He remained stable and was extubated on [**8-2**]. Ceftriaxone was replaced with Cefpodoxime on [**8-3**]. His pulmonary hemorrhage was attributed to inflammation of prior eroded tissue from old TB, with a new pneumonia as the precipitant. # Elevated creatinine - He also had mild renal insufficiency which was likely secondary to contrast nephropathy after the IR procedure. The patient was transferred to the medical floor on [**2193-8-3**], and his creatinine normalized with IV fluids and time. He demonstrated continued clinical improvement, with small amount of hemoptysis post-procedure. He remained afebrile with normal vital signs after transfer from the ICU. He was discharged on [**2193-8-4**] and will complete a 7 day course of both azithromycin and cefpodoxime, to be completed on [**2193-8-6**]. He will schedule a follow up appointment with Dr. [**Last Name (STitle) **], his PCP, [**Name10 (NameIs) **] the week of discharge. No other medications were started. The patient is a full code. Medications on Admission: Patient takes no medications regularly Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*10 Tablet(s)* Refills:*0* 2. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: hemoptysis pneumonia Secondary Diagnoses: history of tuberculosis, treated with three drug regimen in [**Country 651**] in [**2190**] Discharge Condition: stable and improved, no recurrence of hemoptysis post-procedure Discharge Instructions: You were admitted to the hospital after coughing up blood. You were treated for a pneumonia with antiobiotics. Tests showed that you did not have tuberculosis again. You had another episode of coughing up blood while in the hospital, and you had a short stay in the intensive care unit. At this time, a procedure was performed to help stop the bleeding in your lungs, which was successful. You continued to do well after the procedure, and you were discharged on [**2193-8-4**]. Please call Dr. [**Last Name (STitle) **] to set up an appointment this week. You should discuss with him when to have another exam of your chest. This exam of your chest should be within the next 3 months. The following changes were made to your medications: you were not taking any medications before you came to the hospital. you will continue taking two antibiotics: cefpodoxime 200 mg twice a day for two days, finish on Tuesday azithromycin 250 mg once a day for two days, finish on Tuesday Please call Dr. [**Last Name (STitle) **] or 911 if you have red or black urine, if you cough up large amounts of blood, if you have trouble breathing, if you develop fevers, chills, or chest pain or any other concerning medical symptoms. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] J. [**Doctor Last Name **], at [**Telephone/Fax (1) 8236**] to set up an appointment in the next week. ICD9 Codes: 486, 5849
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Medical Text: Admission Date: [**2126-8-13**] Discharge Date: [**2126-8-19**] Date of Birth: [**2043-6-28**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: worsening shortness of breath, chest pressure Major Surgical or Invasive Procedure: [**2126-8-15**] 1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic Ultra bioprosthetic valve. 2. Coronary artery bypass grafting x1 with a left internal mammary artery to left anterior descending coronary arteries. 3. Resection of left atrial appendage. History of Present Illness: Mr. [**Known lastname 87158**] is an articulate 82 year old man with a history of aortic stenosis and progressive shortness of breath. His past history is significant for a history of diabetes mellitus, hypertension, hyperlipidemia, CAD s/p MI in [**2099**] and [**2117**]. He had been in stable health over the past 2-3 years until 6 months when he began to develop significant dyspnea on exertion. His dyspnea on exertion has recently worsened so that he can only walk approximately 50 yards before he has to stop due to SOB and leg pain. Although he reports SOB for the past 20 years, but states it has been acutely getting worse for the past 3-4 months. He denies any syncope, presyncope, dizziness, or anginal CP. He is on coumadin for recurrent atrial fibrillation. Pt denies any orthopnea or PND but does report ankle edema. Past Medical History: 1. Severe critical symptomatic aortic stenosis. 2. Single-vessel coronary artery disease. 3. Atrial fibrillation PMH: - Diabetes Mellitus - Pulmonary hypertension - Hypertension on medications - CAD - hyperlipidemia - Atrial fibrillation on warfarin - "Post-polio syndrome" - he reports only orthopedic issues that require chronic narcotics for pain control. He was intermittently on an "iron lung" during the early stages of his poliomyelitis - Peripheral neuropathy multiple herniated disks s/p back surgeries - s/p pneumonia two years previously - benign neoplasm lg bowel Past Surgical History: - s/p back surgeries - s/p total knee replacement (right) x 2 - s/p surgery for lanryngeal cancer [**2104**] -bilat cataract -Appendectomy -tonsillectomy Social History: Tobacco history: remote cigar hx -ETOH: h/o heavy drinking, quit in [**2097**] -Illicit drugs: denies Family History: Father with unknown hx, and mother with valvular disease (unknown cause). No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Physical Exam: Pulse:53bpm Resp:20 O2 sat: 99%-RA B/P: Right 132/55 Left 120/60 Height: 5'7" Weight: 82.1 kg General:NAD A&O Skin: Dry/intact HEENT: NCAT Neck: No LAD Chest: CTAB Heart: irreg irreg, Grade III Systolic Murmur Abdomen: Soft NTND +BS Extremities: Warm, well perfused. Distal pulses intact. 2+ edema BLE Neuro: A&Ox3 Pulses: Palp DP/PT/Fem bilat. Palp Radials Carotid: radiated murmur bilat Pertinent Results: [**2126-8-18**] 06:40AM BLOOD WBC-7.9 RBC-4.06* Hgb-10.4* Hct-31.5* MCV-78* MCH-25.8* MCHC-33.1 RDW-17.7* Plt Ct-150 [**2126-8-18**] 06:40AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-134 K-4.4 Cl-96 HCO3-29 AnGap-13 [**2126-8-18**] 06:40AM BLOOD PT-13.7* INR(PT)-1.2*PREBYPASS TTE: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a small area of diastolic flow into the main PA distal to the PV. There is no thrombus or SEC in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. POSTBYPASS The LV is hyperdynamic. RV systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The LAA is no longer visualized. The remaining study inchanged from prebypass [**2126-8-19**] 05:40AM BLOOD WBC-7.1 RBC-4.04* Hgb-10.5* Hct-31.7* MCV-79* MCH-26.1* MCHC-33.2 RDW-17.9* Plt Ct-157 [**2126-8-19**] 05:40AM BLOOD PT-14.7* INR(PT)-1.3* [**2126-8-19**] 05:40AM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-135 K-4.4 Cl-94* HCO3-32 AnGap-13 Brief Hospital Course: Mr. [**Known lastname 87158**] is a 83 yr old gentleman referred for CT surgery by Dr. [**Last Name (STitle) **] for consideration of aortic valve replacement and coronary artery bypass grafting. The patient was felt to be a good candidate although higher risk than normal. The patient understood the risks, benefits, possible alternatives and wished to proceed. On [**8-15**] he underwent aortic tissue valve replacement and CABG x 1 Lima to LAD and LAA resection, bovine patch by Dr. [**Last Name (STitle) 914**]. Bypass time 116mins cross clamp time was 100mins. Please see intraop note for further details. He arrived from the unit intubated and sedated on propofol, he was hypertensive as he was reversed and extubted that evening and was started on Niacardipime. Oral antihypertensive medications were initiated and nicardipine was discontinued. He cotinued to progress well and was transferred to the floor on POD#2. His chest tubes and pacing wires were discontinued in timely fashion and without difficulty. His post-operative CXR showed a small left pneumothorax that has since resolved. Pt remains in rate controlled a-fib tolerating beta-blocker well. He is tolerating a full diet without swallowing difficulty. He is a known diabetic and was resarted on his pre-op diabetic regimen. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Langdon of [**Location (un) **] in good condition with appropriate follow up instructions. Medications on Admission: Lipitor 10mg qhs zetia 10 mg daily valsartan 80 mg po daily digoxin 0.25 mg po qhs oxycodone 5/325 1tab tid/prn zolpidem 10 mg po qhs prn insomnia warfarin 5 mg PO daily -last dose 9/15 omeprazole 40 mg po daily Diltiazem XL 180mg daily metoprolol tartrate 50 mg [**Hospital1 **] flurbiprofen 100 mg tid diazepam 5 mg TID glyburide 5 mg qpm metformin 1000 mg POBID KCl 10 Meq Qam lasix 40 mg daily MVI daily docusate 200mg [**Hospital1 **] senna 2 tabs [**Hospital1 **]/PRN ASA 325 mg po daily Alka Seltzer daily Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? Atrial Fibrillation Goal INR 2-2.5 First draw [**2126-8-20**] with PCP prior to [**Name Initial (PRE) **]/c from rehab. 2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO HS (at bedtime). 5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose to change daily for goal INR 2-2.5, dx: afib. 11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 13. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 16. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Clipper House Discharge Diagnosis: 1. Severe critical symptomatic aortic stenosis. 2. Single-vessel coronary artery disease. 3. Atrial fibrillation PMH: - Diabetes Mellitus - Pulmonary hypertension - Hypertension on medications - CAD - hyperlipidemia - Atrial fibrillation on warfarin - "Post-polio syndrome" - he reports only orthopedic issues that require chronic narcotics for pain control. He was intermittently on an "iron lung" during the early stages of his poliomyelitis - Peripheral neuropathy multiple herniated disks s/p back surgeries - s/p pneumonia two years previously - benign neoplasm lg bowel Past Surgical History: - s/p back surgeries - s/p total knee replacement (right) x 2 - s/p surgery for lanryngeal cancer [**2104**] -bilat cataract -Appendectomy -tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2126-10-1**] 1:30 Cardiologist: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2126-10-11**] 11:40 Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 87159**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 87160**] in [**11-25**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? Atrial Fibrillation Goal INR 2-2.5 First draw [**2126-8-20**] with PCP prior to [**Name Initial (PRE) **]/c from rehab. Completed by:[**2126-8-19**] ICD9 Codes: 4241, 4168, 412, 2859, 4019, 2724
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Medical Text: Admission Date: [**2127-9-13**] Discharge Date: [**2127-9-15**] Date of Birth: [**2054-11-9**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1232**] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Clot evacuation, bladder fulgeration History of Present Illness: 72yM with h/o mech aortic valve and atrial fibrillation on coumadin as well as history of recurrent bladder cancer (Transitional Ceel), status post TURBT on [**2127-8-15**]. His post op course was complicated by urinary retention requiring Foley replacement [**Date range (1) 9910**] with intermittent hematuria and passage of small clots since. Was admitted to urology service on [**9-2**] for this and underwent cystoscopy, fulguration, clot evacuation, and catheter exchange. Underwent two days of CBI with weaning and then had successful trial of foley removal. He came to the ED today with 3-4h h/o urinary retention, bladder spasms, and gross hematuria/clots. Patient denies other symptoms including fever, chills, nausea, vomiting, SOB, CP. Reports persisent dysuria since proceedure with one episode of urinary incontinence. . Urology saw pt in ED and 20French 3-way foley was placed and hand irrigated x2. CBI initiated but persistent light pink to fruit punch output. Noted to have 6pt Hct drop and ED reporting EKG changes with V3-V6 ST depressions in setting of elevated rates from RVR. Other vitals okay. Pt given benzos, morphine, oxybutin as well as 18L of CBI. Was continuing to have issues with clots and requiring high levels of nursing care so this, combined with Hct drop (although stable on recheck), and EKG changes prompted [**Hospital Unit Name 153**] admission after urology had previously accepted pt to the floor. . On ICU arrival pt in sporadic pain, but excruciating when present. CBI running with bloody fluid in bag. Urology manually irrigated when pt arrived to ICU. Urology potentially planning for OR in AM. Pt feeling okay inbetween pain spasms except for feeling tired. Past Medical History: Recurrent Bladder ca s/p multiple resections, BCG, mitomycin x8, docetaxel and Adriamycin AVR in [**2100**] with a mechanical valve . Carbomedics Bileaflet (INR Goal = 2.5-3.5) HTN Atrial fibrillation HLD Erectile dysfunction OSA -> CPAP h/o diverticulitis Surgical Hx: Surgical History significant for AVR, hernia repair, tonsils, hydrocelectomy [**2120**], TURBT [**12/2123**], Bladder biopsy [**2123**] and 7/[**2124**]. Social History: Married. Retired barber. Denies tobacco, recreational drugs, or alcohol excess although has alcohol hx Family History: Father with [**Name2 (NI) 499**] cancer in his 70s Physical Exam: Admission: Vitals: 98.0 / 149 (Afib) / 124/83 / 20 and 99% on RA General: Alert, oriented x 3, in distress when spasms present HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: IRIR, elevated rate in 120s, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, BS+ GU: foley in place with CBI running, Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: HR: 80s-90s GU: No FOley, voiding spontaneously Pertinent Results: [**2127-9-13**] 07:25AM BLOOD WBC-5.1 RBC-3.75* Hgb-12.9* Hct-37.0* MCV-99* MCH-34.4* MCHC-34.9 RDW-14.6 Plt Ct-184 [**2127-9-13**] 07:25AM BLOOD Neuts-52.4 Lymphs-37.8 Monos-7.2 Eos-1.9 Baso-0.7 [**2127-9-13**] 07:25AM BLOOD PT-21.0* PTT-34.7 INR(PT)-1.9* [**2127-9-13**] 07:25AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-144 K-4.6 Cl-106 HCO3-25 AnGap-18 [**2127-9-13**] 11:30AM BLOOD CK(CPK)-54 [**2127-9-13**] 11:30AM BLOOD CK-MB-3 cTropnT-<0.01 [**2127-9-14**] 06:05AM BLOOD CK-MB-2 cTropnT-<0.01 [**2127-9-14**] 06:05AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8 [**2127-9-15**] 04:09AM BLOOD WBC-3.4* RBC-2.90* Hgb-10.0* Hct-27.8* MCV-96 MCH-34.5* MCHC-36.0* RDW-14.6 Plt Ct-139* [**2127-9-15**] 04:09AM BLOOD PT-29.6* PTT-37.7* INR(PT)-2.9* [**2127-9-15**] 04:09AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-143 K-4.0 Cl-111* HCO3-26 AnGap-10 [**2127-9-15**] 04:09AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.0 [**2127-9-13**] 07:25AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]->1.035 [**2127-9-13**] 07:25AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM [**2127-9-13**] 07:25AM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 Brief Hospital Course: 72yM with h/o mech aortic valve and atrial fibrillation on coumadin as well as history of recurrent bladder cancer (Transitional Ceel), status post TURBT on [**2127-8-15**] presenting with recurrent hematuria and passage of clots since proceedure, now improved s/p CBI. . # Hematuria with clots and urinary obstruction: Intermittent since TURBT on [**8-15**]. Had been home for 10 days but had sudden urinary retention likely due to clot obstructing bladder outlet. Urology saw in ED and aggressively irrigated, started oxybutin, and CBI. He underwent cystoscopy which showed a large clot with bleeding. A vessel was cauterized. He was transfused 1 unit PRBC. He was given oxybutynin for spasm. His hematuria resolved. FOley was removed and he voided spontaneously prior to discharge. He was given Cephalexin while inpatient. He will follow up with urology. . # Afib with RVR: RVR in ED resolved with diltiazem administration. Rates actually down into 60s with one dose of 120mg (was on home dose equivalent to 120mg QID). Diltiazem was decreased to 360mg daily at discharge. Warfarin was stopped and he will have INR check on [**9-18**] and will call PCP with result to restart warfarin [**9-18**]. INR therapeutic at time of discharge. . # Mechanical Aortic Valve: See above for anticoagulation management. . # HTN: Well controlled on only diltiazem. Diltiazem dose decreased as above. Medications on Admission: Coumadin 2.5mg every day except 5mg on Friday Diltiazem 360mg q.a.m. and 120 q.p.m. Simvastatin 5mg Qd Percocet PRN Amoxicillin PRN ppx Docusate Ascorbic Acid Co-Enzyme Q MTV Niacin Vitamin E Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day as needed for bladder spasms. Disp:*20 Tablet Extended Rel 24 hr(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for headache, pain. 5. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day for 3 days. Disp:*6 Capsule(s)* Refills:*0* 6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). Disp:*60 Capsule, Extended Release(s)* Refills:*1* 7. Outpatient Lab Work INR and hematocrit check [**2127-9-17**], results to be faxed to [**Telephone/Fax (1) 164**], warfarin dosing to be decided by PCP based on INR goal 2.5-3.5. 8. niacin Oral 9. coenzyme Q10 Oral 10. vitamin E Oral 11. ascorbic acid Oral 12. Zocor 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Bladder cancer, gross hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications except as noted. You have indicated that you NO longer take Iron tablets and that you do NOT take zocor as prescribed (40mg/day) but take 5-10mg day. Please review this with your PCP. Your diltiazem has been decreased: Prescribing: diltiazem HCl (Oral) 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). Do NOT take a dose at night unless your PCP tells you to at follow up. Please do not take warfarin (coumadin) until you have your INR checked on [**9-18**]. You will have your INR checked in the [**Hospital Ward Name 23**] center and you should call your PCP with the result that day so he may advise you what dose of warfarin to start taking the evening of [**9-18**]. -Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr[**Doctor Last Name **] office tomorrow to schedule/confirm your follow-up appointment AND if you have any questions. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**] Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] regarding your medications and post operative course and INR monitoring/coumadin dosing. You should call and schedule an appointment to be seen in the next 1-2 weeks. UPCOMING APPOINTMENTS: Labwork in [**Hospital Ward Name 23**] center on [**2127-9-18**]-hematocrit and INR check. Call Dr.[**Name (NI) 5049**] office with INR result on [**9-18**] to decide on warfarin dosing which should begin [**9-18**]. Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-9-18**] 11:30 Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-9-25**] 12:30 Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-10-2**] 11:30 ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2114-2-4**] Discharge Date: [**2114-2-15**] Service: HISTORY OF PRESENT ILLNESS: The patient is a 79 year old woman who presented with dyspnea on exertion. She had four episodes of loss of consciousness over the past six months. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg per day. 2. Lopressor 12.5 mg b.i.d., increased recently to 25 mg b.i.d. 3. Benadryl. 4. Trazodone. 5. Colace. PAST MEDICAL HISTORY: 1. Macular degeneration. She is legally blind for three years. Status post left cataract surgery. 2. Status post fall and fracture of the right arm and shoulder. 3. History of narrow valve which was consistent with aortic stenosis. Cardiac catheterization found an 80 millimeter aortic valve gradient, moderate to severe mitral regurgitation. HOSPITAL COURSE: The patient was taken by the plastic surgery service and went to the operating room on [**2114-2-8**], for an AVR valve replacement, #21 tissue type. She tolerated the procedure well and postoperatively was transferred to the Intensive Care Unit where upon she was transferred to the floor on postoperative day number one. She did well on the floor and her capital was increased. Physical therapy was involved in her care and she made progress, however, was not making as good a try as possible because of her comorbidities and her advanced age. On [**2114-2-12**], in the morning, she complained of some shortness of breath and chest x-ray showed a large pleural effusion for which she was given Lasix and diuresed out. She had an increased effusion on the left side after the chest tube pull in the Intensive Care Unit. The patient was not acutely unstable. The patient resolved and her shortness of breath decreased and her effusion went down. Follow-up chest x-ray was obtained on [**2114-2-14**], which shows reduction in the effusion as well as markedly better clinical examination. The patient is comfortable. Physical examination as of this day reveals no jugular venous distention, no carotid bruits. The thoracic incision is clean, no clicks, no discharge, no erythema. The heart has a systolic ejection murmur. The lungs are mostly clear with diminished sounds on the left bases in upright position. The patient is being discharged to rehabilitation on Lasix, dose treatment see page one and on 20 meq K-Dur b.i.d., Captopril 12.5 mg p.o. t.i.d., Lopresor 12.5 mg p.o. b.i.d., In addition, she will receive Amiodarone 400 mg p.o. b.i.d. for one week and then 400 mg q.d. for brief arrhythmia which she suffered in the Intensive Care Unit immediately postoperative. She was also to be given Aspirin 325 mg p.o. q.d. and Ranitidine 150 mg p.o. b.i.d. [**Name6 (MD) 475**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9632**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2114-2-14**] 19:42 T: [**2114-2-14**] 19:53 JOB#: [**Job Number 38883**] ICD9 Codes: 4280, 5119, 2720, 4019
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Medical Text: Admission Date: [**2119-5-21**] Discharge Date: [**2119-6-1**] Date of Birth: [**2063-11-21**] Sex: F Service: SURGERY Allergies: Morphine / Azithromycin / Erythromycin Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain, nausea, vomiting, and inability to pass flatus Major Surgical or Invasive Procedure: total abdominal colectomy with end ileostomy & mucous fistula History of Present Illness: 55 y.o. woman with PMH of several bowel operations presents with abdominal pain, nausea, vomiting and no flatus or bowel movements x 1 day. Past Medical History: 1. depression 2. bipolar disease 3. CHF Past Surgical History 1. emergent sigmoidectomy for perforated diverticuli 4 years ago 2. reversal of ostomy 3 months later 3. emergent ostomy for SBO 4. reversal of ostomy 5. appendectomy 6. lumpectomy right breast Social History: 1 PPD tob x 40 years, occasional EtOH Family History: noncontributory Physical Exam: T: 98.8 HR: 94 BP: 105/59 RR: 20 96%RA Gen: awake, alert, NAD HEENT: neck supple, no masses CV: regular rate and rhythm, no m/r/g Pulm: clear to auscultation bilaterally, no w/r/r Abd: nondistended, nontender, ostomy intact on R side of abdomen, mucous fistula intact on L Ext: warm, well-perfused Pertinent Results: [**2119-5-21**] 04:20AM WBC-13.8* RBC-5.22 HGB-17.3* HCT-48.2* MCV-92 MCH-33.0* MCHC-35.8* RDW-14.4 [**2119-5-21**] 04:20AM ALT(SGPT)-56* AST(SGOT)-38 ALK PHOS-138* AMYLASE-141* TOT BILI-0.6 CT abdomen [**5-21**]: Dilated large bowel proximal to the anastomosis extending to the cecum measuring up to 9 cm in maximal diameter without small bowel dilation. Abd XRay [**5-21**]: Gas filled loops of dilated colon & minimally distended loops of small bowel. Multiple air-fluid levels seen within the large bowel. [**2119-5-30**] 03:00AM BLOOD WBC-10.3 RBC-2.99* Hgb-9.6* Hct-27.7* MCV-93 MCH-32.1* MCHC-34.7 RDW-15.0 Plt Ct-412 Brief Hospital Course: Pt presented to the ED where abdominal CT and Xray demonstrated dilated large bowel and she was found to have a WBC of 13.8. Pt was admitted to the SICU. On HD1 endoscopy demonstrated no obstruction and normal mucosa. On HD3 she was brought to the OR for an ex-lap. Pt was found to have a gangrenous right colon which was treated with a partial colectomy, ileostomy, and mucous fistula with placement of a rectal tube. Pt returned to the SICU postoperatively. On HD3 she was intubated and was started on pressors. She was extubated on HD 10. Shortly thereafter the pt's bowel function returned and her diet was advanced. She was discharged home with VNA on HD12. Medications on Admission: 1. Buspar 60 [**Hospital1 **] 2. Abilify 30 daily 3. Nexium 20 daily 4. Lasix 20 daily 5. Advair daily Discharge Medications: 1. Aripiprazole 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while using narcotics to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*5* 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: gangrenous right colon bipolar disease depression asthma Discharge Condition: good Discharge Instructions: Diet as tolerated. Resume your prehospitalization medications. No bathing (showers are OK - pat wounds dry), no strenuous activity, no driving while using narcotics. No lifting objects heavier than a gallon of milk. Contact your MD if you develop fevers>101, increasing redness or drainage from your wounds, inability to tolerated oral diet, or if you have any other questions or concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in approximately 2 weeks. Please call ([**Telephone/Fax (1) 2300**] to schedule an appointment. ICD9 Codes: 0389, 4280
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Medical Text: Admission Date: [**2124-12-24**] Discharge Date: [**2124-12-26**] Date of Birth: [**2059-12-26**] Sex: M Service: MEDICINE Allergies: Lithium / Erythromycin Base / Cogentin / Stelazine / Clozaril Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Transfer from [**Hospital **] Hospital for CVVH Major Surgical or Invasive Procedure: HD line placement L neck, CVVH Intubation History of Present Illness: The patient is a 64-year-old male with multiple medical problems including a history of chronic kidney disease (stage IV) secondary to presumed lithium toxicity with renal tubular acidosis, history of endocarditis in [**2110**] and presumed endocarditis in [**2124-7-7**], schizoaffective disorder, who was admitted to the [**Hospital **] Hospital on [**2124-8-31**] for treatment of MSSA bacteremia and presumed endocarditis with a six week course of nafcillin in the context of a hip fracture with hardware in place in the left hip. The [**Hospital 228**] hospital course at [**Hospital1 **] was complicated by 2 major gastrointestinal bleeds secondary to multiple duodenal erosions and ulcerations, severe malnutrition with anasarca and weakness. In the week preceding [**2124-12-17**], the patient was noted to be less alert by the chronic medical service that was following him. He had been having continued diarrhea with a recent history of Clostridium difficile colitis for which he was treated with Flagyl and was again found to be Clostridium difficile positive. The patient was also found to have a urinary tract infection with urine culture growing enterobacter cloacae. The patient's diarrhea and urinary tract infection were accompanied with volume depletion and metabolic acidosis. On [**2124-12-15**], the patient became hypotensive with blood pressures in 80s/30s, nonresponsive to aggressive fluid hydration. He was transferred to the ICU and started on Levophed as well as increased antibiotic coverage. . In the ICU, he was started on po vanc and continued on IV flagyl for treatment of cdiff. He had an episode of afib w/ rvr and is s/p cardioversion for hypotension. He was treated with Vanc/Zosyn for broad coverage in the setting of septic shock and continued on cipro for treatment of an enterobacter UTI. He was afebrile during his ICU course and has been off pressors for several days however his blood pressure was thought to be too low to tolerate HD so he was transferred to [**Hospital1 18**] for CVVH. . On arrival, he states he feels mildly SOB. He denies cough. He endorses R testicular pain. No f/c/n/v. He feels hungry and thirsty. Past Medical History: 1. Bipolar disorder versus schizoaffective disorder with history of suicide attempts and ECT tx (Followed in the past by PACT team [**Telephone/Fax (1) 95230**]). 2. Enterococcal endocarditis in [**2110**]. 3. Questionable MSSA endocarditis, [**2124-8-7**]: TEE at [**Hospital1 **] was negative for vegetation and abscesses, so diagnosis of endocarditis was not clear. However, given MSSA bacteremia at the time, and presence of hardware in the left hip, a six week course of nafcillin dating from first negative culture on [**7-30**], [**2123**] was recommended and completed on [**2124-9-11**]. 4. Noninsulin dependent diabetes. 5. Hypertension. 6. Coronary artery disease status post myocardial infarction x2. 7. Echocardiogram performed [**2124-9-6**] showing ejection fraction to 50%, focal thickening of the mitral and aortic valves, and mild pulmonary hypertension. 8. Gastroesophageal reflux disease. 9. Benign prostatic hypertrophy. 10. Chronic kidney disease, stage 4 with nephrotic syndrome and renal tubular acidosis secondary to presumed lithium toxicity with a baseline creatinine of 2.5 while at the [**Hospital **] Hospital. 11. DVT 12. Recent h/o afib w/ RVR. 13. Hyperlipidemia 14. s/p fall w/ occipital bleed 15. Duodenal ulcers w/ 3 recent GI bleeds 16. L hip femoral neck fracture s/p hemiarthroplasty in [**6-13**] 17. L radial fx [**6-13**] Social History: Prior to his hospitalization for hip surgery and then transfer to the [**Hospital **] Hospital, the patient lived in an apartment by himself with PACT team support for psychiatric issues. He was at [**Hospital 671**] rehab from [**2124-7-5**] until [**Month (only) **]. The patient has a girlfriend, [**Name (NI) **], who visits him occasionally. The patient has a sister who is also his health care proxy who lives in [**Name (NI) 4565**] but is very involved in his health care. The patient had a smoking history of 1.5 packs a day x30-40 years. The patient has a rare history of alcohol use. Denies illicit drug use. Family History: H/o bipolar disorder and depression in the family. Physical Exam: Vitals: T: 98 BP: 129/51 P: 89 R: 16 O2: 92% on 2L NC General: Groggy and slow to answer but awake, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, RIJ in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, but non-tender, hyperactive bs Ext: anasarca, wwp, able to move all extremities Pertinent Results: [**2124-12-24**] 03:24PM TYPE-MIX [**2124-12-24**] 03:24PM O2 SAT-74 [**2124-12-24**] 02:13PM TYPE-ART TEMP-37.8 PO2-87 PCO2-41 PH-7.26* TOTAL CO2-19* BASE XS--8 COMMENTS-AXILLARY [**2124-12-24**] 02:13PM LACTATE-1.7 NA+-137 K+-3.3* [**2124-12-24**] 02:13PM freeCa-1.10* [**2124-12-24**] 02:00PM URINE HOURS-RANDOM UREA N-280 CREAT-74 SODIUM-52 [**2124-12-24**] 02:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017 [**2124-12-24**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2124-12-24**] 02:00PM URINE RBC-32* WBC->1000* BACTERIA-NONE YEAST-MANY EPI-0 [**2124-12-24**] 02:00PM URINE WBCCLUMP-MANY [**2124-12-24**] 01:16PM GLUCOSE-57* UREA N-95* CREAT-5.5*# SODIUM-142 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-19* ANION GAP-16 [**2124-12-24**] 01:16PM estGFR-Using this [**2124-12-24**] 01:16PM ALT(SGPT)-4 AST(SGOT)-13 ALK PHOS-66 TOT BILI-0.2 [**2124-12-24**] 01:16PM TOT PROT-3.1* ALBUMIN-1.3* GLOBULIN-1.8* CALCIUM-7.3* PHOSPHATE-7.7*# MAGNESIUM-1.8 [**2124-12-24**] 01:16PM VIT B12-1222* FOLATE-16.8 [**2124-12-24**] 01:16PM VANCO-18.1 [**2124-12-24**] 01:16PM WBC-18.0*# RBC-2.62* HGB-8.3* HCT-26.1* MCV-100*# MCH-31.8 MCHC-31.9 RDW-18.5* [**2124-12-24**] 01:16PM NEUTS-77* BANDS-4 LYMPHS-12* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [**2124-12-24**] 01:16PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ [**2124-12-24**] 01:16PM PLT SMR-NORMAL PLT COUNT-293 [**2124-12-24**] 01:16PM PT-15.6* PTT-83.1* INR(PT)-1.4* Brief Hospital Course: This is a 64 M w/ pmh of stage IV CK, 3 recent UGI bleeds in the setting of duodenal ulcers, recent tx for MSSA endocarditis w/ 3+ AR, recent cardioversion for afib w/ rvr, transferred to [**Hospital1 18**] for consideration of CVVH in the setting of hypotension and likely continuing septic physiology. . # Hypotension: Currently relatively hypotensive given h/o hypertension. Vanc/Zosyn were started on [**12-16**] for empiric broad-spectrum coverage for septic shock at OSH. Blood cx from OSH on [**12-16**] w/ ngtd. Had been afebrile during his ICU stay at OSH. WBC count 18 from 27 on the 14th. Given leukocytosis, likely c/w continued sepsis. Possibly from c diff colitis as seemed to improve with po vancomycin. Patient was placed on continued PO vanc and IV vanc/zosyn. His hypotension continued to progress. He was intubated for airway protection after he became acutely less responsive, diaphoretic and pale. His sister was called and she decided to make him CMO. The tube was removed and the patients blood pressure continued to drop until he passed at 855 PM. . # C. diff colitis: Currently being treated w/ po vanc (D1 = [**12-13**]) and IV flagyl (unknown time course). Has a history of chronic diarrhea of unknown etiolgy. - continue po vanc X 14 after last day of broad-spectrum antibiotics ([**12-24**]) . # Acute renal failure on chronic renal failure: His baseline cr was 2.6 on admission to [**Hospital1 **]. Cr now 5.6 on transfer. ? from ATN from hypotension. Has a h/o nephrotic syndrome w/ albumin of 0.7. Clearly has anasarca. Blood pressure on the low side so unclear if he would tolerate HD. - renal consult for possible CVVH-unable to place line on HD 2, on HD 3 acutely hypotensive and L IJ line placed emergently. CVVH never initiated as patient made CMO. - renal diet - nephrocaps - phos binders given phos of 7.7 . # Hypoxia: h/o smoking so likely has some underlying COPD. Likely a component of volume overload/pulmonary edema given renal failure. - continue ipratropium nebs - CXR - CVVH vs HD as above . # Enterobacter clocae UTI: Per OSH, blood cx from [**12-16**] w/ NGTD. - cipro started on [**12-13**] (no [**Last Name (un) 36**] data), will d/c as now s/p an 11-day course - send UA/cx . # DVT: R superficial femoral vein thrombosis [**First Name8 (NamePattern2) **] [**Hospital1 **] report. Is very high risk for recurrent GI bleed. The risk/benefit ratio was discussed at [**Hospital1 **] and thought to favor anticoagulation. - heparin ggt-held given need for HD line, never re-initiated . # Afib: Currently in sinus. Status post cardioversion on [**12-20**] in the setting of hypotension. Has been on heparin ggt and amio was started to prevent recurrent afib. Likley afib occurred in the seting of septic shock from ? cdiff. - will discontinued amiodarone . # Anemia: Macrocytic. Had an upper GI bleed during his last [**Hospital1 18**] hospitalization and 2 additional GI bleeds at [**Hospital1 **] requiring 6 U PRBC. This may also be c/b B12 deficiency as it appears that his B12 level was low in [**4-13**]. - guiac stools - transfuse for hct < 21 . # Decubitous ulcers: Stage 1 sacral decubitous ulcer. - wound consult . # DM: BS well-controlled w/o insulin coverage at [**Hospital1 **]. - trend for now - add insulin SS if needed . # Aortic regurgitation: 3+ on [**8-14**] ECHO thus although EF > 55%, functionally his forward flow is not normal. . # Bipolar disorder/Schizophrenia: continue valproic acid, wellbutrin, seroquel, lamictal . # GERD: continue pantoprazole 40 mg [**Hospital1 **] given h/o duodenal ulcers and GI bleed during last [**Hospital1 18**] hospitalization . # Hyperlipidemia: continue simvastatin . # BPH: hold terazosin as has a foley in place . # FEN: No IVF, replete electrolytes, renal diet . # Prophylaxis: heparin ggt, VRE carrier, known cdiff + . # Access: Lines: 1- Right IJ line (placed [**2124-12-16**]) - will order PICC and d/c 2- Right radial A-line (placed [**2123-12-21**]) - will d/c if not needed . # Code: FULL CODE . # Communication: Patient, sister ([**Telephone/Fax (1) 108572**] . # Disposition: pending above Medications on Admission: 1. Ciprofloxacin 400 mg IV q. 24 hours. 2. Zosyn 2.25 grams IV q. 8 hours. 3. Vancomycin 1 gram IV daily (dose given daily depending on daily a.m. vanco trough). 4. Vancomycin 250 mg p.o. t.i.d. 5. Flagyl 250 mg IV q. 8 hours. 6. Bicitra 10 mL p.o. b.i.d. 7. Valproic sodium 750 mg p.o. b.i.d. 8. Omeprazole 40 mg p.o. q. 12 hours. 9. Epogen 40,000 units subcu once weekly. 10.Lamictal 50 mg p.o. b.i.d. 11.Calcitriol 0.25 mcg p.o. daily. 12.Ipratropium bromide 0.5 mg 0.25% inhaled q. 4 hours p.r.n. shortness of breath. 13.Tylenol 650 mg p.o. q. 6 hours p.r.n. temperature greater than 101. 14.Atrovent inhaler q. 4 hours p.r.n. shortness of breath. 15.Folic acid 1 mg p.o. daily. 16.Cholecalciferol 400 units p.o. daily. 17.Oxycodone 5 mg p.o. q. 6 hours p.r.n. pain. 18.Wellbutrin SR 100 mg b.i.d. 19.Seroquel Extended Release 200 mg p.o. q. h.s. 20.Amiodarone 400 mg p.o. t.i.d. 21. Heparin gtt with q6 hours PTTs 22. NovaSource renal at 20 mL an hour around the clock with 250 mL normal saline flushes every 4 hours Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Expired secondary to cardiopulmonary compromise from sepsis likely C.diff. Complicated by acute on chronic renal failure. Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2124-12-26**] ICD9 Codes: 4241, 0389, 5845, 5990, 5856, 5180
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Medical Text: Admission Date: [**2136-3-13**] Discharge Date: [**2136-3-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: Lightheadeness, Gastrointestinal bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Colonoscopy Blood transfusions History of Present Illness: Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status post repair, MVR s/p porcine valve placement, atrial fibrillation on coumadin, and diverticulosis who presented with lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He admits to feeling weak one day prior and his wife reports he has had increased fatigue throughout the week prior to presentation. He notes he woke up early on morning of admission feeling very dizzy and "woozy." His wife reports he has had bloody stools for at least a week. He also has had relatively severe nosebleeds and had excessive bleeding from a cut on his hand over the past week. He denies any changes to his coumadin doses or other changes in his medications recently. In the ED, initial vs were: T 97.3, P 78, BP 122/60, R 16, O2 sat 98% on RA. A foley was placed and per report approximately 200 cc of urine drained. He was found to have a 12 point Hct drop from his prevoius value taken last summer and INR greater than assay as well as acute renal failure. Patient was given 1 L of NS, vitamin K 5 mg PO x1, protonix 40 mg IV x1 and 2 units of PRBCs and 4 units of FFP were ordered. Additionally, patient got up in the ED to urinate and fell. He was possibly unresponsive mom[**Name (NI) 11711**]. CT head was negative. He did sustain bilateral knee hematomas at the time. He denies any recent changes in his coumadin dose and has been on coumadin for about two years. He reports taking some supplements but mostly vitamins and melatonin. His last colonoscopy was in [**11/2131**] and showed diverticulosis of the sigmoid colon. EGD at that time showed a large hiatal hernia and gastritis with normal biopsies. In the MICU, the patient reports feeling well and denies ever having chest pain, shortness of breath, abdominal pain, or nausea and vomiting. His greatest concern on transfer to the floor is that his urine appeared quite bloody. Review of Systems: The patient denied any fevers, chills, weight loss, or recent illnesses. No nausea, vomiting, abdominal pain, or melena. He denied any chest pain, shortness of breath, or palpitations. He did report some worsened urinary hesitancy and feeling of being unable to void fully on the day prior to presentation. Past Medical History: -Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD, SVG to PDA) -Ascending Aortic Aneurysm s/p repair in [**2134**] -Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**] -Atrial fibrillation -Diabetes Mellitus -Hypertension -Benign Prostatic Hypertrophy -Obesity -Hiatal hernia -S/p pacemaker in [**2129**] -S/p left knee surgery -Splenic hypodensity -Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood) Social History: He is a retired optometrist and a veteran of WWII. He smoked while he was in the Air Force and has not smoked since leaving the army in the [**2067**]'s. Extremely rare alcohol use. He lives at home with his wife. Family History: Non-contributory Physical Exam: Vitals: T:97.1 BP: 119/47 P: 60 R: 16 O2: 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: large hematoma on L knee Pertinent Results: LABORATORY RESULTS =================== On Presentation: WBC-10.6# RBC-3.23*# Hgb-9.2*# Hct-28.1*# MCV-87 RDW-15.8* Plt Ct-182 ----Neuts-85.9* Lymphs-9.0* Monos-4.7 Eos-0.2 Baso-0.1 PT->150* PTT-68.5* INR(PT)->21.8* Glucose-271* UreaN-40* Creat-2.6*# Na-137 K-4.8 Cl-101 HCO3-23 Calcium-9.1 Phos-4.6* Mg-2.9* On Discharge: WBC-6.7 RBC-3.76* Hgb-11.2* Hct-32.4* MCV-86 RDW-16.3* Plt Ct-192 PT-18.7* PTT-29.0 INR(PT)-1.7* Glucose-86 UreaN-14 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-25 Cardiac Enzymes: CK 258 -- 256 -- 276 CK-MB: 4-- 4 -- 4 TropT 0.03 -- 0.02 -- 0.03 OTHER STUDIES =============== CT head [**2136-3-13**]: IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Possible remote infarct in the left cerebellar hemisphere. 3. Diffuse pagetoid changes of the calvarium. Clinical correlation recommended. 4. Maxillary and ethmoid sinus disease, likely chronic in nature. Clinical correlation recommended. Chest Radiograph [**2136-3-13**]: IMPRESSION: Interval improvement in lung aeration with band-like atelectasis at the left lung base. Hiatal hernia. Mildly prominent small bowel loops in the upper abdomen. Recommend correlation with abdominal radiographs if there is need for further evaluation. ECG [**2136-3-14**]: Regular ventricular pacing with probable underlying atrial fibrillation. Compared to the previous tracing pacing is now more consistent. Brief Hospital Course: 88 year old man with significant cardiac history admitted with significant coagulopathy, acute renal failure and a GI bleed. 1) Gastrointestinal bleed: On presentation the patient had 12 point hematocrit drop from baseline and this was presumed to have taken place over the previous week when he had been having bleeding events. He never evidenced any signs of hemodynamic instability though his tachycardic response could be blunted by his beta blockade. At presentation he had guiac positive brown stool but no hematochezia or melena. His coagulopathy was corrected and he was transfused. Given overall he appeared quite stable the decision was made to postpone endoscopy until hematocrit was between 1.5 and 1.7. Given the patient's history of divericulosis this was considered the most likely cause of bleeding and gastritis or upper source was considered much less likely given he had not had melena. Eventually, the patient underwent upper and lower endoscopy of [**2136-3-16**], which showed no active source of bleeding but erythema and congestion in the lower part of the stomach with a small AVM. Presumed source of bleeding was this gastritis in the context in his initial severe coagulopathy. The patient was discharged on [**Hospital1 **] PPI therapy to follow up with GI as an oupatient. At the time of discharge his hematocrit had been stable around 32 for >48 hours. 2) Coagulopathy: The etiology of the patient's coagulopathy is unclear. [**Name2 (NI) **] typically has had his INR checked monthly and review of records by his [**Hospital3 **] reveals he has been stable with INR's between 2 and 2.5 for a long time. No antibiotics, illnesses, or diet change. On holding his coumadin and reversal with vitamin K and FFP this quickly corrected. He was discharged on half of his usual coumadin dose with close follow up in his [**Hospital3 **]. They will also inspect his most recent set of coumadin pills to make sure he had not received pills of a different dosage in error. He was also counseled to stop his supplements for the moment as these could possibly interfere with his coumadin metabolism. The patient was also restarted on his aspirin prior to discharge. 3) Acute Kidney Injury: On presentation the patient's Cr was increased at 2.6. This quickly corrected with volume resuscitation and transfusions, which suggests this was due to pre-renal kidney injury due to his blood loss. At the time of discharge Cr was less than one. 4) Bilateral knee hematomas: These occurred after traumatic fall in the ED. He was seen by orthopedics who were confident that this was superficial bleeding in the pre-patellar bursae with no other major pathology. This was observed and no further management was instituted. 5) Coronary Artery Disease: The patient never had chest pain or signs of active ischemia though he did have TWI that resolved in the ED. Three sets of cardiac enzymes remained stable suggesting no demand infarction. He was continued on his statin and restarted on ACEi and beta blocker prior to discharge. 6) Aortic aneurysm s/p repair: Given lack of significant abdominal pain and the patient's rapid improvement with volume replacement no particular management for his history of aneurysm repair was considered necessary. 7) Benign Prostatic Hypertrophy: The patient was continued on his home finasteride and terazosin in the hospital. Given complaints of increased difficulty with urination he initially had a foley catheter placed. This was discontinued after he left the ICU without difficulties with urination. He did have some hematuria while the catheter in place but this resolved after removal and was thought most likely due to foley trauma in the context of coagulopathy. 8) Diabetes Mellitus type 2: The patient was continued on his home insulin regimen with some reduction in his standing doses while NPO. Reasonable control of his blood pressures was obtained with this regimen. 9) Hypertension: The patient was nevery hypotensive. Initially, all of his home anti-hypertensives and diuretics were held. Eventually his metoprolol, furosemide, and ACEi were restarted but his calcium channel blocker continued to be held as he was normotensive without it. He received [**Hospital1 **] IV and then PO PPI for his GI bleed. He had pneumoboots for DVT prophylaxis. He was full code. Prior to discharge he was tolerating a full diet. Medications on Admission: Felodipine SR 10 mg daily Finasteride 5 mg qam Furosemide 20 mg daily Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8 units qpm Lisinopril 2.5 mg daily Metoprolol Tartrate 50 mg daily Simvastatin 40 mg QHS Terazosin 5 mg QHS Aspirin 325 mg qam Coumadin 5 mg 5 days, 10 mg 2 days Benefiber Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 5 in the morning, 8 in the evening units Subcutaneous twice a day. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Please follow up with your primary care provider. [**Name10 (NameIs) 2172**] dose may need to be adjusted according to your blood work. Disp:*30 Tablet(s)* Refills:*2* 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*3 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: GI Bleed Supratherapeutic INR Hiatal hernia Arterio-venous malformations Discharge Condition: Vital signs stable, HCT 33, INR 1.6 Discharge Instructions: You were admitted because you were bleeding from your GI tract. This was most likely due to your blood being much too thin from your coumadin. The gastroenterologists looked and they only saw some small foci of disordered vessels as a source of bleeding. You seemed to stop bleeding once your blood was clotting appropriately again but the gastroenterologists coagulated the probable site of bleeding just in case. It is unclear why your blood was so much thinner than it has been. It is possible you got an incorrect prescription or somehow doses were confused. You will need close monitoring of your coumadin over the next weeks until your INR is stable once again. Your medications have been changed. You have been started on OMEPRAZOLE, a medication to help stop further bleeding from the AVM. You should also stop taking the Warfarin you have and fill a new prescription (you were given this). You will start taking 2.5 mg/day and follow up with the [**Hospital 2786**] clinic at [**Location (un) 620**] early next week. Your FELODIPINE has been held as you were not on this medication in the hospital and you had no high blood pressure. You should discuss with your regular doctor, Dr. [**Last Name (STitle) 2204**], whether you need this medication. We have stopped 1 of your hypertension (high blood pressure) medications. We have stopped your felodipine. You should continue with your metoprolol, lasix, and lisinopril. Your blood pressure has been fine while in the hospital. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] to see if this medication needs to be re-added. Please return to the hospital or call your doctor if you have chest pain, shortness of breath, fevers or chills, or any other concerning changes in your health. Followup Instructions: You have a follow up scheduled in [**Location (un) 620**] anticoagulation clinc on Tuesday at 1:00 pm. They would like you to bring the coumadin pills you were taking prior to this in order to make sure these were the appropriate dose. You also have a follow up appointment with stomach and colon specialist Dr. [**Last Name (STitle) 1940**] on [**2136-5-11**] at 3PM. Please confirm this with his clinic. The clinic number is [**Telephone/Fax (1) 463**]. Please follow-up with Dr. [**Last Name (STitle) 2204**] next week. His office number is [**Telephone/Fax (1) 2205**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] ICD9 Codes: 5849, 2851, 5990, 4019
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Medical Text: Admission Date: [**2143-6-9**] Discharge Date: [**2143-6-12**] Date of Birth: [**2095-12-24**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: IPH, SAH s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 47M intoxicated and fell down approx 15 steps. At OSH he was found to have RR 8 intubated. ETOH 350. Was found to have R frontoparietal SDH with traumatic SAH. Past Medical History: HTN, dyslipidemia Social History: unknown Family History: unknown Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT:L side parietal lac. Pupils:5->2 EOMs UTA Neck: in c-collar Extrem: Warm and well-perfused. Neuro: Mental status: Intubated on propofol. Propofol held. Moves all extremities spont. Appears to attempt to follow commands. Face symmetric Motor: UTA strength Sensation: UTA Toes mute Coordination: UTA Neuro Exam on Discharge: Mental status: Alert and Oriented x 3. Appears to attempt to follow commands. Pupils: 5-->3 bilaterally No pronator drift Motor: Moves all extremities spont. Face symmetric, tongue midline Sensation: intact to light touch Coordination: intact Pertinent Results: Labs on Admission: [**2143-6-9**] 02:10AM BLOOD WBC-9.7 RBC-4.98 Hgb-15.9 Hct-45.7 MCV-92 MCH-32.0 MCHC-34.9 RDW-13.7 Plt Ct-323 [**2143-6-9**] 04:10AM BLOOD Neuts-76.4* Lymphs-18.7 Monos-3.6 Eos-0.8 Baso-0.5 [**2143-6-9**] 02:10AM BLOOD PT-14.2* PTT-21.6* INR(PT)-1.2* [**2143-6-9**] 04:10AM BLOOD Glucose-187* UreaN-8 Creat-0.7 Na-145 K-4.0 Cl-107 HCO3-23 AnGap-19 [**2143-6-9**] 04:10AM BLOOD ALT-85* AST-45* LD(LDH)-283* AlkPhos-56 TotBili-0.7 DirBili-0.2 IndBili-0.5 [**2143-6-9**] 04:10AM BLOOD Albumin-5.1* Calcium-8.9 Phos-4.3 Mg-2.5 [**2143-6-9**] 02:10AM BLOOD Lipase-46 [**2143-6-9**] 04:10AM BLOOD Phenyto-15.4 [**2143-6-9**] 02:10AM BLOOD ASA-NEG Ethanol-311* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: [**2143-6-11**] 06:00AM BLOOD WBC-8.4 RBC-4.54* Hgb-14.6 Hct-42.1 MCV-93 MCH-32.2* MCHC-34.7 RDW-13.3 Plt Ct-287 [**2143-6-11**] 06:00AM BLOOD Plt Ct-287 [**2143-6-11**] 06:00AM BLOOD PT-13.5* PTT-24.5 INR(PT)-1.2* [**2143-6-11**] 06:00AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-139 K-4.3 Cl-101 HCO3-27 AnGap-15 [**2143-6-9**] 04:10AM BLOOD ALT-85* AST-45* LD(LDH)-283* AlkPhos-56 TotBili-0.7 DirBili-0.2 IndBili-0.5 [**2143-6-11**] 06:00AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.5 Mg-2.3 [**2143-6-11**] 06:00AM BLOOD Phenyto-3.8* Imaging: CT Head [**6-9**]: FINDINGS: There are extensive foci of subarachnoid hemorrhage throughout the right frontotemporal region with a thin right hemispheric subdural hemorrhage measuring up to 4 mm. Subdural hemorrhage also layers along the tentorium with a thin layer along the falx cerebri. Multiple foci of right temporal intraparenchymal hemorrhage measure up to 3.8 x 1.4 cm with surrounding vasogenic edema. There is mild mass effect on the right lateral ventricle with 3 mm of leftward shift of normally-midline structures. The basilar cisterns appear grossly patent. The calvaria appear intact. There is a moderate left frontoparietal subgaleal hematoma, presumably, the site of "coup." Moderate mucosal thickening involves the maxillary sinuses and ethmoid air cells bilaterally, as well as the right sphenoid and bifrontal air cells. There may be a few opacified right mastoid air cells. IMPRESSION: Multiple foci of right temporal intraparenchymal hemorrhage with multifocal right frontoparietal subarachnoid hemorrhage. A small amount of subdural blood layer along the right cerebral convexity, as well as along the tentorium and falx cerebri. 3-mm of leftward shift of midline structures is associated. NOTE ADDED IN ATTENDING REVIEW: Comparison with the [**Hospital **] Hospital NECT, performed some 2.5 hrs earlier (and since uploaded into PACS) demonstrates significant interval evolution of, particularly, the multifocal right temporal hemorrhagic contusions with surrounding edema, as well as the multifocal SAH and slight generalized edema involving the right hemisphere, which could reflect underlying [**Doctor First Name **]. The slight shift of normally-midline structures is also new over the short-interval. CT Chest/Abd/Pelvis [**6-9**](OSH) negative for acute traumatic injury CT C-spine [**6-9**]: No fracture or acute alignment abnormality. Prominent posterior osteophyte at C6 could cause cord injury with the appropriate traumatic mechanism, though evaluation of intrathecal details is limited on CT. Brief Hospital Course: The patient was admitted to the hospital for eval of intraparenchymal and diffuse right frontoparietal subarachnoid hemorrhage. 47M intoxicated and fell down approx 15 steps. At OSH he was found to have RR 8 intubated. ETOH 350. Was found to have R frontoparietal SDH with traumatic SAH. He receieved cerebrex and transferred to [**Hospital1 18**] for further evaluation. On hospital day number one, [**6-9**], the pt underwent a head CT w/o contrast which demonstrated multifocal right temporal hemorrhagic contusions, multifocal SAH and slight generalized edema. He was admitted to the trauma ICU and started on phenytoin. Later that day, a repeat CT was stable and the patient was extubated and transferred to the neurosurgery service. On [**6-10**], the patient was transferred to the stepdown unit. The patient was started on a CIWA scale. On [**6-11**] and [**6-12**] the patient's neuro exam remained stable. He had episodes of asymptomatic bradycardia into the 30's-40's. The patient's cardiac medications were held. A cardiology consult was obtained. The patient was cleared by cardiology to go home with the recommendation that beta blockers are discontinued until further outpatient evaluation. The rest of his hospital stay was uneventful with his lab data and vital signs within baseline values, and his pain controlled. He is being discharged today in stable condition. Medications on Admission: Unknown Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 3 days. Disp:*9 Capsule(s)* Refills:*0* 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): to start when 500 [**Hospital1 **] doses are complete . Disp:*120 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. Disp:*60 Tablet(s)* Refills:*0* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily): Medication should be held/reviewed secondary to bradycardia. 13. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily (). 14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: right intraparenchymal and subarachnoid hemorrhages s/p fall Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 14074**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2149-2-10**] Discharge Date: [**2121-1-27**] Date of Birth: [**2149-2-10**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: A 1330 gm male infant, Triplet #1, born to a 22 year old gravida 2, para 1 to 4, mother (2 pregnancies, 4 infants) with prenatal screens of A positive, antibody negative, Group B Streptococcus unknown, hepatitis B surface antigen negative, RPR nonreactive. PAST MEDICAL HISTORY: Past medical history by report remarkable for possible fetal alcohol syndrome, developmental delay and depression in Mom. Antepartum history remarkable for triplets, reportedly by spontaneous conception. Prior admission to [**Last Name (un) 10076**] for preterm labor. Received magnesium sulfate and Betamethasone. Admitted to [**Hospital6 649**] on [**1-31**], with premature rupture of membranes, preterm labor and poor biophysical profile with triplet #1, monitored with recovery of profile of concerning triplet. No fever. On day of delivery had onset of labor and decision was made to deliver by cesarean section. Infant emerged with spontaneous cry, Apgars of 8 at one minute and 8 at five minutes. PHYSICAL EXAMINATION: Examination on admission remarkable for preterm infant in moderate respiratory distress with stable vital signs. Skin pink. Anterior fontanelle soft. Palate intact. Normal facies with mildly deformed nose. Moderate retractions with fair air entry. Rales, no murmur. Normal femoral pulses. Abdomen, soft, nondistended with no hepatosplenomegaly. Normal male genitalia. Testes descended bilaterally. Hips stable. Normal perfusion. Normal tone and activity for gestational age. HOSPITAL COURSE: (By systems) 1. Cardiovascular - Cardiovascularly stable throughout admission with normal blood pressures. The patient developed a murmur on day of life #4 and echocardiogram was obtained which was negative for patent ductus arteriosus. The murmur resolved. The patient was again noted to have a murmur on day of life #14 which was clinically consistent with PPS, no further cardiovascular issues. 2. Respiratory - The patient was intubated shortly after birth and received Surfactant times one dose, weaned rapidly on ventilator settings and was extubated on day of life #1 to CPAP of 5. Weaned off of CPAP to room air on day of life #3, however, placed back on CPAP for frequent spells. The patient again weaned off of CPAP on day of life #10 to room air. On day of life #15 was placed back on low-flow nasal cannula again for spells. The patient was loaded with caffeine prior to initial extubation, had frequent episodes of apnea and bradycardia of prematurity. On day of life #7, received a caffeine bolus and the caffeine dose was increased with some improvement in spells. Again given a caffeine bolus on day of life #15 for increased spells. The patient continues to have spells from 0 to 10 per day, usually mild but occasionally requiring some stimulation. 3. Fluids, electrolytes and nutrition - Initially NPO and on intravenous fluids. A central PICC line was placed on day of life #1. Parenteral nutrition was started on day of life #1. Enteral feeds were initiated on day of life #2 and were advanced as tolerated. Feeding advance was held around day #4 when there was concern that the patient had developed a patent ductus arteriosus when an echocardiogram was negative for a patent ductus arteriosus, feeds continued to advance and the patient tolerated this well. Reached full feeds on day of life #8 and calories were then advanced, currently on 150 cc/kg/day of PE-26 with ProMod. Feeds every 3 hours secondary to history of aspirates and spits. Feeds gavaged over 45 minutes. The patient was started on Vitamin E and Fer-In-[**Male First Name (un) **]. Birthweight was 1330 gm. Weight on [**2-26**] was 1410 gm. Patient with good weight gain on his current feeding regimen. 4. Gastrointestinal - Bilirubin levels monitored, and phototherapy initiated on day of life #2 for a bilirubin of approximately 7/0.2. Peak bilirubin of 5.9/0.3. Phototherapy was discontinued on day of life #6 for bilirubin of 5.5/0.3, rebound bilirubin on day of life #7 was 5.7/0.2. 5. Infectious disease - Complete blood count and blood culture sent on admission, white count of 9.9 with 34 polys and 1 band. The patient was started on Ampicillin and Gentamicin. Blood cultures showed no growth at 48 hours and antibiotics were discontinued. Complete blood count and blood culture were sent on day of life #15 secondary to increased spells and revealed blood count of 12.5 with 40 polys and 4 bands. The patient was monitored off of antibiotics and blood culture showed no growth at the time of this dictation. Noted on day of life #14, and was treated with warm soaks and monitored, left eye drainage was improving. 6. Hematology - Initial hematocrit 34.1%, last hematocrit on day of life #15 was 29.7% with a reticulocyte count of 2.0. The patient has not required any blood products in the time course covered by this dictation. 7. Neurology - Head ultrasound on day of life #8 was negative. 8. Routine health care maintenance - Primary pediatrician is Dr. [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) 33629**] of [**Hospital 3597**] Pediatrics. Newborn state screen was sent on day of life #3 and had an indeterminate result for the homocystinuria test. A repeat state screen was sent and is pending at the time of this dictation. The patient has not yet received any immunizations. The patient will need a hearing screen and carseat test prior to discharge home. 9. Ophthamology - The patient has not yet has his first eye examination. DISPOSITION: Plan is to transfer patient to [**Hospital **] Hospital when ready for Level 2 nursery. MEDICATIONS: Caffeine, Fer-In-[**Male First Name (un) **], Vitamin E. DISCHARGE DIAGNOSIS: 1. Prematurity at 29 weeks gestational age. 2. Status post surfactant deficiency, respiratory distress syndrome. 3. Feeding immaturity. 4. Status post hyperbilirubinemia. 5. Status post rule out sepsis. 6. Heart murmur probably PPS [**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**] Dictated By:[**Last Name (NamePattern1) 50027**] MEDQUIST36 D: [**2149-3-3**] 06:19 T: [**2149-3-3**] 07:36 JOB#: [**Job Number 55324**] ICD9 Codes: 769, 7742
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Medical Text: Admission Date: [**2122-10-31**] Discharge Date: [**2122-11-2**] Date of Birth: [**2061-9-18**] Sex: M Service: MEDICINE Allergies: Penicillins / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 7333**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: -Central Venous Line Placement -Dialysis Line Placement History of Present Illness: 61M transferred from [**Hospital3 26615**] hospital with CAD s/p 3V CABG and AVR @ [**Hospital3 2358**] [**4-/2121**] (90% distal left main extending to LAD and ostium of LCX with 80% mid-RCA) for NSTEMI, s/p DDD pacer implant for intermittent complete heart block @ [**Hospital1 3343**] [**9-/2122**] transferred from OSH for evaluation and management of VT with HD instability requiring shocks x 1. He was admitted to OSH after being started back on metoprolol which caused him symptoms of light-headedness, lethargy, and mental slowing (which he had previously experienced leading him to stop taking metoprolol and lisinopril). He stopped the medication himself and began to feel better but became extremely SOB when walking up stairs and ended up lying on the floor due to his inability to catch his breath which prompted him to call 911 and present to OSH. He was assessed has possibly having ACS and underwent ROMI with trops <0.03 -> 0.16 -> 0.12, negative MB's throughout and EKG with pacer rhythm and 100% capture. He was started on ASA 325, given lovenox 1mg/kg SQ. . Then rapid response was called at 3am today at OSH for VT with HR to 280 with pt found to be diaphoretic and dyspneic but then uresponsive for 5 seconds. VT self-teriminated after 2 minutes and pt started on amiodarone drip @ 3:30AM, crit found to be 26 (stable from admission)and rec'd 1u pRBCs and trop drawn and found to be 0.14. Later went into monomorphic VT with rate in the 250's @ 11:45AM, shocked x 1 with return to paced rate of 88 and was apparently neurologically intact and AOx3 following. He was transferred to the ICU and transferred to [**Hospital1 18**] for further evaluation and treatment. . On the floor he describes shaking chills occasionally over the past 3 weeks after having his pacemaker placed although he denies frank fevers. He also denies pain, redness, or drainage from the site of his pacemaker. He also describes having a cough over the past week but states it is non-productive. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. . Cardiac review of systems is notable for dyspnea on exertion, negative for paroxysmal nocturnal dyspnea, negative for orthopnea, ankle edema, palpitations. . Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes type 2 +, Dyslipidemia +, Hypertension + 2. CARDIAC HISTORY: - CABG: Per report, CABG with AVR in [**4-/2121**] (90% distal left main extending to LAD and ostium of LCX with 80% mid-RCA) - PERCUTANEOUS CORONARY INTERVENTIONS: C. Cath [**9-/2122**] with clean grafts per report at [**Hospital1 1774**] - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: HTN HLD DM2 R total hip replacement Social History: Married, works as carpenter. Denies drugs, alcohol, smoking. Family History: father with CAD, brother with carotid vascular disease, paternal grandfather with CAD Physical Exam: ADMISSION EXAM: VS: 100.9 98 127/62 14 98% on 2L GENERAL: NAD, sleeping comfortably in bed HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP not appreciated CHEST: pacemaker pocket-no erythema, no discharge, no tenderness to palpation CARDIAC: RRR, normal S1, S2, + mechanical click, no murmurs/rubs/gallops appreciated LUNGS: anterior lung fields clear to auscultation, patient refused to sit up for posterior lung exam ABDOMEN: soft, nontender, nondistended, +BS EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Neuro: CN 2-12 grossly intact, normal strength and sensation throughout Pertinent Results: ADMISSION LABS: [**2122-10-31**] 05:56PM GLUCOSE-142* UREA N-11 CREAT-0.8 SODIUM-133 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13 [**2122-10-31**] 05:56PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2122-10-31**] 05:56PM WBC-15.0* RBC-3.35* HGB-9.8* HCT-28.1* MCV-84 MCH-29.3 MCHC-35.0 RDW-14.1 [**2122-10-31**] 05:56PM NEUTS-90.7* LYMPHS-5.0* MONOS-3.9 EOS-0.2 BASOS-0.1 [**2122-10-31**] 05:56PM PLT COUNT-429 [**2122-10-31**] 05:56PM PT-29.0* PTT-45.8* INR(PT)-2.8* [**2122-10-31**] 05:56PM CRP-143.7* [**2122-10-31**] 05:56PM SED RATE-62* . MICRO: 4/4 bottles positive for coagulase negative staph . ECHO [**2122-11-2**] No atrial septal defect is seen by 2D or color Doppler. Two pacemaker leads are seen entering the right atrium from the SVC, without definite associated vegetations. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. The anterior attachment of the prosthesis is normal. The posterior half of the prosthesis appears hypermobile/partial dehiscence extending nearly [**12-14**] way around the prosthesis (clip [**Clip Number (Radiology) **]). An echolucent space is seen posteriorly with systolic flow into this space which is then contiguous with the right atrium with continus flow (aorta to right atrial fistula). There are mobile echodensities (clip [**Clip Number (Radiology) **], 84) seen at the posterior attachment site of the prosthesis c/w tissue, sutures and/or vegetations. No aortic regurgitation is seen through this area. There is trivial valvular aortic regurgitation (normal for this prosthesis). The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. IMPRESSION: Partially posterior aortic valve prosthesis dehiscence with flow from the aorta into the right atrium. Vegetations vs. suture vs. tissue in the area.Moderate to severe tricuspid regurgitation. . RUQ US [**2122-11-2**] IMPRESSION: 1. Mildly coarsened hepatic echotexture. No frank biliary dilatation. 2. A few peripheral echogenic foci in the liver likely represent small portal branches; however, portal venous gas cannot be entirely excluded. If there is clinical concern for ischemic bowel, further assessment should be performed with CT. 3. Diffuse gallbladder wall thickening. 4. Splenomegaly to 15 cm. . KUB [**2122-11-1**] FINDINGS: Two supine and one left lateral decubitus image show no evidence of free air. There are air-filled loops of nondilated small bowel. There is air and stool seen within the colon extending into the sigmoid and rectum. There is no evidence of obstruction or ileus. Patient is status post a total left hip arthroplasty with no evidence of loosening. There are degenerative changes of L4 and L5 in the right hip. The bases of the lungs are clear. Sternotomy wires and pacemaker wires are seen within the chest. IMPRESSION: No evidence of obstruction or ileus. . KUB [**2122-11-2**] FINDINGS: Three supine frontal images of the abdomen show newly dilated loops of small bowel measuring up to 3.4 cm in the left upper quadrant. Given history of recent arrest, the dilation may be secondary to ischemia. Could also consider the possibility of an early or partial small-bowel obstruction. There is no obvious free air, although exam is somewhat limited due to supine positioning. There has been interval placement of a femoral line on the right groin. A catheter overlies the left upper quadrant, and is likely external to the patient. Again noted is dense calcification of the aorta and iliac vessels. A left total hip arthroplasty is unchanged. IMPRESSION: Interval increasing dilation of air-filled loops of small bowel loops raises concern for ischemia. Brief Hospital Course: Mr. [**Known lastname 91160**] is a 61M transferred from [**Hospital3 26615**] hospital with CAD s/p 3V CABG and AVR in [**2120**], NSTEMI, s/p DDD pacer implant for intermittent complete heart block in [**9-/2122**] transferred from OSH for evaluation and management of VT with HD instability requiring defibrillation. . # Septic shock/endocarditis with aortic valve dehiscence: The patient underwent pacemaker placement [**2122-10-2**]. He was febrile on admission with elevated wbc count and described weeks of shaking chills. Blood cultures grew coag negative staph and he was started on Vancomycin. His blood pressure decreased to the SBPs in the 80-90s. He was started on cefepime in addition to vancomycin. A TEE showed aortic valve dehiscence with flow from the aorta to the right atrium and possible vegetations. He later went into PEA briefly then his pulse returned but because of hypotension and poor O2 saturation he was intubated and put on pressors. His blood pressure continued to fall and he was requiring 4 pressors and large volumes of IVF. A dialysis catheter was placed to try to remove some volume and manage his potassium. However, after this was placed his BP would not tolerate dialysis. Shortly after he went into asystole and passed away. . # VT/rhythm: In [**Month (only) 359**] he had a syncopal event thought to be related to heart block so a pacemaker was placed. He was transferred to [**Hospital1 18**] from an OSH after he had pulseless VT requiring defibrillation. He was not in VT when he arrived at [**Hospital1 18**]. He was planned to have an EP procedure and prior to the procedure he was started on atenolol to prevent VT. However, before he could undergo any procedure he developed septic shock and aortic valve dehiscence and then expired as above. . Medications on Admission: HOME MEDICATIONS: ASA 81 mg daily metformin 1000 mg qam Vitamin D 1000 u daily Coumadin simvastatin 80 mg lisinopril 10 mg daily (stopped taking) metoprolol 50 mg daily (stopped taking) . Medications on transfer: atenolol 25 mg daily ASA 325 daily atorvastatin 40 mg daily NG heparin drip ISS bisacodyl docusate milk of magnesia Simethacone guafenesin acetaminophen metformin 1000 mg amiodarone infusion Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Septic Shock Presumed Endocarditis Mechanical Disruption of aortic valve Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a ICD9 Codes: 2762, 4275, 4280, 2767, 2724, 4019, 0389, 5849
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Medical Text: Admission Date: [**2191-4-17**] Discharge Date: [**2191-6-29**] Date of Birth: [**2191-4-17**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Known lastname 67149**] is a newborn, 865 g, 26 and 5/7 weeks' gestation twin, admitted to the NICU with prematurity and respiratory distress. She was born at 1:01 a.m. on [**2191-4-17**]. She is an 856 g product of a 26 and [**5-29**] week twin gestation to a 31-year-old, G3, P3-->5, mother, with an [**Name (NI) 37516**] of [**2191-7-19**]. Previous obstetric history is notable for a term [**Doctor Last Name **] and 36-week twin delivery. Prenatal labs included blood type O+, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, GBS negative. This pregnancy was notable for spontaneous di-di twin gestation complicated by cervical shortening noted at 24 weeks. The mother was admitted at that time for bed rest and monitoring and was given betamethasone [**3-28**] through [**3-29**]. Ultrasound showed estimated fetal weight at the 60th percentile with normal amniotic fluid volumes and normal biophysical profiles and vertex breech positioning. The mother experienced spontaneous rupture of membranes on [**4-13**], approximately 84 hours prior to delivery and was begun on ampicillin and erythromycin. Later that evening, she was noted to have progressive cervical dilation and was taken to the OR for repeat cesarean section delivery. No fevers or other signs of chorioamnionitis were noted. At delivery, the infant emerged with moderate tone and spontaneous cry requiring stimulation and blow-by oxygen for resuscitation. Apgar scores were 8 and 8. The infant was intubated in the delivery room for respiratory distress and was later brought to the NICU. PHYSICAL EXAMINATION: On admission weight was 865g (25th to 50th percentile) length 34 cm (25th to 50th)percentile head circumference 25 cm (50th percentile) Gen: well-developed, premature infant responsive to the exam, intubated on the vent. Vital signs: T96.5 HR169 RR50 BP 54/36 (MAP40) HEENT: Fontanel soft and flat, Palate intact. Ears/nares normal. Neck: Supple. No lesions. Chest: Coarse, moderate aeration with PPV. Positive retractions with spontaneous breath sounds. Cardiac: Regular rate and rhythm. No murmur. Abdomen: Soft. No hepatosplenomegaly.No mass. 3-vessel cord. Quiet bowel sounds. GU: Normal preterm female. Anus patent. Femoral pulses 2+. Extremities: Back normal. No lesions. Neurologic: Tone and activity appropriate for gestational age. HOSPITAL COURSE: Respiratory: This patient was initially intubated as previously stated in the delivery room and was on conventional ventilator of SIMV for 2 days. The patient did receive surfactant x 2. The patient was then extubated to CPAP and was on CPAP x 1 week. She was then weaned to nasal cannula and remained on nasal cannula x 4 days and was then slowly weaned to room air. The patient has been on room air for the past several weeks and has now completed a 5-day spell count with no episodes of apnea or bradycardia. Cardiovascular: The patient is status post diagnosis of patent ductus arteriosus treated with 3 courses of Indocin. The most recent echocardiogram on [**2191-5-10**] showed a trivial PDA. The patient now has a soft systolic murmur. Fluids, electrolytes and nutrition: Initially this patient was maintained on PN and intralipids. The infant was slowly advanced to full p.o. feeds of Enfamil AR ad lib. At this time, the patient is tolerating approximately 140 cc/kg/day minimum of Enfamil AR. On average, she takes in between 170- 200 cc of Enfamil AR p.o. ad lib. She is voiding and stooling well. Her birth weight was 865 g. Discharge weight at this time is 2495 g. GI: The patient does have a remote history of hyperbilirubinemia for which she was treated with phototherapy x 3 days. Peak bilirubin was 3.9/0.3. Phototherapy was discontinued after 3 days with rebound bilirubin was 3.5/0.3. Hematology: This patient was transfused once during this hospitalization 20 cc/kg of packed red blood cells. She is now maintained on iron with her most recent hematocrit of 26.5 and reticulocyte count of 6.4. She is also status post ampicillin and gentamicin x 7 days for her initial rule out sepsis evaluation at birth. All blood cultures were negative to date. LP performed at that time also revealed negative CSF culture. Neurology: The infant's most recent head ultrasound was performed on [**2191-6-24**], and revealed a small germinal matrix cyst. Sensory/audiology: Hearing screen was performed with automated auditory brain stem responses. The infant passed this examination on [**2191-6-27**]. Ophthalmology: Mature. Eyes were examined most recently on [**2191-6-27**], revealing mature retinal vessels. A followup exam is recommended in 6 months. Psychosocial: [**Hospital6 256**] social worker is involved with this family. The contact social worker can be reached at [**Telephone/Fax (1) 8717**]. At the time of discharge, the patient is in stable condition. DISPOSITION: Home with mother. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 56424**] of [**Hospital1 8**], [**Hospital1 67150**] Health Center. Contact Office number [**Telephone/Fax (1) 47660**]. DISCHARGE MEDICATIONS: The patient is currently receiving ferrous sulfate. CAR SEAT POSITIONING SCREENING: The patient did pass her car seat test on [**2191-6-27**]. IMMUNIZATIONS: This infant did receive her first hepatitis B vaccine on [**2191-5-18**]. She has subsequently received her Pediarix, DTaP and Prevnar on [**2191-6-22**]. 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 and 35 weeks with 2 of the following: Day care 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 first 24 months of the child's life), immunization against influenza is recommended for all household contacts and out-of-home caregivers. FOLLOW UP: We recommend that this patient have a followup appointment with her primary PMD within 1-2 days following discharge. DISCHARGE DIAGNOSIS: 1. Prematurity. 2. Respiratory distress syndrome. 3. Sepsis evaluation. 4. Hyperbilirubinemia. 5. Apnea of prematurity. 6. Patent ductus arteriosus status post 3 courses of Indocin. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) 62404**] MEDQUIST36 D: [**2191-6-28**] 14:51:06 T: [**2191-6-28**] 15:26:40 Job#: [**Job Number 67151**] ICD9 Codes: 769, 7742
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Medical Text: Admission Date: [**2162-9-18**] Discharge Date: [**2162-9-21**] Date of Birth: [**2142-4-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2108**] Chief Complaint: call out from ICU after admission for severe mononucleosis Major Surgical or Invasive Procedure: PICC line plcmt and PICC line removal History of Present Illness: 20 yo W no PMHx who initially presented to [**Hospital6 **] with > 1 week of fevers and vague symptoms including abdominal pain. She was found to have a positive monospot and found to have liver, pancreatic, pleural inflammation. Given her pleural effusions she was transferred to [**Hospital1 18**] ICU. She did well for the 1 day she was in the [**Hospital Unit Name 153**] and called out to the floor. Fevers were ongoing up to 103F. She complained of abd pain in the RUQ only during abd exams but no longer at rest. She had no sore throat. Had pleuritic chest pain of the low mid chest / epigastric region and inspiratory induced cough. She had no hemoptysis or leg swelling. No diarrhea or constipation. Mild chills. Very fatigued. All other systems are negative. Past Medical History: None Social History: Lives w/ mom, dad and 7 other siblings. Is nursing student at [**Hospital1 **] [**Location (un) 86**]. No patient contact. [**Name (NI) **] been doing well. - Tobacco: denies - Alcohol: denies - Illicits: denies - Sexually active over the past 2 years, did not wish to disclose partner number. Family History: Paternal aunt - "bone cancer" - died from PE. Father - DVT, provoked No AI, Inflammatory, connective tissue d/o. No other hx of cancer. Physical Exam: VS: Tmax 102.6 at 9 p.m. [**9-18**] Tcurrent 99.0 BP 111/67 HR 88 RR 12 99% on 1L GEN: NAD, AOX3 HEENT: MMM, OP CLEAR CARD: RRR, no m/r/g PULM: poor air movement, bilateral dullness at bases ABD: patient currently refusing abdominal exam EXT: WWP no c/c/e NEURO: AOx3, CN2-12 normal, grossly normal Pertinent Results: [**2162-9-19**] 04:57AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.6* MCV-98# MCH-34.5* MCHC-35.3* RDW-21.8* Plt Ct-261 [**2162-9-18**] 07:49PM BLOOD WBC-11.0 RBC-2.88* Hgb-9.1* Hct-26.4* MCV-91 MCH-31.6 MCHC-34.6 RDW-14.7 Plt Ct-238 [**2162-9-19**] 04:57AM BLOOD Neuts-39* Bands-0 Lymphs-38 Monos-5 Eos-2 Baso-0 Atyps-14* Metas-0 Myelos-2* [**2162-9-18**] 07:49PM BLOOD Neuts-49* Bands-0 Lymphs-39 Monos-6 Eos-1 Baso-1 Atyps-4* Metas-0 Myelos-0 [**2162-9-18**] 07:49PM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2* [**2162-9-18**] 07:49PM BLOOD Fibrino-321 [**2162-9-19**] 04:57AM BLOOD Parst S-PND [**2162-9-19**] 04:57AM BLOOD Ret Aut-5.0* [**2162-9-19**] 04:57AM BLOOD Glucose-86 UreaN-3* Creat-0.5 Na-139 K-3.5 Cl-104 HCO3-26 AnGap-13 [**2162-9-18**] 07:49PM BLOOD Glucose-98 UreaN-3* Creat-0.6 Na-138 K-3.7 Cl-105 HCO3-26 AnGap-11 [**2162-9-18**] 07:49PM BLOOD ALT-111* AST-170* LD(LDH)-1106* AlkPhos-141* TotBili-1.3 DirBili-0.6* IndBili-0.7 [**2162-9-18**] 09:14PM BLOOD Lipase-112* [**2162-9-19**] 04:57AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0 Iron-PND [**2162-9-18**] 07:49PM BLOOD Albumin-3.0* Calcium-8.0* Phos-2.5* Mg-2.0 Iron-120 [**2162-9-19**] 04:57AM BLOOD VitB12-PND Folate-PND Ferritn-PND TRF-PND [**2162-9-18**] 07:49PM BLOOD calTIBC-254* Hapto-<5* TRF-195* [**2162-9-18**] 07:49PM BLOOD Triglyc-245* [**2162-9-18**] 07:49PM BLOOD HBsAg-PND HBsAb-PND HAV Ab-PND IgM HBc-PND [**2162-9-18**] 09:14PM BLOOD HIV Ab-PND [**2162-9-18**] 07:49PM BLOOD HCV Ab-PND [**2162-9-19**] 04:57AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND [**2162-9-21**] 07:10AM BLOOD WBC-7.1 RBC-2.96* Hgb-9.3* Hct-27.2* MCV-94 MCH-31.6 MCHC-34.3 RDW-15.7* Plt Ct-274 [**2162-9-21**] 07:10AM BLOOD Neuts-32* Bands-3 Lymphs-45* Monos-5 Eos-3 Baso-0 Atyps-9* Metas-3* Myelos-0 [**2162-9-20**] 06:10AM BLOOD Neuts-38* Bands-9* Lymphs-38 Monos-1* Eos-1 Baso-0 Atyps-13* Metas-0 Myelos-0 [**2162-9-21**] 07:10AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-141 K-3.2* Cl-105 HCO3-28 AnGap-11 [**2162-9-21**] 07:10AM BLOOD ALT-81* AST-102* LD(LDH)-785* AlkPhos-273* TotBili-0.7 [**2162-9-19**] 04:57AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0 Iron-64 [**2162-9-19**] 04:57AM BLOOD calTIBC-247* VitB12-346 Folate-12.2 Ferritn-1393* TRF-190* [**2162-9-18**] 07:49PM BLOOD HBsAg-PND HBsAb-POSITIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE [**2162-9-18**] 07:49PM BLOOD HCV Ab-NEGATIVE [**2162-9-19**] CXR AP: The lung volumes are low. Borderline size of the cardiac silhouette. Moderate bilateral pleural effusions with subsequent areas of basal atelectasis. Minimal overhydration. Time Taken Not Noted Log-In Date/Time: [**2162-9-19**] 11:29 am SEROLOGY/BLOOD CHEM # 08445L. LYME SEROLOGY (Pending): [**2162-9-19**] 4:57 am Immunology (CMV) CMV Viral Load (Pending): [**2162-9-18**] 10:36 pm Immunology (CMV) CMV Viral Load (Pending): [**2162-9-18**] 7:49 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Pending): MONOSPOT AT [**Hospital6 **]: POSITIVE CT ABDOMEN AT [**Hospital6 **]: [**2162-9-15**] IMPRESSION: bilateral lower lobe consolidations with bilateral small pleural effusions Appendix is top normal in size. Periappendiceal fluid may be secondary to free fluid within the patient's pelvis. No significant periappendiceal fat stranding or appendicolith identified at this time. Recommend clinical correlation. Geographic low attenuation region within the superomedial aspect of the spleen which likely represents a focal area of infarction in this patient with splenomegaly. Recommend clinical correlation. RADIOLOGY READ AT [**Hospital1 18**] [**2162-8-21**]: suggests possible organized hematoma of the spleen which is small. TRANSTHORACIC ECHO DONE AT [**Hospital6 **]: NORMAL LV FUNCTION Brief Hospital Course: INFECTIOUS MONONUCLEOSIS: complicated by hemolytic anemia realted to cold agglutinins. She also has evidence of multiorgan involvement including liver inflammation, pancreatic inflammation, serositits of pleura as well as the usual inflammation of her upper respiratory tract. Her EBV IgM returned positive (>5) on [**9-21**] from [**Hospital6 **] in addition her monospot was positive. Multiple other tests had been sent including hepatitis serologies, HIV, Lyme serologies, CMV viral load which were all pending upon the time of discharge and will need to be followed up by the patient's PCP. [**Name10 (NameIs) 87394**] smear mainly looking for babesia was negative. Her hemolysis stabilized, LFTs and LDH improved, fever curve trended downward and the patient was discharged home with PCP follow up. URINARY TRACT INFECTION, UNCOMPLICATED: Pyuria. No culture data. Treated with cipro x 3 days. POSSIBLE SPLENIC HEMATOMA: per [**Hospital6 **] this splenic abnormality possibly represents a splenic infarct, per the radiology team at [**Hospital1 18**] after images were uploaded it may represent a organized hematoma. Given splenomegaly and mono a organized hematoma was more clinically likely. Her HCT remained stable after her hemolysis stablilized. She did not have any LUQ pain. Given the small splenic bleed she was told to strictly avoid driving or contact sports or vigorous exercise for 6 weeks. In addition she was told the warning signs of possible splenic rupture or bleed including syncope, presyncope, diaphoresis or left upper quadrant pain. Medications on Admission: HOME MEDICATIONS: NONE TRANSFER MEDICATIONS: Ciprofloxacin HCl 500 mg PO po bid x 3 days Morphine Sulfate 2-4 mg IV Q4H:PRN pain Guaifenesin-CODEINE Phosphate [**4-26**] mL PO/NG Q4H:PRN Acetaminophen 650 mg PO/NG Q6H:PRN fever Discharge Medications: 1. Outpatient Lab Work Chem 7, CBC with differential, LDH, AST, ALT, Alk phos, total bilirubin. Please have these labs drawn on [**9-27**] or [**9-28**]. Results to be faxed to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **]. Fax# [**Telephone/Fax (1) 6808**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Infectious Mononucleosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fevers and found to have mono. This was complicated by fluid around your lungs (pleural effusions), liver and pancreas inflammation, break down of your red blood cells causing anemia (called hemolysis) and a likely small bleed in your spleen. You improved and are being discharged home to follow up with your primary care physician. [**Name10 (NameIs) **] is very important that you avoid any contact sports, vigorous exercise or driving for 6 weeks as your spleen is at risk of bleeding again if there is any trauma. There are many tests that are still pending and unlikely to be positive. You can follow up with these tests with your primary care physician. NO MEDICATION CHANGES. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] P. Location: [**Location (un) 2274**]-[**Location (un) **] Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 34405**] Appointment: Tuesday [**2162-9-28**] 10:40am ICD9 Codes: 5990, 5119
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Medical Text: Admission Date: [**2187-5-17**] Discharge Date: [**2187-6-4**] Date of Birth: [**2187-5-17**] Sex: F Service: Neonatology TRANSFER DATE: [**2187-6-4**], to [**Hospital6 3872**]. HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 43385**] is 32 6/7 weeks, 1740 gm female twin number 1 who was admitted to the Newborn Intensive Care Unit for management of prematurity. This II mother. Prenatal screens, blood type A+, antibody negative, rapid plasmin reagin test non-reactive, hepatitis B surface antigen negative, rubella immune. This pregnancy was complicated by preterm labor with a cerclage placed on [**2186-12-28**], at twelve weeks gestation. The mother was admitted to [**Hospital1 69**] on [**3-5**], membranes. Pregnancy also complicated by borderline hypertension and insulin dependent gestational diabetes mellitus. Mom received a full course of Betamethasone prior to delivery. On date of delivery with progressive spontaneous labor to a vaginal delivery. Neonatology present at delivery. The infant received DIM suction and facial CPAP. Apgar scores were 7 at one minute and 8 at five minutes of age. PHYSICAL EXAMINATION: Physical examination on admission, weight 1740 gm, (50 percentile), length 42.5 cm, (25 to 50 percentile). Head circumference 31.5 cm, (50 to 75 percentile). General appearance, this is a premature infant with decreased tone and respiratory distress. Skin, smooth and pink, no rashes or birthmarks noted. Head and neck examination, anterior fontanel open and flat, sutures approximated. Eyes, positive red reflex bilaterally. Lips, gums, palate intact. Thorax symmetrical. Lungs, positive grunting, flaring and retracting with poor aeration bilaterally. Heart, regular rate and rhythm, no murmur auscultated, +2 pulses in upper and lower extremities. Abdomen was soft, no hepatosplenomegaly, three vessel umbilical cord. Genitalia consistent with preterm female, patent anus, positive meconium shortly after delivery. Trunk and spine, straight, no dimples or masses noted. Clavicles intact. Hips stable. Tone consistent with gestational age. HOSPITAL COURSE: Respiratory, the infant was admitted to the Newborn Intensive Care Unit with significant grunting, flaring and retracting, placed on nasal prong CPAP. Nasal prong CPAP was weaned within a few hours and infant weaned to room air with oxygen saturation greater then 95%, grunting, flaring and retracting quickly resolved. The infant has continued to be on room air for the remainder of her hospitalization. The patient has occasional bradycardic spells, no Methylxanthine have been required. Cardiovascular, the patient's blood pressure has been stable throughout her hospitalization. No saline boluses or pressor support has been required. A soft intermittent murmur has been noted during her hospitalization felt to be a PPS murmur. Fluids, electrolytes and nutrition, upon admission to the Newborn Intensive Care Unit, the patient was started on intravenous fluids of D10W at 80 cc per kg per day. D sticks have been within normal range throughout her hospitalization. Enteral feeds were initiated on day of life two and she quickly advanced to full volume feeds by day of life five. The patient is currently receiving feeds of premature Enfamil enriched to 26 calories with ProMod. Feeds are partially by bottle and partially by gavage. Last set of electrolytes on day of life four, sodium of 147, potassium of 5.3, chloride of 117 and a total carbon dioxide of 16. The patient is voiding and stooling without difficulty. The patient's weight at the time of transfer is [**2154**] gms (4 lbs 5.5 oz), length 45 cm, head circumference 32.5 cm. Gastrointestinal, peak bilirubin on day of life three was 8.2 with a direct bilirubin of 0.3. Phototherapy was started at that time. Phototherapy was discontinued on day of life six and rebound bilirubin on day of life seven was 5.2 with a direct bilirubin of 0.2. There have been no issues with feeding intolerance during her hospitalization. Hematology. The infant has not received any blood products during her hospitalization. Hematocrit at the time of admission was 43.5. Infectious Disease. A complete blood count and blood culture were drawn upon admission to the Newborn Intensive Care Unit. White blood cell count 10,000, platelet count of 284,000, hematocrit of 43.5 with 19% neutrophils and 2% bands. The patient received forty-eight hours of Ampicillin and Gentamicin. The blood culture drawn on admission was negative. Neurology, head ultrasound was not indicated for this 32 6/7 weeks infant. Sensory, a hearing screen was performed with automated, auditory brain stem responses. The patient passed in both ears. Ophthalmology, eye examination was not indicated for this 32 6/7 weeks. Psychosocial, a [**Hospital1 69**] social worker has been involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) 43386**]. CONDITION AT TRANSFER: Infant stable on room air, tolerating full feeds. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1280**] Hospital. Name of primary pediatrician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 6930**] Pediatrics, phone number [**Telephone/Fax (1) 38703**]. CARE RECOMMENDATIONS: Feeds at transfer, premature Enfamil enriched to 26 calories by concentration and MCT oil with ProMod added. MEDICATIONS: Iron supplements, a car seat position screening has not yet been performed. State newborn screening status, last newborn screen was sent on [**2187-6-1**], no abnormal results have been reported. Immunizations received, the patient has not received any immunizations at this time. Immunizations recommended, 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 then 32 weeks, 2) born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the house or with preschool siblings, 3) with chronic lung disease. Influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease, once they reach six months of age. Before this age, the family and other care givers should be considered for immunizations against influenza to protect the infant. DISCHARGE DIAGNOSES: 1) Prematurity at 32 6/7 weeks. 2) Transitional respiratory distress. 3) Rule out sepsis. 4) Hyperbilirubinemia. 5) Mild apnea of prematurity. [**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**] Dictated By:[**Name8 (MD) 35942**] MEDQUIST36 D: [**2187-6-3**] 14:32 T: [**2187-6-3**] 15:08 JOB#: [**Job Number 43387**] ICD9 Codes: 7742, V290
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Medical Text: Admission Date: [**2142-12-11**] Discharge Date: [**2142-12-14**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Peripheral vascular disease and left foot two toe gangrene Major Surgical or Invasive Procedure: 1) Abdominal aortic unilateral extremity run off, angioplasty of superficial femoral artery, popliteal tibioperoneal trunk and peroneal arteries, stent of superficial femoral artery and Cypher stent to tibioperoneal trunk and peroneal artery. 2) Amputation left 1st and 2nd toes History of Present Illness: 84yF with known bilateral lower extremity vascular disease, seen as an outpatient and scheduled for angiogram and angioplasty. She was unable to make it into the hospital on her scheduled day secondary to inclement weather. She was noted to have a fever at her nursing home, and was sent to an outside hospital for evaluation. They then transferred her from the outside hospital to [**Hospital1 18**] for evaluation. Social History: Resident of [**Hospital6 59521**] Home nonsmoker or drinker Family History: unknown Physical Exam: Vital signs: 97.6-100-24 97/46 oxygen saturation room air 97% General: no acute distress HEENT: no caroitd bruits Lungs: clear to auscultation bilaterally Heart: irregular irregular rythmn ABd: begnin PV: left ist and 2nd toe witrh ulcerations on dorasl aspect of toes with erythema to mid leg. Pulses: radial and femoral pulses 1+ bilaterally, distal [**Last Name (un) **] monophasic dopperable signal only bilaterally. Neuro: grossly intact Pertinent Results: [**2142-12-11**] 01:40PM WBC-9.3 RBC-4.23 HGB-12.0 HCT-35.9* MCV-85 MCH-28.3 MCHC-33.3 RDW-15.3 [**2142-12-11**] 01:40PM NEUTS-89.2* BANDS-0 LYMPHS-7.7* MONOS-2.6 EOS-0.4 BASOS-0 [**2142-12-11**] 01:40PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2142-12-11**] 01:40PM PLT COUNT-282 [**2142-12-11**] 01:40PM PT-15.4* PTT-30.4 INR(PT)-1.5 [**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 [**2142-12-11**] 09:41PM WBC-6.2 RBC-3.78* HGB-10.4* HCT-31.4* MCV-83 MCH-27.4 MCHC-33.0 RDW-15.2 [**2142-12-11**] 09:41PM NEUTS-88.6* LYMPHS-7.1* MONOS-3.4 EOS-0.8 BASOS-0.1 [**2142-12-11**] 09:41PM MICROCYT-1+ [**2142-12-11**] 09:41PM PLT COUNT-268 [**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 Brief Hospital Course: [**2142-12-11**] Evaluated in the emergency room and admitted to vascular surgical service for Iv antibiotics and wound care and bed rest. Blood cultures were drawn results no growth but not finallized. Wound culture gram positive cocci in pairs.Patient give Vancomycin 1 GM, levofloxcin 500mgmnIV and flagyl 500mg IV before admission. She underwent a arteriogram with angioplasty to left distal SFA, popliteal arteries and Tibial peroneal trunk , and peroneal arteries.Stenting of SFA,[**Doctor Last Name **] and proximal AT and peroneal arteries without complication and was transfered to ICU for moniteringover night. [**2142-12-12**] Podiatry consulted.Postoperative cadrdiac enzymes were CK 236, MB 4 Troponin <0.01 No EKG changes. Patient underwent radical debridment of bone and soft tissue of 1st and 2nd toe. [**2142-12-13**] [**2142-12-14**] continued to do well. wounds claen dry and intact with no erythema, induration of tenderness. Coumadin restarted and heparin discontinued. Patient transfered to Nursing home for continued recovery. Will continue antibiotics of augmentin 500mgm tid x 7 days. Dressing dsd to amputation site qd. Keep foot elevated when in chair or bed. Partial weight bearing left heel when ambulating essential distances. Follwup as directed in 2 weeks. Medications on Admission: new: augmentin 500mgm tid x 7 days percocet tab 5/325mgm [**12-15**] q4-6h prn Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Peripheral vascular disease and left foot two toe gangrene blood loss anemia, transfused, corrected HTN hypercholesterolemia osteoporosis arthritis h/o CVA h/o Left leg sarcoma Discharge Condition: Stable Discharge Instructions: [**Name8 (MD) **] MD for temp >101.5, redness or drainage from groin puncture site, redness or drainage from left toe amputation sites, persistent pain, or any other questions. You may put partial weight on your left heel, but do not bear weight on your left toes. moniter INR as needed to maintain goal of 2.0-3.0 Followup Instructions: With Dr. [**Last Name (STitle) **] in 2 weeks. Please call for appt. [**Telephone/Fax (1) 2625**] With Dr. [**First Name (STitle) 3209**] [**Telephone/Fax (1) 543**] Completed by:[**2142-12-14**] ICD9 Codes: 2851, 4019, 2724
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Medical Text: Admission Date: [**2129-5-12**] Discharge Date: [**2129-5-17**] Date of Birth: [**2107-10-30**] Sex: F Service: GYNECOLOGY HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15942**] is a 21 year-old G2 P1 who presented to [**Hospital1 69**] on postpartum day/postoperative day number eight status post primary low transverse cesarean section on [**2129-5-5**] (failed IOL, complicated by preeclampsia) with dyspnea since the evening prior to admission. She stated that the shortness of breath began with gradual onset. She denies any chest pain, palpitations, hemoptysis, cough, fever, or chills. She states that the dyspnea is increased while she is in the supine position. OB HISTORY: G2 P1. [**2129-5-5**] primary low transverse cesarean section for failed induction of labor for increased blood pressures. The patient developed preeclampsia by increased blood pressures, edema, headache, protein to creatinine ratio of 0.7. Also of note is the fact that experienced an intraoperative hemorrhage resulting in a hematocrit of 20% and was not transfused at that time. GYN HISTORY: 1. SAB times one. 2. History of OCP use in the past with no evidence of thrombosis. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Primary low transverse cesarean section. MEDICATIONS: An antihypertensive of which the patient could not recall. ALLERGIES: No known drug allergies. FAMILY HISTORY: There is a paternal history of cardiac disease. No history of clotting disorders or deep venous thrombosis and no history of acute myocardial infarction. SOCIAL HISTORY: The patient denies tobacco, alcohol or drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs blood pressure 160/95. Heart rate 85 to 95. Respiratory rate 20 to 22. O2 sat was 89% on room air improving to 96% on face mask O2. In general, the patient was in mild distress and was tachypneic. Neck no JVD. Cardiovascular regular rate and rhythm with 2 out of 6 systolic ejection murmur. Pulmonary decreased breath sounds at bilateral bases along with fine rales at bilateral bases. Abdomen was soft, nontender, nondistended with the fundus firm 4 cm below the umbilicus. Her incision was significant for blanching erythema surrounding the incision with no fluctuance or no drainage noted. Extremities 2+ pitting edema. Neurological grossly intact. Deep tendon reflexes were 2+. LABORATORIES ON ADMISSION: CBC white blood cell count 11.2, hematocrit 19.4, platelets 517, fibrinogen 403, ALT 38, uric acid 5.5. Chem 7 sodium 140, potassium 4.7, chloride 105, bicarb 19, BUN 15, creatinine 0.5. Arterial blood gas 7.45/108/31/22 on 6 liters of O2. Portable chest x-ray was performed and was pending at that time. Electrocardiogram revealed sinus tachycardia at 98 beats per minute with normal axis and no strain. INITIAL IMPRESSION: The patient is a 21 year-old G2 P0 eight days postoperative status post primary C section presents with dyspnea, tachypnea, tachycardia, hypertension, and peripheral edema. Also of note the patient has cellulitis surrounding her incision. Differential diagnosis at that time included congestive heart failure, peripartum cardiomyopathy, or pulmonary embolism. The decision was made to proceed with echocardiogram and CT angiogram at that time. She was also begun on Kefzol intravenous for cellulitis. HOSPITAL COURSE: 1. Cardiopulmonary: The patient was admitted to the Medical Intensive Care Unit for more comprehensive evaluation and further medical management. Initially under gyn care the patient improved symptomatically after initial dose of 10 mg intravenous Lasix. Chest x-ray revealed cephalization of the pulmonary vasculature with bilateral pleural effusions. Echocardiogram was normal. CT angiogram revealed no evidence of pulmonary embolism and confirmed bilateral pleural effusions. The patient received 10 mg intravenous Hydralazine times two, 10 mg Labetalol intravenous times three, 10 mg intravenous of Lasix for a total of two doses, all for elevated systolic blood pressures in the 200s. She was begun on a nitroglycerin drip and morphine prn. She also received intravenous Lasix as needed. The patient's hypoxia was determined to be most likely secondary to her hypertension and volume overload and improved significantly with blood pressure control and diuresis. On HD 2 she was transferred to gyn service. The patient's antihypertensive regimen was increased during her stay and the patient was discharged on 400 mg of Labetalol b.i.d. On discharge the patient had blood pressures in the range of 120s to 160s/90s. 2. Infectious disease: Abdominal wound cellulitis was significantly improved on intravenous Kefzol. Her T max on [**2129-5-12**] was 103. She was afebrile for greater then 48 hours prior to discharge. She was also found to have a urinary tract infection during her stay, which was also treated with Kefzol. This was changed over to po Keflex, which the patient was discharged home on. 3. Hematology: The patient's hematocrit on admission was 19.4. The decision was made on the day of admission to give the patient 2 units of packed red blood cells with intravenous Lasix as needed. The patient's hematocrit improved significantly initially to 24 and subsequently to 27 at the time of discharge. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern4) 10591**], M.D. [**MD Number(1) 47472**] Dictated By:[**Last Name (NamePattern1) 38927**] MEDQUIST36 D: [**2129-5-19**] 11:03 T: [**2129-5-19**] 13:55 JOB#: [**Job Number 47473**] ICD9 Codes: 5990, 4280, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5123 }
