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Admission Date: [2185-8-4] Discharge Date: [2185-8-17] Date Birth: [2100-6-22] Sex: Service: NEUROLOGY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: unresponsiveness, L sided weakness Major Surgical Invasive Procedure: intubation/extubation History Present Illness: Mr. [Known lastname 112244] 85-year-old right-handed man presenting Intracerebral hemorrhage background dementia, congestive heart failure, renal failure, prior pneumonia, prior "stroke" (not worked-up). asleep daughter arrived. [Name2 (NI) ] refused get breakfast 7:30 - sometimes happens. said goodbye daughter. [Name (NI) ] got around 10 10:30 AM, walking bathroom without walker. 11 back bed told daughter go away, wanted sleep - normal him. 11:30 daughter tried move him, noted moving left side drooling. dysarthric, able speak understand. 911 called taken [Hospital3 ], neurologist, per patient's family. Head CT performed showing large hemorrhage. intubated transferred [Hospital1 18]. saw Cardiologist blood pressure otherwise stable - asked come back six months. Dementia diagnosed PCP, [Name10 (NameIs) ] admission [Hospital3 ] pneumonia also resulted daignosis Alzheimer's disease. also AMI (6/[2184]). otherwise well, eating poorly - get bed much seems less interested - eaten well last two weeks. Review systems negative except above, per family. ROS patient limited. Past Medical History: - Coronary artery disease - Dementia, provisionally Alzheimer's type - Pneumonia - 'TIA' - five six months ago, worked full, seems TIA - fluent aphasia without features, recovered minutes. - Congestive heart disease, likely post-infarctive setting prerenal state pneumonia, AMI - Hypertension - Hyperlipidemia - prior surgery Social History: Smoking: Smoked youth, per daughter. Alcohol: None. Drugs: No. Living Situation: Lives daughter. Education Language: English. Functional Baseline: Able feed self, dress, toilet indpendently. Dependent ADL's. Other: Retired mail handler. Family History: Mother diabetes. Father unknown. Sibling alcoholism. Physical Exam: Physical Exam Admission: Vitals: afebrile F; HR 52 BPM; BP 152/64 (had SBP ~ 100) mmHg; O2Sat 100 % CMV 18 x 450, FiO2 0.5 General Appearance: Leaning left, little spontaneous movement, awake. HEENT: NC, ETT place. Neck: Supple reduced ROM. Lungs: Clear within limits exam, vent sounds. Cardiac: Bradycardic regular. Normal S1/S2. Abdominal: Soft, NT, BS+. Extremities: edema, cool (particularly right), delayed capillary refill trophic changes feet. Neurologic Examination: Mental status: Awake attentive events room. Appropriate head shake nod simple questions. mild behavioral discomfort given ETT despite sedation off. Tends pay attention right. Cranial Nerves: I: tested. II: Pupils symmetric, round reactive light, 3 2 mm bilaterally. Visual fields full confrontation right, left. III, IV, VI: Extraocular movements conjugate without nystagmus, difficult get left. V, VII: Jaw midline, facial droop left. VIII: Hearing intact voice. IX, X: examinable. [Doctor First Name 81]: examinable. XII: examinable. Tone Bulk: Tone increased legs, right arm flaccid. Power: Dense paresis left arm, left leg moves noxious stimulation foot. Reflexes: B Br Pa Ac R 2 1 2 0 0 L 3 2 2 1 0 Toes upgoing bilaterally. Sensation: Withdraws increased arousal painful stimulus right, withdraws right (foot, hand). Coordination Cerebellar Function: tested. Gait: tested. *************** Physical Exam Discharge: Expired Pertinent Results: [2185-8-4*] 04:40PM TYPE-ART RATES-/16 TIDAL VOL-450 O2-100 PO2-412 PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 AADO2-259 REQ O2-51 INTUBATED-INTUBATED [2185-8-4] 05:03PM GLUCOSE-147* LACTATE-2.0 NA+-136 K+-4.4 CL--102 TCO2-21 [2185-8-4] 05:04PM FIBRINOGE-263 [2185-8-4] 05:04PM PT-10.6 PTT-28.3 INR(PT)-1.0 [2185-8-4] 05:04PM PLT COUNT-205 [2185-8-4] 05:04PM WBC-8.8 RBC-4.04* HGB-12.8* HCT-38.3* MCV-95 MCH-31.7 MCHC-33.5 RDW-13.1 [2185-8-4] 05:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2185-8-4] 05:04PM TSH-1.6 [2185-8-4] 05:04PM TRIGLYCER-149 HDL CHOL-42 CHOL/HDL-2.7 LDL(CALC)-41 [2185-8-4] 05:04PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-2.1 CHOLEST-113 [2185-8-4] 05:04PM CK-MB-2 cTropnT-<0.01 [2185-8-4] 05:04PM LIPASE-43 [2185-8-4] 05:04PM estGFR-Using [2185-8-4] 05:04PM UREA N-19 CREAT-1.7* [2185-8-4] 05:15PM URINE HYALINE-1* [2185-8-4] 05:15PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [2185-8-4] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2185-8-4] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2185-8-4] 05:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG CT head [8-4]: IMPRESSION: 1. Large intraparenchymal hemorrhage involving mainly right frontoparietal region intraventricular extension, significant change. Mass effect right lateral ventricle unchanged midline shift left. 2. New increase size right temporal [Doctor Last Name 534] lateral ventricle likely due trapping. 3. Stable subarachnoid blood right sylvian fissure new subarachnoid blood seen left temporal region. Brief Hospital Course: 85-year-old right-handed man hx dementia, CHF, renal failure, prior stroke found unresponsive home. CT head revealed large right lobar intraparenchymal hemorrhage mass effect intraventricular extension. admitted neuro ICU initially close monitoring, later made CMO. Neuro: monitored closely Q1hr neuro checks overnight. started nicardipine drip BP control goal < 160. Aspirin anticoagulants held. Neurosurgery consulted declined acute surgical intervention. Per discussion daughters made DNR/DNI extubated [8-5]. Palliative care consulted discussion made CMO. put morphine gtt PRN ativan. transferred floor inpatient hospice. Due continued discomfort/agitation transitioned dilaudid drip [8-16] ativan increased. passed away peacefully 12:40am [2185-8-17]. Daughters bedside declined autopsy. Cardiovascular: maintained telemetry monitoring. BP monitored closely controlled nicardipine metoprolol ICU, made CMO cardiac meds withdrawn. PENDING LABS: None TRANSTIONAL CARE ISSUES: None, pt expired [2185-8-17]. Medications Admission: - Aricept 2.5 mg PO QD - Metoprolol succinate 50 mg PO QD - ASA 325 mg PO QD - Remeron 15 mg PO QHS - Lipitor 40 mg PO QHS - Trazodone 12.5 mg PO QHS - Vitamin - Namenda 10 mg PO BID - Celexa 10 mg PO QD - Eye drops Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right lobar intraparenchymal hemorrhage Discharge Condition: Expired Discharge Instructions: Mr. [Known lastname ] admitted [Hospital1 69] [2185-8-4] found unresponsive home. CT scan head showed large bleed right side brain. breathing tube placed admitted neuro ICU. discussion family decision made remove breathing tube next day pursue aggressive interventions. Palliative care consulted per family's wishes made CMO [8-5]. started morphine drip transferred ICU inpatient hospice care. passed away peacefully 12:40am [2185-8-17]. Followup Instructions: n/a [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "5859", "40390", "41401", "2724", "412", "V1582" ]
Admission Date: [2167-8-14] Discharge Date: [2167-8-15] Service: NEUROSURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: fall Major Surgical Invasive Procedure: none History Present Illness: 85 s/p unwitnessed fall today - wife heard fall, found back living room floor - complained headache nausea afterwards. LOC, mild confusion solmnent. Past Medical History: PMH: Hypertension MI last year s/p multiple falls, COPD, Anemia Pulmonary fibrosis polymyalgia rheumatica neck arthritis PSH: Cataract surgery TURP R colectomy Social History: SH: remote tob, ETOH drugs, retired salesman, lives [Location 583] wife Family History: FH: NC Physical Exam: PE: 97.9 90 161/96 16 95%3L NC Oriented year, month, oriented state, mild confusion, somnolent Difficulty following commands participated physical exam Moves extremities good strength RRR CTAB soft NT.ND 2+ LE edema, swelling hands Pertinent Results: Labs: Trop-T: 0.03 138 100 11 116 AGap=15 3.6 27 1.0 estGFR: 71 / >75 (click details) CK: 81 MB: Notdone Ca: 9.0 Mg: 2.1 P: 2.6 5.8>33.9<242 Rads: CT Head: Acute right 16 mm SDH overlying cerebral convexity shift left 3 mm. Compression right lateral ventricle. Subdural blood also layers along falx superiorly along tentorium bilaterally. Right parietal subgaleal hematoma. fracture. CT C-spine: Slightly limited motion. Mild anterior widening interspace C2-3, C3-4, C4-[5-11] chronic acute ligamentous injury cannot excluded. fracture subluxation. Mild septal thickening may reflect pulmonary edema. Brief Hospital Course: Patient intubated airway protection -repeat CT shift - Dr. [Last Name (STitle) 739] thought proceed would need surgically evacuated given pts comorbidities, worsening status, aspirin plavix thought prognosis grave. Upon discussion daughter wife decision made Mr. [Known lastname 168] would wanted proceed would comfort measures only. extubated ICU keep comfortable. expired [2167-8-15]. Medications Admission: [Last Name (un) 1724]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1 QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone 5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva, MiraLax Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: traumatic cerebral hemorrhage Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2167-10-13]	[ "496", "2859", "4019" ]
Admission Date: [2155-3-26] Discharge Date: [2155-6-10] Date Birth: [2098-11-22] Sex: Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 290] Chief Complaint: Autologous BMT Major Surgical Invasive Procedure: continuous renal replacement therapy hemodialysis intubation mechanical ventilation tracheostomy paracentesis History Present Illness: Mr. [Known lastname ] 56-year-old male diagnosed follicular lymphoma transitioning marginal zone lymphoma 01/[2154]. long preceding history night sweats dry cough, followed development right leg swelling right inguinal mass. [2154-1-31] developed swelling right lower extremity mass inguinal area. CT scan abdomen pelvis [2154-2-18] revealed generalized lymphadenopathy beginning crural lymph nodes extending inferiorly periaortic, mesenteric, celiac, pararenal, common iliac, external iliac chains. right groin, large lymph node mass approximately 6 x 5 x 6.6 cm. also rounded low-density area medial femoral artery felt represent thrombosed femoral external iliac veins. Overall, findings concerning lymphoma. referred CT chest [2154-2-19] showed prominent adenopathy, principally left supraclavicular left axillary regions, largest mass measuring 2.6 cm left axilla. Based that, referred excisional biopsy right inguinal adenopathy [2154-2-26] revealed follicular lymphoma partial marginal zone differentiation, grade I-II large cell quantitation. cells CD19 CD20 positive also co-expressed CD5 CD10. also kappa light chain restricted. expression CD-23 cyclin D1. Ki67 20-30%. lymphoma felt represent transitional state follicular lymphoma marginal zone B-cell lymphoma. started R-CVP. tolerated therapy fairly well, suffered fatigue, hyperglycemia, flushing, hypertension. prednisone dose treatment eventually lowered 200 mg daily 100 mg daily. received 2 days neupogen cycle chemotherapy. three cycles R-CVP, vincristine discontinued due neuropathy. underwent PET scan [2154-5-1] third cycle continued show extensive FDG avid disease. However, night sweats leg swelling improved. continued R-CVP two additional cycles, fifth cycle, noticed recurrence right inguinal lymphadenopathy. also developed recurrent night sweats cough. lymphadenopathy grew quite quickly became size quarter span 24 hours. underwent second PET scan [2154-6-12] showed little significant change, hyperactive adenopathy left axilla extensively diaphragm mesentery, para-aortic pelvic regions. underwent second excisional biopsy [2154-7-2] showed follicular lymphoma, grade I-II. decision made hold R-CVP lymphoma longer responding current therapy. CYTOGENETICS CD19 CD20 positive, also co-expressed CD5 CD10, kappa light chain restricted; expression CD-23 cyclin D1; Ki67 20-30%. CHEMOTHERAPY HISTORY [Date range (1) 83066]: received cyclophosphamide, vincristine, prednisolone plus rituximab (R-CVP) x 3 cycles; vincristine discontinued due neuropathy. Night sweats leg swelling improved. [2154-5-1]: PET Scan showing extensive FDG avid disease [Date range (1) 83067]: continued R-CVP two additional cycles, fifth cycle, noticed recurrence right inguinal lymphadenopathy. also developed recurrent night sweats cough. [2154-6-12]: repeat PET - little interval change [2154-7-2]: repeat lesion biopsy - similar findings [2154-8-5]: transferred care [Hospital1 ], presented bilateral inguinal lymphadenopathy; received 4 cyclyes R-Bendamustine local oncologist time transfer; planned two cycles R-bendamustine [2155-1-22]: Mobilization HiDAC, final cumulative CD-34 yield 5.19 x 10e CD-34 cells/kg three days, discharged Cipro, Neupogen Compazine. WBC discharge 20.9. Two weeks later WBC 0.7 one week later 0.5 w/ANC 0, asymptomatic. Started Moxifloxacin neupogen. Stem cell harvesting [Date range (1) 83068]. [2155-2-25]: W1 Rituxan/Zevalin: WBC 7.3, Hct 34.9, Plt 244. [2155-3-4]: W1 Rituxan/Zevalin: WBC 5.4, ANC 4560, Hct 32.5, Plt 292. Today presents admission BEAM autologous BMT. current complaints. Denies headache, nausea, vomiting, diarrhea, abdominal pain, weakness, fevers, chills, recent night sweats, blurry vision, shortness breath. Reports mild ongoing cough significantly improved prior occasional fatigue counts get low. Past Medical History: Diagnosed follicular lymphoma transitioning marginal zone lymphoma [1-/2154] (These cells CD19 CD20 positive also co-expressed CD5 CD10. also kappa light chain restricted. expression CD-23 cyclin D1. Ki67 20-30%.) Right thigh lymphedema (significantly improved, per patient) RLE DVT compression (was coumadin [2154-11-25]) Mild diverticulitis s/p vasectomy, tonsillectomy Social History: Works management position metal fabrication plant overseeing production quality control. married four children, ages [8-17]. family live Hooksett, [Location (un) 3844]. denies current tobacco use. previously smoked quit 15 years ago 20-pack-year history. generally drinks several martinis day decreased drinking treatment. Family History: father - died 80, lung cancer, Charcot-[Doctor Last Name ]-Tooth disease, pulmonary embolism mother - alive 80, diabetes asthma three brothers - good health family history leukemia lymphoma 2 children previous marriage 2 children current marriage Physical Exam: ADMISSION: VS: 96.6 132/96 109 18 98/ra 195lbs 71" GENERAL: NAD HEENT: Sclerae anicteric. PERRLA. EOMI. O/P clear. Neck: Supple. Lymph: cervical, supraclavicular, axillary lymphadenopathy; left supraclavicular fullness; possible right inguinal lymphadenopathy although possibly scar tissue biopsy CARDIAC: RRR Normal S1/S2 R/G/M LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds; HSM EXTREMITIES: edema . DISCHARGE: [2155-6-10] Tmax: 36.5 ??????C (97.7 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 117 (109 - 117) bpm BP: 79/57(62) {64/40(48) - 93/59(68)} mmHg RR: 30 (21 - 30) insp/min SpO2: 95% Heart rhythm: ST (Sinus Tachycardia) Wgt (current): 80.3 kg (admission): 98.2 kg Height: 72 Inch 24 HR: SMN: Total In: 1,807 mL 722 mL PO: TF: 1,017 mL 602 mL IVF: Blood products: Total out: 0 mL 0 mL Urine: 0 mL 0 mL NG: Stool: Drains: Balance: 1,807 mL 722 mL Respiratory support: O2 Delivery Device: Trach mask 50% SpO2: 95% Physical Examination: General Appearance: Well nourished, acute distress, Thin, Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Tracheostomy place, NG tube place Lymphatic: Cervical Supraclavicular adenopathy Cardiovascular: PMI Normal, S1: Normal, S2: Normal, murmurs, rubs, gallops. Chest: Expansion: Symmetric Excursion, Dullness, CTAB. Abdominal: Soft, Non-tender, Bowel sounds present, Distended, + fluid wave. Non-tender. Extremities: edema, Cyanosis, Clubbing, 2+ Peripheral pulses. Musculoskeletal: Muscle wasting, Unable stand, Skin: Warm, Rash, Jaundice Neurologic: Attentive, Follows commands, Responds verbal stimuli, Oriented x3, Moving extremeties equally, Strength [4-2] UE & LE bilat, Dizzy supine position, Moving extremeties equally, sensation intact. Pertinent Results: LABS ADMISSION: [2155-3-26] 10:15AM