Medical Text: Admission Date: [**2107-1-2**] Discharge Date: [**2107-1-22**] Date of Birth: [**2081-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: fiberoptic intubation, IR-guided central line placement, IR-guided PICC placement History of Present Illness: Patient is a 25 yo M with PMHx sig. for microcephaly/cerebral palsy and is non-verbal and severely contracted at baseline who presents with lethargy and was found to be in DKA at OSH. Per his mother, he developed a fever to [**Age over 90 **] yesterday. His grandmother, who also cares for him, recently had a cough treated with 5 day course of antibiotics. However, the patient never developed a cough; he may have looked a little more short of breath today. Throughout the day today, he did became increasingly lethargic, though he completed eating his breakfast and lunch without problems. His mother felt that he was not responding as well to her voice, ie smiling or looking at her. His limbs were also more flaccid than at baseline. In addition, she noticed that his eyes were twitching, which has occurred in the past with fevers. They were also bloodshot. His mother noticed that he has been urinating more and drooling less. She denied any vomiting, diarrhea. He has had H1N1 already in [**Month (only) **]. He also had a cough, treated with amoxicillin, in [**Month (only) 1096**]. He usually gets over these episodes rather quickly. . He was taken to [**Hospital3 **], where VS were rectal temp of 100.5, SBP 95, hyperglycemia to 1392, Na 162, and Cr 2.2. He was given CTX there for UTI despite a U/A with neg nitrite, leuk est. He was not given insulin. CT head at OSH reports no acute pathology. . In the ED, vital signs were initially: 97.0, 98, 117/79, 18, 98%. Exam was sig. for slight rhonchi on the right. Labs were sig. for glucose of 1208, Na 170, Cl 128, creatinine 2.6, HCT of 61, lactate 3.1. U/A showed ketones. CXR showed no infiltrate. BCxs, UCx were obtained. He is receiving NS 100 cc/hr. He was not started on insulin gtt. VS on transfer: 99, 117/87, 16, 100% on 2L. Past Medical History: Microcephaly/Cerebral Palsy Kyphosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47817**] rod Social History: Pt lives with his parents. He goes to a day program from 9AM -3PM. His grandmother also cares for him. He is wheelchair bound. He is fed pureed foods and Ensure once a day. Family History: Both parents are healthy. No history of heart disease, DM. Aunt with epilepsy Physical Exam: Temp:97.0 HR:98 BP:117/79 Resp:18 O(2)Sat:98 GEN: The patient is in no distress and appears comfortable. NECK: Supple. No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. HEENT: L pupil 2 mm larger than R, both reactive. Erratic nystagmus. MM dry. CHEST: Lungs are clear without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: Normoactive BS, soft, NT, ND. EXTREMITIES: no peripheral edema, warm. NEUROLOGIC: Alert. Wrists, elbows bilaterally flexed. Increased tone in shoulder joint, less in elbow joint bilaterally. SKIN: There is a maculopapular rash on the back, which the mother states is his usual rash on dependent areas. Erythematous rash on R groin. Pertinent Results: RIGHT UPPER QUADRANT ULTRASOUND [**1-3**]: There is limited assessment, particularly in the midline, due to overlying bowel gas. Where visualized, the liver demonstrates no focal or echotexture architecture abnormality. Main portal vein is patent with normal hepatopetal flow. No intra- or extra-hepatic biliary ductal dilatation is noted, with the common duct measuring 3 mm. The gallbladder is filled with echogenic shadowing stones. No evidence for gallbladder wall thickening or pericholecystic fluid is seen to suggest acute cholecystitis. The patient is nonresponsive, therefore [**Doctor Last Name 515**] sign cannot be assessed. No ascites is seen in the right upper quadrant. IMPRESSION: Cholelithiasis, without findings of acute cholecystitis. CT CHEST/ABD/PELVIS [**1-5**]: 1. Bibasilar areas of consolidation and peribronchovascular ground-glass opacities, probably representing combination of atelectasis with possible aspiration, inflammation, and/or infection. Trace right pleural effusion. 2. Patulous and edematous distal esophagus with circumferential wall thickening and intraluminal fluid, may represent esophagitis, clinical correlation recommended. 3. Nearly diffuse small and large bowel wall thickening and hyperenhancement consistent with enteritis/colitis, such as infectious/inflammatory, less likely ischemic. Appendix not visualized. No bowel obstruction seen. 4. Area of hypoattenuation within the right hepatic lobe has somewhat rounded appearance but has vessels coursing through it, suggestive of perfusion heterogeneity or focal fatty infiltration. CT SINUS [**1-5**]: 1. Diffuse mild mucosal thickening with layering high-density fluid seen throughout the paranasal sinuses. Fungal colonization is not excluded, nor is infection. 2. Area of demineralization along the superior aspect of the medial right maxillary sinus wall. 3. Opacification of the [**Last Name (un) **]- and oropharynx, with ET tube and NG tube in place. 4. Partial opacification of the visualized right mastoid air cells. 5. Marked ventriculomegaly with very thin cerebral cortex, incompletely visualized on the current study. ECHO [**1-10**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CT CHEST/ABDOMEN/PELVIS [**1-12**]: 1. Extensive right lung and left lower lobe consolidations with air bronchograms are new compared to two days prior, with increased left greater than right small pleural effusions. 2. Foley balloon catheter located within the urinary bladder. There is new diffuse anasarca with slight increase in small ascites. No definite findings to account for increased abdominal pressure otherwise. 3. While small bowel loops which are better distended today show no wall thickening, there is apparent persistent wall thickening along the ascending and descending colon, representing non-specific colitis. 4. Patulous esophagus with circumferential wall thickening, again possibly representing esophagitis. Intraluminal fluid extends to the thoracic inlet, increasing risk for aspiration. 5. Rounded peripheral hypodense region in the right hepatic lobe re-demonstrated on non-contrast study, probably representing focal fatty infiltration. CXR [**1-22**]: One supine view. Comparison with the previous study done [**2107-1-21**]. Bilateral interstitial infiltrates consistent with edema persist. Mediastinal structures are unchanged. These are partially obscured by bilateral [**Location (un) 931**] rods. An endotracheal tube, nasogastric tube and PICC line remain in place. All of these are somewhat obscured by orthopedic hardware but appear unchanged. IMPRESSION: Limited study demonstrating persistent bilateral interstitial infiltrates consistent with edema. MICRO: All cultures from admission through [**1-12**] negative, including flu, RSV, urine, stool and sputum. Sputum did grow yeast. [**2107-1-13**] 8:18 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2107-1-15**]** GRAM STAIN (Final [**2107-1-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2107-1-15**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM------------- 2 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S [**2107-1-17**] 2:35 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2107-1-17**]): [**9-26**] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2107-1-19**]): Commensal Respiratory Flora Absent. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 86088**] ([**2107-1-15**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): YEAST. Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.2 <0.5 Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- >500 pg/mL * Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL ADMISSION LABS: [**2107-1-2**] 170 / 128 / 57 --------------< 1208 3.9 / 22 / 2.6 CK: 530 MB: 3 Trop-T: 0.04 Ca: 8.9 Mg: 3.1 P: 3.6 ALT: 86 AP: 321 Tbili: 1.0 Alb: 4.4 AST: 49 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 474 Osms:434 freeCa:1.26 Lactate:3.1 pH:7.10 (venous) CBC: 5.7 > 17.4 / 61 < 122 N:80.7 L:15.6 M:2.8 E:0.1 Bas:0.7 URINE Prot 25 Glu 1000 Ket 15 OTHER LABS Hgb A1c: 9.7 ENZYMES & BILIRUBIN CK(CPK) [**2107-1-13**] 03:39AM 291 [**2107-1-12**] 06:17AM 297 [**2107-1-11**] 05:30AM 790* [**2107-1-10**] 02:19AM 2699* [**2107-1-9**] 03:59AM 5212* [**2107-1-8**] 01:59PM 8391* [**2107-1-8**] 05:02AM [**Numeric Identifier 86089**]* [**2107-1-7**] 08:59PM [**Numeric Identifier **]* [**2107-1-7**] 01:04PM [**Numeric Identifier 86090**]* [**2107-1-7**] 06:57AM [**Numeric Identifier 26950**]* [**2107-1-7**] 03:31AM [**Numeric Identifier 57835**]* [**2107-1-6**] 08:11PM [**Numeric Identifier **]* [**2107-1-6**] 12:08PM 9652* [**2107-1-6**] 04:17AM 6016* [**2107-1-5**] 06:00AM 1322* [**2107-1-3**] 09:59PM 1169* [**2107-1-3**] 06:30PM 1185* [**2107-1-3**] 02:20PM 1233* [**2107-1-3**] 06:01AM 748* [**2107-1-2**] 09:25PM 530* RENAL & GLUCOSE Creat [**2107-1-19**] 05:02PM 1.0 [**2107-1-18**] 05:23AM 1.2 [**2107-1-17**] 03:48AM 1.3* [**2107-1-16**] 04:20PM 1.5* [**2107-1-15**] 04:00PM 1.7* [**2107-1-14**] 05:57PM 1.8* [**2107-1-13**] 03:39AM 2.1* [**2107-1-12**] 02:09PM 2.4* [**2107-1-11**] 05:30AM 2.5* [**2107-1-8**] 01:59PM 2.4* [**2107-1-7**] 01:04PM 2.7* [**2107-1-7**] 03:31AM 2.6* [**2107-1-6**] 08:11PM 2.4* [**2107-1-5**] 08:44PM 2.0* [**2107-1-5**] 03:58AM 1.6* [**2107-1-3**] 02:20PM 1.2 [**2107-1-2**] 09:25PM 2.6* BLOOD GASES (all venous) pO2 / pCO2 / pH [**2107-1-21**] 01:32PM 52* / 45 / 7.37 [**2107-1-19**] 12:40PM 43* / 50* / 7.42 [**2107-1-17**] 03:47PM 60* / 45 / 7.48* [**2107-1-13**] 01:22AM 42* / 40 / 7.34* [**2107-1-8**] 05:21AM 40* / 28* / 7.33* [**2107-1-5**] 04:09PM 46* / 42 / 7.14* [**2107-1-4**] 11:05PM 39* / 47* / 7.13* [**2107-1-4**] 02:22PM 52* / 53* / 7.11* DISCHARGE LABS: [**2107-1-22**] 145 / 112 / 19 ---------------< 124 3.7 / 21 / 0.8 Ca: 8.0 Mg: 2.0 P: 3.0 6.3 > 9.0 /27.3 < 523 Brief Hospital Course: [**Known firstname **] is a 25 year-old with cerebral palsy who is non-verbal at baseline. He was brought to the hospital by his family for fever, lethargy and concern for dehydration. He was noted to be in diabetic ketoacidosis/hyperosmolar hyperglycemic nonketotic syndrome with profound hyperglycemia. His hopsital course was complicated by aspiration pneumonia and respiratory failure/ARDS requiring mechanical ventilation, septic shock requiring pressor support and renal failure. He also developed a ventilatory associated pneumonia with sputum growing pseudomonas and stenoptrophomonas. He currently has improved significantly in terms of hemodynamics and renal fuction which are both at baseline and his persistant issue has been difficulty assessing readiness for extubation. ACTIVE PROBLEMS: 1. RESPIRATORY FAILURE As above, initially in setting of aspiration with development of ARDS. Improved over time and then subsequently developed ventilator associated pneumonia as above. Now being treated with antibiotics. Intubation was difficult even with use of fiber optics. Extubation has been complicated by difficulty predicting readiness. This is due to a combination of the following: a) 6mm ETT which has non-trivial resistance. He actually appeared to fatigue when kept on pressure support ventilation for more than a couple hours. b) abnormal baseline respiratory mechanics secondary to his body habitus and underdeveloped lungs and also with chronic respiratory acidosis c) difficulty assessing mental status d) concern about need for reintubation. 2. VENTILATOR ASSOCIATED PNEUMONIA He developed new fevers on [**1-12**]. Sputum grew pseudomonas and then stenotrophomonas. Day of transfer, [**2107-1-22**] is day [**7-16**] of meropenem for pseudomonas and day [**3-16**] of bactrim for stenotrophomonas. 3. ELEVATED B-GLUCAN Isolated elevation in beta glucan x 3 with unclear significance. Have been treating with micafungin as has been persistantly febrile. This was changed to voriconazole on [**1-21**]. He should have a repeat beta glucan. 4. DIABETES MELLITUS Now on lantus 15 units and regular insulin sliding scale. When taking meals, should have sliding scale changed to shorter acting. 5. FEVERS Likely secondary to VAP but persisted intermittently even with treatment. Concern also for fungal infection given elevated beta glucan. Central line removed and pan cultured as well. Other possible source is sinus as has evidence of disease on CT. 6. CEREBRAL PALSY Continued baclofen and valium for contractures. 7. ANEMIA This has been stable. Unclear baseline. Initially with gastrocult positive emesis. FOB negative. No evidence of hemolysis. RESOLVED PROBLEMS: 1. SEPTIC SHOCK: Required phenylephrine from [**1-4**] - [**1-10**] with one day also requiring vasopressin. Covered very broadly with antibiotics including antifungals. No culture growth. Likely [**1-4**] ARDS/distributive physiology. 2. ARDS As above, no inciting organism identified. Likely [**1-4**] large aspiration in setting of vomiting. 3. DIABETIC KETOACIDOSIS/Hyperosmolar hyperglycemic nonketotic syndrome Very hyperglycemic and with Hgb A1c 9.7 so more consistent with DMII. Improved on insulin gtt and then transistioned to SQ. Trigger may have been viral URI. 4. HYPERNATREMIA Initially [**1-4**] profound dehydration. Resolution hindered by IVF resusitation. Has improved with enteral free water. 5. ACUTE RENAL FAILURE Became anuric in setting of sepsis. Also with elevated intra-abdominal and bladder pressures which increased the MAPs necessary for renal perfusion. Improved without need for dialysis. 6. ELEVATED CK This elevated after agressive fluid resusitation leading to significant edema including scleral edema and likely resulted from the anatomical limitations on fluid distribution exacerbated by oligura. This improved with improving urine output and resolution of edema. 7. ACCESS Significant diffculty with IV access requiring IO access intilliary and IR guided IJ line and then PICC. Unable to get arterial blood gases. 8. Elevated lipase and transaminases: RUQ US with cholelithiasis but not evidence of cholecystitis. 9. Thrombocytopenia Initially low platelets which improved with resolution of sepsis. 10. LLE edema Asymmetric but multiple ultrasounds negative for DVT Medications on Admission: Fexofenadine 30 mg daily Ranitidine 75 mg [**Hospital1 **] Diazepam 6 mg/4 mg/6 mg Baclofen 5 mg TID Discharge Medications: 1. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-4**] Drops Ophthalmic Q2H (every 2 hours) as needed for eye lubrication. 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 7. Diazepam 2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Diazepam 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. 12. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 13. Meropenem 500 mg IV Q8H 14. Pantoprazole 40 mg IV Q24H 15. Fentanyl Citrate (PF) 100 mcg/2 mL (50 mcg/mL) Syringe Sig: 25-50 mcg Intravenous every four (4) hours as needed for agitation. 16. Voriconazole 200 mg IV Q12H 17. Sulfameth/Trimethoprim 185 mg IV Q8H Day 1 = [**1-19**] 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 19. Midazolam 0.5-1 mg IV Q4H:PRN discomfort Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary: Septic shock, respiratory failure, diabetic ketoacidosis, Hyperosmolar hyperglycemic nonketotic syndrome, diabetes mellitus, ventilator associated pneumonia, acute renal failure Secondary: cerebral palsy Discharge Condition: Mental Status: non-verbal, baseline Level of Consciousness: Alert Activity Status:Bedbound Discharge Instructions: Dear [**Doctor Last Name **], You were admitted with high sugar and dehydration. You got very sick and needed medicine to support your blood pressure and a tube to help you breath. You are doing much better. You are going to [**Hospital1 **] to have the tube removed in a setting where they are more prepared to manage the potential complications in people your size. We will miss you. Followup Instructions: per [**Hospital1 **] has been followed by [**Last Name (un) **] here PCP ICD9 Codes: 5849, 5070, 0389, 2760, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5124 }
Medical Text: Admission Date: [**2105-1-13**] Discharge Date: [**2105-1-16**] Date of Birth: [**2034-7-2**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2597**] Chief Complaint: Intermittent claudication Major Surgical or Invasive Procedure: Right femoral to above-knee popliteal artery bypass with an 8-mm PTFE graft History of Present Illness: This 70-year-old gentleman is status post an aortobifemoral bypass in the distant past for aneurysm with occlusive disease. He has developed bilateral superficial femoral artery occlusions with severe disabling claudication. The left side was treated with an angioplasty. The right side is not amenable to catheter-based intervention. Arteriography showed reconstitution of an above-knee popliteal artery with 3-vessel runoff below the knee. Past Medical History: AAA with illiac artery aneurysms treated with an aortobifemoral graft [**2089**]. Bilat carotid endarterectomies CAD - coronary angioplasty and stenting [**2103**] CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential SVG to AM/PDA)[**2089**] Hyperlipidemia HTN AODM Cerebral hemorrhage mid [**2085**]??????s Prior CVA Social History: Patient is married with 8 children. Lives with: Wife Occupation: [**Name2 (NI) **] fitter - retired ETOH: Rare Tobacco: denies Family History: non contributory Physical Exam: Please See H&P Pertinent Results: [**2105-1-13**] 06:51PM GLUCOSE-153* UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14 [**2105-1-13**] 06:51PM estGFR-Using this [**2105-1-13**] 06:51PM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-40 [**2105-1-13**] 06:51PM CK-MB-2 cTropnT-<0.01 [**2105-1-13**] 06:51PM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-1.9 [**2105-1-13**] 06:51PM HGB-11.9* HCT-35.4* [**2105-1-13**] 06:51PM PLT SMR-VERY LOW PLT COUNT-50* [**2105-1-13**] 06:51PM PT-14.3* PTT-30.9 INR(PT)-1.2* [**2105-1-13**] 05:25PM TYPE-ART PO2-203* PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 [**2105-1-13**] 05:25PM GLUCOSE-137* LACTATE-1.9 NA+-136 K+-4.1 CL--105 [**2105-1-13**] 05:25PM HGB-12.8* calcHCT-38 [**2105-1-13**] 05:25PM freeCa-1.15 [**2105-1-13**] 03:46PM TYPE-ART PO2-101 PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0 [**2105-1-13**] 03:46PM GLUCOSE-143* LACTATE-1.6 NA+-138 K+-3.9 CL--107 [**2105-1-13**] 03:46PM HGB-14.2 calcHCT-43 [**2105-1-13**] 03:46PM freeCa-1.23 Brief Hospital Course: This 70-year-old gentleman is status post an aortobifemoral bypass in the distant past for aneurysm with occlusive disease. He has developed bilateral superficial femoral artery occlusions with severe disabling claudication. The left side was treated with an angioplasty. The right side is not amenable to catheter-based intervention. Arteriography showed reconstitution of an above-knee popliteal artery with 3-vessel runoff below the knee. Patient was admitted for Right femoral to above-knee popliteal artery bypass with an 8-mm PTFE graft. Post-op patient was noted to be doing well with minimal pain and stable hct. POD1: Patient continued to do well had a small hematoma at his groin site. DP and PT pulsed were dopplerable bilat. POD 2: Foley was removed. Patient voided appropriately. Patient was started on Plavix and tolerated a regular diet. POD 3: Patient was seen by PT and cleared for home without services. Medications on Admission: [**Last Name (un) 1724**]: Plavix 75', Folate-B6-B12, Gabapentin 1200', Glimepiride 1 mg', Lopressor 50', Simvastatin 80', Sitagliptin 100', ASA 81, Niacin, Omega FA, Vit E 400'. Discharge Medications: 1. Oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 10 days. Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: otc - while on pain medication. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at bedtime: home med. 6. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime): home med. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): home med. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO at bedtime: home med. 9. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day: home med. Discharge Disposition: Home Discharge Diagnosis: Intermittent claudication with right superficial femoral artery occlusion. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**2-26**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over 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 over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2105-1-29**] 12:40 ICD9 Codes: 4019, 2724
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Medical Text: Admission Date: [**2126-8-23**] Discharge Date: [**2126-9-19**] Date of Birth: [**2048-6-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old female involved in a motor vehicle accident. She was an unrestrained driver with no loss of consciousness, but was hit by a dump truck with significant intrusion into the car. She has complaint of chest pain and systolic blood pressure of 88 and heart rate of 100 in the field. 78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. Major Surgical or Invasive Procedure: placement of G tube History of Present Illness: HISTORY OF PRESENT ILLNESS:78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. Seventy-eight-year-old female involved in a motor vehicle accident. She was an unrestrained driver with no loss of consciousness, but was hit by a dump truck with significant intrusion into the car. She has complaint of chest pain and systolic blood pressure of 88 and heart rate of 100 in the field.admitted to [**Hospital1 18**] on [**7-29**] with C2 fracture, bilateral pleural hematomas, L breast implant rupture, rib fractures, splenic laceration s/p splenectomy and s/p nephrostomy tube placement, who returned to [**Hospital1 18**] from rehab on [**8-23**] with hypoxia and respiratory distress. Past Medical History: PMH: Amyloidosis, depression, kidney stones, hx of tubal ligation, L hip replacement Social History: SH: 2 cigs per day, 1-2 drinks per day Family History: FH: daughter [**Name (NI) 372**] is currently undergoing temporary guardianship Physical Exam: Tc afebrile HR 96, BP 161/67, RR 34, 99% on PS [**7-5**], 40% FI02 Gen: lying in bed, eyes open, minimal mvmt. HEENT: trach in place, copious sputum out of trach opening, coughing,mmm, OP benign Neck: in C collar CV: RRR, difficult to auscultate given breath sounds Resp: coarse upper airway sounds bilaterally Abd: multiple dressings covering postop incisions, ileostomy bag c/d/i Ext: warm, well perfused Skin: ecchymoses on legs and arms. MS: Awake, opens eyes to voice but not command and looks to right at calling of name, not consistently to left. Wiggles toes to commands, will not squeeze hands to command, will not lift arms to command. CN: PERRLA, blinks to threat bilaterally. Full eye movements horizontally but seems to have R gaze preference. No evidence of nystagmus, no ptosis. Grimaces to stim on both sides of face. Corneal reflex present. Face symmetric but difficult to assess wtih collar. Hears voice. No speech. +cough. Motor: Nl bulk, perhaps increased tone to passive motion in bilateral upper extremities. Spontaneously wiggles toes R more briskly than L, and spontaneously flexes R arm at elbow. Otherwise, no spontaneous movements. ON passive flexion she does resist my motion in both upper extremities. On painful stimulation she grimaces but only withdraws in RUE and RLE. Reflexes: [**Hospital1 **] Tri BR Pat Ach Plantar L 2 2 1 1 1 down R 2 2 1 2 1 down [**Last Name (un) **]: feels pain in all four extremities. Pertinent Results: [**2126-8-23**] 04:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [**2126-8-23**] 04:10AM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2126-9-18**] 02:30AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.1* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.3 Plt Ct-465* [**2126-9-17**] 02:13AM BLOOD WBC-10.7 RBC-2.87* Hgb-9.0* Hct-26.0* MCV-91 MCH-31.3 MCHC-34.5 RDW-15.3 Plt Ct-457* Brief Hospital Course: ID: Patient has been consistently febrile, initially started on vancomycin and zosyn for presumed pneumonia, sputum cultures and blood cultures positive for yeast. She was treated with meropenam, vancomycin, flagyl, and then on [**8-31**] caspofungin added. She continues to be febrile. Since [**8-30**] blood cultures have been negative, sputum continues to grow yeast. GI: On [**8-29**] she was noted to have rise in her LFT's and abdominal tenderness, she was taken to the OR for an exploratory laparotomy and found to have an ischemic colonic perforation. R colectomy and ileostomy placement was performed at that time. She is still not receiving feeds through the G tube. Heme: Initially anemic, now hct has been stable in mid-20's. Neuro: Pt when admitted on [**8-23**] was noted to follow commands and express pain. She was on her home regimen of paxil for anxiety. On day of admission she was started on propofol for agitation, it caused hypotension and it was weaned. She was at that time noted to be sedated but still following commands. On [**8-24**] she was switched to a versed drip. On [**8-26**] she was unarousable, versed stopped and only given morphine PRN. She was noted on [**8-27**] to follow commands and "awake and alert." [**8-29**] went to the OR, and afterwards was treated with propofol and fentanyl. On [**8-30**] she was noted to have minial movement of her LUE and none of her RUE, but moved both lower extremities in response to pain. On [**9-1**] she was reported to be "following commands" and responding to painful stimuli. She has been on a fentanyl drip until [**9-5**], when she was switched to a fentanyl patch. On [**9-7**] fentanyl patch was d/c'ed and she has only been receiving fentanyl prn dressing changes. Today, it was noted that despite being off sedation for several days, she has not been awake or following commands initially However this status has continues to improve and patient had remained afebrile on trach trial up to 5 hours, she will need continued wound care to incision with wet to dry dressing Medications on Admission: M A H : p r o z a c , t y l , [**Initials (NamePattern5) 373**] [**Last Name (NamePattern5) 374**],[**First Name3 (LF) **],dulcolax,diazepam,colace,lovenox,prevacid,lopressor, oxycodone Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-2**] Drops Ophthalmic Q2H (every 2 hours). 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for <2.0. 13. Caspofungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. ventilator dependent respiratoy failure, chronic anemia, sepsis, poor nutritional status, tube feed dependence Discharge Condition: Stable Discharge Instructions: Please continue to ween ventilatory status (pt has been on trach trial for 4-5 hr windows, continue local wound care, to midline incicion, continue to monitor urine output via nephrostomy tube and ostomy ourtput, please continue to ensure that she does not become dehydrated. Followup Instructions: F/U recommended with interval CT scan [**1-3**] weeks to evaluate fluid collection in right pelvis for catheter to be removed if fluid is no longer draining as weel as be evaluated by Dr. [**Last Name (STitle) 375**] please call regarding f/u and progress Trauma Clinic Trauma W/LMOB 3a [**Hospital1 18**] ([**Telephone/Fax (1) 376**]. TRAUMA OUTREACH NURSE TRAUMA OUTREACH W/LMOB 2G [**Hospital1 18**] ([**Telephone/Fax (1) 377**] Completed by:[**2126-9-19**] ICD9 Codes: 0389, 5070, 496, 2859, 4019
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Medical Text: Admission Date: [**2119-10-11**] Discharge Date: [**2119-10-17**] Date of Birth: [**2119-10-11**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: [**First Name9 (NamePattern2) 65644**] [**Known lastname 57455**] was born at 35 and 2/7 weeks gestation by stat cesarean section for a nonreassuring fetal heart tracing. Her mother is a 35 year- old gravida 7 para 5 now 6 woman. The mother's prenatal screens are blood type 0 positive, antibody negative, rubella equivocal, RPR nonreactive, hepatitis B surface antigen negative and group B strep positive. By report there was late prenatal care with only 2 prenatal visits before delivery. This pregnancy was previously uncomplicated. Rupture of membranes occurred spontaneously 7 and a half hours prior to delivery. The mother did receive antepartum antibiotics. The infant emerged with Apgars of 8 at 1 minute and 9 at 5 minutes. Hypoglycemia and hypothermia in L&D prompted NICU admission. PHYSICAL EXAMINATION: A vigorous preterm nondysmorphic infant. Anterior fontanelle soft and flat. Comfortable respirations. Lungs sounds clear and equal. Heart was regular rate and rhythm. No murmur. Abdomen soft, nontender, nondistended. No hepatosplenomegaly. Three vessel umbilical cord. Normal female genitalia, patent anus and age appropriate tone and reflexes. The birth weight was 2225 grams. The birth length was 40.5 cm birth head circumference is to follow. NICU COURSE: 1. Respiratory status, the infant has remained in room air throughout her NICU stay. She had only one episode of desaturation with feeding on day of life number 1, but had no further episodes of apnea, bradycardia or desaturation. On examination respirations were comfortable. Lung sounds clear and equal. 2. Cardiovascular status, she has remained normotensive throughout her NICU stay. Heart was regular rate and rhythm. No murmur. She has no cardiovascular issues. 3. Fluid, electrolyte and nutrition status, she initially had some hypoglycemia on admission to the NICU, which was resolved with feedings. Since then she has remained euglycemic. She is eating 20 calorie per ounce formula on an ad lib schedule taking approximately 160 to 180 ml per kilo per day. Her weight at the time of discharge his 2140 grams. 4. Gastrointestinal status, her peak bilirubin occurred on day of life number four and was total 10.8, direct 0.4. On the day of discharge her total bili is 9.9, direct 0.4. She never received any phototherapy. 5. Hematology. Her hematocrit at the time of admission was 51.9. Platelets were 265,000. She has never received any blood product transfusions. 6. Infectious disease status, a blood culture was done at the time of admission. It remains negative to date. She has never received any antibiotics. 7. Sensory, hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. 8. Other, she required isolette care secondary to hypothermia. She weaned slowly and now has been stable in a crib for more than 24 hours. Toxic screen was done secondary to late and limited prenatal care. It was negative. Mother is aware of testing. 9. Psycho/social, parents have been involved in the infant's care throughout her NICU stay. She is discharged home with her parents. She is discharged in good condition. Her primary pediatric provider will be Dr. [**First Name8 (NamePattern2) 51097**] [**Name (STitle) 12332**] at [**Hospital **] Community Health Center, [**Location (un) 669**], [**State 350**]. Telephone number [**Telephone/Fax (1) 3581**]. RECOMMENDATIONS AFTER DISCHARGE: Formula feeding on ad lib schedule. She is discharged on no medications. She has passed a car seat position screening test. Her state newborn screen was sent [**2119-10-14**]. She received her first hepatitis B vaccine on [**2119-10-16**]. Recommended immunizations, Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infant's who meet any of the following 3 criteria, born at less than 32 weeks, born between 32 and 35 weeks with 2 of the following, day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or 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 first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. The infant will have a visiting nurse visit after discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 35 and 2/7 weeks. 2. Hypoglycemia, resolved. 3. Hypothermia, resolved. 4. Sepsis ruled out. 5. Mild hyperbilirubinemia of prematurity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2119-10-17**] 06:16:40 T: [**2119-10-17**] 06:46:18 Job#: [**Job Number 65645**] ICD9 Codes: V053, V290
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Medical Text: Admission Date: [**2155-2-9**] Discharge Date: [**2155-2-18**] Date of Birth: [**2086-12-2**] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Penicillins Attending:[**First Name3 (LF) 106**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->Ramus/OM, RCA)/AVR(21mm tissue) [**2155-2-13**] History of Present Illness: 68 y/o male with prior cardiac history and multiple risk factors who presented who acute onset of shortness of breath and chest pain. Was initially treated in the emergency room and eventually underwent a cardiac catheterization. Cath revealed three vessel coronary disease. Echo showed moderate to severe aortic stenosis and moderate aortic regurgitation. He was then referred for surgical revascularization and aortic valve replacement. Past Medical History: Coronary Artery Disease s/p MI x 2 s/p PTCA of LAD Hypertension Diabetes Mellitus L4-L5 spondylolisthesis h/o Congestive Heart Failure s/p right Rotator Cuff Repair s/p bilateral Ulnar nerve transposition s/p post. and ant. cervical disk procedures and fusions s/p iridectomy s/p right total knee replacement Physical Exam: General: WD/WN male in NAD HEENT: NC/AT, PERRLA, EOMI, OP benign Neck: Supple, FROM, -lymphadenopathy, Carotid 2+ w/ Bilat. radiation murmur Lungs: CTAB -w/r/r CV: RRR, +S1,S2 with SEM Abd: Soft, NT/ND, +BS without masses Ext: - C/C/E pulses 2+ throughout Neuro: Non-focal, MAE, A&O x 3 Pertinent Results: [**2155-2-9**] 05:30AM BLOOD WBC-13.4*# RBC-4.27* Hgb-12.5* Hct-37.0* MCV-87 MCH-29.4 MCHC-33.9 RDW-14.3 Plt Ct-637*# [**2155-2-15**] 05:00AM BLOOD WBC-11.5* RBC-3.36* Hgb-10.2* Hct-29.1* MCV-87 MCH-30.4 MCHC-35.1* RDW-15.4 Plt Ct-155 [**2155-2-15**] 05:00AM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.0 [**2155-2-17**] 05:15AM BLOOD Glucose-35* UreaN-12 Creat-0.8 Na-136 K-4.5 Cl-97 HCO3-28 AnGap-16 [**2155-2-10**] 04:33PM BLOOD ALT-11 AST-14 AlkPhos-105 Amylase-61 TotBili-0.4 [**2155-2-17**] 05:15AM BLOOD Mg-2.3 [**2155-2-9**] 05:40AM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE [**2155-2-14**] 10:11AM BLOOD freeCa-1.12 [**2155-2-9**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, pt was initially seen by cardiac surgery following his cardiac cath. Patient was eventually consented for surgery and on [**2155-2-13**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3 and aortic valve replacement. Please see op note for surgical details. Patient tolerated the procedure well and was transferred to the CSRU in stable condition receiving Neo-Synephrine, Dobutamine, and Levophed drips. Later on op day sedation was weaned and patient awoke neurologically intact. He was then weaned from mechanical ventilation and extubated. He was weaned from all Inotropes/Pressors on post op day one and was then transferred to the cardiac step-down unit. B Blockers and Diuretics were initiated and patient was gently diuresed towards his pre-op weight. Chest tubes and Foley catheter were removed on post op day two. And epicardial pacing wires were removed on post op day three. Pt was followed by physical therapy during his entire post op course for strength and mobility. Patient had a relatively uncomplicated post op course and was at level 5 by post op day five. His exam and labs were stable on post op day five and he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Glyburide 5mg [**Hospital1 **] Cimetidine 400mg [**Hospital1 **] Indural LA 160mg qd Indural XR 30mg Advicor 500/20 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO HS (at bedtime). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-8**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Tagamet 400 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Coronary artery disease/Aortic regurgitation s/p Coronary Artery Bypass Graft x 3 and Aortic Valve Replacement Diabetes Mellitus Hypertension Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 1270**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2155-2-19**] ICD9 Codes: 4241, 486, 4280, 4111, 4019, 2720, 412
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Medical Text: Admission Date: [**2114-11-18**] Discharge Date: [**2114-12-6**] Date of Birth: [**2063-5-6**] Sex: M Service: TRA [**Hospital **] MEDICAL COMPLAINT: The patient in an MVC. HISTORY OF PRESENT ILLNESS: This is a 51 year-old male who had an MVC into a building. The patient was restrained, was unresponsive except to painful stimuli upon presentation to the emergency room. He required 2 units of blood transfused while in the trauma bay. He had emesis. Patient is Portuguese speaking. At the time of presentation to the emergency department the patient had unknown allergies, unknown medical history, unknown family history, unknown medications and unknown past surgical history. PHYSICAL EXAMINATION: His vitals on presentation was heart rate in the 120s, blood pressure 100/palp. Breath sounds at 82. Patient was intubated. Bilateral chest tubes were placed. He had altered mental status, GCS of 13. He had a scalp laceration. He was intubated in the emergency room. Lungs were clear. There were broken ribs on the right noted when placing the chest tube in. His abdominal examination was obtained which was negative. He had normal tone upon his rectal examination, which was guaiac negative. LABORATORY DATA: Upon presentation to the emergency department, white count of 18.0, hematocrit 29.8 with a platelet count of 220. His chem-10 was normal as well as his coagulations. His alcohol level was 125 on presentation. Amylase was 69 and fibrinogen 161. CT of chest was obtained upon presentation to the emergency department. Trauma film was obtained which showed widening mediastinum secondary to rotational differences. An extremely limited pelvis due to the fact that the patient was moving while the images were taking place. The CT of cervical spine was also obtained which showed a fracture of the right transverse process of C7 with questionable extension to the right lamina. The fracture fragments were only minimally displaced with mild narrowing of the neuroforamen at that level. There was no extension of the vertebral artery canal. Patient also was noted to have small apical right pneumothorax and emphysematous changes of the lungs bilaterally. A CT of head was also obtained in the emergency department which was notable for no evidence of intracranial hemorrhage. CT of pelvis was then obtained while in the trauma bay. Patient was noted to have a right small apical anterior inferior pneumothorax, status post chest tube placement on the right. Atelectasis versus contusion of the posterior right lung. Mild emphysematous changes along the upper lobes bilaterally. An x-ray of the patient's right hand was conclusively normal without any evidence of fracture. HOSPITAL COURSE: Patient was then admitted to the trauma service under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He was admitted to the trauma surgical Intensive Care Unit for evaluation. Follow up chest x-ray was obtained on the [**2114-11-19**] for interval changes of his pneumothorax and placement of the endotracheal tube. There was relative [**Name (NI) 70433**] of the right upper quadrant of the abdomen and sharp demarcation of the medial right hemidiaphragm which would correspond to a basilar pneumothorax on CT of torso. A neurosurgery consult was obtained while the patient was in the trauma bay for his cervical fracture. The patient was then placed on a cervical collar and is to remain so for several weeks (6 to be exact) in which case he is to follow up in the neurosurgery clinic. Plastic surgery was also consulted for his right hand laceration in which there was no evidence of fracture. Plastic surgery service subsequently signed off. Patient remained in the trauma and the neurosurgical Intensive Care Unit for several days from [**11-18**] until [**2114-11-29**]. Patient did relatively well. His bilateral chest tubes were removed without incident during his time in the trauma Intensive Care Unit. There were no complications from such. In addition an additional chest tube was placed in the patient's anterior wall of the left lung due to the fact that on placement of the chest tube in the emergency department it was noted that the patient's lung was highly fibrotic to the chest wall and we were concerned for noncommunication between the placement of the original chest tube and the pneumothorax. The patient tolerated this well without any evidence of increased pneumothorax. He was placed on suction, 2 chest tubes to the left, 1 chest tube on the right for several days. On the third day after placement of the third chest tube all the chest tubes were subsequently removed, 1 each additional day while the patient was in the trauma SICU. There was, however, noted to be a CT scan of the patient chest which was accomplished on [**2114-11-28**] which showed a small loculated pneumothorax, a small pig-tail tube was placed in the patient's chest along the second intercostal space on the left. The patient tolerated this procedure well without any complaints. This pig-tail was then subsequently placed to suction for a total of 5 days and was removed. Chest x-ray following removal of this showed no evidence of a pneumothorax. Patient had minimal output of blood from the chest tube. The patient was also due to an incident in the trauma bay in which a resident was lacerated after removing glass from the patient's scalp. The resident received a laceration and an HIV work up was obtained. The patient was noted to be HIV positive with a viral load greater than 100,000 and a CD4 count of less than 100. An ID consult was then obtained on the [**11-29**] in which case the patient was started on [**Doctor Last Name **] therapy for his HIV and was begun on prophylaxis of PCP pneumonia which included azithromycin and Bactrim. The patient was also started on ciprofloxacin. It was noted with talking with the patient at this time that a history of a pneumococcal empyema requiring 2 surgeries 2 years ago and 2 lymph node biopsies. The patient was also noted to have a history of asthma, alcoholism, depression, post herpetic neuralgia, steroid dependence and questionable thrush and questionable adrenal insufficiency. After several days in the trauma Intensive Care Unit the patient was then moved to the floor for further evaluation which was done on [**2114-11-30**]. The patient obtained PT/OT evaluation in which it was noted that patient had unstable gait. Started on [**Doctor Last Name **] therapy and had a pig-tail to suction which was removed on the [**12-3**] on the floor. Patient remained afebrile until the [**12-4**] where it was noted that he had temperatures of 101.9. Cultures were obtained. A urine culture was noted to have E coli with greater than 100,000 per colony. Patient was then started on ceftriaxone 1 gram q 24 for treatment of his urinary tract infection empirically. On speaking with the infectious disease consultation it was agreed upon to have the patient on ceftriaxone for 3 days. On the [**12-6**] the patient passed his PT evaluation and is cleared to go home. Additional films of the patient's hands were also obtained in this time which again showed no fractures of his wrist or his humerus, his elbow or his shoulder. This was done due to the fact that patient was complaining of pain on the right side of his hand. The patient is being discharged home. His white count is currently 6.7 with a hematocrit of 23.5 and a platelet count of 538. The patient did not require any transfusions during his hospitalization in this hospital. CD4 count was noted to be 66 with a CD8 count of 1465 with a CD4/CD8 ratio of .1. The patient had no surgical intervention during his hospital course here. PHYSICAL EXAMINATION: He is afebrile today. Vital signs stable. Lungs are clear. Heart rate showed regular rate and rhythm. No murmurs, rubs or gallops. Abdomen is soft, nontender, nondistended. Right hand is decreased swelling, good range of motion. Patient is awake, alert and oriented x3. He is ambulating and doing well. He is being discharged on Tylenol, Colace, senna, Percocet, Bactrim, ritonavir, atazanavir, azithromycin, __________, abacavir, lamivudine, Colace and senna. He is told to follow up with his PCP regarding his HIV status. He has been scheduled to meet with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2114-12-13**] at 9:30 in the morning. He is also told to follow up with his pulmonologist, Dr. [**Last Name (STitle) 70434**] at the [**Hospital6 12736**] Center for evaluation of his pulmonary status given the fact of his past empyemas. He is also told to make an appointment in 1 to 2 weeks in the trauma clinic and to call the trauma clinic office to schedule an appointment with Dr. [**Last Name (STitle) **]. He has been discharged with pain medications and told not to operate or drive heavy machinery while on medications. He was also told that he was going to be discharged on antibiotics and to take his medications as prescribed. He was told to come to the emergency department for the following reasons: Temperature greater than 101.1, increased rest pain, abdominal distention, any increased nausea or any shortness of breath. DISCHARGE CONDITION: Good. Tolerating p.o., ambulating and voiding. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**] Dictated By:[**Last Name (NamePattern1) 29268**] MEDQUIST36 D: [**2114-12-6**] 12:47:59 T: [**2114-12-6**] 14:34:21 Job#: [**Job Number 70435**] ICD9 Codes: 5185, 2851, 5990, 2875, 4019
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Medical Text: Admission Date: [**2179-5-21**] Discharge Date: [**2179-6-1**] Date of Birth: [**2104-2-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Chief Complaint: Abdominal pain and diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy PICC placement History of Present Illness: Mr. [**Known lastname 39861**] is a 75M with history notable for metastatic prostate cancer, HTN, CAD s/p recent stenting, severe AS, dCHF, heart block s/p pacemaker, prior gastric ulcers, pancytopenia, and prior anemia felt secondary to GI bleed who presented to [**Hospital1 **] [**Location (un) 620**] on [**2179-5-20**] with abdominal pain and diarrhea. For two days prior to presentation, patient had constipation, but no N/V. Saw his PCP [**5-19**], and had KUB which was c/w constipation. Was started on bowel regimen with colace and mag citrate, and on the morning of [**2179-5-20**], woke up with fecal urgency and had multiple large semi formed bowel movements. After multiple bowel movements, he was extremely fatigued prompting him to call 911. In addition to his fecal urgency, he also complained of worsening diffuse abdominal pain, worse with palpation/manipulation. He denied any melena, nausea or vomiting. He initially presented to [**Hospital1 **] [**Location (un) 620**], where per report he had guaic positive stools. His labs were notable for Hct 28. plt 158, INR 1.1, Cr 1.3 (up from baseline 1), slightly elevated Tbili 1.67. Lactate was 2.3. While at [**Hospital1 **] [**Location (un) 620**], the patient was transferred to the ICU as his HCT decreased from 28 to 22 and he was oliguric. Rec'd transfusion. OF note, he remained hemodynamcially stable He underwent a CT abd/pelvis which showed a multifocal small bowel abnormality with acute on chronic inflammation, and of note there were some intervening loops of small bowel that appeared normal, raising the question of possible Crohn's. He was also noted to have a large amount of stranding in the left pelvic sidewall and left lower retroperitoneum of the abdomen, indicating acute inflammation. There was a distinct and abnormal portion of the sigmoid colon suggestive of focal colitis, possibly ischemic. He has extensive atherosclerotic disease with moderate-severe narrowing of the SMA and possibly the celiac, but [**Female First Name (un) 899**] patent. Also of note, he was found to have an isolated segment of peripheral portal vein thrombus without more proximal thrombus. CT scan also raised concern for left common femoral artery pseudoaneurysm that was not seen on [**5-12**] ultrasound. He was evaluated by GI and surgery, who did not feel there was a need for acute surgical intervention. Plan was to proceed with conservative measures including fluid resusictation and antibiotics. Given rsk factors, GI didn not think he was a cnadidate for an EGD or colonsocopy. Per family's request, he was transfered to [**Hospital1 18**] for further management. Of note, the patient recently had multiple cardiac procedures, including a DES to LAD in mid [**Month (only) 958**] by Dr. [**Last Name (STitle) **], and a DES to RCA in late [**Month (only) 958**] with a complication of a left groin hematoma post procedure. Additionally, given bradycardia and Wenkebach rhythm, had a pacemaker placed on [**2179-5-5**]. Plans at that time were to continue ASA and Plavix for minimum of one year. Regarding his aortic stenosis, he was deemed high risk and decision was made for valvulplasty at a later date. On arrival to the ICU, patient is lethargic requesting fluids. Complaining of moderate abdominal pain worse with manipulation. Otherwise no other complaints. States last bowel movement was several hours ago. Review of systems: (+) Per HPI. Also endorses 10 lbs weight loss in last 3 weeks, claiming general malaise for this period. Also c/o L/R shoulder pain for last few days. Endorses chronic left lower extremity swelling since lymph node removal in the [**2137**]'s. (-) Denies recent travel, food aversion/abdominal angina. No fever, chills, night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, changes in bowel habits. Denies dysuria, frequency, or urgency. Denies myalgias. Denies rashes or skin changes. Past Medical History: 1. Severe aortic stenosis. Workup in process for valvuloplasty with Dr. [**Last Name (STitle) **]. 2. Diastolic congestive heart failure with an EF of 70%. 3. Hypertension. 4. Metastatic prostate cancer on Lupron. 5. Gastroesophageal reflux disease. 6. Gastric ulcer, details not very clear. 7. Mild ascending aortic dilation. 8. Lymphoma in [**2141**], lymphedema of his right lower extremity status post lymph node removal in [**2141**]. 9. He has a history of testicular cancer (?). . Other medical problems are: 1. CAD status post stent. 2. Left inguinal hernia. 3. Advanced heart block status post pacemaker recently placed in [**2179-4-15**]. 4. Anemia felt due to GI bleed. 5. Ulcers. 6. Lymphoma. 7. Pancytopenia; was supposed to have a bone marrow biopsy. Social History: The patient lives at home. No history of smoking. Drinks 1 glass of wine a night. No illicit drug use. Lives with wife and 2 dogs. Works as insurance broker. 2 daughters that live near by and 1 son who is a colorectal surgeon in [**State 108**] Family History: Mother passed away age [**Age over 90 **] from multiple comorbidities. Father passed away in his 50's from heart disease. Brother passed away age 69 from complications of diabetes. Sister passed away age 70 from MI and had a history of ETOH abuse. Denies history of IBD/Celiacs/Liver disease. Physical Exam: Admission examination Vitals: T:100 BP: 139/54 P: 77 R: 28 O2 94% on 2L General: Alert but lethargic, oriented, no acute distress. Ashen appearing. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: JVP not elevated, no LAD. Supple neck. No supraclavicular LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, loud crescendo decrescendo murmur, late peaking with blurring of S2 with carotid radiations best auscultated in aortic region. Otherwise no other adventitious heart sounds appreciate. PMI slightly lateralized towards axilla. Abdomen: Ventral hernia appreciated in the midline. Tenderness to moderate palpation, worst in the LLQ. soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: dark yellow urine Ext: warm, well perfused, 2+ pulses, RLE with indurated nonpitting edema 2-3x larger than LLE. No pain in calf. Pertinent Results: ADMISSION LABS: [**2179-5-21**] 05:30PM BLOOD WBC-8.0# RBC-3.30* Hgb-10.0* Hct-29.5* MCV-89 MCH-30.3 MCHC-34.0 RDW-15.2 Plt Ct-141* [**2179-5-21**] 05:30PM BLOOD Neuts-95* Bands-1 Lymphs-0 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2179-5-21**] 05:30PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+ Burr-OCCASIONAL [**2179-5-21**] 05:30PM BLOOD PT-16.7* PTT-29.1 INR(PT)-1.6* [**2179-5-21**] 05:30PM BLOOD Glucose-115* UreaN-41* Creat-1.2 Na-142 K-4.8 Cl-112* HCO3-21* AnGap-14 [**2179-5-21**] 05:30PM BLOOD ALT-18 AST-21 LD(LDH)-148 AlkPhos-105 TotBili-4.7* DirBili-1.1* IndBili-3.6 [**2179-5-21**] 05:30PM BLOOD Albumin-3.4* Calcium-8.0* Phos-4.1 Mg-2.7* [**2179-5-21**] 05:30PM BLOOD Hapto-140 [**2179-5-21**] 05:57PM BLOOD Lactate-1.0 Micro: Blood cultures [**5-20**], [**5-21**] ([**Location (un) 620**]): pending Urine culture [**5-20**] ([**Location (un) 620**]): <10,000 org/ml GNRs Images: CXR [**2179-5-20**] ([**Location (un) 620**]): The lungs are clear. Heart size is within normal limits. Pulse generator in the left chest with electrodes in the right atrium and right ventricle has the expected appearance. Aortic arch calcification indicates atherosclerosis. Mediastinal contour is normal. No suspicious bone findings or degenerative changes in the left AC joint. CT Abd/Pelvis w/contrast [**2179-5-20**] ([**Location (un) 620**]): 1. MULTIFOCAL SMALL BOWEL ABNORMALITY SUGGESTING ACUTE ON CHRONIC INFLAMMATION. AS THERE DO APPEAR TO BE NORMAL INTERVENING LOOPS OF SMALL BOWEL, THIS RAISES THE QUESTION OF CROHN'S DISEASE. THE ENTEROPATHY APPEARS TO BE LIMITED TO THE WALL FOR THE MOST PART WITH ONLY MINIMAL AREAS OF INFLAMMATION THAT [**Month (only) **] EXTEND INTO THE SEROSA BUT THERE IS NO MESENTERITIS OR ABSCESS. 2. LARGE AMOUNT OF STRANDING IN THE LEFT PELVIC SIDEWALL AND LEFT LOWER RETROPERITONEUM OF THE ABDOMEN, INDICATING ACUTE INFLAMMATION. DISTINCT AND ABNORMAL PORTION OF THE SIGMOID COLON WITHIN THE PELVIS SUGGESTS FOCAL COLITIS OF WHICH ISCHEMIC COLITIS IS POSSIBLE. NO PERFORATION OR PNEUMATOSIS. 3. EXTENSIVE ATHEROSCLEROTIC DISEASE WITH MODERATE-SEVERE NARROWING OF THE SMA AND POSSIBLY OF THE CELIAC ARTERY BUT PATENT [**Female First Name (un) 899**]. THIS WOULD RAISE THE PATIENT'S RISK FOR ISCHEMIC BOWEL DISEASE. 4. EXTENSIVE CORONARY ARTERY DISEASE AND AORTIC VALVE CALCIFICATION, LIKELY REFLECTING AORTIC STENOSIS, AS SUGGESTED ON CTA CHEST FROM [**Hospital1 18**] [**Location (un) **] IN [**2179-3-17**]. 5. BILATERAL RENAL INFARCTS SUBACUTE AND CHRONIC IN APPEARANCE. EXTENSIVE ATHEROSCLEROSIS BILATERAL RENAL ARTERIES AS WELL. 6. ISOLATED SEGMENT 5 PERIPHERAL PORTAL VEIN BRANCH THROMBUS WITHOUT MORE PROXIMAL THROMBUS. MARKEDLY ATROPHIC LEFT LOBE OF THE LIVER. 7. CONCERN FOR LEFT COMMON FEMORAL ARTERY PSEUDOANEURYSM. THIS WAS NOT SEEN AT [**2179-5-12**] ULTRASOUND AT [**Hospital1 18**] [**Location (un) **] AND FINDINGS APPEAR TO HAVE EVOLVED SINCE THAT TIME AND THE LEFT COMMON FEMORAL ARTERY APPEARS SLIGHTLY LARGER, THOUGH IT IS DIFFICULT TO COMPARE BETWEEN THE MODALITIES. 8. LEFT PUBIS HETEROGENEOUS SCLEROSIS LIKELY REFLECTS PROSTATE . IMPRESSION: CT abd/pelvis [**2179-5-31**] 1. No evidence of visceral perforation as questioned. 2. Interval increased segmental small bowel thickening and dilatation up to 4-cm extending to the terminal ileum with increased ascites and subtle relative mucosal [**Name2 (NI) 39862**] of bowel loops in left upper quadrant. No transition point identified. Persistent stable sigmoid and descending colitis. Overall, findings are compatible with known ischemic colitis and enteritis. 3. Persistent ascites and anasarca. 4. Unchanged moderate bilateral pleural effusions with atelectasis. 5. Fluid layering in the lower esophagus, placing patient at increased risk for aspiration. 6. Severe hepatosteatosis. 7. Bilateral cortical and parapelvic renal cysts. Left renal cortical thinning. 8. Severe diffuse atherosclerotic disease, without evidence of frank vessel occlusion. 9. Left superior pubic ramus sclerosis may represent metastatic disease in the setting of known prostate cancer. , EKG ([**Location (un) 620**]): Sinus rhythm with rate of 76. LAD. Poor RWP. TWI in AVL, V1, flattening in V2 (changed from prior, may be lead placement). PR interval 0.24 msec, normal QT. No evidence of STE/Flattening. . ECHO [**4-/2179**] [**Hospital1 18**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.7 cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is borderline/mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: The patient is a 75 year old man with known severe aortic stenosis, diastolic HF, hypertension, metastatic prostate cancer, distant past lymphoma, s/p recent 2 stents several weeks prior to presentation, now here with likely diffuse ischemic injury to his small bowel and colon. The patient was initially transferred from [**Hospital1 **] [**Location (un) 620**] with abdominal pain and diarrhea after being diagnosed with colitis. Unclear cause, but some concern for either embolic vs vascular insult, as atypical distribution of areas of involvement. The patient intially improved on bowel rest, but his pain worsened after a trial of liquids and strict bowel rest was resumed. Increasing abdominal pain in the setting of PO intake, but has not improved significantly since transition back to NPO status. A PICC was placed with plans for initation of TPN on [**5-26**]. Fever to 101F on [**5-29**], without focal identifiable source beyond the potential for translocation of bacteria from the ischemic bowel. We continue to discuss with the patient and his family regarding the severity of his illness and his wishes for his care. #Abdominal Pain/Patchy colitis and bowel necrosis: Patient's pain symptoms staretd after diarrhea. Radiographic imaging at OSH confirmed patchy acute on chronic small intestin inflammation with possible question of inflammatory disease. Additionally, stranding on the left pelvic sidewall and lower retroperitoneum suggestive of focal colitis to which ischemic colitis was entertained. While theoretical the patient may have had poor forward flow in the presence of diarrhea and severe AS, the patient's presentation is not necessarily consistent with ischemic etiology. While sigmoid involvement is possible in the rectalsigmoid area (Sudeck's point), distribution of inflammation of the small intestine with patchy inflammation is not consistent with a vascular territory or watershed area. Additionally, CT read showed a patent [**Female First Name (un) 899**] with thrombosis downstream less likely. Lastly, lactate was initially elevated above 2, but decreased with rehydration to less than 1. Other possibilities included diverticulitis, but would not explain small intestinal findings. IBD is possible although less likely for initial occurrence to be in a patient in his 70's. Infectious colitis possible, however stooling has stopped with decreased PO intake and C.Diff negative at OSH. Stool studies were negative for Cdiff and ova and parasites while here. Bilirubin initially elevated but this was indirect hyperbilirubinemia with benign ultrasound and resolved without particular intervention. While gastritis is possible and his history is unclear regarding PUD, this would not explain his CT findings. Antibiotics were held (was given ertapenem at OSH) as it was felt the patient was not actually experiencing bowel necrosis. CBC was trended and no evidence for infection. IV PPI was DCd as he had received 48 hours of IV PPI and no evidence of further bleeding. Abdominal exam remained relatively benign although he did have pain the night of admission. GI was consulted and recommended flexible sigmoidoscopy, which showed extensive bowel necrosis. Colorectal surgery felt the patient was not an operative candidate due to the small and large bowel distribution. After transfer to the floor pt was on tube feeds, and abdominal pain progressed. Repeat abdominal CT [**5-31**] showed worsening of bowel wall edema/necrosis. His prognosis appeared quite limited, given the extent of the ischemic colitis and necrosis, as well as his underlying medical conditions. Ongoing discussion regarding the patient's wishes and hopes for his treatment, especially in the setting of a poor prognosis. Pallative care was consulted. See goals of care below. # Hyoxia - day prior to death pt was developed acute onset wheezing and subsequent hypoxia requiring transfer to the ICU. Pt developed wheezing which was initially responsive to albuterol, but subsequently became more hypoxic and dyspneic. In the setting of severe AS, dCHF and several liters positive over LOS, high likelihood that pulmonary edema/flash edema were a component. Other possibilities included ischemic event vs ossible albuterol induced tachycardia with subsequent flash. Pt was given lasix 20mg IV x1, with significant improvement in symptoms. Pt also became febrile to 101 peripherally with shaking chills and new obscuration of L hemidiaphragm concerning from evolving HAP (at that time was on vanc/cipro/flagyl), though this doesn't exactly fit with the reportedly acute time course. Further, pt with chronic RLE lymphedema appearing enlarged, mildly erythematous and tender, in setting of no DVT ppx, concern for VTE. Also of note, pt with persistent bilateral pleural effusions. Abx coverage broadened to vanc/zosyn. . #GI Bleed: Guiac positive stools at OSH in presence of HCT drop from 28 to 22. Reported history of gastritis/PUD. This was also in the presence of fluid resuscitation. Per report, patient did receive 2 U PRBC transfusiion. HCT appears to have stabalized in house without further epsiodes of diarrhea or suggestions of GIB. Was continued on omeprazole 20mg daily. HCT was monitored closely without signs of further bleeding. . #AS/Diastolic CHF: Per reports severe AS 0.8-1.0 aortic valve area. Future plans might include valuvloplasty if patient continues to have CAD symptoms per Dr.[**Name (NI) 8664**] note in 3/[**2179**]. I's and Os carefully monitored with pt positive 1L over the first 2 days of hospitalization but developed no signs of acute on chronic diastolic CHF. Initially started on metoprolol then switched to carvedilol for better blood pressure control to help minimize afterload and strain on ventricle. #CAD s/p recent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]: The patient had two DES placed in the last month, one in the RCA and one in the LAD. On presentation to the OSH had a mild troponin elevation but EKG appeared improved from [**5-12**] with resolution of previous Q waves and elevation likely due to procedure <10 days before given troponin stays in system for two weeks. At initial Hct drop at OSH ASA and clopidogrel were held but then restarted soon after with stable Hct given high risks of stent rethrombosis. He never had chest pain or clear signs of ACS. #Normocytic Anemia with concurrent Pancytopenia: Per prior reports has a history of pancytopenia. Prior Heme Onc notes from [**4-/2179**] during patient's admission for catherizations/pacemaker placement discuss likely marrow suppression from Lupron use or MDS. Coupled with history of radiation for metastatic prostate cancer, further marrow dysfunction is possible. Coupled with low reticulocyte counts, MDS high on differential. Interestingly, white count while in normal limits, was elevated about 2x higher than baseline. Haptoglobin/LDH did not suggest hemolysis, although he did have an elevated bilirubin with the majority being indirect, but this rapidly resolved as quickly as it presented. It was considered that he may have an underlying Gilberts, but unclear. . #hypotension - on return to the [**Name (NI) 153**] pt was hypotensive requiring 3 pressors. Dr. [**Last Name (STitle) 217**] had discussions with the patient's son, who is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-rectal surgeon, by phone (son in [**Name (NI) 108**]). Aggressive therapy was maintained until the son could travel to [**Name (NI) 86**]. The following day his son came and family decided to turn off pressors. Pt [**Name (NI) **] within the hour. . #Fever: Presumed related to ischemic bowel and progression of necrosis. Started on cipro/metronidazole when abdominal pain worsened, then added vancomycin with pending blood cultures. . #[**Last Name (un) **]: Likely prerenal. Improved with IVF. Pt was hydrated judiciously and [**Last Name (un) **] resolved. . #Question pseudoaneursym on CT: no evidence on physical exam. HCT drop may be related to aneursym pooling. Serial exams were not concerning for further enlargement/bleed. . #1st degree AV blockade: s/p pacemaker DCCI recently. . #History of prostate cancer: Has been on Lupron previously. Followed by Dr. [**Last Name (STitle) **]. . PT [**Name (NI) 5485**] [**2179-6-1**]. Medications on Admission: Home Medications: -meclizine 12.5 q.8 hours (Listed in OMR, patient denies) -omeprazole 20 mg p.o. daily -ferrous sulfate 300 mg p.o. b.i.d. -lisinopril 20 mg p.o. daily -Plavix 75 mg p.o. daily -multivitamin 1 tablet once daily -aspirin 325 mg p.o. daily . Medications on Transfer: Ertapenem 1 gram IV qday (day 1 [**2179-5-20**]) Aspirin 81 mg qday Sennosides 2 tabs po qday prn ondansetron 4 mg IV q8hrs prn morphine sulfate 2 mg IV q4 hours prn docusate sodium 100 mg [**Hospital1 **] prn acetaminophen 1000 mg q6 hr prn pain esomperzaole 40 mg IV bid Clopidogrel 75 mg po qday aspirin 324 mg po qday Discharge Medications: Pt [**Hospital1 **] Discharge Disposition: [**Hospital1 **] Discharge Diagnosis: Pt [**Hospital1 **] Primary Diagnoses: Regional Enteritis (ischemic bowel) Anemia Dehydration Critical aortic stenosis Coronary artery disease Discharge Condition: Pt [**Hospital1 **] Discharge Instructions: Pt [**Hospital1 **] ICD9 Codes: 486, 4241, 4280, 4589
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Medical Text: Admission Date: [**2133-9-18**] Discharge Date: [**2133-9-28**] Date of Birth: [**2055-4-9**] Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 78-year-old woman with a history of hypercholesterolemia and non-insulin-dependent diabetes mellitus with a history of stable angina who was in her usual state of health; however, she had sharp episodes of chest pain. The patient did relate this information to her primary care physician, [**Name10 (NameIs) **] the patient was told that it was gastroesophageal reflux disease. She had these episodes multiple times over the past year. On the day of admission, she had worsening symptoms and presented to the Emergency Department at the [**Hospital6 1760**] where she received intravenous Lopressor, as well as Heparin, and she was ultimately taken to the Cardiac Catheterization Lab on [**2133-9-18**]. This revealed a left ventricular ejection fraction of 56%, 90% proximal right coronary artery lesion and 90% proximal left anterior descending lesion as well. As a result of the cardiac catheterization findings, the patient was taken to the Operating Room the following day. PAST MEDICAL HISTORY: Hypercholesterolemia. Type 2 diabetes mellitus. Stable angina. Gastroesophageal reflux disease. History of deep venous thrombosis with a PE in [**2131**], unclear of the details. History of glaucoma. MEDICATIONS ON ADMISSION: Metformin 850 mg p.o. b.i.d., Metoprolol 50 mg p.o. q.d., Zocor 20 mg p.o. q.d., Protonix 40 mg p.o. q.d., Glyburide 3 mg p.o. b.i.d., Quinine Sulfate 260 mg p.o. q.d., Cosopt eye drops, Travatam eye drops, Multivitamin. ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: The patient was subsequently taken to the Operating Room on [**2133-9-19**], where she underwent coronary artery bypass grafting times three with LIMA to the left anterior descending, saphenous vein to the diagonal and a saphenous vein to the posterior descending artery, as well as closure of a PFO with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. Postoperatively the patient was taken from the Operating Room to the Cardiac Surgery Recovery Unit on Neo-Synephrine and Propofol drip. The patient was weaned from mechanical ventilation and extubated on the night of surgery. On postoperative day #1, the patient had some problems with hypotension, remaining on Neo-Synephrine drip but had otherwise progressed to satisfactory condition in her postoperative course. On postoperative day #2, the patient remained hypotensive, requiring Neo-Synephrine drip, and for that reason, she stayed in the Intensive Care Unit. Over the next few days, the patient did have multiple episodes of rapid atrial fibrillation which became difficult to trace. She was started on Amiodarone intravenous drip, and her oral course of beta-blocker was increased subsequently over the next few days. On [**9-24**], postoperative day #5, the patient remained very difficult to rate control, in atrial fibrillation, and an Electrophysiology consult was obtained at that time. It was their recommendation to continue beta-blocker, as much as her rate and blood pressure would tolerate, as well as to continue the Amiodarone. It was also their recommendation to check TSH, as well as to anticoagulate her. An intravenous Heparin drip was started at that time, and she has been transitioned to oral Coumadin dosing for anticoagulation for postoperative atrial fibrillation. Of note, the patient's TSH at that time was 13. She had an Endocrinology consult the following day, and it was their recommendation not to replace any thyroid hormone at that time, yet their recommendation was to follow-up with her primary care physician [**Last Name (NamePattern4) **] [**12-4**] weeks, and if her TSH was still high at that time, they recommended thyroid replacements, but due to the course of her being in the Intensive Care Unit due to postoperative state, they did not feel that this was the appropriate time to treat this elevation in TSH. The patient remained hemodynamically stable over the next couple of days, while we were initiating her Coumadin dosing. She now has a therapeutic INR today of 2.2 and is ready to be discharged home. CONDITION ON DISCHARGE: The patient is afebrile. Neurologically she is intact with no apparent deficits. Her lungs are clear to auscultation. Her heart is regular, rate and rhythm. She is in normal sinus rhythm with a rate in the 60s. Her blood pressure is in the 110s/50s for the most part. Her respiratory rate is 18-20, and her room air oxygen saturation is ranged between 95 and 97%. The patient's sternal incision, as well as her endoscopic vein harvest leg incisions are clean and dry with no erythema and no drainage noted. DISCHARGE MEDICATIONS: Simvastatin 20 mg p.o. q.d., Quinine Sulfate 260 mg p.o. q.h.s., Timoptic eye drops 1 drop to the right eye once a day, Travatam eye drops 1 drop as directed, Glyburide 3 mg p.o. b.i.d., Lopressor 75 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. x 5 days, Potassium Chloride 20 mEq p.o. b.i.d. x 5 days, Colace 100 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., Aspirin 81 mg p.o. q.d., Percocet 5/325 one p.o. q.4-6 hours as needed for pain, Amiodarone 400 mg p.o. q.d. x approximately 6 more weeks, this can be discontinued at the discretion of the patient's cardiologist, Dr. [**First Name4 (NamePattern1) 1399**] [**Last Name (NamePattern1) 17915**], she was placed on it for postoperative atrial fibrillation, Metformin 500 mg p.o. b.i.d., Coumadin 2 mg p.o. today, [**9-28**], and tomorrow [**9-29**]. FOLLOW-UP: She has an appointment to follow-up in Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50159**] office, on Wednesday, [**9-30**], with his physician assistant, [**Name9 (PRE) 8797**], 2:30 p.m. Dr.[**Name (NI) 50160**] office will continue the Coumadin dosing from thereon, and her INR levels will be followed through his office as well. The patient should also follow-up with her primary care physician regarding TSH level which was elevated at 13. Of note, other thyroid function studies, which were checked, include T4 of 7.0, free T4 of 1.2, T4 index of 6.6, and a T-uptake of 0.94. A free T3 level was also sent, but the results are still pending since those were handled at an outside laboratory. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times three with a closure of a patent foramen ovale. 2. Postoperative atrial fibrillation. 3. Diabetes mellitus type 2. 4. Hypercholesterolemia. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2133-9-28**] 13:18 T: [**2133-9-28**] 13:24 JOB#: [**Job Number 50161**] ICD9 Codes: 9971, 4111, 2720
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Medical Text: Admission Date: [**2113-5-20**] Discharge Date: [**2113-5-22**] Date of Birth: [**2054-5-1**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old male with chronic renal insufficiency and known coronary artery disease status post inferior myocardial infarction in [**2101**], status post CABG in [**2105**] [**Hospital1 **], hypertension, hypercholesterolemia, and tobacco use, who presented to [**Hospital3 3834**] with substernal chest pain. The patient states that around 9:30 pm, he was lying down on the bed and developed [**11-3**] substernal chest pressure. He felt it might be from overeating, so he forced himself to vomit with no relief. The pain continued with radiation to the back, arms, bilateral jaw, nausea, vomiting, shortness of breath, or palpitations, or diaphoresis. He presented to [**Hospital3 3834**], where he was found to have global ST depression, and was given a half of dose, TNK and Aggrastat and Heparin drip, also borderline hypotension, SBP in the 90s-100 which was sensitive to fluid. He received in addition to above, aspirin 325 mg, IV Lopressor, Heparin, 6 mg of Morphine, and 1.2 liters of normal saline. The patient was then transferred to [**Hospital1 69**] for catheterization. On arrival, he was evaluated by CCU and was found to be stable and pain free, and was decided to transfer to unit and in anticipation for catheterization in the am. REVIEW OF SYSTEMS: No fever or chills, nausea, vomiting, diaphoresis, normal bowel movements, no dysuria, no melena, no bright red blood per rectum, no cough, no claudication, no orthopnea, paroxysmal dyspnea, increased edema, increased dyspnea on exertion. PAST MEDICAL HISTORY: 1. Coronary artery disease status post inferior myocardial infarction in [**2101**]. CABG in [**2105**], several peripheral vascular disease. 2. Hypertension. 3. High cholesterol. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Heparin drip. 2. Aggrastat. 3. Aspirin. 4. Prinivil. 5. Lipitor. 6. Lopressor. 7. Zantac at home. 8. Aspirin. 9. Gemfibrozil. 10. Prinivil. 11. Lipitor. 12. Metoprolol. 13. Zantac. SOCIAL HISTORY: Retired soldier. Positive tobacco. Positive alcohol. PHYSICAL EXAMINATION: Vital signs on admission: Atrial fibrillation, heart rate 88, blood pressure 89/60, and 98% on 3 liters nasal cannula. Sleeping in bed, position in Trendelenburg in no acute distress, and comfortable. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Oropharynx is clear. Mucous membranes moist. Neck: Patient is flat, no bruits. Chest was clear to auscultation bilaterally. Regular, rate, and rhythm, no murmurs, rubs, or gallops, no S3, normal S1, S2. Abdomen has positive bowel sounds, nontender, and nondistended and no hepatosplenomegaly. Extremities: No edema, warm, no clubbing or cyanosis. Skin: No rash. OUTPATIENT HOSPITAL LABORATORIES: White blood cells 12, hematocrit 39.6, platelets 306. Sodium 138, potassium 4.8, chloride 103, bicarb of 26, BUN 21, creatinine 1.0, glucose of 164, INR of 1.0. CK of 166, MB 19, MB 111, troponin greater than 25. ELECTROCARDIOGRAM AT OUTSIDE HOSPITAL: Normal sinus rhythm at 87, normal axis, normal intervals, ST depressions, in I, II, greater than III, aVF, V2-V3, right sided V4, strain. Electrocardiogram at [**Hospital1 **]: Normal sinus rhythm at 91, normal axis and normal intervals, but significant ST depressions in V4 through V6, significantly improved. HOSPITAL COURSE: The patient was admitted to CCU service. Had a bedside echocardiogram which was limited of optimal with no obvious focal wall motion abnormalities through the inferior wall, so the inferior wall may be more hypokinetic, [**2-27**]+ mitral regurgitation, [**1-26**]+ tricuspid regurgitation. Patient presented to initial CK 114, troponin 0.05 on arrival, to [**Hospital3 **], CK 166, MB 19, troponin greater than 25 but pain free. Peak CK 571, MB 106, troponin greater than 50, stable and pain free on night of admission. Catheterization the next morning. Coronary angiography of this right dominant circulation revealed severe LMCA and right coronary artery disease. The LMCA and RCA were both totally occluded proximally without any filling of distal vessels. Graft angiography demonstrated a patent LIMA to mid left anterior descending artery that supplied a small distal vessel and a small diagonal 2 that ran parralel as a "twin left anterior descending artery" system. The LIMA also supplied a small proximal vessel and a small bifurcating D1 0 via retrograde flow. The saphenous vein graft to PDA was widely patent and also filled a small diffusely diseased PLV via retrograde flow. The saphenous vein graft to OM-1 touchdown on the lower pole of the moderate bifurcating OM-1, the small mid and distal left circumflex was also supplied via retrograde flow. The saphenous vein graft to OM had an 85% distal stenosis just proximal to the anastomosis. Resting hemodynamics revealed normal RV filling pressures with a RV mean pressure of 7 mg Hg and RV end diastolic pressure of 11. The mean PCW was 17. The cardiac output was preserved at 5.5. Left ventriculography was not performed. The stenosis in the saphenous vein graft OM near the distal anastomosis was successfully treated by angioplasty and stenting using a 2.5 x 18 mm velocity Hepakote stent with no residual stenosis, no angiographic evidence of dissection, and TIMI-3 flow. The patient remained stable and was called out to the floor. He was continued on aspirin, Plavix, and a statin, and was started on low dose beta blocker. He remained normotensive. On [**2113-5-22**], the patient had an echocardiogram which was pending at the time of discharge. CKs were coming down. Left femoral groin showed no evidence of hematoma or bruit. The patient was counseled to quit smoking multiple times throughout the hospital course, however refused. He was also recommended to stay until receiving his echocardiogram results so that he would be able to bring them to his primary care doctor, however, he declined. He was discharged to home to followup with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**], whom he does not remember their name. He had an echocardiogram performed on [**2113-5-22**] which was pending at the time of discharge. However, it subsequently returned showing ejection fraction of 40%, normal left ventricular wall thickness, and cavity size, regional wall motion abnormalities, including basal inferior akinesis with basal and mid inferolateral mid inferior hypokinesis, right ventricular chamber size, and free wall motion are normal. The aortic valve is mildly thickened. No aortic regurgitation is seen, moderate mitral regurgitation, and borderline pulmonary artery systolic hypotension are also visible. DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction status post catheterization with stent. 2. Native three vessel coronary artery disease. 3. Moderate diastolic ventricular dysfunction. 4. Mild systolic dysfunction with ejection fraction of 40%. 5. Hypercholesterolemia. RECOMMENDED FOLLOWUP: He must see doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**] as soon as possible. DISCHARGE MEDICATIONS: 1. Atorvastatin 20 mg po q day. 2. Ranitidine 150 mg po bid. 3. Aspirin 325 mg po q day. 4. Plavix 75 mg po q day x9 months. 5. Lisinopril 5 mg po q day. 6. Metoprolol 25 mg po bid. 7. Nitroglycerin prn. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 2918**] MEDQUIST36 D: [**2113-5-24**] 10:57 T: [**2113-5-29**] 13:34 JOB#: [**Job Number 40148**] ICD9 Codes: 4019, 2720, 3051
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Medical Text: Admission Date: [**2102-1-17**] Discharge Date: [**2102-3-5**] Date of Birth: [**2039-4-20**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Consulted by ED for change in mental status, ?seizure Major Surgical or Invasive Procedure: brain biopsy History of Present Illness: Pt is a 62 year old man with a hx of diabetes, HTN, high cholesterol, former cocaine use, and multiple strokes who presents with altered mental status and question of seizure. He was transferred from [**Hospital **] hospital for higher level of care. On the day of admission, he was at rehab when he was found minimally responsive with eyes open with leftward gaze and bilateral UE and left LE "twitching". He was diaphoretic and FSG = 89 (apparently low for him). 1mg glucagon given at 9:15AM. At 9:30, FSG 126 BP 200/110 HR 122. He was given nitropaste at 10AM. EMS was called and he was brought to [**Location (un) **] ED. In ER, he was found to be febrile and unresponsive. His blood pressure was elevated 200's/100's and he has another episode of "extremity shaking". He rec/d ativan 1mg x2, lopressor, Levoflox, CTX (2g), and was put on a labetalol drip. Neurology was consulted and felt that seizures may be due to hypertensive urgency vs new stroke causing secondary HTN. Recommended head CT (not done) and LP (Tube 1: 196 RBC 4 WBC, Tube 4: 7RBC 3WBC, no diff, prot/gluc pending). He was transferred here for ICU level of care. In our ED, he was loaded with dilantin and given an additional ativan for another episode of questionable seizure activity. He was intubated for airway protection prior to imaging. He has a history of multiple strokes in the past and has been followed at multiple institutions. He was last seen here by Dr. [**Last Name (STitle) **] for follow up in [**2101-1-25**] after his [**10-30**] admission for multiple strokes thought to be secondary to small vessel disease. At that time, he was found to be abulic, with left hemiparesis and right leg plegia. Strength in the left leg was noted to be 3+/5 at that time. He was hyperreflexic in and toes are upgoing bilaterally. He was continued on Aggrenox for stroke prevention. According to his family, he has had multiple other strokes since this time and was transitioned from Aggrenox to Plavix at some point. He was recently admitted to Caritas [**Hospital3 **] [**12-28**] for acute stroke (p/w decreased verbal output) and was found to have left insular and and left aca/mca watershed infarcts. Aspirin was added to Plavix and Norvasc was increased for HTN. Since that time, he has been doing well at rehab. He walks with a walker at baseline and is talkative and interactive with his family. His family is not aware of any recent fevers, chills, headache, cough, shortness of breath, N/V, or diarrhea. They say that they last saw him yesterday and he appeared "fine". He has not had a seizure before although his daughter noted that he had an episode of whole body shaking from fever (?rigors) in the setting of a UTI in the past. Past Medical History: -Hypertension -Diabetes -High cholesterol -History of cocaine abuse -Multiple strokes in the past attributed to drug use and noncompliance with his medical regimen: [**11-16**] admitted for Right leg weakness showed left parietal and right middle cerebral peduncle infarcts. MR also showed basilar artery stenosis and old right pontine and midbrain infarcts. -s/p knee surgery Social History: From [**Country 3594**] originally. Currently lives in a nursing home/rehab after his last admission to [**Hospital3 **] 2 weeks prior to this admission. Former cocaine and MJ use. Denies tobacco use. Quit ETOH last year. Former high school teacher, taught automotive class. Family History: Mother had a stroke in her 40's; HTN; DM Physical Exam: Exam: (prior to intubation) T: 101.8 HR98-125 BP 150-185/80-109 RR16 O2 Sat 100% (on NRB) Gen: Eyes closed, minimally responsive, spontaneously moving left arm and leg semipurposefully. HEENT: NC/AT, dry oral mucosa, +blood on lips, but cannot open mouth as pt has jaw held shut. Neck: rigid CV: Tachy, Nl S1 and S2 Lung: Clear to auscultation anteriorly Abd: +BS soft, non-distended Ext: No edema Neurologic examination: Mental status: Unresponsive, does not open eyes to verbal or tactile stimulation. Grimaces to noxious stim and moves his left side to noxious stim. Doesn't follow commands. . Cranial Nerves: No blink to threat bilaterally. Pupils: 3mm briskly reactive bilaterally. Roving eye movements with left gaze preference, is readily able to cross midline to right. +corneal bilaterally, VOR intact, Grimaces to nasal tickle: face appears asymmetric, with decreased movement of the left face. Unable to assess gag. . Motor: Normal bulk bilaterally. Tone normal. Withdraws in all 4 extremities, but right leg is more sluggish than other extremities. . Sensation: Grimaces in all 4 extremities. . Reflexes: B T Br Pa Ach Right 2 2 2 3 clonus Left 3 3 3 3 clonus . Toes upgoing bilaterally Coordination: unable to assess Pertinent Results: . [**2102-1-17**] 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2102-1-17**] 06:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [**2102-1-17**] 06:10PM SED RATE-38* [**2102-1-17**] 06:10PM CRP-3.1 . [**2102-1-17**] 06:10PM PT-14.4* PTT-23.5 INR(PT)-1.3* [**2102-1-17**] 06:10PM PLT SMR-NORMAL PLT COUNT-412 [**2102-1-17**] 06:10PM NEUTS-88.7* BANDS-0 LYMPHS-8.7* MONOS-2.1 EOS-0.1 BASOS-0.3 [**2102-1-17**] 06:10PM WBC-16.6*# RBC-3.96* HGB-11.6* HCT-33.2* MCV-84 MCH-29.3 MCHC-34.9 RDW-15.2 . [**2102-1-17**] 06:10PM cTropnT-<0.01 [**2102-1-17**] 06:10PM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-4.7* MAGNESIUM-1.8 [**2102-1-17**] 06:10PM LIPASE-21 [**2102-1-17**] 06:10PM ALT(SGPT)-19 AST(SGOT)-26 CK(CPK)-172 ALK PHOS-187* AMYLASE-136* TOT BILI-0.2 [**2102-1-17**] 06:12PM LACTATE-3.0* [**2102-1-17**] 09:47PM LACTATE-5.7* . [**1-17**]: CXR: No radiographic evidence of pneumonia. . CT head [**1-17**]: No acute intracranial hemorrhage or mass effect. Small wedge- shaped hypodensity in the left frontal lobe may represent a chronic infarct but is new compared to [**2100-11-11**]. MRI/MRA head with and withou gad; [**1-18**]: Exam compared to prior study of [**2100-11-11**]. FINDINGS: There is a focus of abnormal diffusion in the region of the posterior limb of the internal capsule and thalamus on the left side with abnormal signal on the T2-weighted sequence, consistent with subacute infarction. There are abnormal signal foci in the anterior insula on the left and in posterior frontal sulci with contrast enhancement consistent with relatively recent infarction. There is some increase in signal in this posterior frontal cortical region on the nonenhanced T1-weighted sequence consistent with laminar necrosis. There are multiple abnormalities in the basal ganglia, periventricular white matter and centrum semiovale unchanged from previous examination consistent with remote lacunar infarction and microvascular angiopathy. There is mild prominence of ventricles and sulci consistent with mild brain atrophy. There is no evidence of a focal extra- axial lesion or fluid collection. There is increased signal in the right maxillary sinus consistent with sinus disease unchanged from prior study. The appearance of the left maxillary sinus has improved since previous exam. IMPRESSION: Recent infarctions of varying age in the left basal ganglia, thalamus, insula region and frontal cortex as described. MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES [**1-18**]: Exam compared to prior study of [**2100-7-9**]. There is decreased visualization of the A1 portion of the right anterior cerebral artery compared to the previous examination. This may represent progressive atherosclerosis or could represent a technical issue. The irregularity of the distal basilar artery is not well visualized on the present examination which again could be technical in nature. There is persistent decreased visualization of the right posterior cerebral artery unchanged from previous examination. There is persistent irregularity of the M1 portion of the left middle cerebral artery. IMPRESSION: Findings consistent with atherosclerosis involving in particular the left middle cerebral artery and the right posterior cerebral artery. There may also be some progressive disease involving the A1 portion of the right anterior cerebral artery. . MRI brain with and without gad [**1-23**]: Multiplanar T1- and T2-weighted images of the brain was obtained without and with intravenous gadolinium administration. Comparison is made to the prior recent MRI exam from [**1-17**], [**2101**]. There is persistent area of restricted diffusion involving the posterior limb of the left internal capsule abutting the left basal ganglia which is slightly larger in size, most likely consistent with evolution of the previously seen subacute infarct. There is moderate dilatation of the lateral ventricles. Chronic periventricular T2 hyperintensities are noted consistent with chronic microvascular ischemic or gliotic changes. There is an area of subtle enhancement involving the left frontal lobe consistent with an area of recent infarction, probably a few weeks old. An area of enhancement is also noted in the left subinsular region which also represents the sequelae of prior ischemic event or infarction. There is normal enhancement seen along the superior sagittal sinus which appears to be patent. Chronic mucosal thickening is noted within the paranasal sinuses, unchanged in appearance since the previous exam. There are old infarcts involving the brainstem and the right aspect of the pons. IMPRESSION: Evolving areas of infarction involving the left frontal lobe and the left subinsular region. Progression of the previously seen subacute infarct involving the posterior limb of the left internal capsule. MAGNETIC RESONANCE VENOGRAPHY: 2D time-of-flight magnetic resonance venography was performed. There is normal signal seen along the superior sagittal sinus which is patent. The visualized internal cerebral veins, transverse and straight sinuses are patent. There is no evidence for venous sinus thrombosis. IMPRESSION: Unremarkable magnetic resonance venography with normal signal and patency seen involving the superior sagittal sinus. . MRA OF THE CIRCLE OF [**Location (un) **] [**1-23**]: 3D time-of-flight MRA of the circle of [**Location (un) 431**] was performed. Comparison is made to the prior examination of [**2102-1-17**]. There has been further reduction of signal involving the entire basilar circulation suggestive of worsening thrombotic disease versus spasm of the vessel itself. There is significantly decreased attenuation and signal involving the middle cerebral circulation, left greater than right with diminished signal along the M1 segment of the left MCA. The findings could represent further embolic disease versus further thrombosis of the middle cerebral circulation. There is also attenuation of the proximal A2 portion of the anterior cerebral artery. IMPRESSION: Further reduction of signal involving the basilar circulation and the middle cerebral arteries in comparison to the previous exam of [**2102-1-17**], most likely indicating worsening thrombotic disease and occlusion of these vessels. There is near occlusion of the left MCA in comparison to the previous exam. Further followup is suggested as clinically indicated. . EEG [**1-18**]: This is an abnormal portable EEG due to the presence of a slow and disorganized background. This finding suggests an encephalopathic pattern most likely due to medication effect. There were no lateralizing or epileptiform abnormalities seen. . EEG [**1-22**]: This is an abnormal EEG due to the presence of diffuse background slowing and generalized bursts of mixed frequency delta and theta slowing. No focal or epileptiform features were observed. This EEG is most common with encephalopathy. Common causes of encephalopathy are medications, metabolic causes and infectious processes. Encephalopathies can obscure focal findings. . ECHO [**1-19**]: The left atrium is elongated. 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2100-7-13**], there is no significant change. [**1-19**]: CSF: NEGATIVE FOR MALIGNANT CELLS. Rare lymphocytes and monocytes. WBC RBC Polys Lymphs Monos Eos 21 187* 17 68 15 21 1890* 412 50 7 1 . TotProt Glucose 42 94 . PROTEIN ELECTROPHORESIS CSF-PEP neg . HSV-PCR negative BRAIN Bx RESULTS: Acute ischemic encephalopathy. Scattered eosinophilic, crenated cortical neurons. Perivascular hemosiderin and arteriolosclerosis. No significant inflammation. No diagnostic infectious process. No intravascular lymphoma or other diagnostic neoplasia. #2, RIGHT FRONTAL DURA: Dense connective tissue. No significant inflammation. CT CHEST [**1-31**]- had requested to be performed with contrast to r/o malignancy, but performed WITHOUT contrast. IMPRESSION: Small bilateral effusions and bibasilar atelectasis. No evidence of malignancy. CT NECK [**2-6**] - performed for ?neck abscess IMPRESSION: Confluent soft tissue density within the anterior inferior neck, with posterolateral displacement of the thyroid to the left. The confluent soft tissue density may represent hematoma versus edema. No areas of active extravasation are identified on this study. Underlying neoplasm cannot be entirely excluded. CTA abdomen/pelvis to look at kidneys [**2-7**]: CONCLUSION: 1. Normal sized kidneys both supplied by a single renal artery, which appears widely patent and normal in caliber. No evidence of renal artery stenosis. Normal adrenal glands. 2. Moderate amount of intraabdominal and pelvic hematoma most likely following recent PEG placement. The intraabdominal component anteriorly included on the preceding non-contrast CT of [**2102-2-6**] is no larger than on previous CT. Repeated CT abdomen/pelvis [**2-14**]: IMPRESSION: 1. No evidence of new intraperitoneal or retroperitoneal hemorrhage. 2. Interval decrease in the amount of the high-density fluid within the pelvis. 3. Bilateral small pleural effusions and associated atelectasis. 4. Mixed sclerotic and lytic changes within the left iliac bone not typical for Paget's disease. Metastatic disease or chronic infection cannot be completely excluded. Recommend correlation with PSA and bone scan. CT head [**2-13**] repeated for ?new infarcts: NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by patient motion. The ventricles are unchanged in size and appearance compared to the recent MR exam. There is no evidence of acute intracranial hemorrhage or shift of the normally midline structures. Multiple areas of infarction are again noted, particularly in the left frontal lobe and subinsular cortices bilaterally. An evolving (subacute-chronic) infarct is again noted in the left putamen. No new areas of major vascular territorial infarction are appreciated on today's exam. The visualized paranasal sinuses are well aerated. There is partial opacification of right mastoid air cells, which may be related to fluid, mucosal thickening, or both. Post-surgical changes of the right frontal calvarium are noted. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Multiple old infarcts noted, and evolving infarction of the left putamen again appreciated. No new areas of major vascular territorial infarction are appreciated on today's study. CT ABDOMEN W/CONTRAST [**2102-3-3**] 4:24 PM The lung bases demonstrate small bilateral pleural effusions with associated atelectasis. The liver, pancreas, spleen, adrenal glands are unremarkable. Right mid pole renal cyst, measures simple fluid. There is a left mid pole low-attenuation renal lesion which is too small to fully characterize. An NG tube tip is seen in the distal pylorus. A PEG tube is seen in place in the body of the stomach. There is markedly dilated small bowel with a clear transition point seen within the right lower quadrant in the distal small bowel seen best on coronal images on series 4, image 16. Distal to this transition point, there is collapse of the distal ileum and entire colon. Contrast is seen in the ascending and transverse colon, ending at the splenic flexure. However this contrast is of high density and is likley residual contrast from the prior feeding tube procedure of [**2-28**]. Contrast is seen in the proximal small bowel loops but is not present in the distal ileum at the the site of the focal transition. There is no free intraperitoneal air. Also seen in the midline in the site of previous hematoma, there is a focal fluid collection with rim enhancement just below the abdominal wall. Superinfection cannot be excluded. Within the subcutaneous tissue of the abdominal wall, there are several granulomas which may be secondary to prior injections. CT PELVIS WITH IV CONTRAST: The urinary bladder is catheterized. There is a foley catheter. The prostate and rectum are unremarkable. There is no free fluid. BONE WINDOWS: Again seen is a mixed sclerotic pattern seen predominantly within the left iliac bone unchanged compared to prior study, probably representing chronic fibrous dysplasia. IMPRESSION: 1. High grade complete small-bowel obstruction of the distal ileum with transition point in the right lower quadrant seen best on coronal images (series 4, image 16). Contrast in the colon is likely from prior exam as there is no contrast in the distal small bowel at the site of the focal transition. 2. Well-demarcated fluid collection just below the anterior abdominal wall in the site of previously seen hematoma. Superinfection cannot be excluded. 3. Mixed sclerotic appearance of left iliac bone, unchanged most consistent with chronic fibrous dysplasia. Brief Hospital Course: 62 yo man with a hx of HTN, DM, high cholesterol, and multiple strokes who presents with altered mental status and possible seizure at his rehab in the setting of hypertension and fever. Exam at admission was notable for minimal responsiveness, left gaze preference, and decreased movement of his right LE (old). . 1. Neuro/strokes: -Neuro exam throughout much of admission remained stable as follows: encephalopathic, not following commands, non-verbal, not-tracking; PERL, often has a left gaze preference (does not correlate with seizure on LTM), but can move eyes to either side; right visual field cut; R-facial droop, R-hemiplegia, limited spontaneous movement LUE and LLE, responding to noxious RUE with grimace, triple flexion RLE. Tone increased in the lower extremities. Bilateral upgoing toes. -MRI/MRA with/without gado upon admission: L-int. capsule infarct; multiple lesions on Flair (L>R) (see report in "results" section). -Workup performed to determine etiology - multiple past strokes were often related cocaine use and vasospasm; this was in differential, but tox screen was negative at admission. -Patient noted to be very hypertensive throughout much of entire admission - thought to be one possible etiology for new stroke -Patient was kept on ASA; aggrenox changed to plavix as aggrenox could not be crushed for NG tube; both were later held for anemia, then restarted when HCT appeared more stable. -MRV and MRI/MRA repeated [**1-23**]: MRV nl, MRI evolving infarct L-int. capsule, evolving infarct L-insular region; MRA near occlusion prox L-MCA, worsening basilar as well: restarted plavix and started amlodipine for vasospasm: this rapid detoriation also posed question of vasculitis -Started solumedrol 1g q24 hrs iv on [**1-25**], which was switched to Prednisone on [**1-28**] and eventually weaned off once brain bx neg for vasculitis. -Brain biopsy [**1-27**] (held plavix) to rule out vasculitis; post-op CT head with no complications -CT brain repeated [**2-13**] with evolution of left putamen infarct, mult other old infarcts, nothing new on scan. -Exam upon transfer to floor as follows: patient easily awakened, looking around room, but often with left gaze preference, spontaneously moving face but not following any commands even with miming; no blink to threat on right, + on left, perrlb 3->2, right facial droop, left arm and leg with spontaneous movement, right arm plegic with no w/d to stim, right leg with triple flexion to stim. Both toes upgoing. -Aspirin 325 and Plavix were initially used to treat the patient after his strokes, but they are being held as he is unable to take PO; they should be restarted when GTube can be used once again. -Would recommend neuro consult to help manage stroke/seizure issues. 2. Seizures: -EEG after admission: slow and disorganized background, no lateralizing or epileptiform abnormalities; repeat EEG [**1-21**]: slowing right fronto-temporal>left. -No seizures observed while in hospital for majority of hospital course in ICU; patient continued on dilantin, with goal of 10, but level very difficult to achieve, requiring frequent dilantin boluses. As no seizure activity, this was eventually allowed to trend down, with switch to [**Month/Year (2) 13401**] and wean of dilantin once [**Month/Year (2) 13401**] therapeutic. - Patient was transferred to floor on [**2-13**]. On day of transfer, some tonic posturing of left arm noted (versus agitation - associated with high blood pressure). For possibility that this was seizure (unclear), [**Name (NI) 13401**] was increased from 1000bid to 1500 mg [**Hospital1 **]. - Patient started having more brief partial onset secondarily generalized seizures consisting of turning of the head, face contortion, followed by tonic flexion of left elbow and the clonic jerking, all within less than 10 seconds per seizure. He was monitored on LTM, and found to have both clinical and subclinical events; furthermore, many events (ie "total body shaking") were not consistent with seizure, but rather agitation. Events that correlated with EEG activity involved left arm flexion and tonic posturing and left gaze deviation with tachycardia. - Dilantin was added and the patient continued to have several seizures in a day; therefore, depakote was added. Levels were bolused to try to maintain levels near 20 and 80 respectively but this was never achieved. Later free dilantin level was 2.0 with a total level of 10.8. - When ileus developed 4 days after depakote load and kept recurring, depakote was allowed to drift down, as it was felt to be contributing to the ileus and the elevated LFTs. Depakote was weaned to [**Telephone/Fax (3) 58581**] on the day of transfer, with plans to wean this further. -On the day of transfer to [**Hospital1 112**], seizure-like events were rare, occurring once every few days; VPA level was 50, and PHT level was 6.8, which was felt to be within goal based on a 20% free dilantin:total dilantin ratio. He was also continued on IV ativan for added seizure prophylaxis as he could not tolerate PO meds. -Seizures were thought to be related to ileus + sbo, and poor absorption of PO [**Hospital1 13401**]; when he is able to take PO meds by G-Tube, [**Hospital1 13401**] should be reconsidered. 3. GI/Small bowel obstruction -TF and GI prophylaxis were initiated as an inpatient. LFTs were normal. -As he required tube feeds, a PEG tube was placed. For days after the peg, the hematocrit dropped and the wbc count rose. He had a gastrograffin test with no extravasation of contrast per SICU team; they felt the site was not likely to be infected. He did undergo CT abdomen and pelvis, which revealed moderate hematoma (likely from PEG placement); this was felt to potentially explain the drop in HCT. The scan was repeated approximately one week later, and revealed no new hematoma, interval decrease in the size fo the high-density fluid within the pelvis (likely old hematoma), as well as bilateral small pleural effusions and atelectasis. -Several CTs of the torso had revealed: "Mixed sclerotic and lytic changes within the left iliac bone not typical for Paget's disease. Metastatic disease or chronic infection cannot be completely excluded. Recommend correlation with PSA and bone scan." This was not worked up. -Ileus developed with KUB confirmed dilated loops of small bowel on [**2-22**] and was treated with NGT to low wall suction. Surgery was consulted. He maintained bowel movements and flatus and ileus improved but recurred resulting in emesis on [**2-28**]. Repeat KUB showed multiple dilated loops of small bowel. Surgery was reconsulted and CT abdomen was done showing high grade small bowel obstruction with transition point noted at the distal ileum, with collapse of the ileum and colon distal to this point. A small amount of contrast was seen but was felt to be due to fluoroscopy 2 days earlier for NJ placement. Family was presented options of surgery versus conservative management and wished for transfer for surgical management of his bowel obstruction. -He has had G-tube to gravity and NGT to intermittent suction; NGT output on the day of transfer to [**Hospital1 112**] was 600cc overnight. All PO meds are being held for the time being. 3. Diabetes: -The patient was placed on FS QID + RISS; remained on and off insulin drip and sliding scale until his regimen was adjusted to avoid the insulin drip further. He was started on metformin and had better blood glucose control. When he was made NPO, he was continued on the insulin sliding scale only. . 4. HTN: -Hypertension was a major issue throughout admission with BPs as high as 280s systolic on occasion, (particularly with arousal and pain). -Goal SBP less than 180 via isosorbide mono, captopril increased, metoprolol continued and increased, amlodipine for vasospasm. He initially required a labetalol drip but was finally able to tolerate meds by G-tube. He ruled out for MI with serial enzymes. Echo [**1-19**] showed no change compared to [**2099**] with no major valve abnormalities and EF 55%. -Nephrology was consulted and recommended CTA kidneys which was negative; other w/u for underlying d/o including urine metanephrines, etc. negative. They also recommended continuing propofol initially for BP control, but this had the side effect of making him difficult to wean from the vent. -BP eventually under better control once clonidine introduced - propofol could be weaned to off, and eventually standing lasix was implemented with better blood pressure control. BP range decreased by [**2-17**] and only infrequently went as high as 200 systolic. Usual range was 140-180 systolic, on multiple medications including clonidine patch. He was transferred to the floor at this point. -When he was unable to tolerate PO BP meds, he was changed to a regimen of IV enalaprilat, lopressor, hydralazine, and lasix (low-dose, for electrolyte and fluid imbalance earlier in hospital course). He was previously on imdur 40 mg [**Hospital1 **], captopril 100 mg tid, hydralazine 25 mg qid, metoprolol 150 mg tid, and verapamil 80 mg tid, as well as lasix 20 mg [**Hospital1 **]. He was hypertensive to 180s on the day of discharge/transfer to [**Hospital1 112**]; we have been using lopressor and hydralazine prn in addition to his current regimen to control transient increases of blood pressure. . 5. Pulmonary: -The patient was initially intubated in ED for airway protection. A chest xray was initially negative, and repeated chest xrays showed mild congestion but no pneumonia. He was extubated on [**1-20**] and reintubated [**1-27**] following brain biopsy. He was difficult to wean because of his increased secretions, as well as the inability to wean off propofol without his blood pressure increasing above 200 systolic. -CT of the chest was performed to r/o pulmonary malignancy as a part of multiple repeat stroke workup - negative, but unfortunately performed without contrast -He had a trach placed, with the intention of weaning propofol. He developed an infection at the site of the trach, treated with vanco, and no surgical debridement. -When BP was under better control, he was weaned to trachmask, and transferred to the stepdown unit. . 6. ID: -He had developed fevers during the first month of his admission. This was worked up with multiple sets of blood cultures (all negative), and initial LP upon admission as follows: -Tube one: 4WBC (14 poly, 80L, 6 mono) RBC 196; tube 4: 3WBC(7 poly, 87L, 6 mono), RBC 7; prot 36; glc 81 (serum 120); gram stain negative; tending towards viral infection -He underwent repeat LP on [**1-19**]: OP 29cm; sent for cytology and viral panel Protein 42 Glucose 94 CSF-PEP: Pnd WBC 2 RBC 187 Poly 17 Lymph 68 Mono 15 EOs WBC 2 RBC 1890 Poly 41 Lymph 50 Mono 7 EOs 1 -ESR 38, CRP 3.1 (upon admission) -initial CXR neg; UA negative/UCx negative; Blood Cx x3 negative -CSF Cx: HSV-PCR negative (at [**Location (un) **]: [**Numeric Identifier 58582**]) and here. -He was empirically treated with Ceftriaxone, Vanco and Acyclovir until cultures, HSV PCR came back: d/c-ed [**1-21**]. -Initial CT abd/pelvis with contrast to r/o infection showed no pathology - By the beginning of [**Month (only) 958**], the WBC count was trending down and sputum cultures showed only moderate growth oropharyngeal flora -Inflammatory markers resent [**1-25**]: ESR 90, CRP 161.5, RPR, sent cryptococcus Ab CSF [**1-24**] - all negative -Developed elev wbc count on [**1-30**], which was monitored as he had no current signs of infection. -Following the PEG tube and Trach placement, WBC count went as high as 20s, and he had recurrence of fevers. He was treated with Levaquin and Flagyl for the possible source of infection being the PEG. CT of the abdomen did not reveal infection, but did show a retroperitoneal hematoma. After several days on this antibiotic, his neck was noted to be edematous and erythematous around the site of the trach, and trach site abscess or phlegmon was felt to be the source of the infection. He was treated with vancomycin for two weeks; this was discontinued before he was transferred to the floor. The neck was not debrided. -He had no further infectious issues while on the floor, and remained afebrile with a normal white blood cell count on the day of transfer. . 7. Heme: -He had periodic drops in hematocrit. He dropped to 22.4 on [**1-23**]; he received 2uPRBC; plavix and ASA were on hold; guaiac'ed stools (negative) and sent hemolysis labs, anemia labs. Hematocrit became more stable at 28. Iron was started once studies showed some iron deficiency anemia. B12 was normal. Iron was discontinued when he could no longer tolerate PO meds and NGt was to suction. . 8. FEN: -Renal consult was obtained for high blood pressure - see "CV" above. No evidence of renal artery stenosis, pheochromocytoma, or other neuroendocrine tumors by labs. Renal had recommended propofol for BP management, but as this prevented weaning, clonidine was eventually added with good effect. Lasix was also added for further diuresis, as he was net positive >27 L since admission and appeared edematous (though albumin and prealbumin also lower since admission). -PICC Line was placed for ease of access, and triple lumen was d/c'ed -Tube feeds were continued per nutrition recommendations; these were later held when he developed SBO. -TPN was started, and this should be continued after transfer to [**Hospital1 112**]. 9. Dispo: -He was in the neuro ICU (with the SICU team comanaging) for most of the admission -Full code per discussions with Daughter: [**Doctor First Name **] [**Telephone/Fax (1) 58583**]. However, family discussion was held later in the admission and he was changed to DNR/DNI, which his daughter and sister agreed upon. He was transferred to [**Hospital1 112**] for further workup of his GI issues (above). Medications on Admission: ASA 81mg Plavix 75mg qd Lopressor 150mg [**Hospital1 **] Zocor 40mg qd Zoloft 100mg po qd Lantus [**7-4**] Detrol 2mg qd Nexium 40mg qd Norvasc 10mg qd Capoten 50mg TID Imdur 90mg qd RISS Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous 4xd: SLIDING SCALE AS FOLLOWS: if BG <70, give [**11-28**] d50; if BG 71-150, do nothing; if BG 151-200 give 2 units regular insulin; if bg 201-250 give 4 units; if bg 251-300 give 6 units; if bg 301-350 give 8 units; if bg 351-400 give 10 units; if bg>400 give 10 units and call HO. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed: for pain/fever. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 13. Lorazepam 1-2 mg IV PRN seizure lasting more than 2 minutes, more than 2 seizures in one hour Please call HO if you need to give this. 14. Thiamine HCl 100 mg IV DAILY 15. Folic Acid 1 mg IV DAILY 16. Pantoprazole 40 mg IV Q24H 17. Phenytoin 150 mg IV Q8H 18. Metoprolol 10 mg IV Q4H WHILE NPO 19. HydrALAZINE HCl 10 mg IV Q6H WHILE NPO 20. Enalaprilat 2.5 mg IV Q6H GIVE WHILE PT NPO 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 23. Furosemide 20 mg IV DAILY 24. Lorazepam 1 mg IV QID GIVE WHILE PT NPO 25. Valproate Sodium 500 mg IV Q12H 26. Valproate Sodium 250 mg IV UNDEFINED in midday Discharge Disposition: Extended Care Facility: [**Hospital6 13753**] - [**Location (un) 86**] Discharge Diagnosis: Strokes Seizures Small bowel obstruction Ileus S/p trach trach site infection S/p PEG retroperitoneal hematoma Malignant Hypertension Akinetic mutism Discharge Condition: Stable exam - akinetic mute, hemiparetic - see discharge summary for details. Discharge Instructions: Transferred to [**Hospital1 112**] for further workup of small bowel obstruction. Followup Instructions: Please f/u with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] - ([**Telephone/Fax (1) 7394**] - call for appointment after discharge from hospital, or follow up with [**Hospital1 112**] neurology if seen and family prefers. Completed by:[**2102-3-5**] ICD9 Codes: 5119, 3051
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Medical Text: Admission Date: [**2117-6-7**] Discharge Date: [**2117-6-10**] Date of Birth: [**2056-4-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2108**] Chief Complaint: RUQ pain, jaundice Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: 61 yo M with h/o cholecystectomy about 7 years ago p/w RUQ pain, jaundice and fever. Saw his PCP prior to admission and was sent to ED for uncontrollable shaking and fever. He has been having intermittednt RUQ pain for the last few days, and jaundice for the last few weeks. He was initially seen at [**Hospital 1562**] Hospital for complaints of 2 days of rigors and fever and was noted to have common bile duct dilation on RUQ u/s to 12 mm and fever to 102. Also with elevated AST, ALT, bilirubin. Amylase and lipase wnl (47 and 47 at outside hospital). Also noted to have leukocytosis. He was given a dose of zosyn and toradol for pain control, as well as a 1L bolus of IVF for hypotension and transferred here for further workup and ERCP . In the ED, initial vitals were 97.6 71 90/58 16 100% RA. RUQ u/s done showing intra and extrahepatic biliary dilation with CBD measuring 1.3 cm diameter with no obstructive cause seen. Patient was given a dose of gentamicin 80 mg. He was also given about 3L of IV normal saline for systolic BP in 80s-90s, R IJ central line placed and levophed started as well with increase in pressures to 120s. ERCP team consulted in ED and recommended giving gentamicin and ERCP in AM. VS on transfer: 65 128/69 18 97% . On the floor, he has no complaints. Pain has resolved, no nausea, vomiting, diarrhea, constipation, headache, or other complaints. Has been having intermittent RUQ pain about once every 2 weeks x 2-3 years, but acutely worsened over the the past few days, with jaundice occuring over the past week. Review of sytems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Cholecystectomy ([**2112**]) Appendectomy Bipolar disorder Social History: live with wife, no [**Name2 (NI) **] contacts, smoked a pack per day x 30 years but doesn't smoke anymore, has not had EtOH in 18 years, no h/o IVDU Family History: no h/o GI disease, malignancy Physical Exam: Admission Physical Exam: General: Alert, oriented, no acute distress, jaundiced HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ttp in RUQ and RUL, nondistended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2117-6-7**] 09:30PM WBC-12.1* RBC-3.85* Hgb-11.6* Hct-33.3* Plt Ct-211 ALT-216* AST-157* LD(LDH)-182 AlkPhos-155* TotBili-5.7* DirBili-4.7* Glucose-107* UreaN-18 Creat-1.4* Na-142 K-4.2 Cl-111* HCO3-22 AnGap-13 Lactate-0.8 [**2117-6-8**] 05:18AM WBC-6.4 RBC-3.46* Hgb-10.5* Hct-31.5* MCV-91 Plt Ct-188 PT-13.7* PTT-30.0 INR(PT)-1.2* Glucose-86 UreaN-17 Creat-1.3* Na-145 K-4.1 Cl-116* HCO3-23 AnGap-10 ALT-172* AST-111* LD(LDH)-153 AlkPhos-138* DirBili-4.0* [**2117-6-9**] [**2117-6-9**] 05:35AM BLOOD WBC-5.4 RBC-3.82* Hgb-11.4* Hct-33.8* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 Plt Ct-220 [**2117-6-10**] 06:10AM BLOOD Na-145 K-4.1 Cl-109* [**2117-6-9**] 05:35AM BLOOD ALT-141* AST-67* TotBili-2.5* MICRO: Blood Cultures [**2117-6-7**] x 2 PENDING LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2117-6-7**] 9:41 PM Intra- and extra-hepatic biliary dilation with the common bile duct measuring up to 1.3 cm in diameter. The obstructing cause is not seen; however, the pancreatic duct is also visualized measuring at the upper limits of normal. CHEST PORT. LINE PLACEMENT Study Date of [**2117-6-7**] 10:49 PM Right internal jugular central venous catheter terminating in the proximal-to-mid SVC without evidence of pneumothorax. ERCP [**2117-6-8**] Impression: Large peri-ampullary diverticula Successful biliary cannulation A moderate diffuse dilation was seen at the main duct with the CBD measuring 13 mm. The intrahepatics were also moderatley dilated. Many round stones ranging in size from 7 mm to 12 mm were seen at the main duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. The sphincterotomy was performed to facilitate extraction of the stones. A CRE balloon was introduced for dilation and the diameter was progressively increased from 8 to 10 mm to extend the sphincterotomy. Multiple rounds stones were extracted successfully using a 9 -12mm biliary balloon [**Last Name (un) **]. A repeat balloon cholangiogram revealed no further filling defects in the bile duct. Some pus was seen exiting the duct once the stones were all cleared from the biliary tree. Otherwise normal ercp to third part of the duodenum Dx: Choledocholithiasis, cholangitis Recommendations: NPO overnight and assess for pain in the am. If no pain, advance diet as tolerated. Watch for bleeding, perforation, and pancreatitis. Continue IV antibiotics. Complete a total of 14 days antibiotics due to cholangitis. No need for repeat ERCP unless patient again develops obstructing stones evidenced by increasing LFTs, jaundice, RUQ. Please call Dr.[**Name (NI) 12202**] office at [**Telephone/Fax (1) 1983**] with any further questions or concerns. Please call the on call ERCP fellow at [**Telephone/Fax (1) 2756**] with any immediate concerns such as fever, abdominal pain, bleeding, following your procedure. Return to the ICU for ongoing. Brief Hospital Course: CHOLANGITIS: related to CBD stones, given broad spectrum antibiotics (vanc/zosyn) x 2 days and ERCP w/ sphincterotomy and stone removal. His symptoms and LFTs improved, he was afebrile on discharge and transitioned to PO cipro x an additional 12 days. Blood cultures were no growth to date at the time of discharge. DIABETES INSIPIDUS: Na of 146 when NPO in the setting of ERCP, he likely has diabetes insipidus given prior lithium use. He said that he thinks his nephrologist had discussed this with him. No formal testing was done to diagnose this but it seems to be the most likely cause, he will f/u with his nephrologist. Medications on Admission: Seroquel 25 mg [**1-19**] QHS Klonopin 0.5 mg [**Hospital1 **] Abilify 10 mg QHS Imipramine 50 mg QHS Lamictal 100 mg [**Hospital1 **] Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 2. quetiapine 25 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)) as needed for insomnia. 3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Cholangitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cholangitis (infection of your bile duct system), you underwent an ERCP to remove a stone from the bile ducts and will need to continue antibiotics for the next 12 days. Please avoid any aspirin, ibuprofen / aleve / motrin / advil / naproxen for the next 5 days. Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge from the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 14916**]. ICD9 Codes: 5849
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Medical Text: Admission Date: [**2171-2-4**] Discharge Date: [**2171-2-9**] Date of Birth: [**2111-11-28**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Tricor Attending:[**First Name3 (LF) 1406**] Chief Complaint: crescendo angina Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram [**2171-2-4**] insertion of intar aortic balloon pump [**2171-2-4**] urgent coronary artery bypass grafts (LIMA-LAD,SVG-OM,SVG-RI) [**2171-2-4**] History of Present Illness: This 59 year old white male has has several weeks of chest discomfort while walking. He had worsening symptoms at less exertion and underwentn catheterization to reveal double vessel disease. He then had unstable, rest angina after cath and an intra aortic balloon was placed with resolution of pain. Past Medical History: hypertension hyperlipidemia diverticulosis gout gastroesophageal reflux h/o renal stones Social History: Last Dental Exam: Lives with:Partner Contact:[**Name (NI) **] [**Name (NI) 35996**] (partner): [**Telephone/Fax (1) 35997**] Occupation:Works in upholstering Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-19**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Family History:Premature coronary artery disease- Father died of sudden cardiac death secondary to massive MI at age 61 Race:Caucasian Physical Exam: Pulse:76 Resp:20 O2 sat:100/RA B/P Right:118/67 Left:120/79 Height:5'7" Weight:210 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 [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit-none appreciated Right: Left: Pertinent Results: [**2171-2-4**] Cardiac Catheterization 1. Selective coronary angiography of this right dominant system demonstrated severe multivessel and LMCA disease. The LMCA had a 50-60% ostial lesion with dampening of the vatheter on engagement of the artery juts after the patient experience a vaso-vagal reaction. The LAD had severe diffuse disease proximally with a mid vessel occlusion (after S1) and reconsitution via right - left collaterals. The mid-distal vessel appeared reasonable for grafting. The ramus intermedius was a small diameter but long vessel with an 80% ostial lesion. The LCx was atretic in the AV groove with a major OM branch. The RCA had mild diffuse plaquing with a severe focal lesion in the ostium of a small (upper pole) PL. 2. Limited resting hemodynamics revealed normotension initially with the vaso-vagal reaction upon sheath insertion. This required atropine and dopamine but did eventually resolve. 3. At the end of the case the patient developed chest tightness. ECG showed no evidence of acute ischemia but because of significant coronary disease an intra-aortic balloon pump was placed. With insertion of the IABP sheath the patient had a second vaso-vagal reaction which was transient. [**2171-2-4**] ECHO PRE-CPB: The study is limited as poor gastric windows are obtainable. 1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with apical hypokinesis. 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The IABP tip is seen 3 cm below the LSCA. 6. There are three aortic valve leaflets. They are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: Again the gastric windows are not accessible. The patient is AV-Paced, on low dose phenylephrine. Unchanged biventricular systolic fxn. 1+MR, no AI. Aorta intact. Brief Hospital Course: Mr. [**Known lastname 174**] was admitted to the [**Hospital1 18**] on [**2171-2-4**] for further management of his chest pain. He underwent a cardiac catheterization which revealed severe three vessel disease. As he had chest pain during the procedure, an Intra-aortic balloon pump (IABP) was placed. He continued to have chest discomfort and thus the decision to bring him to surgery was made. He was evaluated and worked-up in the usual preoperative manner by the cardiac surgical service. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, his IABP was weaned and removed. He then awoke neurologically intact and was extubated. On postoperative day two he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service worked with him daily. He continued to make steady progress and was discharged home on postoperative four. Follow up appointments were given and precautions, restrictions and medications were discussed. Medications on Admission: CHLORPHENIRAMINE-HYDROCODONE 10 mg-8 mg/5 mL Suspension, Extended Rel 12 hr -1 tsp by mouth twice a day as needed for cough COLCHICINE 0.6 mg Tablet - 2 Tablets x1 for Gout attack Then 1 po q 1-2 hr PRN. Max 8 tablets / day. Give until relief, N/V, diarrhea or max dose reached; diarrhea likely will precede pain relie INDOMETHACIN Dosage uncertain LISINOPRIL 40 mg daily METOPROLOL SUCCINATE 25 mg Daily NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet sublingually As needed as needed for chest pain Take one SL NTG for exertional chest pain. [**Month (only) 116**] take a second pull in 5 minutes if needed. call 911 if CP persists OMEPRAZOLE 40 mg once a day PRN ROSUVASTATIN 20 mg Daily ASPIRIN 81 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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Take in morning with potassium. Disp:*7 Tablet(s)* Refills:*0* 4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. 5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain]. Disp:*40 Tablet(s)* Refills:*0* 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: coronary artery disease with unstable angina hypertension hyperlipidemia diverticulosis gout gastroesophageal reflux h/o renal stones 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 Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) 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 5) No lifting more than 10 pounds for 10 weeks 6) Take lasix and potassium in the morning for 1 week then stop. 7) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2171-3-14**] at 1pm Cardiologist: Dr. [**Last Name (STitle) 35998**] on [**2171-3-1**] at 3:20pm wound check on [**2171-2-14**] at 10:30 in [**Last Name (un) **] Office Building Please call to schedule appointments with: Primary Care: Dr.[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] [**Telephone/Fax (1) 133**]) in [**4-18**] 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** Completed by:[**2171-2-8**] ICD9 Codes: 4111, 4019, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5135 }
Medical Text: Admission Date: [**2118-10-10**] Discharge Date: [**2118-10-25**] Date of Birth: [**2070-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Altered mental status requiring intubation Major Surgical or Invasive Procedure: Intubation w/ mechanical ventilation History of Present Illness: The pt is a 48y/o M with PMH of Hepatitis C, inoperable HCC and alcoholic cirrhosis admitted with encephalopathy after being found unresponsive with an empty bottle of oxycontin nearby. Pt has a longstanding history of alcohol-induced cirrhosis and Hepatitis C with associated portal hypertension, varices, ascites and encephalopathy, and hepatocellular carcinoma. His most recent scans are notable for recurrence of his hepatocellular carcinoma following his radiofrequency ablation (5/[**2118**]). At his most recent oncology visit on [**2118-10-5**], he was found to have a rapid deterioration in his liver function and was felt not to be a candidate for further cancer-directed therapies. Per report, on the day of this admission, he was found to be unresponsive by his family and was taken to [**Hospital3 **]. There he was intubated for airway protection in the setting of a GCS of 8. CT A&P demonstrated an advanced tumor of the left lobe of the liver and abdominal varices. RLL consolidation consistent with PNA was also seen. CT Head negative for acute process. He was sent to [**Hospital1 18**] for further managemnt. He was given zosyn and clindamycin as treatment for his pneumonia. OG tube showed brown aspirate and he was given zantac for GI protection. On arrival to [**Hospital1 18**], T 95.9, HR 91, BP 136/96, RR 18. He was given 1 L NS and transferred to MICU. Past Medical History: 1. Cirrhosis Child's class C, complicated by varices, encephalopathy, and ascites. 2. Hepatitis C secondary to IV drug use. 3. Hepatocellular carcinoma status post RFA in [**2118-5-5**]. 4. Alcohol abuse, hx of DTs. 5. Polysubstance abuse with cocaine & heroin. 6. Nephrolithiasis. 7. Chronic back pain status post motor vehicle accident with multiple rib fractures. 8. Depression. Social History: The patient is currently living in a trailer on his mother's property in [**Location 23962**]. Social stressor is that his mother is going to kick him out and he needs to find a new location for his trailer. The patient is currently smoking 2 packs per week, has significant tobacco history of 1 to 2 packs per day x 30 years. Alcohol use per HPI. No current IV, illicit or herbal drug use. He is not currently sexually active. He is on disability. Recently broke up with his girlfried, which is an additoinal stressor and contributed to his increased drug and alchohol use. Family History: He does not know of any liver disease or colon cancer. Father with a history of alcoholism Physical Exam: VS - Temp 97.5, BP 140/85, HR 83, R 18, O2-sat 100% RA GENERAL - Chronically ill appearing man, Comfortable HEENT - Mild scleral icterus, No JVD, MMM, OP clear LUNGS - CTA bilat HEART - RRR, III/VI Systolic murmur at apex ABDOMEN - Moderately distended, + shifting dullness, no HSM, NT, no rebound/guarding EXTREMITIES - WWP, 3+ pitting edema of LE's, 2+ peripheral pulses (radials, DPs) SKIN - multiple spider angiomas on chest NEURO - No asterixis, A/OX3 Pertinent Results: [**2118-10-10**] 06:15PM BLOOD WBC-10.7 RBC-3.00* Hgb-10.4* Hct-29.3* MCV-98 MCH-34.6* MCHC-35.4* RDW-18.6* Plt Ct-223# [**2118-10-11**] 05:05AM BLOOD WBC-10.3 RBC-2.48* Hgb-8.6* Hct-24.5* MCV-99* MCH-34.7* MCHC-35.2* RDW-18.9* Plt Ct-192 [**2118-10-11**] 01:49AM BLOOD PT-26.8* PTT-39.1* INR(PT)-2.7* [**2118-10-10**] 06:15PM BLOOD Glucose-128* UreaN-39* Creat-1.1 Na-126* K-3.3 Cl-92* HCO3-26 AnGap-11 [**2118-10-11**] 05:05AM BLOOD Glucose-79 UreaN-41* Creat-1.3* Na-131* K-3.3 Cl-100 HCO3-23 AnGap-11 [**2118-10-10**] 06:15PM BLOOD ALT-39 AST-154* AlkPhos-119* TotBili-11.2* [**2118-10-11**] 01:49AM BLOOD Ammonia-140* [**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-10**] 06:24PM BLOOD Lactate-1.9 [**2118-10-10**] 11:53PM BLOOD Lactate-1.7 [**2118-10-10**] CXR The ET tube is seen in situ with its tip approximately 13 mm from the carina. The NG tube is seen traversing the gastroesophageal junction and following a course towards the stomach. There are bibasal effusions along with atelectasis/probable consolidation at the lung bases. Follow up with AP and lateral chest radiographs would be helpful to assess for atelectasis vs. consolidation. There is apparent deformity of the left humeral head which is not well visualized and if there is suspicion of trauma to the left shoulder joint, dedicated views of the left shoulder would be helpful. [**2118-10-12**] Abd U/S 1. Cirrhosis and large infiltrative mass in the left lobe of the liver consistent with patient's known hepatocellular carcinoma. There is probable new tumor ingrowth into the left portal vein which is non-occlusive. 2. Moderate ascites [**2118-10-22**] 06:32AM BLOOD WBC-9.8 RBC-2.23* Hgb-8.3* Hct-24.4* MCV-110* MCH-37.4* MCHC-34.1 RDW-21.3* Plt Ct-106* [**2118-10-17**] 05:30AM BLOOD Neuts-76.6* Lymphs-15.4* Monos-6.1 Eos-1.6 Baso-0.4 [**2118-10-22**] 06:32AM BLOOD PT-24.8* PTT-42.4* INR(PT)-2.4* [**2118-10-10**] 09:45PM BLOOD Fibrino-257 [**2118-10-24**] 05:20AM BLOOD Glucose-104 UreaN-8 Creat-0.7 Na-132* K-2.7* Cl-103 HCO3-22 AnGap-10 [**2118-10-22**] 06:32AM BLOOD ALT-39 AST-102* LD(LDH)-402* AlkPhos-94 TotBili-7.8* [**2118-10-24**] 05:20AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.3* [**2118-10-17**] 05:30AM BLOOD %HbA1c-4.5* [**2118-10-12**] 05:09AM BLOOD Ammonia-38 [**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-10**] 11:53PM BLOOD Type-ART pO2-263* pCO2-39 pH-7.51* calTCO2-32* Base XS-7 Brief Hospital Course: The pt is a 48y/o M with PMH of Hepatitis C, HCC and alcoholic cirrhosis admitted with altered mental status requiring intubation for airway protection in the setting of suspected opioid overdose. Encephalopathy - The etiology of the patient's AMS was likely multifactorial involving end stage liver disease,?anoxic-insult given unknown down time, and opiate toxicity. Head CT negative at OSH. Upon admission, the patient was sedated and intubated. Pt began regimen of lactulose with >4BMs per day; with a decrease in NH4 from 140-->38 during his MICU stay. The patient's mentation improved during his admission, sedating medications were weaned down before extubation, and upon transfer out of MICU he was A&O to person and place and following commands. Pt. was on CIWA on transfer to floor and gradually cleared w/ less and less lorazepam. AT time of D/C he was A/Ox3 for several days. Respiratory failure/PNA ?????? Pt was intubated for unresponsiveness and a GCS of 8 at an OSH. CT of chest demonstrated RLL consolidation c/w possible aspiration PNA. Upon admission to the MICU, the patient was still intubated and sedated with propofol. Empiric zosyn was started for coverage of aspiration PNA which was changed to Unasyn on [**10-11**]. Repeat CXR on [**10-12**] showed improving lung fields with no signs of consolidation. Sputum GS grew GPCs in pairs, chains, and clusters on [**10-12**]. The pateitn was weaned off sedation on [**10-11**], extubated, and placed on 2LNC O2 with adequate oxygen saturation. Upon transfer, the patient was stable from a pulmonary standpoint. On the floor he did not have any pulmonary distress, but did spike a fever to 102.5 while on unasyn, so he was switched to vanc/levo/zosyn. His CXR was negative and he quickly defervesced so Abx were stopped after a short course. EtOH Cirrhosis/HepC/HCC ?????? Per recent history, the patient has a h/o EtOH abuse, his HCC is rapidly progressing and his liver function is rapidly declining. Upon admission, he had many stigmata of liver disease, both on exam (encephalopathic, scleral icterus, palpable mass in epigastric area c/w HCC mass in left lobe, mild ascites, spider angioma, extensive ecchymosis) and laboratory testing (elevated INR and abnormal liver enzymes). Pt was given vit Kx1 without change in his INR. The liver team was consulted and followed the patient during his stay. An U/S of RUQ on [**10-12**] showed no signs of portal vein thrombosis, cirrhosis and large infiltrative mass in the left lobe of the liver c/w patient's known hepatocellular carcinoma; there is probable new tumor ingrowth into the left portal vein which is non-occlusive. Pt. was offered hospice house but could not wait until this was available, he decided to leave AMA. Hx of heavy EtOH abuse - The patient was maintained on CIWA scale with 1mg of ativan per protocol in the MICU. The ativan was weaned to 0.5mg on [**10-12**] and completely off two days later. Pt. stated that he would continue to drink on d/c. Hypotension: On [**10-11**], the patient developed hypotension to 80/40's. Likely secondary to physiology of hepatic failure and possibly opioid toxicity. Given IVF boluses and bolus of albumin with good response. Home BP medications were held. Pt remained hemodynamically stable afterwards. Guaiac + NGT aspirate - pt with history varices and significant variceal bleeding, also EtOH abuse. Hct stable in mid-20's during admission and hemodynamics not c/w acute bleed. The patient was Type and Screened, adequate peripheral access was achieved and he was placed on a PPI and Hct remained stable for the duration of admission. Medications on Admission: CLONIDINE - 0.1 mg Tablet - 1 tablet twice a day FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 spray inhaled apply to each nostril twice daily FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a day LACTULOSE - 10 gram/15 mL Solutio- 30mls four times a day LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1 patch daily wear 12 hours on then take off MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime NADOLOL - 40 mg Tablet - 1 Tablet(s) by mouth daily NICOTINE - 14 mg/24 hour Patch 24hr - 1 patch daily PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 tablet PO twice a day SPIRONOLACTONE [ALDACTONE] - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day Medications - OTC FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth daily HEXAVITAMIN - Tablet - 1 tablet daily THIAMINE HCL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Folic Acid 1 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 Q12H (every 12 hours). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal twice a day. 8. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO every six (6) hours. Disp:*3600 ML(s)* Refills:*2* 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Hepatic encephalopathy Hepatocellular carcinoma Secondary alcohol abuse Hepatitis C Discharge Condition: Against medical advice Discharge Instructions: YOU ARE LEAVING AGAINST MEDICAL ADVICE. You have been diagnosed with hepatic encephalopathy and hepatocellular carcinoma. You will need to take your lactulose and Rifaximin exactly as prescribed so that you do not become confused again. We stopped your clonidine and nadolol because your blood pressure was low. We started you on a calcium supplement because your nutrition was poor. We increased your spironolactone to 200mg daily and your lasix (furosemide) to 80mg daily because your legs were swelling with fluid. We did not change any of your other medications. We started you on rifaximin to help stop you from getting confused. Please take all of your medications exactly as prescribed. If you have any confusion, fevers, chills, nightsweats, chest pain, shortness of breath, abdominal pain, bleeding, black tarry stools, vomiting blood or any other concerning symptoms call your doctor immediately or go to the emergency department. Followup Instructions: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2118-10-26**] 4:10 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2118-11-2**] 3:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-11-7**] 11:30 Completed by:[**2118-10-29**] ICD9 Codes: 5070, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5136 }
Medical Text: Admission Date: [**2138-10-6**] Discharge Date: [**2138-11-3**] Date of Birth: [**2062-3-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4616**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Left Craniotomy for resection of brain mass One CyberKnife treatment ([**2138-11-3**]) History of Present Illness: This is a 76 year old Creole speaking man who was found wondering around his senior center with new confusion. Family saw him last week and he was his normal self. He was taken by EMS to LMH and CT head showed a large Left frontal cystic lesion and a small area of edema in the left cerebellum. CXR showed a 5 cm left peri-hilar mass. He was given 10 mg of Decadron and was transferred to [**Hospital1 18**] for further management. Past Medical History: HTN, prostate CA s/p seed treatment and chemotherapy in [**2134**] with a urologist at [**Hospital3 **], GERD Social History: He is a right handed Creole man. His family reports that he was a marine and worked in metal welding. He has a long history of Tobacco use 1ppd but now smoke about 10 cigarettes daily. Family History: unknown Physical Exam: Upon Admission: PHYSICAL EXAM: O: T:99.7 102 137/79 18 99% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:[**4-13**] EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, interpretation by family. Orientation: Oriented to person, hospital, month and day Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-15**] throughout. Mild right pronator drift Coordination: normal on finger-nose-finger. At transfer, he speaks French-Creole, is oriented to self, follows commands readily, PERRL 4-2mm, Incision is clean/dry/intact. No drift, no clonus, reflexes are 2+ throughout. tongue is at midline. . DISCHARGE EXAM: VS: 98.6, 122/70, 90, 20, 95% RA, BG 103-241 General: Elderly man in NAD, comfortable, appropriate HEENT: Longitudinal scar over the left frontal area. PERRL, sclerae anicteric, MMM, OP clear Neck: Supple. Lungs: CTA bilat, no r/rh/wh Heart: RRR, nml S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no palpable masses or HSM Extrem: WWP, no c/c/e Skin: no concerning rashes or lesions Neuro: grossly non-focal Pertinent Results: [**2138-10-6**] 06:05PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE EPI-<1 [**2138-10-6**] 06:35PM PT-13.3 PTT-29.7 INR(PT)-1.1 [**2138-10-28**] LENIs - negative for DVT DISCHARGE LABS: [**2138-11-3**] 07:55AM BLOOD WBC-8.9 RBC-4.30* Hgb-12.2* Hct-37.1* MCV-86 MCH-28.3 MCHC-32.8 RDW-15.9* Plt Ct-339 [**2138-11-3**] 07:55AM BLOOD Glucose-87 UreaN-15 Creat-0.7 Na-136 K-4.3 Cl-95* HCO3-32 AnGap-13 [**2138-11-3**] 07:55AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.0 MRI brain [**2138-10-8**] 1. Left frontal and left cerebellar hemispheric enhancing lesions demonstrating marked slow diffusion. In the setting of the findings on the recent chest CT, these intracranial lesions would be most suggestive of metastases from primary small cell carcinoma of the lung. 2. Additional round focus of slow diffusion and relatively [**Name2 (NI) 15403**] [**Name (NI) 90467**] in the medial left temporal lobe, without convincing enhancement. Although a focal infarct, particularly embolic, is not entirely excluded, given the signal characteristics similar to the other lesions, above, this is concerning for a third metastatic deposit. 3. Relatively T1-hypointense regional bone marrow signal; while this may simply represent red marrow reconversion in response to anemia or systemic treatment, this finding should be correlated with clinical and laboratory data. CT torso:[**2138-10-7**] 1. Large 4.4-cm left perihilar mass concerning for primary lung cancer. There is associated left hilar and mediastinal lymphadenopathy. 2. Severe right hydronephrosis with cortical atrophy and a 9-mm calculus in the proximal right ureter. This represents a chronic process, likely secondary to UPJ obstruction from a crossing vessel. 3. No evidence of osseous metastatic disease CT head [**10-10**]: expected postoperative changes, moderate pneumocephalus. no hemorrhage MRI Brain with and without contrast [**10-11**]: expected postoperative changes with good resection of left frontal lesion. No acute infarcts. stable left cerebellar lesion. Lower Extremity Dopplers [**10-13**]: No right- or left-sided lower extremity DVT. Lower Extremity Dopplers [**10-20**]: No DVT of the bilateral lower extremity. [**2138-10-25**] Abd XR - Nonspecific air-fluid levels within non-distended loops of small and large bowel. Although nonspecific, this could potentially be related to gastroenteritis, considering the provided clinical history. 18 mm and 3 mm diameter calcifications located in the right abdomen may be related to renal and ureteral calculi considering presence of right ureteral calculus on CT of [**2138-10-7**]. Brief Hospital Course: This is a 76 year old Croele-speaking man who was found confused wandering around his Senior Center, and was taken to an OSH, where CT showed multiple brain lesions including a large left frontal lesion and a small area of edema in the left cerebellum. # Brain Mets: Originally admitted to neurosurgery under the care of Dr. [**Last Name (STitle) 65817**]. He was getting Q4 hr neuro checks on the floor. MRI brain was ordered as was a CT torso. He was on Keppra. Decadron was held for possible lymphoma. He was started on Bactrim for a slightly positive UA. Neuro-onc and neuro-radation services were consulted. MRI revealed a large Left frontal tumor and a small cerebellar mass. He had an fMRI and was taken to the OR with Dr. [**Last Name (STitle) **] on [**2138-10-10**]. The patient was extubated in the OR. Immediately post-operative the patient was opening his eyes to voice and moving all extremities. There was some soft tissue edema noted above the left ear and an Ace wrap was applied for 1 hour. The patient was started on Decadron 4 mg every 6 hours. Keppra was continued. Ancef was continued post operativly for three doses. The patient was brought to the SICU for recovery and a post operative Head Ct was performed which was consistent with expected post-operative change with some pneumocephalus. On [**2138-10-11**], a MRI with and without constrast was performed which was consistent with expected post-op changes. He was deemed fit for transfer to the floor and PT and OT consults were ordered. The patient was then transferred to the oncology service for cyberknife therapy. # Lung Mass: CT chest showing 4.4cm left peri-hilar mass concerning for primary lung cancer. Hematology-oncology consulted and wanted to see him as an outpatient after final pathology from brain lesion was confirmed. Discharged with outpatient follow up. # Right Renal Calculus: Urology consult was called for right renal calculus. Imaging indicates that this is a longstanding process for him and recommended nonurgent follow up as an outpatient. Urinalysis and urine culture were sent [**10-7**] and urine culture was negative. During his hospital stay he completed a 7 day course of Bactrim for WBCs in urine and altered mental status suspiscious for UTI. Discharged with outpatient follow up with urology. # Hyponatremia: On [**10-14**] the patient's serum Na was 130 and so he was placed on a fluid restriction and started on salt tabs. Patient was continued on fluid restriction on day of discharge, and salt tabs were discontinued. Labs to be rechecked 1 week post discharge. # Physical Therapy and Placement: He was seen and evaluated by physical therapy and occupational therapy who felt that he would benefit from rehab. He remained afebrile and stable during his course on the floor. Screening lenis continued to be done Q7 days and were negative as of [**10-20**]. # Goals of Care: Multiple family meetings occurred with social work, case management and the neurosurgery team. The family stated that they could not provide 24 hour supervision at home and evaluation for placement was initiated. On [**10-28**] patient had a LENIs for surveillance which was essentially negative. OMED was consulted to management while receiving cyberknife treatment. On [**10-30**] he underwent mapping for his cyberknife treatment and was transferred to OMED in stable condition. He completed 1 cycle of cyberknife on day of discharge and tolerated the procedure well. He will have 4 more treatments. TRANSITION OF CARE: -continuation of Cyberknife treatment as an outpatient. To be completed on [**2138-11-5**]. -continue 1L fluid restriction for treatment of hyponatremia. Hyponatremia has been improving with fluid restriction. Would re-evaluate the need for fluid restriction in the near future. Re-check sodium within 1 week from discharge. Medications on Admission: Norvasc 2.5 QD, Flomax 0.4mg QD, HCTZ 25 QD, Vit D 1000 Units QD, Prilosec 20 QD, APAP Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): Hold for SBP < 100. 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/ha. 13. insulin regular human 100 unit/mL Solution Sig: Per insulin sliding scale units Injection ASDIR (AS DIRECTED): Please see the attached sheet for the patient's regular insulin sliding scale. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Brain Tumor Lung Mass Large Kidney stone with hydronephrosis Hyponatremia Dysphagia Malnutrition hyperkalemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known firstname 90468**], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You presented to [**Hospital1 18**] for treatment of metastatic lung cancer to your brain. You had brain surgery followed by 1 day of CyberKnife therapy. You will continue to have CyberKnife therapy for another 4 treatments while you are outside fo the hospital. The following changes were made to your medication: ADDED: -Bisacodyl 10mg po daily -docusate sodium 100mg by mouth daily -Dexamethasone 2mg orally twice a day -Insulin sliding scale -Levetiracetam 750mg by mouth twice a day -Ondansetron 4mg po every 8 hours as needed for nausea -senna 1 tab by mouth daily -Vitamin D 800units by mouth daily -Trazadone 25mg by mouth as needed for insomnia -acetaminophen 325-650mg every 6 hours as needed for pain CHANGED: - Increased your dose of norvasc from 2.5mg daily to 5mg daily by mouth STOPPED: none We are in the process of arranging follow-up. The patient will need to have follow-up in the following clinics: 1. Hematology-Oncology Thoracics Division- please call ([**2138**] to arrange an appointment for a new patient at the next earliest available new patient appointment. The clinic is located in [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) 24**]. 2. Brain [**Hospital 341**] Clinic- please call ([**Telephone/Fax (1) 27543**] to arrange an appointment for 1-2 weeks after discharge. You will also need to follow-up with the neurosurgeons during this appointment. The clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. 3. The patient will also need to follow-up with Urology in [**1-12**] weeks from discharge for hydronephrosis and right kidney stone. To make an appointment, their number is [**Telephone/Fax (1) 164**]. Followup Instructions: We are in the process of arranging follow-up. The patient will need to have follow-up in the following clinics: 1. Hematology-Oncology Thoracics Division- please call ([**2138**] to arrange an appointment for a new patient at the next earliest available new patient appointment. The clinic is located in [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) 24**]. 2. Brain [**Hospital 341**] Clinic- You will be contact[**Name (NI) **] with this appointment after you complete CyberKnife Treatment. Please call ([**Telephone/Fax (1) 27543**] if you need to change this appointment date. The clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. 3. The patient will also need to follow-up with Urology in [**1-12**] weeks from discharge for hydronephrosis and right kidney stone. To make an appointment, their number is [**Telephone/Fax (1) 164**]. . Patient will need to have 3 more CyberKnife treatments for which he will need to return to [**Hospital1 18**] ([**Location (un) **]. [**Location (un) 86**]) to the [**Hospital Ward Name 332**] Basement ([**Hospital Ward Name 516**]) for treatment: Tuesday, [**2138-11-4**] at 9:15, Wednesday [**2138-11-5**] at 9:15, and Thursday [**2138-11-6**] at 10:15. ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5137 }
Medical Text: Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-6**] Date of Birth: [**2095-1-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: left hip fracture noted at [**Hospital1 **] s/p mechanical fall Major Surgical or Invasive Procedure: Left Hemiarthroplasty History of Present Illness: 74 yo female with who presented to [**Hospital1 **] s/p fall, found to have left subcapital fracture by CT of hip, transferred to [**Hospital1 18**] for further management. She initally was in an MVA last year when it was noted that she had a AAA on CXR. She then had an elective Thoracoabdominal aortic aneurysm resection/repair with hospital course c/b post-op respiratory failure, recurrent Afib, multiple bronchs, L sided lung collapse, trach on [**2169-1-26**] after failed extubation of [**2169-1-23**]. Trach was removed at Rehab, however she was readmitted in [**2-11**] with slight hyperfunction of false vocal cords, bilateral vocal cord immobility with ~1mm glottic gap requiring trach placement on [**2169-3-7**]. Pt was walking with her walker when she tripped on the carpet and fell onto her left L hip hitting her head at home. Denies LOC, HA, neck pain, CP, SOB, weakness, LH. Assisted to bed, able to bear wt for 2 steps. Pain localized to medial thigh with movement of LLE. Was brought to [**Hospital1 **], initially XRay unrevealing, CT though showed fx of L hip. Ortho evaluated in ED, plan to perform ORIF during this admit after risk stratified; NWB on L, no traction indicated, anticoagulate. Given extensive comorbidities, she was admitted to Medicine for periop management. Past Medical History: 1. Thoracic and abdominal aortic aneurysm, repair [**1-14**], c/b resp failure and trach. 2. Bilateral vocal cord paralysis, s/p repeat trach [**3-14**]. 3. Clostridium difficile positivity. 4. VRE positivity. 5. Postoperative atrial fibrillation requiring cardioversion. 6. Hypertension. 7. Type 2 diabetes. 8. Osteoarthritis. 9. Lower back pain. 10. Hypercholesterolemia. 11. Left Breast Cancer - s/p lumpectomy 12. Atrial fibrillation - this was first noted post op from the AAA repair. She was started on a BB and amio at that time then DCCV. She has not been on coumadin. . PAST SURGICAL HISTORY: -Thoracic/abdominal aortic aneurysm repair, [**2169-1-10**]. Social History: Retired RN, she was living at home at the time of the hip fracture. Her husband and daughter involved in her care. No tob, etoh, other drugs. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Globe reporter has been following her [**Last Name (un) 26796**] in [**Hospital1 18**] s/p her hip fracture Family History: DM, ? type - in mother Physical Exam: Vitals: T 98.4 HR 64 BP 130/61 RR 24 Sat 92% on mist O2 Gen: elderly caucasian woman with trach mask in place, breathing comfortably, A+Ox3, NAD HEENT: NCAT, no bruising or ecchymosis, PERRL, EOMI, MMM, OP clear Neck: supple, trach in place, no LAD CV: RRR nl s1 s2 no m/g/r Lungs: CTA b/l Abd: soft, nt, nd, +bs Ext: L medial thigh pain with external rotation Neuro: no sensory deficit in affected limb EKG: sinus, nl rate, nl axis, nl intervals, LAE, Q III, aVF; flat T's throughout limb leads and V4-V6, TWI in V1-V3, no sig change since prior EKG [**2169-3-7**] Pertinent Results: Admission labs: GLUCOSE-132* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 WBC-9.9 RBC-4.31 HGB-12.1 HCT-36.6 MCV-85 MCH-28.0 MCHC-32.9 RDW-16.5* NEUTS-84.0* LYMPHS-11.9* MONOS-3.5 EOS-0.2 BASOS-0.4 ANISOCYT-1+ MICROCYT-1+ PLT COUNT-179 PT-14.7* PTT-25.5 INR(PT)-1.5 CXR [**8-25**]: Cardiomegaly unchanged. The aorta is very tortuous and dilated as seen previously. There are postoperative changes in the left hemithorax with rib fractures/ressections, which is unchanged when compared to prior study. There is again noted a left retrocardiac opacity silhouetting the left hemidiaphragm, which is improved when compared to the prior study likely representing atelectasis or scarring. The right lung is grossly clear. The patient is status post tracheostomy. Tracheostomy tube appears to be in appropriate position. In the left upper quadrant, there are metallic wires and surgical clips. There is mild S-shaped scoliosis of the thoracolumbar spine with some mild dextroconvex thoracic component and levoconvex lumbar component. No evidence of pneumothorax. There is mild upper zone redistribution of the pulmonary vascularity, which could represent mild CHF. There are degenerative changes of the sternoclavicular joints bilaterally. HIP UNILAT MIN 2 VIEWS LEFT [**8-25**]: Unusual small lucency involving the medial cortex of the left proximal femur without clear fracture line identified. Knee film [**8-27**]: The alignment appears normal. There are some mild degenerative changes. No fracture is identified. Echo [**8-28**]: Normal regional with low normal left ventricular systolic function. Dilated ascending aorta. Mild-moderate pulmonary artery systolic hypertension. Compared with the prior study (tape reviewed) of [**2169-1-12**], the ascending aorta is minimally more dilated. Global left ventricular systolic function is similar. Micro: [**8-31**] sputum grew PSEUDOMONAS AERUGINOSA and ESCHERICHIA COLI, both pan-sensitive. VRE and MRSA screens were negative here. Has had a h/o of this in the past. Discharge labs: [**2169-9-5**] 05:32AM BLOOD WBC-9.3 RBC-3.82* Hgb-10.5* Hct-33.2* MCV-87 MCH-27.5 MCHC-31.7 RDW-15.4 Plt Ct-260 [**2169-9-4**] 05:52AM BLOOD PT-14.6* PTT-26.3 INR(PT)-1.4 [**2169-9-5**] 05:32AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-137 K-4.0 Cl-102 HCO3-27 AnGap-12 [**2169-8-25**] 07:00PM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE Brief Hospital Course: 74 yo F s/p fall, found to have left subcapital hip fracture by CT, admitted to medical service for risk stratification prior to ORIF. She then had resp failure following ORIF requiring MICU stay for diuresis and suctioning. She was transferred to the floor and has been recovering well. #) Left Hip Fx. She was kept non weight bearing until Left hemiarthroplasty on [**8-29**]. She has multiple cardiac risk factors making her intermediate risk and could achieve at least 4 mets prior to recent surgery. She had a normal perfusion on a Persantine MIBI preop in [**1-14**] at [**Hospital 620**] Hosp. A pre-op echo was preformed on [**8-28**] revealing normal regional wall motion with low normal left ventricular systolic function and mild-moderate pulmonary artery systolic hypertension. When compared with the prior study of [**2169-1-12**], the ascending aorta is minimally more dilated with similar global left ventricular systolic function. She received aggressive pulmonary toilet (chest PT, incentive spirometry, encourage coughing) prior to surgery to maximize her lung function. Her pain was well controlled with acetaminophen 1000mg q6h and oxycodone 5mg Q4H PRN prior to surgery. The cemented left unipolar hip hemiarthroplasty was done on [**8-29**] without complications. She was transfused 2 units of blood for post-op anemia. She received Lovenox SC BID for prophylaxis. She should remain on this until she has adequate activity. On discharge her wound was without evidence of infection and had some serous drainage. #) Post-op Hypoxemia - After the hip surgery, she was persistently and progressively hypoxemic and was requiring increasing suctioning. She was transferred to the MICU on [**8-30**]. Her MICU course was significant for low grade temps and increased sputum production. She was started on empiric Zosyn and Vanco for hospital-acquired PNA. Her O2 sats gradually improved and she made less secretions. In rehab, she will continue to need suctioning and incentive spirometry as well as to continue Zosyn/Vanc for a total of 7 days, ending on [**9-9**]. Her sputum culture grew pseudomonas (pansensitive), e.coli (pansensitive), and staph aureus (MRSA). . #) Pain management: She hallucinations with the IV Dilaudid given to her for her post-op pain. Therefore, her post op pain was controlled with Tylenol 1 gm q6 hrs and oxycodone 5 mg po prn. She also has chronic abdominal pain from her AAA surgery since [**Month (only) 956**]. The pain service was consulted who recommended starting neurontin 600 mg qhs. This should be titrated as tolerated. Neurontin is for chronic pain from thoracoabdominal aneurysm repair. At discharge, the Neurontin was controlling her pain somewhat. . #) CAD (no known CAD though multiple cardiac risk factors including age, DM, HTN). She had a normal stress test at [**Location (un) 620**] prior to aneurysm repair. She was continued on ASA 81mg qd, Simvastatin 10mg daily, and Metoprolol. . #) Mild dystolic disfunction. She was on lasix QOD prior to admission. This was not restarted at present, but if she continues to require large amounts of TM O2, then consider restarting. . #) AFIB: h/o postoperative atrial fibrillation requiring cardioversion in [**1-14**]. She was in NSR and well rate controlled with Amiodarone 400 daily and Metoprolol. She will f/u with Dr. [**Last Name (STitle) **] as an outpatient about this. She will likely need coumadin once she is no longer on Lovenox. . #) Trach care: She takes Guaifenesin prn, Atrovent neb prn, and needs aggressive pulm toilet. Scheduled outpt pulm f/u. She also needs ENT f/u (?h/o laryngeal dysfunction) . #) Type 2 diabetes: She was on Avandia 4mg daily prior to the surgery. However, she has bot been requiring insulin here on a RISS. She also has not been eating much. She may need to start the Avandia again in the future as she eats more. #) GERD: She is on Protonix 40 daily. #) Insomnia: We continued her on outpatient dose of Ativan 0.5mg qhs:prn #) Depression: Celexa 40mg qd. Her mood was hopeful on discharge. Medications on Admission: -APAP prn -Protonix 40 daily -Avandia 4mg daily -Amiodarone 400 daily -Aspirin 81 daily -Simva 10 daily -Bisoprolol 5mg daily -Senna prn -Colace qd -Celexa 40mg qd -Citracal 2 tabs [**Hospital1 **] -KCl 20 mEq qd -Gaifenesin prn -Vicodin prn -Lasix 20mg qod -Ativan 0.5mg qhs:prn -Atrovent neb prn Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours for 7 days: Last dose is on [**9-9**]. 2. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days: Last dose is [**9-9**]. 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q8H (every 8 hours). 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 7. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): Continue this until that patient is ambulatory or at least one month. Check weekly Cr and adjust the dose if necessary. 8. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for sbp < 110, hr < 55 . 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Max 4gm per day. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Give before washing or PT. 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 110 . 16. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR Injection ASDIR (AS DIRECTED). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 21. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 23. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day: Hold if NPO. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Left Hip Fracture Hypoxic respiratory failure pneumonia Secondary Diagnoses: S/P Thoracoabdominal aortic aneurysm repair Diabetes Hypertension Tracheostomy Discharge Condition: Good, O2 sat is 99% on 35% trach mask. All other vitals are normal. Discharge Instructions: Please call your primary care physician or return to the hospital if you experience chest pain, shortness of breath, worsening pain, or have any other concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] (PCP), [**Telephone/Fax (1) 8477**] in [**3-15**] weeks. Please follow-up the [**Hospital **] Clinic regarding your history of vocal cord paralysis. ([**Telephone/Fax (1) 6213**] Please follow-up in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic. ([**Telephone/Fax (1) 46112**] in [**3-15**] weeks. You have the following appointments scheduled: 1. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] (pulmonary) Where: [**Hospital 273**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-9-25**] 3:45 2. You have an appointment with Dr. [**Last Name (STitle) **] (cardiologist) on [**10-11**] at 11:00AM at the [**Location (un) 620**] office. Call [**Telephone/Fax (1) 4105**] if you are unable to make this. 3. You have an appointment with Dr. [**Last Name (STitle) **] (orthopedics) on [**10-12**] at 2:20PM on the [**Location (un) **] of the [**Hospital Ward Name 23**] Center at [**Hospital1 771**]. Call [**Telephone/Fax (1) 9118**] if you are unable to make this. ICD9 Codes: 2851, 5180, 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5138 }
Medical Text: Admission Date: [**2144-6-22**] Discharge Date: [**2144-7-7**] Date of Birth: [**2085-7-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4975**] Chief Complaint: Hypoxia, tachypnea Major Surgical or Invasive Procedure: Pericardiocentesis [**2144-7-5**] Fine needle aspiration of axillary node [**2144-6-30**] History of Present Illness: She is a 58-year-old [**Last Name (un) 18355**] resident with mental retardation, COPD, and no reported past cardiac history who presents for examination of distended belly, anemia and noted to have large pericardial effusion. Given mental retardation, interview with patient is extremely limited, and pt. minimally able to report symptoms. Pt. was admitted to [**Hospital3 **] after ECHO for workup of shortness of breath revealed moderate pericardial effusion without tamponade. Repeat ECHO 24h later showed stable-to-improved effusion and was discharged with plans for f/u ECHO in 14d. . Today, she presented to ED from NH with short episode hypoxia with recovered with albuterol and 02 and started on levofloxacin. also had KUB given some abdominal distension which reportedly was concerning for ileus. she was transferred to [**Hospital1 18**] for evaluation of a distended belly in setting of previous volvulus. In ED, she had a distended abd with minimal TTP, normal LFTs, pancreatic enzymes, without leukocytosis. She was guaiac negative with VSS and received Abdominal CT shich showed large pericardial effusion and presacral, perihepatic fluid, but no acute abdominal process. Given large pericardial effusion without previous comparisons, pt. was admitted for planned f/u ECHO in the AM. . Spoke with pt.'s brother and wife who report that 8 weeks ago, she started to become pale, have increased shallow breathinig, low grade temps to 100-101, with some abdominal distension that has been ongoing. Concern for GERD, COPD, UTI, all diagnosed within this time period. UTI tx. with levaquin. she has had no bloody or black stools per family until she starte Fe So4. Past Medical History: - Mental retardation of unknown etiology. - DJD. - Bilateral knock knees (talus valgus, pes planus). - Neurodermatitis. - Psoriasis. - History of obesity. - Status post volvulus and colonic resection. - Status post left oophorectomy. - Fe deficiency anemia 28.5 at [**Hospital3 **] 1 week ago - GERD Social History: Social history is significant for the absence or EtoH use. Patient is a resident at [**Last Name (un) 18355**] Center. Family History: Father died of prostate cancer, CABG, MIs; he also had colon CA. maternal aunt with ovarian and breast cancer. MI and CAD throughout family on both sides. Physical Exam: VS - T 99.8 137/65 HR 101, 95%RA, no pulsus Gen: middle-aged woman, NAD, repititious and perseverative, follows commands. Oriented x 1. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pale, no with sublingual pallor, MMM Neck: unable to assess JVP as pt. will not allow herself to be reclined. at 45 degrees, JVP flat. CV: PMI located in 5th intercostal space, midclavicular line. RR, borederline tachycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no wheezes or rhonchi. mild, occ. crackles at Right base. Abd: mildly distended, obese, with difficult abodminal exam as pt. denies belly pain but seems to grimace on palpation of RUQ>RLQ. No organomegaly noted in context of bodyhabitus and difficulty participating in exam. No abdominial bruits. Ext: 2+ pitting edema to knees (new per PA at bedside. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. + hirsutism Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ 2+ DP 2+ PT 2+ Neuro: CN II-XII grossly intact, moving all 4 ext. spontaneously, follows commands. Pertinent Results: Echocardiogram [**2144-6-23**] 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. Right ventricular chamber size and free wall motion are normal. Trivial mitral regurgitation is seen. There is a moderate to large sized circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There is substantial right atrial collapse and brief diastolic invagination of the right ventricular outflow tract (cine loops #15 and #28), consistent with low filling pressures or early tamponade. IMPRESSION: Moderate-to-large pericardial effusion with echocardiographic findings of early tamponade. . CT chest, abdomen & pelvis W/CONTRAST [**2144-6-29**] IMPRESSION: 1. Diffuse lymphadenopathy in the axillary, supraclavicular and mediastinal regions. Pulmonary nodules in the left lung apex is also noted. This is concerning for a neoplastic process. Differential diagnosis includes primary lymphoma or lung neoplasm. 2. Small pericardial effusion, decreased in size. 3. Bilateral small pleural effusions. 4. Splenic hypodensity. 5. Multiple hepatic subcentimeter hypodensities which are too small to characterize. 6. Cholelithiasis without evidence of cholecystitis. 7. Diffuse colonic distention up to 12.2 cm. No evidence of obstruction. . Pericardial fluid: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. CD45-bright, low-side scatter lymphoid cells comprise 23% of total analyzed events. Of these, B cells comprise approximately 15% of lymphoid-gated events and do not express aberrant antigens. Surface immunoglobulin expression is extremely dim-to-absent, precluding evaluation of clonality. T cells comprise approximately 80% of lymphoid gated events, express mature lineage antigens, and have a helper-cytotoxic ratio of 5.0. Natural killer cells represent approximately 3% of lymphoid gated events. No expansion of CD34-immunoreactive events are identified in the "blast gate". Monocytic cells comprise 6% of total analyzed events. . Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a lymphoproliferative disorder are not seen in specimen. Correlation with clinical findings and morphology (see 08-[**Numeric Identifier 78642**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . L axillary lymph node FNA Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells comprise approximately 9% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens.T cells comprise approximately 89% of lymphoid gated events and express mature lineage antigens (CD2,3,5,7). . Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by non-Hodgkin B-cell lymphoma are not seen in specimen. Review of cytospin slide (1096V-[**7-1**]) shows predominantly blood with admixed lymphocytes and numerous degenerated cells precluding definitive morphologic assessment. Correlation with clinical findings and morphology is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2144-7-6**] 07:00AM 9.4 3.38* 8.2* 28.6* 85 24.3* 28.7* 16.3* 389 [**2144-7-5**] 07:00AM 9.8 3.21* 7.8* 26.8* 83 24.3* 29.2* 16.5* 381 [**2144-6-25**] 01:36AM 9.6 3.73* 9.0* 29.9* 80* 24.2* 30.1* 15.5 410 [**2144-6-24**] 06:00AM 7.1 3.27* 8.2* 27.0* 83 25.0* 30.2* 15.8* 355 [**2144-6-23**] 10:30AM 10.5 3.40* 8.2* 27.5* 81* 24.2* 29.9* 15.7* 385 [**2144-6-22**] 04:30PM 8.8 3.46* 8.5* 28.2* 82 24.5* 30.1* 15.7* 381 . DIFFERENTIAL Neuts Lymphs Monos Eos Baso [**2144-6-30**] 04:20AM 89.0* 5.5* 4.5 0.9 0.1 [**2144-6-25**] 01:36AM 89.3* 5.6* 4.8 0.2 0.1 [**2144-6-22**] 04:30PM 89.1* 4.7* 4.6 1.5 0.2 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2144-7-6**] 07:00AM 101 13 0.3* 144 3.8 109* 29 [**2144-7-5**] 07:00AM 103 12 0.3* 141 3.6 107 26 [**2144-6-25**] 01:36AM 155* 10 0.4 144 3.6 110* 26 [**2144-6-24**] 03:50PM 109* 8 0.3* 143 3.9 109* 25 [**2144-6-23**] 10:30AM 126* 9 0.4 138 3.9 103 28 [**2144-6-22**] 04:30PM 117* 13 0.4 140 4.1 105 29 . ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos Amylase TotBili [**2144-6-30**] 04:20AM 27 19 292 129* 14 0.5 [**2144-6-22**] 04:30PM 14 14 245 134* 0.5 . OTHER ENZYMES & BILIRUBINS Lipase [**2144-6-30**] 04:20AM 15 . Brief Hospital Course: 58 yo F with mental retardation & h/o volvulus s/p colonic resection admitted with hypoxia & abdominal distention, also repeat echocardiogram given newly diagnosed pericardial effusion. . # Pericardial Effusion: s/p pericardiocentesis when early signs of tamponade seen on echocardiogram. Bloody pericardial effusion ~510cc's removed, ?malignancy. However no evidence of malignancy cells seen on flow cytometry as well as cytology. W/u already started at [**Hospital6 **] and so far studies negative except for elevated ESR, CRP & CA 125. Required overnight CCU stay after pericardial drain placed. Developed afib with RVR during stay. No evidence of reaccumulation of fluid seen on repeat echocardiogram or vital signs including nml pulsus. . # Atrial fibrillation with RVR: ?r/t pericardial effusion, worsened after pericardiocentesis during which time she stayed in the CCU given pericardial drain. She was treated with IV metoprolol, diltiazem then finally started on an emsolol drip for good control. This was weaned off with the onset of Verapamil which was uptitrated during stay. Metoprolol was also added for better rate control. The decision was made for no anticoagulation given bloody pericardial effusion, pt was continued on full strength aspirin. . # CT findings: Diffuse lymphadenopathy in the axillary, supraclavicular and mediastinal regions with pulmonary nodules in the left lung apex which were concering for neoplastic process. Pt underwent L axillary lymph node biopsy for concern of malignancy, ?Lung CA, lymphoma vs. other other cancers. However, pathology was not diagnostic. Pt with no prior colonoscopies or vaginal exams, however with nml mammograms & per report, last [**3-/2144**] nml. Guaiac negative stools during admission. Pt will need outpt evaluation for excisional lymph node biopsy vs mediastinoscopy for tissue diagnosis, if desired by the family. . # Abdominal distension: Appeared to be chronic, however worsened acutely during admission. No evidence of volvulus, cholecystitis or obstruction; imaging showed significant amounts of air with colonic distention, likely colonic ileus. Surgery was consulted and recommended endoscopic decompression per GI. However, GI recommended rectal tube placement with was effective in decompressing her abdomen. Pt initially made NPO, however resumed regular diet gradually. had no episodes of nausea or vomiting, however it was difficult to access abdominal pain. Per GI, pt will require intermittent decompression with rectal tube until ileus resolves. Also given possibility of malignancy, it's recommended that pt under colonoscopy as part of further workup. . # Microcytic anemia: c/w anemia of chronic disease; low retic count, however hematocrit stable. Guaiac negative stool x 1 in the ED. We continued iron supplementation, ?other stools guaiac'ed. . # Peripheral edema: Unclear if new, no evidence of chronic venous stasis and no significant ascites seen on CT despite abdominal distention. No evidence of proteinuria, however sl.lower albumin. ?heart failure, however no other evidence on PE. Liver function appears nml. . # Neurodermatitis: continued topicals # DJD: continued celecoxib & tylenol. . DNR/DNI Medications on Admission: - Multivitamin 1 tab - CaCo3 1250mg qdaily - Celebrex 100 mg twice a day - artifical tears PRN - Eucerin cream topical every day, - Vitamin E and Vitamin D ointments - Chlorhexidine topical - FeSo4 325 mg [**Hospital1 **] - started on levaquin 500mg at NH today given transient hypoxia . ALLERGIES: NKDA Discharge Medications: 1. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO bid (). 4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes. 5. Eucerin Cream Sig: One (1) application Topical once a day. 6. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: Two (2) Capsule PO twice a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 12. Verapamil 120 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8 hours). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Last Name (un) **] center Discharge Diagnosis: Pericardial tamponade s/p pericardiocentesis Atrial fibrillation with RVR Colonic ileus with abdominal distension s/p rectal decompression Mental retardation Degenerative joint disease s/p volvulus with colonic resection Discharge Condition: stable Discharge Instructions: You were admitted with pericardial tamponade and you underwent draining of the fluid around your heart. Laboratory analysis of the fluid did not reveal a cause. You were also found to have multiple enlarged lymph nodes in your chest. You had a biopsy of one of these nodes that was not diagnostic. You should speak with your doctor about having an excisional biopsy of one of your lymph nodes. During your hospitalization, you had abdominal distention from an ileus that resolved with rectal tube decompression which should be continued intermittently as needed. . MEDICATION CHANGES: - start Toprol XL 125mg po daily, Verapamil 180mg po q8h - Aspirin 325mg po daily Continue to take your other medications as prescribed. . Please call your PCP or come to the ED if you develop chestpain, shortness of breath or any other worrisome symptoms. Followup Instructions: Please f/u with PCP at the residence within 1 week of discharge. You should discuss whether you should have a mediastinoscopy or excisional biopsy of one of your lymph nodes. Completed by:[**2144-7-7**] ICD9 Codes: 2760, 496
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Medical Text: Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-8**] Date of Birth: [**2069-10-1**] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old male with known coronary artery disease status post percutaneous transluminal coronary angioplasty to the left anterior descending coronary artery in [**2130**] and [**2131**] status post non Q wave myocardial infarction in 10/89, presented with a two year history of increasing dyspnea on exertion, chest pressure. Persantine thallium was performed that showed anterior wall ischemia. He had a catheterization done on [**2143-1-1**] at an outside hospital that revealed three vessel disease with a normal EF. PAST MEDICAL HISTORY: Significant for type 2 diabetes, hypertension, coronary artery disease status post percutaneous transluminal coronary angioplasty to the left anterior descending coronary artery in [**2130**] and [**2131**]. He has had a history of chronic obstructive pulmonary disease. He is a former smoker. He quit two years ago. Bright red blood per rectum in [**10/2142**] transfused one unit. Had an ultimately negative esophagogastroduodenoscopy and colonoscopy. He is status post a _______ lens implant for contacts in his right eye and has a dilated right pupil. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: [**Year (4 digits) 37612**] 2.5 500 b.i.d. SOCIAL HISTORY: He is widowed and lives with his brother. REVIEW OF SYSTEMS: Revealed positive shortness of breath and dyspnea on exertion. Denies any claudication, history of gastrointestinal bleed, history of diabetes. PHYSICAL EXAMINATION: Temperature 98.6. Pulse 76. Blood pressure 146/76. O2 sat on 2 liters is 95 and 96% on room air with 88 and in no acute distress. Alert and oriented times three. Heart was regular rate and rhythm. 2+ radial pulses. Extremities warm and dry. Abdomen was benign. Respiratory was decreased breath sounds throughout with no wheezes or rhonchi. Gastrointestinal, abdomen was large, obese with positive bowel sounds, soft, nontender, nondistended. His lower extremities were notable for varicosities. Carotids without audible bruits. He was edentulous. ASSESSMENT/PLAN: The patient is a 73 year-old male with three vessel coronary artery disease who presented to Dr. [**Last Name (STitle) **] in need of coronary artery bypass grafting. He was therefore admitted and went to the Operating Room on [**2143-1-3**]. Preoperative laboratories were notable for a white count of 9000, hematocrit 35, platelets 307. Chemistries were unremarkable. BUN and creatinine of 18 and 1.2. Chest x-ray was negative except for changes consistent with chronic obstructive pulmonary disease. Urinalysis was negative. On the [**1-3**] the patient underwent a four vessel coronary artery bypass graft, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to obtuse marginal one, saphenous vein graft to obtuse marginal two and saphenous vein graft to the posterior descending coronary artery with Dr. [**Last Name (STitle) **] and Tavaf. He was transferred to the Cardiac Surgery Recovery Unit. He was alert and oriented and extubated on the night of the operation. His Swan was removed. His Lopressor and Lasix and aspirin were started on postoperative day number one. His diet was advanced. He was transferred to the floor. While on the floor the patient began aggressive physical therapy and was noted to have high O2 requirements secondary to poor pulmonary toilet as well as the patient's prior chronic obstructive pulmonary disease. Physical therapy worked with the patient aggressively. He was able to get to a level 3 or 4 by postoperative day number 3. Postop laboratories were notable for a hematocrit of 24 down from 35 preop. He had BUN and creatinine of 27 and 1.4 up from 1.0. The remainder of his electrolytes were within normal limits. He continued incentive spirometry and his ambulatory assistance with physical therapy as well as his diuresis. His diuresis was, however, changed to q day Lasix instead of the standard b.i.d. for the postoperative coronary artery bypass graft. The patient ultimately by postop day four the patient's hematocrit was 24 and stable. BUN and creatinine were normalized to 1.2. He was started on his [**Last Name (STitle) 37612**] and began to have more normal glycemia since his Lopresor was titrated to bring his heart rate down into the 70s. On discharge his examination was noted for a temperature of 99.0, pulse 72, regular in sinus, 107/65, 22 respiratory rate, 92% on 1 liter. Room air sats were 90%. He was in no acute distress. He had decreased breath sounds throughout. His sternum was stable with no erythema or exudate. He had staples intact. Chest tube wires were all removed. The patient had no drains. The remainder of his examination was unremarkable. The saphenous vein harvest on the right lower extremity was clean, dry and intact with no drainage as well. The patient was therefore deemed appropriate and stable for discharge to Pawtuckets near where his daughter lives. [**Name2 (NI) **] is a resident of [**Location **]. His follow up will include to see Dr. [**Last Name (STitle) **] one month from the time of discharge. He should have a wound check in one week. DISCHARGE MEDICATIONS: Lopressor 50 mg po b.i..d, Lasix 20 mg po q.a.m., Colace 100 mg po b.i.d., Zantac 150 mg po b.i.d., Percocet as needed for pain as well as Glucotrol Glucophage combination, which the trade name is [**Name (NI) 37612**] 2.5/500 b.i.d. DISCHARGE STATUS: Stable. DISPOSITION: To rehab. DISCHARGE DIAGNOSIS: Three vessel coronary artery disease status post coronary artery bypass grafting. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2143-1-8**] 08:46 T: [**2143-1-8**] 08:59 JOB#: [**Job Number 29838**] ICD9 Codes: 4111, 496, 412, 4019, 2720
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Medical Text: Admission Date: [**2118-1-28**] Discharge Date: [**2118-2-2**] Date of Birth: [**2056-1-1**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2009**] Chief Complaint: transfer for ERCP Major Surgical or Invasive Procedure: ERCP with sphincterotomy and stent History of Present Illness: 62 yo female w/ PMH sig for metastatic ovarian cancer diagnosed 10 years ago, s/p TAH and BSO, adjuvant chemo (last treated [**9-24**]), and peritoneal stripping in [**2110**], HTN, hyperlipidemia, who presented initially to [**Hospital6 33**] with malasie and transferred to [**Hospital1 18**] for ERCP. History is taken from chart review and sister. She initially presented to [**Hospital3 **] beginning of [**1-26**] and was diagnosed w/ an SBO and chronic cholecystitis discharged home on cipro. She represented [**1-25**] to the OSH with left flank pain, poor appetite, nausea and emesis. Per sister, + constipation, infrequent on/off emesis one episode bloody, no fevers/chills, ~100lb weight loss over one year. No shortness of breath/chest pain. . An abdominal US was sig for contracted gallbladder w/ wall thickening, sludge concerning for acute cholecystitis superimposed on chronic inflammatory changes, with mildly dilated CBD 9mm, and loculated ascites. MRCP was notable for dilatation of intrahepatic bile ducts and proximal CBD, with midportion of the CMB narrowed by extrinsic mass. She was guaic neg. Labs [**1-25**] sig for wbc 11, h/h 13.4/40.7, ast 306, alt 144, t bili 3.8, ap 776, lipase 215. Urine cx grew enterococcus faecium (prior urine cx [**1-21**] sig for enteroccocus R to amp/vanc/macrobid, S linezolid/gent) and she was started on linezolid. She was transferred to [**Hospital1 18**] for ERCP. Labs on transfer sig for down trending ast/alt 127/94, ap 585, but persistently elevated t bili 3.9. . ERCP was notable stricture at the common hepatic duct and bifurcation of main biliary duct w/ mild post-obstructive dilation compatible w/ extrinsic compression. A sphincterotomy was performed and biliary stent placed. She had brief episode of sbp in 90s, received 100mcg of neo. During procedure, patient had retained food in the stomach and with worry for aspiration in setting of possible SBO, she remained intubated. . Currently, patient is intubated and sedated. . Review of sytems: Unable to assess Past Medical History: -- Metastatic ovarian cancer: s/p TAH/BSO, peritoneal stripping -- Hypertension -- Hyperlipidemia Social History: Lives with her mother, in [**Location (un) 686**]. Self ambulates. Retired, worked for state in public relations. No ETOH/cig/illicits Family History: No family hx of breast or ovarian cancer. Cousin with lymphoma. Father AMI at 47yo. Sister w/ HTN. Physical Exam: General: Sedated, intubated, no jaundice HEENT: Sclera mildly icteric, dry MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior breath sounds clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, non-tender, non-distended, bowel sounds present, areas of firmness along lower quadrants, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2118-1-28**] 09:23PM URINE COMMENT-DUE TO ABNORMAL URINE COLOR INTREPRET DIPSTICK WITH CAUTION [**2118-1-28**] 09:23PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE EPI-2 [**2118-1-28**] 09:23PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 [**2118-1-28**] 11:11PM PT-14.1* PTT-30.8 INR(PT)-1.2* [**2118-1-28**] 11:11PM PLT COUNT-248 [**2118-1-28**] 11:11PM WBC-9.4 RBC-4.70 HGB-12.1 HCT-38.7 MCV-82 MCH-25.8* MCHC-31.3 RDW-17.2* [**2118-1-28**] 11:11PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.4* [**2118-1-28**] 11:11PM ALT(SGPT)-80* AST(SGOT)-77* LD(LDH)-307* ALK PHOS-592* TOT BILI-2.8* [**2118-1-28**] 11:11PM estGFR-Using this [**2118-1-28**] 11:11PM GLUCOSE-165* UREA N-7 CREAT-0.6 SODIUM-137 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-12 . ERCP [**2118-1-28**]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. Biliary Tree: A single stricture of malignant appearance that was 40 mm long was seen at the common hepatic duct and bifurcation of the main biliary duct. There was mild post-obstructive dilation. These findings are compatible with extrinsic compression.Likely large mass at porta hepatis causing Bismuth III type stricture. Unable to access left system. Right system appears moderately dilated Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was placed successfully. Area of stricture bridged successfully. Distal end of stent within CBD. Impression: Cannulation of the biliary duct was successful. A single stricture of malignant appearance that was 40 mm long was seen at the common hepatic duct and bifurcation of the main biliary duct. There was mild post-obstructive dilation. These findings are compatible with extrinsic compression. Likely large mass at porta hepatis causing Bismuth III type stricture. Unable to access left system. Right system appears moderately dilated A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was placed successfully. Area of stricture bridged successfully. Distal end of stent within CBD. . CXR [**2118-1-31**] In comparison with study of [**1-30**], allowing for differences in patient position, there is little change. Left basilar opacification persists, consistent with volume loss and pleural effusion. Diffuse pulmonary metastases are again seen. CT Torso w/contrast: 1. Mid-small bowel obstruction, likely due to omental and anterior abdominal wall mass. 2. Necrotic left pelvic side-wall mass, possibly nodal. 3. Enlarged celiac axis, paraaortic, and right external illiac lymph nodes. 4. Innumerable bilateral pulmonary nodules compatible with metastatic disease. 5. Bilateral pleural effusions, left greater than right with compressive atelectasis on the left side. 6. Stent within the CBD, but the distal tip does not difinitely enter into the duodenum. There is periportal edema and mild biliary ductal dilation. . Microbiolgy: C diff neg X 3, most recent from [**1-30**]. Sputum culture GRAM STAIN (Final [**2118-1-30**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. Blood culture [**1-29**] NGTD . Discharge labs: [**2118-2-2**] 04:04AM wBC 6.5 Hgb 9.4* HCt 27.7* MCV 80* Plts 210 INR 1.3 Glucose 132* BUN 5* Cr 0.4 Na 131* K 3.8 Cl 97 CO2 30 Mg 2.0, Ca 7.9, Phos 3.2 ALT 15, AST 15, Alk phos 200, T bili1.0 Brief Hospital Course: Cholecystitis: MRCP notable for extrinsic mass w/ dilatation of CBD and hepatic duct. No evidence for cholangitis. Patient is currently s/p ERCP that was notable for stricture at the common hepatic duct and biliary duct. Sphincterotomy and stenting was performed. Her LFTs continued to improve and she remained hemodynamically stable. . SBO: Suspected SBO, given high grade emesis, abdominal pain and distension and from residual food seen in stomach during procedure. Likely secondary to presumed extensive peritoneal involvement of her ovarian cancer. CT torso was done which confirmed incomplete partial small bowel obstruction of small and large intestines without definite transition point identified. Pt was kept NPO and NG tube was placed to low-intermittent suction with improvement in patient's emesis and pain. Dilaudid and fentanyl patch also improved patient's pain. Pt's emesis resolved completely. Pt developed diarrhea as well, this was C diff negative x3. By discharge, her emesis had stopped, and she was started on clear liquid diet with mild nausea. The NG tube was left in place in the event of recurrent emesis. . Metastatic Ovarian Cancer: Extensive pulmonary mets as well as abdominal disease seen on CT torso, pt and family was made aware of this metastasis. [**Month (only) 116**] benefit from systemic chemotherapy. She requested transfer back to [**Hospital1 34**] for management per her primary oncologist. . Aspiration PNA: Concern for aspiration PNA given aspiration event, leukocytosis, and tachycardia. Cefepime and Metronidazole were added to linezolid and pt improved significantly. Sputum cx nondiagnostic and blood cx remained negative. She will need an 8 day course of linezolid, flagyl and cefepime (last dose [**2118-2-5**]) UTI: per OSH results, sig for 100,000 Vanc resistent enterococcus (VRE). Continued linezolid. Urine culture here was negative. . Diarhea: She developed significant diarrhea, requiring rectal tube. Stool was negative for C diff X 3. . NSVT: Pt developed significant NSVT, probably [**1-18**] beta blocker withdrawal and hypokalemia [**1-18**] diarrhea/emesis. Repleted K and started metoprolol 5mg IV Q4H to good effect. She was transitioned to po metoprolol 25 mg po tid on the day of discharge, which can be titrated up as necessary. HTN: Restarted betablocker as above . Hyperlipidemia: Holding statin . FEN: on clear liquid diets as of today, replete electrolytes, regular diet -- If cannot start tolerating POs soon will need nutrition consult for possible TPN . Prophylaxis: Subutaneous heparin . Access: peripherals . Code: Full . Communication: Patient . Disposition: transfer back to [**Hospital **] hospital today [**2118-2-2**] Medications on Admission: Transfer medications: linezolid 600mg [**Hospital1 **] lopressor 50mg daily pantoprazole 40mg [**Hospital1 **] paxil 20mg daily simethicone 80mg tid simvastatin 40mg daily sucralfate 1gm letrozole 2.5g daily lovenox 40mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Linezolid 600 mg IV Q12H 5. Pantoprazole 40 mg IV Q12H 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Prochlorperazine 10 mg IV Q6H:PRN nausea 8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 9. CefePIME 1 g IV Q12H 10. HYDROmorphone (Dilaudid) 0.5 mg IV Q2H:PRN Pain Hold for sedation or RR<12 11. Potassium Chloride 40 mEq / 100 ml SW IV ONCE Duration: 1 Doses 12. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses 13. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses 14. Metoprolol Tartrate 5 mg IV Q4H hold for SBP <100, HR <55 15. 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. 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Cholecystitis Small Bowel Obstruction Aspiration pneumonia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair. NG tube in place, not to suction. Foley catheter in place. VRE precautions. PICC in place. Discharge Instructions: You were transferred to [**Hospital1 18**] for ERCP. We found a mass compressing the biliary tree. You had a stent placed to relieve obstruction. You were also vomiting, because of a small bowel obstruction. We treated you for an aspiration pneumonia and placed an nasogastric tube for your obstruction. We are transferring you to [**Hospital6 33**] for further managment based on your request. Followup Instructions: You are being transfered to [**Hospital6 33**] for further management. . Follow up with your primary oncologist and primary care doctor after discharge. ICD9 Codes: 5070, 5990, 4019, 2724, 2768
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Medical Text: Admission Date: [**2103-10-13**] Discharge Date: [**2103-10-16**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 3326**] Chief Complaint: CC: SOB Major Surgical or Invasive Procedure: No major surgical or invasive procedures. History of Present Illness: HPI: 64 yo male with Hx of CAD s/p NSTEMI, severe COPD with multiple intubations on chronic steroids, who p/w onset of SOB over several hours. One day prior to admission, pt reports that he had been sitting in bed and noted the gradual progression of SOB over several hours. Denies sudden onset SOB, CP, pleuritic pain, orthopnea, pnd, inc le edema. States that it feels like a COPD flare. +occ cough, unchanged from chronic pattern. +yellow sputum, unchanged in frequency or character. Took ipratroprium/albuterol nebs x10, without improvement and decided to come to the ED. . In ED, 108, 140/90, 23, 88% ra. Durintg time in room, bp dropped to 97/69, rec'd 1.5L NS w/ subsequent improvement in BP. Rec'd cipro 250 mg. Also rec'd solumdrol 125, and underwent bipap while in ED. Past Medical History: PMH: 1. COPD on 4 L O2 at home and s/p multiple admissions and intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02, and BiPap QHS. 2. Hypertension 3. Hyperlipidemia 4. CAD s/p NSTEMI ([**2101**]) [**4-10**] with cath normal 5. Chronic low back pain L1-2 laminectomy from accident at work 6. Steroid induced hyperglycemia 7. Left shoulder pain for several months 8. Cataract 9. GERD 10. Chronic indwelling urethral catheter. Social History: Married with six children. Lives at home in [**Location (un) 16174**] with wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint. Former smoker. Quit 25 years ago. 20 pack year history. Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use. Activity limited due to prior spine and current shoulder problems. Family History: Mother with asthma and [**Name (NI) 2481**] Father with [**Name2 (NI) 499**] cancer Physical Exam: PE: 97.1, bp 123/43, 92, 18, 99% 4L NC Well appearing male, not utilizing acc mm, breathing comfortably in NAD. PERRL. OP clr, MMM 6cm JVP Regular S1,S2. No m/r/g. LCA b/l. +inc expiratory time. +bs. soft. nt. nd. no le edema. Pertinent Results: EKG: 85bpm, nl axis, nl interval, non-specific IVCD, unchanged. . CXR [**2103-10-13**] AP UPRIGHT PORTABLE CHEST X-RAY: The study is limited secondary to patient's positioning. The right costophrenic angle is not seen. The cardiac silhouette is normal in size. The aorta is tortuous. There is stable overinflation of bilateral lung fields, with flattening of the cardiac silhouette, and bilateral hemidiaphragms. Hyperlucency bilaterally and symmetrically is consistent with diffuse emphysema. The imaged lung fields are otherwise clear, with slight stable scarring at the left lung base. There is no pneumothorax, and the pulmonary vasculature is normal. IMPRESSION: 1. No acute cardiopulmonary process. 2. Underlying diffuse bilateral emphysema. . [**2103-10-15**] 5:09 pm URINE **FINAL REPORT [**2103-10-16**]** URINE CULTURE (Final [**2103-10-16**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . [**2103-10-13**] 1:05 pm URINE Site: CATHETER **FINAL REPORT [**2103-10-14**]** URINE CULTURE (Final [**2103-10-14**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . [**2103-10-13**] BLOOD CX: NEGATIVE . [**2103-10-13**] 02:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016, BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD; RBC-[**11-25**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2103-10-13**] GLUCOSE-114* UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15, CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-1.7, WBC-14.0* RBC-4.52* HGB-12.2* HCT-37.8* MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4, NEUTS-67.9 LYMPHS-24.3 MONOS-4.3 EOS-3.2 BASOS-0.4, PLT COUNT-333 Brief Hospital Course: A/P: 64 yo male with HTN, severe COPD with FEV1 20%, on home oxygen 4L and chronic steroids, with multiple prior intubations, admitted with COPD flare and hypotension. . 1) Shortness of breath: The patient's presentation was consistent with a COPD flare. There was no new infiltrate on Chest X-ray, and there was no change in the consistency/amount/frequency of his sputum production. Pulmonary embolism is highly unlikely. It was felt there was no indication for antibiotics. We continued his steroids at prednisone 60mg po qd, and discharged the patient on a taper over 10 days. We continued albuterol and ipratropium bromide nebulizer treatments, scheduled. The pt was started on fluticasone and salmeterol inhalers, and he will use these as an outpatient. He did not have to go on Bipap. At discharge, he was able to walk around the ICU five times. He reports this is his baseline. He will follow up with Dr. [**Last Name (STitle) 575**], his pulmonologist in the next 2 weeks. . 2) [**Name (NI) **] The pt had one episode of SBP in the 90s in the ED. He was asymptomatic. We considered a normal variation in BP, and could not r/o mild volume depletion given insensible losses vs adrenal insufficiency as pt is on steroid taper. We recommend cortstim on the pt as an outpatient. We continued steroids for COPD flare. Our goal was for MAP<60 and UOP<30cc/hour, supported with fluid boluses if need be, however he did not require this. He was with stable VS throughout his [**Hospital Unit Name 153**] stay. No more episodes of hypotension. He was placed on his high blood pressure medications while in the [**Hospital Unit Name 153**]. . 3) [**Name (NI) 20182**] The pt's urine cultures came back positive for >3 colony types, consistent with fecal contamination. Urology felt that this was likely colonization, given he has a chronic indwelling catheter. The catheter was changed on [**2103-10-15**], and urology recommended Macrodantin for 3 day course given the cath change. The pt is to follow up with Dr.[**Name (NI) 20183**] at [**Hospital1 112**] for potential transurethral needle ablation of the prostate for benign prostatic hyperplasia. . 4) [**Name (NI) 3674**] Pt has history of anemia in past, unclear when his last colonoscopy was. Will have pt follow up with PCP as outpatient to schedule colonoscopy. Stools were guiaic negative. . 5) Coronary Artery Disease- No current evidence of angina. We continued his ACE inhibitor/[**Name (NI) **]/statin. . 6) Code status- FULL. Medications on Admission: Meds: 1.Aspirin 325 mg qd 2.Atorvastatin Calcium 10 mg qd 3.Calcium Carbonate 500 mg qd 4.Cholecalciferol (Vitamin D3) 400 unit qd 5.Senna 8.8 mg/5 mL [**Hospital1 **] 6.Sertraline 50 mg qd 7.Albuterol Sulfate 0.083 % Neb q4hours 8.Ipratropium Bromide Nebq4hours 9.Multivitamin qd 10.Lisinopril 5 mg qd 11.Prednisone 30mg qd on taper(down from 40mg on [**7-25**]) 12.Percocet Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*4* 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*3* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Please see your primary care physician for refills of this medication. . [**Date Range **]:*30 Tablet(s)* Refills:*0* 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). [**Date Range **]:*1 Disk with Device(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). [**Date Range **]:*30 Lozenge(s)* Refills:*0* 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). [**Date Range **]:*30 Tablet Sustained Release(s)* Refills:*2* 9. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 2 days: To Complete a 3 day course. . [**Date Range **]:*8 Capsule(s)* Refills:*0* 10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation every six (6) hours. [**Date Range **]:*120 nebulizer* Refills:*2* 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours). [**Date Range **]:*120 nebulizer treatment* Refills:*2* 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). [**Hospital1 **]:*qs MDI* Refills:*2* 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation. [**Hospital1 **]:*60 Capsule(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: for constipation. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 17. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once a day for 7 days: Take 4 tab po qd for 1 day, then 3 tab po qd for 2 days, then 2 tab po qd for 2 days, then 1 tab po qd for 2 days. . [**Hospital1 **]:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 20184**] medical services Discharge Diagnosis: 1. Chronic Obstructive Pulmonary Disease flare/exacerbation 2. Chronic indwelling urethral catheter 3. Benign Prostatic Hypertrophy 4. Hypertension 5. Hyperlipidemia 6. Coronary artery disease 7. Chronic lumbago 8. Gastroesophageal Reflux Disease Discharge Condition: Stable Discharge Instructions: If you experience worsening shortness of breath, coughing and sputum production increased in quantity or quality, please report to the emergency room immediately. If you notice that you are requiring more inhalers or oxygen than normal, please come to the ER. Please follow up with your physicians (see information below). Please take all of your medications. Followup Instructions: 1. Provider: [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 612**]. Date/Time: You will be called by [**Name8 (MD) 20185**], RN from Dr. [**Name (NI) 20186**] office regarding a time in the next two weeks for you to come in. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2103-11-6**] 9:30 AM. 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2103-11-26**] 11:30 4. Please follow up with Dr.[**Name (NI) 20183**] at [**Hospital6 13185**], Urology, for evaluation for your transurethral needle ablation of the prostate. 5. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2104-4-7**] 11:00 Completed by:[**2103-10-17**] ICD9 Codes: 4019, 2724, 412, 4589