BLOOD WBC-3.9* RBC-4.62 Hgb-13.8* Hct-41.5# MCV-90 MCH-29.9 MCHC-33.3 RDW-15.7* Plt Ct-144# [2155-3-26] 10:15AM BLOOD Neuts-88.5 Lymphs-4.0* Monos-6.4 Eos-0.7 Baso-0.3 [2155-3-26] 10:15AM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9 [2155-3-28] 12:00AM BLOOD Gran Ct-4380 [2155-3-26] 10:15AM BLOOD UreaN-14 Creat-0.8 Na-141 K-4.6 Cl-102 HCO3-32 AnGap-12 [2155-3-26] 10:15AM BLOOD ALT-35 AST-33 LD(LDH)-157 AlkPhos-102 TotBili-0.3 DirBili-0.1 IndBili-0.2 [2155-3-26] 10:15AM BLOOD TotProt-7.0 Albumin-4.5 Globuln-2.5 Calcium-10.0 Phos-3.8 Mg-2.0 UricAcd-8.3* LAB TRENDS ADMISSION: WBC: MAX 47.8 [2155-5-13] --> 35.3 [2155-5-20] --> 25.9 [2155-5-28] -->18.9 [2155-6-3] --> 15.5 [2155-6-10] HCT: stable 28-33 past 2 weeks PLT: stable 40-70 past 2 weeks. COAGS: within normal limits. CHEM7: Patient HD Tues, Thurs, Sat LFTS: AST: 1341 & ALT: 2472* MAX [2155-4-12] trended AST: 59* ALT: 40 [2155-4-23] AST & ALT normal since [2155-5-28]. LDH: 1466 MAX [2155-4-12] trended normal [2155-5-17] ALK PHOS: 170 [2155-4-12] trended MAX 248 [2155-4-15] 172 [2155-6-10]. TBILI: 10.0 MAX [2155-4-12] trended 2.9 [2155-6-10] LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [2155-5-8] 08:46AM 173 196* 11 15.7 123 CORTISOL Stimulation Test: [2155-5-25] 03:30PM 29.41 [2155-5-25] 02:37PM 17.91 HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HAV [2155-4-10] 03:46AM NEGATIVE POSITIVE NEGATIVE POSITIVE NEGATIVE HEPARIN DEPENDENT ANTIBODIES: Negative [2155-5-27] 12:00PM ASPERGILLUS ANTIGEN: 0.1 <0.5 considered negative [2155-5-20] B-GLUCAN: 65 pg/mL Negative Less 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater equal 80 pg/mL LABS DISCHARGE: [2155-6-10] 04:21AM BLOOD WBC-15.5 RBC-2.61* Hgb-10.0* Hct-31.1* MCV-119* MCH-38.1* MCHC-32.0 RDW-19.6* Plt Ct-40* [2155-6-10] 04:21AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.1 [2155-6-10] 04:21AM BLOOD Plt Ct-40* [2155-6-10] 04:21AM BLOOD Glucose-140* UreaN-54* Creat-5.0* Na-139 K-5.5* Cl-103 HCO3-23 AnGap-19 **PRIOR HD TODAY* [2155-6-10*] 04:21AM BLOOD ALT-27 AST-34 AlkPhos-172 TotBili-2.9* IMAGING: RUQ ULTRASOUND [2155-4-8]. IMPRESSION: 1. Apparent reversed flow main portal vein normal flow direction left right portal veins. findings discrepant appear artifactual nature. Given etiology findings unclear, whether true portal vein reversal possibly proximal thrombus, would recommend focused MRI abdomen including 2D time-of-flight sequences (with saturation bands determine directionality flow) portal vein clarify issue. 2. Cholelithiasis evidence acute cholecystitis. 3. Small amount ascites. MRI Abdomen. [2155-4-9]. IMPRESSION: 1. Reversal flow within main portal vein, breath-hold imaging free breathing. 2. Reversal flow within right anterior portal vein breath-hold imaging. 3. Suggestion reversed flow within right posterior portal vein breath-hold, antegrade flow free breathing. may reverse depending phasicity respiration. 4. Directionality flow within left portal vein clearly demonstrated examination. 5. Interval increase ascites since yesterday's examination. 6. evidence focal hepatic lesion hepatic portal vein thrombus. 7. Suggestion siderosis within spleen. Possibility iron deposition within liver cannot excluded without dual-echo gradient-echo images (omitted abbreviated examination due patient intolerance examination). 8. Cholelithiasis. biliary abnormalities noted. MR HEAD W/O CONTRAST Study Date [2155-5-2] 12:31 PM IMPRESSION: 1. Hyperintense subarachnoid material, involving sulci cerebral hemispheres, likely representing subarachnoid hemorrhage, less likely proteinaceous material seen meningitis. Oxygen therapy also appearance. 2. evidence masses, mass effect infarction. ECHO: [2155-5-23] 3:47:46 PM Conclusions: left atrium right atrium normal cavity size. Left ventricular wall thicknesses cavity size normal. Regional left ventricular wall motion normal. Left ventricular systolic function hyperdynamic (EF>75%). Tissue Doppler imaging suggests normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. masses vegetations seen aortic valve. mitral valve appears structurally normal trivial mitral regurgitation. mass vegetation seen mitral valve. pulmonary artery systolic pressure could determined. pericardial effusion. Compared prior study (images reviewed) [2155-4-21], findings similar. CT TORSO: [2155-5-23] 1:53 PM CHEST CT: Bilateral small pleural effusions, left increased compared prior study right slightly increased compared prior study. Linear atelectasis right lower lobe left lower lobe accompanied small patchy consolidations left lower lobe. new compared previous study. Small amount pericardial effusion noted (series 2, image 34). Central line catheter noted tip right atrium. Tracheostomy. Nasogastric tube tip stomach. ABDOMINAL CT: Small-to-moderate amount ascites demonstrated. Limited evaluation liver due lack i.v. contrast artifacts. evidence intrahepatic extrahepatic bile duct dilatation. pancreas within normal limits. Gallbladder nondistended. Adrenals unremarkable bilaterally. Spleen normal size attenuation non-contrast scan. Visualized small bowel demonstrate diffuse mucosal thickening without evidence dilatation. findings may caused ascites GVHD. Retroperitoneal mesenteric lymphadenopathy, small numerous, measuring 1 cm mesentery 1.4 cm retroperitoneum. PELVIC CT: Moderate amount fluid seen pelvis. Urinary bladder distended. Rectal tube seen rectum. OSSEOUS STRUCTURES: Degenerative changes lumbar sacral vertebra. IMPRESSION: 1. Bilateral small pleural effusions, slightly larger compared prior study. 2. Linear atelectasis right lower lobe left lower lobe left lower lobe patchy consolidation new compared prior study. 3. Moderate amount ascites. 4. Limited evaluation liver due artifacts. CXR: [2155-6-6] FINDINGS: Indwelling support monitoring devices similar position, cardiomediastinal contours unchanged. suggestion increasing layering effusions semi-upright projection. Persistent left retrocardiac opacity probably due atelectasis. Patchy opacities right mid right lower lung could due either atelectasis early sites pneumonia, followup radiographs may helpful regard. Brief Hospital Course: 56 year old male PMH follicular lymphoma transitioning marginal zone lymphoma s/p R-CVP admitted BEAM auto-SCT (C1D1 ([2155-3-26]) per BMT protocol, initiated carmustine day -7, followed etoposide/cytarabine days -6 -3, melphalan day -2 ([2155-3-31]). underwent Autologus stem cell transplant [2155-4-2]. Post-transplant course complicated mucositis, diarrhea, febrile neutropenia, transient hyperuricemia responded 1 dose allopurinol. [2155-4-11], patient transferred ICU respiratory distress, altered mental status, renal failure, transaminitis secondary [Last Name (un) ]-occlusive disease. 1. Respiratory distress - patient tachypneic 40s admission ICU increasing oxygen requirement, thought represent attempted compensation metabolic acidosis low lung volumes atelectasis. patient failed trial bipap intubated placed A/C mechanical ventilation. evidence pneumonia noted >7L fluid positive admission, increasing ascites secondary hepatic complications. Serial CXRs course ICU stay demonstrated reduced lung volumes small amounts atelectasis new consolidation, effusion, intravascular congestion. Patient remained intubated [Hospital Unit Name 153] a) impaired mental status b) restrictive physiology [3-4] increased intra-abdominal pressure. patient remained ventilator approximately three weeks; respiratory status remained relatively stable mental status precluded extubation. experience episode leukocytosis, detailed below, treated pseudomonas ventilator associated pneumonia improvement leukocytosis. patient eventually received tracheostomy subsequently weaned trach collar, coincided improvement mental status. 2. Hypotension - etiology initially thought combination a) intravascular volume depletion [3-4] decreased effective circulating volume splanchnic vasodilation liver failure, b) sedation. Sepsis thought contributing factor well, maintained broad-spectrum antimicrobial coverage, infectious source identified majority hospitalization. CT imaging unremarkable infectious source. patient initiated levophed [4-12] prolonged ongoing pressor requirement without obvious cause hypotension. Although cortisol levels normal, suggesting adrenal insufficiency, patient trialed three day course steroids, temporarily improved pressures removed pressor requirement. Following conclusion steroid trial, patient required vasopressor support maintain blood pressure. cortisol stimulation test performed better assess impaired adrenal response, reveal significant abnormal findings. Ultimately, vasopressin started levophed weaned. CVVH stopped, patient episode symptomatic hypotension, vasopressin briefly restarted. rest ICU course, patient maintained pressors perfusion monitored assessing mental status. initiated HD, tolerated well without ultrafiltration. hypotension may related liver disease addition severe deconditioning. persistently orthostatic somewhat improved restarting midodrine. mentates well blood pressure 60s systolic. Please continue encourage thigh high compression stockings increase peripheral resistance. Please elevate head bed patient tolerates continue passive motion bed. Autonomics consulted prior discharge feels like hypotension likely related dysautonomia given hypotension even supine. Autonomics recommended continuation midodrine trial florinef started rehabilitation. Florinef started low dose (0.1 mg daily) uptitrated based patient response maximum 0.4 mg daily. felt hypotension likely related deconditioning aggressive PT pursued. 3. Leukocytosis - Elevated WBC count beginning [4-13] persistent hypotension. Filgrastim discontinued [4-12]; therefore, could account persistent leukocytosis. Patient high risk nosocomial infection (critically ill, ascites, multiple tubes/lines) difficult-to-interpret fever curve CVVH. empirically started broad spectrum antibiotics mild improvement leukocytosis obvious source cultures. Multiple paracenteses negative SBP. Much later [Hospital 228] hospital course, re-elevation white blood cell count corresponded new positive sputum culture Pseudomonas. patient treated seven days ceftazidime per infectious disease recommendations, leukocytosis improved still remained dramatically elevated. large volume paracentesis performed fluid sent cytology flow cytometry, revealing. Ultimately, CVVH catheter tip grew strain pseudomonas [6-4] sputum [5-12]. felt colonizer surveillance blood cultures negative. infectious sources identified. antibiotics ultimately discontinued well. longer precautions active infections. leukocytosis continues improve, remain elevated. component elevation may due auto splenectomy appears occurred hospitalization. 4. Transaminitis/Hepatic Failure - Right upper quadrant ultrasound abdominal MRI demonstrated reversal flow portal vein, suggestive cirrhosis. admission intensive care unit, noted new significant ascites. Rising INR worsening mental status suggestive progression hepatic failure. Liver biopsy confirmed diagnosis [Last Name (un) ]-occlusive disease. Infectious workup hepatitis negative. Per Hepatology, patient would candidate liver transplant. patient started defibrotide treatment protocol [2155-4-9] close monitoring coags, plts, hct, fibrinogen due concern bleeding (goal INR < 1.5, plts > 30, Hct > 30, Fibrinogen > 150). LFTs peaked [Date range (1) 14806] TBili 10, trended gradually. 25 days treatment defibrotide, head MRI revealed subarachnoid hemorrhage, necessitated discontinuation treatment. patient subsequently continued show gradual, mild improvement functional status, continued large ascites exam requiring periodic taps. Currently requiring paracentesis every 10-14 days ascites continue monitored tapped PRN. ICU course, LFTs gradually improved; however, bilirubin remain elevated 2.9 discharge. liver clinic follow-up Dr. [Last Name (STitle) 497] within one month discharge. 5. Depression: patient appears extremely frustrated depressed current state. started low dose amphetamine salts 5mg [Hospital1 ] increase energy blood pressure. cardiac status monitored closely well mood new medication. also titrated slowly attempt increase energy. 6. Thrombocytopenia: platelets fallen dramatically hospitalization. remained stable around 50. initial concern HIT, antibody returned negative [5-28]. Platelets transfused patient actively bleeding. Caution used blood thinners due low platelet level. 7. Ileus - Attributed critical illness ascites opioid -based sedation. Abdominal x-ray CT scan negative obstruction. patient started reglan aggressive bowel regimen. Following withdrawal sedation patient's respiratory status improved, ileus improved well. Lactulose continued less frequently prophylaxis hepatic encephalopathy eventually discontinued. reglan stopped. developed loose stools/ diarrhea treated below. 8. Diarrhea - Patient continued loose stools ever since ileus resolved. stool frequency improved stopping lactulose continued remain loose. C diff. toxin checked multiple times remained negative. likely diarrhea related tube feeds banana flakes added recently subsequent improvement diarrhea. 9. Altered mental status - Attributed hepatic encephalopathy addition sedating meds treatment abdominal pain. Standing lactulose started therapy hepatic encephalopathy also given broad spectrum antibiotics treatment possible infections. Patient protracted hospital course minimal improvement mental status began show dramatic improvement mid [Month (only) 547], approximately one month initiation defibrotide. mental status continued improve throughout ICU course able interact appropriately. antibiotics lactulose ultimately discontinued. 10. Renal failure - patient found new renal failure began [2155-4-10]. Per renal, etiology consistent ischemic ATN. initial hypotensive insult likely secondary hepatorenal syndrome. patient started CVVH [2155-4-12] worsening metabolic acidosis. continued severely oliguric throughout admission restoration renal function. patient's severe volume overload corrected gradually via CVVH continued ongoing pressor requirement. Midodrine started effort improve patient's blood pressures could transitioned HD. eventually transitioned HD without ultrafiltration, tolerated well. 11. EKG Changes: patient subtle ST depressions beginning [Month (only) 116] setting decreased mentation hypotension. ruled MI depressions since resolved. likely related demand setting hypotension. 12. Neutropenic fevers - admission, patient kept broad spectrum antibiotics neutropenic fevers (vancomycin/cefepime/ganciclovir/micafungin). Infectious disease consulted. Patient culture negative source infection identified. Antibiotics stopped [4-12] following recovery neutrophil counts. treated later hospital course pseudomonas pneumonia (see above). 13. Hyperglycemia: Patient blood sugars persistently 200-300. Regular insulin added TPN, patient placed Regular Insulin SS. may represent diabetes. need ongoing monitoring upon discharge rehabilitation center follow-up primary care provider. 14. Follicular Lymphoma: Patient status post BEAM Auto SCT [2155-4-2]. Patient engrafted. Received IV solumedrol x1 anti-inflammatory effect. Received filgrastim ANC>1000 (discontinued [2155-4-12]). continued atovaquone prophylaxis PCP concern absorbed appeared present diarrhea. given one dose inhaled pentamidine [2155-6-9] continued atovaquone. diarrhea continues improve, remain atovaquone likely need another dose inhaled pentamidine one month [2155-6-9]. also remains Acyclovir prophylaxis. 15. Deep Vein Thombosis Prophylaxis: Patient started heparin due low platelets. Patient repeatedly offered pneumoboots, usually declined wear pneumoboots. Encourage aggressive physical therapy. Medications Admission: Multivitamin current medications Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) needed dry eyes. 2. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times day). 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): give every day, dialysis days give daily dose dialysis. 4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) needed insomnia. 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once day (in morning)). 7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once day (in evening)). 8. Insulin Regular Human 100 unit/mL Solution Sig: per scale Injection ASDIR (AS DIRECTED). 9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 10. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): uptitrate tolerated. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary: - Follicular Lymphoma - Renal Failure, Acute tubular necrosis, requiring hemodialysis. - Respiratory Failure - Hepatic Failure Secondary Venous Occlusive Disease - Hypotension - Multi-Drug Resistant Pseudomonal Pneumonia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Bedbound. Blood pressure: SBPs 50-80s good mentation. concerned blood pressure, monitor change mental status. Patient tolerating low blood pressures attributed deconditioning. Discharge Instructions: admitted bone marrow transplant. prolonged hospital course complicated liver failure, infection, persistent low blood pressure, kidney failure, respiratory failure ultimately required trach tube placement. clinical status ultimately improved. discharged rehab facility care. started many different medications hospital course. follow medication list provided time discharge. pleasure taking part medical care. Followup Instructions: need see following providers within timeframe below. working schedule appointments you, please call following offices [2-1] days time get appointment information: PROVIDER: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD SPECIALTY: HEMATOLOGY/ONCOLOGY TELEPHONE: ([Telephone/Fax (1) 3936] TIMEFRAME: within 2-4 weeks PROVIDER: [Name10 (NameIs) ] [Name8 (MD) ], MD SPECIALTY: LIVER TELEPHONE: ([Telephone/Fax (1) 1582] TIMEFRAME: within 2-4 weeks. need see primary care doctor within 2 weeks discharge rehab facilty. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "5845", "51881", "2762", "5180", "2875", "311" ]