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Medical Text: Admission Date: [**2199-2-19**] Discharge Date: [**2199-2-25**] Date of Birth: [**2158-11-18**] Sex: F Service: Medicine CHIEF COMPLAINT: Lethargy, hyperglycemia. HISTORY OF PRESENT ILLNESS: This is a 40 year-old woman with history of type I diabetes with nephropathy, hypertension, and chronic headaches who presents with lethargy and increased blood sugars over the past week. The patient was recently admitted on [**2-11**] for worsening headaches. Extensive work up in the past has shown these headaches to be sometimes correlated to anemia, as was the case on the previous admission. She was transfused two units of packed red blood cells with resolution of her headache. She was noted at that time to be hyperglycemic secondary to missed insulin doses and hypertensive. She was discharged on Catapres with appropriate follow up. Since discharge, the patient had been doing well with occasional chronic typical headache relieved by Percocet. Her blood sugars were running slightly high in the 300's over the course of the week. In addition her blood sugars were high at night, causing her to add additional insulin. Over the three days prior to admission, blood sugars were increased. She wet to he [**Female First Name (un) 3408**] for her scheduled appointment and was told to come to the emergency department for hyperglycemia. On further review, patient was noted to have increased lethargy, decreased strength, decreased p.o. intake, nausea, emesis, polyuria and polydipsia. The patient denies any fevers, chills, new headaches, vision changes, chest pain, palpitations, shortness of breath, cough, abdominal pain, dizziness, or light headedness. PAST MEDICAL HISTORY: 1) Insulin dependent diabetes mellitus with nephropathy, retinopathy, and neuropathy. Two previous admissions for diabetic ketoacidosis. 2) Gastroparesis. 3) Chronic headache. 4) Hypertension. 5) Anemia secondary to renal disease. 6) Barrett's esophagitis. 7) Status post left cephalic vein clot secondary to PIC line in [**2198-4-30**]. 8) History of sepsis and endocarditis. 9) History of depression. 10) History of amenorrhea with increased prolactin. 11) Hypercholesterolemia. 12) Previous echocardiogram from [**2198-3-31**] showed ejection fraction of 45 to 50 percent with mild mitral regurgitation. MEDICATIONS: 1) Catapres patch .1 mg change q. week, patient not using. 2) Lasix 40 mg p.o. q.d, 3) Reglan 15 mg p.o. q.d., 4) Protonics 40 mg p.o. q.d., 5) Percocet p.r.n. headache. 6) NPH insulin 25 q. A.M., 4 q. P.M., 7) Sliding scale Humulog insulin. 8) Allergies: no known drug allergies. Notes vomiting with Erythromycin. SOCIAL HISTORY: Patient is divorced, works as an accountant, currently living with her parents because of her increased care requirements secondary to her numerous illnesses. Denies tobacco or alcohol. FAMILY HISTORY: No history of early coronary artery disease, diabetes, hypertension, hypercholesterolemia. ADMISSION PHYSICAL EXAMINATION: Temperature 97 degrees, heart rate 81, blood pressure 103/36, 99 percent on room air. General: this is a drowsy middle aged woman who is easily arousable. She sluggishly is able to answer questions, otherwise in no apparent distress. Pupils were reactive, extraocular movements were intact, sclerae are anicteric. There was no photophobia. Oropharynx was clear. Neck is supple without bruits. There is no jugular venous distention. There is bilateral shotty cervical lymphadenopathy, tender. Chest is clear to auscultation bilaterally. The heart is regular, tachycardic, S1, S2, with a II/VI systolic murmur at the left upper sternal border. Abdomen was soft, nontender, nondistended, with normal active bowel sounds. Extremities showed no clubbing, cyanosis or edema. Pulses are thin, palpable bilaterally. ADMISSION LABORATORIES: CBC showed white count of 8.5, hematocrit of 33, platelets of 264. Chem-7 is significant for sodium of 126 which corrects to 135, potassium of 6.6, chloride of 99, bicarb of 5, BUN is 74, creatinine 4.9, glucose of 702. Urinalysis significant for greater than 300 protein, greater than 1,000 glucose, 40 ketones, specific gravity 1.021, count 5.5. Electrocardiogram shows normal sinus rhythm at 83 beats per minute, T wave flattening in [**Last Name (LF) 1105**], [**First Name3 (LF) **]. ST elevations in V1 through V3. ST depressions in V4 through V6, I, AVL. This shows no change from previous electrocardiogram from [**2199-1-14**]. Chest x-ray is clear. HOSPITAL COURSE: The patient received a total of 20 units of insulin in the emergency room with improvement in her sugars. She was then admitted to the Intensive Care Unit for close observation and during correction of her hyperglycemia. She was then called out to the regular medicine service on [**2-20**], when it was noted that her cardiac enzymes were significantly elevated, most notably for a troponin of 21.2, which later went up to as high as 29.1. The patient was medically managed for non-Q wave myocardial infarction, and it was decided to try to avoid cardiac catheterization secondary to the potential and likely damage that the dye load would cause to her kidneys. Therefore, she underwent echocardiogram which showed no focal wall motion abnormalities but did demonstrate global hypokinesis of the ventricular wall. She then underwent Persantine Thallium, which demonstrated a small fixed anterior filling defect. The patient was placed on beta blocker, heparin, aspirin, and Lipitor for her post myocardial infarction regimen. ACE inhibitors were avoided secondary to her renal function. During her course, the patient's cardiac enzymes gradually improved, and she had no symptoms or further electrocardiogram changes or cardiac enzyme elevations. Her course, however, was complicated by labile hypertension, with surges into the 220s/110s. She was given increasing doses of Lopressor, with eventual stabilization of blood pressure in the 130s to 150s/80s. By [**2-25**], the patient's hypertension was fairly stable, blood sugars were stable in the high 100s, and she was having no cardiac symptoms and had normal CKs. She was discharged to home with services, with plans for follow up with Dr. [**Last Name (STitle) 19512**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with [**Hospital6 1587**]. DISCHARGE DIAGNOSES: 1. Non-Q wave myocardial infarction. 2. Diabetic ketoacidosis. 3. Hypertension. 4. Diabetes mellitus. 5. Hypercholesterolemia. 6. Chronic renal insufficiency. DISCHARGE MEDICATIONS: 1) NPH 25 units q. A.M., 5 units q. P.M., 2) Humulog sliding scale. 3) Lasix 40 mg p.o. q.d., 4) Reglan 15 mg p.o. q. day, 5) Protonics 40 mg p.o. q.d., 6) Lopressor 100 mg p.o. b.i.d., 7) Norvasc 10 mg p.o. q.d., 8) Lipitor 10 mg p.o. q.d., 9) Epogen 3,000 units subcutaneous injections three times a week. 10) Kayexalate 30 grams p.o. q.d. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 19513**] Dictated By:[**Last Name (NamePattern1) 19919**] MEDQUIST36 D: [**2199-2-25**] 12:21 T: [**2199-2-26**] 20:47 JOB#: [**Job Number 19921**] ICD9 Codes: 2767
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Medical Text: Admission Date: [**2131-12-31**] Discharge Date: [**2132-1-4**] Date of Birth: [**2060-3-7**] Sex: M Service: NEUROLOGY Allergies: Procardia / Aliskiren Attending:[**First Name3 (LF) 8850**] Chief Complaint: Altered Mental Status. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known firstname 95455**] [**Known lastname 95456**] is a 71-year-old man with a history of diastolic CHF, CAD, type II diabetes mellitus, and most recently a insular glioblastoma diagnosed in [**2131-9-16**] now status post radiotherapy and temzolomide currently being managed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. Mr. [**Known lastname 95456**] presents from his [**Hospital1 1501**] after having acute onset of lethargy at 06:00 p.m. this evening. He was monitored closely and his vital signs remained stable. At around 11:30 pm he was noted to have increased left sided weakness and new left sided facial droop. He was brought to [**Hospital1 18**] Emergency Department by EMS for further evaluation of his altered mental status. In the Emergency Department initial vital signs were: Temperature 97.3 F, pulse 70, blood pressure 137/79, repsiration 16, and oxygen saturation 97% on 2 liters via nasal cannula. Patient was found to be lethargic but arousable. CT head was performed showing interval increase in hemorrhage around the mass, now with acute area of hemorrhage 2.6 cm x 1.4 cm. Neurology was consulted urgently for left sided facial droop and weakness. Given evidence of bleed they recommended holding home aspirin and maintaining blood pressure control. Per ED team, Dr. [**First Name8 (NamePattern2) 1151**] [**Last Name (NamePattern1) **] from the Neuro-Oncology Service reviewed the imaging and did not recommend any changes to current antiepilectic and steroid regimen at this time. He recommended further imaging only if significant change in neurologic examination. Laboratory findings were notable for troponin 0.11, Hct 35 (baseline), creatinine 1.2 (baseline), INR 1.0, PTT 20.8. Patient's EKG was unchanged compared to prior. Chest X-ray was without evidence of an acute cardiopulmonary process. Patient received no medications or IV fluids prior to transfer to the Medicine ICU for serial neurologic examinations. On arrival to the ICU the patient appears comfortable. He attempts to follow simple commands but is too lethargic to follow any complex commands or to speak in full sentences. ROS: Difficult to obtain given lethargy. Patient does deny any headache, chest pain, shortness of breath, abdominal pain. Per OMR he has urinary incontinence. Past Medical History: -Right frontotemporal glioblastoma multiforme WHO Grade IV, status post biopsy on [**2131-9-27**], on protocol using hypofractionated involved-field radiotherapy with temozolomide followed by Cyberknife boost -Ischemic stroke -Malignant HTN -CAD s/p IMI -Chronic diastolic CHF -PAF (ED visit [**7-25**]) -Type II diabetes mellitus -Anxiety/Depression Social History: He is a resident of [**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 19207**] & Nursing Center in [**Location (un) 38**], MA. He is a retired rocket scientist from [**Country 532**]. He worked for USSR space program and NASA. A former pipe smoker, he quit in [**2097**]. He is a social drinker and he does not abuse illicit drugs. Family History: Father: Type [**Name (NI) **] diabetes and hypertension. Mother: [**Name (NI) **] [**Name (NI) 3730**]. Brother: Type [**Name (NI) **] Diabetes. Physical Exam: VITAL SIGNS: Tempperature 96.3 F, blood pressure 160/88, pulse 65, respiration 18, and oxygen saturation 96% in room air. GENERAL: Lethargic, opens right eye to loud verbal stimuli SKIN: No rasheS, jaundice, or splinters HEENT: Left eye s/p cataract surgery, left pupil appears chronically dilated, right eye pupil 3 --> 2 mm, EOMI, anicteric, dry MM, no supraclavicular or cervical lymphadenopathy, no JVD, no thyromegaly or thyroid nodules CARDIOVASCULAR: Irregular, bradycardic S1 and S2 wnl, no m/r/g PULMONARY: Irregular respirations concerning for sleep apnea versus [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations, rhonchorus breath sounds at bilateral bases ABDOMEN: Non-distended, positive bowel sounds, soft, non-tender, and without masses EXTREMITIES: No clubbing, cyanosis, or edema DRAINS: Portacath in place, Foley catheter in place. NEUROLOGICAL EXAMINATION: Awake, alert, and oriented x 1 only. He is lethargic, keeps eyes open for only seconds, answers questions appropriately, cooperative while awake, and has mild left-sided facial droop. Tongue at midline. Strength and sensation difficult to assess given lethargy. Left arm appears weaker than right. Patient able to wiggle fingers and toes in both hands and feet symmetrically. Pertinent Results: Imaging: [**2131-12-30**] Head CT: 1. Large mass in the right frontal lobe with adjacent new hemorrhage at the right putamen. 2. Subacute infarcts in the right occipital lobe and right posterior corona radiata. 3. No subfalcine herniation or uncal herniation. 4. No hydrocephalus. [**2131-12-31**] Chest X-Ray: 1. No focal lung consolidation. 2. Right Port-A-Catheter with tip at the mid SVC in similar position compared to prior. 3. Upper mediastinal silhouette widened could be due to goiter. Correlate with physical exam. Microbiology: [**2132-1-2**] URINE CULTURE-PRELIM {PROTEUS MIRABILIS} >100,000 ORGANISMS/ML [**2132-1-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEGATIVE [**2131-12-31**] URINE CULTURE-FINAL {PROTEUS MIRABILIS} PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2131-12-31**] MRSA SCREEN MRSA SCREEN-NEGATIVE Labs on admission: [**2131-12-31**] 05:05AM BLOOD WBC-10.0 RBC-4.03* Hgb-12.0* Hct-36.0* MCV-89 MCH-29.8 MCHC-33.4 RDW-17.0* Plt Ct-255 [**2131-12-30**] 11:38PM BLOOD Neuts-86.9* Lymphs-8.8* Monos-3.8 Eos-0.2 Baso-0.3 [**2131-12-31**] 05:05AM BLOOD PT-11.7 PTT-21.6* INR(PT)-1.0 [**2131-12-31**] 05:05AM BLOOD Glucose-160* UreaN-43* Creat-1.0 Na-143 K-3.8 Cl-101 HCO3-34* AnGap-12 [**2131-12-31**] 05:05AM BLOOD ALT-21 AST-17 CK(CPK)-50 AlkPhos-89 TotBili-0.5 [**2131-12-31**] 05:05AM BLOOD CK-MB-4 cTropnT-0.09* [**2131-12-31**] 05:05AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.2 [**2131-12-31**] 04:51AM BLOOD Type-ART pO2-76* pCO2-42 pH-7.50* calTCO2-34* Base XS-7 [**2131-12-31**] 04:51AM BLOOD Lactate-1.3 [**2131-12-31**] 04:51AM BLOOD freeCa-1.14 Labs on discharge: [**2132-1-4**] 04:30AM BLOOD WBC-10.7 RBC-3.42* Hgb-10.3* Hct-29.9* MCV-88 MCH-30.3 MCHC-34.5 RDW-16.6* Plt Ct-238 [**2132-1-4**] 04:30AM BLOOD Glucose-160* UreaN-49* Creat-1.0 Na-142 K-3.6 Cl-106 HCO3-27 AnGap-13 [**2132-1-4**] 04:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2 Finger stick glucose on day of discharge: 331 <-- 143 <-- 220 <-- 298 Brief Hospital Course: Patient with acute mental status change found to have intraparenchymal hemorrhage at site of glioblastoma multiforme on CT scan. Initially admitted to the ICU, and then transferred to the floor in stable condition. (1) Altered Mental Status: His head CT shows increased hemorrhage around known glioblastoma multiforme. It is not clear whether his symptoms on presentation are secondary to this hemorrhage, increased edema from his tumor, possibly a new ischemic stroke, or the UTI. Patient's known intracranial lesion also raises concern for seizure activity though this is less likely given his seizure prophylaxis and clinical history. There was no evidence of intoxication or other metabolic etiologies to explain his lethargy. His daughter does report that the rehab facility had wanted to start a trial of additional antidepressants in the last week, however, this would not support the acute change in mental status evening prior to admission. Throughout the day of admission, the patient's mental status improved without intervention. He has baseline confusion and at times seems that he did not fully comprehend certain questions despite being A&O x3. His mental status has stabilized and there is no concern at this time that he is unable to protect his airway. (2) Intraparenchymal Hemorrhage: Patient with acute mental status change found to have intraparenchymal hemorrhage at site of glioblastoma multiforme on CT scan. There was no history of recent head trauma or use of anticoagulation, except for aspirin 325 mg daily. His last XRT and chemotherapy was in [**Month (only) **] [**2131**]. Platelets and coags within normal limits. Serial neurological exams were done and there was clinical improvement. It is believed that the intracranial hemorrhage has stabilized and the patient was transferred from the intensive care unit to the floor. Goal BP was systolic blood pressure in the 140's-160's. We held his antihypertensive medications during his time in the ICU in order to meet this goal. Patient is being discharged on reduced dose of labetalol 800 mg [**Hospital1 **] to 400 mg [**Hospital1 **]. We will stop his aspirin on discharge. (3) Diabetes: This was poorly controlled on presentation with fingerstick blood glucose >350 and remained >400 upon transfer to floor. Home oral hypoglycemics were held during admission. He continued fingerstick blood glucose and home insulin regimen (75 units of Glargine qhs). Also, we placed the patient on an Humalog ISS during his admission. Of note, patient was eating constantly throughout the day during admission, making glucose control difficult. We discharged patient on his home regimen of oral and subcut insulin. (4) Urinary Tract Infection: This was found on admission, initially treated with bactrim. Culture grew Proteus, resistent to Bactrim, discharging patient on cefazolin to complete a 7 day course (Day 1 is [**2132-1-2**]). (5) Elevated Cardiac Enzymes: Patient has known history of CAD s/p IMI. EKG unchanged compared to prior on presentation. Patient denies symptoms of chest pain or shortness of breath. His elevated cardiac may be due to demand in the setting of hypertension as patient has a history of poorly controlled blood pressures and atrial fibrillation. Patient cardiac enzymes were stable at 0.09 and CK-MB was flat at 4. He was not started on treatment for ACS as it was not believed that this was the cause of his elevated troponins. In addition, given recent bleed heparin and aspirin would be contraindicated in this patient given recent cranial bleed. Patient denied chest pain, shortness of breath, nausea or diaphoresis during his admission on the floor. (6) Atrial Fibrillation: Patient currently in sinus rhythm. Labetolol was decreased during ICU stay due to persistent sinus bradycardia; pressures remained in the 140s-160s. (7) Chronic Diastolic Heart Failure: Patient with significant history of multiple intubations for dCHF exacerbations. Held many of his BP meds initially. BP stabilized on modified home regimen. He was discharged with decreased labetalol dose as stated above. Patient denied SOB during admission after receiving several gentle IV fluid boluses. His lower extremity edema was stable during admission. (8) Anemia: Patient's Hct was at a baseline, remained stable throughout his admission. (9) Anxiety/Depression: Home clonazepam and buspirone was held initially for accurate neuro exam. He was restart upon discharge as patient's mental status is back at baseline. Medications on Admission: - AMLODIPINE- 10 mg daily, last received [**12-30**] @ 2PM - DIOVAN 160 mg [**Hospital1 **], last received [**12-30**] @ 6AM - BUSPIRONE- 5 mg [**Hospital1 **], last received [**12-30**] @ 8PM - CLONAZEPAM- 0.5 mg Tablet qHS, last received [**12-29**] - CLONIDINE- 0.2 mg/24 hour 2 Patches Weekly on Saturdays, last received [**12-29**] - DEXAMETHASONE- 3 mg [**Hospital1 **], last received [**12-30**] @ 8PM - EPLERENONE- 50 mg daily, last received [**12-30**] @ 8AM - GLYBURIDE- 5 mg [**Hospital1 **] - Lantus 75 units at bed time, last received [**12-30**] - LABETALOL- 200 mg tab, 4 tablets [**Hospital1 **], last received [**12-30**] @ 8PM - LEVETIRACETAM- 500 mg tab, 1 tab, TID, last received [**12-30**] @ 10PM - OMEPRAZOLE- 20 mg Capsule, 1 tab, daily, last received [**12-30**] @ 8AM - SIMVASTATIN- 40 mg Tablet, 1 tab, daily, last received [**12-30**] @ 5PM - TIMOLOL [BETIMOL]- 0.5 % Drops- 1 gtt(s) OU twice a day - TORSEMIDE- 10 mg tab, 3 tabs, daily, last received on [**12-30**] @ 8AM - ACETAMINOPHEN- 325 mg, 2 tabs, q4h PRN for pain - ASPIRIN- 325 mg Tablet, 1 tab, daily, last received [**12-30**] @ 8AM - DOCUSATE SODIUM- 100 mg, 1 tab, [**Hospital1 **], last received on [**12-30**] - SENNA- 8.6 mg tab, 1 tab, [**Hospital1 **] PRN (received none in [**Month (only) **]) - Nitroglycerin 0.4 mg SL tab PRN for chest pain, last received on [**12-25**] once with chest pain resolved - Milk of Mag, 30 ml by mouth if no BM in 48 hours prn - Bisacodyl 10 mg supp, insert 1 PR if no BM in 12 hours after MOM - [**Name (NI) 20342**] enema, insert 1 PR if no BM in 12 hours after suppository - Magnesium citrate, 1 bottle PO if no BM in 12 hours after [**Name (NI) **] enema PRN unless contraindicated Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Buspirone 5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Transdermal once a week: on Saturdays. 6. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO twice a day. 7. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Lantus 100 unit/mL Cartridge Sig: 75 units Subcutaneous at bedtime. 10. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Timolol 0.5 % Drops Sig: One (1) drop Ophthalmic twice a day. 15. Torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain/fever. 17. Docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Please give up to 3 x q 5 minutes. 20. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30mL PO once a day as needed for constipation: Please give if no BM in 48H. 21. Bisacodyl 10 mg Suppository Sig: One (1) PR Rectal once a day as needed for constipation: if no BM in 12H. 22. [**Name (NI) 20342**] Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once a day as needed for constipation: if no BM after suppository. 23. Magnesium citrate Solution Sig: One (1) bottle PO once a day as needed for constipation: if no BM in 12 hrs after [**Name (NI) **] enema prn, unless contraindicated. 24. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 25. cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous twice a day for 4 days. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Glioblastoma mulitiforme Urinary tract infection 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: It was a pleasure to take care of you during your admission. You were admitted for confusion; your confusion improved, and you were treated for an urinary tract infection. Please make the following changes to your medications: -START cefazolin 1g intravenously twice daily for 4 days for your urinary tract infection -REDUCE Labetolol to 400mg daily for your blood pressure - STOP aspirin 325mg once daily Please continue all other medications as prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: NEUROLOGY When: FRIDAY [**2132-1-25**] at 11:00 AM With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2132-5-21**] at 10:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**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: 431, 5990, 2760, 4280, 412
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Medical Text: Admission Date: [**2161-4-20**] Discharge Date: [**2161-4-24**] Date of Birth: [**2101-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfonamides Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2161-4-21**] Mitral valve repair (28mm Annuloplasty band) Past Medical History: Mitral regurgitation, Coronary artery disease/myocardial infarction tatus post coronary stent, Congestive heart failure, Hypertension, Hypercholesterolemia, h/o skin cancer status post removal, Hemorrhoids, remote fracture of fingers and toes, skin cancer status post removal, status post hernia repair x 2, status post repair of facial laceration, status post cyst removal from his scrotum, status post vasectomy, status post left arm surgery Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse or IVDU. Patient smokes marijuana daily. Works as a motorcycle repairmen and carpenter. Active in his job, but does not exercise regularly. Family History: non-contributory. There is no family history of premature coronary artery disease or sudden death. Physical Exam: On physical examination, his heart rate is 64. Blood pressure is 118/68. His height is 65" and he weighs approximately 175 lbs. In general, he appeared to be in no acute distress. His skin is mostly unremarkable with multiple healed scars throughout his body. HEENT examination revealed extraocular movements are intact. Pupils are equal, round, and reactive to light. Oropharynx is benign. His neck is supple, full range of motion without any JVD. His lungs are clear to auscultation bilaterally. Cardiac examination revealed regular rate and rhythm with a soft murmur of mitral regurgitation. His abdomen is soft, nontender, and nondistended with positive bowel sounds. Extremities are warm and well perfused with no edema. Neurologically, he is grossly intact, alert, and oriented x3, moving all extremities. Pertinent Results: [**2161-4-20**] Echo: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %)with hypokinesia of the mid and apical portions of the inferior, inferolateral and inferoseptal walls. There is moderate global RV free wall hypokinesis. 3. The ascending, transverse and descending thoracic aorta are normal in diameter. There are simple atheroma in the aortic arch and descending thoracic aorta. 4. There are three aortic valve leaflets. Trace aortic regurgitation is seen. There is no aortic stenosis. 5. The mitral valve leaflets are mildly thickened. There is moderate/severe mitral valve prolapse of the A2 and A3 scallops. The P2 portion is mildly restricted in movement. Severe (4+) mitral regurgitation is seen. The mitral valve annulus measures 3.7 cms with the anterior leaftlet measuring 3.47 cm and the posterior leaflet measuring 1.35 cm. The Csept distance is 3.57 cm. 6. There is no pericardial effusion. 7. Dr. [**Last Name (STitle) **] was notified in person of the results during the procedure on [**2161-4-20**] at 820 am. POSTBYPASS: 1. The patient is on phenylephrine, epinephrine, milrinone infusions and AV paced. 2. RV function is improved compared to the prebypass study. 3. LV function is worse than prebypass, now with EF of 30%. Inferior, inferoseptal, and inferolateral walls are akinetic. 4. An annuloplasty ring is noted in the mitral postion. It appears well seated. There is trivial mitral regurgitation. Peak gradient is 6 mm Hg and the mean gradient is 3 mmHg across the mitral valve. 5. Aortic contour is smooth after decannulation. Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and on [**4-20**] he was brought to the operating room where he underwent a mitral valve repair. 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. Pacing wires and chest tubes were removed per Cardiac surgery protocol. CXR without pneumothorax. Patient transferred from the ICU to the floor. Patient experienced post op afib and was started on Amiodarone and betablockade was increased and converted back to sinus rhythm. Patient was evaluated by physical therapy and cleared for d/c to home. Medications on Admission: ASA 325', Plavix 75', Lisinopril 15', Lasix 20', Simvastatin 80', Metoprolol 25', Sertraline 75', Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for recent stent . Disp:*30 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:*2* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): dose decreased while on amiodarone. Disp:*30 Tablet(s)* Refills:*2* 5. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 tabs daily for 6 days then one tab daily there after. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral regurgitation status post Mitral Valve repair Secondary: Coronary artery disease/myocardial infarction tatus post coronary stent, Congestive heart failure, Hypertension, Hypercholesterolemia, h/o skin cancer status post removal, Hemorrhoids, remote fracture of fingers and toes, skin cancer status post removal, status post hernia repair x 2, status post repair of facial laceration, status post cyst removal from his scrotum, status post vasectomy, status post left arm surgery Discharge Condition: good Discharge Instructions: Adhere to 2 gm sodium diet shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks([**Telephone/Fax (1) 62**]) Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**2-13**] weeks ([**Telephone/Fax (1) 250**]) [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks Please call for [**Hospital Ward Name 4314**] Completed by:[**2161-4-24**] ICD9 Codes: 4240, 9971, 4280, 2875, 412, 2859, 4019, 2720
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Medical Text: Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-18**] Date of Birth: [**2132-2-21**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 65 year old female with a past medical history notable for diabetes mellitus, hypertension, coronary artery disease status post myocardial infarction and coronary artery bypass graft, right lower lobectomy, asthma and congestive heart failure, who presents complaining of cough times one week, malaise and fatigue. The patient had a low grade temperature of 99.6 F., at home. The patient denied any lower extremity edema or weight gain. The patient's peak flows at home were in the 150 range. The patient was recently admitted to the hospital [**1-28**] until [**2-5**] for similar complaints of shortness of breath and cough. At that time, she was treated with steroids, Azithromycin and nebulizers for a presumed bronchitis exacerbation. In the Emergency Room, the patient was treated with a Combivent nebulizer, Solu-Medrol intravenously, Levaquin and Lasix. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Neuropathy. 3. Hypertension. 4. Coronary artery disease status post inferior myocardial infarction in [**2182**]; status post coronary artery bypass graft in [**2190**]; most recent catheterization in [**2196-8-1**] with an ejection fraction of 40%; left internal mammary artery with 40% disease and right coronary artery with 90% disease. 5. Status post right lower lobectomy for question of tuberculosis disease at age 16. 6. Asthma. 7. Congestive heart failure. 8. Fibromyalgia. 9. Osteoarthritis. 10. Low back pain secondary to spinal stenosis. ALLERGIES: Penicillin and tetracycline. MEDICATIONS AT TIME OF ADMISSION: 1. Aspirin 325 mg a day. 2. Prednisone taper. 3. Protonix 40 mg a day. 4. Trandolapril 2 mg a day. 5. NPH 34 units in the morning and 26 units at night. 6. Subcutaneous insulin. 7. Albuterol inhaler. 8. Fluticasone inhaler. 9. Valium p.r.n. 10. Sotalol 80 mg twice a day. 11. Nystatin swish and swallow. SOCIAL HISTORY: The patient lives at home independently. She has around 12 siblings. She has a 30 pack history of tobacco but quit in [**2182**]. She does not use any alcohol. PHYSICAL EXAMINATION: Temperature 99.5 F.; pulse 96; blood pressure 110/60; respiratory rate 24; pulse oximetry 95% on two liters. In general, a sad tearful female with a flat affect. HEENT: Pupils are equal, round and reactive to light. Mucous membranes were moist. Neck is supple without any jugular venous distention. Chest: Crackles at the lung bases about [**2-3**] of the way up. Cardiovascular: Regular rate, no murmurs. Abdomen is soft. Extremities are warm without edema with good pulses. Neurological is alert and oriented times three. LABORATORY: Data at the time of admission is white blood cell count of 10.3 with 70% neutrophils, hematocrit of 39.7, platelets of 226. Sodium 134, potassium 4.4 hemolyzed, chloride 95, bicarbonate 29, BUN 24, creatinine 1.4 with baseline of 1.0, and glucose of 120. Chest x-ray shows blunting of the left costophrenic angle, right middle and lower lobe pneumonia. EKG with normal sinus rhythm at a rate of 95, old Q waves in the inferior leads with no acute ST changes. HOSPITAL COURSE: 1. Hypoxic hypercarbic respiratory failure: The patient was initially admitted to the Medical Floor for treatment of her multi-lobar pneumonia. She initially maintained an oxygen saturation of greater than 95% on three liters of nasal cannula, however, developed hypoxia to 80% with saturation of 90% on non-rebreather, in the setting of a narrow complex tachycardia while she was on the floor. However, the patient remained hypoxic at about 96% on a nonrebreather; therefore she was transferred to the Fenard Intensive Care Unit. In the Intensive Care Unit her arterial blood gas revealed a pH of 7.16, a pCO2 of 74 and pO2 of 94 with abnormal mental status. The patient's culture data revealed a Methicillin resistant Staphylococcus aureus pneumonia and the patient's antibiotic regimen was changed to Vancomycin. There was also a question of aspiration. The patient was initially tried on a trial of Bi-PAP, however, she did not tolerate this very well and her mental status decreased to the point of requiring intubation. Initially there was significant confusion regarding her code status, as on a previous admission it was documented that she wanted to be resuscitated but did not want to be intubated. So, after discussion with various of her attendings and given her clinical status, the decision was made to intubate the patient as she was in acute respiratory distress. The patient continued to require high ventilatory support and had adult respiratory distress syndrome physiology. 2. Tachycardia: The patient, just prior to her transfer to the Intensive Care Unit, had a tachycardia that was presumed to be either an atrial tachycardia versus an NRT. She decreased her rate from the mid 200s to 100 after receiving diltiazem 20 mg intravenously and was followed closely in the Intensive Care Unit. She had multiple episodes of tachycardia and the Electrophysiology Service was consulted as well as the Electrophysiology physician, [**Name10 (NameIs) **], occasionally her rhythm would break with Idenosine and occasionally with Diltiazem and eventually she was on a diltiazem drip. There was a question of amiodarone loading as well. Of note, her Sotalol, which she had been maintained on as an outpatient, had been discontinued during her hospital course as she had started to develop renal failure. 3. Hypotension: The patient remained hypotensive after she was intubated and was not fluid responsive. Her MAPs were around 50. She was started on norepinephrine and vasopressin and the etiology was thought to be sepsis although it then also became cardiogenic later in her hospital course. 4. Acid Base: The patient had a mixed respiratory and metabolic acidosis. She was given intravenous fluids and her respiratory status was maintained with a ventilator, although it was very difficult to correct her acid base status given her overwhelming sepsis as well as her worsening renal failure. 5. Acute Renal Failure: The patient had worsening renal failure likely secondary to acute tubular necrosis with anuria. CVH was debated upon, however, ultimately a change in the patient's code status did not require use of this node of volume removal. DISPOSITION: After extensive discussion with the family, initially the patient was clearly full code as she was intubated, ventilated and on pressors, however, after two to three family meetings and multi-system organ failure including cardiovascular, pulmonary, renal with overwhelming sepsis, Methicillin resistant Staphylococcus aureus pneumonia and progressive overall worsening, it was decided that goal for care would change from "Do Not Resuscitate" "Do Not Intubate" followed by COMFORT MEASURES ONLY status. The patient had multiple family members who came to see her prior to her demise. The patient expired at 03:55 a.m. on [**2198-2-18**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Name8 (MD) 231**] MEDQUIST36 D: [**2198-4-5**] 13:13 T: [**2198-4-6**] 22:25 JOB#: [**Job Number 9246**] ICD9 Codes: 4280, 5845, 4275, 0389, 2761, 4271
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Medical Text: Admission Date: [**2124-10-6**] Discharge Date: [**2124-10-12**] Date of Birth: [**2068-11-10**] Sex: F Service: MED Allergies: Azmacort / Clindamycin / Versed / Fentanyl / Morphine Attending:[**First Name3 (LF) 6114**] Chief Complaint: hematuria Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: 55-year-old female with MMP including demyelinating syndrome, neurogenic bladder, adrenal insufficiency, and recent admission for exacerbation of asthma/COPD with elevated WBC who was found on that admission to have L renal infarct with associated arterial thrombosis, hepatic artery tortuosity/aneurysm, secundum ASD and a negative hypercoag work-up although warfarin anticoagulation has been continued with INR goal [**1-18**] maintained. . On [**2124-10-5**], 1 d. PTA, the patient noted to Dr. [**First Name (STitle) **], her primary care provider that she has been having gross urinary bleeding when voiding; she notes passing a bolus of blood "the size of a softball." In order to determine if the bleeding was vaginal or urinary in nature, she straight-cathed herself and note that there was blood and clots in the urine. Her INR on that day was therapeutic at 2.6 on warfarin 7 mg po qhs. She was then directed to the [**Hospital1 18**] ED. . On presentation, she notes that she previously has had hematuria, but can't remember the details due to memory problems she attributes to her demyelinating syndrome. She also admits to a craming pain in the abdomen which she cannot quantify, but is loated at the left abdomen and radiates downward and to the back. She denies nausea, but does admit to one episode of mildly bloody, mildly bilious emesis, although she cannot remember the details. She denies diarrhea, melena, or BRBPR. She denies fevers and night sweats. She admits to epistaxis occuring over the last number of days and says that she had cauterization of the nose performed to stop the bleeding but does not recall where or by whom. Past Medical History: Left renal infarct with arterial thrombosis. ASD, secundum ? hepatic artery aneurysm ?h/o eosinophilia Asthma. Restrictive lung disease. Unknown demyelinating syndrome (L leg paresis, bilateral arm weakness, demyelination on brain MRI, neurogenic bladder) Adrenal insufficiency. Osteoporosis. Hypothyroidism. History of chest nodules. Dyslipidemia. History of K breast papilloma with nipple discharge. Anxiety. Labile hypertension. History of right IJ thrombus in [**2112**]. IgG deficiency. Anemia. Status post cholecystectomy in [**2112**]. Dysfunctional uterine bleeding by history. Atypical pap smears. Common bile duct stenosis s/p sphincterotomy. Gastritis and prepyloric ulcers per EGD. Bilateral hearing loss. G-tube and self-catheterization Social History: The patient states she lives with her husband. Over 50 pack year smoking hx; quit in [**2109**]. Denies any recent alcohol or IV drug abuse. Family History: Family history is notable for coronary artery disease. Father had [**Name2 (NI) 499**] cancer, her mother had breast cancer, and her sister had brain cancer. Physical Exam: Physical Exam: Vital signs Temp: 99.6 F Pulse: 90 bpm BP:132/86 RR: 17/min O2Sat: 86%,RA . Gen: Drowsy, pleasant 55y/o female in no respiratory distress. Derm: skin normal coloration, no rash. HEENT: Eyes: no scleral icterus. PERRLA, EOM full but jerky with occasional dipping movements. Ears: normal shape and external auditory canals. Reduced hearing in R ear on finger rub test. Nose: septum midline: + epistaxis. Throat: Oropharynx clear. Mucous membranes tacky. Top and bottom dentures. No LAD. No thyromegaly. Pulm: Reduced movement of air. No dullness to percussion. No audible wheezing, rhonchi, or bronchial breath sounds. CV: S1, S2 normal, RRR. III/VI systolic harsh murmur loudest at base with some radiation to RUSB. Abd: Nonobese, vertical well-healed scar right of midline. Bowel sounds present but not hyper/hypoactive. No aorta/renal artery bruits. Voluntary +/- involuntary guarding, severe tenderness left lower quadrant, no detectable masses. No hepatosplenomegaly. CVA: Tender to percussion on the left CVA and only slightly on the right CVA. Ext: Pedal and radial pulses [**1-18**]+, somewhat bounding. No edema. Neuro: Muscle tone decreased in both LEs, L less tone than R; rigidity in both LEs, L>R. Hip flexors symmetric and [**4-19**]. Knees, ankles and toes [**3-20**] left, [**4-19**] right. Light touch sensation intact in upper and lower extremities and face. Pertinent Results: On previous admission: HCV Ab, HepBsAg, HBsAb, GHcAb all negative [**Doctor First Name **] negative B2microglob, ATIII, protC, protS, V leiden, LAC, aCL all negative C3 118, C4 20 * ANCA ([**Hospital1 **]) borderline positive by indirect IF, pANCA pattern * On this admission: [**2124-10-5**] 11:15PM WBC-10.3# HCT-37.4 PLT COUNT-530* MCV-99* RDW-14.6 [**2124-10-5**] 11:15PM NEUTS-72.8* LYMPHS-20.3 MONOS-4.9 EOS-1.4 BASOS-0.6 [**2124-10-5**] 11:15PM MACROCYT-1+ [**2124-10-5**] 12:17PM PT-20.3* INR(PT)-2.6 [**2124-10-5**] 11:15PM SODIUM-140 POTASSIUM-3.7 CHLORIDE-101 BICARB-28 UREA N-12 CREAT-0.9 GLUCOSE-88 * [**2124-10-5**] 12:17PM CHOLEST-232* * [**2124-10-6**] 09:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2124-10-6**] 09:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2124-10-6**] 09:50AM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 CT Abd/Pelvis w&w/o contrast ([**2124-10-6**], 01:49a): 1) Mild to moderate hydronephrosis of the left kidney which extends down to the mid ureter with perinephric stranding. There is hyperattenuating fluid within the left renal collecting system consistent with an obstructing clot. 2) Peripheral, wedge-shaped areas of hypoenhancement within the left kidney are improved when compared to previous study without evidence of cortical scarring. This may indicate that these areas of hypoattenuation represented infection or inflammation rather than infarcts. 3) 2 cm soft tissue nodule in the left anterior abdominal wall which is new since the previous study and may represent a small hematoma. PA AND LATERAL CHEST ([**2124-10-6**]): The heart size is at the upper limits of normal. The mediastinum is not widened. There is minimal left basilar atelectasis. There is no evidence of pneumonia or failure. The previously visualized right middle lobe opacity has resolved. Brief Hospital Course: ## Hematuria. The patient has left renal infarction and right renal vein thrombosis. TEE has documented the presence of a secundum ASD, raising the possibility of paradoxical embolus. Pyelonephritis is also a consideration, considering the findings on CT, but bleeding is out of proportion to other findings. The patient has been anticoagulated on warfarin and perhaps has been supratherapeutic, causing hemorrhage of the infarcted kidney. Because the infarcted kidney may have a higher propensity to bleeding, we will hold anticoagulation and institute a lower dose of warfarin when appropriate aiming for a target INR of 2.0. Once patient transfered to the floor patient had one episode of passing clots and after produced clear urine. Patient was kept on heparin for anticoagulation and started on lower dose of coumadin for goal INR of 2.0. Urology stated that the patient would most likely continue to pass clots but no further intervention was needed at this time since patient with normal urine output. Upon discharge patient sent home with coumadin and bridged with lovenox. ## Klebsiella urosepsis - Patient found to be septic and transfered to the MICU. Patient hypotension responded well to fluids and given Zosyn for coverage. Patient urine culture and blood culture came back positive for KLEBSIELLA PNEUMONIAE. After 1 day in the MICU patient was transferred back to the floor and continued on Zosyn. When the sensitivities came back it was found that the Klebsialla was only intermediate sensitive to Zosyn and patient was switched to meropenum. Patient was continued on meropenum upon discharge. ## Epistaxis: Likely also secondary to supratherapeutic anticoagulation. Recently received cautery to limit epistaxis. . ## Rheumatologic Disease: The patient's hematuria, epistaxis, and hemoptysis, coupled with her history of thrombosis, history of "demyelinating disease," and the presence of hepatic artery irregularity suggest the possibility of a unifying rheumatologic diagnosis of vasculitis. pANCA was borderline positive and and an extensive hypercoagulability work-up was negative. Nevertheless, the hematuria may be explained by renal infarction, and epistaxis may be underlying the hemoptysis. . ## ?Hypercoaguability: Renal vein thrombosis may be caused by a thrombophilia but an hypercoagulability work-up was negative. Cancer screening with colonoscopy and mammogram is up to date and negative for malignancy. The patient does have a family history of malignancy, but has no other stymptoms to suggest a specific malignancy and has been imaged thoroughly. A chest nodule is stable on follow-up. The patient is due for a pap smear. . ## Adrenal insufficiency - Patient given stress dose steroids in the MICU when she was found to have urosepsis. Upon transfer to the floor patient put on PO prednisone and slowly tapered. . Medications on Admission: ADVAIR DISKUS 500-50MCG--Use one puff by mouth twice a day ALBUTEROL --Take 2 puffs four times a day ALBUTEROL SO4 0.083 %--One neb q 4-6 hrs as needed [**Doctor First Name **] 60MG--Take one by mouth twice a day BACLOFEN 10 MG--Two tabs three times a day BECLOMETHASONE (NASAL) --Take 2 sprays each nostril twice a day CALCIUM CARBONATE 500MG--Take one by mouth three times a day with meals CLONAZEPAM 1 MG--Two tabs three times a day COLACE 100MG--Take one by mouth three times a day while on narcotics to soften stool COUMADIN 7MG QHS to maintain inr [**1-18**] CYCLOBENZAPRINE 10 MG--Take one pilll up to three times a day as needed IPRATROPIUM BROMIDE 14 GM--2-3 puffs inh four times a day LEVOXYL 50MCG--Take one pill every day LIPITOR 10MG--Take one pill every day LORAZEPAM 1MG--One by mouth three times a day as needed NUTREN 1.0/FIBER --One can three times a day as needed PREDNISONE 5MG--As directed, discontinued [**2124-9-23**] RANITIDINE 150 MG--One by mouth twice a day ROXICET 5 MG/325 MG--[**12-17**] by mouth every 4-6 hours as needed for pain ULTRAM 50MG--One to two every 6 hours as needed VITAMIN D 400U--Take one by mouth every day [**Month/Day (2) **] 4MG--Two every 6 hours as needed for spasms Discharge Medications: 1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (). 3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD (). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (). 9. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 3 days: Please take 40mg tab (two 20mg tabs ) once a day for 3 days starting on [**2124-10-13**] . Disp:*6 Tablet(s)* Refills:*0* 11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO qd () for 3 days: Please take 30mg prednisone (three 10mg tabs) once a day for 3 days after finishing course of 40mg prednisone. Disp:*9 Tablet(s)* Refills:*0* 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 3 days: Please take 20mg prednisone once a day for three days (one 20mg tab) after finishing three day course of 30mg prednisone. Disp:*3 Tablet(s)* Refills:*0* 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 3 days: Please take 10mg prednisone (one 10mg tab) once a day for three days after finishing 3 day course of 20mg prednisone. Disp:*3 Tablet(s)* Refills:*0* 14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 3 days: Please take 5mg prednisone once a day for three days after finishing 3 day course of 10mg prednisone. Disp:*3 Tablet(s)* Refills:*0* 15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 17. Tizanidine HCl 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 18. Meropenem 1000 mg IV Q8H 19. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous twice a day for 7 days. Disp:*14 ml* Refills:*3* 20. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 21. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for 6 months. Disp:*180 Tablet(s)* Refills:*3* 22. Outpatient Lab Work Patient should have her INR checked on Saturday, [**2124-10-14**] and Monday, [**2124-10-16**]. Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Hematuria Klebsiella urosepsis Discharge Condition: Patient is tolerating PO, urinating and having bowel movements without difficulty. Discharge Instructions: Please continue to lovenox until INR level becomes therapeutic. You will have to have your blood work (INR) checked every [**1-18**] days to determine if the level therapeutic. INR goal is 2. If INR < 2 continue to take lovenox along with the coumadin. If the INR is >2.5, please hold your coumadin dose. Please follow up with your primary care doctor, Dr. [**First Name (STitle) **] next Thursday [**10-19**] to have INR checked and coumadin adjusted if need be. Please finish prednisone taper as prescribed, 40mg for 3 days first, then 30mg for three days, then 20mg for three days, then 10mg for three days, and finally 5mg for three days. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2124-10-18**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-10-19**] 11:20 Patient needs her INR checked on Saturday, [**10-14**] as well as on [**10-16**]. Scripts are included for this lab work and patient should call her PCP later that day to get the results and titrate her doses of lovenox/coumadin as recommended above. ICD9 Codes: 5990
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Medical Text: Admission Date: [**2126-9-22**] Discharge Date: [**2126-10-7**] Date of Birth: [**2062-8-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Tetracycline Analogues / Keflex / Propofol Analogues / Vancomycin / Nuts / Pepper / Eggs / Coconut / Bleach / Aztreonam / Carbapenem / Erythromycin Base Attending:[**First Name3 (LF) 783**] Chief Complaint: Mechanical Fall w vertebral fracture Major Surgical or Invasive Procedure: orthopedic surgery fixation of thoracic spine intubation mecanical ventilation [**First Name3 (LF) **] transfusion History of Present Illness: This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline 2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid obesity, asthma, hypothyroidism and anxiety who was transferred to [**Hospital1 18**] s/p mechanical fall from OSH ED ([**Hospital 36837**] Healthcare. The patient fell down 10 stairs at her son's house. Per report there was possible LOC and head strike, CT head in OSH ED negative for ICH or fracture, but positive for subgaleal hematoma at the vertex. CT spine showed T10 vertebral body fx, T8-10 spinous process fx and R tranvsverse fx of T11-12. She was briefly hypotensive in the ED, SBP nadir 80s with improvement to 133 after 1L NS and was transferred to [**Hospital1 18**] for further management. At OSH ED she also got Zofran, Tylenol, Lidoderm patch. In the [**Hospital1 18**] ED, VS 109/38 64 20 98% 2L. Admission labs notable for K 6.2 (not hemolyzed), Cr 3.3 (baseline 2.0-2.5), HCT 29 (baseline 32-35), INR 1.0, CK 2056. There were no EKG changes and she received 10U Regular Insulin, 1 amp D50 and Kayexalate x1, with improvement in her K to 5.8, but worsening renal failure (Cr 4.2) and rising CK (3045). She was seen by ACS and Ortho Spine and was neuro intact, no urinary retention or incontinence of bowel or bladder. She is being transferred to medicine for [**Last Name (un) **] and hyperkalemia, plan for OR tonight with Ortho-Spine for stabilization of transverse T11-12 fractures. Consulting services are ACS, Ortho-Spine and Neurosurgery. Documented UOP 300cc in past 12 hours. She was seen by ACS and Ortho Spine and was neuro intact, no urinary retention or incontinence of bowel or bladder. ROS: The patient says she has had increased muscle/joint aches recently which she attributes to OA. She has felt increasingly disoriented and dizzy recently. She says her vision has seemed cloudier recently. Past Medical History: - OSA on CPAP - DMII, peripheral neuropathy - CKD baseline 2-2.5 - HTN - dCHF (LVEF >55%) - morbid obesity - asthma - hypothyroidism - anxiety Social History: Lives with her husband, [**Name (NI) 9102**], in [**Name (NI) 5871**]. She has a son who lives in [**Name (NI) 36838**]. Former smoker, denies alcohol or illicit drug use. Family History: Mother- MVP, hypothyroid. Father- lung CA, smoker, mets to brain. Brother- healthy, lives in [**Name (NI) 4565**], 3 sons, all healthy. Physical Exam: ADMISSION PHYSICAL EXAM VS - 99.1 120-145/41-60 70-82 20 96% 2L NC GENERAL - well-appearing woman in NAD, comfortable, appropriate, lying flat on her back. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - obese, no elevation in JVP appreciated. LUNGS - CTA anteriorly, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Uncomfortable lying all the way flat, more comfortable with head of the bed raised 10 degrees. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-18**] in LEs, sensation grossly intact throughout. DISCHARGE PHYSICAL EXAM VS - 98.2 Tmax 100.3 136/82 72 20 99%RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, lying flat on her back. HEENT - + mild TTP over frontal and maxillary sinuses, improved from prior, NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - obese, no elevation in JVP appreciated. LUNGS - CTABL, no r/rh/wh, good air movement anteriorly, resp unlabored, no accessory muscle use. Breath sounds distant [**2-14**] obesity HEART - PMI non-displaced, RRR, + 3/6 systolic murmur heard best at LUSB, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS [**2126-9-22**] 08:23PM URINE HOURS-RANDOM UREA N-425 CREAT-209 SODIUM-13 POTASSIUM-85 CHLORIDE-12 [**2126-9-22**] 08:23PM URINE OSMOLAL-383 [**2126-9-22**] 07:30PM GLUCOSE-217* UREA N-73* CREAT-4.3* SODIUM-131* POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-24 ANION GAP-15 [**2126-9-22**] 07:30PM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-2.0 [**2126-9-22**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2126-9-22**] 06:00PM URINE [**Month/Day/Year 3143**]-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-SM [**2126-9-22**] 06:00PM URINE RBC-32* WBC-9* BACTERIA-NONE YEAST-NONE EPI-0 [**2126-9-22**] 06:00PM URINE MUCOUS-RARE [**2126-9-22**] 06:00PM URINE EOS-NEGATIVE [**2126-9-22**] 01:00PM GLUCOSE-257* UREA N-68* CREAT-4.2* SODIUM-133 POTASSIUM-5.8* CHLORIDE-97 TOTAL CO2-25 ANION GAP-17 [**2126-9-22**] 01:00PM CK(CPK)-3045* [**2126-9-22**] 01:00PM cTropnT-0.04* [**2126-9-22**] 01:00PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.9 [**2126-9-22**] 06:20AM GLUCOSE-223* UREA N-62* CREAT-3.5* SODIUM-133 POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-22 ANION GAP-19 [**2126-9-22**] 06:20AM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.9 [**2126-9-22**] 01:20AM GLUCOSE-234* UREA N-62* CREAT-3.3* SODIUM-131* POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-23 ANION GAP-16 [**2126-9-22**] 01:20AM estGFR-Using this [**2126-9-22**] 01:20AM CK(CPK)-2056* [**2126-9-22**] 01:20AM COMMENTS-GREEN TOP [**2126-9-22**] 01:20AM K+-5.9* [**2126-9-22**] 01:20AM WBC-7.2 RBC-3.14* HGB-9.5* HCT-29.0* MCV-92 MCH-30.1 MCHC-32.6 RDW-13.0 [**2126-9-22**] 01:20AM NEUTS-84.7* LYMPHS-10.5* MONOS-4.3 EOS-0.3 BASOS-0.2 [**2126-9-22**] 01:20AM PLT COUNT-218 [**2126-9-22**] 01:20AM PT-11.0 PTT-30.1 INR(PT)-1.0 K 6.2-->5.8-->5.3-->5.3 Cr 3.3-->3.5-->4.2-->4.3-->4.1-->3.9-->4.1 MICROBIOLOGY BCx [**9-25**] x2: No Growth BCx [**10-2**]: pending URINE CULTURE (Final [**2126-9-25**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**2126-9-25**] 4:43 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2126-9-29**]** GRAM STAIN (Final [**2126-9-25**]): [**11-7**] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2126-9-29**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Sensitivity testing performed by Sensititre. [**2126-10-4**] 9:24 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2126-10-4**]): [**11-7**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. [**2126-10-2**] 10:20 am [**Month/Day/Year 3143**] CULTURE **FINAL REPORT [**2126-10-5**]** [**Month/Day/Year **] Culture, Routine (Final [**2126-10-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>2 R ERYTHROMYCIN---------- =>4 R GENTAMICIN------------ 2 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S IMAGING OSH IMAGING CT Abd Pelvis w/o contrast: - Rt 11th posterior rib fracture, appears acute - T10 Vertebral body fracture (s7:52), t8, 9, 10 spinous process fractures. Rt trv process fracture pf T11, T12 - Right buttock and low back hematoma - 12 x 19 x 12 cm mass in pelvis - peripheral calcification, central areas of fat and soft tissue - likely represents a large dermoid. - gallstones. atrophic kidneys. CT Head w/o contrast: subglaleal hematoma at the vertex CT C-spine: Congenital unfused anterior and posterior arch of C1. Congentital fusion of C2 and C3 vertebral bodies. No fracture. Degenerative disease C5-7. L hip and AP pelvix 3 views: No acute fracture or dislocation L spine, 2 views: Degenerative changes in the lumbar spine, no acute fracture Thoracic spine, 2 views: Diffuse degenerative changes with overhanging osyeophyte formation. Possible ankylosing spondylitis. [**Hospital1 18**] IMAGING MRI Entire spine [**2126-9-22**] 1. There are 11 thoracic vertbral bodies. This results in a discrepancy between the CT and MRI vertebral level labeling. Utilizing 11 vertebral bodies with this report's numbering system, the T9 vertebral body is fractured. T9 vertebral body fracture without retropulsion or compromise of the spinal canal. The anterior longitudinal ligament is disrupted at this level. If there is to be surgical intervention, consider correlation at time of surgery with plain radiographs. 2. Increased fluid signal in the L4-L5 and L5-S1 intervertebral discs may reflect disc injury or alternatively may reflect normal signal which appears higher than expected due to degenerative loss of normal high signal in the adjacent intervertebral discs. 3. Spinous process and transverse process fractures in the lower thoracic spine are better appreciated on the prior CT. DISCHARGE LABS [**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] WBC-5.3 RBC-2.57* Hgb-7.8* Hct-24.4* MCV-95 MCH-30.2 MCHC-31.7 RDW-14.3 Plt Ct-486* [**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] Glucose-80 UreaN-63* Creat-2.5* Na-142 K-4.0 Cl-108 HCO3-24 AnGap-14 [**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] ALT-56* AST-48* AlkPhos-104 TotBili-1.7* Brief Hospital Course: This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline 2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid obesity, asthma, hypothyroidism and anxiety who was transferred to [**Hospital1 18**] s/p fall down stairs, found to have thoracic vertebral fractures. # Traumatic thoracic spine vertebral body fractures: S/P fall down 10 stairs. No signs and symptoms of cord impingement, rectal tone intact. The patient was planned for urgent orthopedic fixation procedure but CPK and Cr found to be rising with decreasing urine output, so transfered to medicine for stabilization before surgery (see below). Patient was optimized medication and underwent open reduction of T fracture/dislocation, and T8-T12 posterior fusion and instrumentation on [**9-24**], with estimated [**Month/Year (2) **] loss of 1300 mL. PT saw patient and recommended rehab. Post surgical pain well controlled with medication at time of DC. # Respiratory Failure/Shortness of breath: Post operatively, extubation was difficult [**2-14**] increased fluid balance. Patient was optimized and was subsequently extubated after diuresis. Of note, in the ICU Sputum Cx were sent emperically and grew MSSA. When the patient was extubated she was afebrile without cough or prominent pulmonary sx, so the decision was made not to treat. Patient has paroxsyms of breathlessness without hypoxia. CXR and CT torso was otherwise unremarkable. - Patient will need to continue CPAP while at rehab and would benefit from outpatient pulmonary follow-up. # Acute on chronic renal failure: The patient was oliguric at presentation, urine output improved with gentle fluids (fluid recussitation limited by h/o CHF and limitation that patient must lie flat). All meds renally dosed, and nephrotoxic meds held until Cr improved. [**Last Name (un) **] thought likely [**2-14**] pre-renal. After IVF, PRBC, and diuresis in the ICU, the patient's Cr normalized to baseline (2.0-2.5). # S/P Fall: Unclear history of loss of consciousness leading to fall with Thoracic fractures, and the patient endorses several months of feeling dizzy. CPK ~3000 at peak, thought to represent mild rhabdo. The patient was thought to be volume depleted on presentation, given elevated Cr, low UOP, and good response to IVF and PRBC. Fall could have been [**2-14**] orthostasis, so HCTZ was Discontinued. Alternatively, fall may have been [**2-14**] dizziness and confusion from medication effect, as she was on Topamax 100 HS at the time of the fall. Topamax was DCed. TSH was within normal limites, tele showed no events, felt unlikely to be cardiac in origin. The patient no longer felt dizzy at discharge, but had mobilized very little given post surgical pain. # Anemia: During admission the patient had several episodes of anemia requireing multiple PRBC transfusions. It was felt that [**Last Name (un) **] had led to transient low EPO state. The patient was not felt to be actively bleeding either at her trama/sugical sites or elsewhere. Hct bumped appropriately after PRBC given, and [**Last Name (un) **] improved by time of DC. - recheck Hct in 4 days after admitted to rehab to make sure Hb remains stable. # Sinus infection: The patient complained of sinus pressure and nasal discharge after being extubated, which improved without specific therapy. Thought to be related to a viral etiology. # Diarrhea: The patient was initially constipated having some gassy abdominal pain, so a bowel regimin was started. After that she began having loose stools. Since she had been exposed to Cipro and Levofloxacin, C diff was sent, though suspicion was not high b/c BMx were 1/day and soft not profusely wattery. - C diff pending at time of discharge # LFTs elevated: LFTs were found to be mildly elevated, unclear etiology, not related to acute presentation. - F/U w outpatient PCP to monitor for resolution or pursue futher work up # Blurry vision: The patient says that her R eye had blurry vision since the fall, and improved during admisison. Denies floaters or flashes of light or other worrisome signs of retinal detachment. No other neurological signs. She says she has blurry vision at baseline, and since this acute worsening the vision in her R eye has been getting better since she has been in the hospital. Possible etiologies include dry eyes (has a h/o this), acute hyperglycemic episode (glucose had been 200s-300s), or worsening of known cataracts. # UTI: E. coli grew in urine in the setting of normal UA but [**Last Name (un) **]. UTI may have contributed to [**Last Name (un) **] presentation, so warrents treatment for complicated UTI given DMII. - continue Cipro for a total of 14 day course, last day of therapy is [**2126-10-8**] # MSSA in sputum: The patient had difficulty with extubation after procedure, so sputum cultures were sent and grew MSSA. The patient says she continues to have some SOB, no cough. Has had several low grade temps but has never spiked. Repeat Sputum culture grew the same organism, may represent colonization. - continue to monitor fever curve, if spikes consider treating with linezolid (the patient is Vanc allergic) # Coag negative staph in [**Month/Day/Year **] Cx: No growth from other cultures. Likely contaminent. # DM: The patien was placed on ISS. Dose was decreased for NPO for procedure and while intubated in the ICU. When the patient started eating again she was transiently hyperglycemic with FS 200s-300s, her insulin was titrated back to her home dose and FS improved to well controlled. # Asthma - albuterol prn # OSA - CPAP at night - monitor on continuous O2 monitoring # HTN, HLD, CV risk factors, dCHF: Fluid recussitation was gentle given dCHF. Cont home meds except HCTZ was discontinued. # Hypothyroidism - cont Levothyroxine Sodium 50 mcg PO/NG DAILY # Anxiety - cont Bupropion, hold Topamax because of side effect of dizziness # Pelvic mass: incidentally found on CT abd. Likely dermoid, 12 cm in size. Unlikely to be related to current presentation. The mass was discussed w the patient, and F/U w gynecology was obtained. # L renal cystic lesions: Also incidentally found on CT abd. Unlear if it is a cyst, may need US follow up per PCP. # PPX: pneumoboots and heparin sq (held for surgery, then restarted several days after per ortho recs) TRANSITIONAL ISSUES - Large pelvic mass seen on CT scan, likely dermoid. F/U with PCP and Gyn to further eval and possibly remove mass - L renal cystic lesions, may need US F/U per PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] cultures pending at discharge, will communicate with rehab if positive cultures - Recheck Hct 4 days after admission to rehab to check that Hct is stable. - F/U w outpatient PCP to monitor for resolution of LFT elevations or pursue futher work up Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. BuPROPion 150 mg PO DAILY 2. Gabapentin 100 mg PO HS 3. Lisinopril 2.5 mg PO DAILY 4. Calcitriol 0.25 mcg PO EVERY OTHER DAY 5. Topiramate (Topamax) 100 mg PO HS 6. Simvastatin 10 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO BID 8. Glargine 44 Units Breakfast Glargine 44 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Albuterol Inhaler [**1-14**] PUFF IH Q4H:PRN wheezing 11. Symbicort *NF* (budesonide-formoterol) unknown units Inhalation unknown 12. Carvedilol 25 mg PO BID 13. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Fall thoracic spinal fractures acute on chronic renal failure Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure caring for you at [**Hospital1 827**]. You were admitted after a fall where you sustained spinal fractures, and you were found to have worsening kidney function. You underwent orthopedic surgery for your spinal fractures, and required care in the intensive care unit as well as several transfusions of [**Hospital1 **]. After several days the breathing tube was removing and transfered to the floor. Your kidney function improved with IV fluids. You were discharged to rehab to regain your strength. It is important that you keep all follow up appointments, and take all medications as prescribed. Your CT scan showed a pelvic mass, which you should follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 36839**]t for further evaluation. You will also need follow up with a lung doctor after you leave a rehab. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] ICD9 Codes: 5849, 2851, 5990, 2762, 3572, 2767, 2449, 311, 4280
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Medical Text: Admission Date: [**2145-7-15**] Discharge Date: [**2145-7-20**] Date of Birth: [**2069-3-8**] Sex: F Service: NEUROLOGY Allergies: Coumadin Attending:[**First Name3 (LF) 6075**] Chief Complaint: right sided weakness and confusion Major Surgical or Invasive Procedure: IV TPA History of Present Illness: Pt. is 76 yr old woman with PMH as below called in as code stroke. Last known well at 5:15, then a few minutes later at [**Hospital1 1501**] when she was due to get her meds she was noted to have right sided weakness and confused. EMS called. [**Hospital1 2025**] was on divert, and pt. brought here. Neurology called 5:59 PM. On initial evaluation, she had a NIHSS stroke scale of [**9-22**]. She was not aphasic. She was taken to CT scanner which was negative for any signs of new infarction. STAT labs drawn, no recent surgeries. Contrast allergy to dye, no CTA. Past Medical History: 2 heart attacks b/l CEAs, on coumadin which has been d/c'ed bypass of left carotid htn mild dementia high chol AAA surgery Social History: lives in nursing home/[**Hospital3 **] facility, daughter very involved. remote history of tobacco. Family History: noncontributory Physical Exam: T-not recorded BP-143/94 HR-70 RR-24, 99% RA Gen: lying in bed in mild apparent distress Heent: NCAT, oropharynx clear Neck: supple, no carotid bruits Chest: clear to auscultation b/l CV:regular rate, normal s1s2, no m/r/g Ext: no c/c/e, 2+ dorsalis pedis Neurologic Exam: MS: Oriented to person, place and time. Alert. Able to say months of year backwards. Fluent speech, repetition, naming intact. Memory [**4-15**] registration, recall 0/3 at 5 minutes. No apraxia, neglect, frontal signs. CN: Visual fields intact to confrontation R surgical pupil , L pupil reactive 3->2mm. R eye amblyopia. Eomi without nystagmus. Normal facial sensation R facial droop with [**Month (only) **]. NLF on R side. Hearing intact to finger rub. Palate rises symmetrically. Tongue midline. Motor: Normal tone and bulk. No tremors or fasciculations. The pt. is full strength on left side and antigravity on R hemibody which can easily be overcome. Reflexes: There are [**3-19**] Plantar reflexes Sensory: Intact to pinprick, vibration, proprioception and temperature throughout. Coordination: Intact FTN b/l. Intact [**Doctor First Name **]. Gait: Romberg sign narrow based, stable, good arm swing. Tandem intact. Pertinent Results: [**2145-7-15**] 7:36p Na:145 K:4.8 Cl:105 Glu:146 Comments: Green Top Tube [**2145-7-15**] 7:20p CK: 31 MB: Notdone Trop-*T*: <0.01 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi 142 105 26 --------------< 150 3.9 24 1.0 93 6.0 \ 14.5 / 182 / 42.4 \ PT: 12.2 PTT: 23.4 INR: 0.98 Comments: Note New Normal Range As Of 12 Am [**2145-6-12**] Fibrinogen: 339 Cardiology Report ECG Study Date of [**2145-7-15**] 7:13:42 PM Normal sinus rhythm. Left atrial abnormality. Left axis deviation. Probable left anterior fascicular block. T wave inversions in leads VI-V2 - cannot exclude anteroseptal ischemia. No previous tracing available for comparison. CT HEAD W/O CONTRAST [**2145-7-15**] 7:16 PM Streak artifact limits evaluation of the left temporal lobe. It also limits evaluation of the posterior fossa. There is no evidence of intra or extraaxial hemorrhage. The ventricles and sulci are prominent, probably secondary to age related involutional changes. There is no hydrocephalus, mass effect, or shift of the normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved and the middle cerebral arteries appear symmetric bilaterally. There is some probable calcification of the cavernous carotids bilaterally. Multiple bilateral hypodensities consistent with some lacunar infarcts are seen. The visualized paranasal sinuses and mastoid air cells are clear and the osseous structures are unremarkable. IMPRESSION: No evidence of intracranial hemorrhage, or other acute abnormality. Multiple hypodensities bilaterally consistent with lacunar infarcts. CAROTID SERIES COMPLETE [**2145-7-16**] 1:51 PM FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right, peak systolic velocities are 73, 53, 107 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.4. This is consistent with no stenosis. On the left, peak systolic velocities are 60, 39, 150 in the ICA and CCA, ECA respectively. The ICA to CCA ratio is 1.5. This is consistent with no stenosis. There is antegrade flow in the right vertebral artery. The left vertebral artery is not visualized. IMPRESSION: No evidence of stenosis in either carotid artery status post endarterectomy. Cardiology Report ECHO Study Date of [**2145-7-16**] Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. MR HEAD W/O CONTRAST [**2145-7-17**] 11:43 AM FINDINGS: On the diffusion images increased signal is seen in the left side of the pons. Additionally, a small area of increased signal is seen in the left corona radiata. In absence of ADC map, it is unclear whether this is due to subacute infarcts or T2 shine through. Mild changes of small vessel disease are seen in the periventricular white matter. A chronic right frontal cortical infarct is identified. An area of chronic blood products is also seen in the left frontal subcortical region which could be secondary to prior trauma or ischemia. Moderate changes of some brain atrophy are noted. On coronal images, no evidence of increased signal is seen within the hippocampal region. IMPRESSION: Increased signal on the diffusion images with corresponding T2 abnormalities involving the left side of the pons and left corona radiata could be due to subacute infarcts or due to T2 shine through. In absence of ADC map, this could not be distinguished. Chronic right frontal cortical infarct. Moderate changes of brain atrophy. Brief Hospital Course: 1) Stroke: The patient presented with a right sided paralysis. She was evaluated in the ED and head CT showed no bleed, so she received TPA starting at 8:07 pm. While pushing the TPA, she was thought to develop a right third nerve palsy with pupil sparing, but this resolved. The TPA was stopped, but repeat CT with no bleed, so the remaining dose of TPA was given. She had improvement in the symptoms post-tpa, and the etiology of this was unclear. MRI showed a left pons area of signal intensity on diffusion weighting that corresponded to her weakness, which suggested she had an ischemic stroke. She was continued on aspirin and aggrenox 24 hours after TPA, and her atenolol was held. She was ruled out for MI with two sets of troponins and telemetry showed no events. Echo showed no source of embolism. Carotid ultrasound showed no significant stenosis. She slowly regained function and by the time of discharge back to her [**Hospital3 **] facility she only had mild R sided weakness. PT and OT evaluated her and felt her functioning to be adequate to not require acute rehab or skilled nursing. For secondary stroke prevention she was continued on her aggrenox and was started on a baby aspirin that she should take for two weeks post stroke. 2) Hyperglycemia: Her fasting sugars were initially elevated on presentation. She was kept on an insulin sliding scale and her sugars were less than 150 during admission. If elevated in the future, a hemoglobin A1C should be checked. 3) Hypertension - Her atenolol was initially held and can be restarted approximately 1 week after the ischemic event. 4) Hypercholesterol - she was kept on Niaspan. She was started on Zetia due to an LDL of 212, since her PCP reported that statins had previously been ineffective for her. A statin could be added to synergize with Zetia if her LDL is still not at goal in [**3-18**] months. She should stay on a low cholesterol diet. 5) Peripheral vascular disease - Her trental was continued. 6) Dementia - Her reminyl was continued. The daughter expressed concerns that this medication was not working and she was instructed to discuss the continuation of this medication with her mother's PCP. Medications on Admission: aggrenox niaspan 500 atenolol trental reminyl meclizine tylelol Discharge Medications: 1. Niacin 100 mg Tablet Sig: Five (5) Tablet PO qhs () as needed for inc lipids. Disp:*150 Tablet(s)* Refills:*3* 2. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q 24H (Every 24 Hours). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lansoprazole 15 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* 4. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release Sig: One (1) Cap PO BID (2 times a day). Disp:*60 Cap(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) for 7 days. Disp:*7 Tablet, Chewable(s)* Refills:*0* 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* RESTART ATENOLOL 1 week after discharge. Discharge Disposition: Home With Service Facility: Halmark Health Discharge Diagnosis: Subacute infarct in L pons and corona radiata, chronic right frontal cortical infarct. Discharge Condition: improved, with very mild R hand weakness. Discharge Instructions: please call Dr.[**Name (NI) 5255**] office at [**Telephone/Fax (1) 1694**] to make a follow up appointment. Can restart your atenolol in 1 week. Continue aspirin for 1 more week, then can d/c. Followup Instructions: please call [**Telephone/Fax (1) 1694**] for follow up with Dr. [**Last Name (STitle) 1693**]. You need to give your registration information to his scheduler. ICD9 Codes: 2720, 412, 4019
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Medical Text: Admission Date: [**2135-8-22**] Discharge Date: [**2135-8-28**] Date of Birth: [**2087-5-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2135-8-24**] Coronary artery bypass grafting x4 with a left internal mammary artery graft to the left anterior descending and reverse saphenous vein graft to the ramus intermedius branch, first diagonal branch, and left ventricular branch. History of Present Illness: This is a 48 year old male with a 4 week history of intermittent chest pain. His anginal episodes would last approximately 20 minutes and resolve spontaneously. On the day of admission, he experienced rest pain associated with left arm numbness. He denied SOB, syncope, presyncope, nausea, vomiting and diaphoresis. He sought medical attention at the [**Hospital1 18**]. While in the EW, his chest pain was relieved with sublingual Nitro and Morphine. His first set of cardiac enzymes were negative. He was subsequently admitted for further evaluation and treatment. Past Medical History: Active smoker - 1ppd for 20 years Hypercholesterolemia History of spontaneous bilateral pneumothoraces - s/p pleurodesis Hemorrhoids Polypectomy - [**2134-12-11**] Social History: Active smoker, 20 pack year history. Admits to several alcoholic drinks per day. He works as a consultant. He lives with a male partner. Family History: Unknown, patient adopted Physical Exam: Vitals: BP 110-130/70-90, HR 64-78, RR 18, SAT 98% RA General: Well developed male in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD Heart: REgular rate, normal s1s2, no murmur LUngs: Clear bilaterally Abd: Soft, nontender Ext: Warm, no edema Pulses: 2+ distally, no carotid/femoral bruits Neuro: Nonfocal Pertinent Results: [**2135-8-28**] 04:55AM BLOOD Hct-28.4* [**2135-8-27**] 05:24AM BLOOD WBC-12.5* RBC-2.79* Hgb-9.2* Hct-26.5* MCV-95 MCH-33.0* MCHC-34.8 RDW-14.0 Plt Ct-187 [**2135-8-27**] 05:24AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-135 K-3.9 Cl-100 HCO3-26 AnGap-13 [**2135-8-27**] 05:24AM BLOOD Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 26581**] was admitted and ruled out for a myocardial infarction. The following day, he underwent stress testing which was notable for ischemic ECG changes with angina. Nuclear imaging revealed severe and reversible anterior wall defects extending from the apex to the mid chamber; and a moderate, reversible defect in the inferior wall, most notable in the mid chamber. There was global hypokinesis with apical akinesis. There was ischemic dilatation with an end-diastolic volume of 177 ml. The left ventricular ejection fraction was 33%. Subsequent cardiac catheterization showed a right dominant system with severe three vessel disease. Left venriculography showed a preserved ejection fraction of >60% with mild anterolateral hypokinesis. Angiography showed that the LAD had a long 90-99% stenosis after the first septal extending to the origin of D2; the Ramus had an ulcerated 60-70% plaque in its proximal segment; the circumflex had an ulcerated stenosis and was totally occluded after a large collateral to the RCA; the OMs were small and occluded; and the RCA was occluded proximally and filled with L->R collaterals. Based on the above results, cardiac surgery was consulted and further evaluation was peroformed. Workup was essentially unremarkable and he was cleared for surgery. On [**2135-8-24**], Dr. [**Last Name (STitle) **] performed four vessel coronary artery bypass grafting. Within 24 hours, he awoke neurologically intact and was extubated without incident. He weaned from inotropic support without difficulty. He was transfused with PRBC to maintain hematocrit near 30%. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. Over several days, medical therapy was optimized. He responded well to Lasix and by discharge, was near his preoperative weight with oxygen saturations over 90% on room air. He remained in a normal sinus rhythm. The rest of his postoperative course was routine and he was discharged to home on postopertive day four. Medications on Admission: None Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(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. 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* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Hypercholesterolemia hemorrhoids h/o spontaneous bilateral pneumothorax s/p pleurodiesis Coronary artery disease - s/p CABG Discharge Condition: Stable Discharge Instructions: Shower, wash incision with soap and water and pat dry. No lotions, creams, powders, or baths. Call with fever, redness or drainage from incisions, or wieght gain more than 2 pounds in one day ro five in one week. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks. Dr. [**Last Name (STitle) 5781**] in 2 weeks. Completed by:[**2135-9-28**] ICD9 Codes: 4111, 2720, 3051
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Medical Text: Admission Date: [**2187-3-26**] Discharge Date: [**2187-4-5**] Date of Birth: [**2105-12-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2972**] Chief Complaint: LLQ Pain and BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: 81 y/o M w/ h/o AAA s/p repair, colon ca s/p sigmoidectomy, diverticulitis, prostate cancer, and non-small cell lung cancer p/w 4 days of LLQ pain. Patient states that for the past four days he has had a band like abdominal pain across his lower abdomen. On day of admission his home health aide noted bright red blood in his stools and so patient referred to the ED. . In the ED, initial vs were: VS 97.8 106 129/83 18 100%. Patient with BRB on DRE and mild LLQ pain (intermittent). HR improved with 1L NS. CT A/P done in ED showed no acute abdominal pathology c/w patient's symptoms. Patient was observed and had one further episode of BRBPR in the ED prior to ICU transfer. Repeat Hgb went from 10.9 on arrival to 8.2 (baseline Hgb [**11-19**]). . On arrival to the ICU, patient comfortable with stable VS. On further questioning, denies any recent f/c/n/v/ns/diarrhea/ constipation/weight gain or weight loss/chest pain/syncope or other complaints. Denies melena. Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Medical History: 1) Non Small Cell Lung Cancer: found during [**5-13**] hospitalization, s/p LUL lobectomy [**2183-7-28**], complicated by left recurrent laryngeal nerve palsy. 2) Abdominal Aorta Aneurysm: s/p repair [**5-13**] 3) Colon Carcinoma: s/p sigmoid colectomy [**2171**] 4) Prostate cancer: s/p radical prostatectomy [**2169**] 5) 3 vessel CAD w/ hx remote MI in [**2164**] - no stents 6) Hypercholestermia 7) h/o recurrent small bowel obstructions 8) Diverticulitis 9) HTN 10) Hypercholesterolemia 11) Squamous cell cancer of face surgically resected and getting XRT. Social History: Lives alone but has a HHA/VNA. Son is nearby. He has two children and seven grandchildren. Previously he worked for the electric company as a street lamp worker. Habits: 20 pack year smoking history, quit 20 years ago. Quit alcohol 50 years ago, drank scotch "for a long time." Denies any other drug use. Not currently sexually active. Family History: His son is a diabetic. Brother died of myocardial infarction in his 70s. He had a brother with a myocardial infarction in his 80s. His mother died of cardiogenic shock in her 80s. His father also died from "heart problems." Physical Exam: On admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2187-3-26**] 06:25PM BLOOD WBC-8.2 RBC-3.30* Hgb-9.7* Hct-27.9* MCV-84 MCH-29.2 MCHC-34.6 RDW-16.1* Plt Ct-203 [**2187-3-26**] 06:25PM BLOOD PT-13.1 PTT-22.8 INR(PT)-1.1 [**2187-3-27**] 12:29AM BLOOD WBC-7.0 RBC-3.34* Hgb-9.9* Hct-28.2* MCV-84 MCH-29.6 MCHC-35.1* RDW-16.0* Plt Ct-145* [**2187-3-27**] 12:40AM BLOOD Hct-26.2* [**2187-3-27**] 09:41AM BLOOD Hct-27.9* [**2187-3-26**] 06:25PM BLOOD Glucose-135* UreaN-28* Creat-1.2 Na-137 K-4.8 Cl-103 HCO3-21* AnGap-18 . Imaging: [**2187-3-26**] CT Abdomen/Pelvis Impression: 1. Status post sigmoid colectomy and prostatectomy. No small-bowel obstruction. Moderate fecal load, limiting the evaluation of intraluminal colonic mass but no obstructing mass is noted. No colonic wall thickening. No acute diverticulitis. 2. Right inguinal hernia with a loop of non-obstructed small bowel. Fat-containing left inguinal hernia. 3. Interval progression of T12 compression fracture since [**2183**] with now almost complete loss of vertebral height, but minimal retropulsion into the spinal canal. 4. Stable left adrenal nodule. Cholelithiasis without acute cholecystitis. Unchanged increased lung base interstitial marking suggestive of pulmonary fibrosis. 5. Status post AAA repair with persistent thrombosed [**Female First Name (un) 899**]. 6. If clinical concern remains high for colonic mass, recommend followup with colonoscopy. . [**2187-3-27**] CXR Cardiac size is top normal. There is no change in diffuse emphysema and peripheral reticular abnormality, left greater than right, consistent with pulmonary fibrosis. There is evidence of loss of volume in the left lung consistent with left upper lobe wedge resection. Mild increase opacity of the left lower lobe is likely atelectasis. There is no pneumothorax or pleural effusion. There are no new lung abnormalities suggestive of pneumonia. . [**2187-3-28**]: colonoscopy: Diverticulosis of the whole colon. Large amount of old blood and clots were seen throughout the colon, but not in the terminal ileum. This is likely a right-sided diverticular bleed. No active, ongoing bleeding at present. Limited view of mucosa given extensive old blood. Brief Hospital Course: Acute blood loss anemia [**1-9**] GIB: The patient was initially admitted to the MICU for a GI bleed. Serial hematocrits were stable after receiving 2 units of PRBCs from [**3-26**] (admission)-[**3-27**] and he was transitioned to the regular medical floor. Pt was maintained with 2 large bore IVs, active type and screen, consented and crossmatched. His home aspirin and antihypertensives were held. GI was consulted and recommended colonoscopy for the morning on [**2187-3-28**]. Colonoscopy showed multiple diverticuli and bleeding (see above). Overnight on [**5-3**] pt had 2 episodes large volume BRBPR with HR in 110s. Pt recieved 2U of PRBCs and did not have further bleeding until [**3-30**] when he started to have melanotic stools. His hematocrit was trending down and he was transfused to a hematocrit of >28. His melana resolved and GI felt an EGD would not be necessary at this time. It was felt his melana was residual blood from his previous bleed. In total pt recieved 6 [**Location 2984**] throughout hospitalization. # Dementia: continued namenda # Hypertension: lisinopril and metoprolol were held. They were held upon discharge as well and based on patient's outpatient blood work and blood pressure readings, the decision should be made in the outpatient to restart these medications. # CAD: aspirin was held # SC nodule: pt was noted to have a small subcutaneous nodule very low in LLQ. Pt stated that it had been present for many years (though pt is variable historian). Management deferred to primary care provider. # Prostate/Lung/Colon/Skin cancer: management deferred to outpt providers. # HLD: continued lipitor Medications on Admission: Lipitor 10mg daily lisinopril 5mg daily metoprolol 25mg [**Hospital1 **] namenda 10mg [**Hospital1 **] aspirin 81mg daily (started in last 3-4 weeks) Discharge Medications: 1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Outpatient Lab Work Please check Hematocrit [**Last Name (LF) 2974**], [**4-6**] and send results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**0-0-**]. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: primary: rectal bleeding secondary: htn, hypercholesterolemia Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted for bleeding for bloody bowel movements. You had a colonoscopy which showed out-pouchings of your colon (called diverticulosis) without active bleeding or polyps. The bleeding initially probably came from one of those outpouchings but we could not tell which one. After your colonoscopy, you started having bleeding in your stool again. This time the bleeding slowed down considerably. Your blood levels remained stable. It was felt the minimal blood in your stool was residual blood from your previous bleed. You should follow up with your outpatient doctor for a re-check of your blood level. You also had some difficulty with shortness of breath. A CT scan was performed that did not show any acute concerning causes of shortness of breath. This may be due to underlying lung disease. Your oxygen levels were normal while walking. You should follow up with your doctor for further managment. When you go home please continue your home medications with the following changes: 1. HOLD Lisinopril 5 daily 2. HOLD Metoprolol 25 mg [**Hospital1 **] 3. HOLD Aspirin 81 mg daily ****These two medications should be re-adjusted at your follow up visit on [**Hospital1 766**]. Your blood pressure was not elevated and with concern for bleeding, these were not re-started.*** 4. START Protonix 40 mg twice a day. This will help decrease the acid in your stomach. It is important that you keep all of your doctor's appointments. Followup Instructions: You have the following appointment arranged for you: Name: [**Last Name (LF) **],[**First Name3 (LF) **] B. Appointment: [**Last Name (LF) 766**], [**4-9**], at 3:00 PM at Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **] Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**0-0-**] The GI doctors [**Name5 (PTitle) 2985**] they did not need to follow up with you. If you ever need to see them in the future the number to call Phone: [**Telephone/Fax (1) 2986**] . The doctor you saw in the hospital was [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**], MD. ICD9 Codes: 2851, 4019, 412, 2720
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Medical Text: Admission Date: [**2153-8-2**] Discharge Date: [**2153-8-22**] Date of Birth: [**2095-10-27**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with no significant past medical history. He presented with a three-day history of right upper quadrant and intermittent at first and made better by food; however, he had decreased appetite by the time of admission. He had nausea with one episode of non-bloody vomiting after drinking one cup of soup. He also complained of chest pain, but he did not have any shortness of breath. He reported symptoms of nausea and vomiting one month prior to admission; however, at that time no intervention was taken. He has a primary week. He denied any orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema. He denied fevers or chills. He denied melena, bright red blood per rectum, hematochezia, or [**Doctor Last Name 352**] stool. He did report have report having dark urine. He has decreased appetite. He was initially sent to [**Hospital 8**] Hospital, but he was transferred over here with an Amylase of 2660, total bilirubin of 11, with a direct bilirubin of 7.7. Right upper quadrant ultrasound showed two stones at the common bile duct at 11 mm. PAST MEDICAL HISTORY: He has no past significant medical history or surgical history. MEDICATIONS: Ranitidine 150 mg p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: He is married with a daughter. [**Name (NI) **] works in the trucking business. He reported smoking. Occasional alcohol use. He denied any drug abuse. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 98.8??????, blood pressure 143/77, heart rate 113, respirations 35, oxygen saturation 97% on room air. General: He was alert, awake, and oriented times three. He was in no apparent distress. HEENT: He had icteric sclerae. Pupils equal, round and reactive to light and accommodation. He had no jugular venous distention. Pulmonary: Lungs had decreased breath sounds at the bases. Cardiovascular: He was tachycardiac. No murmurs, rubs or gallops. Abdomen: Nondistended but tender to palpation diffusely, especially at the midepigastric and right upper quadrant area. He had no [**Doctor Last Name 515**] sign. Extremities: He had no clubbing, cyanosis or edema. Neurological: The patient was alert, awake, and oriented times three. Cranial nerves II-XII intact. No motor or sensory deficits. LABORATORY DATA: On admission white blood cell count 7.1, hematocrit 42.5, platelet count 114,000; sodium 137, potassium 4.3, chloride 99, bicarb 22, BUN 32, creatinine 1.9, glucose 115; neutrophils 37, lymphocytes 8, monocytes, 9, 6 bands; ALT 129, AST 77, alkaline phosphatase 191, total bilirubin 6.7, amylase 858, lipase 937. Chest x-ray was with poor inspiratory effort with left hemidiaphragm, elevated and large amount of dilated loops of bowel with gas. He had a right pleural effusion which was moderate to large. Right upper quadrant ultrasound showed a common bile duct of 7.3 mm, thickened gallbladder walls, no fluid, two stones in the gallbladder, non-obstructing, with an echogenic liver. HOSPITAL COURSE: The patient was thought to have acute pancreatitis possibly due to gallstones. 1. GI: The patient was thought to acute pancreatitis possibly secondary to gallstones. He had an ERCP done in which a large stone was found impacted in the distal common bile duct. It was removed with along with a sphincterotomy. His cystic duct was patent though. The biliary tree had mild, diffuse dilatation. Before the procedure and after, he was started on Ampicillin, Ciprofloxacin, and Metronidazole for empiric coverage of possible cholangeitis. He was continued NPO. He did have some postresidual distention of his abdomen. KUB was consistent with ileus, but no obstructions were visualized. He continued to have right upper quadrant pain. He was given Demerol IM 50-75 mg. He reported great relief with the Demerol. Because of his ileus, and orogastric tube was inserted; however, the patient had denied a nasogastric tube because of previous deviated septum. He felt very uncomfortable accepting a nasogastric tube. He was placed on Protonix. He had not been able to tolerate clear sips. He was started on TPN which continued until [**8-21**]. During this time, his LFTs had resolved to essentially normal. He continued to have somewhat elevated amylase and lipase but overall had a general decline. On discharge, his amylase and lipase were still elevated. On [**8-14**], the patient's white blood count increased from the mid teens to 19. His hematocrit was in the low 30s, so a CT was performed. The CT did not show any evidence of bleeding. It did show subphrenic collection of fluid. It also showed bilateral pleural effusion. Radiology aspirated the subphrenic collection draining approximately 30 ml. The abdominal fluid did not grow any bacteria. During this time, he was also started on Ampicillin, Levaquin, and Metronidazole. Past cultures returned back negative, and the antibiotics were discontinued. He had one other event of decreased hematocrit. It came back as 25, so a gastric lavage was performed which was negative. Repeat hematocrit was 29.6. The 25 hematocrit may have been a spurious value. Repeat CT was again performed which showed similar subphrenic fluid collection with bilateral pleural effusions. A repeat CT was done because of increased pain after the aspiration of his subphrenic collection. The CT was done to rule out any source of bleed. Surgery consult was also requested. Surgery did not feel that surgical intervention was needed at this time; however, they felt that after this episode had resolved, the patient should be followed up in the Surgery Clinic for future cholecystectomy. The patient was able to tolerate some clear sips. His diet was advanced, and TPN was stopped. He now leaves with an abdomen that is less distended, soft, with normal bowel sounds. He has had bowel movements with the encouragement of suppositories. He has not really had any nausea or vomiting for much of his admission. His amylase and lipase are still somewhat elevated. His ALT and AST are within normal limits; however, his alkaline phosphatase, amylase, and lipase remained somewhat elevated. 2. Pulmonary: The patient came in with a moderate to large right pleural effusion. He also had left-sided pleural effusions. He been intubated during the ERCP and was easily extubated; however, he had increased oxygen requirements. He had required face mask. He was given Lasix a few times. He responded well to 10 mg IV Lasix. However, not much fluid was taken off based on repeat chest x-rays. He had complained of some chest pain but had no electrocardiogram changes. After the thoracentesis procedure, he had some right-sided chest pain and right flank pain. He became tachypneic greater than usual at a rate in the 50s. An ABG was done which showed respiratory alkalosis. No electrocardiogram changes were noted. He was given Lasix and had improved respirations. The patient has had right lateral wall chest pain, particularly on movement, respirations, coughing, or sneezing. Chest x-ray did not show any pneumothorax. He is not in any respiratory distress and has no shortness of breath. This was considered to be postprocedural from reexpansion of the right lower lung. Throughout the whole time, the patient never really complained of any shortness of breath; however, he was always somewhat tachypneic in the low 30s. He was also started on Combivent and Albuterol/Atrovent nebulizers which had some moderate affect. The tachypnea was thought to be due to 1) atelectasis, 2) pleural effusions, 3) splinting from the right upper quadrant abdominal pain after the CT, and he had a subphrenic fluid collection which was thought to have increase his abdominal pain and subsequently his shallow, rapid respirations. He was eventually switched to nasal cannula, and now he is on room air with oxygen saturations of 94%. He has received one diagnostic thoracentesis and two attempts at therapeutic thoracentesis; the second one removing a large amount of fluid from the right lung. Chest x-rays after the procedure did not reveal any pneumothorax. After the third and final thoracentesis, the patient had a much more aerated right lung. Repeat chest x-ray did show some right lower lobe and possibly right middle lobe atelectasis. 3. Cardiovascular: The patient never really had an ischemic event. He had an echocardiogram done which showed an ejection fraction of 40%, and within the echocardiogram, he had no gross evidence of abdominal cardiac function. 4. Renal: The patient had an elevated creatinine after the ERCP which increased to 2.9; however, with hydration, the patient's creatinine had decreased gradually. On discharge it is 1.4, slightly increased from his 1.2 low. On admission his creatinine had been 1.9. 5. Heme: The patient had a slowly drifting hematocrit. He was transfused with 1 U of red blood cells once the hematocrit had been recorded as 25, and he responded to the 1 U. 6. Pain: The patient had been controlled with Demerol initially 50-75 mg IM; however, it was switched to 100 mg Demerol and then finally converted to a PCA. When he was on PCA, the patient required less pain medication. He was converted to oral Dilaudid on [**8-21**] because of some right flank pain. He required Dilaudid 4 mg almost every 6 hours; however, he has decreased pain. FOLLOW-UP: The patient will be seen by Surgery in two week, [**9-11**], at 10:15 with Dr. [**Last Name (STitle) 34985**], at the [**Hospital6 1760**]. He will be considered for a possible cholecystectomy. He will also be followed up with his primary care physician either in [**Name9 (PRE) 8**] or with the [**Hospital3 **] at [**Hospital6 256**] where he will be assessed for his pleural effusions and subphrenic fluid collection, pulmonary status, and resolution of the gallstones, and pancreatitis. DISCHARGE MEDICATIONS: Dilaudid 2-4 mg p.o. q.4 hours p.r.n., Heparin 5000 U subcue b.i.d., Protonix 40 mg p.o. q.d., Dulcolax 10 per rectum q.8 hours p.r.n., Combivent 2 puffs q.4 hours. CONDITION ON DISCHARGE: The patient will be discharged to [**Hospital **] [**Hospital **] Hospital. DISCHARGE DIAGNOSIS: Gallstone pancreatitis. DISCHARGE STATUS: The patient is stable. [**Last Name (LF) **], [**Name8 (MD) **] M.D. [**MD Number(1) 9783**] Dictated By:[**Name8 (MD) 4877**] MEDQUIST36 D: [**2153-8-22**] 10:09 T: [**2153-8-22**] 11:41 JOB#: [**Job Number **] [**Hospital3 **], [**Hospital1 34986**], [**Hospital1 8**], [**Numeric Identifier 34987**], phone [**Telephone/Fax (1) 34988**](cclist) ICD9 Codes: 5849, 5119, 5180, 2765, 3051