Admission Date: [2182-8-1] [Month/Day/Year ] Date: [2182-8-23] Date Birth: [2103-1-20] Sex: Service: MEDICINE Allergies: Penicillins / ciprofloxacin / Cephalosporins Attending:[First Name3 (LF) 3063] Chief Complaint: Weakness/Fluid Overload Major Surgical Invasive Procedure: drainage pericardial effusion drainage plerual effusion pleacement removal temporary dialysis catheter placement tunneled dialysis catheter History Present Illness: 79M PHX h/o Fib Coumadin, moderate severe AI s/p AVR [2182-6-27], reccently readmitted [7-15] BRBPR likely [1-17] anticoagulation diverticulosis discharged [7-23] [Hospital1 100] Home, readmitted worsening weakness fluid overload. Patient states since sent [Hospital 100] Rehab, gotten worse, better. participate physical therapy, able walk walker well before. breathing much worse baseline- mostly feels weak. seen Dr [Last Name (STitle) 911] office [7-31] found patient fluid overload admitted monitoring fluid status house likely IV diuresis. house previous admission, Aspirin stoppd coumadin continued. Patient also complaining new stool incontinence, found c. diff positive per PCR started 2 weeks metronidazole completed [2182-8-2]. admission patient TTE's [7-19] [7-22] demonstarted moderate pericardial effusion without signs tamponade (likely [1-17] recent CT surgery). Admission c/b initially difficult control Afib/RVR finally controled diltiazem CD 120 mg po daily metoprolol tartrate 75 mg po daily; also fluid load (known CHF LVEF 45%) treated IV diureis. discharged [Hospital 100] Rehab [7-23]. . arrival floor, patient comfortable complaints. REVIEW SYSTEMS review systems, s/he denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis. S/he denies recent fevers, chills rigors. S/he denies exertional buttock calf pain. review systems negative. Cardiac review systems notable absence chest pain, syncope presyncope. patient occasional PND, [1-18] pillow orthopnea, occasional palpitations Fib, sometimes trouble breathing exertion. Past Medical History: - Moderate-to-severe aortic insufficiency dilated LV (LVEF 50-55%), s/p bioprosthetic AVR [2182-6-27] - Recent cardiac catheterization showing obstructive coronary artery disease, however, found elevated filling pressures, requiring diuresis - Atrial fibrillation, currently Coumadin thromboembolic prophylaxis - Hypertension - Kidney transplant [2155] due PCKD, baseline creatinine approximately 1.6 - Hyperlipidemia - Peripheral neuropathy - Diverticulitis - Pseudogout - Osteoporosis Social History: Patient previously worked engineer channel 5. currently lives house himself. wife passed away 9 years ago. Prior history 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). illicits. daughters ([Doctor First Name ] (daughter) - ([Telephone/Fax (1) 101330], [Female First Name (un) ] (daughter) [0-0-]) involved. Family History: family history early MI, arrhythmia, cardiomyopathies, sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION VS- T=98.1 BP=103/69 HR=101 RR=18 O2 sat=97RA Pulsus-10mmHg GENERAL- mild resp distress. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK- Supple JVP 16 cm. CARDIAC- PMI located 5th intercostal space, midclavicular line. irregularly irregular, normal S1, S2. murmurs appreciated. thrills, lifts. S3 S4. LUNGS- chest wall deformities, scoliosis kyphosis. Resp somewhat labored, [Month (only) ] breath sounds b/l bases ABDOMEN- Soft, NTND. HSM tenderness, mild ascites percussed, Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES- warm, pulses well palpated, 3+ pitting edema distal LE lower knee b/l SKIN- stasis dermatitis, ulcers, scars, xanthomas. Back- 2+ pitting sacral edema [Month (only) 894] VITAL SIGNS: 98.0. 85. 140/76. 24. 98% RA GENERAL: A&Ox3. NAD. HEENT: Sclera anicteric. PERRL, EOMI, MMM. JVP elevated. CARDIAC: irregularly irregular, nl S1, S2. III/VI systolic ejection murmur. LUNGS: Decreased breath sounds bilaterally bases. ABDOMEN: +BS, soft, NTND. HSM. EXTREMITIES: 1+ lower ext edema bilaterally ankles. SKIN: large ecchymosis left leg small ecchmyosis around tunneled cath site. ACCESS: tunneled catheter place. Pertinent Results: ADMISSION [2182-8-1] 07:30PM GLUCOSE-150* UREA N-57* CREAT-1.8* SODIUM-141 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [2182-8-1] 07:30PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.7 [2182-8-1] 07:30PM WBC-5.5 RBC-3.65* HGB-11.3* HCT-36.7* MCV-101* MCH-31.0 MCHC-30.8* RDW-19.4* [2182-8-1] 07:30PM PLT COUNT-162 [2182-8-1] 07:30PM PT-40.4* INR(PT)-4.0* LABS: [2182-8-23] 06:07AM BLOOD WBC-6.6 RBC-2.60* Hgb-7.9* Hct-25.7* MCV-99* MCH-30.5 MCHC-30.9* RDW-19.7* Plt Ct-169 [2182-8-23] 06:07AM BLOOD PT-33.8* PTT-36.0 INR(PT)-3.3* [2182-8-22] 05:51AM BLOOD PT-27.4* PTT-34.1 INR(PT)-2.6* [2182-8-21] 07:10AM BLOOD PT-23.5* PTT-32.9 INR(PT)-2.2* [2182-8-20] 06:00AM BLOOD PT-22.1* INR(PT)-2.1* [2182-8-18] 05:58AM BLOOD PT-17.3* PTT-31.2 INR(PT)-1.6* [2182-8-17] 06:39AM BLOOD PT-15.5* PTT-31.8 INR(PT)-1.5* [2182-8-15] 02:51AM BLOOD PT-16.5* PTT-99.3* INR(PT)-1.6* [2182-8-14] 05:19AM BLOOD PT-17.5* PTT-32.2 INR(PT)-1.6* [2182-8-13] 05:05AM BLOOD PT-17.3* PTT-34.4 INR(PT)-1.6* [2182-8-23] 06:07AM BLOOD Glucose-76 UreaN-33* Creat-3.2* Na-135 K-4.8 Cl-97 HCO3-26 AnGap-17 [2182-8-13] 05:05AM BLOOD ALT-13 AST-23 AlkPhos-283* TotBili-0.8 [2182-8-23] 06:07AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1 [2182-8-18] 05:58AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 Iron-37* [2182-8-18] 05:58AM BLOOD calTIBC-131* Ferritn-748* TRF-101* [2182-8-11] 06:07AM BLOOD Hapto-173 [2182-8-1] 07:30PM BLOOD TSH-2.3 [2182-8-13] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE PERICARDIAL FLUID CYTOLOGY: NEGATIVE MALIGNANT CELLS. PLEURAL FLUID CYTOLOGY: NEGATIVE MALIGNANT CELLS. Paucicellular specimen scattered mesothelial cells, histiocytes, predominantly blood. [2182-8-2] 5:15 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [2182-8-2]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. FLUID CULTURE (Final [2182-8-5]): GROWTH. ANAEROBIC CULTURE (Final [2182-8-8]): GROWTH. FUNGAL CULTURE (Final [2182-8-16]): FUNGUS ISOLATED. ACID FAST SMEAR (Final [2182-8-3]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. [2182-8-4] 10:55 BLOOD CULTURE Source: Line-picc. FINAL REPORT [2182-8-10] Blood Culture, Routine (Final [2182-8-10]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. Cefazolin interpretative criteria based dosage regimen 2g every 8h. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 2. Piperacillin/Tazobactam sensitivity testing performed [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. Cefazolin interpretative criteria based dosage regimen 2g every 8h. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 3. Piperacillin/Tazobactam sensitivity testing performed [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. Cefazolin interpretative criteria based dosage regimen 2g every 8h. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| KLEBSIELLA PNEUMONIAE \| \| KLEBSIELLA PNEUMONIAE \| \| \| AMPICILLIN/SULBACTAM-- 4 8 4 CEFAZOLIN------------- <=4 <=4 <=4 CEFEPIME-------------- <=1 <=1 <=1 CEFTAZIDIME----------- <=1 <=1 <=1 CEFTRIAXONE----------- <=1 <=1 <=1 CIPROFLOXACIN---------<=0.25 <=0.25 <=0.25 GENTAMICIN------------ <=1 <=1 <=1 MEROPENEM-------------<=0.25 <=0.25 <=0.25 PIPERACILLIN/TAZO----- TOBRAMYCIN------------ <=1 <=1 <=1 TRIMETHOPRIM/SULFA---- <=1 <=1 <=1 Anaerobic Bottle Gram Stain (Final [2182-8-5]): Reported read back DR. [Last Name (STitle) ] [Last Name (NamePattern4) 101334] [2182-8-5] 0530. GRAM NEGATIVE ROD(S). [2182-8-4] 10:54 URINE Source: Catheter. FINAL REPORT [2182-8-6] URINE CULTURE (Final [2182-8-6]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available request. Cefazolin interpretative criteria based dosage regimen 2g every 8h. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 CEFAZOLIN------------- <=4 CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CIPROFLOXACIN---------<=0.25 GENTAMICIN------------ <=1 MEROPENEM-------------<=0.25 NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ <=1 TRIMETHOPRIM/SULFA---- <=1 ANAEROBIC CULTURE (Final [2182-8-4]): Test performed suprapubic kidney aspirates received syringe. TEST CANCELLED, PATIENT CREDITED. [2182-8-7] 6:09 pm PLEURAL FLUID PLEURAL FLUID. FINAL REPORT [2182-8-13] GRAM STAIN (Final [2182-8-7]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. concentrated smear made cytospin method, please refer hematology quantitative white blood cell count.. FLUID CULTURE (Final [2182-8-10]): GROWTH. ANAEROBIC CULTURE (Final [2182-8-13]): GROWTH. [2182-8-6] 11:38 BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2182-8-12] Blood Culture, Routine (Final [2182-8-12]): GROWTH. [2182-8-6] 2:52 CATHETER TIP-IV Source: left picc line. FINAL REPORT [2182-8-8] WOUND CULTURE (Final [2182-8-8]): significant growth. [2182-8-5] 10:10 BLOOD CULTURE Source: Line-white port PICC. FINAL REPORT [2182-8-11] Blood Culture, Routine (Final [2182-8-11]): GROWTH. Echo [2182-8-2] moderate global left ventricular hypokinesis (LVEF = 35%). Right ventricular chamber size normal. moderate global free wall hypokinesis. bioprosthetic aortic valve prosthesis present. aortic valve prosthesis cannot adequately assessed. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Tricuspid regurgitation present cannot quantified. large pericardial effusion. effusion appears circumferential. right ventricular diastolic collapse seen. IMPRESSION: Large circumferential pericardial effusion. echocardiographic signs tamponade. Right ventricular hypertrophy enlargement raise suspicion underlying pulmonary hypertension (not confirmed study), may limit sensitivity echocardiographic evaluation tamponade. CXR [2182-8-1]: Large right pleural effusion markedly increased. Moderate cardiomegaly partially obscured right pleural effusion. atelectasis lower lobes bilaterally, right greater left, right upper lobes. probably small left pleural effusion. pulmonary edema. Sternal wires aligned. IMPRESSION: Markedly increase size large right pleural effusion. CXR [2182-8-14]: Small-to-moderate bilateral pleural effusions decreased substantially. Although cardiac silhouette remains enlarged, less distention mediastinal veins previous mild pulmonary edema largely cleared. Left lower lobe remains collapsed. supraclavicular central venous dual-channel catheter replaced small-bore catheter, ending mid-to-low SVC. TTE [2182-8-5]: Left ventricular wall thicknesses cavity size normal. small (<0.5cm) pericardial effusion along basal inferolateral wall, basal lateral, apical lateral wall. evidence hemodynamic compromise. IMPRESSION: small pericardial effusion without evidence hemodynamnic compromise RENAL ULTRASOUND [2182-8-9]: 1. Persistent though improved high resistance waveforms throughout arterial system including intrarenal main renal arteries. 2. Irregularly irregular waveforms suggests arrhythmia. 3. Stable large rounded calcifications unclear etiology. Predominantly pyramidal location suggestive medullary nephrocalcinosis; however, scattered cortical calcifications consistive diagnosis. hydronephrosis. RIGHT LEFT CARDIAC CATH [2182-8-12]: 1. Resting hemodynamics revealed markedly elevated left right-sided filling pressure consistent severe diastolic heart failure. also moderate pulmonary arterial hypertension. 2. cardiac output cardiac index preserved. FINAL DIAGNOSIS: 1. Severely elevated filling pressures consistent diastolic heart failure. 2. Preserved cardiac output cardiac index. Brief Hospital Course: 79 yo PMHx moderate severe AI decreased EF s/p bioprosthetic AVR [2182-6-27], recently admitted [Date range (1) 57819] BRBPR, presenting weakness fluid overload, cardiac echo significant worsening pericardial effusion, going pericardiocentesis day admission, hospitalization complicated renal failure requiring dialysis, klebsiella urosepsis, atrial fibrillation RVR. #Acute Diastolic Heart Failure: Patient presented Dr. [Name (NI) 39743] office weighing 15 lbs previous [Name (NI) ] edemetous exam. admitted [Hospital1 1516] diuresis. transferred CCU following pericardial drainage aggressive diuresis. started Lasix ggt moderate UOP. goal 2L daily metolazone added minimal improvement. Diuresis eventually held setting rising creatinine poor UOP ultimately dialysis initiated removal fluid (see below). believed symtoms might secondary constrictive cardiomyopathy. Cath [8-12] showed elevated R L-sided pressures preserved CI CO. Due progressive renal failure renal graft, commenced HD via temporary catheter tunnelled line placed durable access. volume removal HD, respiratory status peripheral edeam improved. #Moderate Pericardial Effusion: Previously visualized increased based echo done admission. Small amount RV diastolic collapse. Pulsus 10mmHg, ECG shows mild electrical alternans. Voltage unchanged prior ECG. Pt bloody pericardial drainage drain placement, felt [1-17] high INR (4). Repeat echo showed resolution effusion. #Respiratory distress: pt admitted required several liters 02 via face mask maintain saturations low 90's. CXR consistent pulmonary edema. Oxygen saturations improved following pericardial drainage diuresis. continued SOB O2 requirement right sided thoracentesis performed drained 2L exudate many RBCs. diuresis later HD, volume overload oxygen requirement likewise improved. #Klebsiella sepsis: Pt positive blood culture urine culture Klebsiella, blood growing three pan-sensitive strains. febrile hypotensive time diagnosis treated broadly vanc/cefepime prior narrowing ceftriaxone. Pt remained afebrile normotensive following initiation abx. Pt's PICC line removed (+) BC drawn it. completed total 2 week course CTX ending [2182-8-18]. #Atrial Fibrillation RVR: CHADS2 score 3, coumadin home. Coumadin held intially INR supratherapeutic admission, resumed prior d/c. Prior admission, pt rate-controlled metoprolol 75mg [Hospital1 ] 120mg daily diltiazem. dilt held briefly allow pt tolerate HD, resumed first HD sessions. [Hospital1 ], doses adjusted toprol xl 100mg daily diltiazem CR 180mg daily. occasionally RVR 110-120 late doses, responds quickly oral meds. INR 3.3 [Hospital1 ] increasing slowly past days hospitalization despite decreasing warfarin. need 1mg daily daily INR checks stabilized. Nutritional optimization necessary. #Renal Failure: s/p renal transplant 25 years ago PKD baseline creatinine 1.6. initally kept home cyclosporine prednisone immunosupression. Renal transplant service followed pt throughout admission. Pt's Cr continued trend diuresis 3.9. etiology initially felt ATN, given lack renal recovery, eitology became unclear. diuresis held pt believed pre-renally intravascularly depleted despite fluid overloaded. respond albumin ultimately became oliguric. Given anasarca lack response diuretics, HD initiated. received tunnelled HD line [8-20] durable access. CSA discontinued initially restarted [Month/Day (4) ] attempt 2 week trial course rescue graft. continue 100mg daily. urine output increase noted 2 weeks, probably discontinue cyclosporin. prednisone continued 5mg daily. may regain renal function, remains oligo-anuric [Month/Day (4) ]. anuric x24hr greater, please bladder scan rule obstruction/retention. need HD MWF LTAC, followup renal transplant surgery. #Recent GI Bleed: H/H monitored. recieved 1 unit pRBCs admission anemia felt [1-17] decreased epo setting renal failure phelbotomy. marroon stools 5 days without signfiicant HCT drop setting heparin gtt, likely diverticular. GI consulted intervention taken. f/u GI outpatient. #Delirium: Felt multifactorial, ICU delerium well uremia. Pt's mental status improved HD. aggitated rather endorsed delusions grandeur hypoactivity. Care taken maintaine sleep-wake cycle. #Hyperlipidemia: Patient maintained home atorvastatin 20mg daily. #Depression: SW provided support pt famiyl hospital stay. maintained home SSRI. #Gout: Febuxostat changed renally-dosed allopurinol setting renal failure #depression: started citalopram 10mg daily, need titratrion depressive symptoms continue next several weeks. # Code status: Pt intially full code admission. became mroe ill setting renal failure, expressed wishing die also endorsed wanting things done could prolong life. Multiple conversations pt family, particularly prior starting HD. Ultimately, pt endorsed wanting DNR/DNI and, given episodes delerium, pt's daughters felt consistant father's wishes. agreement going forward HD. # dysphagia: diet advanced regular time discharge1. PO diet: thin liquid regular consistency solids. 2. Meds whole thin liquid applesauce. Transitional Issues: - need titration warfarin INR goal [1-18] - f/u renal transplant surgery - f/u cardiology CHF volume management - HD MWF - Trial cyclosporin 100mg daily roughly 2 weeks. Check 24hr trough one week level goal <100. oliguria persists 2 weeks, likely stop cyclosporin. . MEDICATIONS STARTED Allopurinol 150 mg PO EVERY DAY . MEDICATIONS CHANGED Diltiazem ER increased 120mg daily 180 mg daily Metoprolol Tartrate 75 mg PO BID Metoprolol Succinate XL 100 mg PO DAILY Warfarin 2.5mg 1mg daily . MEDICATIONS STOPPED: Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] Flagyl course completed Furosemide Febuxostat . Pending tests [Hospital1 ]: -none Medications Admission: Preadmission medications listed correct complete. Information obtained webOMR. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Ascorbic Acid 500 mg PO TID 3. Calcium Carbonate 1000 mg PO DAILY 4. Cholestyramine 4 gm PO DAILY 5. CycloSPORINE (Sandimmune) 100 mg PO Q24H 6. Diltiazem Extended-Release 120 mg PO DAILY 7. Febuxostat 40 mg PO DAILY 8. Ferrous Sulfate 325 mg PO TID 9. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 11. Furosemide 40 mg PO BID 12. Lovastatin NF 20 mg ORAL DAILY Reason Ordering: Wish maintain preadmission medication hospitalized, acceptable substitute drug product available formulary. 13. Metoprolol Tartrate 75 mg PO BID 14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 15. Multivitamins 1 TAB PO DAILY 16. Omeprazole 40 mg PO DAILY 17. PredniSONE 5 mg PO DAILY 18. Vitamin 800 UNIT PO DAILY 19. Warfarin 2.5 mg PO DAILY16 [Hospital1 ] Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Allopurinol 150 mg PO EVERY DAY 3. Citalopram 10 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Nephrocaps 1 CAP PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 7. Senna 1 TAB PO BID:PRN constipation 8. Ascorbic Acid 500 mg PO TID 9. Calcium Carbonate 1000 mg PO DAILY 10. Ferrous Sulfate 325 mg PO TID 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 12. PredniSONE 5 mg PO DAILY 13. Vitamin 800 UNIT PO DAILY 14. Lovastatin NF 20 mg ORAL DAILY Reason Ordering: Wish maintain preadmission medication hospitalized, acceptable substitute drug product available formulary. 15. Omeprazole 40 mg PO DAILY 16. Diltiazem Extended-Release 180 mg PO DAILY hold SBP < 100, HR < 60. 17. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 18. Cholestyramine 4 gm PO DAILY 19. Metoprolol Succinate XL 100 mg PO DAILY hold SBP < 100, HR < 60 20. Warfarin 1 mg PO DAILY16 21. CycloSPORINE (Sandimmune) 100 mg PO Q24H [Hospital1 ] Disposition: Extended Care Facility: [Hospital ] rehab macu [Hospital ] Diagnosis: primary: pericardial effusion tamponade s/p drainage renal failure . secondary: Klebsiella UTI bacteremia atrial fibrilation acute chronic dialstolic heart failure [Hospital ] Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. [Hospital ] Instructions: Mr. [Known lastname 57554], . pleasure taking care [Hospital1 ]. admitted hospital found much fluid body clinic. found fluid around heart, drained. Unfortunately, here, kidney failed started dialysis. also treated infection blood urine here. . Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. . need continue dialysis Monday, Wednesdays Fridays. also need follow cardiologist outpatient. mild bleeding intestines, see GI doctor outpatient. also see heart failure specialist outpatient. spend time getting stronger rehab physical therapy. Many changes made medications explained following sheet. wish best luck, Mr. [Known lastname 57554]! Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2182-8-28] 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: TRANSPLANT CENTER When: THURSDAY [2182-9-5] 3:00 PM With: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Congestive Heart Failure Clinic [2182-9-10] 1pm Dr. [Last Name (STitle) ] [Location (un) 436] [Hospital Ward Name ] center, [Hospital Ward Name ] Phone: ([Telephone/Fax (1) 2037] Department: DIV. GASTROENTEROLOGY When: TUESDAY [2182-8-27] 2:00 PM With: [Doctor First Name 23138] [First Name8 (NamePattern2) 23139] [Name8 (MD) 815], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Completed by:[2182-8-25]	[ "5845", "5070", "5990", "2761", "4280", "42731", "4168", "4019", "311", "2724", "V1582" ]
Admission Date: [2109-3-28] Discharge Date: [2109-4-4] Date Birth: [2032-2-8] Sex: Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: SOB exertion Major Surgical Invasive Procedure: CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA), AVR (tissue) [2109-3-28] History Present Illness: Ms. [Known lastname ] 77 ywar old male presented DOE, underwent stress test positive, referred cardiac catheterization showed severe thre vessel disease aortic stenosis. Past Medical History: Hypercholesterolemia Anemia Bilateral knee arthritis s/p TURP s/p appy Social History: pipe smoker, etoh. Works director research center Family History: Father deceased MI 72 Mother deceased MI 76 Physical Exam: admission: NAD HEENT unremarkable Lungs CTAB RRR 3/6 systolic murmur Abd benign edema Neuro intact Carotids transmitted bruits Pertinent Results: [2109-4-3] 06:23AM BLOOD Hct-25.0* [2109-4-2] 06:23AM BLOOD Hct-25.6* [2109-3-31] 05:55AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.1* Hct-29.1* MCV-82 MCH-28.5 MCHC-34.9 RDW-18.2* Plt Ct-155 [2109-4-4] 06:32AM BLOOD PT-19.9* PTT-60.5* INR(PT)-1.9* [2109-4-3] 06:23AM BLOOD UreaN-28* Creat-1.1 K-3.9 Brief Hospital Course: Mr. [Known lastname ] admitted morning surgery, taken operating room [2109-3-28] underwent CABG x 3 (LIMA->LAD, SVG->OM & PDA) AVR 25 mm CE pericardial valve. wsa transferred intensive care unit critical stable condition. Postoperatively noted right pneumothorax chest tube placed near total resolution pneumothorax. ws extubated POD 0, invasive lines mediastinal drains discontinued POD 1. multiple episodes atrial fibrillation ws treated amiodarone anticoagulated heparin coumadin. INR [4-4] 1.9 ready discharge home. Dr.[Name (NI) 5765] office contact[Name (NI) ] follow INR discharge. Medications Admission: Lipitor Toprol ASA FeSo4 Glucosamine Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed pain. Disp:40 Tablet(s) Refills:0 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 7 days. Disp:14 Tablet(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO day 7 days: 400 mg(2 tablets) daily 1 week, 200 mg(1 tablet) daily d/c'd Dr. [Last Name (STitle) ]. Disp:90 Tablet(s) Refills:0 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:0 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:0 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO bedtime: Check INR [4-5] results called Dr. [Last Name (STitle) ]. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD hypercholesterolemia arthritis post-op AFib Discharge Condition: good Discharge Instructions: lifting > 10# 10 weeks may shower, bathing swimming 1 month creams, lotions powders incisions call fever, redness drainage incision weight gain 2 pounds one day five one week. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (STitle) ] [12-28] weeks Dr. [Last Name (STitle) ] [12-28] weeks INR check coumadin dosing Dr. [Last Name (Prefixes) ] 4 weeks Completed by:[2109-4-4]	[ "41401", "4241", "42731", "2720" ]
Admission Date: [2154-1-7] Discharge Date: [2154-1-17] Date Birth: [2090-2-7] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal cancer. Major Surgical Invasive Procedure: [2154-1-7]: Transhiatal esophagectomy, placement jejunostomy tube, pyloroplasty, umbilical hernia repair. History Present Illness: patient 63-year-old lady presented nine-month history voice change. Despite medical history, excellent performance status preoperatively. Upon daughter's request, underwent upper endoscopy [2153-9-26] showed nodule gastroesophageal junction biopsied. Pathology specimen indicated high-grade dysplasia. However, repeat pathologic evaluation specimen obtained [Hospital1 24300] Hospital confirmed presence intramucosal carcinoma setting high-grade dysplasia. Endoscopy, EUS PET scan performed suggesting T1a, N0, stage esophageal carcinoma. operative indication, patient brought operating room transhiatal esophagectomy. Past Medical History: Non-insulin dependent diabetes Hypertension Hypercholesterolemia Rheumatic fever Glaucoma Diverticulosis Roscea PSH: lap chole [2151] right tigger finger [Doctor First Name ] [2152], L rotator cuff repair [2149], C4-6 laminectomy foraminotomy [2147], facial resurfacing [2149], b/l glaucoma [Doctor First Name ], left LE vein striping Social History: Married, lives family. Tobacco quit 34 years ago, ETOH occasional Family History: Father- throat ca died 60yrs [Name (NI) 82040] sister died [Name2 (NI) 499] ca [2128] Physical Exam: VS: T: 98.8 HR: 95-100 SR BP: 110-120/60-70 Sats: 96% RA Wt: 77.1 kg General: sitting chair apparent distress Card: RRR Resp: diminished breath sounds bases otherwise clear GI: bowel sounds positive, abdomen soft. J-tube place site clean erythema Extr: warm 1+ bilateral edema Incision: neck incision clean, dry intact steri-strips, abdominal clean dry intact staples Neuro: non-focal Pertinent Results: [2154-1-14] WBC-6.3 RBC-3.07* Hgb-9.0* Hct-26.4* Plt Ct-304 [2154-1-12] WBC-7.5 RBC-2.79* Hgb-8.1* Hct-23.5* Plt Ct-254 [2154-1-11] WBC-7.2 RBC-2.78* Hgb-8.2* Hct-23.4* Plt Ct-217 [2154-1-7] WBC-5.6 RBC-3.51* Hgb-10.3# Hct-28.9 Plt Ct-227 [2154-1-17] Glucose-250* UreaN-18 Creat-0.6 Na-135 K-4.9 Cl-94* HCO3-33* [2154-1-16] Glucose-244* UreaN-24* Creat-0.7 Na-134 K-3.9 Cl-97 HCO3-29 [2154-1-15] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103 HCO3-27 [2154-1-15] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103 HCO3-27 [2154-1-14] Glucose-257* UreaN-30* Creat-0.7 Na-141 K-4.0 Cl-107 HCO3-22 [2154-1-13] Glucose-139* UreaN-27* Creat-0.8 Na-143 K-3.4 Cl-110* HCO3-23 [2154-1-12] Glucose-116* UreaN-21* Creat-0.7 Na-142 K-4.5 Cl-112* HCO3-21* [2154-1-8] Glucose-183* UreaN-8 Creat-0.6 Na-138 K-4.5 Cl-106 HCO3-24 [2154-1-7] Glucose-120* UreaN-11 Creat-0.7 Na-139 K-3.1* Cl-104 HCO3-25 AnGa [2154-1-9] ALT-74* AST-69* LD(LDH)-257* AlkPhos-57 Amylase-41 TotBili-0.8 [2154-1-15] Calcium-8.8 Phos-2.4* Mg-1.8 Culture: Blood cultures [2154-1-9]: growth x2, Urine Culture growth CXR: [2154-1-16]: significant interval improvement within right subpulmonic effusion, small size. persistent bibasilar atelectasis. lungs otherwise clear signs pneumonia congestive heart failure. Cardiomediastinal silhouette stable moderate cardiomegaly tortuosity aorta. [2154-1-13]: 1. pneumothorax following chest tube removal. 2. Slight worsening right lower lobe atelectasis adjacent pleural effusion. substantial change left lower lobe atelectasis. [2154-1-10]: improvement left small pleural effusion atelectasis, however progression small right pleural effusion atelectasis. Lines tubes remain similar position. cardiomediastinal silhouette stable tiny amount mediastinal air consistent post-esophagectomy changes [2154-1-7]: Interval placement ET tube, NG tube, left chest tube, epidural catheter appropriate positions. Interval left pleural effusion bibasilar atelectasis. Brief Hospital Course: Mrs. [Known lastname 4886] admitted [2154-1-7] Transhiatal esophagectomy, placement jejunostomy tube, pyloroplasty, umbilical hernia repair. transferred ICU intubated stable condition left chest tube suction, NGT low-wall suction, foley, neck JP, Bupivacaine/Dilaudid epidural pain control. POD1 extubed. found hypotensive epidural titrated administered fluid bolus good result. POD2 bed chair transferred Floor returned ICU respiratory distress, atelectasis hypoxemia. spiked fever, pan cultured grew organism. sensitive narcotics epidural removed. pain managed Tylenol Toradol. Beta-blockers started tachycardia. POD3 pain better control, gently diuresed pulmonary toileting continued. POD4 chest film showed right lower lobe effusion/atelectasis. right lower lobe ultrasound showed minimal effusion. started trophic tube feeds. continued improve transferred ICU POD5. POD6 chest-tube NGT removed. activity increased increase discomfor started Roxicet good control. seen physical therapy recommended STR. bowel function returned tube feeds increased. Nutrition consulted recommended Fibersource HN Goal rate 55 cc/hr. POD7 [Hospital ] clinic consulted better management diabetes. started insulin. grape juice challenge given obvious anastomoses leak. started clear liquid diet advanced fulls. POD8 JP removed. insulin titrated elevated blood sugars. medications converted PO meds. POD 9 required gentle diuresing. electrolytes replete. continued make steady progress transferred rehab. follow-up Dr. [Last Name (STitle) ] outpatient. Medications Admission: Lisinopril 40mg qAM, Lipitor 20mg qHS, metformin 500mg [Hospital1 ], Avandia 4mg [Hospital1 ], glyburide 5mg [Hospital1 ], Aspirin 81mg daily, vitamin 2 AM, 2PM, Calcium 600mg +VitD 1 AM, 1PM, HCTZ 25mg qAM, doxycycline 100mg [Hospital1 ], omeprazole 20mg qAM, Lunigan drop 1 drop eye qHS Discharge Medications: 1. Latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 2. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Five (5) PO BID (2 times day). 3. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO three times day. Disp:90 Tablet(s) Refills:2 4. Atorvastatin 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times day). Disp:60 Tablet,Rapid Dissolve, DR(s) Refills:2 6. Hydrochlorothiazide 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. 7. Nutren Pulmonary Full strength; Tube Feeds via J-tube Cycle 70 ml/hr x 15 hrs 8. Ibuprofen 100 mg/5 mL Suspension [Last Name (STitle) ]: One (1) PO Q8H (every 8 hours) needed. 9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [Last Name (STitle) ]: One (1) PO DAILY (Daily). 10. Oxycodone 5 mg/5 mL Solution [Last Name (STitle) ]: Five (5) MMML PO Q4H (every 4 hours) needed pain. 11. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: Ten (10) ML PO every six (6) hours needed pain. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization [Last Name (STitle) ]: Three (3) Inhalation every 4-6 hours needed shortness breath wheezing. 13. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: Three (3) ML Inhalation Q6H (every 6 hours). 14. Insulin Glargine 100 unit/mL Cartridge [Last Name (STitle) ]: Thirty Two (32) Units Subcutaneous Dinner time. 15. Lisinopril 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO day: please titrate blood pressure tolerates. Home dose 20mg daily. 16. Aspirin 81 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO day. 17. Regular Insulin Sliding Scale 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 0 Units 141-160 mg/dL 4 Units 4 Units 4 Units 0 Units 161-180 mg/dL 6 Units 6 Units 6 Units 0 Units 181-200 mg/dL 8 Units 8 Units 8 Units 4 Units 201-220 mg/dL 10 Units 10 Units 10 Units 6 Units 221-240 mg/dL 12 Units 12 Units 12 Units 10 Units 241-260 mg/dL 14 Units 14 Units 14 Units 12 Units 261-280 mg/dL 16 Units 16 Units 16 Units 14 Units 281-300 mg/dL 18 Units 18 Units 18 Units 16 Units 301-320 mg/dL 20 Units 20 Units 20 Units 18 Units Discharge Disposition: Extended Care Facility: [Hospital 671] Healthcare Center Discharge Diagnosis: Non-insulin dependent diabetes Hypertension Hypercholesterolemia Rheumatic fever Glaucoma Diverticulosis Roscea PSH: lap chole [2151] right tigger finger [Doctor First Name ] [2152], L rotator cuff repair [2149], C4-6 laminectomy foraminotomy [2147], facial resurfacing [2149], b/l glaucoma [Doctor First Name ], left LE vein striping Discharge Condition: stable Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 4741] experience: -Fever > 101 chills. -Increased shortness breath, cough sputum production -Chest pain -Difficulty painful swallowing, abdominal pain, diarrhea -Incision develops drainage -HOB elevated 30 degree indefinitely Feeding tube sutures become loose break, please tape tube securely call office [Telephone/Fax (1) 4741]. feeding tube falls out, save tube, call office immediately [Telephone/Fax (1) 4741]. tube needs replaced timely manner tract close within hours. put medication tube unless liquid form. Flush feeding tube 50cc every 8 hours use every feeding. Followup Instructions: Follow-up Dr. [Last Name (STitle) ] [Telephone/Fax (1) 4741] [1-31] 2:00 pm [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) 24] Report [Location (un) 861] Radiology Department Barium Swallow appointment. Completed by:[2154-1-17]	[ "5180", "5119", "25000", "4019" ]