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Medical Text: Admission Date: [**2160-1-28**] Discharge Date: [**2160-1-29**] Date of Birth: Sex: F Service: General Cardiology NOTE: This dictation will cover the period from the point that the patient was admitted to the point that the patient was transferred to the Intensive Care Unit. Hence, it will serve as a dictation from [**2160-1-28**] to [**2160-1-29**]. The rest will be dictated by the Medical Intensive Care Unit house staff. CHIEF COMPLAINT: The patient's chief complaint is chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with a history of coronary artery disease, status post coronary artery bypass graft (saphenous vein graft to left anterior descending artery, saphenous vein graft to diagonal, and second obtuse marginal to posterior descending artery) in [**2152**], with a history of an abnormal MIBI studies times two, status post abnormal MIBI in [**2159-9-3**] with moderate reversible defect at the apex, septum, inferolateral wall. She deferred catheterization on last admission in the setting of flat enzymes and positive MIBI. The patient now presents with shortness of breath that awoke her this morning which has progressively worsened through the morning. The patient has no chest pain. No fevers. No chills. No nausea. No vomiting. No abdominal pain. No dysuria. No melena. No swelling in the lower extremities. At 6:45 a.m., she developed 8/10 chest pain which decreased to [**6-12**] with three sublingual nitroglycerin and then [**3-12**] status post 2 mg of morphine sulfate. She was started on nitroglycerin drip in the Emergency Room. She was guaiac-negative. She was started on a heparin drip. The patient was then chest pain free. She states that otherwise she has not had chest pain or shortness of breath since her last admission. She states that she is able to do all of her activities of daily living without difficulty. On [**2159-9-24**], the patient had a Persantine MIBI with a moderate reversible perfusion defect in the apex, septum, inferolateral walls, and an ejection fraction at that time of 59%. She had apical hypokinesis new since MIBI in [**2157-9-3**]. An echocardiogram in [**2158-11-3**] revealed an ejection fraction of 60%, nonobstructive focal hypertrophy of the basal septum. No aortic stenosis. No aortic regurgitation. Trivial mitral regurgitation. There was 1+ tricuspid regurgitation. PAST MEDICAL HISTORY: (Otherwise, the patient's past medical history is significant for) 1. Coronary artery disease; status post coronary artery bypass graft with saphenous vein graft to left anterior descending artery, saphenous vein graft to diagonal, and second obtuse marginal to posterior descending artery in [**2142**] with a recent abnormal stress MIBI (as mentioned above). The patient is status post four catheterizations. 2. History of emphysema. 3. History of hypertension. 4. History of hyperlipidemia. 5. History of type 2 diabetes. 6. Status post corneal transplant. 7. History of diverticulosis. 8. Status post appendectomy. 9. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 10. Status post right lung lobe puncture in the setting of catheterization (per patient). MEDICATIONS ON ADMISSION: 1. Tylenol 325-mg tablets one tablet by mouth at hour of sleep. 2. Isosorbide mononitrate 90 mg by mouth once per day. 3. Aspirin 325 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Docusate 100 mg by mouth twice per day. 6. Metformin 500 mg by mouth twice per day. 7. Protonix 40 mg by mouth once per day. 8. Valium 5 mg by mouth as needed. 9. Ranitidine 150 mg by mouth twice per day. 10. Albuterol as needed. 11. Nasacort. 12. Plavix 75 mg by mouth once per day. ALLERGIES: The patient's allergies are to SULFA. FAMILY HISTORY: The patient's family history is significant for diabetes, coronary artery disease, and myocardial infarction in father. SOCIAL HISTORY: Her social history is significant for the fact that she lives alone in [**Location (un) **] housing. She is divorced. She does all of her activities of daily living. No ethanol. No tobacco. CODE STATUS: She is a full code. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 96.3 degrees Fahrenheit, her heart rate was 57, her blood pressure was 110/48, her respiratory rate was 20, and her oxygen saturation was 97% on room air. Generally, a very pleasant female in no acute distress. She was alert and oriented times three. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. The extraocular movements were intact. The oropharynx was clear. The mucous membranes were moist. The neck was supple with no jugular venous distention. There was no lymphadenopathy. Cardiovascular examination revealed a regular rhythm, bradycardic. No murmurs, rubs, or gallops were noted. The lung examination revealed there were bilateral bibasilar crackles. No wheezes or rales. Otherwise, the lungs were clear. The abdomen was flat, soft, nontender, and nondistended. Guaiac-negative. There were good bowel sounds. Extremity examination revealed the extremities were clear of any clubbing, cyanosis, or edema. There were 2+ dorsalis pedis pulses. Bilaterally, the patient groin was free of any bruits. Neurologic examination revealed cranial nerves II through XII were intact. Strength was [**5-7**] and symmetric. The toes were downgoing. The skin was clean, dry, and intact. There were no lesions or rashes were noted. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's admission laboratory data included a white blood cell count of 4.8, her hematocrit was 40.5, and her platelet count was 91 (baseline 82 to 150). Differential revealed neutrophils of 61 and lymphocytes of 26. Sodium was 138, potassium was 4.3, chloride was 100, bicarbonate was 30, blood urea nitrogen was 26, creatinine was 1, and her blood glucose was 156. Her calcium was 9, her magnesium was 1, and her phosphate was 4. Creatine kinase was 44. Troponin was less than 0.01. RADIOLOGY/IMAGING FINDINGS: A chest x-ray was significant for mild tortuosity. The lungs were clear. Chronic scarring of the right lung base. Scoliosis, status post median sternotomy. Electrocardiogram revealed a right bundle-branch block. There was a sinus rhythm. There were ST depressions in V4 through V6. There was a normal axis. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The [**Hospital 228**] hospital course by issue/system was as follows. 1. CHEST PAIN ISSUES: The patient's first set of cardiac enzymes were negative. She was continued on nitroglycerin as well as heparin drip. The plan was that the patient would be ruled out for a myocardial infarction. Initially, the patient was resistant to have cardiac catheterization. Hence, it was decided that the patient would be medically managed. The patient did rule out for a myocardial infarction. On day two of admission, the patient agreed to a cardiac catheterization which revealed the following. Left ventriculography revealed no mitral regurgitation with an left ventricular ejection fraction of 55%. Coronary angiography revealed a right-dominant system. The left main coronary artery with mild diffuse disease. The left circumflex with serial 70% stenosis before grafted obtuse marginal. The right coronary artery to mid PL filled by left-to-right collaterals. The saphenous vein graft diagonal to obtuse marginal was patent with 70% focal stenosis in obtuse marginal limb. The saphenous vein graft to left anterior descending artery had a 3-mm X 13-mm cypher stent delivered to obtuse marginal. Status post procedure, the patient was maintained on Integrilin. Status post procedure, the patient was noted to be hypotensive to 96/57. The patient underwent a computed tomography scan to rule out a retroperitoneal bleed due to a 6-point hematocrit drop from 40 to 33. This computed tomography scan revealed no retroperitoneal bleed. However, the patient became agitated again and became hypotensive to 90/60 and then dropped to 70/50. The patient was transiently placed on a dopamine drip. A second femoral line was placed. The patient was taken to the Medical Intensive Care Unit. 2. CORONARY ARTERY DISEASE ISSUES: While on the Cardiology floor, the patient was continued on aspirin, atenolol, Lipitor, as well as a nitroglycerin drip. 3. GASTROINTESTINAL ISSUES: The patient was on a bowel regimen and proton pump inhibitor. 4. EMPHYSEMA ISSUES: The patient was on albuterol and Atrovent. 5. ANXIETY ISSUES: The patient was on Valium at hour of sleep as needed. 6. DIABETES ISSUES: For diabetes, her metformin was held and she was continued on a regular insulin sliding-scale and four times per day fingerstick blood glucose checks. The patient was nothing by mouth while she ruled out and was on intravenous fluids. 7. CODE STATUS ISSUES: Her code status was full. NOTE: For the rest of the [**Hospital 228**] hospital course by system, please refer to the Medical Intensive Care Unit discharge note. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2160-2-28**] 15:50 T: [**2160-3-1**] 07:09 JOB#: [**Job Number 98661**] ICD9 Codes: 4111, 4280, 2875, 4019
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Medical Text: Admission Date: [**2188-8-9**] Discharge Date: [**2188-8-21**] Date of Birth: [**2119-10-6**] Sex: F Service: SURGERY Allergies: PEPPERS Attending:[**First Name3 (LF) 598**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2188-8-13**] 1. Diagnostic laparoscopy. 2. Lysis of adhesions. 3. Drainage of abscess. History of Present Illness: Pt is 68 y/o F with h/o atrial fibrillation who presents with worsening lower abdominal pain for past week and a half. Pt did have diarrhea earlier in the week, but currently is feeling constipated. No nausea/vomiting. Pt also denies fevers but is having chills. Pt presented to [**Hospital1 18**]-[**Location (un) 620**] where she was noted to be hypotensive with BP in 80s and in atrial fibrillation. Pt was resuscitated with 7L crystalloid prior to being transferred to [**Hospital1 18**] ED. Last colonoscopy was more than 10 years ago. Pt did have right breast lumpectomy for DCIS earlier in the week. Past Medical History: PMH: - Chronic atrial fibrillation - Hypertension. PSH: - Tonsillectomy. - Appendectomy. - D&C. - Fibroid ablation. -S/P Right breast lumpectomy for DCIS -S/P Reexploration R breast for more tissue sampling Social History: No alcohol or tobacco. lives with husband Family History: Aunt with breast cancer. Father with lung cancer. Brother with prostate cancer. Physical Exam: Temp 97.8 P 120 BP 98/60 R 16 SaO2 98% RA Gen: no acute distress Heent: no scleral icterus neck: supple Lungs: clear Heart: irregular rate and rhythm abd: soft, nondistended, moderately tender in lower abdomen rectal: no masses, guaiac negative Extrem: no edema Pertinent Results: [**2188-8-9**] 03:35AM WBC-7.3 RBC-3.14*# HGB-8.7*# HCT-26.2*# MCV-84 MCH-27.7 MCHC-33.2 RDW-14.5 [**2188-8-9**] 03:35AM NEUTS-79.7* BANDS-0 LYMPHS-15.2* MONOS-4.3 EOS-0.7 BASOS-0.2 [**2188-8-9**] 03:35AM PLT COUNT-279 [**2188-8-9**] 03:35AM GLUCOSE-128* UREA N-12 CREAT-0.7 SODIUM-140 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12 [**2188-8-9**] CT Abd/pelvis :There is an irregular fluid collection in the pelvis with fluid surrounding the sigmoid colon. The findings are likely due to perforated diverticulitis and abscess formation. The abscess appears multilocular about 7 cm in diameter. [**2188-8-11**] CT Abd/pelvis : 1. Bilateral pleural effusions with associated compressive atelectasis. 2. Some decrease in size of the main multiloculated pelvic fluid collection secondary to perforated sigmoid diverticulum.Smaller pockets of air and gas are seen surrounding the sigmoid colon. Again, the collection is not amenable to transcutaneous drainage. Brief Hospital Course: Mrs. [**Known lastname 97450**] was evaluated by the Acute Care team in the Emergency Room and subsequently admitted to the SICU for further management od her perfforated sigmoid diverticulitis as she was hypotensive and in rapid atrial fibrillation. As she was fluid resuscitated her heart rate and blood pressure returned to [**Location 213**]. She maintained NPO, bowel rest and IV antibiotics as a conservative treatment. Her WBC was rising and her pain was controlled with narcotics. Interventional Radiology was then consulted about drainage of her pelvic abscess but felt the area was too difficult to reach. A deciision was made to continue conservative treatment another day to see if she improved. Unfortunately her WBC continued to rise and her abdominal pain persisted. She was taken to the Operating Room on [**2188-8-13**] and underwent an exploratory laparotomy with lysis of adhesions and drainage of pelvic abscess. She tolerated the procedure well and returned to the SICU in stable condition. She did require reintubation after arriving in the SICU as she was hypoventilating but was easily extubated the following day. Following transfer to the surgical floor on [**2188-8-15**] she continued to make steady progress. She remained afebrile and her WBC was normal. Her antibiotics were changed from IV Zosyn and Vancomycin to oral Cipro and Flagyl on [**2188-8-18**]. Her creatinine was noted to be elevated to 1.4, she was given IV fluid bolus and labs were re-checked. Her other electrolytes were repleted as indicated. A renal ultrasound on [**2188-8-21**] showed no obstruction. Her repeat Cr was 1.3 on [**8-21**] pm. She wished to go home at this time and she was ready for discharge on [**8-21**], with follow-up at [**Location (un) 620**]. Patient was ambulating, tolerating diet at this time. It was noted that her TSH was elevated (7.2) during her hospital stay which she will need repeated as an outpatient during her follow up with her PCP. Medications on Admission: aspirin 325 mg daily Plavix 75 mg daily albuterol 90 mcg 2 puffs q4h prn sob fluticasone 220 mcg 2 puffs daily hctz 25 mg daily metoprolol 100 mg [**Hospital1 **] Discharge Medications: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. metronidazole 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours): thru [**2188-8-27**]. Disp:*27 Tablet(s)* Refills:*0* 3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): thru [**2188-8-27**]. Disp:*18 Tablet(s)* Refills:*0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-3**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: 1. Complicated diverticulitis with abscess 2. Acute kidney injury 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 abdominal pain due to a small hole on your colon. You eventually required operative drainage as bowel rest and antibiotics alone were ineffective. * Currently you have improved and are able to tolerate a regular diet and stay well hydrated. * Your right abdominal drain remains in place and should be emptied daily, noting the amount, color and consistency of the drainage. Write the amounts down daily and bring this with you to your next appointment. * You also need to follow up with Dr. [**Last Name (STitle) **] from radiation oncology. The treatments won't start right away but you will meet with him on Friday and discuss a plan. * If you develop any increased redness or drainage from your abdominal drain OR if you have fevers > 101, more abdominal pain or any new concerns please call your doctor or return to the Emergency Room. Followup Instructions: Follow up with your primary care doctor within the next [**2-3**] weeks for a general physcial and for re-checking your thyroid function labs as your TSH was elevated during your hospital stay along with your kidney function. You will need to call for an appointment. Dr. [**Last Name (STitle) **], radiation oncology [**Telephone/Fax (1) 9710**] Appointment Friday [**2188-8-22**] at 9AM. [**Hospital Ward Name 516**], [**Hospital Ward Name 332**] basement Wednesday, [**2188-8-27**] Radiology at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name8 (NamePattern2) **] [**Location (un) 33570**] CT scan of abdomen and pelvis. Call them for a time. Continue discharge antibiotics for 2 weeks. Follow-up at [**Hospital1 **] in [**Location (un) 620**] for labs on Monday. Call to schedule time. Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2188-9-1**] 11:45 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2188-8-21**] ICD9 Codes: 5119, 5180, 5849, 4019
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Medical Text: Admission Date: [**2194-12-8**] Discharge Date: [**2194-12-14**] Date of Birth: [**2125-12-15**] Sex: F Service: CARDIOTHORACIC Allergies: Ibuprofen Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2194-12-9**] Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Epic Porcine), reduction aortoplasty [**2194-12-8**] Cardiac Cath History of Present Illness: 68 year old female with coronary artery disease status post myocardial infraction with angioplasty in [**2175**] and known aortic stenosis who has been followed by serial echocardiograms. Over the past year, she has noted progressive dyspnea on exertion, fatigue and mild peripheral edema. He most recent echocardiogram revealed severe aortic stenosis with a mean gradient of 36mmHg. Given the progression of her symptoms and the severity of her aortic stenosis, she had been referred for surgical management. Admitted today s/p cardiac catherization as preop for AVR with Dr [**Last Name (STitle) **] in the morning. Past Medical History: Aortic stenosis Coronary artery disease s/p angioplasty Myocardial infarction [**2176-9-30**] Hypertension Dyslipidemia Diabetes mellitus type 2 Pancreatitis [**2179**] developiong diabetes after GERD Anemia Bilateral shoulder fractures (Left [**2191**], Right [**2192**]) Past Surgical History: Cholecystectomy with drainage of pancreatic cyst Incisional hernia repair [**2188**] Ganglionic cyst of wrist surgical excised Social History: Race: Caucasian Last Dental Exam: 6 months ago - clearance obtained. Lives with: Alone, son and [**Name2 (NI) **] in law live upstairs in 2 family house (Husband recently passed away from pancreatic cancer). Occupation: Retired Tobacco: Quit [**9-/2176**]. 48 year pack history ETOH: Denies Family History: Sister with CABG at age 70. Uncle died of MI at age 21. Mother with angina. Father with fatal MI at age 74. Physical Exam: Pulse: Resp:20 O2 sat: 97% RA B/P Right:91/58 Left: Height: 4'[**93**]" Weight: 181 General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Distant breath sounds Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None [x] 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 Bruit: Transmitted murmur vs bruit B/L Pertinent Results: [**2194-12-8**] Cardiac cath: 1. No angiographically-apparent flow-limiting CAD. 2. Normal pulmonary capillary wedge pressure. 3. Mild pulmonary arterial hypertension. 4. Low normal systemic systolic arterial pressure with occasional hypotension. 5. Sheaths to be removed. 6. Additional plans per Dr. [**Last Name (STitle) **]. Admit to CSurg. 7. Reinforce primary preventative measures against CAD. 8. Follow-up with Dr. [**Last Name (STitle) 39486**]. [**2194-12-8**] Carotid U/s: 1. No evidence of internal carotid artery stenosis on either side. 2. Reversal of flow in the right vertebral artery, which is usually associated with subclavian steal. Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname 18654**] was admitted following her cardiac cath and underwent pre-operative work-up. On [**2194-12-9**] she was brought to the operating room where she underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta blockers and diuretics were started and she was diuresed towards her pre-op weight. Later on this day she was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. During her post-op course she worked with physical therapy. On post-op day five she appeared ready for discharge home with VNA services and the appropriate medications and follow-up appointments. She will take lasix for 2 weeks and then resume her spirinolactone if instructed by Dr. [**Last Name (STitle) 39487**]. Medications on Admission: Aspirin 81mg daily Cardizem CD 240mg daily Cozaar 50mg twice daily Spirinolactone 25mg daily Zocor 40mg daily Zetia 10mg daily Glucophage 1000mg twice daily Humalog sliding scale 10-15 units TID Lantus 50units daily Amitriptyline 10mg daily Calcium 600mg daily Vitamin D 2000units daily Multivitamins Mobic 15mg daily Omeprazole 20mg daily Ativan 0.5 mg po QHS Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. 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* 9. Mobic 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. insulin glargine 100 unit/mL Cartridge Sig: Please refer to provided instruction sheet for daily dose and sliding scale Subcutaneous As Instructed. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Past medical history: Coronary artery disease s/p angioplasty Myocardial infarction [**2176-9-30**] Hypertension Dyslipidemia Diabetes mellitus type 2 Pancreatitis [**2179**] developiong diabetes after Gastresophageal reflux disease Anemia Bilateral shoulder fractures (Left [**2191**], Right [**2192**]) Past Surgical History: Cholecystectomy with drainage of pancreatic cyst Incisional hernia repair [**2188**] Ganglionic cyst of wrist surgical excised Angioplasty [**2175**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - 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 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. 6) No lifting more than 10 pounds for 10 weeks 7) Take lasix and potassium daily in the morning for 14 days then stop. You may then resume your spirinolactone if instructed by Dr. [**Last Name (STitle) 39488**]. 8) You may resume your insulin sliding scale and night time lantus 20 units. Please refer to dosage sheet provided. 9) 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 10_ You may resume your at home vitamins. **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) **] [**1-8**] at 1:15pm Cardiologist: Dr. [**First Name (STitle) 39489**] [**Name (STitle) 39488**] on [**1-9**] at 10:45am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-3**] 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:[**2194-12-14**] ICD9 Codes: 4241, 5119, 4019, 2724, 4168, 412
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Medical Text: Admission Date: [**2138-3-15**] Discharge Date: [**2138-3-25**] Date of Birth: [**2079-8-12**] Sex: M Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Cryptogenic cirrhosis awaiting liver transplant. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old male with cryptogenic cirrhosis who presents to FAR10 which is the 3rd time for preoperative evaluation for liver transplant. He denies any fevers, cough, chills, nausea, vomiting, diarrhea, headache, or urinary symptoms. He finished his recent course of Valcyte. PAST MEDICAL HISTORY: History of cirrhosis. History of ascites encephalopathy. History of varices. Noninsulin dependent diabetes. Hypertension. Sleep apnea. Lumbar disk problems. History of left ankle fusion. Erectile dysfunction. Undescended testicle on the right side. Esophageal varices status post banding in [**2137-8-26**] and subsequent banding in [**2137-11-26**]. History of chronic lower extremity edema, right greater than left. Shortness of breath, baseline with 2- 3 L on nasal cannula at home, [**2-28**] pillow orthopnea. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lactulose, losartan 50 mg daily, Protonix 40 mg daily, Lantus 20 units, regular insulin sliding scale, Lasix 80 mg b.i.d., Aldactone 100 mg daily, Neoral 10 mg daily, Valcyte. PHYSICAL EXAMINATION: Vital signs: The patient is afebrile, vital signs stable. Weight 109 kg, 95% on 3 L. General: Awake, alert and oriented x3. No acute distress. Fingersticks are 121. Lungs: Decreased breath sounds at bases. Cardiovascular: Regular rate and rhythm. Abdomen: Soft, obese, nontender, nondistended, no ascites, guaiac negative. Extremities: Bilateral venous stasis changes. LABORATORY DATA: On admission WBC was 4.8, hematocrit 39.1, platelet count 41; INR 1.5, PTT 37; sodium 134, 2.7, 105, 20, 15, 1.2, 111. Chest x-ray from [**2138-3-8**], demonstrated no acute CP processes. EKG from [**2138-3-8**], was normal sinus rhythm at 65, no ST/T wave changes. Echocardiogram demonstrated an ejection fraction of 60%. CT of the abdomen and pelvis demonstrated cirrhosis, positive splenomegaly. HOSPITAL COURSE: On [**2138-3-15**], the patient was admitted for possible liver transplant surgery. The patient was prepped preoperatively with routine medications prior to admission for liver transplant surgery. The patient went to the OR on [**2138-3-15**], where an orthotopic liver transplant with a duct-a-duct biliary reconstruction was performed by Drs. [**First Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 816**]. Two drains were placed; 1 drain was placed in the portal space and another behind the liver. The abdomen was closed. The skin was closed with staples. The patient was stable and went to the ICU postoperatively. Please see the operative note from [**2138-3-15**], for more details. On postoperative day 1, the patient had a liver ultrasound demonstrating patent portal and hepatic veins, main hepatic artery was seen. The left and right branches were not visualized on this technically limited study. A short interval followup is recommended. Labs on [**2138-3-16**], revealed a WBC of 10.3, hematocrit 29.4, platelets 119; sodium 145, 3.8, 102, 16, BUN and creatinine of 19 and 1.1, glucose 217; LFTs included an ALT of 786, AST 2072, alkaline phosphatase 88, amylase 59, total bilirubin 5.3. The patient was intubated and was receiving morphine for pain management. He was weaned off the ventilator. He received Unasyn, Bactrim, fluconazole and ganciclovir. A bronchoscopy was performed on [**2138-3-17**], due to a slow wean off the ventilator. The bronchoscopy revealed that the patient had right lower lobe pneumonia. Cultures were sent, and cultures reported that the patient Pseudomonas aeruginosa from the bronchioalveolar lavage. The patient received Lasix for continued diuresis. The patient was placed on Bactrim, Zosyn, vancomycin and fluconazole. The Zosyn and vancomycin was for the pneumonia. Ultrasound was performed on [**2138-3-18**], to the liver demonstrating the patent hepatic vasculature. On [**2138-3-18**], the patient was still intubated on assist-control. The patient received diuresis. He was continued on antibiotics. He was afebrile and bradycardiac. The ET tube was changed over a catheter for incompetent balloon. The patient was given multiple units of blood products. On [**2138-3-19**], tube feeds were started. Antibiotics were changed, and levofloxacin was added for Pseudomonas. The patient was intubated and sedate. Pupils were equal, round and reactive to light. Lungs were coarse bilaterally. Abdomen was soft. There was 1+ edema of the lower extremities. The dressing was clean, dry and intact. On [**2138-3-19**], his weight was slowly dropping. Labs that day demonstrated a WBC of 2.7, hematocrit 31.5, platelet count 36, sodium 142, 4.2, 102, 31, BUN and creatinine of 43 and 1.3, glucose 115. His AST decreased significantly to 800, ALT 1603, alkaline phosphatase 82. Total bilirubin was 8.2. INR was 1.8. FK was started on [**2138-3-17**], and was slowly increased in dose. On [**2138-3-19**], the patient had chest x-ray to evaluate his pneumonia and ET tube manipulation demonstrating that the right perihilar consolidation or edema is clearing with lung essentially clear. No pleural effusions. Heart normal size. Mediastinum is midline. The patient was extubated and doing well. He was transferred to the floor on [**2138-3-20**]. There the patient was afebrile, vital signs stable, good input and output. Two JPs with good output. The patient received physical therapy. Diet was advanced. On [**2138-3-22**], the patient had another chest x-ray since the patient needed increase O2 requirement. The impression stated that there was continued improvement of the right infrahilar opacity. There were no signs of pleural effusion, focal infiltrates or evidence of overt pulmonary edema. Since being on the floor, the patient has required from 2-4 L of oxygen to keep an O2 saturation of 94%, but no exertional shortness of breath witnessed. The patient continued with physical therapy, Lasix, pulmonary toilet and incentive spirometer. He was doing well. He was walking around. He was voiding. He was eating well. On [**2138-3-23**], on postoperative day 7, the patient continued on fluconazole and Levaquin. The second JP drain was removed. The patient continued on MMF, prednisone and FK. Central line was removed on the 26th. The patient was screened for rehab. On postoperative day 9, the patient required a little bit more pain medication. Dilaudid was increased to every q.3-4 hours. He was afebrile with vital signs stable. Fingersticks have been relatively high in the 200-300s. The patient has been on 2 L at 95% O2. He had good input/output. He had bibasilar rales but non- labored. The patient otherwise is doing well status post liver transplant complicated by Pseudomonal pneumonia, but the patient is receiving pulmonary toilet. He is to have levofloxacin x 10 days. The patient did receive chest x-ray on [**2138-3-25**], demonstrating no significant interval change in the lung parenchyma, no signs of pleural effusion or overt pulmonary edema. Physical therapy felt that the patient should go to rehab. A bed is available on [**2138-3-25**]. The patient may be going to rehab soon. DISCHARGE MEDICATIONS: Fluconazole 400 mg q.24, Bactrim SS 1 tablet daily, Protonix 40 mg 1 tablet q.24 hours, Colace 100 mg b.i.d., Dilaudid 2 mg q.4-6 hours p.r.n., levofloxacin 500 mg tablet 1 q.24 hours discontinue after [**2138-3-30**], prednisone 20 mg daily, Valcyte 900 daily, Lasix 20 mg b.i.d., MMF 500 p.o. q.i.d., the patient will go on insulin sliding scale, the patient will possibly be placed on tacrolimus 3 mg b.i.d. FOLLOW UP: The patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2138-4-3**], at 10 a.m., also on [**2138-4-10**], at 8:40 a.m., and [**2138-4-17**], at 9 a.m.; please call [**Telephone/Fax (1) 673**] if any changes need to be made for the appointment. He will also be seeing Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], [**Telephone/Fax (1) 2422**], on [**2138-4-22**]. He will also be meeting with a GI group on [**2138-4-22**], at 10 a.m. The patient needs to call [**Telephone/Fax (1) 673**] for any fevers, chills, nausea, vomiting, inability to take medications, any redness, bleeding, pus from incision or capped bile drain. The patient will labs every Monday and Thursday for CBC, CHEM10, AST, ALT, alkaline phosphatase, total bilirubin, albumin and Prograf trough level. Fax the results to the transplant office. Pathology results from [**2138-3-15**], demonstrated 1) liver parenchyma with mild micro-macrovesicular status which involves 10% of the liver parenchyma, 2) mild portal mononuclear cell inflammation, nonspecific, 3) iron stain demonstrated no increased stainable iron, 4) there was no significant fibrosis seen on the trichrome stain, 5) on the native liver, hepatectomy with established cirrhosis, 3 reactive lymph nodes, negative vascular biliary margins, no fatty changes seen, chronic cholecystitis and cholelithiasis and mild septal mononuclear cell inflammation. Labs from [**2138-3-25**], demonstrated a WBC of 5.9, hematocrit 37.2, platelets 52; UA from [**2138-3-24**], is unremarkable; sodium 136, 3.5, 100, bicarb 31, BUN and creatinine 16 and 1.0, glucose 123; ALT 162, AST 27, alkaline phosphatase 173, total bilirubin 3.3; FK on [**2138-3-25**], was 12.8. The patient may be able to go to rehab today depending on Dr.[**Name (NI) 42792**] decision. FINAL DIAGNOSIS: End-stage liver disease with cryptogenic cirrhosis, Type 2 diabetes, hypertension, OSA, and Pseudomonas pneumonia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2138-3-25**] 14:24:34 T: [**2138-3-25**] 15:21:22 Job#: [**Job Number 57683**] ICD9 Codes: 5185, 5715, 4019
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Medical Text: Admission Date: [**2121-6-11**] Discharge Date: [**2121-6-17**] Date of Birth: [**2065-1-9**] Sex: M Service: Cardiothoracic CHIEF COMPLAINT: This patient is a postoperative admit. He was directly admitted to the operating room where he underwent coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 56-year-old gentleman with known coronary artery disease and insulin dependent diabetes mellitus, who had been previously admitted in [**2121-5-11**] with chest pain, congestive heart failure and ruled out for myocardial infarction at that time, but had a positive exercise tolerance test and was brought to cardiac catheterization during that admission. At that time his catheterization showed normal left main, left anterior descending coronary artery 95% occluded, circumflex coronary artery 70% occluded, obtuse marginal #1 70% occluded, right coronary artery 70% occluded, no left ventriculogram was done at that time due to an elevated creatinine, however his ejection fraction by echocardiogram at that time was 40-45%. PAST MEDICAL HISTORY: 1. Diabetes mellitus with associated neuropathy. 2. Hypertension. 3. Hypercholesterolemia. 4. Chronic renal insufficiency with a baseline creatinine of 2.1 to 2.5. 5. Congestive heart failure. 6. Anemia. 7. Bilateral claudication. 8. Peripheral vascular disease. PAST SURGICAL HISTORY: 1. Right fifth metatarsal resection. 2. Tonsillectomy. 3. Left eye vitrectomy. 4. Bilateral laser surgery to both eyes. ALLERGIES: Sulfa, ampicillin and codeine, all of which make him nauseated. MEDICATIONS DURING LAST ADMISSION: 1. Zestril 40 mg q.d. 2. Lasix 40 mg q.d. 3. Norvasc 10 mg q.d. 4. Coreg 6.25 mg b.i.d. 5. Glipizide 10 mg b.i.d. 6. Digoxin 0.125 mg q.d. 7. Lipitor 40 mg q.d. 8. Aspirin 81 mg q.d. 9. Pepcid AC no dose or frequency provided. 10. Insulin 70/30, 21 units in the AM and Lente 19 units in the PM. 11. IV Natrecor. 12. Epoetin 5,000 units subcutaneous q. Saturday. 13. Vitamin B12 1,000 mcg q. day. LABORATORY DATA: On his last admission white count was 7.9, hematocrit 34.4, platelet count 211, sodium 140, potassium 4.4, chloride 104, CO2 25, BUN 41, creatinine 2.3, glucose 191. EKG was sinus rhythm with a rate of 88, ST wave changes laterally. PHYSICAL EXAMINATION: Heart rate 80 and sinus rhythm, blood pressure 168/69, respiratory rate 18, oxygen saturation 97% on room air. Lungs: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, S1 and S2 with a 2/6 systolic ejection murmur. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly, positive bowel sounds. Pulses: Radial 2+ on the right, 1+ on the left; femoral 2+ bilaterally; dorsalis pedis 1+ bilaterally; posterior tibial 2+ bilaterally. Extremities: Well perfused, no clubbing, cyanosis or edema, no varicosities. Neurological: Pupils equally round and reactive to light. Extraocular movements intact. Cranial nerves II-XII were grossly intact. HOSPITAL COURSE: As stated previously, on [**6-11**] the patient was a direct admission to the operating room at which time he underwent coronary artery bypass grafting. Please see the operating room report for full details. In summary, the patient had a coronary artery bypass grafting x 4 with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the posterior descending coronary artery, saphenous vein graft to obtuse marginal #1 and obtuse marginal #2 sequentially. His bypass time was 127 minutes with a cross-clamp time of 112 minutes. He tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer the patient's mean arterial pressure was 76. He was in sinus rhythm at 95 beats per minute. He had dobutamine at 5 mcg per kg per minute, Neo-Synephrine at 0.3 mcg per kg per minute and propofol at 10 mcg per kg per minute. The patient did well in the immediate postoperative period. He was noted however to have a mixed metabolic respiratory acidosis. His ventilator was manipulated until the acidosis corrected itself. Once the acidosis corrected itself the patient's anesthesia was reversed and he was successfully weaned from the ventilator and extubated. On the first postoperative day the patient remained hemodynamically stable. He was weaned from his dobutamine drip and was scheduled to be transferred to the floor, however check of his electrolytes prior to transfer revealed a rising creatinine as well as some hyperkalemia. The patient was treated with Kayexalate and was kept in the intensive care unit to monitor his renal status. Additionally a renal consultation was called on the patient. Given his tenuous renal status the patient stayed in the intensive care unit for an additional three days waiting for his creatinine to plateau. On postoperative day four the patient's creatinine was back down to his baseline, and on postoperative day five he was transferred to [**4-11**] for continuing postoperative care and cardiac rehabilitation. Over the next two days the patient's activity level was increased with the assistance of the nursing staff and physical therapy. On postoperative day six it was decided that the patient was stable and ready to be discharged to home. At the time of discharge the patient's physical examination was as follows: Vital signs were temperature 98.2, heart rate 75 and sinus rhythm, blood pressure 122/76, respiratory rate 18, oxygen saturation 95% on room air. Weight preoperatively was 107.9 kg, at discharge 113.6 kg. Laboratory data was white count 8.0, hematocrit 27.4, platelet count 248, sodium 140, potassium 3.8, chloride 102, CO2 26, BUN 50, creatinine 2.3, glucose 117. Physical examination was alert and oriented x 3, moving all extremities, followed commands. Lungs had diminished distant breath sounds, no rales appreciated. Cardiac was regular rate and rhythm, S1 and S2. Sternum was stable. The incision with Steri-Strips was open to air, clean and dry. The abdomen was soft, nontender, nondistended with normal active bowel sounds. Extremities were warm, well perfused, [**12-12**]+ edema bilaterally. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Atorvastatin 40 mg q.d. 3. Glipizide 10 mg b.i.d. 4. Protonix 40 mg q.d. 5. Furosemide 40 mg q.d. 6. Norvasc 10 mg q.d. 7. Multivitamin 1 q.d. 8. Metoprolol 50 mg b.i.d. 9. Insulin 70/30, 10 units q.a.m. and Lente 10 units q.p.m. 10. Dilaudid 2-4 mg q. 4-6 hours p.r.n. 11. Regular Insulin sliding scale q. 6 hours as needed. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting x 4 with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery, saphenous vein graft to obtuse marginal #1 and obtuse marginal #2 sequentially. 2. Hypertension. 3. Hypercholesterolemia. 4. Chronic renal insufficiency. 5. Congestive heart failure. 6. Anemia. 7. Diabetes mellitus with associated neuropathy. 8. Status post right fifth metatarsal resection. 9. Status post tonsillectomy. 10. Status post left eye vitrectomy. 11. Status post bilateral laser surgery of the eye. CONDITION ON DISCHARGE: Good. DISPOSITION: Discharged to home with services. FOLLOW UP: He is to be seen in the wound clinic in two weeks; to be seen in Dr.[**Name (NI) 18056**] office in three to four weeks; and to be seen by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2121-6-17**] 11:47 T: [**2121-6-17**] 12:01 JOB#: [**Job Number 18057**] ICD9 Codes: 5849, 4280, 2767, 2762, 2720
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Medical Text: Admission Date: [**2163-7-20**] Discharge Date: [**2163-8-9**] Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 89-year-old female, with a history of atrial fibrillation, coronary artery disease, who underwent colonoscopy on [**2163-5-10**] which showed a large cecal mass. Biopsies revealed well- differentiated adenocarcinoma for which she was admitted on [**2163-7-20**] for right hemicolectomy. PAST MEDICAL HISTORY: Sick sinus syndrome. Coronary artery disease. Atrial fibrillation. Hypertension. Osteoporosis. PREADMISSION MEDICATIONS: 1. Fosamax. 2. Lasix. 3. Lisinopril. 4. Lopressor. 5. Digoxin. 6. Prozac. 7. Amiodarone. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient has never smoked cigarettes. She lives in the [**Hospital3 **] Center secondary to an inability to take care of herself. She is retired. She has a large family. She is Russian speaking. HOSPITAL COURSE: The patient was admitted on [**2163-7-20**]. She was taken directly to the operating room where an epidural was placed in an attempt to avoid general anesthesia, secondary to the patient's high respiratory and cardiac risk. The patient tolerated the procedure with minimal blood loss. Postoperatively, the patient was eventually mildly hypotensive secondary to hypovolemia and was bolused fluid. She was also given a unit of packed red blood cells due to postoperative anemia complicating preexisting anemia. She was also treated for hypokalemia. She received serial Crit's to insure that the patient was not bleeding significantly. The patient was monitored cautiously during the resuscitative period, and evaluated for congestive heart failure, despite the fact that her EF was greater than 55 percent, particularly because of O2 saturations in the low-90's, although this was not an initial finding on chest x-ray. The patient received aggressive chest physical therapy, as well as received a rule out for myocardial infarction, which was confirmed negative by enzymes. On the night of postoperative day 4, the patient experienced a decrease in O2 saturation, satting only in the 70 percent range on a nonrebreather after nebulizer treatments. The patient received a chest x-ray which showed bilateral pulmonary edema. She had bilateral wheezes and rales, right side greater than left. Her ABG showed both a respiratory, as well as metabolic acidosis. The patient was transferred to the ICU for closer monitoring and treatment. The patient had a triple-lumen subclavian catheter inserted while in the unit. The patient was intubated and placed on a ventilation system, was given Lasix as needed, and received serial ABG's. She was made NPO, and a G-tube was placed. A right A-line was also placed for closer monitoring. The patient spiked a temperature to 103.8, which prompted a fever work-up including UA, urine culture, sputum culture, and blood culture. The patient was placed on Zosyn for a question of pneumonia. While in the unit, despite the fact that the patient had pulmonary edema, as well as a question of pneumonia, it was also decided that the patient had a component of acute respiratory distress syndrome. The patient also experienced issues with atrial fibrillation which required an increase in Lopressor treatment. She eventually had a feeding tube placed to initiate tube feeds. Over time, cultures came back with coag-negative staph in 1 blood culture, and E. coli in the urine. The patient was continued on Zosyn, but also placed on vancomycin. The patient was finally successfully extubated on the [**7-31**]. Her diuresis was continued aggressively to pull fluid off. After extensive treatment with Lasix, the patient developed a metabolic alkalosis, and for that reason was placed on Diamox, both to aid with diuresis and with correction of her metabolic alkalosis. On the 3, the patient underwent a speech and swallow study which she failed, and for that reason was left NPO, and left on aggressive tube feed treatment. On the 3, it was confirmed that one of the patient's blood cultures was confirmed with Enterococcus, and the patient was started on linezolid. She had experienced another decrease in oxygen saturation, requiring nonrebreather mask and increased pulmonary toilet. The patient also experienced increase in confusion at that time. She received Haldol, as well as continued persistence with fever/infection work-up. On the 5, the patient had a beside swallow reattempted which she failed. On the night of the 8, the patient was transferred to the Vascular ICU to continue a closer eye on her, but because she did not need the super close attention of the regular ICU. While in the VICU, the patient continued to flourish, and her respiratory status improving. She reached her baseline preoperative weight, and her Lasix was stopped. She did not require persistent replacement of potassium and magnesium for hypokalemia and hypomagnesemia. The patient continued to tolerate her tube feeds well. It is now [**2163-8-9**], and the patient will be discharged as soon as a bed is available at [**Hospital 100**] Rehab. The patient is in good condition. She will be discharged with a Dobbhoff in place and on tube feeds at 40 cc/h, and in 1 week will require a swallow study. If, at that time, she is able to swallow, the tube feeds can be DC'd, and the patient placed on a diet. She does require physical therapy, for which the patient was started on in house, but will need continued therapy as the days go on. DISCHARGE MEDICATIONS: 1. All the patient's antibiotics are being DC'd with the exception of linezolid which she will be required to complete a 10-day course of. 2. She will be discharged on Tylenol prn for pain. 3. Albuterol nebs 1 neb q 4 h. 4. Amiodarone 400 mg po bid. 5. Heparin 5,000 U subcu tid. 6. Insulin sliding scale. 7. Atrovent 1 neb q 6 h. 8. Lopressor 50 mg po tid. 9. Miconazole powder 1 application tid prn. 10.Nystatin oral suspension 5 ml po qid prn. 11.Prevacid 30 mg per Dobbhoff qd. FOLLOW UP: She is to follow-up with Dr. [**Last Name (STitle) **] in [**12-31**] weeks. She is to have her speech and swallow in approximately 1 week. She should follow-up with her primary care physician in approximately 2 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**] Dictated By:[**Last Name (NamePattern1) 3956**] MEDQUIST36 D: [**2163-8-9**] 10:24:38 T: [**2163-8-9**] 11:11:26 Job#: [**Job Number 94628**] ICD9 Codes: 2851, 486, 4280
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Medical Text: Admission Date: [**2155-11-14**] Discharge Date: [**2155-11-27**] Date of Birth: [**2102-5-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: acute alcoholic hepatitis Major Surgical or Invasive Procedure: paracentesis History of Present Illness: This is a 53 year old female with a hx of alcoholism and binge drinking since her teenage years who presents with liver failure. She initially presented to [**Hospital1 34**] from [**10-31**] to [**11-4**] with jaundice, and found to have a Bili of 30 and an INR of 2.3. During that admission she also developed mild ARF, Cr. to 1.4, but it improved to 1.1 at the time of discharge. She was also noted to have a leukocytosis of 16.7 but only small ascites on ultrasound, not tapped. She was evaluated for other forms of liver disease which was negative, including negative hepatitis viral serologies, negative [**Doctor First Name **], and a ceruloplasmin of 29. It was thought to be alcoholic hepatitis and she was started on 40mg PO steroids starting [**11-1**]. She was seen in follow up by Dr. [**Last Name (STitle) 31823**], GI, and she was feeling "miserable" with decreased PO intake. On labs drawn then, her bili had worsened to 41 and her creatinine was 2.2 with a BUN of 47. She also had a worsened WBC count to 29K. She was readmitted to [**Hospital1 34**], given IVF with no improvement in her renal function and poor UOP. She is transferred to [**Hospital1 18**] for further evaluation and treatment of hepatorenal syndrome. She underwent an abdominal ultrasound prior to transfer with marking for paracentesis but did not get a paracentesis. . The patient states that her last drink was 4 weeks ago. On admission she had c/o mild abdominal discomfort and fullness. She has also experienced dypnea on exertion while moving to the bathroom. Patient had emotional breakdown on the floor. She wanted to go home. She was found to be sinus tachycardia to 110s. Her oxygen saturation dropped to 88% in RA from 92-93% and came upto 92% on 3LNC. Liver team wanted her to be monitored closely and requested ICU transfer. . On arrival to the MICU her vitals were T 99.4 Hr 110 BP 101/53 RR 24 92% 3LNC. She states that she feels calmer. Deneis any chest pain, shorntess of breath, palpitations, HA, visual changes, cough, diarrhea, constipations, f/c, rash, focal weakness or numbness. No other complaints. Past Medical History: Alcoholism Liver disease Prolapsed bladder Depression Social History: Married with children. Very heavy drinker until recently but has trouble quantifying currently. Denies IVDU Family History: NC Physical Exam: VS: T 99.4 Hr 110 BP 101/53 RR 24 92% 3LNC. Gen: NAD, icteric HEENT: NCAT, EOMI, PERRL. Icteric sclera. OP clear, MMM. Neck: difficult to assess JVP given prominent carotids, no LAD Heart: tachycardic, regular rhythm, no m/r/g Lungs: Bibasilar crackles right greater than left Abd: soft +BS, distended, +fluid wave, non-tender Extrem: 1+ BLE edema, DP 2+ Skin: very jaundiced Neuro: CN II-XII in tact bilaterally. Strength is [**4-7**] in upper and lower extremities and sensation is intact bilaterally. No tremor/asterixis. Pertinent Results: [**2155-11-15**] 10:05AM BLOOD WBC-11.4* RBC-2.74* Hgb-9.9* Hct-27.7* MCV-101* MCH-36.2* MCHC-35.9* RDW-18.1* Plt Ct-54* [**2155-11-15**] 10:05AM BLOOD Neuts-94.8* Lymphs-2.8* Monos-2.0 Eos-0.4 Baso-0 [**2155-11-15**] 10:05AM BLOOD PT-23.6* PTT-55.5* INR(PT)-2.3* [**2155-11-15**] 10:05AM BLOOD Glucose-75 UreaN-60* Creat-2.4* Na-135 K-3.7 Cl-105 HCO3-13* AnGap-21* [**2155-11-15**] 10:05AM BLOOD ALT-134* AST-198* LD(LDH)-290* AlkPhos-117 Amylase-104* TotBili-40.6* [**2155-11-26**] 04:05AM BLOOD ALT-85* AST-122* LD(LDH)-201 AlkPhos-91 TotBili-32.6* [**2155-11-15**] 10:05AM BLOOD Albumin-3.6 Calcium-7.4* Phos-4.8* Mg-2.7* Iron-48 Cholest-56 [**2155-11-15**] 10:05AM BLOOD calTIBC-47* Ferritn-1446* TRF-36* [**2155-11-15**] 10:05AM BLOOD Triglyc-144 HDL-11 CHOL/HD-5.1 LDLcalc-16 [**2155-11-15**] 10:05AM BLOOD CEA-5.8* AFP-1.8 [**2155-11-15**] 10:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2155-11-15**] 10:05AM BLOOD AMA-NEGATIVE [**2155-11-15**] 10:05AM BLOOD [**Doctor First Name **]-NEGATIVE [**2155-11-15**] 10:05AM BLOOD IgG-979 IgA-316 IgM-188 [**2155-11-15**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2155-11-15**] 10:05AM BLOOD HCV Ab-NEGATIVE [**2155-11-18**] 04:47PM BLOOD Lactate-2.4* K-2.9* [**2155-11-15**] 10:05AM BLOOD CA [**65**]-9 -Test [**2155-11-15**] 10:05AM BLOOD CERULOPLASMIN-Test [**2155-11-20**] 05:10AM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION ANALYSIS-Test . Brief Hospital Course: 53 year old female with hx of alcoholism admitted to MICU with hepatic and renal failure. . # Hepatic failure: Her hepatic failure was secondary to alcoholic hepatitis/cirrhosis. She was followed by liver team. Patient was treated for spontaneous bacterial peritonitis and hospital acquired pneumonia with vancomycin and zosyn. She also received albumin, octreotide and midodrine for hepatorenal syndrome. During her course of hospital stay, her mental status progressively worsened and required intubation in order to give her lactulose and other necessary medications. Patient also developed pneumonia most likely secondary to aspiration. Goals of care were discussed with the family as her clinical condition worsened. Decision was made to make the patient's status comfort measures only as she was not a transplant candidate currently due to recent alcholol intake. Patient passed away on [**2155-11-27**]. . # Respiratory Failure: Tachypnea on admission. [**2155-11-17**] V/Q scan not suspecious for pulmonary emboli. Lower extremity non invasive sutidies did not show evidence of deep venous thrombosis. Intubated on [**11-21**] for worsening mental status, underlying multifocal pneumonia and tachypnea, with large amount of aspirate surrounding vocal cords. She had worsening metabolic acidosis which also played a role in her ventilation, as is apparent on her ABGs. Sputum samples only showed oropharyngeal flora. Antibiotics and goals of care as above. . # Acute renal failure: Renal function worsened during admission, likely secondary to hepatorenal syndrome. Lasix initially then pressors did not improved her urine output, and hemodialysis was not an option that would have improved her outcome in the long-term. Her electrolytes were repleated carefully given her renal failure. . # Metabolic acidosis: Secondary to renal failure. . #Mental Status ?????? Patient initialy with evidence of waxing/[**Doctor Last Name 688**] levels of consciousness with clear confusion in presence of liver failure suggestive of hepatic encephalopathy. Subsequently she was intubated and sedated. When sedation was decreased, she was increasingly confused and agitated as her condition worsened. . # Anemia: Had been Stable 24-26. Stool brown, guaiac negative. Patient had no prior endoscopies to document varices. She was not actively bleeding during the hospital stay. . Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired ICD9 Codes: 5849, 5070, 2762, 2859
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Medical Text: Admission Date: [**2182-8-29**] Discharge Date: [**2182-9-20**] Date of Birth: [**2124-3-20**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Codeine / Morphine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: s/p Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical)[**9-5**] s/p Cardiac [**Month/Year (2) **] [**8-30**] History of Present Illness: 58 yo F with PMH of CAD s/p PCI x3 presents with chest and left arm discomfort, along with SOB, for the past 1 week. Past Medical History: Coronary Artery Disease s/p Multiple PCI's (stent LAD [**2171**], [**Year (4 digits) **] [**2179**], [**2182**]) Congestive Heart Failure Hypertension Hypercholesterolemia Fibromyalgia Chronic Obstructive Pulmonary Disease Asthma Chronic Renal Insufficiency(1.3) Lower back pain Hiatal hernia PSH: Ectopicx2 in [**2155**],79 Social History: 50 pack year h/o smoking (quit in [**2179**]) does not drink alcohol Family History: not contributory Physical Exam: Afebrile, HR 80, BP 140/52 RR 22 5'3" 126kg Gen: Sleepy but arousable, AAOx3 HEENT: no lymphadenopathy, no carotid bruits Neck: JVP around [**8-21**] cms Heart: S1 S2, RRR, 3/6 SEM Lungs: BS w/ rales 1/2 up Abd: soft/NT/ND, BS+ Ext: 1+ edema, warm, well-perfused Neuro: no focal deficits, MAE Pertinent Results: TTE [**8-30**]: Severe mitral regurgitation with probably rheumatic mitral valve disease. Moderate to severe pulmonary artery systolic hypertension. Left ventricular cavity enlargement with regional dysfunction c/w CAD [**Month/Year (2) **] [**8-30**]: 1. One vessel coronary artery disease.2. Severe diastolic ventricular dysfunction.3. Moderate precapilary pulmonary hypertension.4. Successful deployment of a Cypher drug-eluting stent in the distal RCA Carotid U/S [**9-4**]: Moderate plaque with bilateral 40-59% carotid stenosis. Of note, both of the stenoses will fall into the lower end of the range. [**2182-8-29**] 04:30PM BLOOD WBC-13.2* RBC-4.62 Hgb-11.8* Hct-36.5 MCV-79* MCH-25.5* MCHC-32.2 RDW-16.4* Plt Ct-390 [**2182-9-4**] 07:50AM BLOOD WBC-12.3* RBC-4.52 Hgb-11.8* Hct-36.4 MCV-81* MCH-26.1* MCHC-32.4 RDW-17.3* Plt Ct-352 [**2182-9-12**] 01:23AM BLOOD WBC-19.0* RBC-3.78* Hgb-10.0* Hct-30.8* MCV-82 MCH-26.4* MCHC-32.4 RDW-18.6* Plt Ct-354 [**2182-9-19**] 06:21AM BLOOD WBC-12.8* RBC-3.11* Hgb-8.4* Hct-26.9* MCV-87 MCH-27.0 MCHC-31.2 RDW-20.6* Plt Ct-508* [**2182-8-30**] 01:00AM BLOOD PT-13.9* PTT-45.1* INR(PT)-1.3 [**2182-9-13**] 02:24AM BLOOD PT-27.6* PTT-39.4* INR(PT)-5.0 [**2182-9-20**] 12:30AM BLOOD PT-17.3* PTT-54.8* INR(PT)-2.0 [**2182-8-29**] 04:30PM BLOOD Glucose-120* UreaN-26* Creat-1.3* Na-141 K-4.1 Cl-100 HCO3-27 AnGap-18 [**2182-9-19**] 06:21AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-138 K-3.7 Cl-100 HCO3-29 AnGap-13 [**2182-9-14**] 08:49AM BLOOD ALT-178* AST-96* LD(LDH)-516* AlkPhos-127* Amylase-66 TotBili-1.7* [**2182-9-18**] 05:37PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018 [**2182-9-18**] 05:37PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG [**2182-9-18**] 05:37PM URINE RBC-[**12-1**]* WBC-[**3-16**] Bacteri-MOD Yeast-NONE Epi-[**6-21**] Brief Hospital Course: Pt. was admitted on [**8-29**] and then underwent both a Cardiac Echo and [**Month/Year (2) **] on [**8-30**]. The Echo revealed severe MR [**First Name (Titles) **] [**Last Name (Titles) **] showed 1 vessel CAD and a stent was placed in the distal RCA. Cardiac surgery was consulted following these procedures for replacement/repair of her mitral valve. But pt needed to be aggressively diuresed before surgery d/t CHF (pt was SOB and fluid overloaded-Edema & bilat pleural effusions). Please see medical records for CXR reports. She continued to be followed by us along with medicine and cardiology (see notes in medical records). PT. underwent a carotid u/s on [**9-4**] along with a dental consult and was cleared for surgery pending her WBC(12). On [**9-5**] pt was brought to the operating room where she underwent a mitral valve replacement with a mechanical valve. She tolerated the procedure well with no complications. Please see op note for surgical details. She was transferred to CSRU in stable condition on a Propofol gtt. Later on op day pt was weaned from mechanical ventilation and propofol and was extubated. She was MAE, following commandes, and A&O. On POD #1 pt appeared somewhat hypoxic w/ CXR showing CHF. Albuterol MDI, along with Diuresis, Oxygen via face tent and NC was started. Heparin was being given and Coumadin would be started later that night until target INR/PT/PTT was reached. POD #2 pt was stable and being diuresed with increased pulmonary toilet. Chest tubes and Swan-Ganz catheter were removed. On POD #3 Levofolx was started for increased WBC and yellow sputum. Sputum was cultered. She also received a blood transfusion b/c HCT was 24. Pt. remained in the CSRU until POD #12 and was then transferred to step-down unit. During that time (POD #[**4-23**]) she continued to have pulm symptoms and required aggressive pulm toilet w/ high flow oxygen. Pt. was encouraged to get OOB and ambulate. Pulmonary eventually was consulted. Also during this time pt's heart rhythm went into atrial flutter (EP followed pt). Amiodarone and Verapamil were started. Pt. also experienced a rise in her WBC while in the CSRU, multiple cultures were performed and appropriate antibiotics coverage was given. From POD #13 to 15 her oxygen was slowly weaned down. Also during here entire post-op period her Coumadin and Heparin were adjusted to reach a goal INR of 2.5 to 3 d/t her mechanical valve. Physical therapy followed pt during post-op period as well. She was transferred to rehab on POD #15 in stable condition and will have her INR followed and coumadin adjusted until goal is reached. She will also make appropriate f/u's with physicians. Medications on Admission: 1. Atenolol 50mg qd 2. Plavix 75mg qd 3. Protonix 40mg qd 4. Lasix 40mg [**Hospital1 **] 5. ASA 325mg qd 6. Folic Acid 7. KCL 8. Lipitor 40mg qd 9. Nitro 10. Atrovent 11. Flovent Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks: Then 200mg qd for 1 month. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2) Inhalation twice a day. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): to maintain target INR 2.5-3. 15. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Mitral Regurgitation S/P Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical)[**9-5**] PMH:Coronary Artery Disease s/p Multiple PCI's Congestive Heart Failure Hypertension Hypercholesterolemia Fibromyalgia Chronic Obstructive Pulmonary Disease Asthma Chronic Renal Insufficiency(1.3) Lower back pain Discharge Condition: Stable Discharge Instructions: Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. Take all of your medications as directed. Please seek medical attention immediately if you feel any chest pain, shortness of breath, or any otehr concerning symptoms. Do not lift more than 10 pounds for 2 months. Do not drive for 1 month. Can take shower. Wash incision with warm water and gentle soap. Gently pat dry. Do not take bath or go swimming. Do not apply lotions, creams, ointments or powders to incision. Followup Instructions: Dr. [**Last Name (STitle) 48108**] 2-3 weeks. Dr. [**Last Name (STitle) **] in 4 weeks. Completed by:[**2182-9-20**] ICD9 Codes: 4111, 9971, 4019, 2724, 2859, 412
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Medical Text: Admission Date: [**2145-12-20**] Discharge Date: [**2145-12-24**] Date of Birth: [**2087-12-9**] Sex: F Service: MEDICINE Allergies: Zanaflex Attending:[**First Name3 (LF) 10293**] Chief Complaint: Chief complaint: Hypotension post-TIPS revision, after transfer from OSH ([**Hospital3 17162**]) with shortness of breath, refractory ascites Major Surgical or Invasive Procedure: TIPS revision, paracentesis x 2 History of Present Illness: History of Present Illness Ms. [**Known lastname **] is a 58 yo woman with a history of HCV cirrhosis s/p TIPS [**3-5**] who presents with increased abdominal distension. . She previously had refractory ascites in early [**2145**], and underwent placement of TIPS for this reason. She was then doing well and was without significant ascites on aldactone. Lasix was added [**11-4**] for some edema. Subsequently her ascites continued to worsen. She was getting therapeutic paracentesis with removal of [**7-4**] L each time every two weeks. US [**11-18**] showed increased velocity in the TIPS. . She was recently admitted to [**Hospital3 **] [**Date range (1) 40579**] with increasing SOB, received 60 mg lasix underwent removal of 10 L of ascitic fluid, with resolution of SOB. Creatinine at that time on admission was 1.8. She had an ultrasound with Doppler [**12-12**] showing increased flow in the TIPS. . She was doing well until [**12-18**] when she presented for routine labs and was found to have renal failure beyond her baseline (creatinine 2.0 elevated from recent b/l 1.5) and hyperkalemia to 5.4 with peaked T waves. She received kayexalate, insulin, bicarb, D50 and was admitted. Diuretics were held. Because of concern for TIPS occlusion, she was transferred to [**Hospital1 18**] for possible revision. . On acceptance to the medicine team, she complains of epigastric pain, worse with lying and accompanied by a sour taste. She denies fevers, chills, change in bowel movements or blood in BM (baseline 4 BM/day on lactulose). Also no chest pain or shortness of breath. No urinary symptoms. . Upon admission to [**Hospital1 18**], plan was to proceed with TIPS revision. The day of admission to the MICU, she underwent TIPS revision and had a 6L paracentesis. Intraoperatively you way hypotensive to SBP 70s, treated with 1L 5% albumin and neo gtt without complication. [**Name (NI) **], pt again became hypotensive to the 70s, asymmptomatic and resolve with 50g 25% albumin and 500cc NS. In total in [**Name (NI) 13042**], pt received 1400cc NS, 800cc Bicarb/D5W and 200cc of 25% albumin. EBL 147ml. . Upon transfer to MICU, patient confirms story as above. States she's had some mild abdominal pain. . Past Medical History: PAST MEDICAL HISTORY: # ESLD secondary to HCV cirrhosis - Hep C dxed [**2126**], unknown exposure: no hx transfusion, IVDU, tatoo placed after hep C diagnosis - genotype IA, treated with multiple courses of interferon unsuccessfully - bx [**2140**] stage 3-4 fibrosis - hx encephalopathy, - grade 3 varices banded [**3-5**]. No history of variceal bleeding. + history of hemorrhoidal bleeding. - hx refractory ascites, s/p TIPS [**2145-3-19**], revised [**8-3**] after presenting with recurrent ascites - on transplant list # Renal insufficiency, baseline creatinine 1.5 per OSH records but previously has bumped to >2 # Diastolic CHF # Asthma # Depression # Anxiety # GERD # IDDM # Seizure disorder # Hypertension # OSA # Refractory nausea - controlled with reglan - ? gastroparesis # s/p CCY # h/o Asthma - stable # Pancytopenia - related to ESLD . Social History: From [**Male First Name (un) **] and visited recently. ? past h/o IVDU. Denies tobacco, EtOH, or current recreational drug use. Family History: Family History: no family history of liver disease Physical Exam: Admission PE: T 96.1 89, 100/58, 23, 99/RA Gen: no apparent distress, appears well HEENT/NECK: could not visualize JVP, supple, oropharynx clear, sclera anicteric Cor: regular, 2/6 systolic murmur heard best at the left upper sternal border Pulm: lungs clear bilaterally except fine bibasilar crackles posteriorly Abd: Distended, soft, nontender. + shifting dullness. No rebound, no guarding. Ext: trace pitting edema bilaterally, warm Neuro: A&O x 3, appropriate, coherent historian, no asterixis. Pertinent Results: EKG [**12-20**]: Normal sinus rhythm at 87 bpm. Normal axis, normal intervals. No evidence of ischemia. . Admission Labs: [**2145-12-21**] 03:40AM BLOOD WBC-4.3 RBC-2.91* Hgb-10.3* Hct-28.5* MCV-98 MCH-35.6* MCHC-36.2* RDW-14.1 Plt Ct-88* [**2145-12-21**] 03:40AM BLOOD Neuts-72.3* Lymphs-15.6* Monos-8.4 Eos-3.2 Baso-0.6 [**2145-12-21**] 03:40AM BLOOD PT-14.6* PTT-32.8 INR(PT)-1.3* [**2145-12-21**] 03:40AM BLOOD Plt Ct-88* [**2145-12-21**] 03:40AM BLOOD Glucose-173* UreaN-35* Creat-1.7* Na-126* K-4.2 Cl-95* HCO3-25 AnGap-10 [**2145-12-21**] 03:40AM BLOOD ALT-24 AST-39 LD(LDH)-246 AlkPhos-393* TotBili-4.9* [**2145-12-21**] 03:40AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.8 Mg-2.1 . Labs prior to discharge: [**2145-12-24**] 06:15AM BLOOD WBC-2.7* RBC-2.43* Hgb-9.1* Hct-23.8* MCV-98 MCH-37.3* MCHC-38.0* RDW-14.5 Plt Ct-66* [**2145-12-24**] 06:15AM BLOOD Glucose-125* UreaN-35* Creat-1.5* Na-129* K-4.1 Cl-97 HCO3-25 AnGap-11 [**2145-12-24**] 06:15AM BLOOD ALT-17 AST-33 AlkPhos-229* TotBili-5.4* . Micro: [**2145-12-21**] URINE CULTURE (Final [**2145-12-22**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . Radographic studies: . LIVER OR GALLBLADDER US [**12-21**] (to evaluate TIPs) IMPRESSION: 1. Patent TIPS with velocities of 100 to 180 cm/s. 2. There is a lack of wall-to-wall flow in the mid to distal TIPS, suggestive of neo-intimal hyperplasia. 3. Interval increase in the amount of ascites since the prior exam. 4. Splenomegaly. Brief Hospital Course: A 57 yo woman with HCV cirrhosis s/p TIPS is transferred from OSH with refractory ascites for consideration of TIPS revision. . # Ascites: The patient had large ascites on exam but was not uncomfortable. Last therapeutic tap had been [**12-13**]. Ultrasound showed lack of wall-to-wall flow in the mid to distal TIPS, suggestive of neo-intimal hyperplasia. Given the history of apparent improvement in ascites after placement and subsequently after revision of TIPS, she underwent TIPS revision with 10 mm balloon and improved flow. Follow-up US two days later showed patent tips. Paracentesis of 6 L was done at the time of revision, and an additional 11.25 liters were taken off two days later, with albumin replacement each time. Diuretics were held for elevated creatinine. PPI was continued for reflux symptoms likely secondary to ascites. . # Hypotension: Intraoperatively while under general anesthesia, patient was hypotensive with SBP 70s. This continued in the [**Month/Year (2) 13042**] post-operatively. Initial hypotension likely related to anesthesia and fluid shift from large volume paracentesis. She was transferred briefly to the MICU, where blood pressure returned to baseline SBP 90s with IVF and albumin. . # Acute renal failure: Creatinine at OSH was increased from baseline 1.5 to 2.0. On admission, creatinine was 1.7. Diuretics were held. Urinary sodium was <10, consistent with prerenal vs HRS. She was given albumin at the time of paracentesis, and creatinine trended down to 1.5 prior to discharge. She was discharged off all diuretics with plans for lab tests in 3 days to monitor kidney function given that she had large volume paracentesis on the day of discharge. . # UTI: She had had a recent E Coli treated with Bactrim at an outside hospital. UA and cultures here were negative. . # Hyponatremia: Sodium was near baseline. She was asymptomatic. . # DM: Lantus was continued at home dose; she was given regular insulin as needed. . # Pancytopenia: Hematocrit and platelets were at baseline. . # Depression/Anxiety. Mirtazapine and trazadone were continued. . # Seizure disorder: Carbamazepine was continued. . Medications on Admission: - Potassium 20mEq PO daily - Spironolactone 200mg PO daily - Lactulose 30ml PO QID, titrated to [**2-28**] BM daily - Rifaximin 400 mg PO TID - Metoclopramide 10mg QACHS - Lasix 40mg daily - Clotrimazole - Levaquin 250mg daily (for E. coli UTI, subseq R to levoflox) - Protonix 40mg daily - Mirtazapine 15mg PO HS - Lantus 26 units SubQ - Carbamazepine 200 mg QAM, 400 mg QPM - Ibuprofen PRN pain - Folic acid 1mg daily - Dulcolax 1 tablet PO Q12H Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Lantus 26 units qhs 7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed. 11. Outpatient Lab Work Please do chemistry panel including creatinine, CBC, and LFTs. Please fax results to: [**Telephone/Fax (1) 697**] ATTN: Dr. [**Last Name (STitle) 497**]. Discharge Disposition: Home Discharge Diagnosis: primary: cirrhosis secondary: renal insufficiency, diastolic congestive heart failure, type 2 diabetes Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because you needed to have your TIPS revised. You had the TIPS revised and fluid taken out of your abdomen. The following medications were changed in the hospital: spironolactone, lasix, levaquin, and potassium were stopped . Please have your labs checked next Monday, [**12-27**] with the attached prescription. . Please call your doctor or return to the hospital if you have chest pain or shortnes of breath, increasing abdominal girth, fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please have your labs checked on Monday, [**12-27**] with the attached prescription. . You will need to have follow-up TIPS surveillance in [**7-4**] weeks. Dr. [**Last Name (STitle) 497**] can arrange this. . You have an appointment for an ultrasound and then at the [**Hospital 20871**] clinic: ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-1-12**] 1:45 TRANSPLANT [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-1-12**] 3:20 Completed by:[**2145-12-25**] ICD9 Codes: 5849, 5990, 2761, 5715, 4280, 5859, 2767
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Medical Text: Unit No: [**Numeric Identifier 69025**] Admission Date: [**2168-10-25**] Discharge Date: [**2168-10-27**] Date of Birth: [**2168-10-25**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 69026**] is a 4.175 kg product of a term gestation, born to a 38 year-old, Gravida III, Para II woman. Prenatal screens 0 positive, antibody negative, hepatitis surface antigen negative. RPR nonreactive. Rubella immune. GBS negative. Pregnancy history: Reportedly benign. Mother presented in spontaneous labor. No maternal fever, no prolonged rupture of membranes. Clear amniotic fluid. Maternal anesthesia by epidural. Vaginal delivery. Loose nuchal cord x1. Apgars were 9 and 9. NICU called to inspect infant at 30 minutes of life for grunting, flaring and retracting. On initial exam, decreased breath sounds on the right chest. Taken to NICU for further management. PHYSICAL EXAMINATION: On admission, birth weight was 4.175 kg. Length was 53.3 cm. Head circumference was 34 cm. Radiant warmer, under oxygen [**Doctor Last Name **] for N2 wash-out. Pink, remarkably comfortable appearing. No grunting, flaring and retracting noted. Non dysmorphic. Anterior fontanel soft and flat. Red reflex deferred. Ears: Normal set without anomalies. Intact palate. Neck supple with intact clavicles. Cardiovascular: Regular rate and rhythm. No murmur, non displaced PMI, good peripheral pulses. Lungs clear to apex with audible breath sounds now bilaterally. Abdomen soft. Positive bowel sounds. Normal male. Testes down bilaterally. Patent anus. No sacral anomalies. Extremities pink and well perfused. HOSPITAL COURSE: Respiratory: X-ray on admission demonstrated bilateral pneumothoraces. Infant placed on oxygen [**Doctor Last Name **] for nitrogen wash-out of 100%. Blood gas on oxy- [**Doctor Last Name **] was pH of 7.37, PC02 of 42, P02 of 125. Infant weaned out of oxygen [**Doctor Last Name **] by midnight on [**10-25**] and is currently stable in room air. Most recent CXR shows resolution of air leaks. Persistent increased opacity most likely represents unresolved atelectasis although congenital malformation is possible. Cardiovascular: Has been cardiovascularly stable throughout hospital course with typical rates 120 to 160s. Fluids, electrolytes and nutrition: Birth weight was 4.175 kg. Discharge weight is . Infant was initially feeding 50 cc per kg per day of D-10-W. Enteral feedings were initiated on day of life 1 and infant is currently ad lib feeding, taking in adequate amounts. Infant has been euglycemic throughout hospital course. Gastrointestinal: No issues. Hematology: Hematocrit on admission was 48.4. Infant did not require any blood transfusions. Infectious disease: CBC and blood culture obtained on admission. CBC was benign. White blood cell count of 19.7; platelet count of 244. 72 polys, 0 bands. Infant received 48 hours of Ampicillin and Gentamycin, at which time they were discontinued and blood cultures remained negative. Neuro: Infant has been appropriate for gestational age. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 59017**], MD, telephone number [**Telephone/Fax (1) 51263**]. RECOMMENDATIONS: Feeds at discharge: Continue ad lib breast feeding. Medications: Non applicable. Car seat position screening test: Not applicable. State newborn screens were sent as per protocol and have been within normal limits. Immunizations received: 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 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. DISCHARGE DIAGNOSES: 1. Moderate respiratory distress. 2. Rule out sepsis with antibiotics. 3. Bilateral Pneumothoraces/pneumediastinum. 4. Would repeat CXR in [**1-11**] months to verify normality of lung fields in order to rulle ourt congenital lung malformation. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) 60288**] MEDQUIST36 D: [**2168-10-26**] 22:09:33 T: [**2168-10-27**] 05:09:44 Job#: [**Job Number 69027**] ICD9 Codes: V290, V053
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Medical Text: Admission Date: [**2200-4-6**] Discharge Date: [**2200-4-19**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male with history of diabetes, hypertension, hypercholesterolemia, CAD, ventricular tachycardia, status post implantable defibrillator with newly diagnosed right upper lobe [**Hospital **] transferred from [**Hospital6 2561**] for right main stem bronchus stent for recurrent ex vacuo effusion, status post thoracentesis times three. The patient was admitted to [**Hospital3 **] on [**2200-2-17**], with ventricular tachycardia following a motor vehicle accident. An implantable defibrillator was placed at that time. He was then readmitted on [**2200-3-26**], for a recurrent pleural effusion, for which he received a pigtail catheter and consideration of possible pleurodesis. However, he was not a candidate for pleurodesis secondary to the pleural effusion ex vacuo. Thus CT surgery placed a chest tube, which was accidentally pulled out by the patient during movement on [**2200-3-30**]. On [**2200-4-4**], the patient became acutely short of breath with drop in sense requiring non- rebreather. Further decompensation occurred while the patient was transferred to the CCU and he ultimately required emergent intubation. Pre-intubation gas 7.42/41/79. The patient's blood pressure decreased following intubation requiring IV fluids and Neo-Synephrine. The patient was transferred to [**Hospital1 18**] for a right main stem bronchus shunt to hopefully resolve his pleural effusion ex vacuo, which was thought to be secondary to right lobar collapse secondary to his obstruction. PAST MEDICAL HISTORY: Diabetes, hypertension, CAD status post MI in [**2197**], status post LAD stent, catheterization in [**2194**] showed three-vessel disease with 50 percent narrowing of the LAD, 30 percent narrowing of the proximal SARC and 60 percent narrowing of the marginal branch. Echo in [**2198-11-18**], showed an EF of 50 percent, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]; and a normal pulmonary artery pressure, history of ventricular tachycardia status post implantable defibrillator, right upper lobe mass diagnosed as squamous cell carcinoma, no endobronchial disease on bronchoscopy done at [**Hospital1 336**] (status post pleuracentesis, fluid was non malignant, MRI revealed mediastinal involvement, thus the patient was considered non- resectable; status post 12 radiation treatments in addition to a course of Paxil and carboplatin), hypercholesterolemia, and history of atrial fibrillation, taken off Coumadin four weeks ago. MEDICATIONS: 1. Avandia 4 mg p.o. q.p.m. 2. Lipitor 20 mg p.o. q.p.m. 3. Trazodone 50 mg p.o. q.h.s. 4. Megace 100 mg p.o. q.d. 5. Amiodarone 200 mg p.o. q.d. 6. Lopressor 25 mg p.o. b.i.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Brother was deceased in his 50s secondary to lung cancer with positive history of tobacco, multiple members with early CAD. SOCIAL HISTORY: The patient is positive tobacco, 0.5 packs per day times 50 years, no alcohol, and worked as a fish cutter in the past. PHYSICAL EXAMINATION: Temperature is 97.2, blood pressure 72/25 with a CVP of four, and heart rate of 65. The patient is on AC with a tidal volume of 600 and respiratory rate of 14, with a PIP of 5, FIO2 of 60 percent, with an O2 saturation of 95 percent. ABG was 7.43/31/75. In general, the patient is intubated, sedated in no apparent distress. Skin, no rash. HEENT, pupils are equally round and reactive to light and accommodation. Sclerae anicteric. Cardiovascular, bradycardia with regular rhythm, no murmurs, rubs, or gallops. Pulmonary, coarse breath sounds on the left, poor air movement on the right. Abdomen, normoactive bowel sounds, soft, nontender, nondistended, no masses or hepatosplenomegaly. Extremities, 1 to 2 plus pitting edema in the upper extremities, left greater than the right, no clubbing or cyanosis. Neurologically, alert, follows commands, strength 4/4 bilaterally in the upper and lower extremities, 1 plus reflexes bilaterally. LABORATORY DATA AND DIAGNOSTICS: White count is 3.9, hematocrit 32.2, platelets 88 with 86 percent neutrophils, 12 percents lymphocytes, and 2 percent monocytes. Sodium is 136, potassium 4.5, bicarbonate 20, BUN 59, creatinine 1.7, and lactate 1.2. EKG, paced at 66 beats per minute, left bundle branch block, questionable new T-wave inversion in V5- V6. Chest x-ray, right upper lobe collapse, positive atelectasis/wide-out of the remainder of the right lung. HOSPITAL COURSE: This is a 75-year-old male with a history of diabetes, hypertension, hypercholesterolemia, CAD status post MI and LAD stent, ventricular tachycardia status post defibrillator, transferred from [**Hospital6 2561**] for right main stem bronchus stent for obstructing right lung mass, diagnosed as squamous cell carcinoma complicated by an ex vacuo pleural effusion. Right lung mass. The patient presents with a diagnosis of non-small cell lung cancer identified as stage 3B squamous carcinoma with mediastinal involvement by MRI with a non- malignant ex vacuo pleural effusion and associated lung collapse, status post 12 radiation treatments and a course of Paxil and carboplatin. Plan for an initial right main stem bronchus stent, however, bronchoscopy revealed multiple endobronchial lesions, thus be more appropriate treatment was thought to be photodynamic therapy. The patient was activated with photodynamic therapy on [**2200-4-10**]. He required three subsequent bronchoscopies for removal of debridement from the right main stem bronchus. Unfortunately, his lung did not re-expand following this intervention and the patient passed before any significant recovery could occur. During his hospital stay, hematology- oncology was consulted to discuss further management as daughter looking to shift care to [**Hospital1 18**]. Discussion initially was made of further chemotherapy. Radiation oncology was consulted and felt no further radiation was indicated as the patient has progressed through 12 treatments of radiation. However, the patient, as stated earlier, passed before recovery from his immediate ailment. Right pleural effusion ex vacuo. The patient presented with a right chest tube in place. The chest tube remained water sealed. Our hope was that this chest tube could be removed following the re-expansion of his lungs after intervention to open up his right main stem bronchus. Unfortunately, his lung did not re-expand and the chest tube remained in place at the time of his death. Respiratory failure. Due to the patient's obstructing mass leading to a pleural effusion ex vacuo, the patient suffered hypoxic respiratory failure. At the outside hospital, a chest tube was placed. It was accidentally dislodged, but ultimately required replacement as the patient had respiratory decompensation. He was transferred, intubated on assist control. He was tried on pressor-support during the course of his ICU stay. However, he was unable to be weaned from the ventilator. Hypotension. The patient presented with blood pressure of 72/25 with a CVP of four on peripheral Neo-Synephrine. His hypotension was initially thought to be due to decreased pre- loads secondary to increased inter-chest pressures from his pleural effusion ex vacuo and positive pressure ventilation. His cortisol was found to be within normal limits. His blood pressure did respond to p.r.n. fluid boluses. He was maintained on Neo-Synephrine. During the course of his stay Vasopressin was added to further support his blood pressures. The patient's condition began to decompensate. During this hospital stay, the patient became septic from likely pulmonary source and required increasing amounts of pressors for support. He ceased to respond to IV fluid boluses and pressor-support was thought to be maximized. The patient was maintained on all these medications till the time of his death. Cardiovascular. Ischemia. The patient's beta-blocker was held due to his hypotension. Troponins were slightly elevated at level of 0.05; however, CK MB remained negative, and EKG unchanged. Rhythm. The patient has a history of atrial fibrillation and ventricular tachycardia, but was paced at a rate of 66 on presentation and remained in sinus. Pump. The patient had significant amount of third spacing; however, no evidence of obvious heart failure. His EF was noted to be 35 to 40 percent. Upper extremity edema. The patient presented with bilateral upper extremity edema, left greater than right; bilateral Dopplers were negative for DVT. This was thought to be secondary to third spacing from aggressive fluid resuscitation. Neutropenic fever. The patient with low-grade fever in the setting of neutropenia. Thus, he was started on empiric ceftazidime. Vancomycin was later added for persistent hypotension, but was subsequently discontinued when the patient was able to be weaned off all pressors. The patient was administered GCSF in hopes of recovering his white blood count and this medication was discontinued when he was no longer neutropenic. Unfortunately, the patient developed worsening functions. Sputum culture grew Gram-negative rods with moderate Haemophilus. He was thus continued on his ceftazidime and vancomycin was restarted in addition to Cipro for double-pseudomonas coverage. Unfortunately, the patient subsequently developed a copious amounts of diarrhea, and was empirically treated for C. Diff. colitis, subsequent toxins were positive. He was continued on Flagyl and his diarrhea subsided. KUB was assessed during the course of his ICU stay and was negative for toxic megacolon. The patient continued to deteriorate. His coagulase were increased. He was administered vitamin K and DIC panel was negative. An ID consult was obtained and on [**2200-4-13**], mucolytic cultures were then growing yeast. The patient was thus started on AmBisome, which was changed to IV fluconazole upon the identification of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] leukopenia in the patient's blood. Ultimately, the patient's ceftazidime was discontinued secondary to drop in platelets and eminent death as this medication was thought to be doing more harm than good. Acute renal failure. The patient presented with elevated creatinine. His renal function worsened in the first few days of his ICU admission. A FENA at the time was 0.3 percent. His creatinine came down with IV fluids and his urine output responded to fluid boluses. However, later in his ICU stay, his creatinine again rose. Urine eos were negative. Protein to creatinine was 1.0; FENA at that time was 0.9 percent with urine output of 423. The patient's progressive worsening renal failure was thought to be due to HEN and secondary to hypotension and sepsis. His creatinine reached as high as 4.2. Diabetes. The patient was initially on a sliding scale insulin, however, he was quickly changed to an insulin drug for improved blood sugar control. Prophylaxis. The patient maintained on PPI, subcutaneous Heparin, and neutropenic precautions. FEN. The patient's nutritional status maintained with tube feeds. Nutrition followed and provided guidance along the way. Code status. As the patient rapidly declined near the end of his stay, despite attempted intervention and photodynamic therapy to improve his overall outcome, a number of family meetings were organized to discuss the patient's wishes regarding further intervention. His daughter had significant difficulties with the decision making. Ethics was consulted to aid and supporting her and making these difficult decisions. Multiple staff were uncomfortable with perceived discomfort on the part of the patient. It was the opinion of ethics that we would continue to support the daughter's wishes as likely this gentleman would desire that, and the daughter did come to a point at which she began to withdraw care. Please see death certificate for the date and time of this patient's death. Dictation on the patient's date of death to be done by the intern covering at that time. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 19957**] MEDQUIST36 D: [**2200-7-30**] 07:00:54 T: [**2200-7-30**] 11:27:41 Job#: [**Job Number **] ICD9 Codes: 5119, 5180, 486, 5845, 0389
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Medical Text: Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-16**] Date of Birth: [**2068-8-5**] Sex: F Service: NEUROSURGERY Allergies: Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1271**] Chief Complaint: CC:[**CC Contact Info 3582**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI:61yo female from OSH who was found at the bottom of a staircase approximately 2.5hrs ago. EMS called and pt transported to [**Hospital3 3583**]. At scene pt noted to be awake and alert. GCS at [**Hospital3 3583**] 6. Intubated at approx. 18:40 Past Medical History: PMHx: Seizure disorder, "frontal lobe syndrome", Ulcerative colitis, Recurrent UTI's(fungal),Neurogenic bladder with chronic suprapubic tube, Peptic ulcer disease, Perforated duodenal ulcer, depression, COPD, Respiratory failure, DVT, Pulmonary embolism, s/p right hemicholectomy, hysterectomy, IVC filter placement, venous access device placement, s/p surgical repair of ankle fracture Social History: Social Hx: single with sig. other, 2 adult daughters,stepchildren Family History: unknown Physical Exam: PHYSICAL EXAM:Propofol off during initial exam @7:55pm O: T:97 BP: 130/ p HR:80-85 R 15 O2Sats 100% Vent Gen: Intubated, sedated en route from [**Hospital3 **]. NAD. HEENT: Pupils: 4.0mm NR Neck: Thin, No bruits Lungs: ETT present, audible airleak. Cardiac: RRR. S1/S2. Abd: Flat, Soft, Suprapubic tube present, BS+ Extrem: Cold, poor skin turgur Neuro: Mental status:Cranial Nerves: I: Not tested II: Pupils NR 4.0mm bil. III, IV, VI: Does not track or follow examiner V, VII: Facial symmetry even. VIII: Does not respond to voice. IX, X: UTA. [**Doctor First Name 81**]: UTA. XII: UTA. Motor: Decreased bulk, No abnormal movements,tremors or seizure like activity.Does not move upper extremities with noxious stimuli. Widraws both lower extremities with noxious stimuli. +Babinski. Pertinent Results: CT Head: [**6-13**] from OSH: Left frontotemporal SDH 1.5 CM Left to right Midline shift, partial effacement of the basilar cisterns. There is mass effect present which encroaches the left lateral ventricle. The subdural measures 1.9CM at the widest point. Discussed with ED radiologist as well. Repeat CT Head: [**6-13**] [**Hospital1 18**]: Final read not available at this time. Noted to have worsening interval changes with Midbrain hemorrhage and Uncal herniation. [**2130-6-13**] 07:50PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2130-6-13**] 07:50PM WBC-23.5* RBC-3.81* HGB-10.3* HCT-32.0* MCV-84 MCH-26.9* MCHC-32.1 RDW-17.8* [**2130-6-13**] 07:50PM PT-13.3 PTT-21.1* INR(PT)-1.1 [**2130-6-13**] 07:50PM PLT COUNT-643* [**2130-6-13**] 07:50PM FIBRINOGE-382 [**2130-6-13**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2130-6-13**] 07:50PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2130-6-13**] 07:50PM URINE RBC-[**6-21**]* WBC-[**12-1**]* BACTERIA-MOD YEAST-FEW EPI-[**3-16**] Brief Hospital Course: Pt was admitted to ICU for monitoring. Her neurologic exam remained poor. Discussion was had with family regarding poor prognosis. After discussion it was decided to make her comfort measures only. She expired. Medications on Admission: Medications prior to admission: Advair 250/50, 1puff [**Hospital1 **], ASA81mg po daily, Tegretol 200mg [**Hospital1 **], Tegretol 100mg po @12noon,Cymbalta 30mg po Daily, Isosorbide mononitrate 30mg po Daily,Asacol 800 mg po TID, Mirtazapine 15mgpo Qhs, Protonix 40mg po daily, Dilantin 200mg TID, Potassium chloride 20meq po BID,Topamax 100mg po BID, Plavix 75mg po daily, Xanax 0.5mg po TID,Percocet 5/325 1-2 tabs p.o. Q6hrs prn pain Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: subdural hematoma Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2130-9-29**] ICD9 Codes: 496
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Medical Text: Admission Date: [**2196-2-11**] Discharge Date: [**2196-2-17**] Date of Birth: [**2134-12-21**] Sex: F Service: C-MED Admitting physician: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. ADMISSION DIAGNOSIS: Chest pain DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x4 vessels. 2. Coronary artery disease. 3. Borderline diabetes mellitus. REFERRALS: Cardiology, cardiac surgery and physical therapy PROCEDURES: 1. Coronary artery catheterization. 2. Coronary artery bypass graft x4 vessels. ADMISSION H&P: Mrs. [**Known firstname **] [**Known lastname 101729**] is a 61-year-old female with a past medical history of hypercholesterolemia, positive Persantine thallium study, arthritis and occult guaiac positive rectal exam who presented with a complaint of shortness of breath for over the duration of one month with progressive dyspnea on exertion. She denied any history of chest pain, reflex dysphasia or odynophagia and presented for coronary catheterization on [**2196-2-11**]. The findings of catheterization were that she had an ejection fraction of 36% in anterior basal and posterior basal normal function and her anterior lateral, apical and inferior margins were hypokinetic. Her right coronary artery had a discrete proximal stenosis of 60% to 70%. Her mid obtuse marginal distal RCA and posterior descending arteries were all normal. Her left main had a stenosis of approximately 40% with diagonal stenosis of 90%. The proximal LAD was 80%, intermediate LAD was 90% and the middle LAD was approximately 60%. The distal LAD was 40%. The circumflex was normal and the obtuse marginal was normal. Her right sided heart pressures were a mean of approximately 12 mmHg. Her PAP was 38, 20 and 26 and her left ventricular end diastolic pressure was 20. She had moderate systolic and diastolic dysfunction. PAST MEDICAL HISTORY: 1. Degenerative joint disease. 2. Pneumonia in [**2189**]. 3. Occult blood one time on a recent screening exam. ALLERGIES: She has no allergies to any known drugs. PREVIOUS MEDICATIONS: 1. Aspirin 325 mg po qd. 2. Prempro 0.625/2.5 mg po qd. 3. Elavil 20 mg po q p.m. 4. Naprosyn 500 mg po bid. PAST SURGICAL HISTORY: 1. Tubal ligation. ADMISSION PHYSICAL EXAM: VITAL SIGNS: She was 5 foot 1.5 inches tall with a weight of 171 pounds. Her blood pressure was 142/82 on the left. On the right it was 135/80. Her pulse was 68. LUNGS: Clear to auscultation bilaterally. CARDIAC: Without murmurs, rubs or gallops. She had a normal S1 and S2. She had palpable DP and PT arteries bilaterally. After her catheterization, cardiothoracic surgery was consulted and plans were made to perform coronary artery bypass graft on [**2196-2-12**] on hospital day #2. On hospital day #2, she went to the Operating Room, where she underwent coronary artery bypass graft x4 vessels with a left internal mammary artery to LAD and vein to diagonal ramus and the right coronary artery. The patient was then transferred to the Cardiothoracic Intensive Care Unit where she was extubated shortly thereafter and out of bed on postoperative day #1. Her chest tube was maintained until postoperative day #2; it was discontinued. On postoperative day #2, she was evaluated by physical therapy and her dressing on postoperative day #3 while taken down, revealed some serosanguinous drainage. Her midline sternotomy was then painted with Betadine and dressed with a dry sterile dressing twice daily over the next couple of days. She was ambulating and able to take care of herself with clear lungs and extremely minimal drainage from her midline incision, therefore plans were made to discharge her on postoperative day #5. That morning, it was noted that she had a run of a questionable ventricular tachycardia on her telemetry monitoring. However, the electrophysiology/cardiology service was contact[**Name (NI) **] and the impression was that this was an artifact with a QRS wave and the patient would not require any further evaluation. Therefore, plans were made to discharge the patient home. DISPOSITION: Discharge to home DISCHARGE CONDITION: Good DISCHARGE MEDICATIONS: 1. Lopressor 50 mg po bid. 2. K-Dur 20 milliequivalents po q day x7 days. 3. Lasix 20 mg po qd x7 days. 4. Lipitor 10 mg po q hs. 5. ASA 81 mg po qd. 6. Elavil 20 mg po q p.m. 7. Percocet 1 to 2 tablets po q 3 to 4 hours. 8. Colace 100 mg po bid. DISCHARGE INSTRUCTIONS: The patient is to follow up with the nurses on Far Six for a wound check in approximately one week, to follow up with her primary care physician in one to two weeks and to follow up with Dr. [**Last Name (STitle) **] in four weeks. She can continue Betadine painting and dressings with dry sterile gauze twice daily until her midline sternotomy heals. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 13391**] MEDQUIST36 D: [**2196-2-18**] 13:14 T: [**2196-2-18**] 13:13 JOB#: [**Job Number **] ICD9 Codes: 4280, 2724
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Medical Text: Admission Date: [**2133-3-28**] Discharge Date: [**2133-4-2**] Date of Birth: [**2072-12-20**] Sex: M Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: This is a 60-year-old man with CAD, PVD who had difficulty speaking after left carotid endarterectomy in [**2133-2-16**]. The patient has had bilateral carotid stenosis. On [**2-21**] while he was sitting in a chair he developed sudden onset of right arm and leg numbness, followed by right arm and leg weakness. He also had difficulty speaking. He was admitted to [**Hospital3 **] and underwent a left carotid endarterectomy on [**2-26**] and afterwards began having severe left sided headache behind his left eye that lasted for hours and was constant. Nevertheless, he visited [**Hospital3 **] for continued headaches and nausea and vomiting. During one of those visits he had a contortion of his right face and bilateral arm jerking and was started on Dilantin with presumptive diagnosis of seizures. He has recovered from that event when was again discharged home. On [**3-13**] he again presented with persistent headaches, confusion and inability to talk. He had difficulty getting his words out. He had a head CT at [**Hospital3 **] which showed a linear hyperintense region in the left central temporal lobe but also other lesions in the left posterior parietal lobes. At that time he was transferred to the [**Hospital1 69**]. MRI of his head showed left MCA/ACA and left MCA/PCA watershed strokes with acute and subacute hemorrhage conversions. It was thought at that time that he had extended his watershed infarcts after carotid endarterectomy leading to a carotid hyperperfusion syndrome. The patient was discharged from the neurologic Intensive Care Unit to a rehab facility. On Thursday, [**2133-3-26**], patient's wife noticed erythema on patient's face. On [**3-27**] the visiting nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 11282**] of a rash on his arms as well. The patient was noted to be febrile and was admitted to the [**Company 191**] Firm. In the EW, patient's Dilantin was discontinued and he was given Tegretol instead. PAST MEDICAL HISTORY: 1) Left CEA in [**2133-2-16**]. 2) CVA in [**2133-2-16**]. 3) Paroxysmal atrial fibrillation. 4) CAD. 5) PVD. 6) Hypercholesterolemia. 7) History of amaurosis fugax. 8) Status post lymph node removal. MEDICATIONS: On admission, Lopressor 25 mg po bid, Dilantin 200 mg po tid, Prilosec 40 mg po q day, Lipitor, Ambien. ALLERGIES: Iodine. SOCIAL HISTORY: The patient lives in [**Location 3146**], tobacco since [**2126**], one pint of alcohol per day. The patient works as a carpenter. FAMILY MEDICAL HISTORY: CAD. PHYSICAL EXAMINATION: On admission, temperature 98.3, pulse 86, blood pressure 94/65, respiratory rate 18, saturations 96% on room air. In general, alert, oriented times three, no apparent distress. HEENT: Pupils are equal, round, and reactive to light, mucus membranes moist, oropharynx clear. No lymphadenopathy. Cardiovascular, regular rate and rhythm, no murmurs. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, non distended, positive bowel sounds. Extremities, no cyanosis, erythema, edema. Neuro, cranial nerves II through XII intact. Skin red maculopapular blanching erythema on face, torso and extremities, sparing the soles. Bilateral lower extremity petechiae, no significant oral lesions noted. HOSPITAL COURSE: 1. Derm: Over the course of patient's stay on [**Company 191**] Firm, patient had rigors and fevers of up to 101 degree. The patient was initially continued on Tegretol. The patient had worsening rash throughout his torso with lip swelling and tongue swelling. The patient did not experience any respiratory difficulties throughout the course of his stay on the [**Company 191**] service. A derm consult was obtained. The dermatology team recommended discontinuing Tegretol. Their thought was that the patient's symptoms were secondary to his hypersensitivity to Dilantin. The patient was treated symptomatically with IV fluids, Zantac, Benadryl and Synalar cream. The patient was transferred to the Medical Intensive Care Unit overnight for observation given risk of respiratory distress. [**Hospital **] Medical Intensive Care Unit stay was uneventful. Skin biopsy was also consistent with hypersensitivity reaction. Over the course of patient's stay in the hospital, patient's rash started to improve with decreasing erythema and edema. 2. Neuro: Patient was seen by neurology service. They recommended stopping all anti-epileptic medications since they thought that his symptoms were likely secondary to carotid reperfusion syndrome and anti-seizure medications are not necessarily beneficial under these circumstances. 3. GI: Patient's LFTs were slightly elevated during his admission. The patient's Lipitor was held due to increased LFTs. His increased LFTs were likely secondary to Dilantin. Patient to follow-up with his PCP to make sure LFTs are trending down and before restarting Lipitor. DISCHARGE DIAGNOSIS: 1. Dilantin hypersensitivity reaction. DISCHARGE MEDICATIONS: [**Doctor First Name **] 60 mg po bid, Zantac 150 mg po bid, Synalar ointment, Eucerin cream. Discharged to home. patient to follow-up with PCP next week as well as with dermatology. Patient's PCP to assess blood pressure before restarting Atenolol. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**] Dictated By:[**Name8 (MD) 5753**] MEDQUIST36 D: [**2133-4-21**] 16:51 T: [**2133-4-21**] 16:57 JOB#: [**Job Number 11284**] ICD9 Codes: 2720