Admission Date: [2118-7-18] Discharge Date: [2118-7-22] Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 458] Chief Complaint: Ventricular Tachycardia Major Surgical Invasive Procedure: Cardiac Catheterization EP study History Present Illness: 86 y/o man w/ hitory CAD s/p 4vessel CABG [2096], CHF EF 35%, Atrial Flutter (not anticoagulated) chronic renal insufficiency sent [Location (un) ] ED outpatient stress test revealed inssesant non-sustained ventricular tachycardia. asymptomatic hemodynamically stable. given dose lidocaine transfered [Hospital1 18] ED. . @ [Hospital1 18] ED started lidocaine drip seen EP. Preliminary plans possible EP study VT ablation. ROS posative dyspnea excertion stable, history synope presyncope. Past Medical History: CAD s/p CABG [2096] 4v disease CRI severe COPD ([9-24] FEV1 0.91, FVC 1.76, decreased TLC, nl DLCO) HTN Hyperlipidemia subclavian stenosis aflutter sotalol prostate CA Social History: Social: Patient lives son, non-[Name2 (NI) 1818], etoh illicits. Ballroom dancing times per week. Family History: Family: family history premature heart disease Physical Exam: VS - 96.6 129/86 86 20 Gen: WDWN elderly male NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. Neck: Supple JVP 8cm. CV: PMI located 5th intercostal space, midclavicular line. RR, normal S1, S2. m/r/g. thrills, lifts. S3 S4. Chest: chest wall deformities, scoliosis kyphosis. Resp slightly unlabored, accessory muscle use. Lungs crackles @ bases bialterally, rhonchi diffuse soft wheezing. Abd: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. Ext: c/c/e. femoral bruits. Skin: stasis dermatitis, ulcers, scars, xanthomas. Pertinent Results: LABS ADMISSION: [2118-7-18] 06:55PM CK-MB-NotDone cTropnT-<0.01 [2118-7-18] 01:00PM GLUCOSE-107* UREA N-33* CREAT-1.7* SODIUM-140 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16 [2118-7-18] 01:00PM WBC-11.1* RBC-4.38* HGB-14.6 HCT-43.9 MCV-100* MCH-33.3* MCHC-33.3 RDW-13.7 [2118-7-18] 01:00PM CK-MB-NotDone cTropnT-0.01 . CARDIAC CATH: 1. Three vessel native coronary artery disease LMCA disease. 2. Patent LIMA, SVG Diaganol, SVG OM. SVG PDA moderate stenosis. 3. Moderate in-stent restenosis left subclavian artery stent. 4. Severe distal subclavian artery stenosis proximal LIMA. 5. Severe pulmonary arterial hypertension. 6. Moderate systemic arterial hypertension. 7. Severe left ventricular diastolic heart failure. . Brief Hospital Course: 86 yo male CAD s/p 4v CABG [2097], CHF EF 35%, atrial flutter/fib, CRI presented [Hospital1 18] stable sustained VT. . #Sustained VT / Rhythm taken EP lab VT ablation successful. VT terminated primary rhythym atrial fibrillation post procedure. Post-procedure, also noticed blue toe PACU. transfered care CCU. arterial venous sheaths pulled blood flow returned foot. DP pulses present w/ doppler bilaterally. re-started home dose sotalol [2118-7-20] resumed normal sinus rhythm [2118-7-21] around 10am. 6 point hct drop noted along continued bleeding groin, CT abdomen performed ruled retroperitoneal bleed. right groin ultrasound also performed rule pseudoaneurysm normal. Subsequently patient started heparin gtts bridge coumadin therapy goal inr [1-22] lovenox 80 mg daily permanent atrial fibrillation. . #CAD Patient also underwent L + R cardiac catheterization. LIMA grafts intact patent. angioplasty performed stents placed. continued ASA 325 mg, moexepril 7.5 mg daily, sotalol 80 mg daily. Atorvastatin 10 mg daily changed simvistatin 40 mg daily since LDL 101 (above goal 70). . #COPD Patient continued home medications atrovent albuterol. Ipratroprium albuterol nebulizer added final hospital day. discharged home medication advair + combivent. Right cardiac catheterization showed severe pulmonary hypertension. . #Subclavian stenosis patient admitted [Hospital Ward Name 121] 6 cardiology service. taken cath lab [7-19] showed proximal L subclavian disease (60-70% stenosis), intervened upon due technical factors. . #CHF continued home medications sotalol, moexepril. Lasix initially held due low blood pressures. Pressures remained systolic 80-90's; [7-21] also experienced one episode bradycardia hypotension likely junctional rhythm dosage sotalol home sotalol reduced 80 mg daily moexepril decreased 7.5 mg daily. Blood pressures remained subsequently sbp's 90-110s maps 60-70's. discharged sotalol 80 mg daily moexepril 7.5 mg daily. . #Incidentaloma Renal cysts found bilaterally CT abdomen exam. renal ultrasound performed showed simple renal cysts bilaterally. . Mr. [Known lastname 25699] remained afebrile entire hospitalization. remained hemodynamically stable 24 hrs prior discharge. home dose sotalol decreased 80 mg daily moexepril decreased 7.5 mg daily. atorvastatin stopped converted 40 mg daily simvistatin. ASA 325 mg daily initiated coumadin therapy started 5 mg daily persistent atrial fibrillation. Home dose medications advair continued started combivent. Lovenox 80 mg daily given 4 days coumadin 5 mg 5 days. INR checked Sunday [2118-7-24] dose warfarin adjusted accordingly. Medications Admission: sotalol 80 mg [Hospital1 ] lasix 20 mg daily lipitor 10 mg daily univasc 15 mg daily advair 250/50 1 puff [Hospital1 ] flonase Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). Disp:1 vial Refills:2 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times day): rinse mouth use. Disp:60 puff Refills:2 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:qs inhaler Refills:2 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO day: dose change based INR. . Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) ] geriatric Discharge Diagnosis: Primary Stable vtac s/p VT ablation atrial fibrillation CAD s/p catherization without intervention Secondary HTN severe COPD subclavian stenosis Discharge Condition: HD stable afebrile. Discharge Instructions: admitted irregular rhythm called Ventricular tacchycardia went catherization lab electrophysiology lab ablation abnormal rhythm. heart rhythm still irregular need coumadin thin blood. Please take medications directed. changed medications. decreased sotalol 80 mg twice daily daily. also decreased moexipril 15 mg daily 7.5 mg daily. also added coumadin 5 mg daily. Please follow-up outpatient appointments. Please return hospital call doctor experience fever, dizziness, chest pain, trouble breathing, abdominal pain concerning symptoms. Followup Instructions: Please follow-up cardiologist, Dr. [Last Name (STitle) ]. appointment Thursday [8-18] 1:30 pm [Location (un) 620]. . Please follow PCP discharged rehab.	[ "4280", "496", "42731", "41401", "4019", "2859" ]
Admission Date: [2199-7-3] Discharge Date: [2199-7-5] Date Birth: [2138-4-19] Sex: Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5893] Chief Complaint: Palpitations Major Surgical Invasive Procedure: None. History Present Illness: 61-year-old gentleman history gastric cancer s/p resection years ago, hypertension, presenting several days palpitations, describeds "fluttering" sensation. Denies chest pain dyspnea. Says episodes every great while, cannot give specific frequency. symptoms, typically resolve matter seconds. Today, however, symptoms persisted several minutes, decided come ED. note, also reported left leg swelling since [5-11], sustained fall crossing street. . ED, initial vs were: 97 133 135/102 18 99%, ECG revealing atrial flutter. given ASA 325 mg diltiazem 20 mg IV x1, transiently brought heart rate 80s, subsequently increased 120s. D-dimer + 800s. CTA chest revealed pulmonary embolism dissection, significant LLL pneumonia. LENIs negative DVT. Lactate 4.7, decreased 2.2 four liters IV fluids. . ICU patient denies respiratory symptoms kind. longer feeling fluttering sensation. Denies fevers, chills, chest pain, dyspnea, cough. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria. . Review sytems: (+) Per HPI. Also endorses dark urine drinks alcohol. (-) Denies recent weight loss gain. Denies headache congestion. Denied arthralgias myalgias. Past Medical History: -Gastric cancer s/p gastrectomy [2175], [Hospital1 112] -Thyroid nodules -S/p quadriceps tendon rupture [2196] -Hypertension -Self-reported hx WPW -Etoh abuse (Last drink earlier today, morning. Denies ever needing medical care withdrawal symptoms, admits drinks morning get rid "the shakes") Social History: Lives himself. Divorced. Several grown children grandchildren. Former chef, longer working. Drinks several drinks per day, etoh history above. Reports smoking [2-9] cigarettes/month, earlier told RN smokes daily. Denies illicit drug use. Family History: Mother's family "circulatory problems." Mother non-fatal MI 60s. Mother's relatives (unspecified) strokes. Physical Exam: Vitals: T:98.3 BP:149/99 P:64 R:12 O2:99% 2 liters General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, OP clear. Poor dentition. Neck: supple, JVD LAD Lungs: CTAB. wheezes, rales, rhonchi. Good inspiratory effort air movement throughout. CV: RRR, normal S1 + S2, murmurs, rubs, gallops Abdomen: Soft, NT/ND, bowel sounds present, rebound tenderness guarding, organomegaly pulsatile masses. Well healed midline vertical incision scar GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: AAO x3, speech fluent, thought process generally clear. Sensation grossly intact throughout. 5/5 strength bilateral upper extremities right lower extremities. Left LE: extend knee 90 45 degrees. Pertinent Results: [2199-7-3] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2199-7-3] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2199-7-3] 08:56PM LACTATE-2.2* [2199-7-3] 06:35PM GLUCOSE-53* LACTATE-4.7* [2199-7-3] 03:17PM GLUCOSE-68* UREA N-12 CREAT-1.0 SODIUM-139 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-21* ANION GAP-24* [2199-7-3] 03:17PM ALT(SGPT)-29 AST(SGOT)-61* ALK PHOS-84 TOT BILI-0.4 [2199-7-3] 03:17PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.9 [2199-7-3] 03:17PM D-DIMER-826* [2199-7-3] 03:17PM WBC-5.3 RBC-4.02* HGB-12.8* HCT-38.5* MCV-96 MCH-31.7 MCHC-33.2 RDW-14.3 [2199-7-3] 03:17PM NEUTS-67.3 LYMPHS-26.4 MONOS-5.6 EOS-0.5 BASOS-0.3 [2199-7-3] 03:17PM PLT COUNT-164 [2199-7-3] 03:17PM PT-12.6 PTT-25.7 INR(PT)-1.1 LENI [7-3]: evidence DVT left lower extremity. CTA [7-3]: 1. Early left lower lobe pneumonia. 2. evidence pulmonary embolism acute aortic process. 3. Severe coronary artery disease. 4. Fatty liver. 5. Thyroid nodularity clinical correlation advised. Brief Hospital Course: 61-year-old gentleman history gastric adenocarcinoma s/p remote surgical resection, hypertension, likely regular significant ETOH intake, presents palpations. EKG concerning atrial flutter CTA concerning PNA. # ATRIAL FLUTTER: EKG ED showed atrial flutter rates 130s. Unclear whether chronic however, patient undergone holter monitoring past without evidence sustained dysrhythmias. Patient also relates history WPW child; seen EP [2191] saw evidence active bypass tract. currently rate control outpatient. Possible triggers episode may include hypoxia pneumonia ETOH use. Mr. [Known lastname ] [Last Name (Titles) 35325] diltiazem ED rate slowed 80s. ICU, patient monitored telemetry rate control necessary. EP consulted recommended patient follow-up 1 month Dr. [Last Name (STitle) ]. beta-blocker started patient's HR's continually 40s-50s. Cardiology also recommended obtaining ECHO outpatient patient right parasternal heave exam. Atrial flutter likely exacerbated intrinsic lung process, may amenable ablation. # LUNG INFILTRATE: Mild opacity left lower lobe reported possible early pneumonia CTA. clinical symptoms signs pneumonia--not hypoxic febrile, cough dyspnea, leukocytosis. Although Mr. [Name13 (STitle) ] received ceftriaxone azithromycin ED, continued ED suspicion true PNA low. # HYPERTENSION: BP high 140s/high 90s upon arrival [Hospital Unit Name 153]. Patient states taking anti-hypertensives past several days. Patient continued HCTZ lisinopril increased 20mg QD. pressures monitored closely, especially risk ETOH withdrawal below. # ETOH ABUSE: Upon arrival [Hospital Unit Name 153], patient gave different histories different interviewers. Admits drink presenting ED order "get rid shakes." Patient put CIWA scale require benzos throught [Hospital Unit Name 153] stay. social work consult put addiction counseling. # CAD: CTA shows evidence severe CAD. Patient risk factors CAD including sex, age, hypertension, ETOH abuse. important see cardiology outpatient work-up issue. would likely benefit ASA therapy beta-blocker (if heart rate tolerates). also needs counseling reducing CAD risk factors. # ELEVATED ANION GAP: Elevated lactate admission, resolved IV fluid administration. Gap closed first morning admission. Ketonuria may due starvation/ETOH ketoacidosis. # LEFT LOWER EXTREMITY SWELLING: Possibly site previous trauma. US negative DVT. Patient instructed follow-up orthopedics. Medications Admission: -Lisinopril 10 mg daily -HCTZ 25 mg daily -Folate 1 mg daily Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Coarse atrial fibrillation Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], pleasure taking care admission. came hospital experiencing palpitations. seen cardiologist thought condition called atrial flutter. see Dr. [Last Name (STitle) ] outpatient evaluation treatment atrial flutter. following changes made medications: 1. Increase lisinopril 20mg QD Please take medications prescribed. Please keep follow-up appointments. Return hospital develop chest pain, shortness breath, continuing palpitations, severe headache, nausea, vomiting, diarrhea, pain urination, cough, fever, increased swelling legs, concerning signs symptoms. Followup Instructions: PCP/NP [First Name9 (NamePattern2) 83923] [Doctor Last Name 122]/ Dr. [Last Name (STitle) ] [Hospital3 26956] [7-16] 2pm Provider: [Name10 (NameIs) ] UNIT Phone:[Telephone/Fax (1) 164] Date/Time:[2199-9-4] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2199-7-30] 1:20 [Hospital Ward Name 23] [Location (un) ]	[ "42731", "2762", "4019", "41401" ]