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Medical Text: Admission Date: [**2164-9-7**] Discharge Date: [**2164-9-12**] Date of Birth: [**2086-10-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old gentleman with a history of AFib and hypertension, who is status post a bicycle accident, where he suffered a concussion over two months ago. He reports problems from the accident including headaches, diplopia, and vertigo have improved other than fatigue. He and the son have noticed that he has become slow and more fatigued. The patient's voice has become softer. His gait is starting to shuffle. The son noticed that he is slower in initiating or changing motor movements. The patient denies any resting tremor or urinary incontinence, although he is urinating much more frequently recently. He had a single fall while walking the [**Doctor Last Name 6641**] when he slipped on a wet log with no other falls. He denies feeling depressed. Denies any changes in appetite or sleep pattern. PHYSICAL EXAMINATION: On physical exam, he is an elderly man in no acute distress. He is alert and oriented with normal language and memory. EOMs are full. Pupils are equal, round, and reactive to light. He has no ptosis. His face is symmetric. His tongue is midline. He has no drift, no resting tremor, some mild paratonia in the arms and legs, but no cogwheeling even with distractions. However, his give-way and effort dependent throughout. He has no specific pattern with impairment, although weakest muscles are iliopsoas at 4-/5. Fine finger movements are rapid and precise. His deep tendon reflexes are 1+ in the arms and 1+ at the knees. Trace ankles and toes are downgoing. Gait has difficulty initiating movements. Needs arms to get up out of a chair. Head CT initially after the accident showed small bilateral frontal hygromas and a slight subarachnoid hemorrhage. On the 19th, he has got a large hygroma with subdural hemorrhage located within the subfalcine, subfalcine herniation . The patient was taken to the operating room for evacuation of the subdural hematoma, which he tolerated without complication. His vital signs remained stable. Postoperative, he is awake, alert, and oriented times three, moving all extremities with good strength with a subtle left drift, subtle left sided weakness. His vital signs remained stable. He did have a right frontal-parietal crani for evacuation of the subdural. He was monitored in the ICU postoperatively, and transferred to the regular floor on postoperative day one. He was seen by Physical Therapy and Occupational Therapy, and found to be safe for discharge to rehab. MEDICATIONS AT TIME OF DISCHARGE: 1. Milk of magnesia 30 cc p.o. q.6h. prn. 2. Atenolol 25 mg p.o. q.d. 3. Percocet 1-2 tablets p.o. q.4-6h. prn. 4. .................... 7.5 mg p.o. q.d. 5. Zantac 150 mg p.o. b.i.d. 6. Fluoxetine 10 mg p.o. q.d. 7. Senna one tablet p.o. b.i.d. prn. 8. .................... bromide inhaler two puffs q.i.d. 9. Colace 100 mg p.o. b.i.d. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**First Name (STitle) **] in one month with a repeat CT. Staples should be removed on postoperative day #10. Surgery was on [**2164-9-8**]. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2164-9-12**] 11:26 T: [**2164-9-12**] 11:36 JOB#: [**Job Number 93362**] ICD9 Codes: 4019
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Medical Text: Admission Date: [**2114-8-23**] Discharge Date: [**2114-9-7**] Date of Birth: [**2075-5-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: Right IJ Central line placement [**2114-8-24**] at [**Hospital1 18**] with removal of (L) subclavian placed at OSH; intubation at OSH [**8-14**] and [**8-16**]; extubated [**2114-8-29**]. History of Present Illness: Mr. [**Known lastname 82971**] is a 39 year old man with diabetes, hypertriglyceridemia, and alcoholism who presented to an OSH on [**8-11**] with abdominal pain in the setting of increased EtOH use over the last month. . There, admission labs were notable for lipase 1687, WBC 11 with 24% bands, Hct 50, AST 125, ALT 99, Na 125, gap of 17. Cholesterol was approximately 3000. CT scan on admission showed evidence of pancreatitis, pancreatic edema with free fluid in the pelvis. He was admitted to the ICU for close monitoring and fluid resuscitation. . At the OSH ICU, he became progressively confused despite treatment with lorazepam per CIWA. He developed respiratory distress on [**8-14**] and was intubated. He self extubated on [**8-16**] and did well initially, though had to be reintubated later that day for respiratory distress and altered mental status. He has undergone multiple attempts at weaning from the vent apparently complicated by increased hypercapnia and hypoxia. . He remained febrile throughout his hospital course. He was started on ceftriaxone and vancomycin empirically on [**8-14**]. Flagyl was added subsequently, and then ceftrixone was changed to levofloxacin. Oral vancomycin was added on [**8-19**]. His antibiotics were again modified to doripenem on [**8-20**] with improvement of his WBC from 25 to 12k by [**8-21**]. A RIJ had been placed on [**8-14**] and was removed on [**8-21**]. Cultures of blood, urine, and lines have been negative as have C diff toxin assays. . On evaluation in the [**Hospital Unit Name 153**], he is intubated and unable to provide any history. Past Medical History: Familial hypertriglyceridemia, Alcohol abuse, HTN, Anxiety, DM, Gout, MVA s/p ankle fracture Social History: Married. Daily drinker 6 beers/day. Uses marijuana and cocaine. No tobacco. Family History: Other family members with Diabetes Physical Exam: On [**Hospital Unit Name 153**] admission: Vitals 102.2 112 139/81 23 100% on AC General Young man intubated and sedated HEENT Sclera anicteric, conjunctiva slightly injected on right Neck Supple Pulm Diminished at right base CV Tachycardic regular S1 S2 no m/r/g Abd Mildly distended, diminished bowel sounds, grimaces with palpation Extrem Warm no edema palpable distal pulses. legs symmetric Neuro Opens eyes to voice, squeezes hands and wiggles toes to command Derm No rash or jaundice Lines/tubes/drains foley yellow urine left subclavian . On [**Hospital Unit Name 153**] transfer: Vitals: T98.6 P97 BP 144/93 RR19 SaO2 96% RA General: Calm, asks appropriate questions, oriented to person, hospital Pulm Decreased breath sounds L base, otherwise CTA CV Tachycardic, nl S1 S2, no m/r/g Abd: s/nt, mildly distended, active bowel sounds Extrem Warm, 2+ distal pulses. legs symmetric, no /c/c/e . At Discharge: VS: 98.9 PO, 92, 144/82, 20, 94% RA GEN: In NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. No [**Doctor First Name **]. LUNGS: CTA(B). COR: RRR ABD: BSx4. Soft/NT/ND. EXTREM: No c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. Pertinent Results: On [**Hospital Unit Name 153**] admission [**2114-8-23**]: WBC-14.0* RBC-2.48* Hgb-8.1* Hct-24.0* MCV-97 MCH-32.5* MCHC-33.6 RDW-13.7 Plt Ct-690* Neuts-71* Bands-1 Lymphs-14* Monos-7 Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-2* Plasma-1* PT-12.6 PTT-24.7 INR(PT)-1.1 Glucose-95 UreaN-19 Creat-0.6 Na-149* K-4.1 Cl-111* HCO3-29 AnGap-13 ALT-18 AST-46* LD(LDH)-474* AlkPhos-67 Amylase-13 TotBili-0.5 Lipase-94* Hapto-613* Triglyc-259* Lactate-0.8 Albumin-2.8* Calcium-8.4 Phos-3.9 Mg-2.1 . Labs at transfer [**2114-9-2**]: WBC-18.3* RBC-2.82* Hgb-8.7* Hct-25.2* MCV-89 MCH-30.9 MCHC-34.6 RDW-14.2 Plt Ct-762* PT-15.2* PTT-67.7* INR(PT)-1.3* Glucose-94 UreaN-11 Creat-0.5 Na-138 K-3.0* Cl-101 HCO3-24 AnGap-16 Calcium-8.7 Phos-3.8 Mg-1.8 . VitB12-633 Folate-14.0 . OSH Imaging: [**8-11**] CT abd/pelvis: severe pancreatitis no necrosis, pseudocyst, or organized fluid collection. fatty liver. . [**8-17**] CT abd/pelvis: increased ascites and RP effusions, no organized collection bilateral pleural effusions . [**Hospital1 18**] Imaging: [**8-23**] EKG: Sinus rhythm. Early R wave progression. No previous tracing available for comparison. . [**8-23**] CT head: Normal study. . [**8-23**] CT Abd/pelvis: 1. Extensive peripancreatic fluid collections extending from the greater curvature of the stomach into the deep pelvis in the presacral area. Areas of hypoenhancement within the pancreas, particularly within the body and neck are identified and concerning for possible necrosis, although artifact from interdigitating fluid cannot be excluded. 2. Small bilateral pleural effusions with associated atelectasis. 3. Air within the bladder likely due to recent Foley catheterization. Clinical correlation is recommended. 4. Diffuse anasarca. . [**2114-8-28**] CT Abdomen/pelvis: 1. No CT evidence of pancreatic necrosis. 2. Grossly unchanged appearance of very large peripancreatic fluid collections, with largest collection adjacent to the greater curvature of the stomach slightly more organized and increased in size than seen previously. 3. Increased bilateral pleural effusions and bibasilar atelectasis . [**8-30**] Lower extremity doppler ultrasound: 1. Deep venous thrombosis involving the calf veins, including both peroneal veins and one of the paired right posterior tibial veins. . [**8-30**] CTA Chest: 1)Left Lower lobe subsegmental pulmonary embolism. 2)Large left pleural effusion with near-complete collapse of the left lower lobe and right lower lobe atelectasis and small pleural effusion. 3)Large pseudocyst has slightly decreased in size since the previous abdominal study and now measures 6.9 x 10 cm. . [**9-2**] CXR: Compared to [**8-30**], the general haziness of the left hemithorax is substantially less, suggesting improvement in the pleural effusion. The right central catheter has been removed and the nasogastric tube remains coiled in the upper stomach. No evidence of acute pneumonia or vascular congestion. . [**2114-9-5**] Gallbladder U/S: 1. No gallstones identified within the gallbladder. 2. Mild right hydronephrosis possibly related to right ureter passing through post-pancreatitis phlegmonous change from prior recent CT scan. 3. Pseudocyst/inflammatory change incompletely evaluated in the region of the distal pancreatic body and tail as noted on CT scan from [**2114-8-11**]. . Micro [**8-23**], [**8-24**], [**8-25**], [**8-26**] BCx - no growth [**8-30**], [**8-31**] Bx- pending [**8-29**] BCx - STAPHYLOCOCCUS, COAGULASE NEGATIVE from central and peripheral sites [**8-25**], [**8-26**], [**8-29**], [**8-30**] UCx - negative [**8-28**] Sputum Cx- sparse growth oropharyngeal flora [**8-31**] IJ catheter tip cx- no significant growth [**8-31**] Blood Cx - No Growth [**8-31**] Stool C.diff - negative Brief Hospital Course: [**Hospital Unit Name 153**] Course [**2114-8-23**] - [**2114-9-2**]: Mr. [**Known lastname 82971**] is a 39M with h/o DM and alcoholism and pancreatitis who is transferred to [**Hospital1 18**] for a higher level of care. . * Pancreatitis - Based on admission labs, pt with pancreatitis on presentation. No evidence of necrosis on OSH imaging and [**Hospital1 18**] imaging. Most likely precipitated by drinking binge. HCTZ can also be associated with pancreatitis though less likely. Triglycerides 259 here but approx 3000 per report at OSH, suggesting there may also be some component of hyperlipidemia as cause. Surgery was consulted who recommended supportive care with fluids and fever management. Pt's increased abdominal pressure may have contributed to his respiratory failure by increasing bibasilar atelectasis and pain leading to spliting. Bladder pressure 11 at transfer and abdomen soft. Once stable, pt was transferred to surgery for further management and evaluation given possible need for resection of pseudocyst. . * Respiratory distress: Pt was intubated at OSH on [**8-14**] for respiratory distress. He has no h/o lung disease. Respiratory distress attributed to increased abdominal pressure exerting pressure on lungs and increasing atelectasis with bilateral pleural effusions as well as pulmonary edema. Also some component of spliting due to pain/pancreatitis. Esophageal balloon demonstrated pressure of 8, suggesting that large plateau pressures were most likely due to non-compliant chest wall rather than intrinsic lung disease. Pt was diuresed without problems and was extubated [**2114-8-29**] without complications. Given that small left PE was on same side as pleural effusion, there was concern that thoracentesis may increase VQ mismatch vs continued effusion leading to lung trapping. IP evaluated pleural effusion and determined thoracentesis could be performed after pt stable 1-2 weeks on anticoagulation regimen; however, pleural effusion on CXR [**2114-9-2**] had significantly decreased. Pt was saturating 96% RA at transfer. . * Pulmonary embolus: Bilateral deep vein thrombi were found on doppler ultrasound on [**8-30**] and a small PE was found chest CTA. A heparin drip was started without bolus for concern about precipitating hemorrhagic transformation of his pancreatitis. No transition to coumadin given need for possible procedures. . * Fever and leukocytosis - Pt spiked intermittent fevers up to 103-104 during acute phase of illness. Tm on transfer was 100.2. This was attributed to pancreatitis. Due to concern for necrosis as cause of fever, pt had repeat CT abdomen/pelvis [**8-28**] with results above. Cultures remained negative and empiric antibiotics were stopped. However, blood cultures from [**8-29**] demonstrated coagulase negative Staph aureus, pan sensitive. Vancomycin (started [**2114-8-30**]) was changed to nafcillin on [**2114-9-1**]. WBC continues to be elevated (18.3 at transfer), possibly due to pancreatitis vs PE vs bacteremia. C. diff negative x2. . * Agitation - Patient 10+ days out from last drink, therefore delirium tremens less likely. [**Month (only) 116**] be delirious from acute illness, medications, prolongued ICU stay. Head CT here negative. His neurontin (on med list from OSH transfer) was held. Also concern for benzo withdrawal as he required heavy sedation with midazolam during intubation. Agitation responded well to ativan PRN and patient was calm and appropriate on transfer. . * Anemia - Hct was very concentrated at initial presentation to OSH (Hct 50) likely [**2-12**] third spacing. Hct on presentation here was 24. Pt was transfused 1 unit cells for Hct 23 -> 28. Haptoglobin 613 making hemolysis unlikely. B12 and folate were normal. There was concern for hemorrhagic pancreatitis given Hct has been slowly decreasing throughout hospital stay with Hct 25.2 at transfer. . * Alcohol and substance abuse - Patient received thiamine, folate and multivitamin. Social work was consulted. . * DM - patient intially on insulin drip given pancreatitis, which was transitioned to ISS. . * HTN - Patient remained hypertensive (SBP 130s-160s) even after home meds of cozaar and HCTZ were restarted. Continued HTN attributed to pain, agitation. . FEN - Patient restarted on tube feeds via NGT prior to transfer. Following transfer to the Surgical floor, his nasogastric tube was removed and he was started on a clear liquid diet, which was gradually advanced to regular. Coumadin was started for his DVT/PE to maintain an INR 2.5-3.0 with background heparin. His foley was discontinued as well; he was able to void without problem. He was evaluated by Physical Therapy due to his prolonged hospitalization and deconditioned state, but after working with him for a few days he was steady on his feet and walking short distances without difficulty. Blood cultures were negative from [**2114-8-30**] and [**2114-8-31**], and Nafcillin was discontinued on [**2114-9-7**]. He remained afebrile and his WBC 10K. On [**2114-9-7**], the Heparin infusion was discontinued. As the patient's INR was 1.7 that morning and close to therapeutic goal of [**2-13**], it was determined that a Lovenox-Coumadin bridge was not indicated. INR goal is 2.5; therapeutic range 2-3. At the time of discharge on [**2114-9-7**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged home without services, and will follow-up with his new PCP on [**Name9 (PRE) 766**], [**2114-9-10**] for further management of Coumadin. Generally, it is recommended that anticoagulation therapy with Coumadin be continued for 6months for an initial PE. Follow-up with a Pancreatologist was also recommended. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Medications at home: Cozaar 100mg PO daily Lipitor 80mg PO daily HCTZ 25mg Po QAM Allopurinol 100mg PO Daily . Medications on transfer from outside hospital: Versed @ 6/hr Fentanyl @ 150/hr Doripenem 500mg IV q8h Clonidine patch 0.3mg q7d Neurontin 400mg q8h Zyprexa SL 10mg q8h Afrin [**Hospital1 **] Lovenox 40mg SQ daily Protonix 40mg IV daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 5. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QAM. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO QDAY in the evening: Please take this medication the same time each day. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Pancreatitis 2. Alcohol Abuse 3. Lower lobe subsegmental pulmonary embolism 4. HTN Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-20**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. DO NOT DRINK ANY ALCOHOL WHATSOEVER . Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [**Name Initial (PRE) **]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Your new PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82972**] ([**Telephone/Fax (1) 82973**]). You have an appointment with him on [**Last Name (LF) 766**], [**2114-9-10**] at 1PM. You will need your PT/INR checked on that day, and Dr. [**Last Name (STitle) 82972**] will tell you how much Coumadin to take. It is recommended that you follow-up with a Gastroenterologist specializing in Pancreatitis. Your new PCP can refer you to a local Gastroenterologist. If you prefer to see a Gastroenterologist at [**Hospital1 18**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] is recommended. Phone: ([**Telephone/Fax (1) 82974**]. Location: [**Hospital Ward Name 452**] Rose 101, [**Hospital Ward Name 516**]. Completed by:[**2114-9-7**] ICD9 Codes: 5180, 2930, 5119, 7907, 2749, 4019, 2859
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Medical Text: Admission Date: [**2135-4-13**] Discharge Date: [**2135-4-18**] Date of Birth: [**2085-8-16**] Sex: M Service: CARDIAC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 49 year-old gentelman who has a many year history of a heart murmur who was found to have mitral valve disease by echocardiogram with a recent onset of chest discomfort and diaphoresis with exertion. Echocardiogram in [**2134-12-6**] showed a moderately dilated left atria, mildly dilated left ventricle, ejection fraction of 60 to 70%, mildly thickened mitral valve leaflets, mild mitral valve prolapse, partial mitral leaflet flail with 3+ mitral regurgitation, 1+ tricuspid regurgitation and mild pulmonary hypertension. The patient underwent cardiac catheterization on [**2135-3-7**], which showed an ejection fraction of 60% with 2+ mitral regurgitation and no coronary disease. The patient was referred to Dr. [**Last Name (Prefixes) 411**] for mitral valve repair. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Mitral valve prolapse. 4. Depression. 5. Psoriasis. 6. Status post tonsillectomy. 7. Status post right knee arthroscopy. 8. Multiple orthopedic injuries. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Enteric coated aspirin 325 mg po q day. 2. Zestril 40 mg po q day. 3. Prozac 60 mg po q day. 4. Hydrochlorothiazide 25 mg po q day. 5. Multivitamins. HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room on [**2135-4-13**] with Dr. [**Last Name (Prefixes) **] for a minimally invasive mitral valve repair. Please see operative note for further details. The patient was transported to the Intensive Care Unit in stable condition on neo-synephrine and Propofol infusions. The patient was weaned and extubated from mechanical ventilation on his first postoperative night requiring low dose neo-synephrine. On the evening of postoperative day number one the patient was noted to have a moderate amount of chest tube drainage and a drop in hematocrit. Chest x-ray showed a right sided pleural effusion. A chest tube was inserted into the right pleural space with immediate drainage of about 500 cc of bloody fluid with fair resolution by chest x-ray. The patient continued to have a drop in hematocrit and a thoracic surgery consult was obtained. Thoracic surgery felt that the postoperative bleeding was self limiting. By postoperative day number two the patient's hematocrit had stabilized and there was no drainage of the chest tube, however, the patient continued to be anemic. The patient was again transfused packed red blood cells and given Lasix and the patient's hematocrit over the next several days began to climb. The patient was started on Lopressor. Repeat chest x-ray showed elevated right hemidiaphragm with little change between inspiratory and expiratory films, right middle and right lower lobe atelectasis. Coughing and deep breathing was encouraged as well as incentive spirometry. Postoperative day number four one of the patient's chest tubes were removed and the other was placed to water seal. Chest x-ray after this was done showed a small right apical pneumothorax unchanged from the previous films. On postoperative day number four the patient was transferred from the Intensive Care Unit to the regular part of the hospital where he began working with physical therapy. On postoperative day number five the patient's last remaining right pleural chest tube was removed and post removal chest x-ray showed unchanged from previous chest x-rays, which was small bilateral effusions right greater then left, elevated right hemidiaphragm, right middle and right lower lobe atelectasis and a small right apical pneumothorax. The patient ambulated with physical therapy and was able to climb one flight of stairs and walk 500 feet while remaining hemodynamically stable and without requiring oxygen and the patient was cleared for discharge to home. CONDITION ON DISCHARGE: Temperature max 100.1. Pulse 65 in sinus rhythm. Blood pressure 111/68. Respiratory rate 15. Room air oxygen saturation 95%. The patient's weight on [**4-18**] is 95.3 kilograms. Preoperatively the patient weighed 93 kilograms. Laboratory data, white blood cell count 7.9, hematocrit 27.3, platelet count 237, sodium 138, potassium 4.4, chloride 102, bicarb 30, BUN 14, creatinine 0.6, glucose 90, PT 12.4, INR 1.0, PTT 23.8. Neurologically the patient is awake, alert, and oriented times three, nonfocal. Heart is regular rate and rhythm without rub or murmur. Breath sounds are clear, decreased right. There is no rhonchi or rales. Abdomen positive bowel sounds, soft, nontender, nondistended. The patient is tolerating a regular diet. Right incisions are clean, dry and intact. There is no erythema. The chest tube site is covered with a dry sterile dressing, which is to be removed on [**4-19**]. Extremities are without edema. DISCHARGE DIAGNOSES: 1. Mitral regurgitation. 2. Status post minimally invasive mitral valve repair. 3. Postoperative right hemothorax. 4. Postoperative elevated right hemidiaphragm. 5. Postoperative anemia. DISCHARGE MEDICATIONS: 1. Percocet 5/325 one to two po q 4 to 6 hours prn. 2. Enteric coated aspirin 325 mg po q day. 3. Zantac 150 mg po b.i.d. 4. Colace 100 mg po b.i.d. 5. Lasix 20 mg po q day times seven days. 6. Potassium chloride 20 milliequivalents po q day times seven days. 7. Niferex 150 mg po q day. 8. Vitamin C 500 mg po b.i.d. 9. Multivitamin one po q day. 10. Lopressor 50 mg po b.i.d. DISCHARGE CONDITION: The patient is to be discharged to home in good condition. DI[**Last Name (STitle) 408**]E FOLLOW UP: The patient is to follow up with Dr. [**First Name (STitle) **] in one to two weeks. The patient is to follow up with Dr. [**First Name (STitle) 216**] in one to two weeks and the patient is to follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2135-4-18**] 12:13 T: [**2135-4-18**] 12:47 JOB#: [**Job Number 100959**] ICD9 Codes: 4240, 5180, 2851, 4019, 2720, 311
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Medical Text: Admission Date: [**2181-1-12**] Discharge Date: [**2181-1-26**] Date of Birth: [**2133-8-30**] Sex: F Service: [**Doctor Last Name 1181**] ID: The patient is a 47 year-old female with chronic obstructive pulmonary disease flare/aspiration pneumonia status post extubation in the Operating Room transferred from MICU to [**Doctor Last Name **] Medicine Service. female with a past medical history significant for juvenile rheumatoid arthritis, type 1 diabetes mellitus, hypothyroidism, asthma/chronic obstructive pulmonary disease, encephalitis with intubation leading to vocal cord paralysis, multiple pneumonias each year, who initially presented on [**1-7**] Hospital in [**Location (un) 8973**], [**State 350**]. At that time she reported a one day history of fever, nausea and vomiting and was diagnosed with viral gastroenteritis. While hospitalized she became dyspneic with wheezing and was started on Levofloxacin on [**1-9**] for a positive infiltrate on chest x-ray for possible aspiration pneumonia, and then on Timentin on [**1-11**] when there was no improvement. Her condition worsened on [**1-12**] with shortness of breath and the patient was bronched revealing edematous vocal cords. During her bronchoscopy the patient had to be intubated for airway protection due to loss of airway. The patient was noted to have a "difficult airway." The patient was then transferred to the [**Hospital Unit Name 153**] at [**Hospital1 346**] for further airway management. She was then transferred to the MICU on [**1-18**]. While in the Intensive Care Unit at [**Hospital1 18**] she was treated for aspiration pneumonia as well as asthma, chronic obstructive pulmonary disease exacerbation with Solu-Medrol 80 mg intravenous q 8 hours, Levofloxacin and Clindamycin. Cultures were negative. Legionella antigen was negative. She was also treated with Albuterol and Atrovent nebulizers. Tube feeds were started on [**1-13**] due to aspiration risk. Aggressive pulmonary toilet was continued on [**1-18**]. High risk extubation was done in the Operating Room and the patient was moved to the PACU in stable pulmonary status. The patient was then transferred to the medical floor. PAST MEDICAL HISTORY: 1. Encephalitis in [**2164**] requiring intubation. 2. Status post intubation in [**2164**] from encephalitis. Vocal cord paralysis injury. 3. Asthma/chronic obstructive pulmonary disease. 4. Pneumonia each year. 5. Type 1 diabetes mellitus. 6. Juvenile rheumatoid arthritis. 7. Hypothyroidism for twenty years. 8. Depression. In [**2164**] she presented to St. [**Hospital **] Hospital in [**Location (un) 8973**], [**State 350**] in [**Month (only) **] with a three week history of headache, swollen legs and extreme fatigue. She was admitted to the hospital with diagnosis of meningitis and treated with antibiotics. Apparently she got worse and went in to a coma and was then transferred to [**Hospital3 2576**] [**Hospital3 **] with diagnosis of encephalitis apparently from a mosquito bite. Her hospital stay was approximately months while in a coma for about three weeks as per the patient. She was intubated at that time, which then resulted in a vocal cord paralysis. Since then she reports having pneumonia each year requiring admission to the hospital at St. [**Doctor First Name **] for approximately one week stays without intubation. She reports her history of type 1 diabetes mellitus starting when she was four years old. At four years old she was also diagnosed with malaria at the time she was living in [**Country 480**] and [**Country 37027**]. The patient was born in [**Country 6257**]. Her history of juvenile rheumatoid arthritis started with hand deformities as well as deformities of the feet at 11 years old. Her chronic obstructive pulmonary disease was diagnosed approximately three years ago. Her asthma was diagnosed around the time she had encephalitis in [**2164**]. ALLERGIES: Sulfa drugs, which she reports having a rash reaction. SOCIAL HISTORY: She quit smoking fifteen years ago. At that time she had been smoking one pack per day. She reports no alcohol use or intravenous drug use. Her mother's phone number is [**Telephone/Fax (1) 37028**]. MEDICATIONS (ON TRANSFER): NPH, Riss Dulcolax, heparin subQ, Prozac, Tylenol, intravenous fluids, Ativan, Fleets enema, Prednisone, Colace, Levofloxacin, Clindamycin, Synthroid, Albuterol and Atrovent nebulizers and Zantac. PHYSICAL EXAMINATION (ON ADMISSION): Vital signs, T equals 98.2. Heart rate 68. Respiratory rate 18. Blood pressure 115/59. Oxygen saturation equals 99% on 3 liters nasal cannula. General appearance no acute distress. HEENT mucous membranes are moist. Normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Cardiovascular regular rate and rhythm. Normal S1 and S2. Sounds, 2 out of 6 systolic ejection murmur at the left upper sternal border. Lungs, coarse inspiratory breath sounds throughout upper airway sounds and slight rales at the bases bilaterally. Abdomen soft, slight distention, nontender, normoactive bowel sounds. Extremities rheumatoid arthritis findings of the hands bilaterally. No edema, cyanosis or clubbing present. LABORATORY DATA: White blood cell equals 20.9, HCT equals 31.8, platelets 496. SMA 7 with sodium of 135, potassium 4.1, chloride 94, bicarb 34, BUN 16, creatinine .6, glucose 181, calcium 8.3, phos 4.1, magnesium 2.1. TSH .06, free T4 1.1, Legionella antigen negative, INR 1.1, PT 12.6, PTT 27.7. Chest x-ray on [**2181-1-12**] was diffuse reticulonodular opacities becoming confluent and air space disease in the right upper lobe. On [**2181-1-15**] significant resolution of ill defined air space opacities with persistent opacity at the right lung base. On [**2181-1-21**] atelectasis at the right lung base with no consolidation, effusion or pneumothorax. HOSPITAL COURSE: The patient is a 47 year-old with asthma and chronic obstructive pulmonary disease exacerbation, aspiration pneumonia status post extubation in the Operating Room one day prior to transfer to the Medical Service, in stable respiratory status. While in the hospital the patient was continued on her steroid taper for asthma/chronic obstructive pulmonary disease exacerbation. She was treated with a fourteen day course of po Levofloxacin and intravenous Clindamycin for aspiration pneumonia. A neck airway CT was obtained, which revealed severe tracheomalacia near clasp of the trachea and bronchomalacia as well as multifocal ground glass lung opacities, small bilateral pleural effusions and bibasilar atelectasis. The pulmonary team of Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] followed the patient throughout the hospital stay. A video swallow study was obtained, which revealed no evidence of aspiration pneumonia, but the patient was maintained on a nasogastric tube with tube feeds during hospital stay for fear of loss of airway or aspiration. A bronchoscopy was attempted, which revealed supraglottic edema with tissue redundancy, which was thought to be secondary to gastroesophageal reflux disease. The patient then had a pH probe placed without manometry (which she refused), which revealed evidence of reflux disease. Dr. [**Last Name (STitle) **] of ENT evaluated the patient. A video probe was done, which revealed swelling of the glottic area. It was decided that no esophagogastroduodenoscopy or bronchoscopy would be performed until the upper airway was cleared. The patient will wait for two to three weeks for the swelling to decrease in the glottic area. A high dose proton pump inhibitor of Prilosec at 40 mg po b.i.d. was prescribed to the patient prior to discharge. While in the hospital the patient was maintained on intravenous Zantac. The patient will follow up with ENT in the next two to three weeks as well as with pulmonary and her primary care physician. [**Name10 (NameIs) **] procedure will be done until her case is reevaluated. A T tube tracheostomy as well as a Y stent in her airway was considered by the pulmonary team while in the hospital, but will be held off until upper airway swelling decreases. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Asthma/chronic obstructive pulmonary disease exacerbation. 2. Aspiration pneumonia. 3. Tracheomalacia/bronchomalacia. 4. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: The patient will continue on her regular medications at home. Her only new medications are Prilosec 40 mg po b.i.d. and Prednisone steroid taper 10 mg po q.d. times two days and 5 mg po q.d. times three days. The patient will have close follow up with ENT, pulmonary and her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 37029**] [**Name (STitle) 34792**] [**Telephone/Fax (1) 37030**]. [**Doctor Last Name **] [**Doctor Last Name **] 12.AAD Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2181-1-26**] 10:23 T: [**2181-1-29**] 07:37 JOB#: [**Job Number 37031**] ICD9 Codes: 5070, 2449, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5170 }
Medical Text: Admission Date: [**2157-1-14**] Discharge Date: [**2157-1-18**] Service: MEDICINE Allergies: Lidocaine (Anest) Attending:[**First Name3 (LF) 8487**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 89-yo M w/extensive hx including HTN, MI, CABG X 2, carotid stenosis s/p bilat CEA, afib, CRI, and non-Hodgkins lymphoma in remission. Presents w/hx of SOB since shortly before noon today until arrival in ED in evening. Hx limited due to patient being taken for VQ study. Basically, pt. notes that he began to feel SOB around lunch time with no precipitant that he can recall. It persisted until he came to ED at which point it began to resolve. Only recent problems pt. can note are difficulty eating since his L CEA as well as recent diarrhea and very little urination. Per pt., nursing home told him diarrhea had a little bit of blood in it. Pt. reports some recent nausea w/o vomiting. No fevers, weight change, sweats, chills. Found to have INR of 10 on arrival at ED. Was given 5 mg SC vit K and 1 unit FFP. Past Medical History: -hypertension -carotid stenosis s/p Rt. CEA'[**52**] and now s/p L CEA with patch angioplasty on [**2156-12-21**] -hypercholestremia -CAD with chronic angina-stable, s/p MI, s/p CABG's x2 -chronic Atrial fibrillation -CHF, EF 50%, O2 dependant --> more recent ECHO [**12-17**] showed EF of 20-30% and 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **] -chronic renal insuffiency ( 1.2-1.6) -on-Hodgkins lymphoma -Major depression with sucidal ideation -macrcytic anemia -chronic low back pain -cervical dissc disease s/p cervical laminectomy -bilateral catracts s/p surgery Social History: Retired educator, wife with [**Name2 (NI) 8483**] in nursing home. Patient lives alone. Former smoker Family History: unknown Physical Exam: 99.9,89,156/71,20,94% on 3.5L GEN: Thin, lying in bed NAD. HEENT: Not assessed; bandages s/p CEA noted CVS: Irregular rhythm, no m/r/g PULM: Coarse inspiratory/expiratory breath sounds bilat in all lung fields but w/good air movement. ABD/GU: No palpable inguinal LAD. NEURO: Grossly normal. SKIN: Multiple ecchymoses bilat in UE's. Otherwise no cyanosis, rashes or other obvious lesions. EXT: trace bilateral LE edema Pertinent Results: .CBC: 9.1 27.8* 149 Diff: N 88.5* L 9.1* M 2.3 Eo 0 Bas 0.1 .PT,PTT,INR: 80.9,45.0,10.7 .Chem-7: 134,4.8,96,19,104,2.8,139 .ALT,AST,ALK,TBILI,ALB - 33,44,144,0.6,3.8 .D-dimer:979 .LDH:414 .CK, MB, Trp: Pend,4,0.20 .CXR: CHEST, ONE VIEW: Comparison with [**2156-12-24**]. The patient is status post CABG. The cardiac and mediastinal contours are stable. There are no consolidations, effusions, pneumothorax, or pulmonary vascular congestion. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: A/P: 89-yo M w/extensive comorbidities who present with sudden onset SOB while at his nursing home, likely to have UGIB given his melena ... # SOB: His shortness of breath was thought to be secondary to his aspiration as he had been complaining of difficulty swallowing after his recent CEA. He also did show increased risk of aspiration on a bedside swallow examination during his hospitalization. His chest xray on admission was negative for signs of volume overload, although his oxygen saturation and comfort improved with some diuresis. He was continued on albuterol and ipratropium nebulizers with good relief. A V/Q scan done on admission was low probability for pulmonary embolism. He required 4L of oxygen at time of discharge to maintain his oygen saturation. ... # GIB. This was likely an UGIB due to supratherapeutic INR. He had no history of NSAID use or EtOH use, his colonoscopy 3 years ago was negative per patient while at [**Hospital3 **]. He received 3 units of PRBC, although his hematocirt slowly trended down with occasional melena. He was started on protonix and his INR was reversed with FFP and vitamin K, but secondary to his respiratory status, he was felt to be a poor candidate for egd and colonoscopy. .... # ARF: His initial presentation of acute renal failure was likely secondary to dehydration as his FeNa was 1% in the setting of home diuretics, rare urine eosinophils, but no peripheral eosinophils were found. He responded well to hydration, but then his creatinine worsened with likely overdiuresis. Laboratory monitoring was held after the patient became comfort measures. ... #Elevated WBC: The patient was without a clear source of infection, he was afebrile although with a WBC up to 14.2 with 78%PMN. His chest xray was clear, blood, urine, stool cultures were negative. . #Elevated Lactate: His lactate peaked at 2.9 but trended down. The etiology was unclear, he was monitored with serial abdominal exams for possible bowel ischemia, given his leukocytosis, although unlikely given his elevated INR . # ANEMIA He received 3 units of PRBC, he anemia was likely secondary to GI blood loss - ... # RECENT L CEA. His surgeons were contact[**Name (NI) **] in regards to holding his plavix given his recent CEA and now acute GI blood loss. He was to continue plavix, but as the patient was changed to comfort measures, plavix was held. .. # HTN/AFIB/CAD His home lasix, and antihypertensive were held in the setting of comfort measures only ... # DEPRESSION His home medications were held in the setting of comfort measures only ... # PPx - Activity as tolerated ... # FEN: He was evaluated to have aspiration risk, but given his comfort measures status, he was continued on a regular diet as tolerated Code CMO Disp: Home with Hospice ... Medications on Admission: Bactrim DS x 7 dd for UTI Trazodone 25 mg Sertraline 25 mg Tablet Aspirin 81 mg Tablet, Delayed Release Cyanocobalamin 500 mcg Folic Acid 1 mg Docusate Sodium 100 mg Atorvastatin 80 mg Coumadin 1 mg Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q4-6H:prn Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**] Puffs q4h:PRN Acetaminophen 160 mg/5 mL Solution Sig: 650mgm PO Q4-6H:PRN Albuterol Sulfate 0.083 % Solution One Inhalation Q6H:PRN Isosorbide Dinitrate 10 mg Tablet Sig Clopidogrel 75 mg Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Hydralazine 10 mg PO Q6H Isosorbide Dinitrate 10 mg TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO q1hr as needed for pain. Disp:*100 mls* Refills:*0* 4. Ativan 0.5 mg Tablet Sig: 1-4 Tablets PO every four (4) hours. Disp:*180 Tablet(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 417**] Hospice Discharge Diagnosis: GI Bleed Discharge Condition: Stable Discharge Instructions: If you experience increased pain, shortness of breath or other concerning symptoms please contact your doctor Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2157-2-15**] 4:00 ICD9 Codes: 5789, 4280, 5859, 5849, 2851, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5171 }
Medical Text: Admission Date: [**2171-5-6**] Discharge Date: [**2171-6-8**] Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 2297**] Chief Complaint: fever, hypoxia, hypotension Major Surgical or Invasive Procedure: 1. Tracheostomy 2. PICC line 3. Mechanical ventilation/intubation History of Present Illness: [**Age over 90 **] yo F with h/o dementia, CVA with residual left sided paralysis who presents from a NH with fevers and hypoxia. Per NH records and family report, pt was found to be febrile to 103F, hypoxic to 88% on RA today and was noted to have a cough. Daughter believes that pt has been "sick" for at least a week as she has been less conversant and responsive. She has also noticed shallow, rapid breathing that occasionally improves after neb treatments. A CXR was reportedly done at the NH on Monday that was negative. However, she had increasing mouth secretions and by Wednesday the daughter believes the [**Name (NI) **] started the pt on an antibiotic for PNA, although this is not listed on the transfer paperwork. Yesterday evening, the patient was noted to have a fever and hypoxia and was transported to ED for eval. . In the ED, initial vitals T 102, HR 111, BP 120/63, RR 20s, O2 sat 100% NRB -> 90% RA -> 99% 6L NC. Labs notable for WBC 8.1 with 77.3%N, lactate 1.7, Na 150, BUN 36, Cr 0.9, UA negative. CXR with small to moderate right pleural effusion with underlying infection that could not be excluded. Given 4L IVFs with improvement in HR to 80s; however, BP trended down as low as 86/38. RIJ TLC placed and started on levophed gtt at 0.04 mcg/kg/min with BPs to 116/66. Also given vancomycin 1 gm IV X 1, zosyn 4.5 gm IV X 1, tylenol 1 gm PR, albuterol nebs and admitted to [**Hospital Unit Name 153**] for further care. Per ED discussion with family, pt is DNR but ok to intubate for now if necessary. . ROS could not be performed with patient as not responding to questions or commands in Mandarin. Past Medical History: h/o CVA with L sided paralysis but contractures in all 4 extremities, PEG Dementia HTN CHF, unclear if systolic or diastolic Spinal stenosis Sciatica h/o peptic ulcer Hypothyroidism Osteoporosis Rheumatoid Arthritis h/o PNA, UTIs MRSA carrier Social History: Widowed. Mandarin speaking. Per family, has resided in NH since CVA 3-4 years ago. Speaks occasionally in very short sentences to daughter but per [**Name (NI) **] and [**Name (NI) **] notes, pt mostly aphasic and non-verbal. No h/o tobacco but significant second hand smoke exposure. No illicits, EtOH. Family History: non-contributory Physical Exam: Admission physical exam: T 98.2 BP 94/40 HR 87 RR 22-27 O2 sat 97% 4L NC Gen - elderly female in no apparent distress, not responsive to commands in Mandarin. Briefly opens eyes to sternal rub. Lying on left side HEENT - sclerae anicteric, difficult to assess MM as pt not cooperative with opening mouth. Cannot assess JVP due to RIJ TLC. CV - RRR, no m/r/g appreciated Lungs - Decreased BS at right base without clear crackles appreciated, exam is limited by pt not taking deep breaths Abd - Soft, mod distended, + BS, PEG in place with surrounding denuded area with macerated tissue. PEG dressing c/d/i. Ext - no LE edema but edema noted in UEs with L > R. WWP with 1+ pulses distally. Neuro - lethargic, briefly opens eyes to sternal rub. No spontaneous movement of any 4 extremities. All 4 extremities with contractures. Increased tone of RUE. LUE flaccid. [**12-25**]+ DTRs b/l. Upgoing toe on left, equivocal on right. Unable to assess remaining neurologic exam due to MS. Skin - no rashes appreciated Pertinent Results: LABS ON ADMISSION: [**2171-5-6**] 12:20AM BLOOD WBC-8.1 RBC-3.19* Hgb-9.6* Hct-30.5* MCV-96 MCH-30.1 MCHC-31.5 RDW-15.0 Plt Ct-287 [**2171-5-6**] 12:20AM BLOOD Neuts-77.3* Lymphs-17.6* Monos-2.5 Eos-1.8 Baso-0.6 [**2171-5-5**] 10:30PM BLOOD PT-11.9 PTT-21.0* INR(PT)-1.0 [**2171-5-5**] 10:30PM BLOOD Glucose-103 UreaN-36* Creat-0.9 Na-150* K-3.9 Cl-114* HCO3-29 AnGap-11 [**2171-5-6**] 03:46AM BLOOD Albumin-2.5* Calcium-6.3* Phos-3.0 Mg-2.1 Iron-49 . . . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2171-6-5**] 04:51AM 12.8* 2.89* 8.7* 26.7* 92 30.0 32.4 16.5* 994* Source: Line-PICC [**2171-6-4**] 04:32AM 13.1* 2.80* 8.3* 26.4* 94 29.7 31.5 16.5* 1002* Source: Line-picc [**2171-6-3**] 03:16AM 12.6* 2.83* 8.4* 26.9* 95 29.5 31.1 16.3* 1019*1 Source: Line-PICC [**2171-6-2**] 02:08AM 8.9 2.84* 8.4* 26.8* 94 29.7 31.5 16.1* 967* Source: Line-PICC [**2171-6-1**] 04:03AM 10.2 2.81* 8.4* 26.8* 96 30.0 31.3 16.4* 993* Source: Line-PICC [**2171-5-31**] 04:24AM 8.0 2.67* 7.9* 25.6* 96 29.5 30.8* 16.4* 919* Source: Line-PICC [**2171-5-30**] 04:15AM 11.4* 2.84* 8.4* 26.9* 95 29.4 31.1 16.8* 971* . . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2171-6-5**] 04:51AM 95 14 0.7 138 3.1* 96 33* 12 Source: Line-PICC [**2171-6-4**] 12:42PM 3.9 Source: Line-pic [**2171-6-4**] 04:32AM 105 13 0.6 139 3.8 99 32 12 Source: Line-picc [**2171-6-3**] 03:16AM 102 12 0.7 134 3.7 98 Source: Line-PICC [**2171-6-2**] 02:08AM 118* 10 0.7 137 3.6 101 28 12 Source: Line-PICC [**2171-6-1**] 08:02AM 3.8 Source: Line-left picc [**2171-6-1**] 04:50AM GREATER TH1 Source: Line-PICC [**2171-6-1**] 04:03AM 112* 9 1.1 132* 7.6*2 101 25 14 Source: Line-PICC [**2171-5-31**] 04:30PM 9 1.1 138 3.7 100 30 12 Source: Line-PICC [**2171-5-31**] 04:24AM 116* 8 1.1 141 3.8 100 29 16 Source: Line-PICC [**2171-5-30**] 04:50PM 115* 8 1.3* 138 3.6 99 32 11 Source: Line-PICC [**2171-5-30**] 04:15AM 100 9 1.2* 138 3.7 97 32 13 . . ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2171-5-30**] 04:15AM 4 22 100 0.2 Source: Line-PICC [**2171-5-29**] 03:54AM 8 22 98 0.2 . . CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2171-6-5**] 04:51AM 8.2* 2.4* 2.0 Source: Line-PICC [**2171-6-4**] 04:32AM 8.1* 2.3* 2.0 Source: Line-picc [**2171-6-3**] 03:16AM 8.0* 2.2* 2.0 Source: Line-PICC [**2171-6-2**] 02:08AM 8.1* 2.5* 2.2 Source: Line-PICC [**2171-6-1**] 04:03AM 7.8* 3.4 2.3 . . BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment [**2171-6-4**] 01:09PM [**Last Name (un) **] 32*1 53* 7.45 38* 10 NOT INTUBA2 [**2171-6-3**] 01:09PM MIX 32*1 51* 7.43 35* 7 [**2171-6-2**] 11:18AM [**Last Name (un) **] 37.23 /19 40 PND PND PND PND PND TRACH MASK [**2171-6-1**] 01:47AM [**Last Name (un) **] 54*1 44 7.45 32* 5 [**2171-5-31**] 10:17PM [**Last Name (un) **] GREEN-TOP/4 [**2171-5-31**] 11:01AM [**Last Name (un) **] 37*1 53* 7.41 35* 6 [**2171-5-30**] 02:15PM ART 37.75 /24 [**Telephone/Fax (2) 83491**] 7.51* 36* 9 INTUBATED [**2171-5-30**] 02:06PM [**Last Name (un) **] 37.76 /24 [**Telephone/Fax (2) 83492**] 7.59*7 35* 11 INTUBATED SPONTANEOU8 GREEN TOP [**2171-5-28**] 05:52PM ART 88 44 7.47* 33* 7 [**2171-5-15**] 09:19PM CENTRAL VE9 39*1 56* 7.31* 30 0 [**2171-5-11**] 04:58PM ART 98 38 7.39 24 -1 [**2171-5-9**] 12:42PM CENTRAL VE9 [**2171-5-8**] 08:07PM ART 37.710 14/0 [**Telephone/Fax (2) 83493**]* 39 7.35 22 -3 431 73 INTUBATED CONTROLLED [**2171-5-8**] 05:58PM ART 127* 55* 7.22*11 24 -5 [**2171-5-6**] 04:12AM MIX [**2171-5-6**] 02:54AM ART 36.8 /23 89 46* 7.38 28 0 NOT INTUBA2 . . WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate [**2171-5-11**] 04:58PM 2.5* [**2171-5-9**] 12:42PM 1.8 [**2171-5-9**] 04:25AM 3.0* [**2171-5-8**] 08:07PM 1.8 [**2171-5-8**] 05:58PM 5.1*1 [**2171-5-6**] 02:54AM 1.2 [**2171-5-5**] 10:52PM 1.7 . . PLEURAL PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos [**2171-5-8**] 10:59AM 72* [**Numeric Identifier **]* 88*1 4* 8* 25 CELL DIFFERENTIAL PLEURAL CHEMISTRY TotProt Glucose LD(LDH) [**2171-5-8**] 10:59AM 0.0 75 40 ASCITES ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph Other [**2171-5-28**] 03:09PM 218* 39* 11* 26* 0 62*1 1*2 PIGMENT LADEN CELLS PRESENT ATYPICAL CELLS,REFER TO CYTOLOGY REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21496**],MD ON [**2171-5-29**] ASCITES CHEMISTRY TotPro Glucose Creat LD(LDH) Amylase TotBili Albumin [**2171-5-28**] 03:09PM 3.0 94 1.0 160 13 0.2 1.3 . . Date 6 Specimen Tests Ordered By All [**2171-5-5**] [**2171-5-6**] [**2171-5-8**] [**2171-5-9**] [**2171-5-14**] [**2171-5-24**] [**2171-5-28**] [**2171-6-1**] [**2171-6-2**] [**2171-6-3**] All BLOOD CULTURE BLOOD CULTURE NOT PROCESSED Influenza A/B by DFA MRSA SCREEN PERITONEAL FLUID PLEURAL FLUID SPUTUM STOOL URINE All EMERGENCY [**Hospital1 **] INPATIENT [**2171-6-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2171-6-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2171-6-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +, GRAM NEGATIVE ROD(S), GRAM NEGATIVE ROD #2, YEAST} INPATIENT [**2171-6-1**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2171-5-28**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT [**2171-5-24**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} INPATIENT [**2171-5-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2171-5-14**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [**2171-5-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2171-5-9**] BLOOD CULTURE NOT PROCESSED INPATIENT [**2171-5-8**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [**2171-5-6**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT [**2171-5-6**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2171-5-6**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [**2171-5-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] OTHER: [**2171-5-6**] 03:46AM BLOOD calTIBC-189* VitB12-852 Folate-GREATER TH Ferritn-177* TRF-145* [**2171-5-6**] 03:46AM BLOOD TSH-2.2 [**2171-5-6**] 03:46AM BLOOD Free T4-1.1 . URINE: [**2171-5-5**] 10:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022 [**2171-5-5**] 10:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . MICRO: Bl cx - no growth to date Urine legionella - negative Influenza DFA - negative Sputum culture ([**2171-6-1**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**5-/2468**]) immediately if sensitivity to clindamycin is required on this patient's isolate. GRAM NEGATIVE ROD(S). MODERATE GROWTH. GRAM NEGATIVE ROD #2. RARE GROWTH. YEAST. SPARSE GROWTH. Urine culture ([**2171-6-1**]): YEAST. 10,000-100,000 ORGANISMS/ML C. diff toxin: negative . CARDIOLOGY: TTE ([**5-6**]): Conclusions The left atrium and right atrium are normal in cavity size. 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 an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild aortic regurgitation. No significant pericardial effusion. Increased PCWP. CLINICAL IMPLICATIONS: Based on [**2168**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . RADIOLOGY: CXR: The heart is moderately enlarged and the aortic contour is tortuous. Vascular calcifications are seen along the aorta and in the right neck. Additionally, rounded calcification along the right mediastinal contour is atypical for lymph node calcification and may also represent vascular calcification. There is small to moderate right pleural effusion with adjacent atelectasis, although right lower lung infection cannot be excluded. There may also be tiny left pleural effusion with some atelectasis. The upper lungs are grossly clear, without evidence of pulmonary edema. Degenerative changes are noted along the thoracic spine. IMPRESSION: 1. Marked cardiomegaly, without evidence of pulmonary edema. 2. Right pleural effusion with atelectasis, although right basilar infection cannot be excluded. . Port CXR post line - RIJ terminating in appropriate position, no PTX . Final Report REASON FOR EXAM: Pulmonary edema. Acquired pneumonia. Comparison is made with prior study performed [**2171-6-3**]. Tracheostomy tube is in standard position. Large right and small to moderate left pleural effusion are unchanged. Cardiomediastinal contours are partially visualized and unchanged. Mild interstitial edema seen in the left lung is stable. There is no pneumothorax. Opacity in the left base is unchanged likely atelectasis. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] Approved: WED [**2171-6-5**] 12:02 PM . . CT Abdomen HISTORY: [**Age over 90 **]-year-old woman with history of CVA, dementia, hospital-acquired pneumonia, status post tracheostomy, now with emesis for four days. A GJ tube. Distended abdomen on exam. The patient underwent exchange of the GJ catheter earlier today. COMPARISON: None. TECHNIQUE: MDCT axial images were obtained from the lung bases to the pubic symphysis following administration of 50 mL of Optiray intravenous contrast that was hand injected via the left upper extremity PICC line. Multiplanar coronal and sagittal reformatted images were generated. CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is a moderate right and small left pleural effusion, with underlying atelectasis. There is fluid within the distal esophagus. The gastrostomy balloon is located within the stomach, and the jejunostomy catheter terminates in the jejunum. The liver is normal. The gallbladder is decompressed. The spleen is not enlarged. The pancreas, adrenals and kidneys are unremarkable. There are dilated proximal small bowel loops and decompressed diatal lops are seen, however contrast progresses into the decompressed loops consistent with a partial obstruction. There is a moderate amount of ascites within the abdomen and pelvis. The greater omentum is abnormal, with nonspecific soft tissue infiltration. This may be related to recent procedure/tube placement and reactive, but in the absence of recent instrumentation could be seen with neoplasm. The abdominal aorta is normal in caliber, with dense vascular atherosclerotic calcifications. CT PELVIS WITH INTRAVENOUS CONTRAST: The uterus is not identified. Two low- density ovoid soft tissue foci measuring up to 2.3 cm in diameter (2:66) in the left hemipelvis, one represents the ovary which contains a cystic mass. There is a Foley catheter in the urinary bladder, which is decompressed. The rectum and sigmoid colon are unremarkable. There is diffuse soft tissue stranding consistent with anasarca. BONE WINDOWS: There are severe compression deformities of L2, T11 and T9, with resultant narrowing of the spinal canal, most severely at T9 and T11. Heterotopic ossification arises from the anterior aspect of the intertrochanteric region of the left femur is likely post-traumatic in etiology. IMPRESSION: 1. Partial small bowel obstruction with transition point in the right lower quadrant. 2. Left ovarian cystic mass with thickening of the omentum and ascites is concerning for ovarian carcinoma, The ovarian mass could be further evaluated with ultrasound. Alternatively, diagnostic paracentesis could be performed 3. Moderate right and small left pleural effusions. 4. Fluid in the distal esophagus. 5. G-tube balloon in the stomach, and jejunostomy catheter terminating in the jejunum. 6. Compression deformities of T9, T11 and L2 with resultant narrowing of the spinal canal, significantly at T9 and T11. Revised report was discussed with Dr. [**Last Name (STitle) **] at 9:30AM on [**2171-5-28**] The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: TUE [**2171-5-28**] 9:32 AM . . Brief Hospital Course: [**Age over 90 **] female with h/o CVA, dementia, RA who presented with fever and hypoxia to the ICU [**2171-5-6**]. She was started on Vanc, Zosyn and Levofloxacin for Health Care associated pneumonia vs. aspiration PNA. Hemodynamically she was stable and transferred to the general medicine floor [**2171-5-7**]. On the general medicine floor patient was continued for treatment of HAP, had G tube replaced to a GJ tube and thoracentesis to eval effusion. Patient received lasix for diuresis. On the floor patient's blood pressure ranged from 92-141/56-87, was re-started on outpatient B-blocker and started on lasix diuresis. She was afebrile, pulse 97-118, 94-99 on 2 L. At 1830 [**2171-5-8**] patient was found to be tachypneic (RR 40s) and ABG demonstrated CO2 55, pH 7.22 and lactate of 5.1. Patient was consequently intubated, required phyenlepineprine for pressor support and transferred to the [**Hospital Unit Name 153**]. [**Hospital 153**] hospital course according to problem list as below. The patient was ultimately discharged with comfort measures. Respiratory distress: Patient known HAP PNA, large effusion and diastolic CHF. Acute episode requiring intubation most likely related to aspiration. Patient with poor urine output, did not respond to lasix and dopamine drip support. Continued Zosyn and Vancomycin for total 8 days treatment ([**Date range (1) 83494**]) of HAP. Scopolamine patch to decrease oral secreations. Continued albuterol, ipratropium nebs prn for wheezing. From [**Date range (1) 11734**], patient was stable on ventilator, however experienced some apneic events due to oversedation and was responsive to narcan. On [**5-22**], after much discussion with HCP and family, Mrs. [**Known lastname **], recieved a tracheostomy by thoracic surgery. On [**5-23**] crepitus was noted around the trach site, thoracic surgery consulted, resolved without intervention. Mrs. [**Known lastname **] was gradually weaned off the vent from [**5-22**] to [**5-31**] using MMV overnight due to apnea and PS during most of the day. On [**5-28**], she had a possible aspiration event after GJ tube replacement, however, she was monitored for infection/fever, which did not develop. A sputum culture from the trach revealed MRSA, however, the trach is likely colonized. Before discharge, Mrs. [**Known lastname **] was tolerating her tracheostomy mask well with no signs of respiratory distress or infection. However, upon discharge after repeated lengthy discussions with her family, it was determined that Ms. [**Known lastname **] was to be treated with comfort measures, so her trach was capped, and started on morphine, ativan, and continued on albuterol nebs while breathing on room air. She was discharged comfortable and breathing room air in the high 80 percents. Abdominal Distension: Patient noted to have abdominal distension on admission to [**Hospital Unit Name 153**]. KUB on [**5-9**] with no obstruction, bowel regimen increased. Pt noted to have increasingly decreased bowel sounds over next week, however portable supine on [**5-24**] showed no obstruction. GJ tube replaced by IR on [**5-27**], with subsequent emesis and drainage of gastric contents out of tract. CT scan abdomen showed properly placed GJ tube, ascites and ovarian mass. Diagnostic paracentesis cytology consistent with adenocarcinoma. G tube placed to suction and J tube to gravity. She was started on tube feeds until she started to drain dark brown mildly heme-positive material from her gastric tube. It was unclear if the drainage was either coffee ground emesis or feculent material from obstruction. She remained NPO at discharge due to comfort measures. Her G-tube was to gravity and J tube clamped. Allergic Reaction: On [**5-13**], day 7 of Zosyn treatment, Mrs. [**Known lastname **] developed a rash on her torso that was maculopapular and erythematous. The rash ultimately spread to her upper and lower extremities, sparing her feet, palms and face. Froom [**Date range (1) **], the rash progressed to blister/bullae-like lesions, then began weepy before crusting and desquamating. Zosyn and Vancomycin were stopped due to concern of allergy and it is thought that the reaction most likely from Zosyn and not Vancomycin. The rash was treated with supportive care and sulfadine creme to prevent super-infection. Due to insensible losses, fluids were repleated as needed. At time of discharge, rash resolved with minimal desquamation. Hypotension: Most likely combination of septic shock (related to HAP) and cardiac failure (see below). Lactate elevated on admission, trended downward. Patient was slowly weaned off pressor support. No aggressive fluid resucitation due to overload on exam and CXR. Over course of ICU stay, Mrs. [**Known lastname **] had intermittent hypotension, usually related to over-sedation. When sedation weaned, blood pressure returned to her normal. Mrs. [**Known lastname **] ultimately tolerated Lasix gtt started on [**5-28**] later transition to Q8 boluses, to diurese excess fluid off with a goal of negative 1 liter/day. Upon discharge she was not on any diuretics with the aim of comfort measures. Cardiac Failure: EF demonstrated new regional wall abnormality and worsened MR, troponin and CK negative. EKG no ST elevation. Most likely suffered strain related to acute respiratory event. Held outpatient BB and CCB due to low blood pressure and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. Anemia: Decreased to 24 from 29. Drop most likely related to IVF and possible suppression for sepsis. Iron studies consistent with anemia of chronic disease. Patient required no transfusions. UTI: Urine with yeast on [**5-9**], foley was changed. On [**5-24**], pt became hypotensive and tachycardic, remained afebrile. Urine grew E. Coli, completed course of Bactrim. Rheumatoid arthritis: Held azathioprine in setting of acute infection and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. Osteoporosis: Continued outpatient calcium and vitamin D and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. Goals of care: Ongoing discussion with family goals of care and patient's quality of life. After trying many interventions for her multiple medical problems, the patient seemed unlikely to recover. Her daughter decided to switch from DNR to DNR/DNI with no escalating care including pressors. After more repeated conversations, it was determined that Ms. [**Known lastname **] goal of care would be to maximize comfort measures. The ICU team then withdrew invasive measures such as ventilation through tracheostomy, and plans for any future G tube use. She was started on morphine, ativan, and continued on albuterol nebs for comfort. The remainder of her home medicines and medicines in the hospital were discontinued. Medications on Admission: Fleet enema daily prn Natural tears 1 ddrop q4h prn Lacrilube ointemnt qhs Levothyroxine 125 mcg daily Calcium carbonate 500 mg [**Hospital1 **] Vitamin D 400 units daily Prevacid 15 mg tab daily Aricept 10 mg daily Multi-delyn liquid 5 ml daily KCL 10 meq qMon,Wed,Fri Metoprolol tartrate 25 mg daily Vitamin C 500 mg (5ml) [**Hospital1 **] Reglan 5 mg/5ML 10 ML tid Scopolamine patch 1.5 mg/72hr behind ear q72h Amlodipine 5 mg daily Lasix 20 mg tab qod Azathioprine 25 mg daily Duoneb qid and q2h prn Tylenol 650 mg prn Docusate 100 mg [**Hospital1 **] prn Milk of Magnesia 30 ml prn Dulcolax 10 mg PR prn Tube feeds: Jevity 1.2 at 60 ml/hr for 15 hrs off at 8am and on at 5pm. 30 ml H2O flush before and after medss via G tube. 300 ml H20 flushes q4h Discharge Medications: 1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO Q2H:PRN as needed for Pain or dyspnea. Disp:*15 mL* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: Primary: pneumonia small bowel obstruction secondary to ovarian cancer acute renal failure secondary to hypovolemia now resolved . Secondary: -asthma -dementia /Alzheimers type -gait disorder -dysphagia Discharge Condition: comfortable, afebrile, stable vitals, extubated, NPO, nonambulatory Discharge Instructions: You were admitted to the ICU for respiratory distress, probable pneumonia, and small bowel obstruction secondary to ovarian cancer. You were treated with antibiotics and you were intubated due to difficulty breathing. You eventually had to have a tube placed in your trachea since you were intubated for such a long time. After several repeated discussions with your family it was decided that you would be provided with measures to maximize your level of comfot, but that we would discontinue attempts for invasive care and escalation of care. We also discontinued use of your feeding tube due to the small bowel obstruction. . You should not take any of your usual home medicines since you are now being medicated only for your own comfort. The only medicine that we will prescribe you is liquid morphine that you should take as needed for pain or until you have achieved comfort. . Please take all medications as prescribed. Please do not hesitate to return to the hospital if you have any concerning symptoms. Followup Instructions: none ICD9 Codes: 0389, 5849, 2760, 5070, 5119, 2762, 5990, 4280, 4019, 2449, 2859
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Medical Text: Admission Date: [**2145-12-6**] Discharge Date: [**2145-12-23**] Date of Birth: [**2078-11-23**] Sex: M Service: SURGERY Allergies: Ephedrine / Adhesive Tape / Oxycodone / Augmentin / Bactrim Ds Attending:[**First Name3 (LF) 695**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: [**2145-12-17**]: Angiogram with coiling History of Present Illness: 67M with history of metastatic renal cell cancer presented to an outside hospital [**2145-11-28**] with BRBPR. He was anticoagulated with coumadin for a mechanical valve and his INR was 3.9, his hematocrit on admission was 24. He was transfused roughly 2 units pRBC, 4U FFP and given vitamin K. He underwent an upper endoscopy [**2145-11-30**] which demonstrated gastritis, duodenitis and an actively bleeding duodenal ulcer which was clipped. He was discharged home on [**2145-12-2**] and returned on the same day with abdominal pain and bright red blood per rectum. He underwent another EGD [**12-3**] which did not show evidence of bleeding, but he did undergo a colonoscopy which demonstrated a splenic flexure mass which is hypervascular, consistent with a hypernephroma. His hematocrit on discharge to [**Hospital1 18**] is 27.4. He is transferred to [**Hospital1 18**] for further management. Past Medical History: RCC [**2140**]; MI [**2136**]; DM- diet controlled PSH: CABGx5 and AVR [**2136**]; Nephrectomy [**2140**]; ERCP x 3 with multiple stent placements [**2144-2-11**]: CBD excision with cholecystectomy, Roux-en-Y and segment III, IV, V, VI and VII mass resections [**2144-9-18**]: Wound revision and closure of incisional hernia with Prolene mesh Supratherapeutic INR Bacteremia, VRE/E.coli [**2145-12-17**] Coil and Gelfoam embolization of the 3rd to 4th order inferior branch off the replaced right hepatic artery Social History: N/[**Doctor First Name **] has no history of alcohol use. He has a smoking history but quit eight years ago. He has no history of IV drug use, marijuana use, tattoos, hepatitis, or piercing. He did have blood transfusions in [**2136**] and [**2140**]. He has one year of college. He has been married for 36 years. Family History: N/C Physical Exam: Vitals: Temp 97.9, HR 92, BP 140/70, RR 16, 92% RA Gen: alert and oriented, somewhat somnolent CVS: RRR, systolic murmur present Pulm: CTA b/l Abd: soft / non distended / min tenderness epigastrium Rectal: giuiac positive, no obvious masses Pertinent Results: On Admission: [**2145-12-7**] WBC-4.0 RBC-3.01*# Hgb-8.2*# Hct-24.9*# MCV-83 MCH-27.2 MCHC-32.9 RDW-17.7* Plt Ct-117* PT-15.0* PTT-30.3 INR(PT)-1.3* Glucose-93 UreaN-12 Creat-0.8 Na-139 K-3.6 Cl-102 HCO3-29 AnGap-12 ALT-15 AST-25 AlkPhos-147* TotBili-1.0 Calcium-8.7 Phos-2.8 Mg-1.7 Albumin-3.0* On Discharge: [**2145-12-23**] WBC-3.6* RBC-3.67* Hgb-10.7* Hct-31.2* MCV-85 MCH-29.2 MCHC-34.4 RDW-18.1* Plt Ct-79* PT-20.2* INR(PT)-1.9* Glucose-104 UreaN-12 Creat-1.1 Na-135 K-4.2 Cl-98 HCO3-32 AnGap-9 ***HEPARIN DEPENDENT ANTIBODIES-PND Brief Hospital Course: 67 y/o male admitted from OSH with recent GI bleeding. Outpatient scope and reports were reviewed and an abdominal CT was showing: - Invasion into the hepatic flexure colonic wall by a tumor closely associated with and possibly arising from the large segment V-VI hepatic mass. Colonic wall thickening from the cecum to the proximal transverse colon, proximal and distal to this mass. - Increase in size of multiple perihepatic masses adjacent to the inferior aspect of the liver in comparison to the prior study. Due to concern for thrombus risk in his prosthetic aortic heart valve, heparin was started and then bridged back to coumadin when it appeared he was not having large amounts of bleeding. He was receiving blood transfusions almost daily to maintain his hematocrit 26-30% Sutent 50 mg was started on [**12-11**], which was the dosage recommended by his Oncologist Dr [**Last Name (STitle) 76148**]. His records had been reviewed by oncology at this institution and it was determined that this was the most appropriate medication given the type of tumor although there was a risk for bleeding. On [**12-16**] he was ordered for bowel prep to attempt a colonoscopy on [**12-17**] and on the morning of [**12-17**] he had multiple large volume bowel movements that were very bloody. He was transfused 4 units pRBCs on [**12-17**] units on [**12-18**], FFP and platelets x 1. His Hct was as low as 9.4% and was restabilized at 30%. On the evening of [**12-17**] an arteriogram was performed. Please see the report for details. He had Coil and Gelfoam embolization of the 3rd to 4th order inferior branch off the replaced right hepatic artery resulting in occlusion of one of the arteries supplying hepatic/hepatic flexure mass. Following the procedure his hematocrit has remained 28-33%. He received an additional 2 units on [**12-22**]. Bowel movements since the time of the procedure have been brown with no evidence of bleeding. His coumadin was only held on the 11th and he has otherwise received 8 mg daily with goal INR 1.5-2 (has aortic valve). Platelet count trended down over the past few days since [**12-17**] when he was 196. Platelet count decreased to 69-79 range. He was started on methadone for pain management as he was requiring frequent dosing of dilaudid. Dilaudid usage has decreased. All other home medications were maintained. He is going home today on coumadin 8mg daily and sutent 50mg daily. He will get daily cbc and inr with results called to Dr. [**Last Name (STitle) 76149**] office [**Telephone/Fax (1) 19102**] (fax [**Telephone/Fax (1) 76150**]). At time of discharge, vital signs were stable. He was ambulatory and tolerating a regular diet. Medications on Admission: Prilosec 20", lasix 40", duoneb QID, advair diskus 250/50 [**Hospital1 **], lactulose, amitriptyline, coumadin 12', colace 100", dilaudid 2 q 4 prn, vicodin 1 tab q 4 prn, zenate 5 qday, iron 325 [**Hospital1 **] 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for > 2 stools daily. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. 6. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Prescribed for pain relief. Disp:*30 Tablet(s)* Refills:*2* 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): Hold for > 2 BMs daily. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Hydromorphone 4 mg Tablet Sig: [**1-8**] Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Sutent 50 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Outpatient Lab Work Daily stat cbc, inr with results called first to Dr.[**Last Name (STitle) 76151**] office [**Telephone/Fax (1) 19102**] and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**] 12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Renal Cell carcinoma with liver metastases now with colonic mass Lower GI bleeding Discharge Condition: Stable, Hct 31.2 upon discharge Ambulatory Alert and Oriented. Caution use of too many narcotics Discharge Instructions: Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, bleeding from rectum, weakness, dizziness, increased abdominal pain. Contact [**Name2 (NI) 76152**] office at [**Telephone/Fax (1) 19102**] for further medication adjustments and continued plan for oncology daily labs for INR and CBC with results called to Dr.[**Last Name (STitle) 76153**] office and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**] Followup Instructions: CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-2-22**] 1:00 Please schedule follow up with Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] will call you with date/time [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2145-12-23**] ICD9 Codes: 5789, 4019, 2724, 496
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Medical Text: Admission Date: [**2134-2-12**] Discharge Date: [**2134-3-5**] Date of Birth: [**2134-2-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 8840**] is the former 1.78 kg product of a 31 and [**5-24**] week gestation pregnancy, born to a 34 year old, Gravida I, Para 0 now I woman. PRENATAL SCREENS: Blood type AB positive, antibody negative, Rubella immune. RPR nonreactive. Hepatitis B surface antigen negative. Group beta strep status unknown. PAST MEDICAL HISTORY: Notable for a temporal lobe seizure, epilepsy disorder since [**2128**]. Episodes of epigastric pain and chronic vomiting. There was no definitive diagnosis but suspicion for porphyria was thought to perhaps be the etiology. She was treated with Dilantin, Neurontin, Zofran and Celexa. During the pregnancy, the patient had multiple evaluations for pregnancy induced hypertension. On the day of delivery, the mother had a severe headache followed by a tonic/clonic seizure. She was admitted for evaluation, where increased blood pressure, increased uric acid and persistent headache and epigastric pain raised grave concern for pregnancy induced hypertension. She was taken to elective cesarean section due to transverse lie. The infant emerged with good tone and cry. He subsequently developed mild grunting, flaring and retracting. Apgars were seven at one minute and seven at five minutes. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight was 1.78 kg; length 44 cm; head circumference 30 cm. General: Preterm infant in moderate respiratory distress. HEAD, EYES, EARS, NOSE AND THROAT: Slightly broad nasal bridge. Anterior fontanel flat. Positive red reflex bilaterally. Palate intact. Skin without rashes or lesions. Chest: Inspiratory crackles; positive grunting, flaring and retracting; symmetric chest movement. Cardiovascular: Normal S1 and S2 without murmur. Pulses 2+ and equal. Abdomen soft, no hepatosplenomegaly or masses. Genitourinary: Normal male; testes descended bilaterally. Anus patent. Trunk and spine intact. Normal sacrum. Extremities: Hips stable. Clavicles intact. Neurologic: Moving all extremities. Slightly decreased tone. Reflexes consistent with gestational age. HOSPITAL COURSE: Hospital course by system, including pertinent laboratory data: 1. Respiratory: [**Known lastname **] was intubated shortly after admission to the Neonatal Intensive Care Unit. He was treated with three doses of Surfactant. His maximum ventilator settings were a peak inspiratory pressure of 22 over a positive end expiratory pressure of 5; intermittent mandatory ventilatory rate of 30, 45% oxygen. He weaned gradually over the next 36 hours and was extubated to nasopharyngeal C Pap on day of life #2. He transitioned to room air on day of life #4 and continued in room air through the rest of his neonatal Intensive Care Unit admission. He has had episodes of apnea and bradycardia intermittently during admission. He usually has two to four episodes per day. He has not received any medication for his apnea of prematurity. At the time of discharge, he is breathing comfortably in room air with a respiratory rate between 30 and 60. 2. Cardiovascular: [**Known lastname **] has maintained normal heart rate and blood pressure. A murmur was noted on day of life #9 and continues through the time of discharge. The murmur is soft and consistent with peripheral pulmonic stenosis. 3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially n.p.o. and treated with intravenous fluids. Enteral feedings were started on day of life #3 and gradually advanced to full volume. At the time of discharge, he is taking 150 cc per kg of Preemie Enfamil 24 calorie per ounce p.o. p.g. He takes about half of his feedings p.o. Serum electrolytes were checked twice in the first week of life and were within normal limits. Discharge weight is 2.22 kg with a length of 44 cm and a head circumference of 30.5 cm. 4. Infectious disease: Due to the unknown etiology of the respiratory distress and unknown group B beta strep status, [**Known lastname **] was evaluated for sepsis. A white blood cell count was 6,500 with an initial differential of 10% polymorphonuclear cells, 0% bands. A repeat on day of life #2 had a white count of 13,500 with 72% polymorphonuclear and 1% band. A blood culture was obtained prior to starting antibiotics. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Hematology: Hematocrit at birth is 45.9%. [**Known lastname **] did not receive any transfusions of blood products during admission. 6. Gastrointestinal: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life three with a total of 7.7 over 0.4 direct mg/dl. Phototherapy was continued for approximately 72 hours. A rebound bilirubin on day of life six was 5.4 total over 0.3 direct. 7. Neurology: A head ultrasound was performed on [**2134-2-19**] and was within normal limits. A follow-up head ultrasound at one month of age is recommended. There are no neurologic concerns at the time of discharge. 8. Audiology: Hearing screening has not yet been performed. 9. Ophthalmology: Initial eye examination was performed on [**2134-3-1**] showing immature retina to zone three; recommended follow-up in three weeks. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to level II care at [**Hospital3 418**] Hospital in [**Location (un) 701**], MA. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital 7740**] Pediatrics, [**Location 53083**], [**Location 942**], [**Numeric Identifier 53084**]. Phone number [**Telephone/Fax (1) 53085**]. CARE AND RECOMMENDATIONS: 1. Feeding: Preemie Enfamil 24 calorie per ounce, 150 cc per kg per day po/pg. 2. Medications: Ferrous sulfate 25 mg per ml dilution, 0.2 ml p.o. q. day. 3. Car seat position screening is recommended but has not yet been performed. 4. State newborn screens were sent on [**2-15**] and [**2134-2-26**] with no notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [**2134-3-2**]. 6. Immunizations recommended: Synagis-RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1.) Born at less than 32 weeks. 2.) Born between 32 and 35 weeks with two of three of the following: Day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, 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: 1. Pediatric ophthalmology screening for retinopathy of prematurity the week of [**2134-3-22**]. 2. Primary pediatrician within three to five days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 31 and 6/7 weeks gestation. 2. Respiratory distress syndrome. 3. Suspicion for sepsis ruled out. 4. Apnea of prematurity. 5. Unconjugated hyperbilirubinemia. 6. Cardiac murmur, consistent with peripheral pulmonic stenosis. [**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**] Dictated By:[**Last Name (Titles) 53086**] MEDQUIST36 D: [**2134-3-5**] 12:26 T: [**2134-3-5**] 05:29 JOB#: [**Job Number 53087**] ICD9 Codes: 769, 7742, V053, V290
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Medical Text: Admission Date: [**2187-8-22**] Discharge Date: [**2187-8-27**] Date of Birth: [**2149-6-25**] Sex: M Service: Medicine and Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old male who presented with a 3-day history of nausea, vomiting, coffee-grounds emesis, and dark stools. Of note, the patient has a history of ethanol abuse and presented with similar symptoms approximately one month prior in [**2187-5-21**]. An upper gastrointestinal series at that time revealed 2+ esophageal varices and 4+ gastric varices. The patient presented to an outside hospital in Excitor, [**Location (un) 7498**] on [**2187-8-21**]. Upon presentation the patient was noted to be orthostatic with a hematocrit of 27.4. He required 4 units of packed red blood cells as well as fresh frozen plasma. An urgent endoscopy was performed which showed findings of gastric varices in the stigmata of a recent hemorrhage. At that time, he was banded five times. The patient was transferred to [**Hospital1 188**] for evaluation of a transjugular intrahepatic portosystemic shunt procedure. Also of note, the patient has a history of ethanol abuse. He quit approximately two months ago (in [**Month (only) 205**]). He has a previous 20-year history of ethanol abuse. He started drinking vodka again (approximately four to five drinks per day) about two weeks prior to admission. Also of note, prior to admission the patient had a 4-day history of a toothache as well as left jaw swelling. He started ibuprofen for this. He was noted to have fevers to approximately 102 with associated chills prior to admission. PAST MEDICAL HISTORY: 1. Ethanol abuse. 2. History of upper gastrointestinal bleed; the first was in [**2187-5-21**]. 3. History of gout. 4. History of psoriasis. 5. History of [**Location (un) 931**] rod placed in [**2166**] for scoliosis. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father has a history of colonic polys, alcohol abuse, and seizures associated with withdrawal, and cirrhosis. Mother has a history of ethanol abuse. SOCIAL HISTORY: The patient is married with no children. He works as a self-employed computer consultant. He is a nonsmoker and denies intravenous drug abuse. He has a history of cocaine abuse in the distant past. He has a history of alcohol abuse as noted above. He has approximately a 20-year drinking history and recently quit two months ago, but restarted within the past two to three weeks prior to admission drinking about four to five drinks on routine. PHYSICAL EXAMINATION ON PRESENTATION: In general, on admission to [**Hospital1 69**], the patient was in no acute distress. Temperature was 99.6, pulse was 64, blood pressure was 154/74, breathing at a rate of 21, saturating 99% on room air. Head, eyes, ears, nose, and throat revealed pupils were equally round and reactive to light. Extraocular muscles were intact. The oropharynx was notable for extremely poor dentition. Sclerae were anicteric. The neck was supple with no appreciable jugular venous distention. The patient had a spider angiomata on the nose. The lungs were without crackles. The heart was regular in rate and rhythm. The abdomen was soft and nontender with slight distention. There was no clubbing, cyanosis, or edema. On neurologic examination, the patient was alert and oriented times three. No appreciable asterixis was seen on examination. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 8.2, hematocrit was 31.7, platelets were 128. Chemistry-7 revealed sodium was 138, potassium was 3.7, chloride was 101, bicarbonate was 23, blood urea nitrogen was 8, creatinine was 0.7, and blood glucose was 90. AST was 61, ALT was 31, amylase was 60, lipase was 27, total bilirubin was 1.6, alkaline phosphatase was 101. PTT was 35.3 and INR was 1.5. HOSPITAL COURSE: 1. GASTROINTESTINAL: The patient presented with a history of upper gastrointestinal bleed in [**2187-5-21**] and repeat upper gastrointestinal bleed upon this admission in [**2187-8-21**]. At the outside hospital, he had received banding times five, and an Octreotide drip was started. The patient received a transjugular intrahepatic portosystemic shunt procedure on [**2187-8-24**] and tolerated the procedure well. The ultrasound showed that the transjugular intrahepatic portosystemic shunt was patent. The velocity within the transjugular intrahepatic portosystemic shunt ranged from 80 cm/sec to 140 cm/sec. The velocity within the portal vein was 32 cm/sec. The left and right portal veins were patent. In addition, the patient was started on ciprofloxacin for a 10-day course for spontaneous bacterial peritonitis prophylaxis. A liver biopsy was also sent during the transjugular intrahepatic portosystemic shunt procedure; the results of which was still pending at the time of discharge. Also, for the esophageal and gastric varices, the Octreotide drip started at the outside hospital was continued. In addition, Protonix was continued as well. After the transjugular intrahepatic portosystemic shunt procedure, lactulose was started, and the patient was instructed to titrate the lactulose to approximately three bowel movements per day to avoid increased encephalopathy which could be associated with the transjugular intrahepatic portosystemic shunt procedure. Hepatitis serologies were also sent which showed hepatitis A antibody positive, hepatitis B surface antigen negative, hepatitis B surface antibody positive, and hepatitis C virus antibody negative. The patient's hematocrit was stable during the hospital course, and he did not require further transfusions. Alpha-fetoprotein levels were sent, and the alpha-fetoprotein level was 5.4. 2. DENTAL: During this hospitalization, the patient was seen by the Dental Service given his history of poor dentition. A Panorex film was performed which showed on tooth #21 there was very apical pathology and multiple caries on multiple teeth including #4, #6, #7, #8, #9, #10, #11, #13, #15, #28, #30, #31, and #32. The assessment at this time was the #21 tooth showed residual signs of a recent acute infection. The patient was started on clindamycin given these findings for the infection. 3. PSYCHIATRY: The patient has a history of ethanol abuse. During this hospital course, the patient was hemodynamically stable and did not show any signs or symptoms of ethanol withdrawal. He was placed on a CIWA scale but did not require any Valium for a CIWA scale. DISCHARGE FOLLOWUP: 1. The patient was to follow up with Dentistry. The patient was given the name of a dentist at the [**Hospital6 1130**] Emergency Clinic. If he were to choose to follow up there, he could follow up telephone number [**Telephone/Fax (1) 45690**]. In addition, the patient has arranged to follow up with a dentist closer to his house two days after discharge for further evaluation of his teeth. 2. He was also to follow up with [**Hospital 3585**] Clinic as well. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed; status post transjugular intrahepatic portosystemic shunt procedure. 2. History of ethanol abuse. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. q.d. 2. Iron 325 mg p.o. q.d. 3. Nadolol 40 mg p.o. q.d. 4. Clindamycin 600 mg p.o. q.8h. 5. Ciprofloxacin 500 mg p.o. b.i.d. (times six days). 6. Lactulose 30 mL to 45 mL p.o. q.6-8h. (to titrate to two to three bowel movements per day). DR.[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 12.697 Dictated By:[**Last Name (NamePattern1) 45691**] MEDQUIST36 D: [**2187-8-27**] 16:43 T: [**2187-8-30**] 14:33 JOB#: [**Job Number 45692**] ICD9 Codes: 2851, 2749, 4019
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Medical Text: Admission Date: [**2119-8-18**] Discharge Date: [**2119-8-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Irregular Heart Rate Major Surgical or Invasive Procedure: TEE Intubation Cardioversion Temporary pacing wire placement Electrophysiology study Dual device pacemaker placement History of Present Illness: history limited by patient sedation/intubation. EVENTS / HISTORY OF PRESENTING ILLNESS: 84 year old male with atrial fibrillation on coumadin, HTN, history of angina who presented to [**Hospital **] Hospital complaining on light headedness, diaphoresis and presyncope and dizziness on the day of admission. No reports of chest pain. Had seen his PCP one week prior for low HR, unknown details. Stopped taking all of his medications a week ago for a few days because he wasn't feeling well per his son but then restarted. At OSH, his EKG showed wide complex tachycardia with right bundle branch block. His systolic blood pressures were hypotensive to systolic blood pressures in the 70's. He was given approximately 4L of iv fluids. He was intubated for unclear reasons although likely airway protection, sedated with versed drip and started on dopamine. He was given 10mg iv vitamin K and aspirin 325mg po x 1. He was then transferred to [**Hospital1 18**] ED. In [**Hospital1 18**] ED, he was continued on versed drip and Cardiology was consulted. Electrophysiology looked at patient's EKG: Irregular, HR 60's-140's, varying between right and left bundle branch block. At baseline, EKG with right bundle branch block. On review of symptoms, he was intubated and sedated and unable to answer questions. All of the other review of systems were negative. *** Cardiac review of systems was unable to be obtained secondary to intubation/sedation. Past Medical History: AFib on coumadin HTN Question of CAD with angina (20 years ago) Social History: Widowed, Lives with his son in a 2 family house (different floors), No tobacco, occasional EtOH. Family History: Non-contributory Physical Exam: VS: T 98.2F HR 68-150, BP 107/63, RR 20 , ?O2 % on ABG: pH 7.28 pCO2 39 pO2 170 on AC 500x14/FiO2%:100 ?PEEP ABG pH 7.37/32/112 on AC 500x14/60/5 . Gen: Well developed and well nourished elderly male, intubated, sedated, and responsive to stimuli moving all 4 extremitites HEENT: Normalcephalic/atraumatic. Sclera anicteric. PERRL, EOMI. MMM, intubated. CV: PMI located in 5th intercostal space, midclavicular line. Irreg irrgeular, occasional pauses and ectopy Chest: Coarse breath sounds bilaterally, faint bibasilar crackles. Abd: Obese, soft, non-tender and non-distended, No hepatosplenomegally or tenderness. No abdominal bruits. Ext: Trace bilateral lower extermity edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP Pertinent Results: [**2119-8-18**] TEE IMPRESSION: No intracardiac thrombus identified. Moderate regional LV systolic dysfunction, c/w CAD. Moderate MR. Mild AS. Mild AR. . [**2119-8-18**] TTE IMPRESSION: Global and regional LV systolic dysfunction c/w diffuse process (multivessel CAD). Moderate mitral regurgitation. Pulmonary artery systolic hypertension. Mild aortic regurgitation. . [**2119-8-18**] CXR - moderate CHF, Small bilateral pleural effusion, left greater than right, Endotracheal tube in satisfactory position. . [**2119-8-23**] PA and Lateral CXR: Pacemaker lead placement in the right atrium and the right ventricle. . [**2119-8-18**] WBC-14.4* RBC-5.24 Hgb-15.8 Hct-48.3 MCV-92 MCH-30.1 MCHC-32.7 RDW-16.0* Plt Ct-190 Neuts-86.4* Bands-0 Lymphs-8.0* Monos-4.5 Eos-0.3 Baso-0.9 [**2119-8-23**] WBC-8.2 RBC-4.42* Hgb-13.7* Hct-38.7* MCV-87 MCH-30.9 MCHC-35.4* RDW-16.1* Plt Ct-139* . [**2119-8-18**] PT-22.8* PTT-28.8 INR(PT)-2.3* [**2119-8-23**] PT-15.3* PTT-26.4 INR(PT)-1.4* . [**2119-8-18**] Glucose-118* UreaN-19 Creat-1.0 Na-132* K-5.2* Cl-103 HCO3-12* Calcium-8.3* Phos-2.0* Mg-2.5 [**2119-8-23**] Glucose-105 UreaN-14 Creat-0.7 Na-142 K-3.9 Cl-108 HCO3-27 AnGap-11 . [**2119-8-18**] CK(CPK)-114 CK-MB-6 cTropnT-<0.01 [**2119-8-18**] CK(CPK)-122 CK-MB-19* MB Indx-15.6* cTropnT-0.18* [**2119-8-19**] CK(CPK)-20* CK-MB-NotDone cTropnT-0.18* . [**2119-8-18**] ALT-49* AST-48* LD(LDH)-273* AlkPhos-67 Amylase-41 TotBili-1.9* TSH-1.3 Free T4-1.4 Lactate-1.4 BTriglyc-54 HDL-38 CHOL/HD-3.3 LDLcalc-78 Brief Hospital Course: In summary, Mr. [**Known lastname 74063**] is an 84 year old male with AFib on coumadin, HTN who presnted to OSH with lightheadedness, presyncope and tachy-brady episodes. # Rhythm - On admission, the patient's rhythm was as follows: tachy-brady, occasional pauses 1.5 sec, underlying right bundle with intermittent left bundle and bigeminy with runs of VTach. The patient arrived to the unit intubated and while the patient was still sedated, a transesophegal echocardiogram was performed to evaluate for thrombus in the setting of chronic afib and rhythm abnormalities. No thrombus was appreciated and the patient then underwent synchronized cardioversion with 200J in syn mode. The patient was converted into normal sinus rhthymn. However, the patient continued to have runs of ventricular tachycardia that were mildly symptomatic. These episodes responded to a lidocaine drip and a temporary pacing wire was placed on [**2119-8-18**]. The patient was also loaded with a beta-blocker in an attempt to control the tachyarrythmia. However, the patient not only had episodes of ventricular tachycardia but also had episodes of bradycardia which made the dosing of the beta blocker difficult. Electrophysiology testing was performed on [**2119-8-21**] but revealed a trigger fascicular ventricular tachycardia which is not amenable to VT ablation. Therefore, on [**2119-8-22**], a dual device pacemaker was placed with leads in the right atrium and right ventricle. It is hoped that the pacemaker will control the patient's bradycardia so that a theraputic dose of beta blocker can be given. On [**2119-8-23**], the patient's metorolol was titrated up to 37.5mg PO TID. The pacemaker was interogated on [**2119-8-23**] and found to be working properly. PA and lateral chest films confirmed the pacemaker's lead placement in the right atrium and right venticle. The patient continued on 48 hours of antibiotics due to the pacemakder placement and will be followed in the device clinic on [**2119-9-1**] at 10:30am. # Pump - On admission, the patient appeared volume overloaded with bibasilar crackles and bilateral infiltrates and pleural effusions on chest x-ray. The patient was diuresed with prn lasix. An echocardiogram done on [**2119-8-18**] showed: EF 35% Global and regional LV systolic dysfunction c/w diffuse process. There was moderate mitral regurgitation. The patient was discharged on standing lasix due to poor left ventricular systolic function. #)CAD-Cardiac enzymes were cycled and an acute coronary process was ruled out. The patient does report a past history of chest pain and the echocardiogram did show regional left ventricular wall motion abnormalities suggestive of a past infarct. Therefore, the patient was started on an ACEinhibitor. The beta blocker was also continued. Additionally, it is recommended that the patient recieve a chemical stress test to evaluate for CAD as an outpatient. #)Anticoagulation: Heparin drip was initially started because patient received Vitamin K at the OSH. Additionally, the coumadin was held due to the temparary pacing wire placement, electrophysiology study, and pacemaker placement. The patient was anticoagulated with a heparin drip, and Coumadin restarted. On [**2119-8-23**], the patient was on coumadin 5mg PO Dialy with an INR of 1.4. The patient will follow up with Dr. [**Last Name (STitle) **] to have the INR checked. # HTN - Initially, the patient was hypotensive. The B-blocker and ACE inhibitor titrated to blood pressure. It is recommended that these continue to be titrated up as tolerated as an outpatient. # Metabolic Acidosis: On admission, a Gap acidosis was suggested by labs and ABG. However, the acidosis resolved. Lactate was found to be within normal limits. The patient is not diabetic or in renal failure. There was no know history of ingestions. The patient will be discharged home with services. The patient will follow up with Dr. [**Last Name (STitle) **] (PCP) on Monday [**2119-9-4**] at 2:45pm. Dr. [**Last Name (STitle) **] will check the INR. Additionally, the patient is scheduled with the device clinic ([**Telephone/Fax (1) 59**]) on [**2119-9-1**] at 10:30am. Finally, the paitient is scheduled with Dr. [**Last Name (STitle) **](cardiologist) on [**2119-9-14**] at 2:30pm at his office at [**Hospital1 18**]-[**Location (un) 620**]. Medications on Admission: coumadin isosorbide atenolol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO at bedtime: please resume your old dose of 3mg mon/wed/fri, and 2mg Tues/Thurs/Sat/Sun. Please have your INR checked frequently and adjust your dose accordingly. Disp:*180 Tablet(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for 3 doses. Disp:*3 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1.) Tachy/Brady syndrome 2.) Bifascicular ventricular tachycardia 3.) Sick sinus syndrome 4.) Atrial fibrillation 5.) Hypertension Discharge Condition: good, hemodynamically stable, chest pain free Discharge Instructions: You were admitted to the hospital because of an irregular heart beat. During your hospitalization you were placed on medications that help prevent your heart from beating too fast (metoprolol), and also had a pacemaker placed to prevent a very low heart rate. Please take all medications as instructed, and continue to keep all health care appointments. Please resume your coumadin as before and follow up with Dr. [**Last Name (STitle) **] to have your INR checked. You have also been placed on a water pill (lasix) to keep fluid off. . If you experience, chest pain, worsening shortness of breath, lightheadedness, dizziness, or loss of consciousness, or your condition worsens in any way, seek immediate medical attention. Followup Instructions: The visiting nurse will check your coumadin level on [**2119-8-25**] and fax the results to Dr.[**Name (NI) 74064**] office. . Please follow-up with Dr. [**Last Name (STitle) **] on Monday [**2119-9-4**] at 2:45. Dr. [**Last Name (STitle) **] will check your INR (coumadin blood test.) . Please follow up with Dr. [**Last Name (STitle) **] on [**2119-9-14**] at 2:30PM at [**Hospital1 18**]-[**Location (un) 620**] ([**Telephone/Fax (1) 4105**]). Please check-in at patient registration at 2:15 on the ground floor of the hospital, and then proced to the [**Location (un) 453**] to Dr.[**Name (NI) 40168**] office. Your in-patient cardiologist recommended that you get a nuclear stress test. Please discuss this with Dr. [**Last Name (STitle) **]. . Please follow up in the device clinic to ensure that your pacemaker is functioning properly: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2119-9-1**] 10:30 ICD9 Codes: 4280, 4271, 2762, 4254, 4019