Admission Date: [2123-8-25] Discharge Date: [2123-9-2] Date Birth: [2042-6-1] Sex: Service: CARDIOTHORACIC Allergies: Atenolol Attending:[First Name3 (LF) 2969] Chief Complaint: Lung Cancer Major Surgical Invasive Procedure: Left lower lobe non-small cell lung cancer, Left vocal cord paralysis 7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes) 7/12 L thoracotomy/LLL lobectomy, L chest wall resect gortex mesh repair, LUL wedge resect History Present Illness: Mr. [Known lastname 14859] 81-year-old gentleman biopsy proven carcinoma left lower lobe, imaging abuts chest wall. prior visit, underwent staging operation showed nodes involved pleural effusion negative malignancy, negative pleural biopsies. adequate reserve tolerate resection surprisingly asymptomatic regarding tumor, clearly adherent invading chest wall. recommended left lower lobectomy en bloc chest wall resection agreed proceed. Past Medical History: - A.fib s/p ablation pacemenaker [2123-5-28] - Chronic obstructive pulmonary disease - +TOBacco - Perihilar lung mass Social History: Married one grown daughter. Used army, studied physical education. TOB+ x >50 yrs, quit 2 months ago. ETOH 1 x per week. Family History: NC Physical Exam: LYMPHATICS: adenopathy neck region supraclavicular fossa. HEENT: sclerae muddy nonicteric. thyromegaly, appreciate carotid bruits. HEART: Irregular rhythm controlled rate. LUNGS: focal wheezing lungs. EXTREMITIES: peripheral edema. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2123-8-28] 05:34AM 11.1* 3.11* 9.0* 26.3* 85 28.9 34.1 15.9* 228 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2123-8-25] 09:00PM 84.8* 9.7* 3.9 1.1 0.5 RED TOP RECEIVED MG RED CELL MORPHOLOGY Anisocy Poiklo Microcy [2123-8-25] 09:00PM 1+ 1+ 1+ RED TOP RECEIVED MG BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT) [2123-8-28] 05:34AM 228 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2123-9-1] 04:05PM 116* 15 1.0 138 4.31 100 25 17 SLIGHTLY HEMOLYZED 1 HEMOLYSIS FALSELY ELEVATES K HEMOLYZED, SLIGHTLY CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2123-9-1] 04:05PM 8.8 3.0 2.11 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2123-9-1] 1:13 PM Reason: eval interval change/ptx s/p last Ct d/c [Hospital 93] MEDICAL CONDITION: 81 year old man s/p LLL lobectomy, left chest wall resection w/mesh, LUL wedge; L CT d/c REASON EXAMINATION: eval interval change/ptx s/p last Ct d/c PA lateral chest, [9-1]. HISTORY: Left lower lobectomy chest wall repair, left upper lobe wedge resection. Chest tube discontinued. IMPRESSION: PA lateral chest compared [8-30]: Left posterior air fluid collection region chest wall resection increased size, predominantly anteroposterior dimension roughly 31 39 mm diameter, still 10.5 12 cm length, contains large component fluid. appreciable layering left pleural effusion significant pneumothorax along pleural margins. Subcutaneous emphysema left supraclavicular soft tissues diminished. Small right pleural effusion stable. Right lung clear. Heart top normal size remains shifted slightly left. Transvenous pacer lead standard position. RADIOLOGY Final Report VIDEO OROPHARYNGEAL SWALLOW [2123-8-31] 11:13 Reason: eval swallow prophiciency. [Hospital 93] MEDICAL CONDITION: 81 year old man left vocal cord paralysis per ENT [8-30] s./p Thoracic surgery, meds/ lobectomy. REASON EXAMINATION: eval swallow prophiciency. INDICATIONS: 81-year-old man left vocal cord paralysis following thoracic surgery. TECHNIQUE: Videotaped oropharyngeal swallowing study. FINDINGS: study performed conjunction speech swallow pathologist. Various consistencies barium administered videofluoroscopy. Due poor bolus control, premature spillover observed piriform sinuses thin liquids. Laryngeal valve closure mildly impaired, left vocal cord showed paralysis. Residue piriform sinuses valleculae could cleared multiple swallows. Pharyngeal contraction symmetric. Mild penetration sips thin liquids observed spillover, throat clearing effective. moderate amount silent aspiration observed multiple sips thin liquids, related spillover, cough effective clearance. Also, reduced sensation lack spontaneous cough. aspiration occurred larger boluses only. smaller boluses thin liquids via straw, trace penetration observed. IMPRESSION: Moderate aspiration larger boluses thin liquids, penetration vestibules seen smaller boluses. Paralysis left vocal cord. SUMMARY: Pt presents mild oropharyngeal dysphagia. demonstrated aspiration penetration thin liquids examination, however, small bolus sizes effective preventing aspiration pt focused swallowing task. Pt also demonstrated deep penetration small straw sips thin liquids. consideration pt's left vocal cord paresis, likely cause poor valve closure thus compromising airway protection larger boluses. Therefore, based examination, recommended pt continue regular PO diet thin liquids taking small sips thin liquids STRAWS. Pt demonstrated good understanding instructions given evaluation. follow-up pt ensure instructions followed meals. RECOMMENDATIONS: 1. recommend pt continue regular PO diet thin liquids PO meds 2. pt take small sips thin liquids 3. Pt use straws Pathology Examination SPECIMEN SUBMITTED: LIPOMA, LATERAL CHEST WALL MARGIN, NEW LATERAL CHEST WALL MARGIN, LEFT LOWER LOBE CHEST WALL, L10 LYMPH NODE, L11 LYMPH NODE Procedure date Tissue received Report Date Diagnosed [2123-8-25] [2123-8-26] [2123-8-30] DR. [Last Name (STitle) ]. BROWN/lfb Previous biopsies: [-7/2603] LT PARIETAL PLEURA, 4 R, LOWER PARATRACHEAL, 4 L LOWER DIAGNOSIS: 1. Excision, central back: lipoma. 2. Lung, left lower lobe chest wall: Squamous cell carcinoma, see synoptic report. 3. Margin, lateral chest wall: Squamous cell carcinoma. 4. New margin, lateral chest wall: Skeletal muscle, carcinoma seen. 5. L10 nodes: carcinoma seen. 6. L11 nodes: carcinoma seen. Lung Cancer Synopsis MACROSCOPIC Specimen Type: Lobectomy. Laterality: Left. Tumor Site: Lower lobe. Tumor Size Greatest dimension: 7 cm. MICROSCOPIC Histologic Type: Squamous cell carcinoma. Histologic Grade: G2: Moderately poorly differentiated. EXTENT INVASION Primary Tumor: pT3: Tumor size directly invades following: chest wall, diaphragm, mediastinal pleura, parietal pericardium; tumor size main bronchus less 2 cm distal carina without involvement carina; tumor size associated atelectasis obstructive pneumonitis entire lung. Regional Lymph Nodes: pN0: regional lymph node metastasis. Location: 10. Number examined: Multiple fragments Number involved: 0. Location: 11. Number examined: Multiple fragments Number involved: 0. Location: Hilar . Number examined: 6. Number involved: 0. Distant metastasis: pMX: Cannot assessed. Margins: Tumor focally present adjacent inked lateral chest wall margin lobectomy/chest wall resection specimen. Direct extension tumor: Chest wall. Venous invasion (V): Indeterminate. Lymphatic Invasion (L): Indeterminate. Clinical: Left lower lobe lung cancer. Gross: Specimen submitted: 1. central back soft tissue, lipoma, 2. lateral chest wall margins, 3. new lateral chest wall margins, 4. left lower lobe chest wall, 5. L10 lymph node, 6. L11 lymph node. specimen received fresh six parts labeled patient's name, "[Known lastname 14859], [Known firstname ]" medical record number. Part 1 additionally labeled "central back soft tissue lipoma" consists 6 x 6 x 2.5 cm portion fatty tissue. specimen sectioned reveal unremarkable fatty cut surfaces. specimen submitted cassettes A-C. Part 2 additionally labeled "lateral chest wall margin" consists 1.5 x 1.0 x 0.5 cm fragment soft tissue, entirely submitted frozen section diagnosis. Frozen section diagnosis Dr. [First Name8 (NamePattern2) 32953] [Name (STitle) 10165] follows: "lateral chest wall margin: positive non small cell carcinoma." specimen entirely submitted follows: D=frozen section remnant. Part 3 additionally labeled "new lateral chest wall margin" consists 2 x 2 x 1.5 cm portion soft tissue, stitch indicating new margin. margin shaved, submitted frozen section diagnosis. Frozen section diagnosis Dr. [Last Name (STitle) ] follows: "new lateral chest wall margin, negative carcinoma." specimen represented follows: E=frozen section remnant, F=portions soft tissue. Part 4 additionally labeled "left lower lobe attached chest wall" consists left lower lobe lung, portion upper lobe, chest wall. portion upper lobe measures 6 x 3 x 2 cm, lower lobe measures 12 x 7 x 6 cm, chest wall measures 14 x 9.5 x 2 cm. specimen oriented white suture superior posterior aspect chest wall. additionally black suture located lateral surface chest wall located inferior 5th rib. bronchial margin shaved submitted frozen section diagnosis. Frozen section diagnosis Dr. [Last Name (STitle) ] follows: "negative carcinoma." specimen sectioned reveal largely necrotic tumor mass within left lobe lung extension soft tissue. mass overall measures 7 x 7 x 6 cm. comes within less 1 mm soft tissue margin, within 0.5 cm stapled upper lobe margin, within 1 cm bronchial vascular resection margin. mass appear involve chest wall ribs 4 5, however ribs 5 6 extends bones soft tissue. Additionally, posterior internal surface 6th rib small 0.5 cm nodule may represent tumor, may represent lymph node. specimen represented follows: G=bronchial margins frozen section remnants. H=vascular margin, I=stapled upper lobe margin, adjacent nodule, J=hilar lymph nodes, K=soft tissue margin ribs 5 6, L=soft tissue margin 6 7, M=soft tissue margin 6 7, N=soft tissue margin internal rib 6, posteriorly pleural surface, O=tumor relationship normal lung pleura, P=tumor necrosis relationship vessels. X,Y = 6th rib margin, Z,AA = 7th rib margin, AB = cross section rib. Portions specimen submitted decalcification. Part 5 additionally labeled "L10 lymph nodes" consists 1.5 x 0.4 cm anthracotic lymph node, bisected entirely submitted cassette Q. Part 6 additionally labeled "L11 lymph nodes" consists multiple anthracotic lymph nodes measuring aggregate 2.5 x 1 x 1 cm. largest bisected submitted R. remainder entirely submitted cassette S. Brief Hospital Course: [8-25]: Patient admitted surgery (L thoracotomy, LLL lobectomy, L chest wall resection gortex mesh repair, LUL wedge resection. Post-operatively, patient transferred ICU. [8-26]: Patient extubated ICU. Patient's pacemaker interrogated abnormal rhythms found normal. [8-27]: Patient's L IJ CVL (3 lumen) withdrawn 2cm improper placement ,patient became hoarse shortly thereafter. [8-28]: Patient transferred floor. [8-30]: Patient's chest tube dislogded accidentally radiology early am. Patient seen ENT c/o hoarseness, discovered L Vocal cord paralysis. [8-31]: Patient speech swallow evaluation c/o hoarseness.see report detail. [9-1]: Patient's chest tube removed. ENT recommended outpatient follow two weeks. [9-2] Pt stable overnight pain controlled po rx. Pt stable discharge home company wife. [Name (NI) 269] services w/ [Location (un) ] [Location (un) 269].Coumadin restart home. Medications Admission: Coumadin 2.5qd, Lasix 40qd,fluticasone, azatioprine, tictropium 1 puff qd, mucinex, prednisone Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [2-15] Puffs Inhalation Q6H (every 6 hours) needed. Disp:1 1 Refills:0 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times day). Disp:1 1 Refills:1 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO q12 (). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. Disp:80 Tablet(s) Refills:0 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Home Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Left lower lobe lung 9cm massNSCLC, L vocal cord paralysis 7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes) Atrial fibrillation s/p ablation/pacer [5-20], Chronic obstructive pulmonary disease, Left lower lobe lung 9cm mass, bullous pemphigoid Discharge Condition: good Discharge Instructions: Call Dr.[Doctor Last Name 4738]/Thoracic Surgery office [Telephone/Fax (1) 170] experience chest pain, shortness breath, fever, chills, pain relieved oral pain medication. Take medications previous surgery. Take new medications directed discharge instructions. may shower 2 days, remove dressing chest tube site change daily needed. driving taking narcotic pain medication. Ambulation much possible. Take bowel medication regularity. Followup Instructions: Dr.[Name (NI) ] office contact regarding follow appointment Follow ENT, Dr. [Last Name (STitle) 1837] ([Telephone/Fax (1) 26719]) 2 weeks. Completed by:[2123-9-2]	[ "42731", "496", "V5861" ]
Admission Date: [2128-10-28] Discharge Date: [2128-11-4] Date Birth: [2054-7-23] Sex: Service: MEDICINE Allergies: Penicillins / Olanzapine Attending:[First Name3 (LF) 1711] Chief Complaint: AFIB CHF exacerbation Major Surgical Invasive Procedure: Cardioversion Right Internal Jugular catheter History Present Illness: 74 year old man history CHF intially admitted [Hospital ] Hospital atrial fibrillation CHF exacerabtion transfered [Hospital1 18] management. History obtained patient medical records since patient could address many aspects presentation. [2128-10-7] presented PCP shortness breath weight gain. time weight 251 lb (aproximately 25 lb increase) noted worsened lower extremity edema. visit also noted atrial fibrilation ventricular rate 130 bpm (most recent ECG [12/2124] reported sinus). time diltiazem 240 mg daily, furosemide 40 mg daily lisinorpil 20 mg daily. furosemide increased 40 mg twice daily started metoprolol succinate 50 mg daily. unclear reasons lisinopril discontinued. [2128-10-14] presented PCPs office symptoms shortness breath found atrial fibrillation rate 150. refered admission [Hospital ] Hospital. initially treated diltiazem, metoprolol, digoxin heparin ggt. ACS ruled cardiac enzymes ECG. also given intravenous furosemide boluses management CHF exacerabtion. [2128-10-16] desaturated developed rapid ventricular response. code called without CPR administration. patient transfered ICU. intubated placed furosemide ggt. started digoxin diltiazem ggt continued. Acetazolamide also started. extubated [2128-10-25] done well 4L NC since (02 sat 98%). [Location (un) ] admission weight 279 lb, improved 250 lb diuresis. TTE [2128-10-16] showed EF55% septal hypokinesis well severe MR (with limited windows). Repeat TTE [2128-10-20] confirmed severe MR two separate jets tracking up. LENIs negative bilaterally. urine output ranged 100 300 ml/hr??. hospitalization course [Location (un) ] complicated delirium disorientation combativeness. developed hypokalemia setting diuresis although sputum cultures grew GNR (? E. Coli) afebrile without CXR changes suggesting PNA. . arrival CCU, reported intermittent cough non-productive buttock pain site sacral ulcerations. denied shortness breath, chest pain, nausea, vomiting, diarrhea, fevers, chills. poor historian could comment prior history. . Cardiac review systems notable absence chest pain, dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope presyncope. . Past Medical History: HTN CHF COPD ?CVA obesity Social History: -Tobacco history: quit 40 yrs ago -ETOH: -Illicit drugs: -wife deceased, former truck driver, lives alone . Family History: NC Physical Exam: admission PE: VS: T=99.8 BP=125/56 HR=110 RR=22 O2 sat= 94% 15L FM GENERAL: obese male NAD. Oriented x2, drowsy arousable. Mood, affect appropriate. Inattentive questioning. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: RIJ place, CVP transduced 15. CARDIAC: PMI located 5th intercostal space, midclavicular line. Tachy, irreg, irreg, normal S1, S2. Unable appreciate m/r/g. thrills, lifts. S3 S4. LUNGS: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. Decreased BS b/l inspiratory crackles bases. ABDOMEN: Obese, soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: c/c/e. femoral bruits. sacral edema. SKIN: 4 sacral decubitus/periscrotal ulcers - stage two, two unstagable. stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [2128-10-28] 04:01PM GLUCOSE-104 UREA N-21* CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-34* ANION GAP-11 [2128-10-28] 04:01PM estGFR-Using [2128-10-28] 04:01PM CALCIUM-9.0 MAGNESIUM-2.9* [2128-10-28] 04:01PM VIT B12-845 FOLATE-17.1 [2128-10-28] 04:01PM %HbA1c-5.9 [2128-10-28] 04:01PM DIGOXIN-1.2 [2128-10-28] 04:01PM HCT-38.0* [2128-10-28] 04:01PM PTT-74.9* [2128-11-2] 08:19AM BLOOD WBC-9.0 RBC-4.64 Hgb-13.3* Hct-39.9* MCV-86 MCH-28.6 MCHC-33.4 RDW-14.7 Plt Ct-304 [2128-11-2] 08:19AM BLOOD Plt Ct-304 [2128-11-2] 08:19AM BLOOD PT-13.0 PTT-27.4 INR(PT)-1.1 [2128-11-2] 08:19AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-144 K-4.6 Cl-103 HCO3-35* AnGap-11 [2128-10-29] 05:17AM BLOOD ALT-28 AST-22 LD(LDH)-226 AlkPhos-75 TotBili-0.5 [2128-11-2] 08:19AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3 [2128-10-28] 04:01PM BLOOD VitB12-845 Folate-17.1 [2128-10-30] 02:20PM BLOOD %HbA1c-5.9 [2128-10-30] 12:25AM BLOOD Triglyc-192* HDL-23 CHOL/HD-8.3 LDLcalc-129 [2128-11-2] 02:30PM BLOOD Type-ART pO2-64* pCO2-63* pH-7.38 calTCO2-39* Base XS-8 [2128-11-2] 02:30PM BLOOD Lactate-1.4 [2128-11-4]: INR 1.1 CXR - [11-2]: FINDINGS: comparison study [10-31], little overall change. Continued moderate cardiomegaly mild engorgement pulmonary vessels. Progressive clearing left basilar atelectasis effusion. Elevation right hemidiaphragm persists atelectatic streaks right lower zone. ECHO: [10-28]: spontaneous echo contrast thrombus seen body left atrium/left atrial appendage body right atrium/right atrial appendage. atrial septal defect seen 2D color Doppler. normal free wall contractility. aortic valve leaflets (3) appear structurally normal good leaflet excursion. Trace aortic regurgitation seen. moderate/severe mitral valve prolapse. partial mitral leaflet flail. eccentric, anteriorly directed jet severe (4+) mitral regurgitation seen. pericardial effusion. Brief Hospital Course: Atrial fibrillation: Apparently new onset since [2128-10-14], however recent ECG prior [2119]. Also pt poor historian. likely precipited CHF exacerbation. TEE revealed clot, DC cardioverted. rhythm control amiodarone load rate controlled metoprolol. anticoagulated heparin gtt (CHADS 2, note unclear h/o CVA), determined current surgical candidate bridging warfarin undertaken. Titrate INR 2.0 - 3.0. . Decompensated diastolic/systolic LV dysfunction: presentation OSH, nearly euvolemic here. exact etiology exacerbation known. concerning precipitant worsening mitral regurgitation, although may precipitated dietary medication noncompliance gut edema poor absorbtion. TTE showed preserved systolic function. Given severe MR component systolic dysfunction well given EF<60. baseline TTE available determine progression LV dysfunction. weight decreased aprx 30 lb furosemide gtt, stabilized diuresis regimen furosemide 60mg po QD. Afterload reduction goal SBP<120 acheived BB ACEI (lisinopril). element Co2 retention sedation, normalized now. goal O2 sat 88-90%, pt weaned O2 day discharge. . Mitral regurgitation: likely chronic process. history RHD reported. evidence ischemic disease OSH suggest acute MR [First Name (Titles) 767] [Last Name (Titles) 8546] mm rupture, evaluated past. TEE shows intracardiac thrombus. TEE revealed partial posterior mitral leaflet severe eccentric mitral regurgitation. Patient seen CT surgery deemed candidate time given AMS, hypercarbia, deconditioning. Dr. [First Name (STitle) ] contact[Name (NI) ] decided postpone Cardiac Catheterization time proximal surgery. look mitral valve clip placement trial possible therapeutic alternative, though immediately obvious option. . Preventative Medicine- Lipid panel revealed(TC-190, LDL-130, TG-192, HDL??????23) A1C-5.9 was. . Delirium: evenings Mr [Known lastname 12667] became disoriented occasionally combative setting acute illness. Likely ICU delirium vs. toxic metabolic cause exacerbated sundowing. Mr [Known lastname 12667] [Last Name (Titles) 53183] poorly zydis. Per sister, patient independent baseline. attempted regulate sleep wake cycle seroquel QHS. RPR, B12, folate WNL. . Medications Admission: home meds confirmed outpt pharmacy: metoprolol succinate 50 mg daily furosemide 40 mg twice daily diltiazem 240 mg daily 20 meq KCL Po daily - transfer amio ggt 20cc/hr lopressor 5 mg q4 IV heparin gtt lasix 20 mg gtt digoxin 250mcg IV daily aspirin 325mg po acetazolamide 250 [Hospital1 ] colace 100mg [Hospital1 ] omeprazole 40mg daily Potassium miconazole topical TID insulin SS albuterol/ipratropium nebs QID reglan prn Ativan prn bisacodyl prn Discharge Medications: 1. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO day. 2. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) D5W Intravenous 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Daily 4 PM: TITRATE INR 2.0 - 3.0. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice day. 7. Lamisil 1 % Cream Sig: One (1) Topical twice day. 8. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO day. 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO day. 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times day) needed constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice day. 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed aggitation. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) needed shortness breath wheezing. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) needed shortness breath wheezing. vial 16. Outpatient Lab Work Please check INR daily > 2.0 Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Acute Chronic Diastolic congestive Heart Failure Atrial fibrillation rapid ventricular response Acute Delerium Mitral Regurgitation Chronic Obstructive Pulmonary Disease Onychomycosis Tinea Pedis Hypertension Discharge Condition: Alert, oriented x2, delerium clearing 1 assist chair, able take steps. Discharge Instructions: acute exacerbation congestive heart failure needed treated Furosemide intravenously increased pill doses. Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs 1 day 6 pounds 3 days. Adhere 2 gm sodium diet. also atrial fibrillation, irregular heart rhythm increases risk stroke. started coumadin prevent strokes stay heparin IV drip coumadin therapeutic. also became delerious hospital sick. clear slowly get better. Followup Instructions: Primary Care: [Last Name (LF) ],[First Name3 (LF) ] Phone: [Telephone/Fax (1) 8577] Date/Time: Please make appt get rehabilitation . Cardiology: [Last Name (LF) ],[First Name3 (LF) ] A. Phone: [Telephone/Fax (1) 23882] Date/Time: Monday [12-13] 10:30am. Completed by:[2128-11-4]	[ "42731", "4280", "4240", "496", "4019", "V1582" ]
Admission Date: [2132-10-7] Discharge Date: [2132-10-14] Date Birth: [2054-12-31] Sex: Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[First Name3 (LF) 2782] Chief Complaint: sudden onset dyspnea Major Surgical Invasive Procedure: Intubation x2 days; History Present Illness: Mr. [Known lastname 5057] 77yo HTN, HL, COPD, newly diagnosed NSCLC , s/p first round chemotherapy. transferred [Hospital1 18] ED midst RBC transfusion developed sudden shortness breath interpreted possible transfusion reaction. . appears severe COPD caused extensive smoking history. poor exercise tolerance worsened preceding months. exertion, including walking street, cause increased RR profound SOB. Albuterol help stop episodes. pursed-lip breathing years. recently underwent TTE evaluation exercise intolerance, point relatively large pericardial effusion tamponade physiology seen. admitted CCU [9-2]- [9-6] underwent pericardiocentesis, revealed malignant cells. recently underwent first chemo session taxol NSCLC. oncologist Dr. [Last Name (STitle) 349] [Location (un) 2274]. . fatigue poor exercise tolerance persisted. found anemic 25 subsequently brought 7 [Hospital Ward Name 1826] blood transfusion. Midway transfusion, developed worsening SOB increased RR. thinks episode similar usual bouts breathlessness, admittedly upset long transfusion taking. Fearing transfusion reaction, brought [Hospital1 18] ED evaluation. . ED, found tachycardic tachypneic. Received 20mg IV lasix underwent BiPAP trial, poorly tolerated. note, continued saturate upper90s 3-4LNC, though remained tachypneic. bedside echo done showed pericardial effusion per ED read. transferred MICU concern increased WOB. VS prior transfer 97.9 108 150/80 36 99/4L. . arrival MICU, intial VS 96.5, 107, 153/63, 95 3LNC. continues purse-lip breath. describes frequent episodes similar breathlessness transfusion, often pass coughing spitting. otherwise feels well aside fatigue. notes recent couging cold-like smpyotms, sore throat, fevers, chills, chest pains pressure. lower extremity edema PND, orthopnea. recent F/C. midst interview, urge urinate abruptly stood use urinal- developed respiratory distress saturations dipping 80s tachypnea 50. episode resolved supplemental 02. felt similar events surrounding infusion. . Review systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss gain. Denies headache, sinus tenderness, rhinorrhea congestion. Denies cough, shortness breath, wheezing. Denies chest pain, chest pressure, palpitations, weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, changes bowel habits. Denies dysuria, frequency, urgency. Denies arthralgias myalgias. Denies rashes skin changes. Past Medical History: - Non-small cell lung cancer - squamous cell carcinoma, s/p MOHS - colonic polyps, last colonoscopy 1 year ago - COPD - gastritis - h/o gout - h/o nephrolithiasis - hypertension - Hyperlipidemia Social History: Lives wife [Location (un) ]. Retired hardware store owner. two boys, live [State ], one grandson. - Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd - ETOH: 1 glass wine/night - Illicit drugs: denies Family History: - family history early MI, arrhythmia, cardiomyopathies, sudden cardiac death - Mother: chronic leukemia, died age 89 - Father: h/o MI, pancreatic cancer, died age 69 Physical Exam: Admission Exam: Vitals: 96.5, 107, 153/63, 95 3LNC General: Alert, oriented, pursed-lip breathing 30s HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: diffuse wheezing heard throughout anterior posterior lung fields. Fair air movement. crackles rhonchi. CV: tachycardic, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly. Abdominal musculature used exhalation. GU: foley place Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema time discharge, patient's vital signs stable O2 sats 96% 2L NC. continued wheezes fair air movement lung exam, basilar crackles. edema elevation JVP. Foley removed. Pertinent Results: Admission Labs: [2132-10-7] 08:23PM URINE HOURS-RANDOM UREA N-679 CREAT-97 SODIUM-71 POTASSIUM-81 CHLORIDE-86 [2132-10-7] 08:23PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2132-10-7] 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2132-10-7] 08:23PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2132-10-7] 08:23PM URINE GRANULAR-2* HYALINE-14* [2132-10-7] 08:23PM URINE MUCOUS-RARE [2132-10-7] 06:36PM LACTATE-1.3 [2132-10-7] 06:30PM GLUCOSE-124* UREA N-30* CREAT-1.5* SODIUM-141 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [2132-10-7] 06:30PM estGFR-Using [2132-10-7] 06:30PM LD(LDH)-395* CK(CPK)-115 TOT BILI-0.8 [2132-10-7] 06:30PM cTropnT-1.00* [2132-10-7] 06:30PM CK-MB-5 proBNP-[Numeric Identifier 91421]* [2132-10-7] 06:30PM IRON-83 [2132-10-7] 06:30PM WBC-3.2# RBC-2.79# HGB-9.1# HCT-25.2# MCV-90# MCH-32.7* MCHC-36.2* RDW-20.8* [2132-10-7] 06:30PM NEUTS-22* BANDS-2 LYMPHS-47* MONOS-19* EOS-7* BASOS-1 ATYPS-0 METAS-0 MYELOS-2* NUC RBCS-3* [2132-10-7] 06:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ SCHISTOCY-2+ BITE-1+ ACANTHOCY-1+ [2132-10-7] 06:30PM PLT SMR-LOW PLT COUNT-132* [2132-10-7] 06:30PM PT-17.8* PTT-26.5 INR(PT)-1.6* Notable Labs: [2132-10-9] 05:15AM BLOOD FDP-40-80* [2132-10-7] 06:30PM BLOOD cTropnT-1.00* [2132-10-8] 04:41AM BLOOD CK-MB-6 cTropnT-0.99* [2132-10-8] 05:24PM BLOOD CK-MB-5 cTropnT-0.65* [2132-10-7] 06:30PM BLOOD calTIBC-257* Hapto-<5* Ferritn-590* TRF-198* [2132-10-7] 06:36PM BLOOD Lactate-1.3 EKG [2132-10-7]: Sinus tachycardia. Left axis deviation. Right bundle-branch block. Probable small R waves leads II, III aVF consider prior inferior myocardial infarction. ST-T wave abnormalities. Low precordial voltage. Compared previous tracing [2132-9-3] rate faster. ST-T wave abnormalities prominent. Precordial voltage less prominent. Clinical correlation suggested CXR [2132-10-7]: 1. Moderate enlargement cardiac silhouette, similar compared prior PET-CT. 2. Dilated tortuous ascending thoracic aorta. 3. Patchy opacities within lung bases, could reflect atelectasis, infection, aspiration. 4. Known spiculated nodule right upper lobe better appreciated recent PET CT. TTE [2132-10-8]: left atrium elongated. right atrium markedly dilated. estimated right atrial pressure 5-10 mmHg. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses cavity size normal. mild global left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular chamber size normal. borderline normal free wall function. aortic valve leaflets (3) mildly thickened aortic stenosis present. Mild moderate ([1-13]+) aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. Mild moderate ([1-13]+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. small pericardial effusion. IMPRESSION: Mild global left right ventricular hypokinesis. Mild moderate mitral regurgitation. Mild moderate aortic regurgitation. small pericardial effusion. Moderate pulmonary hypertension. Compared prior study (images reviewed) [2132-9-6], biventricular function impaired. Valvular regurgitation apparent (previous study focused). Pulmonary hypertension identified. . Labs Discharge: [2132-10-14] 09:45AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.8* Hct-31.2* MCV-99* MCH-31.2 MCHC-31.6 RDW-20.8* Plt Ct-135* [2132-10-14] 09:45AM BLOOD Plt Ct-135* [2132-10-14] 09:45AM BLOOD Glucose-131* UreaN-45* Creat-1.3* Na-143 K-3.7 Cl-99 HCO3-34* AnGap-14 [2132-10-14] 09:45AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 Brief Hospital Course: Mr. [Known lastname 5057] 77yoM COPD, HTN, HLD, recent hospitalization cardiac tamponade presents [Hospital Ward Name ] 7 transfusion unit acute SOB transfusion. 1. ACUTE HYPOXIC RESPIRATORY FAILURE: --PNEUMONIA ACUTE SYSTOLIC CHF: developed acute shortness breath early blood transfusion receiving anemia. Transfusion reaction/TRALI initially suspected though lacked severe pulmonary edema hypoxia support diagnosis. admitted MICU due apparent increased WOB, briefly tried BiPAP ED despite normal saturations. Tamponade ruled US ED. initially stable room air saturations 90s upon admission ICU. related numerous similar episodes shortness breath home related progressive worsening overall respiratory status exercise stamina preceding months. CXR showed mild edema RLL haziness. Widespread wheezing prompted treatment COPD exacerbation. decompensated quickly unit getting agitated foley adjustment. desaturated 70s-80s increased WOB refractory nebs, lasix, NRB. urgently intubated. cause decompensation felt multifactorial. trop 1.00 admission flat CK/MB, new LAD-distributed TWI EKG, new onset systolic dysfunction EF 40-45% TTE (new since last month). cardiac event could potentially caused deterioration CHF exacerbation. Pneumonia possible based RLL infiltrate, treated HCAP vanco/cefepime/levaquin. Sputum culture revealed commensal resp flora sparse GNR. started nebs steroids possible COPD exacerbation well,though quickly tapered due suspicion CHF etiology. aggressively diuresed. extubated [2132-10-9] transfered floor [2132-10-10]. . floor initially saturating 90's 4L NC. continued diuresed gently PO occasional IV lasix. oxygen weaned tolerated goal 02 sat 92%. steroids discontinued [2132-10-13] etiology SOB thought related pulmonary edema possible pneumonia rather COPD exacerbation. vancomycin discontinued based sputum data cefepime levaquin continued speciation available. nebulizers continued throughout hospital stay. day prior discharge, cefipime discontinued patient remained afebrile without leukocytosis; prednisone also discontinued since COPD flare appears primary etiology SOB symptoms resolving. PT consulted worked patient improving functional status. discharged home home PT services, home 02, cardiac telemonitoring. . 2)NSTEMI: troponin elevation 1.00 without similar MB CK elevation. nonspecific lateral wave changes, chst pain pressure suggest ACS. TTE revealed new onset systolic dysfunction EF 45-50%. Cardiology consulted, felt chemotherapy (taxol/cisplatin) likely blame recent MI. Based EKG echo data, possible partial occlusion LAD patient may benefit elective cathetrization. However, based absence symptoms comorbidities patient, oncology, medicine patient's family agreement medical management. [2132-10-12] patient 8 beat run v-tach. EKG essentially unchanged troponins showed continued downward trend. . 