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Medical Text: Admission Date: [**2121-3-27**] Discharge Date: [**2121-4-2**] Date of Birth: [**2042-6-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2186**] Chief Complaint: Hematocrit drop, presumed GIB Major Surgical or Invasive Procedure: EGD Colonoscopy 2 units of packed red blood cells History of Present Illness: 78 yo M w/ prior MWT, PVD (s/p SFA stending on [**2-16**] admission started on [**Month/Year (2) 4532**]), DM, HTN, HCV/EtOH abuse, urinary retention who presents to the ED from PCP's office in setting of confusion, weakness and hypotension. . Of note, the patient had partial amputation of his right great toe, caused by vasulopathy. The patient was recently admitted to [**Hospital1 18**] for right SFA and popliteal stenting at which time he was started on [**Hospital1 **] and pletal. In addition, course was complicated by UTI (Klebsiella) and monitored for EtOH withdrawal. The patient has been at [**Hospital3 **] until this Monday when he returned home. He is unsure of his current medications. He denies any drinking since before [**3-3**] when he was initially hospitalized. The patient thinks he may have had some dark stools earlier in the week. The patient further mentions taking two Aleve per night for back pain. Mr. [**Known lastname 23050**] has an abrasion on his upper lip but cannot remember any trauma. He denies any recent incidents of nausea, vomiting. He denies pain, chest pain, dyspnea, hematemesis of known history of liver disease, but states that he has been drinking since he was 16 years old. He does not remember his earlier endoscopy or any diagnosis of [**Doctor First Name **]-[**Doctor Last Name **] tears. In the ED, initial VS were 98.3F 94 81/44 100% on unknown amount of O2. He received 1.2L of NS, with SBPs to low 100s. Labs revealed an HCT of 21 (baseline 30), thrombocytosis, BUN/Cr 18/1.1, Lactate of 2.4 and normal coags. WBC was wnl. Given these findings, was started on PPI gtt and admitted for further evaluation to MICU. CXR was negative for acute process and CT head revealed no . . On arrival to the MICU, the patient was resting comfortably and had no complaints. He was being prepared for endscopy Past Medical History: -Peripheral arterial disease -Diabetes -Hypertension -Hep C -Urinary retention requiring straight cath at home{has refused TURP} -hx of GI bleed with resolving [**Doctor First Name 329**] [**Doctor Last Name **] tear -ETOH abuse(active) -Dyslipidemia -Right superficial femoral artery and tibioperoneal trunk stenting for nonhealing hallux ulcer. sp right partial hallux amputation [**2120**] Social History: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): alcohol:hx of drinking regularly since he was 16 and has desribed himself as a recovering alcoholic for the last 20 yrs and attends AA but does have relapses and last night he said that he drank a [**1-6**] pt of whiskey and a beer, denies w/d sz of blackouts drugs: denies tob:smoked 4ppd until 15 yrs ago caffeine: [**2-7**] cups of coffee a day Grew up in the [**Location (un) 86**] area. Entered National Guard in [**2055**] and ultimately sent to [**Country 2784**]. Returned in the early 50s and started working as a court officer. He was married once. He and his ex-wife divorced about 25 years ago but still are in close contact. She is remarried. He has a son who owns a local paper company who recently got married. Currently lives alone in a senior living facility in JamaicaPlain but was recently discharged from [**Hospital 100**] Rehab following vascular surgery. Family History: Noncontributory Physical Exam: Admission Exam: SBP 80s --> 110s, HR high 90s General: Alert, oriented x 3, no acute distress, can state the days of the week forward and backward HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, no LAD CV: Heart sounds quiet, but S1, S2 no murmurs auscultated Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, midline scar, bowel sounds present GU: No foley Ext: Warm and without edema, patient has had amputation of right great toe Skin: Hyperkeratosis and sloughing of dead skin on feet Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation guiac + w dark stool Discharge Exam: VS: 97.5 110/60 65 18 100%RA General: Alert, A&Ox3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, no LAD, No JVD CV: Heart sounds quiet, reg rate and rhythm, nl S1/S2, no murmurs auscultated Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, midline scar, bowel sounds present GU: No foley Ext: Warm extremities bilaterally, no edema, patient has had amputation of right great toe, 1+ DP b/l Skin: Hyperkeratosis and sloughing of dead skin on feet, melanotic lesion and dual colored dark lesion with irregular borders in midline of back. superficial abrasion over right knee. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, normal sensation of feet bilaterally Pertinent Results: Admission Labs: [**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*# MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*# [**2121-3-27**] 01:00PM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.8 Eos-0.1 Baso-0.3 [**2121-3-27**] 01:00PM BLOOD PT-11.0 PTT-24.8* INR(PT)-1.0 [**2121-3-27**] 01:00PM BLOOD Glucose-183* UreaN-18 Creat-1.1 Na-135 K-4.5 Cl-103 HCO3-22 AnGap-15 [**2121-3-27**] 01:00PM BLOOD ALT-35 AST-48* LD(LDH)-200 AlkPhos-41 TotBili-0.3 [**2121-3-27**] 01:00PM BLOOD Lipase-60 [**2121-3-27**] 01:00PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1 [**2121-3-27**] 01:00PM BLOOD Hapto-60 [**2121-3-27**] 01:00PM BLOOD TSH-2.1 [**2121-3-27**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2121-3-27**] 01:34PM BLOOD Lactate-2.4* [**2121-3-27**] 08:57PM BLOOD Lactate-1.1 [**2121-3-27**] 08:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2121-3-27**] 08:47PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2121-3-27**] 08:47PM URINE RBC-3* WBC->182* Bacteri-FEW Yeast-NONE Epi-1 [**2121-3-27**] 08:47PM URINE CastHy-4* Hct trend (received 2 units PRBCs on [**3-28**] in AM): [**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*# MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*# [**2121-3-27**] 06:36PM BLOOD Hct-18.5* [**2121-3-28**] 01:02AM BLOOD Hct-23.2*# [**2121-3-28**] 05:16AM BLOOD WBC-7.2 RBC-3.02* Hgb-7.4* Hct-23.9* MCV-79* MCH-24.4* MCHC-30.8* RDW-17.0* Plt Ct-479* [**2121-3-28**] 03:13PM BLOOD Hct-25.7* [**2121-3-28**] 11:38PM BLOOD WBC-9.1 RBC-3.44* Hgb-8.2* Hct-27.9* MCV-81* MCH-23.9* MCHC-29.5* RDW-17.1* Plt Ct-577* [**2121-3-29**] 08:34AM BLOOD WBC-8.4 RBC-3.57* Hgb-8.6* Hct-28.7* MCV-81* MCH-24.1* MCHC-30.0* RDW-17.4* Plt Ct-523* Micro: [**3-27**] Blood culture [**3-27**] MRSA screen [**3-27**] Urine Culture negative [**3-27**] HELICOBACTER PYLORI ANTIBODY TEST positive Imaging: CXR [**2121-3-27**]: 1. No evidence of acute disease. 2. Newly apparent nodular focus projecting along the right lower lung, probably a nipple shadow, although a pulmonary nodule should be considered. When clinically appropriate, repeat PA view with nipple markers is recommended. . CT head w/o contrast [**2121-3-27**]: 1. No evidence of acute intracranial process. 2. Age-related atrophy. 3. Chronic small vessel ischemic disease. . CT abdomen/pelvis w/o contrast [**2121-3-27**]: IMPRESSION: 1. No evidence of retroperitoneal or intramuscular hematoma. 2. Left adrenal hypoattenuating mass is likely an adenoma. 3. Multiple bladder diverticula. 4. Extensive atherosclerotic disease and coronary artery disease. 5. Old right posterior rib fractures and anterior wedge compression of L2 and multilevel lumbar degenerative disease. 6. Multiple tiny renal cysts, too small to characterize but without concerning features. 7. Right femoral stent is noted, patency cannot be assessed. . EGD [**2121-3-27**]: Impression: Small hiatal hernia Mild erythema and friability in the antrum compatible with mild gastritis Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum Recommendations: The findings do not account for the symptoms Serial hcts, monitor stool output; consider extraluminal blood losses given recent femoral puncture. Would consider non-urgent colonoscopy prior to d/c if within patient wishes and no extraluminal bleeding site localized. Would discuss [**Month/Day/Year 4532**]/aspirin with vascular surgery. Given overall well appearance of the patient, would seem in favor of continuing if stent high risk for occlusion. . [**2121-3-29**] CXR: PA and lateral upright chest radiographs were reviewed in comparison to [**2121-3-27**]. Heart size and mediastinum are unremarkable. Lungs are essentially clear. No pleural effusion or pneumothorax is demonstrated. Hyperinflation of the upper lungs most likely reflects emphysema. No nodular opacity along the right lower lung is currently demonstrated, most likely reflecting nipple shadow on the prior examination. . Colonoscopy [**2121-3-31**]: Polyp in the proximal ascending colon (polypectomy) Polyp in the distal ascending colon (polypectomy) Polyp in the hepatic flexure (polypectomy, endoclip) Otherwise normal colonoscopy to terminal ileum Brief Hospital Course: The patient is a 78-year-old man with a history of alcohol abuse, Mallroy [**Doctor Last Name **] tear, peripheral vascular disease, and diabetes who presents with confusion, weakness and hypotension, susequently found to a large hematocrit drop. . # Anemia, probable GI bleed: The patient has a history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear and gastritis. His anemia and episode of hypotension was thought to be secondary to hypovolemia from a GI bleed. The patient received a bolus of normal saline and two units of packed red blood cells. His hematocrit responded by improving from 18 to 23. GI performed an endoscopy which showed gastric erythema and friability, but no obvious source of GI bleed. Because he had recently undergone stenting of peripheral artery, a retroperitoneal bleed remained on the differential. CT of abdomen and pelvis showed no evidence of RP bleed. His hematocrit remained stable and steadily increasing, so he was transferred to the Medicine service with plans to perform colonoscopy after appropriate preparation. His aspirin and [**Last Name (NamePattern1) **] were held. After contacting his vascular surgeon, his [**Name (NI) **] continued to be held in the setting of a likely lower GI bleed. ASA was restarted. Colonoscopy showed 3 polyps but no active bleeding. The polyps were biopsied. The patient's hematocrit remained stable and he had no more bloody stools. Discharged with plans for close outpatient follow-up and repeat hematocrit on [**2121-4-3**]. Crit on discharge was 30.2. . # Presumed urinary tract infection: The patient has a history of urinary retention requiring straight catheterization. His urinalysis in the ICU was suggestive of infection so he was started on ceftriaxone therapy. Urine culture showed mixed bacteria growth, without evidence of UTI. Ceftriaxone was stopped and a repeat Ucx was unremarkable. Antibiotics not restated. . # Alcohol abuse: Patient has history of alcohol abuse, according to old records. It appears he has been at home the last few days, which means he may have started drinking again, though the patient denies it. He was placed on CIWA, though he never triggered and did not require benzodiazepines. He was provided thiamine and folate. Social work was consulted. The patient was discharged on thiamine and folate. . # Diabetes: Provided insulin sliding scale while in hospital. . # Urinary retention: Continued home tamsulosin. . # Incidentalomas: Left adrenal adenoma. Multiple bladder diverticula Old right posterior rib fxs. Anterior wedge compression of L2 . Transitional Issues: - Repeat hematocrit on [**4-3**]. Hematocrit on dischare was 30.2. If drifting downwards, GI would recommend capsule study. - Patient should have dermatology follow up for two skin lesions noted on his upper back - F/u GI biopsies. Patient is concerned about these and would like to be contact[**Name (NI) **] about results - F/u H. Pylori stool antigen Medications on Admission: -cilostazol 100 mg Tablet 1 Tablet(s) by mouth twice a day -clopidogrel [[**Name (NI) **]] 75 mg Tablet 1 Tablet(s) by mouth once a day -metformin 500 mg Tablet 1 Tablet(s) by mouth twice a day -pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet Qday -tamsulosin 0.4 mg Capsule, Ext Release 24 hr 1 Capsule Qhs -aspirin 81 mg Tablet, Delayed Release (E.C.) daily Discharge Disposition: Home With Service Facility: [**Hospital1 100**] Senior Life for Home Care Discharge Diagnosis: Primary Diagnosis: Gastrointestinal bleed Secondary Diagnosis: Peripheral Vascular Disease s/p stent placement Alcohol Abuse Diabetes Skin lesions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 23050**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you were feeling weak and were found to have very low blood levels. It was presumed that you were bleeding from your intestines. You had a scope of your upper and and lower intestinal tract which showed polyps but no active bleeding. You did not have any further episodes of bleeding and your blood counts improved during your time in the hospital. You are safe for discharge home. Your primary care doctor should follow up on the results of the biopsies of the polyps. You should have your blood counts rechecked on Friday [**2121-4-4**] and the results faxed to your primary doctor. Please also discuss with your primary care doctor getting a referral to dermatology to look at the skin lesions on your back. Please continue all your home medications with the exception of the following, which have been changed: 1) Please START Thiamine 100mg daily 2) Please Start Folic acid 1mg daily 3) Please START Simethicone 40mg four times daily as needed for gas 4) START mupirocin cream; apply this on the rash under your nose twice a day Followup Instructions: Department: BIDHC [**Location (un) **] With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD Phone # [**Telephone/Fax (1) 608**] Specialty: Primary Care When: TUESDAY [**2121-4-8**] at 1 PM Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Department: VASCULAR SURGERY When: THURSDAY [**2121-5-15**] at 1:30 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2121-4-2**] ICD9 Codes: 5789, 2851, 4589, 4019, 2724
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Medical Text: Admission Date: [**2200-4-1**] Discharge Date: [**2200-4-6**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old man with past medical history of coronary artery disease, status post stent to the left circumflex artery as well as history of chronic left bundle branch block. The patient was admitted to [**Hospital1 69**] on [**4-1**] with complaint of [**3-16**] weeks of epigastric pain. The patient describes the pain as [**7-20**] and nonradiating. The patient states that the pain was not associated with shortness of breath, nausea, vomiting, lightheadedness, or palpitations. The patient reports that on [**3-31**], he awoke from a nap with severe pain. This prompted him to seek treatment in the Emergency Department. The patient also reports increasing dyspnea on exertion. Several years ago the patient noted dyspnea on exertion with a two block walk. ETT MIBI in [**2194**] disclosed no electrocardiogram changes or perfusion defects. Over the past few months the patient has become short of breath over only a half a block walk. He experiences dyspnea on exertion occasionally accompanied by a nonradiating epigastric pain, though the pain is only 1.5/10. Patient was admitted to Medicine Service on [**3-31**] for evaluation of his epigastric pain. Initial CKs were within normal limits. He was continued on the proton-pump inhibitor and the GI service was consulted. He underwent MRI/MRA for workup for possible mesenteric ischemia. This study was negative. It did disclose intra and extrahepatic ductal dilatation. On 06:30 pm on [**4-1**], the patient noted onset of epigastric pain. The am troponins from that day was elevated at 6.7. The patient was given aspirin, beta blocker, and was started on Heparin. He eventually became pain free. The patient was sent to the SICU for closer observation. At catheterization the patient was found to have three vessel coronary artery disease, left anterior descending artery had 95% calcified stenosis before D1. There is an 80% focal stenosis after D1. The left circumflex had 40% stenosis of OM-2, 40% of the ramus was occluded. Right coronary artery was heavily calcified with 50% stenosis in the mid vessel and 90% stenosis in the branching PL. Furthermore, during the catheterization patient had episode of asystole requiring temporary pacing. Nevertheless, the patient underwent successful stenting of the left anterior descending artery and diagonal. He was admitted to the CCU for further management. PAST MEDICAL HISTORY: 1. Esophagitis/GERD. 2. Coronary artery disease, last catheterization in [**2191-3-11**] disclosed two vessel disease. The patient had PTCA and stent to the left circumflex lesion with 20% residual stenosis. The calculated ejection fraction was 60%. There were no wall motion abnormalities. There was mild mitral regurgitation. Chronic left bundle branch block. 3. Transient ischemic attack. 4. Chronic renal insufficiency. OUTPATIENT MEDICATIONS: 1. Ditropan 5 mg po q day. 2. Nexium 40 mg [**Hospital1 **]. 3. Vicodin 1-2 tablets prn. 4. Vioxx 25 mg po q day. 5. Reglan 5-10 mg po q day. 6. Dyazide 37.5/25 q day. 7. Atenolol 25 mg po q day. 8. Plavix 75 mg po q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home and spends [**Doctor Last Name 6165**] in [**State 108**], former smoker. Drinks 2-3 alcoholic beverages per week. No IV drug use. PHYSICAL EXAMINATION: Pleasant elderly male in no apparent distress. Blood pressure 160/86, heart rate 80s, respiratory rate 21, and O2 saturation is 96% on room air. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mucous membranes moist. Oropharynx is clear. Neck is supple, jugular venous distention 2 cm below mandible. Heart: Regular, rate, and rhythm, distant heart sounds. Lungs are clear to auscultation anteriorly. Abdomen is obese, nontender, positive bowel sounds. Extremities: Trace lower extremity edema, right knee scar, right femoral line in place. Neurologic is alert and oriented times three. Cranial nerves II through XII are grossly intact. Examination is otherwise nonfocal. LABORATORY DATA: White count was 5.1, hematocrit 34.3, platelets 128. Chemistries are a significant for a BUN and creatinine of 126 and 1.7. Magnesium 2.6. IMAGING: MRI/MRA of the abdomen disclosed celiac and SMA widely patent, severe intrahepatic and extrahepatic bile duct dilatation, no common bile duct stone, or ampullary mass identified. ELECTROCARDIOGRAM: Sinus bradycardia at 48 beats per minute, prolonged P-R interval, left bundle branch block, no significant ST segment elevation. HOSPITAL COURSE: The patient is admitted to CCU for further management. 1. Cardiovascular: A. Ischemia: Following patient's catheterization results noted above, the patient was continued on aspirin and Plavix during the remainder of his hospital stay. He was administered beta blocker, ACE inhibitor, and a statin as well. Patient will likely undergo intervention to the right coronary artery in approximately two weeks. B. Pump: Echocardiogram was checked during the patient's admission. Patient had an ejection fraction of 55%, regional left ventricular wall motion is normal, trivial MR is seen, moderate 2+ TR is seen. Pulmonary artery systolic hypertension is noted. C. Rhythm: The patient is noted to have bradycardia during catheterization. The patient developed asystole in catheterization laboratory and required stent placement, a temporary pacer wire. EP consult was obtained. EP service recommended starting a low dose beta blocker, and monitoring the heart rate for his signs and symptoms of chronotropic insufficiency. Etiology of bradycardia/asystole event thought to be related to catheter used during cardiac catheterization. Furthermore, the patient has no history of syncope/presyncope. 2. GI: MRI/MRA results noted above. The patient will require ERCP for further evaluation. 3. Heme: Patient required transfusion 2 units of blood during his hospital stay. 4. Nutrition: Patient maintained on a clear liquid diet initially. His diet was advanced as he tolerated. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Home. FOLLOW-UP INSTRUCTIONS: The patient will follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Flyer. The patient will also followup with his cardiologist, Dr. [**Last Name (STitle) 120**]. The patient will follow up with Dr. [**Last Name (STitle) **] from Gastroenterology in four weeks. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease. 2. NonST elevation myocardial infarction. 3. Severe left ventricular diastolic dysfunction. 4. Pulmonary hypertension. 5. Asystole requiring temporary pacing. 6. Successful stenting of the left anterior descending artery and diagonal. 7. Esophagitis. 8. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Zestril 5 mg po q day. 2. Dyazide 37.5/25 mg po q day. 3. Plavix 75 mg po q day. 4. Lipitor 10 mg po q day. 5. Enteric coated aspirin 325 mg po q day. 6. Nitroglycerin sublingual prn chest pain. 7. Toprol XL 25 mg po q day. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2200-4-6**] 22:59 T: [**2200-4-11**] 07:56 JOB#: [**Job Number 96496**] ICD9 Codes: 9971, 4275, 4280
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Medical Text: Admission Date: [**2181-11-23**] Discharge Date: [**2181-11-28**] Date of Birth: [**2146-4-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: # Seizure # Respiratory distress # L parietal ICH Major Surgical or Invasive Procedure: Intubation Central line Arterial line History of Present Illness: 35F h/o C-section, 2 wks post-partum, admitted to MICU s/p seizure and respiratory distress. Pt had experienced new-onset nighttime snoring and severe evening headaches x 1 week waking her from sleep. At 2 am on day of admission, pt awoke with a severe headache and had a witnessed 45 sec tonic clonic seizure. CT head at [**Location (un) **] demonstrated 2-3 cm L parietal ICH. Patient subsequently had a second seizure, after which she felt "dizzy and not herself." Pt subsequently was intubated for airway protection, and received phenytoin, mannitol, and decadron before transfer to [**Hospital1 18**] for further evaluation. . While in the ambulance, patient became hypoxic (SaO2 40% ) and was producing frothy, pink sputum. On arrival to [**Hospital1 18**], ET was noted to be dislodged. Patient was extubated and then reintubated with SaO2 83-84%. Pt received etomidate, succinylcholine and vecuronium. SaO2 further improved with paralysis, but was difficult to vent (ABG 7.14/71/61 on 480x20, PEEP 15, FiO2% 82). Repeat CT head demonstrated 2-3 cm ICH with surrounding edema, also with ? air-fluid level; CTA chest was completed and demonstrated extensive bilateral opacities. . In transit to MRI, pt became hypotensive with SBP 50-60; MRI was aborted and patient was directed to the MICU. On arrival to MICU, SBP had increased to 180s without additional fluids or pressors. Past Medical History: # C-section ([**2181-11-8**]) # Gestation diabetes during most recent pregnancy # Tonsillectomy Social History: # Personal: Lives with husband and children. # Alcohol: None. # Tobacco: None. # Recreational drugs: None. Family History: Noncontributory Physical Exam: VS: T 99, BP 120/70, HR 120, RR 27 (vented), SaO2 90s Gen: Lying in bed intubated, sedated and paralyzed HEENT: NC/AT, moist oral mucosa Neck: Supple, no carotid or vertebral bruit CV: Tachycardic, 2/6 SEM heard over pre-cordium Lung: Crackles to auscultation bilaterally Abd: +BS soft, nontender Ext: No edema Brief Hospital Course: 35F h/o C-section two weeks prior to admission, admitted with intracranial hemorrhage and subsequent seizures, as well as respiratory distress. . # L parietal ICH: Initially, differential diagnosis included postpartum hypertension, although OB/GYN later confirmed that patient had not had preeclampsia or eclampsia during her pregnancy. Other considerations included possible metastatic choriocarcinoma, sinus thrombosis, mass lesion, or aneurysm. Serum bHCG was negative. MRI demonstrated L parietoccipital lobe hemorrhage with associated infarct, as well as associated subarachnoid hemorrhage in the region, although MRA/MRV were normal. TTE demonstrated [**2-13**]+ MR with no PFO or septal defect, and no hypokinesis. Per neurology, patient was started on verapamil to control SBP (MAP<130) as well as possible vasospasm at the left MCA. Patient was kept on minimal fluids and during her MICU stay, was net even. Patient was also started on phenytoin as well as levetiracetam, with pending discussions with her OB/GYN about this antiseizure regimen as patient would like to breast-feed. ICH was most likely due to venouse thrombosis, for which pt will continue taking aspirin dailyy and follow up with neurology. . # Respiratory failure [**3-16**] ARDS: Patient was initially intubated at OSH, with the endotracheal dislodged during her EMS transit. Patient was also suspected to have aspirated leading to likely ARDS. Patient was ultimately extubated after empiric antibiotics were begun; sputum cultures were negative for PNA. Patient experienced normal postpartum diuresis with large volume urine output, and had a net even fluid status for her MICU stay. . # H/o gestational diabetes: Patient was hyperglycemic on admission, but had not been on insulin therapy as outpatient. In the MICU, patient was continued on regular insulin sliding scale PRN, with goal of FS<150. . # Post-partum care: Pt has been using breast pump in the ICU. . # Anemia: Pt was anemic on admission, with no clear sources of bleeding this was suspected to be dilutional. Medications on Admission: None Discharge Medications: 1. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 3. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO at bedtime for 1 doses: please take evening of [**11-28**] two capsules. Disp:*2 Capsule(s)* Refills:*0* 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO three times a day for 2 days: for the dates : [**11-29**] and [**11-30**]. Disp:*6 Capsule(s)* Refills:*0* 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 days: for the dates [**12-1**] and [**12-2**]. Disp:*4 Capsule(s)* Refills:*0* 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO once a day for 2 days: for the days [**12-3**] and [**12-4**]. Disp:*2 Capsule(s)* Refills:*0* 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime: start [**11-28**]. Disp:*30 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Cortical vein thrombosis c/b left occipital lobe hemorrhage. 2. Generalized seizure. 3. Accelerated hypertension. 4. Acute respiratory distress syndrome. 5. Mild to moderate ([**2-13**]+) mitral regurgitation. Secondary: 1. G2P2. 2. C-section x 2 3. Gestational diabetes mellitus Discharge Condition: Good Discharge Instructions: Please follow carefully the instructions regarding your medications (see below) . Please follow up with your follow up appointments. . Please call your doctor or 911 if you have headache, nausea, vomiting, dizzyness or any other concerning symptoms. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 23**] at 12:15 PM on [**2181-12-5**]. . And Dr. [**First Name (STitle) **] from neurology: Tel [**Telephone/Fax (1) 3767**] on [**12-4**] at 9:30 ICD9 Codes: 431, 5070, 2859, 4240
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Medical Text: Admission Date: [**2198-8-31**] Discharge Date: [**2198-9-6**] Date of Birth: [**2171-1-25**] Sex: F Service: [**Last Name (un) **] Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: None History of Present Illness: 27 y/o female who was in high speed MVA. Positive LOC. Positive ejection from vehicle. Transfered from OSH. En route GCS 15 and hemodynamically stable. The patient was complaining of RUQ and RLE tenderness. Past Medical History: Tonsilectomy L arm ORIF Recent teeth surgery Social History: Smokes 1 ppd Family History: Non-contributory Physical Exam: 97.6 P 87 123/63 RR 18 100% RA Gen: NAD. Lying flat in bed. HEENT: PERRL. NC/AT CV: RRR, no MGR Lungs/Back: CTAB, non-tender spine, no step offs Abd: soft, flat, tender to palp RUQ, normal bowel sounds Ext: warm, 2+ DP/PT bilaterally, no edema Neuro: non-focal Pertinent Results: Abdominal CT (from OSH): grade IV liver laceration, ? R posterior-lateral 6th rib fracture Chest/Pelvis X-ray: Unremarkable chest and pelvis, no evidence of rib fracture Brief Hospital Course: 27 y/o female w/ grade IV liver laceration s/p high speed MVA. Chest x-ray, pelvis, T spine, L spine, and right tib-fib films w/ no evidence of injury. Patient was admitted to the Trauma SICU for close observation of her HCT which remained stable around 30. On HD 3 the patient was transfered to the floor where her HCT continued to remain stable. At this time she was noted to have cellulitis of her left antecub at the site of an old IV. She was started on clindimycin given her history of PCN allergy. However after one day of therapy her cellulitis remained about the same. The antibiotic regimen was changed to vanc and over the course of the next three days, the cellulitis essentially resolved. The patient was discharged home on HD 7. At discharge she still had minimal tenderness to palpation in the RUQ. She was tender to palpation around her right upper chest. This is most likely secondary to chest contusion/?rib fracture. There was no rib fracture noted on chest x-ray. However, on review of the OSH abd ct which films part of the chest, there appears to be a possible 6th rib postero-lateral rib fracture. The patient will be discharged on a 4 day course of clindimycin and percocets for pain control. She will follow up in the trauma clinic next week. Medications on Admission: None Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*25 Tablet(s)* Refills:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 4 days. Disp:*16 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. liver laceration, grade IV 2. right upper chest wall pain likely secondary to rib fx/chest wall contusion 3. left antecub cellulitis at IV site 4. s/p mvc Discharge Condition: Good Discharge Instructions: Please call your primary care doctor or go to the Emergency Department if you have fevers, chills, nausea, vomiting, worsening abdominal pain, lightheadedness or for other concerns. Followup Instructions: Please follow up in the trauma clinic next week. [**Telephone/Fax (1) **] ICD9 Codes: 3051
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Medical Text: Admission Date: [**2121-10-27**] Discharge Date: [**2121-11-6**] Date of Birth: [**2073-9-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: Shortness of breath (initial CC) Transfer from OSH for NSTEMI Major Surgical or Invasive Procedure: Cardiac catheterization with thrombectomy and PTCA of left circumflex artery History of Present Illness: 49 year old male with a history of diabetes mellitus, coronary artery disease with ?PCI and stents, presenting from [**Location (un) **] with shortness of breath and respiratory distress. Initially, the patient presented called EMS with a hx of shortness of breath x 2 hours. He told EMS that he was unable to lie flat and he was thought to be pale and diaphoretic. The patient denied any chest pain or chest pressure; he was tachycardic to the 130s, HTN to 245/128 and oxygen saturations of 75-85% on 2 L NC. He was started on nitropaste, SL NTG in the field. Lopressor, ativan, solumedrol, lasix, levoquin and CTX, vanco were given, and was then bag ventilated given poor saturations and eventually placed on mechanical ventilation and transferred to [**Hospital1 18**] for further management. Upon arrival to [**Hospital1 18**] on transfer from Nashobe, BP still in 150s, slowly trended down to SBP 90s-110s, on a propofol drip for sedation. He received 4L NS with 3L uop. Past Medical History: PAST MEDICAL HISTORY (incomplete, awaiting PCP [**Name Initial (PRE) 14453**]): 1. CARDIAC RISK FACTORS: DM 2 2. CARDIAC HISTORY: - CAD s/p PCI with stent x2 to LCx (~2 years ago) 3. OTHER PAST MEDICAL HISTORY: Unknown Social History: SOCIAL HISTORY: On review of MICU admission note, +EtOH. Family History: Unknown Physical Exam: On admission: 98.6 108 120/71 24 100% on 100% Fi02 AC, Tv 550 RR 18 RR 15 Gen: Appropriately responsive on sedation HEENT: PERRL, MMM Heart: RRR, nl S1/2, no murmurs Lungs: Diminished at bases, upper lungs clear Abd: Benign Extrem: No edema Pertinent Results: [**2121-10-27**] 11:35AM cTropnT-0.27* [**2121-10-27**] 11:35AM CK-MB-42* MB INDX-3.5 proBNP-869* [**2121-10-27**] 03:40PM CK-MB-95* MB INDX-5.1 cTropnT-0.63* [**2121-10-27**] 03:40PM CK(CPK)-1860* [**2121-10-27**] 05:34PM LACTATE-3.4* [**2121-10-27**] 11:11PM CK-MB-117* MB INDX-5.4 cTropnT-1.07* [**2121-10-27**] 11:11PM CK(CPK)-2156* [**2121-10-27**] 11:35AM WBC-27.2* RBC-5.00 HGB-15.6 HCT-46.4 MCV-93 MCH-31.1 MCHC-33.5 RDW-13.4 [**2121-10-27**] 11:35AM NEUTS-87* BANDS-0 LYMPHS-9* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-1* [**2121-10-27**] 11:35AM PT-12.8 PTT-24.1 INR(PT)-1.1 [**2121-10-27**] 11:35AM GLUCOSE-466* UREA N-20 CREAT-1.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-18* ANION GAP-27* [**2121-10-27**] 11:47AM LACTATE-5.7* [**2121-10-27**] 11:35AM ALT(SGPT)-72* AST(SGOT)-106* CK(CPK)-1208* ALK PHOS-116 TOT BILI-0.2 [**2121-10-27**] 11:35AM LIPASE-28 [**2121-10-27**] 03:40PM ETHANOL-NEG Chest CT [**10-27**] 1. No evidence of pulmonary embolism. 2. Sequelae of massive aspiration with bilateral lower lobe consolidation and scattered centrilobular ground-glass opacities. 3. ET and NG tubes positioned appropriately. TTE [**10-28**] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with near akinesis of the basal inferolateral wall and mild global hypokinesis of the remaining segments (LVEF = 40 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Mild regional and mild global left ventricular systolic function. No pathologic valvular flow identified. Cardiac Cath [**10-28**]: FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate diastolic ventricular dysfunction. 3. Moderate systolic ventricular dysfunction. 4. Moderate primary pulmonary hypertension. 5. Acute posterior myocardial infarction, managed by acute ptca. 6. Manual aspiration thrombectomy and PTCA of the late stent thrombosis of the LCX. CT Head [**11-3**] IMPRESSION: 1. Technically limited study secondary to motion artifact without evidence of acute intracranial hemorrhage or mass effect. Consider MR if there is concern for PRES as [**First Name9 (NamePattern2) 12287**] [**Male First Name (un) **] the requisition. 2. Layering secretions in the [**Last Name (un) **]- and oropharynx. CT Abdomen/Pelvis [**11-3**] IMPRESSION: 1. Bibasilar consolidations, right more than left. 2. No evidence of intra-abdominal source of fever. 3. Fatty liver Brief Hospital Course: 49 yo man with presumed CAD, DM who presents w/ resp distress found to be profoundly hypertensive, evidence of aspiration on CT chest and rising CEs. . 1) NSTEMI: Pt presented with shortness of breath, rising troponins, and LBBB (unknown baseline), overall suspicious for ACS, possibly in the setting of hypertensive emergency and flash pulmonary edema. Troponin, CKs rising since presentation to OSH. Pt denied any history of pain. He was started on IV heparin. He was continued on ASA, Plavix which he was taking his coronary stent. Troponins were cycled X 3 with elevation in CK-MB and troponins. ECHO showed akinesis of the basal inferolateral wall and mild global hypokinesis of the remaining segments (LVEF = 40 %). Cardiology was consulted, and cath patient underwent cardiac cath, which showed in-stent restenosis of patient's prior LCx stent, and underwent thrombectomy and re-stenting. Patient was also found to have moderate systolic and diastolic dysfunction, moderate pulmonary hypertension. . 2) Acute on chronic Heart Failure: Patient was found to have moderate systolic and diastolic dysfunction (EF 40%), and required Lasix diuresis for fluid overload and pulmonary edema. He responded well to a Lasix drip, with no supplemental O2 requirement on discharge. . 2) Aspiration PNA - Febrile with WBC count elevated at 27 on initial labs, now trending down likely after fluid resuscitation. Aspiration PNA vs pneumonitis read based on appearance on CT Chest. He was started on vancomycin, cefepime, and ciprofloxacin. Sputum and blood cultures were obtained, but were negative. Patient finished a course of treatment for aspiration PNA and antibiotics were subsequently d/c'ed. . 3) Persistent Fevers - Patient continued to be febrile despite broad antibiotic coverage, and was believed to be febrile [**2-24**] DTs vs. drug fever, as all cultures and infectious w/u was negative following the initial imaging of aspiration PNA vs. pneumonitis. Following the resolution of DTs and d/c of CIWA, patient's antibiotics were discontinued after a full course of treatment for possible aspiration pneumonia. Patient's fevers resolved shortly thereafter with all cultures negative. Likely fevers [**2-24**] DTs or from antibiotics which were started to treat aspiration PNA on intial presentation, and had completely resolved prior to discharge. . 4) Acute renal failure - Pt was admitted with elevated creatinine, which improved upon receiving IVF. Likely [**2-24**] poor perfusion in the setting of NSTEMI. . 5) Mental Status - Patient was initially sedated on a vent, but was weaned off vent and sedation following cardiac catheterization. Once off sedation, the patient went into DTs from alcohol withdrawal, and CIWA scale was promptly initiated and patient was re-intubated with re-initiation of sedation. Patient was gradually weaned off sedation and extubated, and CIWA scale was continued until patient's DTs resolved. Mental status returned to baseline prior to discharge. Patient was seen by social work re: quitting alcohol use and was interested in quitting alcohol use on discharge. . 6) DM: Patient required sliding scale insulin while in-house, and was discharged on insulin with f/u. Medications on Admission: Home Medications: ASA 325 Spironolactone 25 daily Plavix 75 daily Niaspan 500 Glyburide 5 Lisinopril 10 daily Metoprolol 25 daily Simvastatin 40 Metformin 1000 [**Hospital1 **] Medications On Transfer: Aspirin 325 mg PO DAILY CefePIME 2 g IV Q12H Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **] Ciprofloxacin 400 mg IV Q12H Clopidogrel 75 mg PO DAILY Famotidine 20 mg IV Q12H Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Heparin IV per Weight-Based Dosing Insulin SC (per Insulin Flowsheet)Sliding Scale & Fixed Dose Midazolam 1-10 mg/hr IV DRIP TITRATE TO sedation Propofol 5-20 mcg/kg/min IV DRIP TITRATE Simvastatin 80 mg PO DAILY Spironolactone 25 mg PO DAILY Vancomycin 1000 mg IV Q 12H Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Decrease to 162 mg (2 baby aspirin) in 1 month. 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. insulin 75/25 Sig: Forty Five (45) units Injection twice a day. Disp:*1 bottle* Refills:*2* 7. One Touch Ultra Test Strip Sig: One (1) bottle In [**Last Name (un) 5153**] four times a day. Disp:*1 bottle* Refills:*2* 8. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO at bedtime. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Decrease to 75mg, one pill, after 1 month. Disp:*60 Tablet(s)* Refills:*2* 12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-3 tablets Sublingual take 1 tablet under tongue every 5 minutes for total 3 doses as needed for chest pain. Disp:*1 bottle* Refills:*0* 13. Lancets Misc Sig: One (1) lancet Miscellaneous four times a day: Please check your blood sugar at breakfast, lunch, dinner, and before bedtime. Disp:*120 lancets* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Non ST elevation myocardial Infarction Delerium Tremens Acute Renal Failure Diabetes Mellitus Type 2 Acute Respiratory Failure Discharge Condition: stable. Discharge Instructions: You had a heart attack because a stent in your heart artery clotted off. This was opened by a balloon angioplasty and the blood flow was restored. You will need to take Plavix and aspirin every day for at least one year and possibly indefinitely. for the next month, please take PLavix twice daily. Your kidneys had trouble working while you were so sick, they are now normal. You also had DT's from not drinking and was on Valium that is now off. Do not drink any more alcohol, you should seek intensive day therapy and AA after you go home. Your diabetes medicine was also changed to insulin only to be taken before breakfast and dinner. check your fingersticks before meals and at bedtime, write down the results so you can show them to the NP[**MD Number(3) **] [**Hospital **] Clinic at [**Location (un) **]. . Medication changes 1. Stop taking Metformin and Glyburide 2. Start Insulin 75/25 45 units twice daily before breakfast and dinner. Eat lunch about 5 hours after your insulin shot and eat a snack at bedtime. 3. Decrease your Lisinopril to 5 mg daily 5. Increase your Atorvastatin to 80 mg daily 6. Increase your Metoprolol to 150 mg daily . Please call Dr. [**First Name (STitle) **] if you have any recurrent chest pain, nausea, fevers, trouble breathing, or any other concerning symptoms. Followup Instructions: Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62842**] Date/time: Wed [**11-12**] at 11:30am. Diabetes: Nurse [**First Name8 (NamePattern2) 30484**] [**Last Name (Titles) **] Phone: [**Telephone/Fax (1) 27738**] Date/Time: [**2121-11-18**] at 11:00am. [**Hospital6 27369**], [**Location (un) 78692**]. Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 28959**] Date/time: Tuesday [**11-25**] at 10:00am. ICD9 Codes: 5849, 5070, 2762, 4280
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Medical Text: Admission Date: [**2122-5-12**] Discharge Date: [**2122-6-24**] Date of Birth: [**2059-6-12**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 62 year old female status post subarachnoid hemorrhage on [**5-11**], complicated by hydrocephalus. The patient was transferred from [**Hospital 1562**] Hospital to [**Hospital3 **] Hospital where she was was brought to the Intensive Care Unit and treated according to subarachnoid hemorrhage protocol with control of her blood pressure, Dilantin and Nimdipine. The patient was intubated and sedated at [**Hospital1 69**] on arrival. PAST MEDICAL HISTORY: 2. Gastroesophageal reflux disease. 3. Hypercholesterolemia. MEDICATIONS ON ADMISSION: None. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is widowed and lives in [**Hospital1 1562**]. No tobacco history; social alcohol use. PHYSICAL EXAMINATION: On admission, the patient is afebrile, heart rate of 69; blood pressure 120/74; breathing at 10; O2 saturation is 100% on assist control, total volume 750; respiratory rate of 10; PEEP of 5, FIO2 of 40%. Her ICP is 10. The patient is intubated and sedated, grimacing and withdrawing to painful stimuli in all four extremities. Pupils equal, round and reactive to light; 3 to 2 bilaterally. Clear to auscultation bilaterally. Regular rate and rhythm, soft, nontender, nondistended. No cyanosis, clubbing or edema. LABORATORY: Labs from outside hospital were sodium 145, potassium 3.0, chloride 109, bicarbonate 24, BUN 14, creatinine 0.7, glucose 105, white blood cell count 7.2, hematocrit 36, platelets 287. PT 12.3, INR 0.9, PTT 22.9. Arterial blood gas is pH 7.59, pCO2 20, pO2 200. CT scan shows subarachnoid hemorrhage with hydrocephalus. Chest x-ray shows no infiltrates, no effusions. EKG shows normal sinus rhythm. HOSPITAL COURSE: The patient was initially admitted to the [**Hospital1 69**] Intensive Care Unit followed by the Angio Suite. Her initial therapy consisted of keeping her systolic blood pressure less than 140 with Nipride, elevating the head of her bed to greater than 30 degrees, Dilantin 100 mg three times a day; Amlodipine 60 mg q. four hours; vent drain at 20 to 25 cm. The patient had a diagnostic four-vessel cerebral angiogram on [**5-12**]. The left A1, A2, aneurysm was embolized at that time by Dr. [**Last Name (STitle) 1132**]. The aneurysm was noted to be 3 mm and the result of the embolization was good. The patient, postoperatively, moved all extremities well, opened eyes. Amlodipine was then decreased to 30 q. four hours to avoid hypotension. The patient's HHH therapy was slowly weaned over the course of the next several days. The patient was taken off anti-hypertensives. Her blood pressure was in the 110 to 120's following her embolization. The patient was started on Kefzol postoperatively; she had temperatures in the 103.0 F., range on [**5-16**] and [**5-17**]. The patient was noted to have a right pronator drift on [**5-17**]. She was taken back to the Angio Suite where bilateral middle cerebral artery and ACA distal vasospasm was noted. Superselective papaverine infusion was performed for treatment with good success. The patient was managed by controlling the blood pressure to a range of 190 to 200 with a CVP of 10 to 12, and a pCO2 of 35 to 45. The vent drain was set at 10 cm after the procedure. On [**2122-5-19**], the patient became hypoxemic, requiring intubation. Chest x-ray demonstrated right greater than left pulmonary infiltrates. A Cardiology consultation was requested. EKG did not show any ST or T wave changes. Echocardiogram showed an ejection fraction of 30%, anterior septal lateral, severe mitral regurgitation and aortic regurgitation with two plus mitral regurgitation. Mitral valve prolapse, one to two plus tricuspid regurgitation. Cardiology consultation recommended pulmonary capillary wedge pressure in the range of 12 to 18, heparin intravenously, discontinuation of Diltiazem and paralytics. An intraaortic balloon pump was placed to support the low cardiac output. The patient had another diagnostic angiogram on [**5-19**]; Papaverine was instituted in the left ICA. Systolic blood pressure goals were established at 150 to 160, and the drain was changed to 10 cm. The patient was placed on an intra-arterial balloon pump to support her cardiac function. The patient was also placed on Amiodarone to slow down her supraventricular tachycardia. The patient was noted to have platelets decreased to 100; this was felt secondary to heparin-induced thrombocytopenia. The patient should no longer receive heparin and she has demonstrated this reaction. The patient continued to spike fevers and was placed on Vancomycin and Levofloxacin. The patient had another diagnostic angiogram to rule out vasospasm on [**2122-5-23**]. Papaverine was instituted in the left internal carotid artery, the A1 and the MM1. The patient had an IVC, [**Location (un) 260**] filter placed on [**2122-5-24**]. The patient's Levaquin was changed to Ceftazidime shortly thereafter for a sputum culture. The patient had a PEG and tracheostomy on [**6-5**]. On a follow-up CT the patient was noted to have new intracentricular blood and subarachnoid blood around the AComm complex which prompted an engiogram which showed the presence of two new aneurysms not previously visualized on angiogaphy. The patient underwent surgical clipping of these new aneurysms and did well post-op. She subsequently underwent an angiogram which showed that these new aneurysms had been isolated from the circulation. The patient now has a PEG and tracheostomy. She has undergone a VP shunt which was successful, on [**2122-6-22**]. The patient has been afebrile and is now off antibiotics. Her current medications at the time of this dictation are: 1. Tylenol 650 mg p.o. q. four to six hours p.r.n. 2. Insulin sliding scale. 3. Miconazole Powder 2%, one application twice a day. 4. Artificial Tears 1 to 2 drops o.u. p.r.n. 5. Albuterol. 6. Atrovent one to two puffs inhaled q. six hours. 7. Calcium carbonate 1000 mg p.o. p.r.n. 8. Magnesium oxide 400 mg p.o. p.r.n. 9. Potassium chloride p.r.n. 10. Guaifenesin, p.r.n. 11. Nystatin p.r.n. 12. Albuterol nebulizers p.r.n. 13. Dulcolax 10 mg p.o. q. day p.r.n. 14. Reglan 10 mg p.o. or intravenously twice a day p.r.n. 15. Sodium chloride one gram p.o. four times a day. 16. Morphine sulfate 2 mg intravenously q. two hours p.r.n. 17. Zantac 150 mg via NG tube twice a day. 18. Lopressor 25 mg p.o. twice a day. 19. Diperodon nasal ointment, 2%, one application to each nostril twice a day. Methicillin resistant Staphylococcus aureus duration five days beginning on [**6-22**]. 20. Captopril 12.5 mg p.o. three times a day. DISCHARGE DIAGNOSES: 1. Subarachnoid hemorrhage. 2. Five cerebral angiograms. 3. Ventriculoperitoneal shunt. 4. Supraventricular tachycardia. 5. Pneumonia. 6. Denovo formation of aneurysms at the base of the coiled aneurysm. 7. Craniotomy for the clipping of these new aneurysms. CONDITION AT DISCHARGE: The patient will require extensive rehabilitation. She has a PEG and tracheostomy at this point. She will require neurologic rehabilitation. On her current neurological examination, she opens eyes to commands, smiles, does not follow commands other than opening eyes. The patient is being discharged in stable condition. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2122-6-24**] 11:03 T: [**2122-6-24**] 11:45 JOB#: [**Job Number 42595**] ICD9 Codes: 4271, 2875, 4240, 2720
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Medical Text: Admission Date: [**2186-7-20**] Discharge Date: [**2186-8-3**] Date of Birth: [**2116-11-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Penicillins / Sulfamethoxazole Attending:[**First Name3 (LF) 3326**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Bronchoscopy w/ BAL, intubation for tunneled dialysis line placement History of Present Illness: Ms. [**Known lastname 81668**] is a 69 year-old female with h/o insulin-dependent diabetes, chornic kidney disease and complete heart block s/p PPM who was in her usual state of health until 5-6 days ago at which time she developed progressive fatigue, malaise and weakness. She also notes diffuse body aches in hips, back, legs. Yesterday she notes the development of significant shortness of breath with exertion. She has noted shaking chills on occasion without fevers. She had a diffuse headache yesterday but denies dizziness or blurred vision. No mouth sores, bleeding from gums or nose. She denies nausea, vomiting, abdominal pain. No diarrhea, constipation, dysuria. No hematuria, bright red blood per rectum, or dark tarry stools. She notes her blood sugars have been in the 400's for the past week despite eating very little. She denies weight loss. She presented to [**Hospital6 33**] yesterday where labs were notable for WBC count of 95.2K with mostly blasts, smear reviewed by Dr. [**Last Name (STitle) 94913**] of Hematology-Oncology. Hct 34.5, plts 55K. Cr 2.6 from baseline 1.5, uric acid 16.7. LD 1600. Pt received allopurinol and cefepime. Vital signs were stable apart from transient desaturation to 80's on RA with rapid improvement to 97% on 2L. BNP was 5085, she was started on heparin gtt given concern for PE. She was transferred to our ICU given concern for leukostasis with consideration for pheresis. Past Medical History: - Type 2 diabetes: Diagnosed 25 years, insulin-dependent, complicated by peripheral neuropathy - Chronic renal insufficiency (baseline Cr 1.5) - Complete heart block c/b syncope, s/p PPM placement [**2185-9-29**] - Legal blindness - Hypertension - Hyperlipidemia - Morbid obesity - Lymphedema Social History: Pt lives in [**Hospital1 392**], MA with her husband. She previously worked at [**Last Name (NamePattern1) 74733**]in counseling. She denies tobacco, alcohol, illicits. They have 5 children, 9 grandchildren. Family History: Both parents with diabetes, no family history of leukemia, other malignancy. Physical Exam: Physical Exam on admission: VS: 99.3 130/64 80 22 97% 3L; 0/10 pain General- Overweight female lying in hospital bed, appears uncomfortable but in no acute distress HEENT-NC/AT, PERRL, EOMI, no icterus/injection. (+) thrush Lymph- no palpable cervical, submandibular, supraclavicular adenopathy CV- regular, no murmurs, rubs, gallops Resp- Clear to auscultation anteriorly, no crackles/wheezes Abd- rotund, soft, NT/ND, no palpable hepatosplenomegaly Ext- (+) lymphedema changes in LE bilaterally. Skin- few ecchymoses on UE bilaterally Neuro- AAOx3, CN2-12 intact/symmetric, strength grossly intact/non-focal Pertinent Results: ADMISSION LABS: [**2186-7-20**] 12:20AM BLOOD WBC-110.1* RBC-4.26 Hgb-11.8* Hct-35.5* MCV-84 MCH-27.6 MCHC-33.1 RDW-17.6* Plt Ct-73* [**2186-7-20**] 12:20AM BLOOD Neuts-14* Bands-0 Lymphs-2* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-82* [**2186-7-20**] 12:20AM BLOOD PT-14.0* PTT-27.6 INR(PT)-1.3* [**2186-7-20**] 12:20AM BLOOD Fibrino-752* [**2186-7-20**] 12:20AM BLOOD Glucose-239* UreaN-86* Creat-2.6* Na-138 K-2.6* Cl-99 HCO3-26 AnGap-16 [**2186-7-20**] 12:20AM BLOOD ALT-17 AST-39 LD(LDH)-1662* AlkPhos-84 TotBili-0.2 [**2186-7-20**] 12:20AM BLOOD Albumin-3.1* Calcium-8.8 Phos-2.9 Mg-2.3 UricAcd-16.8 Urine studies [**2186-7-20**] 05:57AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014 [**2186-7-20**] 05:57AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2186-7-20**] 05:57AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 Peripheral smear: numerous large immature white blood cells with large nucleoli, some with indented/folded nuclei, few granules in cytoplasm, no auer rods seen. Few lymphocytes, eosinophils. RBC with few burr cells, tear drops. Platelets decreased in number. IMMAGING: CXR [**2186-7-20**]: There is moderate cardiomegaly. Pacemaker leads are in the standard position in the right atrium and right ventricle. The lungs are grossly clear. There is no pneumonia, pneumothorax or pleural effusion. There is mild vascular congestion. TTE [**2186-7-20**]: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Moderate tricuspid regurgitation around a pacer wire. Normal estimated pulmonary artery systolic pressure. CXR [**7-21**]: FINDINGS: In comparison with study of [**7-20**], there is little change. Monitoring and support devices remain in place. Enlargement of the cardiac silhouette persists, though there is no evidence of pulmonary vascular congestion or acute pneumonia. CT Chest w/o contrast 1. Endotracheal tube tip at the carina coursing towards the orifice of the right main stem bronchus. Retraction is recommended. 2. Multifocal diffusely distributed bilateral pulmonary nodular and ground-glass opacities, consistent with infection. 3. Coronary artery calcifications. 4. Catheter in the inferior vena cava, incompletely imaged. MICROBIOLOGY [**2186-7-30**] 2:05 pm BRONCHOALVEOLAR LAVAGE Site: LINGULA GRAM STAIN (Final [**2186-7-30**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2186-8-1**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2186-7-30**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2186-7-31**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2186-7-31**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2186-7-31**]): SPECIMEN COMBINED WITH [**Numeric Identifier 112363**]. Reported to and read back by DR [**First Name (STitle) **] [**2186-7-31**] 8:05AM. PATIENT CREDITED. Blood Culture, Routine (Final [**2186-7-29**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2186-7-24**]): Reported to and read back by [**Doctor Last Name **] EL-OKDI @ 2207 ON [**7-24**] - [**Numeric Identifier 23447**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. All other blood cultures negative, the above culture was thought to be a contaminent Brief Hospital Course: Ms. [**Known lastname 81668**] is a 69 yo F with h/o insulin-dependent diabetes mellitus, chronic kidney disease (baseline Cr of 1.4) and complete-heart block s/p PMM who presented to [**Hospital3 **] with one week with malaise, chills, diffuse arthralgias/myalgias and shortness of breath, found to have WBC of 95K with increased peripheral blasts, elevated creatinine to 2.4, uric acid of 16.5, transferred to [**Hospital1 18**] for further treatment of acute leukemia. # Acute leukemia: Peripheral blood smear showed many myeloid-appearing blasts, most likely c/w acute myeloid leukemia. No auer rods were appreciated, no evidence of DIC clinically or in lab testing, making APL less likely. Bone marrow biopsy was performed. She received two doses of rasburicase and was started on allopurinol with a decrease in uric acid from 16.8 to 0.1. She also received hydroxyurea [**Hospital1 **] to acutely lower her WBC. Echo and line were placed on [**7-20**]. Her urine output was decreased on [**7-21**] and creatinine remained elevated at 2.7 depite continuous IVF with a 1L NS [**Last Name (LF) 1868**], [**First Name3 (LF) **] renal was consulted. She was also started on cefepime for neutropenic prophylaxis. Chemotherapy was administered and she was inducted. She developed Tumor Lysis syndrome and Renal failure, requiring dialysis. # TLS: Recieved rasburicase and allopurinol. Elevated BUN/Cr and other toxins were felt to be contributing to her AMS. # Renal failure: Was felt to be [**3-2**] tumor lysis syndrome. Required dialysis. A temporary port was placed for a while, then removed in anticipation of placement of a tunneled catheter. Tunneled cath was placed, but she was unable to be extubated after the procedure. # AMS:She developed AMS, but was responsive and interactive, giving several word answers to questions. However, after she failed the trial of extubation, she remained sedated and un-interactive # Pneumonia: She developed PNA seen on CT scan in the setting of neutropenia. She was treated with Vanc/vori/cefepime. This was felt to be a large contributor to her failure to extubate. #Decision to withdraw care was made by the family members after she had been on a ventilator for a week, since she had a very poor prognosis and had previously articulated that she did not want to be kept alive by a ventilator for a prolonged period of time. The team held multiple meetings with the patient's husband and children (most of whom attended work rounds on a daily basis) to discuss her medical problems and her wishes. Comfort measures were initiated and the patient expired. Medications on Admission: Insulin Lispro 6-15 units with meals Humulin: 35 units SQ QPM Aspirin 325 mg PO daily Rosuvastatin 40 mg PO QHS Enalapril 20 mg PO daily Hydralazine 50 mg PO TID Amlodipine 10 mg PO daily Torsemide 20mg PO daily Cefepime Allopurinol 100 mg daily Zofran Tylenol Hydralzine 50 mg TID Amlodipine 10 mg daily Morphine 2mg Q4h NG 1 tab every 5 minutes Discharge Disposition: Expired Discharge Diagnosis: Acute leukemia, respiratory failure, renal failure Discharge Condition: Patient expired during hospitalization Discharge Instructions: Dear Ms. [**Known lastname 81668**], It was sincere pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were tranferred for further treatment of your fatigue and shortness of breath. A bone marrow biopsy confirmed that you had acute leukemia. Followup Instructions: patient expired ICD9 Codes: 486, 5856, 5849, 2762, 7907, 2724, 3572, 2767, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5183 }
Medical Text: Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Melena Major Surgical or Invasive Procedure: None History of Present Illness: 89yM with CAD, systolic CHF EF 25-30%, moderate AS, on aspirin and [**First Name3 (LF) **] presenting with severe anemia and melena. 3-4 days of melena, [**3-21**] stools per day. Stool foul smelling, sticky, black. No red blood. No abdominal pain, no nausea or vomiting. No EtOH or NSAIDs, just ASA and [**Month/Day (3) **]. No additional ASA. No history of GI bleeding and no EGD in th epast. Has NYHA class III CHF symptoms at baseline, no angina at baseline. He gets short of breath while walking in the part, does okay around the house. No orthopnea, PND, or pedal edema. Weighed 177lbs on admission, 175 baseline. No other symptoms. No fevers/chills. In ED, had 2 PIV, got 1L IVF, 40mg IV Protonix, and 1 unit pRBC's. Past Medical History: Diabetes Dyslipidemia CAD s/p PCA in [**1-/2182**] Moderate Aortic Stenosis Anemia CKD (baseline creatinine 2.1) Gout CHF, EF 25-30% Social History: Lives in [**Location 1268**] with wife. [**Name (NI) **] 2 daughters and a son. [**Name (NI) **] was born in [**Country 4754**], moved to the US in [**2125**]. Worked in construction as a labor foreman. Married x 54 years, with 3 children and 9 grandchildren. -Tobacco history: Denies -ETOH: Occasional -Illicit drugs: Denies Family History: No know FH of cardiac disease, diabetes, no colon/proste/breast cancer. Parents lived to 70s to 80s with no known medical problems. Children in good health. Brother had heart disease. Physical Exam: Vitals 97,0F, BP 98/51, HR 77, RR 14, O2 sat 97%RA General: NAD, A&O x 3 HEENT: MM slightly dry, JVP 8cm Cardiac: RRR, [**2-23**] mid peaking systolic crescendo decrescendo murmur at the USB with radiation to the precordium and the carotids, good carotid pulsations Lung: CTAB Abdomen: Soft, NT, ND, no masses or organomegaly Rectal: minimal melnea in rectal vault, no red blood, no rectal masses Neuro: A&O x3, grossly normal DISCHARGE EXAM: 98.2F, BP 102/64, 862, 96%RA No JVD RRR, 2/6 systolic murmur Lungs clear to auscultation bilaterally Abdomen benign No peripheral edema A&O x 3 Pertinent Results: [**2182-4-9**] 11:30PM PT-12.8 PTT-29.3 INR(PT)-1.1 [**2182-4-9**] 11:30PM PLT COUNT-233 [**2182-4-9**] 11:30PM NEUTS-68.5 LYMPHS-17.4* MONOS-6.1 EOS-7.3* BASOS-0.6 [**2182-4-9**] 11:30PM WBC-5.0 RBC-2.32*# HGB-7.5*# HCT-22.1*# MCV-96 MCH-32.2* MCHC-33.7 RDW-13.6 [**2182-4-9**] 11:30PM cTropnT-0.05* [**2182-4-9**] 11:30PM CK(CPK)-81 [**2182-4-9**] 11:30PM GLUCOSE-195* UREA N-163* CREAT-2.9* SODIUM-132* POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-25 ANION GAP-14 [**2182-4-10**] 04:32AM PT-12.9 PTT-29.3 INR(PT)-1.1 [**2182-4-10**] 04:32AM HCT-22.4* [**2182-4-10**] 04:32AM ALBUMIN-3.4* CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-2.8* [**2182-4-10**] 04:32AM ALT(SGPT)-79* AST(SGOT)-36 LD(LDH)-177 ALK PHOS-57 TOT BILI-0.6 [**2182-4-10**] 04:32AM GLUCOSE-55* UREA N-158* CREAT-2.7* SODIUM-136 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 [**2182-4-10**] 12:40PM HCT-24.8* [**2182-4-10**] 12:40PM POTASSIUM-5.2* [**2182-4-10**] 03:39PM HCT-25.8* [**2182-4-10**] 06:07PM MAGNESIUM-2.4 [**2182-4-10**] 06:07PM estGFR-Using this [**2182-4-10**] 06:07PM UREA N-134* CREAT-2.3* POTASSIUM-5.3* Echo [**2182-4-10**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (valve area 1.0-1.2cm2). 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 [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2182-3-16**], the heart fate is higher and left ventricular systolic function is slightly more vigorous. The left ventricular ejection fraction may have been slightly underestimated in the prior report. . Estimated valve area is slightly higher in the current report. Chest X-ray [**2182-4-10**]: IMPRESSION: No evidence for pulmonary edema. Suspected tiny or small pleural effusion on the left. Chest X-ray [**2182-4-16**]: IMPRESSION: Unchanged mild cardiomegaly and small bilateral effusions. Brief Hospital Course: 89yM with CAD and systolic CHF, moderate AS, on aspirin and [**Year (4 digits) **], admitted with severe anemia and melena. # GI Bleeding. Hct on admission 22; baseline 30-32. Thought secondary to UGIB (gastritis, PUD). ASA/[**Year (4 digits) **] stopped on admission. Seen by GI; given multiple cardiac problems, any procedure would need to be done by [**Last Name (LF) **], [**First Name3 (LF) **] deferred. Hematocrit stabilized off ASA/[**First Name3 (LF) **]; GI bleeding thought secondary to [**Last Name (LF) **], [**First Name3 (LF) **] this should be permanently discontinued. Metoprolol, lisinopril, and torsemide held in setting of GI bleeding. Hematocrit after [**4-12**] was stable, ranging from 25-30%. Received a total of 5 units pRBC's during admission (last on [**4-16**]); hematocrit at discharge 28%. No bowel movement in 3 days at time of discharge. Discharged on pantoprazole [**Hospital1 **]. # Acute on chronic renal failure. Creatinine 2.7 at time of admission (baseline 2.0-2.2). Creatinine was as low as 1.7 during the admission. Bumped from 1.7 to 2.2 when lisinopril initially restarted; this medication was discontinued again and should be restarted as an outpatient. Torsemide to be restarted on discharge. # Coronary artery disease. [**Hospital1 **] discontinued. Aspirin restarted three days prior to discharge with subsequent stable hematocrit. Statin continued. Metoprolol restarted two days prior to discharge, and lisinopril to be restarted as outpatient. # Chronic systolic heart failure. Well-compensated throughout the admission. Change in x-ray demonstrated accumulation of mild bilateral pulmonary effusions (diuresis was held during the admission). I's/O's closely monitored, and he remained euvolemic throughout the admission. Beta blocker restarted during admission, torsemide to start as outpatient, and lisinopril to be restarted within one week of discharge. # Delirium. Noted to have reversed sleep/wake cycles during the admission, with subsequent confusion. Improved with trazodone, to be continued on discharge. # Gout flare. On [**5-6**], patient had low-grade fever and bilateral great toe pain. Given one dose of colchicine with resolution of fever and pain. # Hyperlipidemia. Continued statin. # Hypernatremia. Did develop hypernatremia during hospitalization. Resolved with increased PO fluid intake. # Full Code, confirmed with patient. Medications on Admission: Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Lisinopril 10mg daily [**Date Range **] 75mg daily Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Torsemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**] hours as needed for pain. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day Zantac 75mg [**Hospital1 **] Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Pantoprazole 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* 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**] hours as needed for pain. 9. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) GI bleed 2) Coronary artery disease Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent, with cane/walker Discharge Instructions: You were admitted with bleeding in your GI tract. This was most likely due to your medication, [**Hospital **], that you recently started taking. Please do not take your [**Hospital **]. Your aspirin was restarted, and you had no further bleeding; you should continue to take this medication. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please take all of your medications as prescribed and keep all follow up appointments. The following changes are made to your medication list: - [**Name8 (MD) **]: DO NOT TAKE THIS MEDICATION, as it likely contributed to your episode of bleeding from your GI tract - Pantoprazole: this is an anti-acid medication that you are prescribed to help prevent bleeding from your GI tract - Lisinopril: This medication will likely be restarted by Dr. [**Last Name (STitle) 131**]; please discuss this medication with him when you see him on [**2182-4-24**] - Trazodone: This is a medication for sleep. Followup Instructions: Appointment #1 MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] Specialty: Internal Medicine-Primary Care Date/ Time: [**2182-4-24**] 10:30am Location: [**Street Address(2) 3375**] [**Location (un) 858**], [**Location (un) **] MA Phone number: [**Telephone/Fax (1) 133**] Special instructions for patient: Appointment #2 MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7965**] Specialty: Cardiology Date/ Time: Location: Phone number: [**Telephone/Fax (1) 62**] Special instructions for patient: The office will call you with an appointment. If you do not hear or have any questions please call the office. Thanks. ICD9 Codes: 5789, 5849, 2930, 2760, 2851, 5859, 4280, 4241, 2749, 2724
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Medical Text: Admission Date: [**2161-8-13**] Discharge Date: [**2161-8-24**] Date of Birth: [**2125-1-11**] Sex: F Service: Neurology HISTORY OF PRESENT ILLNESS: The patient is a 36 year old right handed woman who works as a secretary, with no history of hypertension, heart disease, lung disease, liver disease, renal disease or diabetes mellitus. She has some intermittent sinus problems. She is also being followed for ovarian cysts which do not seem to have bothered her. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2161-8-24**] 11:38 T: [**2161-8-24**] 11:52 JOB#: [**Job Number 35420**] ICD9 Codes: 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5185 }
Medical Text: Unit No: [**Numeric Identifier 75904**] Admission Date: [**2155-12-3**] Discharge Date: [**2156-2-12**] Date of Birth: [**2155-12-3**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: 1380 gram, baby boy, twin #2 [**Name2 (NI) **] to a 29 year-old, G2, P0 now 2 mother. Diamniotic dichorionic twin gestation at 28 and 5/7 weeks. Cesarean section secondary to breech presentation of this twin. The mother was just discharged from the hospital on the [**10-29**] for prolonged admission with shortened cervix and was readmitted on the [**11-1**] with rupture of membranes. The reason for delivery was secondary to progression of labor. There was no maternal fever. The infant emerged with a good spontaneous cry and was doing well with facial CPAP. In preparation for transfer to the NICU, the infant had more apnea and did not tolerate being off the CPAP. He was intubated with a 3.0 ET tube and admitted to the NICU for further care. The Apgars were 7 and 9 at 1 and 5 minutes respectively. PRENATAL LABS: Mom B positive, antibody negative, hepatitis B antigen negative. Rubella immune. RPR nonreactive. Group beta strep status unknown. PREGNANCY HISTORY: Complicated by emergent cerclage at 18 weeks gestation and prolonged admission at [**Hospital1 18**] antepartum floor from the [**10-28**] to the [**10-29**] with preterm contractions and shortened cervix. The patient was beta complete from that time. Di/di IUE assisted pregnancy. Mother with gestational diabetes on insulin, TCOS. SOCIAL HISTORY: Loss of previous IUE assisted pregnancy. Father is a dentist. PHYSICAL EXAMINATION: On admission, weight was 1380 grams (75th percentile). Length 38.5 cm (50th percentile). Head circumference 28.5 cm (75th-90th percentile). Examination on discharge: Weight 3615g (75th-90th%ile), length 51 cm (75th-90th%ile) HC 36 cm (>90th %ile) The patient is alert and awake, very well perfused. Chest: Clear breath sounds bilaterally. Heart: Regular rate. No cardiac murmur. Abdomen: Soft, nontender, nondistended. Bowel sounds within normal limits. Liver at costal margin. Genitourinary: Normal male, cicumcised. Testes descended bilaterally. Neuro: Soft fontanel. Moves all 4 extremities. Tone appropriate for corrected age. Normal reflexes. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The patient was intubated in the delivery room because of apnea. He received one dose of Surfactant and was extubated on the [**11-2**] and put on CPAP on room air. He was transitioned to room air on the [**10-8**]. He needed the nasal cannula again transiently on the [**10-22**] and then again from the 30 to the [**11-5**]. He was presenting with apnea and was started on caffeine. Caffeine was finally discontinued on the [**11-3**], at 33 weeks and [**1-12**] post menstrual age. His last desaturation was [**2-7**] while feeding. He had no apnea or bradycardia during the last 2 weeks of his NICU stay. Cardiovascular: The patient remained hemodynamically stable during this hospitalization. Fluids, electrolytes and nutrition: The patient was made initially n.p.o. and put on 100 ml by kg per day of PN. The feed was begun on the [**11-4**] and was well tolerated and increased progressively. He reached full volume enteral feedings on the [**10-12**]. The calories were increased to 22 on the [**10-14**] to 24 on the [**10-15**] to 26 on the [**10-16**] and were again decreased to 24 on the [**10-7**]. The patient was transitioned to Enfacare 24 on the [**10-20**]. He was taking all feeds by mouth at discharge with evidence of good weight gain. His discharge weight was 3615 g. Gastrointestinal: The patient received phototherapy from the [**11-2**] to the [**10-11**]. The maximum bilirubin was 7.9 and 0.4 on the second of [**Month (only) 1096**]. Hematology: The initial hematocrit was 50.6 and on the last check on the [**10-27**] was 30%. He received iron and vitamin E supplementation until he was transitioned to enfacre 24 kcal/oz. Infectious disease: The mom had rupture of membranes since the [**11-1**]. Blood culture and CBC with differential were obtained on admission. Initial white blood cell count was 6.5 with no left shift. The blood culture remained negative. Antibiotics of ampicillin and gentamicin were begun at birth and were stopped after 48 hours. On the [**11-4**], the patient began to present with desaturations and required again the nasal cannula. A blood culture from the [**11-4**] came back positive for E. Coli. A urine culture from the [**11-5**] came back with E. Coli. The diagnosis was made of urosepsis with E. Coli. The lumbar puncture from the [**11-5**] remained negative and a renal ultrasound on the [**10-7**] was normal. The patient was begun on ampicillin and gentamycin on the [**11-5**]. These antibiotics were changed to Cefotaxime on the [**10-7**] and the patient was treated for a total of 7 days until the [**10-11**]. He has been on amoxicillin prophylaxis for urinary tract infections. To note, the urine culture on the [**10-11**] was negative. He had a VCUG on [**1-29**] that demostrated grade II vesicoureteral reflux bilaterally. He had a normal renal ultrasound at that time. The plan is to remain on amoxicillin and have these studies repeated concurrent with a visit to urology (Dr. [**Last Name (STitle) 3060**] at CH [**Location (un) **] office [**3-9**] at 1:30 pm. Neurology: Head ultrasound on the [**11-4**] and the [**10-11**] and these were normal. His 2 month cranial ultrasound revealed a small right-sided IVH as well as a small left sided cerebellar cyst. Upon consultation with neurology an MRI of his head was obtained on [**2-3**] and this showed a likely subependymal cyst on the posterior aspect of the 4th ventricle (lesion seen on cranial u/s), as well as a 6mm cyst along the right lateral ventricle and a 2 mm cyst along the body of the left ventricle, which are also thought to be subependymal in nature. He also has a 4 mm cyst adjacent to the pineal gland. Neurology examined the patient, reviewed these findings, and met with the family. Their impression is that these areas are unlikely to lead to any clinical effect, but that [**Known lastname **] should be followed in their clinic with a plan for repeat MRI at one year of age. He is scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**3-24**] at 4:30 pm. Audiology: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname **] passed his hearing screen on [**2-9**]. Ophthalmology: The patient's eyes were examined by ophthalmoogy and his retinas were mature without evidence of ROP on [**1-26**]. He needs repeat examination in 6 months. Psychosocial: [**Hospital1 69**] social work was involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72876**], [**Location (un) 15749**], MA. ([**Telephone/Fax (1) 75905**], fax ([**Telephone/Fax (1) 75906**]. CARE AND RECOMMENDATIONS: MEDICATIONS: [**Known lastname **] is on prophylactic amoxicillin 20 mg by kg by day each day by mouth. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi- vitamin preparation) daily until 12 months corrected age. He passed his car seat position screening on [**2-11**]. State newborn screening has been sent per protocol on the [**10-6**] and also on the [**10-14**] and results are pending. Immunizations received: The infant has received hepatitis B vaccine on the [**11-2**]. He received his 2 months immunizations on [**2156-2-2**]. He received synagis on [**2156-2-9**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: (1) [**Month (only) **] at less than 32 weeks; (2) [**Month (only) **] between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received ROTA virus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. Follow-up recommended: Pediatrician appointment scheduled for [**2-16**]. VNA on [**2156-2-13**]. Plan for renal ultrasound and VCUG in 6 weeks after the urinary tract infection. Neonatal [**Hospital 878**] clinic [**3-24**]. DISCHARGE DIAGNOSES: 1. Prematurity at 28 and 5/7 weeks, twin pregnancy, this twin being twin #2. 2. Footling breech presentation. 3. Respiratory distress syndrome. 4. Apnea of prematurity. 5. Rule out sepsis. 6. E. Coli urinary tract infection. 7. Hyperbilirubinemia. 8. Bilateral grade II vesicoureteral reflux. 9. Pineal, bilateral ventricular subepndymal, and 4th ventricle (subependymal) cysts. [**Name6 (MD) 11709**] [**Last Name (NamePattern4) 75907**], MD [**MD Number(2) **] Dictated By:[**Doctor Last Name 75307**] MEDQUIST36 D: [**2156-1-16**] 16:14:43 T: [**2156-1-16**] 17:37:14 Job#: [**Job Number 75908**] ICD9 Codes: 769, 7742, 5990, V053
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Medical Text: Admission Date: [**2163-3-21**] Discharge Date: [**2163-3-25**] Date of Birth: [**2101-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: [**2163-3-21**] 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: 61 yo man with hypertension, hyperlipidemia and a known bicuspid aortic valve who went to see his PCP [**1-12**] with symptoms of right calf pain, expressing his concerns for DVT. A routine EKG showed ST elevations that were thought to be an ischemic process versus left ventricular hypertrophy versus left axis deviation. He was sent to the ER for further evaluation. Troponins were positive to .21. However, the presence of EKG Q-waves were thought to suggest that this was a remote event. An echo demonstrated new anterior lateral hypokinesis, compared to previous studies, overall LV systolic function was decreased (LVEF 45%) and demonstrated new wall motion abnormalities. A cardiac catheterization revealed three vessel coronary artery disease. He has now been referred for surgery. Past Medical History: - Anteroseptal myocardial infarction in [**2162-12-13**] - Dyslipidemia - Hypertension - Bicuspid aortic valve - DVT right leg [**2153**] - Sciatica - Ischemic cardiomyopathy (LVEF 45%) - Obesity - Tobacco and ETOH abuse - Right lower extremity DVT - ?Soft palate lesion Past Surgical History: - s/p Testicular repair Social History: Race: Caucasian Last Dental Exam: 1 yr ago Lives with: Partner in [**Name2 (NI) 3494**] Occupation: Works as a bus driver for Holiday Inn, MSM. Tobacco: 0.5-1ppd x 35 years. -quit [**2163-3-6**]- on Chantix ETOH: 6 drinks/day Family History: Father died at 48 from lung cancer/MI Physical Exam: Pulse: 90 Resp: 16 O2 sat: 100% B/P Right: 125/86 Left: 127/78 Height: 5'8" Weight: 198lbs General: Well-developed male in no acute distress Skin: Warm[X] Dry [X] intact [X] dry, erythematous bilateral infra-mammary eruption HEENT: NCAT[X] PERRLA [X] EOMI [X] anicteric sclera, OP benign, no lesion seen Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 2/6 SEM Abdomen: Obese, 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], MAE, [**6-16**] strengths, non-focal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2163-3-21**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is mildly depressed (LVEF=45 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve is bicuspid. There is mild aortic valve stenosis (valve area 1.8cm2) with Cardiac output 4.0L/min.. Mild to moderate ([**2-13**]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname 100303**]. POST-BYPASS: Preserved RV systolic function. LVEF 45%. The mid anterior and anteroseptal walls are hypokinetic compared to pre CABG. Surgeon informed of these findings. With epinephrin only 0.02 mcg/kg/min they improved signficantly later on. Intact thoracic aorta. Same valvular findings as before. All wall motions similar to prebypass after chest closure. Brief Hospital Course: Mr. [**Known lastname 100303**] was a same day admit after undergoing pre-operative work-up as an outpatient. On [**2163-3-21**] 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. Later this day he was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day one he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He continued to make good progress while working with physical therapy for strength and mobility. On post-op day four he was discharged home with VNA services and the appropriate medications and follow-up appointments. Medications on Admission: Aspirin 325 mg p.o. daily Plavix 75 mg p.o. daily, Metoprolol 50 mg p.o. b.i.d. Lisinopril 10 mg p.o. daily simvastatin 80 mg p.o. daily Chantix Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Disp:*90 Tablet(s)* Refills:*2* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO BID (2 times a day) for 7 days. Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0* 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: this is [**2-13**] of your home dose. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft Past medical history: - Anteroseptal myocardial infarction in [**2162-12-13**] - Dyslipidemia - Hypertension - Bicuspid aortic valve - DVT right leg [**2153**] - Sciatica - Ischemic cardiomyopathy (LVEF 45%) - Obesity - Tobacco and ETOH abuse - Right lower extremity DVT - ?Soft palate lesion Past Surgical History: - s/p Testicular repair 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: trace upper and lower extremity 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: Please come to [**Hospital Ward Name 121**] 6 next Thursday, [**3-31**] at 10AM for wound check. You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**4-14**] at 1:15PM [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) **] on [**4-26**] at 2PM Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**5-17**] 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:[**2163-3-25**] ICD9 Codes: 4111, 412, 2720, 496
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Medical Text: Admission Date: [**2170-7-12**] Discharge Date: [**2170-7-14**] Date of Birth: [**2136-9-29**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5831**] Chief Complaint: Fever and back pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 1004**] originally presented to her PCP [**Last Name (NamePattern4) **] [**2170-7-11**] with a 4 day history of four days of fevers, chills, myalgias, headache, and generalized malaise. On exam, vitals were 102.8, 120 -> 102, 110/70, 18. She had R CVA tenderness, suprapubic tenderness, urine dip + for leukocytes (LG), blood (LG), and nitrites. She was started on a 10d course of ciprofloxacin (500mg PO BID) and ibuprofen (600mg PO PRN fevers and myalgias). Urine cultures from this visit have since grown out >100,000 E coli with sensitivity to ciprofloxacin. She presented to the [**Hospital1 18**] ED on [**2170-7-12**] with increased back pain and persistent fever, where her vitals were 103.2 144 100/55 20 100%/RA. She developed tachycardia and hypotension, resolved on 3L of IVF. She was started on ceftriaxone 2g IV and acetaminophen and transferred to the MICU with nl HR and BP. She was given an additional 3L of IVF, and remained RRR and normotensive for the length of her stay. She had 3 breakthrough fevers (101s-102s) on [**7-13**] controlled with acetaminophen 500-1000mg PO Q6H PRN fever/pain. Follow-up blood and urine cultures were sent but have shown no growth to date. Her hematocrit trended from 32.5->22.0->27.6, likely [**1-2**] hemodilution and menstruation, with autoregulation. Renal U/S showed no stones, masses, hydronephrosis or perinephric fluid collections. She was transferred to the medicine floor late [**7-13**], where her vitals have been stable and normal, and she reports feeling much improved, with reduced back pain, no fevers or myalgias, no dysuria or hematuria, no nausea or vomiting and no headache. While on the floor, she was noted to be having an oral herpes outbreak, which was treated with valacyclovir 2g PO BID x1 day. Past Medical History: - Ulnar fracture s/p open reduction and internal fixation ([**1-/2170**]) - Laparoscopic cholecystectomy s/p recurrent choleclithiasis ([**3-/2170**]) - Recurrent UTIs (once per year), last in [**2168**] - Recurrent oral herpes Social History: Ms. [**Known lastname 1004**] came to the US from [**Country 21363**] nine years ago. She lives with her husband and 2 sons (ags 5 and 1 years old). She works as a cashier in a restaurant and studies English. She does not smoke or drink ETOH. Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS - Temp 97.3 80 94/P 16 98/RA GENERAL - well-appearing woman in NAD, comfortable, appropriate LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, some mild suprapubic tenderness, R>L, otherwise soft/NT/ND, no masses or HSM, no rebound/guarding. Mild right CVA tenderness . EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radial and PT SKIN - Abundant perioral herpetic lesions; otherwise no skin lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation grossly intact throughout Pertinent Results: [**2170-7-11**] 04:00PM NEUTS-82.2* LYMPHS-12.4* MONOS-4.9 EOS-0.3 BASOS-0.2 [**2170-7-11**] 04:00PM WBC-9.9# RBC-3.97* HGB-11.3* HCT-32.7* MCV-82 MCH-28.6 MCHC-34.7 RDW-14.6 [**2170-7-12**] 05:35PM WBC-10.7 RBC-3.99* HGB-11.3* HCT-32.5* MCV-82 MCH-28.2 MCHC-34.6 RDW-14.6 [**2170-7-12**] 05:35PM calTIBC-230* FERRITIN-247* TRF-177* [**2170-7-12**] 05:35PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-2.0 IRON-10* [**2170-7-12**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2170-7-12**] 07:00PM URINE RBC-0-2 WBC-[**2-2**] BACTERIA-OCC YEAST-OCC EPI-0-2 Renal U/S from [**2170-7-13**]: IMPRESSION: No evidence of perinephric abscess. [**2170-7-11**] Urine Culture: ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- 1 S GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Bloood cultures [**Date range (1) 52084**]/[**2169**]: negative and pending as of day of discharge Brief Hospital Course: 33F history of recurrent UTIs who was admitted to [**Hospital1 18**] with 4 days hx of fever, urinary frequency, foul-smelling urine and right-sided back pain found to have sepsis secondary to pyelonephritis. Initialy sent to the unit and then transfered to the medical floor. # Pyelonephritis: Pt initially presented with symptoms consistant with pyelonephritis: fever, chills, right flank pain. Pt found to have sepsis with hypotension and was given 3L IVF. Urine cultures returned positive for E. Coli. Blood cultures were negative up to day of discharge. She was started on empiric Ceftriaxone 2g IV and was sent home on 2 weeks of Cipro after sensitivities returned. Renal ultrasound performed and was negative for abscess, stones or hydronephrosis. Pts symptoms improved during hospitalizaiton and on day of discharge she was asymptomatic with stable vitals, afebrile. Repeat UA and Urine culture were negative. #Microcytic anemia: Hct dropped from 32->22 then back up to 27. This acute drop was likely combination of dilution and menstruation. Iron studies: low iron of 10, low TBIC, and increase in ferritin with Fe/TIBC< 4% (<15%). Findings consistant with iron deficiency anemia in combination with increase in ferritin due to acute infection. HCT was trended. Pt should follow up with her Primary care doctor to start iron therapy given her very low iron levels. #Oral Herpes: Pt found to have herpes vessicles on her upper and lower lips. Was given 2 doses of valacyclovir for treatment of acute episode. Pt told to follow up with her primary care doctor to discuss prophylactic continuous therapy, depending on the number of herpes outbreaks she gets each year. **FOLLOW UP: 1)Low Iron: pt has very low iron, likely needs iron supplements and monitoring of HCT. 2)Oral Herpes: Depending on the number of episodes pt gets a year, she might be a candidate for daily prophylactic medicatins. 3)Pyelo: patient will complete 2 week course of Cipro for complicated pyelonephritis. Medications on Admission: 1. Ciprofloxacin 500 mg PO BID for 10 days 2. Ibuprofren 600 mg PO Q6H PRN fever, pain Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1)Pyelonephritis- complicated 2)Sepsis Secondary 1)Oral Herpes 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 during your hospitalization at the [**Hospital1 69**]. You were admitted for an infection of your urinary tract that involved your kindeys. The infection made you so sick that it lowered your blood presure and caused fevers. You were intially sent to the Intensive Care Unit until you stabalized. Bacteria was found in your urine. You were treated with fluids through your veins and antibiotics and your symptoms improved. On the day you left the hospital, you had no fevers and your blood pressure was normal. You must complete an entire 2 week course of antibiotics. It is very important to take every pill. You were also found to have a viral infection of your lips, called herpes. We gave you Valacyclovir, a medicine that will get rid of the lip infection. You were given 2 pills which will resolve this episode. However, to prevent future herpes outbreaks, it is important to follow up with your primary doctor, Dr. [**Last Name (STitle) **], who can give you medicine that you take every day to prevent outbreaks. You were found to have anemia, low red blood cells. It is likely from menstruation and low iron. It is important to follow up your anemia with Dr. [**Last Name (STitle) **]. The following changes were made to your medications: Ciprofloxacin: You must take 1 pill in the morning, 1 pill in the evening for 2 weeks. You will finish on [**7-27**]. Valacyclovir: you were given 1 day of pills. You do not need to continue this medicine. You came into the hospital on no other medications. Please follow up with Dr. [**Last Name (STitle) **] within 1 week. You must call his office to schedule the appointment. [**Telephone/Fax (1) 9556**]. Followup Instructions: You MUST call Dr.[**Name (NI) 11689**] office to schedule an appointment to see him within 1 week. This is very important. Call #[**Telephone/Fax (1) 86784**]. Department: ORTHOPEDICS When: MONDAY [**2170-7-30**] at 2:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 25538**], NP [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: WEDNESDAY [**2170-10-3**] at 4:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site ICD9 Codes: 5990
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Medical Text: Admission Date: [**2117-3-31**] Discharge Date: [**2117-4-2**] Date of Birth: [**2070-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: MICU call out, initial admit for Hematemesis Major Surgical or Invasive Procedure: EGD x2 History of Present Illness: 46 y.o. male with history of alcoholism and Hep. C, complicated by varices, ascites and encephalopathy who presented with hematemesis. . Patient reported continued alcohol use, but less compared to his routine. He notes two recent stressors - pain and a break-up with his girlfriend, which caused him to rely more heavily on alcohol and in doing so, he noticed "dark" emesis evening of admisison around 10 PM, which was persistent, prompting him to call EMS. He denies fevers, chest pain, SOB, but does report some lightheadedness. He denied any BRBPR, but did not increasing dark to black stools. . In the ED, patient was reported to have 700 ccs of coffee ground and bright red blood emesis. However, he remained hemodynamically stable with SBPs ranging from 123-130 and no tachycardia. A hepatology consult was placed and the patient was started on Ceftriaxone and received 3 L of NS before coming to the floor. . Of note, pt. was hospitalized at [**Hospital1 18**] from [**2-24**] - [**3-10**] for encephalopathy and had an EGD revealing 2 cords of grade I - II esophageal varices, which were banded. He was also found to have portal hypertensive gastropathy at this time. . Patient was initially admited to the MICU and underwent EGD which showed varices. Received 1 unit PRBC with originally with no improvement in hct. Had EGD the following day. Banding was not performed during either EGD. In total received 3 units PRBC, 2U FFP. Last transfusion [**3-31**] at 5PM. . At time of transfer pt has no complaints. Denies any recent vomiting. Continues to have some dark stools. Denies lightheadedness, dizziness, chest pain. Past Medical History: - Etoh cirrhosis, actively drinking, MELD 18 - HCV viral load is 436,000 international units. The patient has not had a liver biopsy nor has the patient had any treatment to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**] (last seen [**12-9**]). - EGD [**2115-12-23**] revealing varices at the lower third of the esophagus, with two bands placed, and portal gastropathy. - Grade 3 esophageal varices with multiple admissions for GIB, banding in past - Ethanol abuse with history of DTs. - h/o Nephrolithiasis. - MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn rotator cuff, and humeral head fracture. - h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia - foot surgery - facial reconstruction as a child - leg cramps - asthma Social History: The patient is single. Moved to cape and is living with friends. Currently moving. He is actively drinking. Has long hx of etoh abuse (since high school, with 1 6 month period of sobriety) and withdrawl. He smokes 1 pack every 3 days, x 30+ years. He is not working. He used to work as a carpenter. He denies IVDA x last 15 years, has used intranasal drugs within the past year or so, +cocaine/heroin use in past; hx of incarceration in the past. Family History: He does not know much about his family history. He does not know of any liver disease or colon cancer. Physical Exam: Tmax 99 Tc 98.6 BP 131/93 (130-140/80-92) HR 80 RR 14 O2 96%RA I/O (24 hr)3216/1455 . Gen: Young male lying in bad in nad HEENT: PERRL, EOMI, OP clear, poor dentition Neck: Supple, no LAD Lungs: CTAB, no carckles. Heart: S1, S2 nl, no m/r/g appreciated Abd: Soft, nontender, nd Ext: No lower ext edema. Neuro: CN II - XII intact, moves all extremities equally Pertinent Results: EGD [**3-31**] Varices at the lower third of the esophagus Medium hiatal hernia Blood in the stomach body Erythema, congestion, nodularity and friability in the stomach body and fundus compatible with portal hypertensive gastropathy Blood in the first part of the duodenum and second part of the duodenum There were no gastric varices. Otherwise normal EGD to second part of the duodenum . EGD [**4-1**] Impression: Esophageal varices Erythema, congestion, nodularity and friability in the stomach body and fundus compatible with portal hypertensive gastropathy Blood in the stomach Otherwise normal EGD to second part of the duodenum Recommendations: Continue once daily PPI. Brief Hospital Course: Pt is a 46 yo M with history of ETOH/HCV cirrhosis with known varices and portal gastropathy admitted with hematemesis. Now being called out of the ICU. . # Hematemesis: Baseline hct 26-30 and patient presented with hct of 22 which then dropped to 19. EGD was performed x2 which showed esophageal varices as likely source of bleed, but no active bleeding from site. He had variceal banding performed recently on [**3-8**]. EGD this admission also showed gastritis. He received a total of 3U prbcs and 2U FFP and hct at time of discharge was 30 and he was without evidence of any further active bleeding. Nadolol and diuretics were originally held in the setting of unstable blood volume, but were restarted upon his discharge. . # Cirrhosis: Secondary to ETOH and HCV. Multiple complications including variceal bleeding, ascites, encephalopathy, coagulopathy, thrombocytopenia. As above, nadolol, lasix, and spironolactone were originally held, but were restarted for discharge. He was taking pentoxyfilline on admission, but this was discontinued per liver team. . # Alcohol abuse: He continues to actively drink with last drink 1 night PTA. He has history of withdrawal, no seizures. He was placed on CIWA scale with prn valium and was continued on MVI, thiamine and folate. Although addressed with social work and case management, he currently refuses rehab as he states that he has been "detoxed" here. . # Hepatic encephalopathy: He was not encephalopathic during this admission. He was continued on lactulose titrated for goal [**4-8**] bowel movements daily. . # Ascites: Fluid from previous paracenteses showed SAAG c/w portal HTN. No paracentesis performed during this admission. He was restarted on spironolactone and lasix prior to his discharge. . # Coagulopathy/thrombocytopenia: Secondary to cirrhosis. In the setting of his GI bleed, he received vitamin K and 2U FFP. . # Asthma: During this admission, he had no active pulmonary issues. He was continued on prn albuteral and ipratropium. Medications on Admission: Meds at home: Has not been taking his meds for 5 days. Meds from last d/c summary: 1. Thiamine HCl 100 mg Qday 2. Hexavitamin Qday 3. Gabapentin 300 mg TID 4. Nadolol 40 mg qday 5. Pentoxifylline 400 mg TID 6. Folic Acid 1 mg Qday 7. Furosemide 80 mg [**Hospital1 **] 8. Spironolactone 150 mg [**Hospital1 **] 9. Lactulose 10 g/15 mL QID 10. Clonidine 0.1 mg [**Hospital1 **] 11. Albuterol 90 mcg prn 12. Sucralfate 1 g QID 13. Atrovent prn 14. Omeprazole 20 mg [**Hospital1 **] 15. Nicotine 21 mg/24 hr Patch 16. Hydromorphone 2 mg Q8hrs:prn . MEds at transfer: Ciprofloxacin 400 mg IV Q12H Duration: 5 Days Multivitamins 1 CAP PO DAILY Diazepam 10 mg IV Q2H:PRN CIWA>10 Nicotine Patch 21 mg TD DAILY Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Pantoprazole 40 mg IV Q12H Gabapentin 300 mg PO Q8H HYDROmorphone (Dilaudid) 0.5-2 mg IV Q6H:PRN Lactulose 30 ml PO QID Goal [**4-8**] BM's per day Thiamine HCl 100 mg PO DAILY Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*qs * Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*0* 4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 7. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*0* 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Titrate to [**4-8**] BMs daily. Disp:*qs * Refills:*0* 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 10. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-5**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*0* 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. Disp:*qs 1 month supply* Refills:*2* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:*4 Tablet(s)* Refills:*0* 15. Atrovent Inhalation 16. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain. Disp:*15 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Esophageal varices Cirrhosis Alcohol abuse/dependence . Asthma Recent Left humeral surgical neck fracture Discharge Condition: Stable with stable hematocrit and hemodynamics. Discharge Instructions: Please call your doctor or return to the emergency room if you develop blood in your vomit or stool, fevers/chills, nausea/vomiting, inability to tolerate food/fluid, heavy alcohol consumption, or alcohol withdrawal. . Please avoid alcohol consumption. . Please follow up with your appointments as scheduled below. Please take your medications as prescribed and be sure to complete an addional 2 days of your antibiotics. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 497**] on [**4-30**] at 2:40pm. . Appointments scheduled prior to this admission: 1. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2117-4-16**] 9:40am 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2117-4-29**] 8:20am 3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2117-4-30**] 1:30pm ICD9 Codes: 2761, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5189 }
Medical Text: Admission Date: [**2126-12-4**] Discharge Date: [**2127-1-12**] Date of Birth: [**2080-3-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: R basilic vein thrombosis Major Surgical or Invasive Procedure: R heart catheterization L internal jugular central venous line L radial arterial line History of Present Illness: Ms. [**Known lastname 28331**] is a 46 year old woman with history of AML s/p allogeneic stem cell transplant from an unrelated donor in [**2124-10-24**], with TBI and Cytoxan for conditioning regimen. Her course was complicated by graft versus host disease of the skin and lungs, hypertension and numerous steroid-related complications such as diabetes, steroid myopathy, and increased peripheral edema. . She presents today from clinic with right arm swelling (she had a PICC in the arm) and was found to have a completely occluded right basilic vein. She has some pain in the right arm, especially with movement. The PICC line was pulled and she was admitted for anticoagulation. . Of note, she was recently discharged after she was admitted with Enterococcal bacteremia (vanco sensitive); she finished her course of ampicillin yesterday. She has otherwise been doing well at rehab-- she has been slowly diuresed and is making some progress with PT. Past Medical History: PMH/PSH: 1) Acute Myelogenous Leukemia type M2 s/p matched unrelated donor stem cell transplant [**10-29**]; complicated by GVHD of the liver, skin and lungs. 2) Bronchiolitis Obliterans - PFTs [**2126-6-6**] showed FEV1 0.47 L/17% of predicted, FEV1/FVC 41% - developed due to GVHD [**6-29**] - at End Stage Lung Disease - severely limited functional status 40 (on prior admission) 3) Right lung abscess, s/p resection 4) Pulmonary nodules with geotrichum 5) Diabetes Mellitus, [**1-25**] steroid treatment 6) Hypertension Social History: Patient lives with mother, but has been at rehab since her [**Hospital1 18**] discharge one week ago. Currently unemployed. Previously worked as stock clerk. Quit smoking 2 years ago. Occasional EtOH use. Family History: No history of oncologic diseases. Physical Exam: Vitals on arrival to the floor: 97.7, 60, 120/92, 100% 3L NC Gen: Obese cushingoid female pleasant, sitting up in bed. Wearin oxygen HEENT: + mucous on eyelashes and injected conjunctivae b/l- old per patient [**1-25**] GVHD. No scleral icterus. Neck: No cervical LAD. JVP could not be appreciated. CV: nml S1, S2, no m/r/g Lungs: occ wheeze, but overall CTA b/l Extremities: 4+ pitting edema of the legs, L + R, to the thigh. No areas of cellulitis on legs or arms. Some weeping of clear fluid from anterior left leg and right arm (at sites where she has scabs and scratches). Extremities somewhat cool to touch, but 2+ DPP b/l and radial pulse. Neuro: CN II- XII grossly intact. Gait deferred. Upper extremities: No increases tone. 2+ DTRs. 4/5 strength throughout. Lower extremities: 2/5 strength present in proximal muscles with [**3-29**] in distal muscles s/l. No reflexes elicited. Pertinent Results: ADMISSION LABS: [**2126-12-4**] 11:20AM BLOOD WBC-6.4 RBC-2.67* Hgb-9.9* Hct-30.7* MCV-115* MCH-37.3* MCHC-32.4 RDW-15.8* Plt Ct-131* [**2126-12-4**] 11:20AM BLOOD Neuts-86.2* Lymphs-7.6* Monos-5.3 Eos-0.7 Baso-0.1 [**2126-12-4**] 11:20AM BLOOD Plt Ct-131* [**2126-12-4**] 11:20AM BLOOD UreaN-37* Creat-1.3* Na-142 K-3.6 Cl-96 HCO3-40* AnGap-10 [**2126-12-4**] 11:20AM BLOOD ALT-15 AST-16 LD(LDH)-255* AlkPhos-669* TotBili-0.3 DirBili-0.2 IndBili-0.1 [**2126-12-4**] 11:20AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8 UricAcd-10.1* Cholest-156 DISCHARGE LABS: RADIOLOGY: [**2126-12-4**] RUE US: Basilic vein thrombosis [**2126-12-4**] Bilateral LE US: No evidence of DVT [**2126-12-11**] Renal US: Unremarkable renal ultrasound without evidence of vascular abnormality. Brief Hospital Course: 1. Anasarca: The patient appeared to be total body overloaded by intravascularly dry at admission. She [**Month/Day/Year 1834**] right heart catheterization on [**2126-12-6**] that showed pulmonary hypertension (systolic BP 45, diastolic BP 20, mean BP 28). She was therefore started on sildenafil. The nephrology service was consulted, and she diuresed well on a regimen on albumin, lasix, and chlorthiazide (then metolazone). Her diuresis was discontinued on [**1-8**] because of development of hypotension occuring in the setting of a urinary tract infection. Subsequently, she was transferred to the [**Hospital Unit Name 153**] for hypotension (see below) where sildenafil was d/c'd as the patient was unlikely benefiting from it in the setting of relatively mild to moderate pulmonary HTN and overall systemic hypotension. 2. UTI: She developed a urinary tract infection with Pseudomonas on [**12-15**] and was treated with a two week course of levofloxacin then ciprofloxacin. A repeat urine culture was obtained for followup on [**1-2**] although she was afebrile and had no urinary complaints. This culture again grew out Pseudomonas, this time quinolone resistant. Her foley catheter was changed, as she refused to have it removed. She subsequently developed a fever to 101.3 on [**1-7**] and was started on cefepime, with addition of vancomycin and flagyl on [**1-8**]. Upon transfer to the [**Hospital Unit Name 153**] for hypotension and tachycardia (see below), she was continued on vancomycin, cefepime, and flagyl. A central venous line and arterial line were placed under sterile conditions. After 24 hours in the ICU, the patient was on 3 pressors with the differential diagnosis including septic vs. cardiogenic shock. Meropenem was added as for double gram-negative and Psuedomonas coverage. In spite of maximal medical therapy, the patient remained maxed out on 3 pressors. A repeat family meeting was held with the pt's HCP and mother, who agreed to make the patient CMO. She expired shortly thereafter. An autospy was offered, but declined. 3. Hypotension and tachycardia: She developed hypotension to the 70's sytolic on [**1-8**] which responded initially to fluid boluses. Her hypotension was thought to reflect both aggressive diuresis and possible urosepsis. She developed tachycardia to the 120's on [**1-9**] with a new RBBB. She was transferred to the [**Hospital Unit Name 153**] where she was given adenosine 6 mg X 2 with conversion to sinus tachycaria after the second dose of adenosine. However, she went back into a wide complex tachycardia with a RBBB pattern soon thereafter. The cardiology team evaluated her and felt that this rhythm was most likely an SVT with rate related aberancy; however the following day, after reviewing the EKG strips with the EP attending, the patient was determined to have a fasicular ventricular tachycardia in the setting of no known prior CAD or ischemic scar. The treatment of choice in this setting would have been verapimil; however this was not feasible as the patient was already on 3 pressors (neo, levophed, and vasopressin). The following day, a dose of verapimil was tried given concern for possibly worsening cardiogenic shock (however the patient's extremities remained warm to palpation, which suggested likely septic shock) with conversion back to sinus tachycardia. She was not cardioverted secondary to the patient's wishes to remain DNR/DNI. Given the patient's lack of improvement in spite of maximal medical care, the patient was made CMO after another family meeting and expired shortly thereafter. 3. C. diff colitis: She experienced loose stools after admission and a stool sample was positive for C. diff toxin on [**12-8**]; she was subsequently treated with a 14 day course of flagyl. This was restarted on [**1-8**] as noted above in the context of recurrent fever and increased stooling. 4. Right basilic vein thrombosis: The patient's PICC line was removed and she was started on IV heparin and then coumadin. Her anticoagulation was discontinued in the setting of heme positive stools and widely varying INR (thought likely to be due to interactions with her many medications). A repeat ultrasound of the upper extremity showed no evidence of persistent thrombus therefore she was not continued on further anticoagulation. 5. AML with history of GVHD: She was continued on cyclosporine, Cellcept, and her prednisone was titrated down per BMT recommendations. 6. Elevated LFTs: Her transaminases, alkaline phosphatase, and bilirubin were moderately elevated and thought to be secondary to GVHD of the liver after review of her medication list and right upper quadrant ultrasound revealed no other clear causes of these findings. Her alkaline phosphatase elevation was probably due at least in part to her bony disease as the bone specific fraction was elevated as well. 7. Acute renal failure: The patient's creatinine was 1.3 at admission peaking at 1.9. She was thought to be intravascularly dry with prerenal failure. Her creatinine improved with addition of albumin to her diuretic regimen consistent with this. 8. Pulmonary hypertension: Ms. [**Known lastname 28331**] [**Last Name (Titles) 1834**] right heart catheterization on [**12-7**] to assess whether pulmonary hypertension might be contributing to her significant edema. This study showed mean pulmonary pressures of 28 and she was subsequently started on sildenafil, which was subsequently d/c'd upon transfer to the [**Hospital Unit Name 153**] (see above). 9. Heme positive stools: As noted above, she had heme positive stools in the setting of anticoagulation with IV heparin and warfarin and recent C. difficile colitis infectoin. In addition, she had a prior history of gastritis on endoscopy and was receiving steroids for her GVHD. She was started on a PPI and her Hct was followed closely. 10. Hyperparathyroidism and vitamin D deficiency: The patient's PTH was rechecked as the differential for her bone changes noted on plain films included osteitis fibrosa. She was evaluated by the endocrinology consult service who felt that her hyperparathyroidism was likely secondary, perhaps due to renal failure or steroid use. Her vitamin D levels were rechecked and found to be low. She was started on weekly vitamin D and daily calcium. She will need repeat vitamin D studies and should follow up with endocrinology for further management. She was started on a bisphosphonate per endocrine recs. 11. Pulmonary osteoarthropathy: She complained of diffuse body pains and aches. Imaging of her extremities was notable for diffuse periosteal reaction. The endocrinology service reviewed the films and felt the history and imaging were most consistent with pulmonary osteoarthropathy. Her pain was treated with oral dilaudid as needed for pain control. 12. Eye pains: Ms. [**Known lastname 28331**] complained of eye soreness. This was thought to be secondary to GVHD. She was started on cyclosporin eye drops and artificial tears. She was evaluated by the opthalmology consult service who recommended addition of Refresh eye drops which she continued with relief of her symptoms. Medications on Admission: Atenolol 100 mg qd Cell cept [**Pager number **] mg qam Cellcept [**Pager number **] mg qpm Hydralazine 25 mg q 6 hrs Neoral 50 mg qam Neoral 25 mg qhs Prednisone 15 mg [**Hospital1 **] Valtrex 500 mg [**Hospital1 **] VFEND 200 mg [**Hospital1 **] Benzonatate Azithromycin 250 mg qod Bactrim DS MWF Lantus 12 U qd HSSI Zolpidem 10 mg qd Oxycodone 5 mg prn Odansetron 4 mg q 8 hrs prn Albuterol prn Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Cardiorespiratory Arrest Septic vs. cardiogenic shock Psuedomonas UTI Fasciular Ventricular Tachycardia AML c/b GVHD R basilic DVT Acute renal failure Anasarca Pulmonary Hypertension Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2127-1-13**] ICD9 Codes: 5849, 0389, 5990, 4271, 4019
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Medical Text: Admission Date: [**2110-6-14**] Discharge Date: [**2110-7-1**] Date of Birth: [**2026-12-2**] Sex: F Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 5790**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [**2108-6-13**] EGD [**2110-6-27**] Esophagogastroduodenoscopy, laparoscopic giant paraesophageal hernia repair and gastrostomy tube History of Present Illness: 83 yo who presented with atypical chest pain and backache,particularly when swallowing. Admitted with a question of esophagealperforation. On endoscopy she had a partial tear just above the GE junction but more notably she had a nearly complete intrathoracic stomach with a giant paraesophageal hernia. We treated her conservatively for several days and a subsequent barium swallow revealed no evidence of leak. Past Medical History: COPD HTN HLP GERD PMR (Steroids) Social History: Cigarettes:[X ] ex-smoker quit: 20 yrs ago ETOH: [X ] Yes drinks/day: [**11-29**] Lives:[X ] Alone Family History: Non-contributory Pertinent Results: [**2110-6-20**] 05:31AM BLOOD WBC-7.8 RBC-2.91* Hgb-8.4* Hct-26.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-13.3 Plt Ct-352 [**2110-6-18**] 03:49AM BLOOD WBC-6.9 RBC-2.97* Hgb-8.8* Hct-26.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-13.5 Plt Ct-317 [**2110-6-15**] 04:51AM BLOOD WBC-9.7 RBC-3.09* Hgb-9.4* Hct-28.3* MCV-92 MCH-30.2 MCHC-33.0 RDW-13.1 Plt Ct-289 [**2110-6-22**] 12:58PM BLOOD Glucose-132* UreaN-44* Creat-1.0 Na-140 K-3.7 Cl-103 HCO3-27 AnGap-14 [**2110-6-19**] 02:14PM BLOOD Glucose-232* UreaN-36* Creat-0.9 Na-141 K-3.8 Cl-103 HCO3-29 AnGap-13 [**2110-6-18**] 02:54PM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-143 K-4.4 Cl-104 HCO3-29 AnGap-14 [**2110-6-15**] 08:42PM BLOOD Glucose-122* UreaN-33* Creat-1.2* Na-136 K-3.5 Cl-103 HCO3-26 AnGap-11 [**2110-6-14**] 10:55PM BLOOD Glucose-150* UreaN-44* Creat-1.4* Na-133 K-3.2* Cl-99 HCO3-25 AnGap-12 [**2110-6-17**] 05:15AM BLOOD ALT-11 AST-16 AlkPhos-43 TotBili-0.3 [**2110-6-22**] 12:58PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9 [**2110-6-16**] 04:30AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8 [**2110-6-17**] 05:15AM BLOOD calTIBC-195* TRF-150* [**2110-6-17**] 05:15AM BLOOD Triglyc-221* HDL-47 CHOL/HD-3.1 LDLcalc-56 [**2110-6-18**] 10:59AM BLOOD Type-ART pO2-66* pCO2-37 pH-7.46* calTCO2-27 Base XS-2 [**2110-6-17**] 08:59AM BLOOD Type-ART pO2-72* pCO2-43 pH-7.47* calTCO2-32* Base XS-6 [**2110-6-14**] 09:49PM BLOOD pO2-81* pCO2-42 pH-7.43 calTCO2-29 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2110-6-17**] 06:05AM BLOOD freeCa-1.13 [**2110-6-28**] 04:51AM BLOOD WBC-11.4*# RBC-2.95* Hgb-8.9* Hct-27.1* MCV-92 MCH-30.1 MCHC-32.7 RDW-13.8 Plt Ct-332 [**2110-6-29**] 03:52AM BLOOD WBC-7.7 RBC-2.76* Hgb-8.3* Hct-25.7* MCV-93 MCH-30.0 MCHC-32.2 RDW-14.0 Plt Ct-297 [**2110-6-30**] 04:51AM BLOOD WBC-7.1 RBC-3.24* Hgb-9.4* Hct-29.7* MCV-91 MCH-29.0 MCHC-31.7 RDW-14.2 Plt Ct-290 [**2110-6-27**] 07:52AM BLOOD Glucose-119* UreaN-30* Creat-0.7 Na-139 K-3.6 Cl-113* HCO3-17* AnGap-13 [**2110-6-29**] 03:52AM BLOOD Glucose-131* UreaN-25* Creat-0.7 Na-140 K-3.8 Cl-107 HCO3-25 AnGap-12 [**2110-6-30**] 04:51AM BLOOD Glucose-122* UreaN-24* Creat-0.7 Na-138 K-4.2 Cl-104 HCO3-28 AnGap-10 [**2110-6-30**] 04:51AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.5* [**2110-7-1**] 04:18AM BLOOD WBC-7.1 RBC-3.01* Hgb-9.0* Hct-27.6* MCV-92 MCH-30.0 MCHC-32.8 RDW-14.5 Plt Ct-297 [**2110-7-1**] 04:18AM BLOOD Glucose-136* UreaN-22* Creat-0.7 Na-136 K-4.2 Cl-103 HCO3-26 AnGap-11 [**2110-7-1**] 04:18AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 Brief Hospital Course: 83 yof pt transferred from Caritas [**Hospital6 **] where she was admitted on [**2110-6-12**] with an atypical chest pain and backache, particularly when swallowing. CXR showed large Hiatal hernia. While waiting for UGI in the Radiology dept she developed respiratory distress and was admitted to the ICU rxed with nebs and IV hydrocortisone.Later, She had a CT scan without contrast since her Cr. was 2.1 which revealed R parenchymal infilterates and markedly distended esophagus. No free air was evident. GI was consulted for EGD,as a safe measure pt was intubated pre EGD. During intubation pt developed hypotension and ST elevation and loss of p waves with junctional rhythm, which was very transient and troponins were 0.02, this was improved as soon as the pt was started on pressors/ neosnephrine. Soon after, EGD was done that showed a perforation just prox to GE junction , clipping attempted , failed to close the perforation. She was started on Levaquin Clinda and Zosyn. Pt was transferred to [**Hospital1 **] for evaluation and definitive management of esophageal perforation. [**2110-6-14**] EGD performed on arrival to [**Hospital1 **] : At 30 cm we could see the GE junction. Right there, there were several metallic clips which had been placed by the outside gastroenterologist presumably. At the site of these clips we could see perforation which measured approximately 1 cm across. This was oriented posteriorly in the esophagus. I went ahead and entered the stomach and noted that it was extremely tortuous consistent with the possible gastric volvulus suggested by the noncontrast CT scan. I was not able to traverse the entirety of the stomach down to the pylorus due to this tortuosity. There is no other site of bleeding or perforation in the stomach. We went back and visualized the replacement of the NG tube to make sure that it went back into the stomach. The perforation itself looked subacute but it was unclear exactly how old it was. Patient was admitted to ICU intubated and treated with antibiotics (Vanco, cipro, flagyl, fluc). Extubated [**2110-6-16**] TPN started for nutrition patient NPO. CXR RLL -? aspiration pneumonia. [**2110-6-19**] transfered to [**Hospital Ward Name 121**] 9 with NPO w/TPN/PICC line and continued on antibiotics. On [**2110-6-27**] Patient taken for surgery for: Esophagogastroduodenoscopy, laparoscopic giant paraesophageal hernia repair and gastrostomy tube. Patient did well transfered back to [**Hospital Ward Name 121**] 9 Continued on TPN and Antibiotics advancing diet to full liquids. Continued TPN adjusting as pos increased. Daily Calorie Count and Crush all meds. Transfered to rehab with TPN-wean on Full liquid diet only for deconditioning and tx. Medications on Admission: Metoprolol 12.5 '' HCTZ 25 ' Levalbuterol inh '''' Lipitor 20 ' Prednisone 10' Bupropion 150' Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for Pain. 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 13. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig: One (1) Recon Soln Injection DAILY (Daily). 14. insulin sliding scale achs Insulin SC Sliding Scale AC and HS Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 4 Units 4 Units 4 Units 4 Units 201-250 mg/dL 8 Units 8 Units 8 Units 8 Units 251-300 mg/dL 12 Units 12 Units 12 Units 12 Units 301-350 mg/dL 16 Units 16 Units 16 Units 16 Units 351-400 mg/dL 20 Units 20 Units 20 Units 20 Units Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: giant paraesophageal hernia Discharge Condition: good Discharge Instructions: Please call Dr. [**Last Name (STitle) **] with any questins or concerns [**Telephone/Fax (1) 2348**]. Call with Fevers greater than 101.5 Call with increased Shortness of Breath Call with increased Cough Call with difficult swallowing,vomiting problems eating. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2110-7-15**] at 10:30 am on the [**Hospital Ward Name 517**] [**Location (un) 453**] in the chest disease clinic. You need to report to x/ray (radiology) on the [**Location (un) **] for your chest x/ray. Completed by:[**2110-7-1**] ICD9 Codes: 5990, 496, 4019
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Medical Text: Admission Date: [**2134-5-6**] Discharge Date: [**2134-5-8**] Date of Birth: [**2062-2-16**] Sex: M Service: MEDICINE Allergies: Aspirin / Ibuprofen Attending:[**First Name3 (LF) 458**] Chief Complaint: ASA desensitization Major Surgical or Invasive Procedure: Cardiac catherization with placement of drug-eluting stent to Right Coronary Artery Aspirin desensitization History of Present Illness: 72 y/o M with hypertension and asthma referred for aspirin desensitization prior to cardiac catheterization [**5-7**]. He describes taking aspirin many years ago in the hospital and having throat swelling and shortness of breath. He gets similar symptoms with ibuprofen. He does not get hives or itching. He has had recent intermittent episodes of substernal/midepigastric discomfort described as gas pain, lasting ~3 hrs., associated with belching, and relieved by TUMS. No associated dizziness, lightheadedness, diaphoresis, palpitations, shortness of breath, or vomiting. No component of exertion or position. No orthopnea, PND, or edema. Symptoms evaluated with ETT-MIBI [**5-5**] during which he exercised for 4:37 reaching 7 METS and 91% of max predicted HR. At peak exercise he had chest discomfort with 2-[**Street Address(2) 82585**] depressions inferiolaterally and ventricular ectopic activity with couplets - chest pain resolved with NTG. Initial images showed inferior defect. Also had asymptomatic 4-beat run of VT in immediate post-recovery period. TTE [**5-6**] showed normal LV size and systolic function (LVEF 65%), 2+ MR, 1+ TR, and trace AR. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative except as noted above. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Prostate Cancer s/p prostatectomy [**2125**] Nasal polyps Asthma s/p removal nasal polyps s/p tonsillectomy CRI - Cr 1.5 on [**2134-5-5**] Social History: One glass of wine daily. Quit smoking in [**2085**]. o tobacco or IVDU. Lives with wife in [**Name2 (NI) **]. retired truck driver Family History: No h/o premature CAD or SCD. Mother died of breast CA at 52. Father died of lung CA at 72. Physical Exam: V/S: T 98.4 HR 95 BP 111/69 Gen: Well-appearing gentleman in NAD HEENT: NC/AT. Sclera anicteric. Conjunctiva pink, no xanthalesma. Neck: Supple with JVP of 6 cm @ HOB 45 deg. No carotid bruit. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI holosystolic 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. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2134-5-6**] 02:19PM BLOOD WBC-8.6 RBC-4.72 Hgb-14.5 Hct-41.9 MCV-89 MCH-30.6 MCHC-34.5 RDW-12.9 Plt Ct-307 [**2134-5-6**] 02:19PM BLOOD Neuts-65.4 Lymphs-24.8 Monos-7.1 Eos-2.2 Baso-0.6 [**2134-5-6**] 02:19PM BLOOD PT-13.6* PTT-24.6 INR(PT)-1.2* [**2134-5-6**] 02:19PM BLOOD Glucose-122* UreaN-27* Creat-1.3* Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [**2134-5-6**] 02:19PM BLOOD Calcium-9.5 Phos-2.8 Mg-1.9 [**2134-5-7**] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91 . . Chest X-ray: Normal heart, lungs, hila, mediastinum and pleural surfaces aside from a descending thoracic aorta, which is at least tortuous and may be mildly dilated. Conventional radiographs recommended for initial assessment Cardiac cath:(Prelim report) Initial angiography showed 80% mid RAC and 50% distal RCA at crux. We planned to treat the mid RCA lesion with PTCA and stenting. Bivaliruding provided adequate support. The patient also received ASA and Plavix prior to the procedure. A 6 French JR4 guide provided adequate suport. Choice Floppy wire crossed the lesion without dufficulty and was positioned in the distal RPDA. A 3.0x12 mm Quantum Maverick RX predilated the lesion at 18 ATM. We then deployed a 3.0x15 mm Endeavor stent RX at 16 ATM. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dissection or distal emboli. We then successfully deployed a 6 French Angioseal closure device into the RCFA. The patient left the carth lab free from angina and in stable condition. COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated two-vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had sequential 50% stenoses in the mid- and distal-vessel. The LCX had mild insignificant plaque. The RCA had an 80% mid-vessel stenosis and a 50% stenosis at the PDA/PLV bifurcation. 2. Resting hemodynamics demonstrated high-normal biventricular filling pressures and mild pulmonary arterial hypertension as above. 3. Successful PTCA and stening of the mid RAC with 3.0x15 mm Endeavor DES. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dssection or distal emboli. 4. Successful deployment of a 6 French Angioseal closure device to the RCFA. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA and stenting of the mid RCA with Endeavor DES. 3. Successful deployment of 6 French Angoseal device to the RCFA. . Discharge labs: [**2134-5-8**] 02:56AM BLOOD WBC-10.0 RBC-4.01* Hgb-12.4* Hct-36.4* MCV-91 MCH-31.1 MCHC-34.2 RDW-13.0 Plt Ct-288 [**2134-5-8**] 02:56AM BLOOD Glucose-87 UreaN-20 Creat-1.3* Na-140 K-4.4 Cl-106 HCO3-27 AnGap-11 [**2134-5-8**] 02:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 [**2134-5-7**] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91 Brief Hospital Course: A/P: 72 M w/ HTN, CRI, asthma, and nasal polyps referred prior to cardiac catheterization for ASA desensitization following a positive ETT. He has Samter's syndrome given h/o asthma, nasal polyp's and aspirin allergy. He underwent aspirin desensitization per protocol and tolerated this well. It was emphasized he will need to consistently and reliably take an aspirin daily and that if he misses a dose, he could potentially have an adverse reaction such as anaphylaxis to aspirin or NSAID's. . Regarding his CAD, inferolateral EKG changes with exercise and preliminary MIBI images, isolated inferior Q on ECG suggest LCx vs. RCA disease. He was hydrated for cardiac catherization and pre=treated with mucomyst for renal protection given his history of chronic renal insufficiency. He then underwent cardiac cath which showed 50% stenoses in the mid and distal LAD, LCX with mild insignificant plaque and RCA with an 80% mid-vessel stenosis and a 50% stenosis at the PDA/PLV bifurcation. He underwent placement of a drug eluting stent in his RCA. No complications form the catheterization procedure. He was started on full dose aspirin and plavix and was continued on these medications at time of discharge. Medications on Admission: toprol XL 50mg qhs monopril 40mg daily diazide 37.5/25 (triamterene/HCTZ) fosamax 70mg daily advair 250/50 1 puff daily albuterol INH prn nasonex 1 sprah in am prednisone 2.5mg qod oscal +d 600 [**Hospital1 **] tylenol 1gram qAM/qPM aleve 440mg aAM/aPM Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 3. Monopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Aspirin allergy Hypertension Chronic Renal Insufficency Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for aspirin desensitization procedure prior to cardiac catheterization. This procedure was successful. Cardiac catheterization showed a partial blockage in one of your coronary arteries that supplies blood to your heart and a stent was placed to help open this blood vessel. The following changes were made to your medications: 1) STARTED plavix 75mg daily - this should be continued for at least 1 year 2) STARTED aspirin 325mg daily. Because of your allergy, you need to make sure to take this EVERY DAY. If you miss more than a few days of aspirin your allergy might return. Followup Instructions: Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 8797**] [**Last Name (NamePattern1) 23246**] in 1 month. An appointment has been made for you on [**5-28**] at 1:15pm. Please call [**Telephone/Fax (1) 82345**] with questions. Please follow up with your PCP as needed. Completed by:[**2134-5-10**] ICD9 Codes: 5859
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Medical Text: Admission Date: [**2168-9-2**] Discharge Date: [**2168-9-10**] Date of Birth: [**2113-9-19**] Sex: M Service: Cardiothoracic Surgery ADMITTING DIAGNOSIS: Coronary artery disease, requiring revascularization. HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man, transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization after a positive exercise tolerance test. The patient reports overall good health and was active in sports until about six months prior to admission, when his activity was curtailed secondary to a knee injury and he began to exercise again two weeks prior to admission. Initially, he felt short of breath and attributed this to deconditioning, but has noted progressive dyspnea over the past several weeks, with chest pressure and heaviness with activity. An exercise tolerance test was requested by his primary care physician, [**Name10 (NameIs) 6643**] came back positive for reversible wall motion defect, with a left ventricular ejection fraction of 54%. PAST MEDICAL HISTORY: Gastroesophageal reflux disease. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o.q.d., Lopressor 25 mg p.o.b.i.d., and heparin 5,000 units s.c. SOCIAL HISTORY: The patient does not use tobacco or alcohol. REVIEW OF SYSTEMS: Noncontributory except as per history of present illness. PHYSICAL EXAMINATION: Neck: Supple without jugular venous distention or bruits. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1 and S2, no murmur, rub or gallop. Abdomen: Soft, nontender, nondistended. Extremities: Without edema. Neurologic: Intact, nonfocal. HOSPITAL COURSE: The patient was admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2168-9-2**] and underwent cardiac catheterization, which demonstrated severe three vessel disease in the left main with an ulcerated 80% stenosing plaque, 50% stenosis of the circumflex discreetly and 80% stenosis of the right coronary system. The patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery bypass grafting. The patient was subsequently taken to the Operating Room on [**2168-9-5**], where coronary artery bypass grafting times four was performed as follows: Left internal mammary artery to left anterior descending artery, right internal mammary artery to right coronary artery, saphenous vein graft to obtuse marginal one and saphenous vein graft to diagonal. Postoperatively, the patient did well. He was on Neo-Synephrine, as he was transferred to the Cardiac Surgery Recovery Unit, which was slowly weaned overnight. The patient was transferred to the floor on postoperative day number two and had an unremarkable postoperative course. He was placed on Lopressor, aspirin and Lasix as well as potassium supplementation. By postoperative day number five, the patient was afebrile with a heart rate in the 70s and blood pressure in the 120s/70s. His lungs were clear to auscultation. His sternotomy looked well healed without any erythema, edema, induration or drainage. His abdomen was soft. His extremities were warm and well perfused without any edema. There was no drainage from the saphenectomy sites. Given this, the patient was deemed stable for discharge. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting. Gastroesophageal reflux disease. Hypertension. DISCHARGE MEDICATIONS: Lopressor 25 mg p.o.b.i.d. Colace 100 mg p.o.b.i.d. Zantac 150 mg p.o.b.i.d. Aspirin 81 mg p.o.q.d. Celebrex 100 mg p.o.b.i.d. Percocet one to two tablets p.o.q.3-4h.p.r.n. pain. Compazine 10 mg p.o.q.4-6h.p.r.n. nausea/vomiting 30 minutes prior to the administration of Percocet. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2168-9-10**] 12:27 T: [**2168-9-10**] 09:53 JOB#: [**Job Number 36616**] ICD9 Codes: 4111, 4019
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Medical Text: Admission Date: [**2107-2-25**] Discharge Date: [**2107-3-9**] Date of Birth: [**2059-5-15**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 47 y/o man with PMH HTN and alcohol/substance abuse, who initially presented to OSH on [**2107-2-24**] ([**Hospital 47**] [**Hospital 1281**] Hospital) unresponsive and who was transferred to [**Hospital1 18**] after diagnosed with locked in syndrome. According to the record, as his girlfriend is unaware of the events surrounding his admission, he went to a party and woke up the following morning at 10 AM, at which point he said he wanted to go back to sleep, but his friend noted some slurred speech and drooling. When he woke up again around noon, his friend noted he was unresponsive; just staring at her. EMS called and found him with gurgling respirations amd BP 210/110. He arrived in ED nonverbal and with snoring respirations; so he was intubated. Initially believed to be substance or seizure related activity; but then CTA obtained and official read noted large infarct involving brainstem, primarily pons; he was diagnosed with locked in syndrome and transfered to [**Hospital1 18**] for further management. Past Medical History: -HTN -substance abuse (alcohol, cocaine) Social History: Currently resided in half-way house. He has 2 daughters- ages 19 and 17. Not employed. His longtime girlfriend says that as far as she is aware, he has not used any substances since [**Month (only) **]. He is a current 1 ppd smoker and has smoked for 30 years. Family History: Unknown/unable to obtain Physical Exam: general: laying in bed, NAD chest: anterior lung fields cta b/l CVS: RRR, S1S2, no murmurs abd: soft, nondistended, +BS ext: warm, no edema Neuro: awake, alert, eyes open to vocie, can respond to questions appropriately (he blinks his eyes to yes and no questions). He was able to correctly identify the president. On cranial nerve exam, his pupils are 4-->3 b/l. Corneal reflex intact. EOMI (he is able to track when asked). He blinks to command. Face symmetric. Motor exam: flaccid tone of all 4 extremities. Unable to move extremities spontaneously or in response to noxious stimuli. Unable to elicit any reflexes and toes are mute. Pertinent Results: [**2107-2-25**] 10:17PM GLUCOSE-103* UREA N-14 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15 [**2107-2-25**] 10:17PM CK(CPK)-347* [**2107-2-25**] 10:17PM CK-MB-1 cTropnT-LESS THAN [**2107-2-25**] 10:17PM CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-2.3 [**2107-2-25**] 10:17PM WBC-13.3* RBC-4.95 HGB-13.6* HCT-40.8 MCV-82 MCH-27.5 MCHC-33.4 RDW-12.9 [**2107-2-25**] 10:17PM PLT COUNT-158 [**2107-2-25**] 10:17PM PT-12.7 INR(PT)-1.1 [**2107-2-25**] 10:17PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2107-2-25**] 10:17PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG [**2107-2-25**] 10:17PM URINE RBC-[**7-8**]* WBC-[**7-8**]* BACTERIA-FEW YEAST-NONE EPI-1 REASON FOR EXAMINATION: Evaluation of tracheostomy position. Portable AP chest radiograph was reviewed in comparison to [**2107-3-5**]. The tracheostomy tube is at the midline with its tip being approximately 4.5 cm above the carina. There is also placement of the percutaneous gastrostomy with pneumoperitoneum demonstrated most likely due to surgery, should be further followed. Lungs are clear and cardiomediastinal silhouette is stable. Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No LV thrombus seen. Normal global biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. CTA IMPRESSION: Findings compatible with basilar artery thrombosis with acute infarctions in the midbrain and left cerebellum and possibly in the pons. The right distal V2 and V3 segment of the hypoplastic vertebral artery is irregular and thread-like with prominent venous plexus surrounding it. Recommend MRA with fat saturated T1-weighted images to exclude the possibility of dissection in this segment. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [**Known lastname **] was transferred from [**Hospital1 **] after it was discovered on CT brain that he had a acute infarctions in the midbrain and left cerebellum and possibly in the pons with occlusion at the basilar artery. He was well beyond the time in which intervention could be performed when he arrived at [**Hospital1 18**]. He was first brought into the outside hospital on [**2107-2-24**] after his girlfriend discovered him that morning unable to move around 11 AM. She let him sleep another 3 hours when she realized that he still had not moved and he needed to go to the hospital. During his course at [**Hospital1 **] he was intubated and pontinbe stroke was then discovered. He arrived at [**Hospital1 18**] on [**2107-2-25**] at 10 pm (35 hours after first being found not moving). CTA brain and neck showed occlusion of the mid basilar artery. It showed that the right vertebral artery was hypoplastic. The right vertebral artery was irregular and threadlike in the right V3 segment. This raised concern for a dissection. MRA neck with T1 fat sats was not performed because it would not have changed management. He was started on aspirin 325mg daily. He had a TTE performed that showed no intracardiac source. He refused a TEE for further evaluation. On HD 4 he was noted to have some movement of his right hand. This was not observed for several days, but was again witnessed at the end of his hospital course. After discussions with ethics, social work, and his girlfriend - a family meeting was held in which Mr. [**Known lastname **] elected (by use of his eyes) to have a trach and PEG placed. Mr. [**Known lastname **] had a BAL that grew S. Aureus on [**2107-2-26**]. He was started on antibiotics Vancomycine and Zosyn that were scaled down to Nafcillin when sensitivities returned. Antibiotic course Nafcillin until [**3-13**] For MSSA Cipro, Cefepime, Flagyl - until [**3-21**] The Cipro and Cefepime are double coverage for VAP the Flagyl is for Aspiration Active Issues By System At Discharge Gastrointestinal / Abdomen: - TF's via PEG Nutrition: - PEG in place - Replete w/ fiber 80 mL/hr (goal) Renal: - Adequate urine output Hematology: - no acute issues Endocrine: - RISS, adequate BG control. Infectious disease: - Purulent sputum, leukocytosis; Nafcillin restarted [**3-5**] for PNA (stop [**3-13**]), cefepime, cipro, flagyl added [**3-7**] (stop [**3-21**]), mini-BAL growing pseudomonas & Hflu, abx x 14d Events by day [**3-5**] CXR: No consolidation. Mild left basal atelectasis [**3-7**] CXR: PEG in place w/pneumoperitoneum, lungs are clear and cardiomediastinal silhouette is stable. EVENTS: [**2-25**]: Admitted to Neuro-ICU with pontine stroke. [**2-26**]: CTA head/neck showing 12mm complete occlusion of the basilar artery. CXR showing worsening opacification of both bases ?aspiration PNA. Bronch'd/BAL showing 2+ GNRs, 2+GPC pairs and febrile to 101.3, vanc/zosyn started. TF started during the day. [**2-27**]: Cont vanc/zosyn, tf cont'd. Decr'd oxygen sats, CXR unchanged, incr PEEP. [**3-1**]: Legal team c/s re consent for trach/peg. Echo -> no LV thrombus seen. d/c abx [**3-2**]: TF held and pt extubated. RPR pending. Able to move mouth, nod, squeezed R hand, w/d BLE to pain [**3-3**]: Patient reintubated and dobhoff placed / enteral feeds were restarted. Prop gtt + fent gtt for sedation. [**3-4**]: Purulent sputum, elevated wbc. mini BAL, CXR, vanc/zosyn started. Meeting held and pt agrees to trach & PEG [**3-5**]: Plan for t/p on [**3-6**]. Contiued thick secretions. D/C'd vanc. Added nafcillin for MSSA in sputum [**3-6**]: s/p trach/PEG. Mini BAL: pseudomonas & GNR#2 [**3-7**]: TFs started. Cefepime, cipro, flagyl added for pseud pna. [**3-8**]: H2B d/c'd. plan d/c ltac [**3-9**]. [**3-9**]: speech and swallow c/s. will remove a-line before transfer to rehab. Medications on Admission: none Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 days. 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 13 days. 10. CefePIME 2 g IV Q12H Duration: 13 Days 11. Nafcillin 2 g IV Q6H Duration: 10 Days 12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you. You were transferred from [**Hospital1 **] after it was discovered on CT imaging that he had a acute infarctions in the midbrain and left cerebellum and possibly in the pons with occlusion at the basilar artery. While at [**Hospital1 **] you had a breathing tube placed. You elected (by use of your eyes) to have a trach and PEG placed (To aide in your breathing and eating). You also had a few infections while in the hospital which are treated with antibiotics. You are to leave with the following. Nafcillin until [**3-13**] For MSSA Cipro, Cefepime, Flagyl - until [**3-21**] The Cipro and Cefepime are double coverage for VAP the Flagyl is for Aspiration (anerobe coverage). Followup Instructions: establish and Outside PCP. Neurology Follow-up Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2107-4-20**] 1:30 Completed by:[**2107-3-9**] ICD9 Codes: 5070, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5194 }
Medical Text: Admission Date: [**2183-9-3**] Discharge Date: [**2183-9-19**] Date of Birth: [**2125-7-5**] Sex: F Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 4057**] Chief Complaint: odynophagia Major Surgical or Invasive Procedure: flex and rigid bronchoscopy x 2 radiation therapy to esophagus lumbar puncture EEG History of Present Illness: . 58F with a history of metastatic RCC complicated by extensive mediastinal mets requiring placement of bronchial stent who was recently admitted for near syncope where she had a work up including head CT, which was without changes, a CTA of the chest which was negative for PE and showed stable masses and an Echo which showed mild hypokinesis and an 40-45%. She noted yesterday she had a low grade temp 100.4 that she states went up to 102 so she contact[**Name (NI) **] her oncologists Dr [**Name (NI) **] and Dr [**First Name (STitle) **] who told her to come to the hospital if it continued above 100.4. She has also been experiencing a significant amount of throat pain from her esphagitis and was encouraged to use lidocaine/ benedryl for this. She has been unable to swallow and her PO intake is down. She has also noted flu like symptoms over the past few days such as myalgias cough with yello sputum, body aches. She just recieved radiation therapy yesterday. She was started on palliative chest XRT ([**2183-8-19**]) and chemotherapy with sunitinib. In the ED she was tachycardiac on presentation to 123 and improved with fluids. She had a T Max of 101.4 for which she was given rectal tylenol. She had nausea and was give 8mg Zofran. Blood and urine cultures were drawn, she was flu swabbed and she was started on Levofloxasin. Her WCC was 1.4 and ANC 1275. lactate 1.1 Past Medical History: PAST ONCOLOGIC HISTORY: The patient was in USOH until winter of [**2181**] when she developed cold symptoms which did not clear with antibiotics. She developed hemoptysis, which was evaluated in [**2182-2-9**] with x-rays of the chest. Lung mediastinal mass was detected on CXR, which was followed by a CT scan, which confirmed a mass in the mediastinum. Scanning also indicated a mass in the left kidney. This was further evaluated with imaging studies of the abdomen, which showed a large left renal mass measuring 15 x 11 cm. Lytic lesion was also detected in the right acetabulum. She was further evaluated with MRI which showed a left renal mass with no evidence of involvement of the left renal vein. MRI scan showed a mass in the vertex of the skull measuring 5 cm in greatest dimension. She underwent a bronchoscopy to evaluate the hemoptysis symptoms and biopsy the lung mass. However, pathology from this study was inconclusive. She underwent a biopsy of the left kidney mass, which showed renal cell carcinoma [**Last Name (un) 19076**] nuclear grade 1. These slides have been reviewed and showed renal cell carcinoma, clear cell type, and nuclear grade 1. With these findings, she underwent radiation therapy to the right hip and leg receiving 10 treatments at the [**Hospital6 5016**]. Following these treatments, she was evaluated by the Biologics group and the Urology group for definitive treatment of renal cell carcinoma. Recommendation was for dendritic cell vaccine therapy. For this therapy, she will require a tumor sample. She is now s/p left debulking nephrectomy [**2183-4-11**]. ====================== PAST MEDICAL HISTORY: - Renal CA metastatic to skull, R hip, lungs, medistiastinum as above - Airway compression, s/p y-stent - sciatica ==================== Social History: Married. Occ Etoh, 30-40pkyr Hx of smoking, no illicits Family History: Non-contributing oncologic history Physical Exam: Vitals: stable HR 100 BP 121/65 O2 98% 2L T 98.1 GENERAL: Laying on the bed with discomfort in her neck [**Name (NI) 4459**] Pt not allowing palpation of neck due to pain CVD tachy Lungs: scattered rhonchi all lung fields Abdomen soft non distended diffuse tenderness Ext WWP Back No CVA tenderness LN No axillary or femoral LN palpated Exam on discharge: 97.6 110/70 100 18 96% RA 590+2260/3750 GENERAL: Laying on the bed, NAD, communicative, A and O x 3 and appropriate [**Name (NI) 4459**]- PERRLa, EOMi, clear oropharynx CV- regular rhythm, tachycardic, no m, r, g Lungs: left lung has improved breath sounds s/p bronchoscopy, clear on right Abdomen soft, non distended, non-tender to palpation, no guarding/rebound, active BS Ext WWP No CVA tenderness LN No axillary or femoral LN palpated Pertinent Results: TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared with the prior study (images reviewed) of [**2183-8-28**], the LVEF has significantly decreased. There is now a small pericardial effusion. . CT abdomen/pelvis 1. Distended gallbladder, with no definite CT evidence of cholecystitis. If clinical concern, this can be further evaluated with HIDA scan. 2. Interval free fluid in the abdomen, mostly at the perihepatic and perisplenic distribution and tracking along the right paracolic gutter into the pelvis. Bilateral pleural effusions. 3. Questionable wall thickenning of the colon at the splenic flexture, could be due to collapsed colon; however this finding can be seen in colitis, if there is clinical concern. 4. Stable right acetabular lesion with pathologic fracture at the right inferior acetabulum, unchanged. Multiple lesions within the spine consistent with metastatic disease, with possible hemangioma at L1. 5. Status post left nephrectomy with no definite evidence of recurrence at the surgical bed. . EEG [**9-15**]: This is a normal video EEG study. Interictal background activity was normal. There were no epileptiform discharges or electrographic seizures. Compared to recording from 24 hours prior, this study contains fewer electrographic seizures . EEG [**9-13**] This is an abnormal portable EEG due to continuous generalized rhythmic spike and slow wave activity at a frequency of 2.5 Hz for the first half of this record consistent with non-convulsive status epilepticus. EEG markedly improved after administration of I.V. Ativan with resolution of non-convulsive status and only brief short bursts of generalized spike slow wave discharges in the latter half of the study. No focal lateralizing features were noted. An irregularly irregular rhythm was seen on cardiac monitor. Based on these findings, we would recommend long-term monitoring for this patient . MR head: Compared to the previous MRI from [**2183-2-18**], the soft tissue component associated with the vertex frontal bone calvarial lesion has markedly decreased in size likely reflecting interval treatment. The bony component appears relatively stable. This may represent treated neoplasm in bone. . Left frontal scalp lesion is unchanged compared to the most recent study. . There is no evidence for intracranial metastatic disease. . There is diffuse pachymeningeal enhancement, which may be related to prior radiation/LP or infectious/inflammatory sequela. Appearance is not suggestive of dural mets. There is a tiny 5- mm left frontal subdural focal thickening or collection which does not cause mass effect. . [**9-19**] CXR (post-bronch): Atelectasis in the left base has minimally improved. Cardiomediastinal contours are unchanged. Patient has known mediastinal and hilar lymphadenopathy and right rib metastatic lesion. There is no evident pneumothorax or enlarging pleural effusion. The left hemidiaphragm is elevated. Stent is seen in the left main bronchus . [**9-15**] CXR: Complete white out of the left hemithorax and shifting of the cardiomediastinum towards the left is unchanged due to collapse of the left lung. Assessment of the left pleural effusion is limited. The right lung is grossly clear. Destructive lesion in the lateral aspect of right mid rib is again noted. . Labs on discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 1.6* 2.90* 8.5* 24.6* 85 29.2 34.3 21.3* 200 . Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos 68 2 14* 14* 0 0 0 2* 0 . PT 11.5 PTT 26.4 INR 1.0 . Glucose UreaN Creat Na K Cl HCO3 AnGap 108* 17 0.6 136 4.4 101 25 14 . ALT AST AlkPhos TotBili 11 15 78 0.2 . Calcium Phos Mg 8.7 3.4 2.2 Brief Hospital Course: 58 year old female with metastatic renal cell carcinoma to skull, mediastinum, lungs, s/p Y stent placement presented with an episode of fever, nausea and worsening dysphagia/odynophagia. . # Fever/odynophagia/dysphagia- Initial differential diagnosis of this constellation of symptoms included esophagitis from radiation, thrush, or mucositis. Flu swab was negative. The patient was initially given levofloxacin in the ED, but this was discontinued. The patient also received supportive care, including magic mouthwash, sucralfate, PPI, H2 blocker, morphine, and reglan. Fluconazole was given for oral/esophageal candidiasis. . # Renal cell carcinoma- Patient recently completed course of radiation therapy to skull and espophagus. Sutent had been started and was initially continued upon admission with good response. Sutent was then discontinued in the setting of developing pancytopenia, which improved following cessation of the drug. . # Mental status- The patient had an episode of altered mental status on [**2183-9-7**] that was attribued to hyponatremia. She required a brief course in the ICU, received IVF and hypertonic saline with improvment in both her mental status and hyponatremia (thought to be due to mild hypovolemia and SIADH). The patient was hypotensive thought to be due to hypovolemia, which improved with IVF. An echocardiogram was obtained, and her LVEF was depressed at 20%. The patient did not have any other signs or symptoms of CHF, and was started on metoprolol and lisinopril. Her depressed EF was non-ischemic in etiology and was thought to be due to either radiation or sutent. . The patient then developed second episode of AMS on [**2183-9-12**]- patient was non-verbal/non-communicative, not somlonent. An LP was performed, which showed a normal opening pressure, with no evidence of infection. The patient received empiric ceftriaxone, vancomycin, and acyclovir which were all discontinued after cultures were negative. An EEG on [**2183-9-13**] showed that the patient was in non-convulsive status epilepticus. She was loaded with ativen and fosphenytoin with near-immediate improvement in her mental status. She again required a brief stay in the ICU to monitor her airway after receiving anti-epileptic therapy. Her airway was never compromised. She initially received phenytoin, but developed a leukopenia thought to be secondary to phenytoin. She is now being bridged to keppra and doing well. She will continue taking phenytoin 100 mg TID for six days. She will continue taking keppra 500 mg [**Hospital1 **] for three days, then keppra 750 mg [**Hospital1 **] for three days, then keppra 1000 mg [**Hospital1 **] ongoing. . # Bronchial stents- The patient underwent a flex bronchoscopy on [**2183-9-11**] which showed increasing tumor burden in the left main stem bronchus. Post-bronchoscopy, the patient was noted to have decreased breath sounds on the left, and a chest film showed a white out of her left lung. The patient never dveloped an oxygen requirement. A scheduled rigid bronchoscopy on [**2183-9-18**] was performed which showed an occluded left main stem with granulation tissue, dilation was performed and a stent was replaced in the left main stem with good effect and significant improvement in her chest film. The patient has scheduled follow up with her outpatient pulmonologist on [**2183-10-6**]. . # PROPHY: mobilization (patient will need continued physical therapy, ppi, bowel regimen) Nutrition: the patient was tolerating some PO intake at discharge, and was also receiving PPN. please cont transition to full regular diet ACCESS: PIV CODE: FULL Medications on Admission: Docusate Sodium 100 mg Capsule PO BID Folic Acid 1 mg Tablet PO DAILY Senna 8.6 mg Tablet Sig: One Tablet PO BID Morphine 30 mg Tablet Sustained Release i tab PO q12 Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H Tessalon Perle 100 mg Capsule Sig: One Capsule PO TID prn Levalbuterol HCl 0.63 mg/3 mL 1 neb q4 hours prn Ipratropium Bromide 0.02 % Solution One (1) neb q6h prn Lactulose(30) ML PO Q8H as needed for constipation. Reglan 10 mg One (1) Tablet PO every 6-8 hours prn nausea Ferrous Sulfate 325 mgOne (1) Tablet PO once a day. Ativan Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 6 days. 6. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. 7. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO every six (6) hours as needed for pain with swallowing. 9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane TID (3 times a day) as needed for pain. 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety/seizure. 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gm PO DAILY (Daily) as needed for constipation. 19. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) Neb Miscellaneous TID PRN () as needed for wheezing/cough. 20. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 21. Guaifenesin AC 10-100 mg/5 mL Syrup Sig: [**4-20**] ml PO four times a day as needed for cough. 22. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary Diagnosis: renal cell cancer with mediastinal/bronchial metastases Secondary Diagnoses: systolic CHF sciatica Chronic sinusitis benign breast cyst C-section seasonal allergies Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital with difficulty swallowing and fever. You finished radiation to your esophagus, and your discomfort was thought to be due to a possible infection in your esophagus or from the radiation itself. You then developed some confusion, which was thought to be due to a low sodium level. You improved somewhat after your sodium was increased and you received IVF. However, you developed increased confusion and an inability to speak, which was due to a seizure. This improved dramatically after you received treatment for your seizure. You will need to continue taking a medication to prevent future seizures. You also had an ultrasound of your heart which showed decreased function (EF of 20%), but luckily you did not have symptoms from this. You also had 2 bronchoscopies to help clean out your airways. You will need rehabilitation. . Medications: Most of your medications have changed. Please see the list provided to your rehabilitation center. - You will be transitioned from phenytoin to Keppra as indicated on your medication list and on the discharge summary. . Please call your doctor or return to the ER if you have increasing pain, confusion, fevers/chills, nausea/vomiting, diarrhea, chest pain or other concerns. Followup Instructions: You should call the neurology clinic ([**Telephone/Fax (1) 2528**] for an appoinment in the next 2-4 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**] 2:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**] 2:00 [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2183-10-6**] 10:00 ICD9 Codes: 486, 0389, 5180, 5119, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5195 }
Medical Text: Admission Date: [**2122-12-23**] Discharge Date: [**2123-1-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Nausea, vomiting and chills Major Surgical or Invasive Procedure: Central Line placement Midline IV placement History of Present Illness: 82 y/o M w/CAD, CHF, HTN, who was in his USOH until 2 days prior to admission when he awoke at 5AM with shaking chills. He then began to have nausea with vomiting and later on profuse diarrhea. Apparently the patient had been having decreased PO intake for a couple of days prior to this episode. Patient states that he had some minor abdominal pain, epigastric in location. He says that the chills he experienced lasted for one hour and then resolved. Patient denies any hematemesis or BRBPR. No sick contacts although patient has 9 grandchildren who visit. The night before he ate take out chicken, however other family members ate the same food and did not have similar symptoms. . ROS: Positive for chronic joint pain, walks with a cane. Denies any chest pain, occasionally has palpitations, has anxiety at times. His ET is limited by joint pain but can walk to end of room without SOB. He says that his legs are always slightly swollen, not worse at present, sleeps in hospital bed at home with raised hed, denies PND, gets up fequently to urinate at night. Denies headache. +fatigue, decreased energy. Past Medical History: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) 2. CHF, TTE [**3-6**] w/depressed EF 3. Hypertension, per daughter pt's bp usually 90s-100s on meds 4. Severe Lumbar Spinal stenosis, mild cervical stenosis 5. Sleep apnea, on 2L home O2 at night 6. Afib, s/p DCCV which failed, now rate controlled, not anticoagulated secondary to fall risk 7. Arthritis 8. Gout 9. COPD? No PFTs Social History: Lives with 2 daughter who look after him, wife deceased, has 9 grandchildren, moved to the US from [**Country 4754**] in [**2064**]. Worked at Sears [**Last Name (un) 40191**] as a firefighter for 41 years, now retired. Has 5 children who all live in the Northeast, lives in [**Location (un) 538**]. Widowed. No tobacco or alcohol x 50 years. Family History: HTN, CAD, CVA Physical Exam: VS: T: 97.6 P: 61 BP: 100/60 R: 18 O2 sat 97% on 2L FS 183 Gen: Elderly man, lying in bed, NAD HEENT: EOM full, anicteric, L facial droop (old) moist, OP clear Neck: supple, JVP flat Chest: Diffuse scattered wheezines, crackles at lower bases b/l CV: nl S1 S2, regular, no m/r/g Abd: obese, soft, nt/nd. +bs. no palpable hepatosplenomegaly. Ext: 2+ pedal edema to upper calf, warm and dry, 2+ dp pulses b/l Pertinent Results: On Admission: [**2122-12-23**] 12:40AM PLT COUNT-167 [**2122-12-23**] 12:40AM NEUTS-82* BANDS-14* LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-12-23**] 12:40AM WBC-19.0*# RBC-4.83 HGB-15.8 HCT-44.5 MCV-92 MCH-32.7* MCHC-35.5* RDW-13.8 [**2122-12-23**] 12:40AM DIGOXIN-0.5* [**2122-12-23**] 12:40AM CORTISOL-36.5* [**2122-12-23**] 12:40AM GLUCOSE-178* UREA N-29* CREAT-1.9* SODIUM-136 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23* [**2122-12-23**] 12:51AM LACTATE-3.7* [**2122-12-23**] 12:51AM COMMENTS-GREEN TOP [**2122-12-23**] 02:45AM PT-14.5* PTT-31.4 INR(PT)-1.4 [**2122-12-23**] 02:45AM PLT COUNT-159 [**2122-12-23**] 02:45AM NEUTS-83* BANDS-12* LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2122-12-23**] 02:45AM WBC-18.9* RBC-4.55* HGB-14.7 HCT-41.6 MCV-92 MCH-32.3* MCHC-35.3* RDW-13.8 [**2122-12-23**] 02:45AM CRP-189.1* [**2122-12-23**] 02:45AM CORTISOL-218.9* [**2122-12-23**] 02:45AM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-2.3*# MAGNESIUM-1.4* [**2122-12-23**] 02:45AM CK-MB-2 cTropnT-0.03* proBNP-2335* [**2122-12-23**] 02:45AM LIPASE-19 [**2122-12-23**] 02:45AM ALT(SGPT)-30 AST(SGOT)-25 CK(CPK)-265* ALK PHOS-73 TOT BILI-1.2 [**2122-12-23**] 02:45AM GLUCOSE-212* UREA N-30* CREAT-1.8* SODIUM-133 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20 [**2122-12-23**] 02:54AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2122-12-23**] 02:54AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2122-12-23**] 02:54AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2122-12-23**] 03:02AM LACTATE-2.7* [**2122-12-23**] 03:02AM COMMENTS-GREEN TOP [**2122-12-23**] 05:26AM LACTATE-2.2* [**2122-12-23**] 05:26AM COMMENTS-GREEN TOP [**2122-12-23**] 08:00AM CK-MB-3 cTropnT-0.02* [**2122-12-23**] 08:00AM CK(CPK)-246* [**2122-12-23**] 02:26PM CK-MB-4 [**2122-12-23**] 02:26PM CK(CPK)-300* [**2122-12-23**] 02:26PM GLUCOSE-278* UREA N-27* CREAT-1.6* SODIUM-136 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17 [**2122-12-23**] 02:37PM cTropnT-0.01 . Upon discharge/other relevant labs: [**2123-1-1**] 06:18AM BLOOD WBC-23.0* RBC-4.01* Hgb-13.1* Hct-36.9* MCV-92 MCH-32.5* MCHC-35.4* RDW-13.5 Plt Ct-254 [**2123-1-1**] 06:18AM BLOOD Plt Ct-254 [**2122-12-31**] 06:08AM BLOOD Glucose-79 UreaN-30* Creat-1.2 Na-137 K-4.0 Cl-98 HCO3-26 AnGap-17 [**2122-12-24**] 04:24AM BLOOD LD(LDH)-195 [**2122-12-23**] 02:26PM BLOOD CK(CPK)-300* [**2122-12-23**] 08:00AM BLOOD CK(CPK)-246* [**2122-12-23**] 02:45AM BLOOD ALT-30 AST-25 CK(CPK)-265* AlkPhos-73 TotBili-1.2 [**2122-12-23**] 02:45AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-2335* [**2122-12-23**] 02:37PM BLOOD cTropnT-0.01 [**2122-12-23**] 08:00AM BLOOD CK-MB-3 cTropnT-0.02* [**2122-12-30**] 06:25AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 UricAcd-9.5* [**2122-12-23**] 02:45AM BLOOD CRP-189.1* [**2122-12-23**] 12:40AM BLOOD Digoxin-0.5* [**2122-12-25**] 01:47AM BLOOD Type-ART Temp-38.6 pO2-71* pCO2-32* pH-7.46* calHCO3-23 Base XS-0 Intubat-NOT INTUBA [**2122-12-25**] 01:47AM BLOOD Lactate-1.9 . Microbiology: Imaging: [**12-23**] CXR: Portable supine AP radiograph of the chest is reviewed, and compared to previous study at 1:09 a.m. The right subclavian IV catheter terminates in the right atrium. No pneumothorax is identified. The lung volume is small with continued slight elevation of the right hemidiaphragm. The heart is normal in size. Again, note is made of tortuosity of the thoracic aorta. IMPRESSION: No pneumothorax. . [**12-23**] KUB: No evidence for small-bowel obstruction. Limited study, which cannot rule out the presence of free air. If of clinical concern, would repeat examination. . [**12-23**] CT Abdomen: 1. Distended gallbladder likely containing gallstones or sludge without evidence for cholecystitis. 2. No evidence for intra-abdominal or intrapelvic bowel abnormality including colitis or diverticulitis. 3. Diverticulosis without evidence for diverticulitis. 4. Low-density lesions within the liver and bilateral kidneys likely representing cysts. These foci could be definitively characterized with ultrasound if clinically indicated. . [**12-23**] EGK: Atrial fibrillation with a mean ventricular response, rate approximately 115. Inferior myocardial infarction. Non-diagnostic T wave flattening in the lateral leads. Compared to the previous tracing of [**2121-3-24**] cardiac now atrial fibrillation. [**12-25**] EKG: Atrial fibrillation Old inferior infarct Low QRS voltages in precordial leads Since last ECG, ventricular response slower . CXR [**12-25**]: The exam is unchanged. Lung volumes are small. Right subclavian IV catheter tip overlies the SVC. Pneumothoraces present. Patchy atelectasis unchanged, no infiltrates. Heart size and mediastinal contour within normal. . Renal Ultrasound [**12-29**]: The left kidney measures 13.7 cm. The right kidney measures 14.7 cm. There is no evidence of perinephric fluid or abscess. In the right kidney there are four cysts identified, as seen on prior CT exam from [**2122-12-23**]. The simple cysts range in size from approximately 4 cm to 7 cm in diameter. In the left kidney there are multiple subcentimeter simple cysts along with a large 3.5 x 3.7 x 4.2 cm simple cyst seen in the mid to lower pole. The bladder is full and unremarkable Brief Hospital Course: Mr. [**Known lastname **] is an 82 yo gentleman with CAD, CHF, ?COPD, A. Fib/flutter admitted with E.coli sepsis and rapid atrial fibrillation. The patient was initially managed in the MICU for 24 hrs with central line placement and IVF resuscitation. He was then transferred to the regular medical floor once stabilized. Initially the patient was doing very well on the floor, sitting in chair [**Location (un) 1131**], heart rate well controlled on digoxin only (sotalol held in setting of relative hypotension on admission). Blood cultures returned positive for gram negative rods resistant to quinolones and therefore his antibiotics were changed from Levofloxacin/Flagyl/Ampicillin antibiotics to Ceftriaxone mid afternoon. Patient also noted to be intermittently wheezing, started on Albuterol/Atrovent nebs and given 2x 40 IV lasix for fluid overload on exam. Overnight, patient spiked temp to 101.6 and went into rapid A. fib with rates in 140s, BP 100/67, given IV diltiazem 10 mg x 2 then 30 mg PO with persistent elevation in HR ranging 120-130s. The patient was transferred back to the MICU for management of his rapid A.fib and sepsis. . In the MICU, patient treated with Ceftriaxone initially. Blood cultures came back positive for E.coli. Patient remained his blood pressures, no evidence of septic shock. Eventually antibiotics were tailored further and he was transferred to the medical floor once again, this time on IV Cefazolin (Ancef). His central line d/ced prior to transfer. . Rapid A. Fib: Patient was taking Sotalol/Dig at home, not on any anticoagulation. He required IV diltiazem in ED for rapid rate. Upon transfer to the floor, patient was initially maintained on Digoxin w/out restarting sotalol for concerns of borderline low BP. His HR was well controlled in the 80s. Dig level 0.5 on admission. Patient later went into rapid afib the same evening in setting of fever spike requiring IV diltiazem. He was started on IV diltiazem->PO with improvement in HR control while in the MICU. Patient also restarted on sotalol which was eventually increased to 80 mg daily for optimal control. His current regimen for HR control includes Sotalol 80 mg [**Hospital1 **] and Diltiazem 300 mg daily sustained release, Digoxin is discontinued. Patient was also started on anticoagulation for A.fib with coumadin. He is currently on 3 mg of coumadin daily. His INR must be checked and reported to his PCP (as outlined in the discharge plan) in case adjustments must be made. Patient was monitored on telemetry throughout his stay in hospital. . E. Coli Sepsis: Blood cx growing E.coli sensitive to Cephalosporins, resistant to quinolones, likely source is GI given hx of N/V/D although unclear. [**Name2 (NI) **] clear source on abdominal CT such as cholecystitis, diverticulitis. Patient was initially treated with broad coverage with Ampicillin/Flagyl/Levofloxacin. He was changed to IV Ceftriaxone and then Cefazolin once the sensitivities were available. Patient is now afebrile x several days, WBC was generally trending down from admission 18->12 but later increased to >20 in setting of gouty flare and in setting of increases steroids. He is discharge with negative urine/blood cultures, afebrile, HR well controlled and generally feeling much better. He should continue narrow spectrum antibiotic coverage with Cefazolin IV to complete a 14 day course. Infectious disease felt that the patient should be treated with IV antibiotics for 14 days since PO antibiotics will likely not be adequate for this type of infection. Renal son[**Name (NI) **] was also performed to r/out any other potential source such as a perinephric abscess, this was negative. Of note, patient developed one episode of diarrhea on [**12-30**] which resolved spontaneously. His stool is negative for C.diff and he has not had any abdominal pain/discomfort to date. . ?COPD. Patient noted to be wheezing upon transfer to the floor. He does not have a documented diagnosis of COPD, no PFTs on record. It was unclear whether this was a COPD flare vs. cardiac wheezing given that the patient required aggressive fluid hydration in the MICU. The patient as treated with Albuterol/Atrovent nebulizers with improvement. He was also diuresed with IV lasix 40 mg [**Hospital1 **] and then put on lasix PO 80 QOD then daily. He is discharged on 80 mg of lasix daily. He diureses well with this dose. Of note, the patient was also started on prednisone for presumed COPD and due to ongoing wheezing. He is discharged on 20 mg of prednisone for COPD and concomitant gouty flare. Steroids should be tapered over the next 12 days. Patient also received a 5 day course of Azithromycin for presumed COPD exacerbation. . Acute Renal Insufficiency: Patient has a baseline creatinine of 1.3-1.5 on prior visits in [**2121**]. On admission his Cr was 1.9 which has trended down to 1.2 on discharge. Likely prerenal secondary to volume depletion from vomiting/diarrhea, was fluid resuscitated in MICU and later diuresed on the floor. Currently patient appears euvolemic with trace pedal edema. His medications were renally dosed throughout this admission. . CAD/CHF: Patient has a depressed EF on echo in [**2121**], %EF not reported. Upon initial transfer to floor the patient appeared fluid overloaded s/p fluid resuscitation in MICU. Patient had elevated JVP, 2+ pitting edema, wheezing with crackles. Cardiac enzymes were negative x 3 on admission. Question of subendocardial ischemia in setting of hypotension based on subtle EKG changes in ST-T segments. BNP elevated on admission as well. Patient required diuresis with IV lasix initially and is not maintained on PO lasix. He is currently euvolemic per exam and stabilized on his current regimen. He should be continued on ASA, Statin. He is currently not on an ACEI (defer to Dr. [**Last Name (STitle) **] his PCP and cardiologist), likely because he does not have a depressed EF. . Gout. Patient has a history of gout in the past. He developed a gouty attack in his right foot on [**12-29**] and then in his left elbow on [**12-31**]. He was treated with Ibuprofen 600 mg x 2 intially and then placed on Indomethacin 25 mg TID with some relief. His steroids were also increased to 20 mg daily. He was not treated with Colchicine which he has taken in the past due to one episode of diarrhea and the potential to cause stomach upset with this medication. This medication can be restarted in the future as per the PCP. [**Name10 (NameIs) **] should also be on prophylaxis with Allopurinol in the future once he is over this acute flare. . Diabetes: Patient is usually managed on oral medication as an outpatient. He requires coverage with regular insulin sliding scale while on steroids. The regular insulin sliding scale can be discontinued once he is off steroids. He is also discharged on Glipizide which he was taking prior to admission. This medication was discontinued while in hospital and he was maintained on a sliding scale regimen with good control. . FEN: Cardiac/diabetic diet; No standing IVF; electrolytes were monitored and replaced as needed. . Prophylaxis: SQ heparin, bowel regimen, PPI (only while on steroids, can be d/ced afterwards) . Code: Full. Confirmed with patient. Medications on Admission: Crestor 5 mg daily Niaspan 500 mg daily Colchicine 0.6 mg daily Sonata 5 mg daily Digitek 125 mcg daily Carbidopa 25/100 3x/day Aspirin 81 mg daily Glipizide 5 mg [**Hospital1 **] Lisinopril 5 mg daily Sotalol 80 mg qam, 40 mg qpm Potassium 20 meq daily [**Doctor First Name **] 180 mg daily Lasix 80 mg qod Doxepin 25 mg prn itching Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous Q12H (every 12 hours) for 10 days. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: Please give 20 mg daily x 4 days then 10 mg daily for 4 days then 5 mg for 4 days. 8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 12. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Sonata 5 mg Capsule Sig: One (1) Capsule PO at bedtime. 14. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection as directed on flow sheet for 12 days. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 17. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 22. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 1887**] Discharge Diagnosis: 1. E. coli sepsis 2. Rapid atrial fibrillation Discharge Condition: Good - breathing comfortably, afebrile, heart rate well controlled Discharge Instructions: Please take all medications as directed Please ensure that you follow up with your primary care doctor (see below) as indicated by his PCP. Please check INR on Saturday [**2123-1-2**] and Monday [**2123-1-4**] and then weekly INR - patient recently started on coumadin, please forward results to PCP listed below who will make adjustments to his medication if necessary: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] One [**Location (un) **] Place, [**Apartment Address(1) 19746**] ([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**] Pager: [**Pager number 40193**] [**University/College 40194**] . Please follow up with other appointments as listed below. . Please return to the hospital if you have any fevers, chills, nausea/vomiting, elevated heart rate or any other complaints Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Date/Time:[**2123-2-18**] 10:00 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] One [**Location (un) **] Place, [**Apartment Address(1) 19746**] ([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**] Pager: [**Pager number 40193**] [**University/College 40194**] Completed by:[**2123-1-1**] ICD9 Codes: 5849
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Medical Text: Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-26**] Service: Green Surgery HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female with a 24-hour history of abdominal pain that started the day prior to admission. The patient also complained of urgency to defecate and nausea. The patient had emesis x 2 the night prior to admission. She felt lightheaded and had increasing abdominal pain. She was taken to [**Hospital **] Hospital where she was hypotensive at the time. She was admitted to the unit. A femoral line was placed and volume resuscitation was initiated. She continued to have worsening abdominal pain this morning. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Atrial pacer. 3. Primary pulmonary hypertension. 4. Ischemic heart disease. 5. Atrial fibrillation. 6. Hypertension. 7. Gout. 8. Myocardial infarction. PAST SURGICAL HISTORY: Open cholecystectomy. MEDICATIONS AT HOME: 1. Amiodarone 200 b.i.d. 2. Lopressor 25 b.i.d. 3. Protonix 40 q.d. 4. Nitroglycerin patch 0.2 p.r.n. 5. Plavix 75 q.d. 6. Aspirin q.d. 7. Digoxin 0.125 q.o.d. ALLERGIES: Codeine causes hallucinations. PHYSICAL EXAMINATION: Vital signs were temperature 95.3, heart rate 79, blood pressure 94/41, respiratory rate 18, 96% on two liters nasal cannula. She was on a Neo-Synephrine drip. Her cardiovascular examination showed a paced rhythm with no murmurs, gallops, or rubs. Her lung examination was clear to auscultation bilaterally. On abdominal examination the patient was distended with decreased bowel sounds. She was tender in the lower left lateral abdomen with mild tenderness in the right lower and left upper quadrants. She exhibited voluntary guarding of the left lower quadrant. There was no rebound tenderness. On rectal examination there were no masses and she was guaiac positive. Her extremity examination showed no evidence of cyanosis, clubbing or edema. LABORATORY DATA: White blood cell count was 15 with 34% bands, creatinine 1.6, amylase in the 600s, lipase 15. CAT scan from yesterday showed a contained perforation and mild thickening of the descending colon with stranding of the mesentery. HOSPITAL COURSE: The patient was taken to the operating room on [**2120-6-18**] emergently with a preoperative diagnosis of ischemic left colon. While in the operating room the patient had a left hemicolectomy, a Hartmann pouch and end ileostomy. Details of the procedure can be found in the operative note. She had complete transmural necrosis of the proximal left decending colon with obvious perforation or peritonitis. The SMA pulse was strong. The presumed etiology was an embolis with ischemia vs. a low flow state (less likely given strong SMA pulse). While in the operating room the patient's blood pressure dropped initially. The patient was treated with increasing IV fluids, Neo-Synephrine drip and was transfused two units of packed red blood cells. In addition, the calcium and bicarbonate were repleted for lactic acidosis. The patient was transferred to the surgical intensive care unit postoperatively intubated and on a Neo-Synephrine drip. Vital signs were stable when transferred to the surgical intensive care unit. While the patient was in the surgical intensive care unit, the patient was heparinized for presumed embolic event. A transesophageal echocardiogram was performed to evaluate for cardiac source of embolus. No thrombus was seen, however the echocardiogram was positive for a right-to-left shunt at rest with the bubble study, consistent with a stretched patent foramen ovale. While in the surgical intensive care unit the patient continued to be intubated until mobilizing her fluids. On postoperative day number three in the surgical intensive care unit, it was attempted to extubate the patient, but the patient started to desaturate to the 80s and so the patient was placed back on the ventilator. She was given Lasix with good diuresis and staff was able to extubate the patient in the afternoon post diuresis. The patient was weaned to O2 by nasal cannula at four liters when her oxygen saturations were greater than 95% with no shortness of breath and her arterial blood gas was within normal limits. On postoperative day five the patient was tolerating clear liquids without any nausea or vomiting. Her intake was greater than 400 cc p.o. that day. Her colostomy stoma was pink with small round brown ischemic areas on the outer aspect. Her ostomy was producing stool and the ostomy nurse replaced the appliance. The patient continued to be monitored in the surgical intensive care unit. Her heparin drip was titrated accordingly. The patient continued to be hemodynamically stable and on postoperative day six the patient was transferred to the floor. While on the floor the patient continued to tolerate p.o. without difficulty. Her ostomy stoma was pink, viable and showed good output. Her abdominal examination continued to be soft and nontender. Anticoagulation was continued as the patient was started on Coumadin. Heparin was discontinued when the INR was greater than 2.0. The patient's diet was advanced. She would continue to tolerate a regular diet without difficulty. Physical therapy was consulted and recommended aggressive physical therapy and rehabilitation placement. The patient was discharged on postoperative day 11 with an INR of 2.0 and her last dose of Coumadin prior to discharge was 0.5 mg on that day. The patient's pain was well controlled and the patient had been out of bed with physical therapy help. Arrangements were made by the case manager for the patient to go to rehabilitation at [**Hospital6 25759**] and Rehabilitation Center in [**Location (un) **]. CONDITION ON DISCHARGE: Good, stable. DISCHARGE STATUS: To rehabilitation at [**Hospital6 25759**] and Rehabilitation Center in [**Location (un) **], [**State 350**]. DISCHARGE DIAGNOSES: 1. Ischemic left colon probable cause thromboembolism, status post exploratory laparotomy, left hemicolectomy, Hartmann pouch, and end ileostomy. 2. Coronary artery disease. 3. Atrial pacing. 4. Primary pulmonary hypertension. 5. Ischemic heart disease. 6. Atrial fibrillation. 7. Hypertension. 8. Gout. 9. Myocardial infarction. DISCHARGE MEDICATIONS: 1. Ostomy care. 2. Amiodarone 200 mg q.d. 3. Famotidine 20 mg b.i.d. 4. Metoprolol tartrate 50 mg b.i.d. 5. Digoxin 125 mcg q.d. 6. Coumadin 0.5 mg q.d. 7. Outpatient laboratory work for Coumadin dosing. DISPOSITION: The patient is to go to rehabilitation and then to follow up with Dr. [**Last Name (STitle) **] in one to two weeks for staple removal and follow up. Dr.[**Name (NI) 6218**] number is included in the discharge summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 28130**] MEDQUIST36 D: [**2120-6-27**] 10:01 T: [**2120-6-27**] 10:24 JOB#: [**Job Number 28131**] ICD9 Codes: 2762, 4019, 412, 2749
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Medical Text: Admission Date: [**2117-7-5**] Discharge Date: [**2117-7-15**] Date of Birth: [**2040-3-14**] Sex: M Service: MEDICINE Allergies: Angiotensin Receptor Antagonist / Ace Inhibitors Attending:[**First Name3 (LF) 783**] Chief Complaint: dyspnea, IVIG-mediated ATN Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 77 year-old r handed male with PMHx significant for CAD s/p MI x3 w/ stent, HTN, afib admitted for IVIG therapy related to recently diagnosed motor neuropathy. . - Following history adapted from neuromuscular fellow note of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - . Pt states that for a couple of years, he has had some difficulty reaching things on high shelves. He began to have to use both his hands to lift anything as heavy as a plate from a high shelf. He did not notice any other problems at that time. In [**Month (only) 1096**] [**2115**], he was diagnosed with atrial fibrillation. In [**Month (only) 404**] of this year, he began to notice some dyspnea on exertion while lifting his paraplegic wife. At the end of [**Month (only) 404**] he noticed he could no longer breathe while lying flat. He went to [**State 108**] in [**Month (only) 956**] and shortly afterward developed severe shortness of breath and lower extremity edema. He was hospitalized in [**State 108**] and given a diagnosis of a left lower lobe infiltrate and started on diuretics and antibiotics. . After discharge his symptoms did not improve. He returned to [**Location 86**] and was admitted to [**Hospital1 18**] with worsening orthopnea, pitting edema and shortness of breath. He was given a diagnosis of diastolic heart failure with an elevated BNP. There was no evidence of MI. He was cardioverted during admission and aggressively diuresed in the CCU. Amiodarone was added. He continued to be hypoxic and require supplemental oxygen. TTE showed EF 50%. . He was discharged to rehabilitation. Since then, he has continued to need supplemental oxygen. He has continued orthopnea and dyspnea on exertion and always sleeps in a chair. He walks with a walker now to carry his oxygen tank and provide a chair if he needs to rest. He can walk around his house without the walker, and admits he often dosen't use the nasal cannula at home. He has been unable to get a chest CT due to the inability to lay flat. . In addition to the breathing problems, a couple of months ago he also developed paresthesias and numbness in the fourth and fifth digits of his left hand. This included the palm and the dorsal surface of the fourth and fifth digits. He also notes weakness of the left hand, particulary his grip. His fourth and fifth fingers "feel big," and when touched feel as though something is between his fingers and the stimulus. He denies neck, wrist and elbow pain. . He denies weakness in the lower extremities. He also denies numbness and paresthesias in the lower extremities. He has not noticed any rippling muscles or twitching. He has had chronic lower extremity cramps at night for years, but this is unchanged. He denies trouble speaking or swallowing, and denies double vision or increased weakness at the end of the day. . A few weeks ago, he had PFTs, which showed an FVC 29% predicted, FEV1 32% predicted. The FEV1/FVC ratio was 111% predicted, which is elevated. The test was consistent with a restrictive lung process. He also had a moderately reduced DLCO. . There is no history of fevers, chills, chest pain, rashes abdominal pain, nausea, vomiting, incoordination, change in vision, change in speech and swallowing. Past Medical History: CAD, s/p stenting of RCA in [**2113**] TTE at OSH: EF=60% as above Atrial fibrillation, diagnosed [**11-14**] s/p cardioversion, on coumadin HTN Hypercholesterolemia Gout s/p Spinal fusion Benign tumor of Left breatst 6 yrs ago Left knee replacement Benign tumor of spine Appendectomy OSA carpal tunnel release bilaterally, [**2089**] rib removal for ? thoracic outlet syndrome bilaterally car accident [**2075**] with head trauma Social History: He has a ninth grade education. He was in the military, then he worked in a machine shop. In the shop, he says the air was constantly thick with smoke from the materials they were using. He lives with his wife. She was paralyzed from the waist down by a spinal cord infacrtion about 15 years ago. He is her primary caretaker. Family History: His father died at age 72 from heart disease. His mother died at age [**Age over 90 **] from heart disease. He has a living brother and a living sister. His other sister died from breast cancer at age 45. There is no history of neurological problems in the family. Physical Exam: GEN: Sitting in chair, NAD HEENT: NC/AT, MMM, o/p clear, neck supple, no carotid bruits, CV:RRR S1/S2 no m/r/g RESP:CTA b/l ABD: soft NT ND + BS EXT: no c/c/e . NEURO EXAM: oriented to person, place and time, patient repeating intact, naming intact, language fluent with normal comprehension. Able to spell WORLD backwards. [**Location (un) **] inact. [**2-11**] registration. [**12-14**] recall after 3 minutes, [**2-11**] with prompting. . CN: PERRL, EOMI, face symmetric, normal sensation, no hearing on left ear, sternocleidomastoid intact, palate symmetric, tongue midline. . MOTOR: He has full strength of neck flexion and extension. There is no pronator drift. Tone is normal. Right deltoid [**4-15**], Left deltoid 4+/5. Right biceps strength is [**4-15**]; left biceps strength is 4+/5. Right triceps [**4-15**], left triceps 4+/5. Wrist extension strength is 4+/5 bilaterally. Wrist flexion is full strength bilaterally. Right finger flexion [**4-15**]. Left 1st, 2nd, and rd digit finger flexion [**3-16**]. Left 4th and 5th digit flexion 4-/5. There is mild 4+/5 weakness of the iliopsoas muscles bilaterally. Dorsiflexion and plantar flexion are also full strength bilaterally. There was mild weakness of toe extension bilaterally. . SENSATION: Decreased sensation to cold temperature from hands to elbows bilaterally. Decreased vibration on toes bilaterally. . DTR: absent throughout. Toes dowgoing bilaterally. . COORDINATION: Finger nose finger without dysmetria, [**Doctor First Name **] normal . GAIT: normal stride and arm swing Pertinent Results: [**Doctor First Name 2841**] - electrophysiologic findigs most c/w multifocal motor neuropathy w/ conduction block, affecting bilateral median nerves and ulnar nerve. Brief Hospital Course: This is a 77 yo man with multifocal motor neuropathy, CAD, HTN, OSA, s/p PCI, hyperlipidemia, restrictive lung disease (diagnosed [**2117-6-25**] with FVC of 34% predicted)who initially presented with slowly progressive dyspnea and orthopnea over six months. The patient also reported weakness of his left hand over the last year. On exam the patient was found to have proximal muscle weakness in his upper and lower extremities. He was also noted to have a numbness from his elbows to his finger tips bilaterally with weakness of his left 4th and 5th digits. He also had largely absent reflexes. The patient's [**Month/Day/Year 2841**] study from [**2117-6-15**] suggested his defecits are from a multifocal motor neuropathy with conduction block. He also seems to have an ulnar neuropathy. The pt was admitted for an elective 5 day course of IVIG for this motor neuropathy. After administration of the IVIG, the pts creatinine increased from 0.9 on [**7-6**] to 1.4 on [**7-8**], to 5.4 on [**7-10**], and to a peak of 7.4 on [**7-11**]. The pt was transferred to the MICU on [**7-11**] for this worsening renal function thought to be secondary to IVIG-mediated ATN, oliguria, and increasing SOB with a mild increase in O2 requirement. In the MICU, the pt was followed by renal. His Bumex was D/C'd, Aspirin and Indomethecin were also D/C'd. Renal US and CXR were obtained. Renal US showed no obstruction. CXR show no pulmonary congestion. Prior to transfer to the floor, the pt was given Lasix 120 mg IV x1 and chlorothiazide 500 mg IV x1. The pt diuresed 2L in response to these doses, and then he further autodiuresed 3-4 L each day subsequently. It was felt the pt had entered into the diuresis phase of ATN prior to discharge. The pt frequently required potassium repletion (K often 3.1-3.4) likely secondary to tubulopathy and inability for K reabsorption during the recovery phase of ATN. Indomethacin was held as was his allopurinol, but prior to discharge his allopurinol was restarted at a lower dose of 100 mg qod. The pts coumadin for his PAF was initially held given the possible need for hemodialysis, but this was restarted at 2.5 mg qhs and titrated up to 5 mg qhs with an INR prior to discharge of 1.6. The pt developed a hyponatremia of 128 on [**7-12**] which improved to 137 prior to discharge after he had been placed on fluid restriction and diuresed. Prior to and after discharge, po intake was encouraged as the pt was in the regeneration phase of his tubules and at risk of dehydration secondary to loss of tubular concentrating capacity. . The pts shortness of breath improved over his stay. The etiology was likely multifactorial including ARF in the setting of diastolic dysfunction and baseline CHF as well as restrictive lung disease. The pt continued on his home BIPAP machine at night. As the pt is on amiodarone IPF is also possible, but the pt is unable to lie flat for a CT. . Prior to discharge the pt began to c/o intense L hand swelling, throbbing, and numbnbess. This was more than at his usual ulnar neuropathy baseline. Venous US on [**7-15**] ruled out venous thrombus. The pt was started on a 6 day outpatient prednisone taper as he has a history of gout and his recent ARF/diuresis was a likely trigger (and his allopurinol had initially been held). Medications on Admission: lopressor 12.5 mg [**Hospital1 **] bumex 2 mg [**Hospital1 **] aspirin 81 mg daily KCL 10 meq daily indomethacin 50 mg [**Hospital1 **] allopurinol 300 mg daily warfarin 2.5 mg daily amiodarone 200 mg daily mevacor 40 mg qhs butalbital prn stool softener combivent BIPAP at night supplemental oxygen Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Chewable(s)* Refills:*2* 6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). [**Hospital1 **]:*15 Tablet(s)* Refills:*2* 8. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day for 5 days: take till potassium checked clinic on [**2117-7-19**]-then take more potassium if indicated by your primary care physician. [**Name Initial (NameIs) **]:*10 packets* Refills:*0* 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: start with this dose. [**Name Initial (NameIs) **]:*6 Tablet(s)* Refills:*0* 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: take after done with 60mg dose . [**Name Initial (NameIs) **]:*4 Tablet(s)* Refills:*0* 11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: start after done with 40mg dose. [**Name Initial (NameIs) **]:*2 Tablet(s)* Refills:*0* 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO use as directed for 6 days: Take 3 tablets for 2 days, take 2 tablets for 2 days, and take 1 tablet for 2 days. [**Name Initial (NameIs) **]:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ulnar neuropathy multifocal motor neuropathy w/ conduction block Acute Renal Failure Obstructive Sleep Apnea Atrial Fibrillation Discharge Condition: stable Discharge Instructions: Please call your neurologist or return to the ED if you experience increased shortness of breath, weakness, numbness, decreased urine output. Please do not take Cholchicine till further notice. Please continue to maintain adequate fluid intake. Please keep all follow up appointments. Followup Instructions: Provider: [**Last Name (NamePattern4) 35872**]/[**Last Name (NamePattern4) 35873**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2117-7-16**] 11:00 . Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2117-7-20**] 8:30 . Provider: [**Name10 (NameIs) 2841**] LABORATORY Where: CLINICAL CTR-[**Location (un) 35874**]-NEUROLOGY DEPT Date/Time:[**2117-7-20**] 10:00 Dr. [**Last Name (STitle) **]/[**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **]-PCP-[**Telephone/Fax (1) 3183**]-[**2117-07-19**] at 1:20PM-Please have your K, Cr and Chem panel checked. Your Cr. at time of discharge had decreased from 7.4 to 3.2 [**Hospital **] CLINIC-[**Hospital 35875**] CLINIC WILL CALL YOU by [**2117-7-16**] with a follow up appointment. If you do not hear from the clinic by [**2117-7-16**]-please call them immeditaly to schedule a follow up appointment. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] ICD9 Codes: 5845, 4280, 2761, 412, 2720, 4019, 2749
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Medical Text: Admission Date: [**2175-6-22**] Discharge Date: [**2175-6-27**] Date of Birth: [**2175-6-22**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 57689**] is a 39 week gestational age infant admitted with respiratory distress. MATERNAL HISTORY: Mom is a 23 year old gravida 2, para 1, now 2, woman with the following antenatal screens. Blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune and group beta strep status negative. PREGNANCY HISTORY: Estimated date of delivery [**6-28**], for an estimated gestational age of 39 and 1/7 weeks. Antepartum course benign. Spontaneous onset of labor leading to spontaneous vaginal delivery under epidural anesthesia. No intrapartum fever or other clinical evidence of chorioamnionitis. Spontaneous rupture of membranes 5.5 hours prior to delivery yielding clear amniotic fluid. Infant received bulb suction and given tactile stimulation. Apgar scores 9 at 1 minute, and 9 at 5 minutes of age. In regular nursery, noted at approximately 5 hours to have nasal congestion with retractions and was transferred to the Newborn Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION: Weight 2465 grams (25th percentile, length 45 cm (10th percentile), head circumference 33 cm (25th to 50th percentile). VITAL SIGNS - heart rate 130, respiratory rate 56, oxygen saturations 100 percent in room air, blood pressure 84/44, mean arterial pressure of 53 and temperature 97.5 axillary. HEENT: Anterior fontanel soft and flat, non-dysmorphic, palate intact, neck and mouth normal, normocephalic, mild nasal flaring. CHEST: Mild retractions, mild intermittent stridor with moderate nasal congestion, good breath sounds bilaterally. Transmitted upper airway sounds but no crackles. CVS: Infant well perfused, regular rate and rhythm. Femoral pulses normal. S1 and S2 normal. No murmurs. ABD: Soft and nondistended. No organomegaly. No masses. Bowel sounds active. Anus patent. Umbilical cord dry. GU: Normal female genitalia. SKIN: Normal. Normal spine, limbs, hips and clavicles. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY - The infant was admitted from Newborn Nursery with retractions and nasal flaring, thought to be related to upper airway congestion. He has remained on room air throughout his hospitalization with oxygen saturations greater than 95 percent. Dexamethasone and Neo-Synephrine drops were started on day of life 0 for upper airway congestion with improvement over the next 2 days. The dexamethasone and Neo-Synephrine were discontinued on day of life 2. Work up breathing has decreased and oxygen saturations have remained in the high 90's. He is currently comfortable in room air with respiratory rates in 30's to 60's. CARDIOVASCULAR - the infant's blood pressure has been normal throughout her hospitalization. No murmurs noted. FLUIDS, ELECTROLYTES AND NUTRITION - Ad lib feeds were initiated on day of delivery and he has continued to feed well by breast and bottle over the course of his hospitalization. Two days prior to discharge the patient had abdominal distension associated with a large gastric aspirate that prompted . Subsequernlty was normal and has tolerated feedings well. KUB unremarkable. Her weight at the time of discharge is 2490 grams. GASTROINTESTINAL - the infant is not clinically jaundiced. No bilirubin was drawn. HEMATOLOGY - hematocrit at birth was 56. No blood products were given. INFECTIOUS DISEASE - CBC and blood cultures were sent on day of life 1. White count of 18.8000, hematocrit of 56, platelet count of 229,000 with 69 percent polys and 1 percent bands. Blood culture was negative. No antibiotics indicated. NEUROLOGY - not indicated for this 39 week old infant. SENSORY - hearing screen was performed with automated auditory brainstem responses. He passed in both ears on [**6-25**]. OPHTHALMOLOGY - eye examination not indicated for this 39 weeker. PSYCHOSOCIAL - [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Social Work has been involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) **]. DEVELOPMENTAL - the infant had issues with low temperatures requiring isolette shortly after admission to the Newborn Intensive Care Unit. She has been weaned from the isolette and temperature has been stable for greater than 24 hours. CONDITION AT DISCHARGE: Stable without increased work of breathing in room air with good oxygen saturations. Temperature stable in open crib. DISCHARGE DISPOSITION: To home with parents. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42437**], at [**Hospital 1411**] Community Health Center - phone No. [**Telephone/Fax (1) **]. CARE RECOMMENDATIONS: Feeds at discharge ad lib, to amend feeds of breast milk or formula. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Not indicated. STATE NEWBORN SCREENING STATUS: First State Newborn Screen was sent on [**6-25**], no abnormal results have been reported. IMMUNIZATIONS RECEIVED: The infant has received her first hepatitis B vaccine on [**6-25**]. No other immunizations given. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] if the infant meet any of the following three criteria: Born at less than 32 weeks. Born between 32 and 35 weeks with two of the following: Daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. Chronic lung disease. Influenza immunization is recommended annually in the Fall for all infant once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. DISCHARGE DIAGNOSIS: Mild respiratory distress related to upper airway congestion. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2175-6-27**] 00:39:05 T: [**2175-6-27**] 02:50:46 Job#: [**Job Number 57690**] ICD9 Codes: V290, V053
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Medical Text: Admission Date: [**2105-7-19**] Discharge Date: [**2105-7-22**] Date of Birth: [**2031-10-4**] Sex: F Service: MEDICINE Allergies: Penicillins / Neomycin Sulfate / Neomycin Attending:[**First Name3 (LF) 1253**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 73 year old woman with past medical history significant for CKD and diastolic heart failure was transferred to [**Hospital1 18**] from [**Hospital 882**] hospital with severe respiratory distress due to hypoxia. Patient has been a resident at [**Hospital 100**] Rehab since her discharge from [**Hospital1 18**] on [**2105-6-3**]. During this admission she was found to have narrow complex tachycardia and anemia. She has had several admissions to [**Hospital 882**] hospital since that time with a notable admission for c.diff colitis in early [**Month (only) **]. . On day of admission, patient presented to [**Hospital1 882**] from [**Hospital 100**] Rehab with cough, hypoxia, and shortness of breath that evolved acutely over two hours prior to presentation to [**Hospital1 882**]. Patient was given Ceftazidime, 80mg IV Lasix, nitro paste, and morphine prior to transfer to [**Hospital1 18**] ED. . Upon presentation to the ED vitals were: T 98.8, HR 81, BP 170/87, RR 30, O2Sat 70% on NRB. After confirming code status with proxy (DNR/DNI) patient was placed on BiPAP with O2Sats coming up to mid 90s. Patient the given levofloxacin IV and admitted to MICU. . Pt has no complaints at this time and would like to leave the hospital. She complains of no shortness of breath, no chest pain, no abdominal pain, and no headache. She is -2.6 L total and -1.5 L over the last 24 hours. . ROS: no fever, chills, night sweats, headache, sinus tenderness, rhinorrhea, congestion, cough, wheezing, chest pain, chest pressure, palpitations, weakness, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, frequency, urgency Past Medical History: 1) Chronic kidney disease 2) Alcoholic cirrhosis 3) Diastolic CHF 4) Cervical malignancy (reported from last hospitalization) 5) Severe c.diff pancolitis (Diagnosed [**2105-6-9**] and still on oral vanco treatment until [**2105-7-25**]) 6) Atrial flutter 7) h/o retinal vein occlusion 8) Ocular hypertension 9) Glaucoma 10) Cataract extraction Social History: Lives alone. Daughter recently passed away from drugs/etoh. Has six children and is one of 16 herself. - Tobacco: Former. Quit in [**2070**]. - Alcohol: History of alcoholism and hospitalized at the [**Hospital1 86076**] in the [**2065**]. Sober since then. - Illicits: None Family History: Mom died of unknown cancer. Daughter died of drugs and alcohol. Physical Exam: Vitals - T: 96.8 BP: 112/46 HR: 72 RR: 24 02 sat: 92% on 4L NC GENERAL: NAD, AAOx3 HEENT: sclera anicteric, PERRL, EOMI, MMM NECK: no LAD, supple, +JVD CARDIAC: RRR, S1/S2, no M/R/G LUNG: light wheezes bilaterally, crackles present on both sides, worse at bases ABDOMEN: soft NT/ND, +BS EXT: pitting edema evident at ankles NEURO: AAOx3 DERM: no rash present Exam upon discharge shows decreased crackles and wheezes and less pitting edema on [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. Pertinent Results: [**2105-7-19**] 07:07PM BLOOD WBC-13.2* RBC-3.54* Hgb-10.7*# Hct-33.4*# MCV-94# MCH-30.1# MCHC-31.9# RDW-20.2* Plt Ct-502* [**2105-7-19**] 07:07PM BLOOD PT-12.2 PTT-24.8 INR(PT)-1.0 [**2105-7-19**] 07:07PM BLOOD Glucose-113* UreaN-21* Creat-1.3* Na-141 K-4.4 Cl-104 HCO3-21* AnGap-20 [**2105-7-19**] 07:07PM BLOOD cTropnT-0.04* [**2105-7-19**] 07:08PM BLOOD Lactate-2.4* [**2105-7-21**] 05:30AM BLOOD WBC-8.5 RBC-2.94* Hgb-8.3* Hct-26.7* MCV-91 MCH-28.4 MCHC-31.1 RDW-20.0* Plt Ct-436 [**2105-7-20**] 03:17AM BLOOD Glucose-87 UreaN-21* Creat-1.4* Na-139 K-4.5 Cl-101 HCO3-23 AnGap-20 [**2105-7-20**] 07:42PM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-139 K-3.8 Cl-100 HCO3-26 AnGap-17 [**2105-7-20**] 03:17AM BLOOD cTropnT-0.05* [**2105-7-20**] 3:17 am URINE [**2105-7-22**] 06:30AM BLOOD Glucose-87 UreaN-24* Creat-1.3* Na-142 K-4.0 Cl-104 HCO3-26 AnGap-16 **FINAL REPORT [**2105-7-20**]** Legionella Urinary Antigen (Final [**2105-7-20**]): 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. [**Known lastname **],[**Known firstname **] [**Medical Record Number 86080**] F 73 [**2031-10-4**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2105-7-20**] 2:43 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. MED MICU [**2105-7-20**] 2:43 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 86081**] Reason: Interval change? [**Hospital 93**] MEDICAL CONDITION: 73 year old woman with likely CHF and pneumonia REASON FOR THIS EXAMINATION: Interval change? Final Report CHEST RADIOGRAPH INDICATION: Chronic heart failure, pneumonia, assessment of interval change. COMPARISON: [**2105-7-19**]. FINDINGS: As compared to the previous radiograph, there is no relevant change. Minimal tendency to increasing consolidation at both lung bases, as manifested by slight decrease in extent of the previously visible air bronchograms. The lung volumes, however, are smaller than on the previous image. In the ventilated parts of the lung parenchyma, the extent of the pre-existing opacity is unchanged. Brief Hospital Course: #.Hypoxia: Pt presented to [**Hospital1 18**] on [**7-19**] with respiratory distress and decreased O2 sats. Patient was given Ceftazidime, 80mg IV Lasix, nitro paste, and morphine prior to transfer to [**Hospital1 18**] ED. Once at [**Hospital1 18**], she was placed on BiPAP with O2Sats coming up to mid 90s. She was started on broad coverage with cefepime and levofloxacin for presumed healthcare-associated pneumonia. CXR was taken and showed both findings suggestive of pulmonary edema and opacity probably representing atelectasis or pleural effusion, but could not rule out infectious processes. It was decided to continue antibiotic regimen. Overnight, pt showed improving oxygen saturation, good urine output, and was taken off BiPap in the early morning. It is unclear whether she suffered flash pulm edema from a supraventricular tachycardia or infectious etiology, but pt had not produced sputum, and remained afebrile throughout ICU course. On [**7-20**], pt was transferred to the general medicine floor on 4L NC, with sats in the low 90s. Pt did not feel short of breath at this time, and for the remainder of her hospital course. Lasix was provided IV upon arrival to the floor, and was switched to PO home dose of Lasix on [**7-21**]. It was presumed that her hypoxia was due to pulmonary edema from the patient's CHF. On the evening of [**7-21**], pt was able to discontinue O2 and did well until discharge on [**7-22**], without SOB. . #.Diastolic CHF: pt was found to be fluid overloaded on admission, and pt was given 80 mg IV Lasix twice while in the ICU. She was -2L when transferred to the floor, with a slight rise in Cr. Lasix was held on the night of [**7-20**], due to this. In the afternoon of [**7-21**], Cr approached baseline, pt was switched to PO home dose of Lasix (20 mg qdaily) and continued to diurese. Upon discharge, pt was approximately negative 3.5-4L. Pt was continued on metoprolol while in the hospital, but was not on spironolactone. Home doses of Lasix, metoprolol and spironolactone should be continued upon discharge, as written. . #.C. difficile pancolitis: pt came to the hospital on PO Vancomycin for C. diff pancolitis, and was originally due to finish this regimen on [**7-25**]. Due to patient being discharged on PO levofloxacin for possible HAP, we lengthened this regimen to avoid relapse to be finished on [**7-31**]. Pt did not complain of abdominal pain or diarrhea during admission. . #.Tachycardia: pt's tachycardia was controlled during hospitalization with home doses of metoprolol and amiodarone, to be continued as written. . #.Chronic kidney disease: pt's Cr showed a small increase during diuresis for fluid overload, but normalized according upon titrating down the dose. . #.Glaucoma: home doses of medications were continued throughout hospital course, and should be continued upon discharge as written. Medications on Admission: 1) traZODONE 25 mg PO/NG HS:PRN insomnia 2) Albuterol 0.083% Neb Soln 1 NEB IH Q6H 3) Magnesium Oxide 400 mg PO/NG TID 4) Lidocaine 5% Patch 1 PTCH TD DAILY 5) Ipratropium Bromide Neb 1 NEB IH Q6H 6) Ferrous Sulfate 325 mg PO DAILY 7) Vitamin D 1000 UNIT PO/NG DAILY 8) Calcium Carbonate 650 mg PO/NG [**Hospital1 **] 9) Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes 10) Amiodarone 200 mg PO/NG DAILY 11) Acetaminophen 325-650 mg PO/NG Q6H:PRN pain 12) Furosemide 20 mg daily 13) Spironolactone 12.5 mg PO/NG DAILY 14) Omeprazole 20 mg PO BID 15) Metoprolol Succinate XL 100 mg PO DAILY 16) Oxycodone 5 mg [**Hospital1 **] 17) Vancomycin 250 mg PO QID Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Daily weights 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-24**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H (every 6 hours) as needed for High BP. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. 20. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 21. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Hypoxia, Congestive heart failure 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: It was a pleasure to take care of you at the [**Hospital1 18**]. You came for further evaluation of shortness of breath and low oxygen in your blood. Tests showed that you had congestive heart failure. You were treated with diuretics (water pills) and your shortness of breath improved. You were treated with antibiotics for possible pneumonia and for C. difficile colitis. It is important that you continue to take all of your medications. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. The following changes were added to your medications: Added levofloxacin Followup Instructions: Name: [**Last Name (LF) 38274**],[**First Name3 (LF) **] X. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Tuesday [**2105-7-28**] 4:40pm Please allow extra time to get to your appointment due to construction in the garage. Thanks. ICD9 Codes: 486, 5180, 4280, 5859