3. ANEMIA: HCT 25 unclear source, though inflammatory disease malignancy myelosupression chemo possible. Though hematrocrit trended downwards days prior discharge, transfusion thought necessary cardiology (goal 25). . 4. NON SMALL CELL LUNG CANCER: currently undergoing taxol chemo; resume outpatient. Atrius oncology service followed patient house. 5. HYPERTENSION: patient recently taken dose 20 mg linisnopril QAM due low blood pressures. Based new diagnosis CHF, lisinopril restarted dose 10 mg QAM; blood pressures remained stable systolics greater 110 house. . 6. GOUT: Allopurinol colchicine continued, active issue admission. Medications Admission: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation q4-6 hours needed SOB, wheezing. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times day). 5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Spray Inhalation twice day. 4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Spiriva HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation day. Disp:30 capsules Refills:2 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [1-13] puff Inhalation every four (4) hours needed shortness breath wheezing. 8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Home Oxygen 1-4 liters per minute continuous oxygen via nasal cannula [Male First Name (un) ]: 99 months Diagnosis: COPD 11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO day. Disp:60 Tablet(s) Refills:0 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every day 1 doses. Disp:1 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Congestive Heart Failure, Possible Pneumonia, COPD, Non-Small Cell Lung Cancer, Anemia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker). Discharge Instructions: Dear Mr. [Known lastname 5057], pleasure participating care [Hospital1 18]. admitted medical ICU presenting emergency department acute onset shortness breath blood transfusion. reaction blood transfusion ruled out. chest xray showed possible signs pneumomia started broad spectrum antibiotics. possible yoru COPD contributing shortness breath also given steroid well usual inhalers. MICU second acute episode shortness breath responsive oxygen. worsening respiratory status intubated (given breathing tube). Laboratory results EKG suggested may heart attack prior hospitalization. echo cardiogram showed new onset congestive heart failure (CHF). likely shortness breath due much volume backing lungs. given lasix help reduce volume lungs respiratory status improved point extubated (breathing tube removed) two days intubated. Cardiology consulted help care suggested possibility cardiac cathetrization look vessels heart. However, along oncolgy team, determined best try manage heart disease medical management. Due continued improvement transferred general medical floor continued monitor respiratory status give lasix manage fluid balance. steroids stopped medical floor medicines pneumonia narrowed treat likely organism. regular inhalers continued. followed blood counts throughout stay deemed necessary transfuse additional blood time. return home home nursing, oxygen, physical therapy services. keep oxygen saturation bewteen 88-92% use 3L oxygen active. also cardiac telemonitoring assist monitoring daily weights blood pressures. results automitically sent Dr.[Name (NI) 17793] office. resume medicines previously taking home following changes: START: lisinopril 10 mg QD (daily) START: lasix 20 mg PO (by mouth) QD START: atorvastatin 80 PO QD START: Spiriva 1 puff [Hospital1 ] (twice daily) CONTINUE: Levofloxacin 750 mg x1 dose ([10-16]) Followup Instructions: Please follow appointments discharge hospital: Name: [First Name8 (NamePattern2) 16883] [Last Name (NamePattern1) ], NP Specialty: Internal Medicine When: Tuesday [10-21] 9:30am Location: [Location (un) 2274]-[University/College ] Address: [Hospital1 3470], [University/College ],[Numeric Identifier 23943] Phone: [Telephone/Fax (1) 17530] Dr. [Last Name (STitle) ] office next week see nurse [First Name8 (NamePattern2) 3639] [First Name8 (NamePattern2) 16883] [Last Name (NamePattern1) ] visit. Name: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 349], MD Specialty: Hematology/Oncology When: Thursday [10-23] 1:30p Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3468] Name: [Doctor First Name 30513] [Doctor First Name 88276], PA Specialty: Cardiology When: Wednesday [10-29] 11:30am Location: [Hospital1 641] Address: [Hospital1 ], [University/College ], [Numeric Identifier ] Phone: [Telephone/Fax (1) 72622] see Dr. [Last Name (STitle) 91422] physicians assistant [First Name5 (NamePattern1) 30513] [Last Name (NamePattern1) 88276] visit. Completed by:[2132-10-15]	[ "41071", "51881", "4019", "41401", "4280", "2724" ]
Admission Date: [2141-2-23] Discharge Date: [2141-3-2] Date Birth: [2063-3-10] Sex: Service: CARDIOTHOR anticipated date discharge [2141-3-3]. dictation done Cardiothoracic Service. REASON ADMISSION: patient postoperative admit directly Operating Room [2-24] aortic valve replacement coronary artery bypass graft. patient seen [12-16] hospital admission cardiac catheterization Cardiothoracic Surgery Service surgery scheduled [2-24] time. time patient initially seen, history physical follows: CHIEF COMPLAINT HISTORY PRESENT ILLNESS: Asked Dr. [Last Name (STitle) ] see 77 year old man history aortic stenosis. patient morbidly obese long standing hypertension history mild dyspnea exertion without chest pain. rest symptoms. patient severe bilateral venous stasis currently diuretics. history congestive heart failure per patient. Recently, stopped diuretics. Serial echocardiograms shown increasing severity aortic stenosis. admitted [Hospital1 190] [2140-1-13] cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypertension. 2. Aortic stenosis. 3. Morbid obesity. 4. Tobacco use. 5. Venous stasis ulcers. PAST SURGICAL HISTORY: 1. Status post left cataract surgery. 2. Status post tonsillectomy. 3. Status post varicocele surgery. MEDICATIONS: 1. Lisinopril 40 mg q. day. 2. Spironolactone 25 mg q. day versus twice day. ALLERGIES: Norvasc, causes increasing lower extremity edema. SOCIAL HISTORY: Tobacco use remote; discontinued 40 years ago. Positive ETOH use; decreased per report wife last four years. PHYSICAL EXAMINATION: Height 5'[47]"; weight 310 pounds. Heart rate 68 sinus rhythm; blood pressure 146/60; respiratory rate 20; O2 saturation 99% room air. general, obese man severely draining venous stasis ulcers acute distress. HEENT: Anicteric, noninjected. Extraocular movements intact. Neck supple jugular venous distention, lymphadenopathy bruits. Oropharynx clear. Cardiovascular regular rate rhythm III/VI perisystolic murmur left sternal border. Lungs clear auscultation bilaterally. Abdomen soft, obese, nontender. Bilateral tinea groins. Extremities bilateral venous stasis changes knees. Ulcers clear green drainage lateral right medial left. Pulses: Carotids two plus bilaterally, radial two plus bilaterally, femoral - left catheterization site; right two plus. Popliteal two plus bilaterally dorsalis pedis posterior tibial, two plus bilaterally. Neurological: Motor sensory grossly intact. Cranial nerves II XII grossly intact. LABORATORY: Data white blood cell count 9.3, hematocrit 33.9, platelets 288. Sodium 136, potassium 4.7, chloride 100, carbon dioxide 30, BUN 23, creatinine 1.1. INR 1.3. EKG sinus rhythm left ventricular hypertrophy, nonspecific ST-T wave changes leads 5 6. Echocardiogram concentric left ventricular hypertrophy, severely dilated left atrium ejection fraction 75%. Mild resting LVOT obstruction. Catheterization showed 50% left main, 20% ostial right coronary artery, 40% diagonal, aortic valve area 1.3 centimeters squared. patient discharged home following catheterization treatment venous stasis ulcers appointment Vascular Surgery follow-up regarding lower extremity ulcers. HOSPITAL COURSE: returned [2-23] admitted directly Operating Room. time, underwent aortic valve replacement #23 tissue valve coronary artery bypass graft times one left internal mammary artery left anterior descending. Please see Operating Room report full details. patient tolerated operation well transferred Operating Room Cardiothoracic Intensive Care Unit. time transfer, patient heart rate 91. a-paced mean arterial pressure 65 central venous pressure 10. Levophed 0.12 mics per kg per minute Propofol 20 mics per kg per minute. immediate postoperative period, patient experienced labile blood pressure. transesophageal echocardiogram performed bedside showed systolic anterior motion. Levophed Neo-Synephrine weaned given volume. patient well hemodynamically following maneuvers. Then, anesthesia reversed. weaned ventilator successfully extubated. remained hemodynamically stable throughout night surgery postoperative day one DICTATION ENDS [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2141-3-2] 18:39 T: [2141-3-2] 21:01 JOB#: [Job Number 22266]	[ "4241", "5180", "41401", "4019" ]
Admission Date: [2152-5-3] Discharge Date: [2152-5-25] Date Birth: [2086-8-10] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Iodine-Iodine Containing / Coreg / Rosuvastatin / metronidazole / alendronate sodium / simvastatin / Ezetimibe / risedronate sodium / Vitamin Attending:[Last Name (NamePattern1) 1572] Chief Complaint: Anticoagulation heparin colonoscopy Major Surgical Invasive Procedure: Elective colonoscopy [2152-5-5] (with MAC) Colonoscopy [2152-5-9] Colonoscopy [2152-5-12] History Present Illness: 65 yo F pt hx rheumatic heart disease s/p mitral valve replacement ([Doctor Last Name 1395]-[Doctor Last Name ] metallic prosthesis) [2104], complicated diastolic dysfunction, mild stenosis,paravalvular leak prone occasional heart failure mild hypotension admitted elective colonoscopy need MAC anestheisa heparin bridging. Pt never colonoscopy. recently (+) blood test colon cancer last week, done Quest (Colovantage). Patient denies recent weight loss, night sweats, fevers, chills, melena, BRBPR, diarrhea, constipation. Patient mild SOB baseline. GI planning perform colonscopy [Year (4 digits) 2974]. Pt's last dose coumadin Sunday. also need SBE prophylaxis per primary cardiologst (although guidelines say necessary, recognizes would like err side caution). . Review systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea congestion. Denies cough, chest pain tightness, palpitations. Denied nausea, vomiting, abdominal pain. recent change bowel bladder habits. dysuria. Denied arthralgias myalgias. . Past Medical History: 1. Rheumatic heart disease status post mitral valve replacement [Doctor Last Name 1395]-[Doctor Last Name ] metallic prosthesis [2104]. 2. Congestive heart failure - ECHO [6-28] EF 50-55% mitral insuffiency 3. Chronic atrial fibrillation. 4. Hypertension 4. HLD 5. Carotid stenosis 6. Vitamin deficiency 7. Borderline diabetes, medications. 8. Anemia, iron supplements. 9. Spontaneous hemarthroses right knee [2150-7-21], [2150-8-19], [10-27] 10. Osteoarthritis knees 11. Migraine headaches 12. Allergic rhinitis . Past Surgical History: 1. Mitral valve replacement [2104] 2. CCY gallstones [2108] 3. Tubal ligation [2110] Social History: patient lives husband. nonsmoker (she quit smoking [2114]). drink alcohol. Denies IVDU. Family History: FHx negative premature coronary artery disease sudden cardiac death. mention one uncles heart condition older age well mother valve problem 50s, eventually passed away age 96. Physical Exam: Physical Exam: Vitals: T: 96.3 BP: 119/62 P: 80 irreg irreg; R: 22 O2: 96 RA General: Alert, oriented, acute distress. Pleasant woman. HEENT: Sclera anicteric, MMM, oropharynx clear skin warm smooth dry. Neck: supple, JVP elevated prominent V wave height 12.5 cm. Carotids 2+ equal without bruit. Chest: Clear auscultation bilaterally, wheezes, fine dry atelectatic rales bases 1/4 up.Left parascapular thoracotomy scar. CV: Irregularly irregular rate rhythm, normal S1 + S2, Gr [1-23] hololsystolic murmur loudest midaxillary line 5th ICS, Gr 2/6 SEM RUSB, rubs gallops, prominent parasternal RV lift. Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, 13 cm liver, 3 FB's costal margin, pulsatile. Cholecystectomy scar. Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis. 2+ pedal medial malleolar pretibial edema. Neuro: Normal muscle tone, moves extremities bilaterally, reflexes 2+ UE LE bilaterally, toes downgoing bilaterally. CNI: tested, CNII: PERRLA 4mm 2mm bilaterally. CNIII, IV, VI: EOMI. CN VII: Facial muscles intact. CN VIII: Intact bilaterally CNIX,X: Palate elevates symmetrically. CNXI: Intact CNXII: Tongue protrudes midline. Gait: normal. Pertinent Results: Admission labs: [2152-5-3] 09:45PM WBC-3.2* RBC-4.03* HGB-11.6* HCT-34.8* MCV-87 MCH-28.9 MCHC-33.4 RDW-14.4 [2152-5-3] 09:45PM PT-21.1* PTT-150* INR(PT)-1.9* [2152-5-4] 05:15AM BLOOD Glucose-86 UreaN-38* Creat-1.2* Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 [2152-5-4] 05:15AM BLOOD ALT-31 AST-52* LD(LDH)-340* AlkPhos-117* TotBili-1.0 [2152-5-4] 02:55AM BLOOD proBNP-2791* [2152-5-4] 05:15AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 Iron-112 [2152-5-4] 05:15AM BLOOD calTIBC-295 VitB12-1741* Folate-GREATER TH Hapto-<5* Ferritn-117 TRF-227 . Imaging: ECHO [2152-5-4]: IMPRESSION: Normal left ventricular function. Ball cage mitral prosthesis normal gradient least mild mitral regurgitation. Dilated hypokinetic right ventricle severe tricuspid regurgitation moderate pulmonary hypertension. Mild aortic regurgitation. Biatrial dilatation right atrium markedly dilated. . Splenic US [2152-5-5]: FINDINGS: Transverse sagittal images obtained spleen. spleen enlarged measuring 16.2 cm. splenic appearance unremarkable. ascites seen left upper quadrant. IMPRESSION: Splenomegaly. . Colonoscopy [2152-5-5]: Impression: Polyp proximal ascending colon (polypectomy) Otherwise normal colonoscopy cecum. . Colonoscopy [2152-5-9]: Impression: blood throughout colon making visualization difficult. mucosa examined. large blood clot proximal ascending colon site prior polypectomy. clip buried within clot. area washed extensively clot could removed. Biopsy forceps used try remove clot successful. erythema active oozing seen superior aspect clot. (endoclip, injection) . Colonoscopy [2152-5-12]: Impression:Blood colon polypectomy site identified presence clips. adherent clot noted adjacent clips. Fresh bleeding noted base. clot removed wash suction. small visible vessel noted. Three clips applied successful hemostasis. 5 cc epinephrine injected mucosa hemostasis. rest colon fully examined. Otherwise normal colonoscopy cecum. Polyp described serrated adenoma requiring repeat colonoscopy 5 years given increased risk finding serrated polyp. Discharge Labs: Brief Hospital Course: 65 yo F pt hx rheumatic heart disease age 7, s/p mitral valve replacement ([Doctor Last Name 1395]-[Doctor Last Name ] mechanical prosthesis) [2104], complicated mitral insufficiency, ? ball variance/and paravalvular leak, pulmonary hypertension RV failure,tricuspid insufficiency normal LV function, admitted elective colonoscopy need MAC anesthesia heparin bridging. . # Positive Colovantage test: Patient undergone routine screening colonoscopy however underwent Colovantage testing came back positive [2152-4-12], indicating increased likelihood colorectal cancer. admitted IV heparin bridge due mechanical valve (pt must anticoagulated; high risk thrombus) starting [12-23] days discontinuing coumadin (stopped [4-30]). Colonoscopy performed [5-5] MAC anesthesia removal single sessile polyp ascending colon. Post procedure stay complicated bleeding, see below. . #Loose bloody stools: [5-7], patient experienced loose stools mixed blood. coumadin held, heparin initially continued. Hct started fall [5-8] 25 given 2 units RBCs. Heparin stopped reprepped colonscopy (#2). remained hemodynamically stable. [5-9], large clot visualized polypectomy site could evacuated, additional clips placed along epinephrine. Heparin restarted procedure. However, [2152-5-11], patient's hct dropped 28 patient experienced increased bloody stools. Patient received one unit RBCs heparin dc'd 6 hrs. repreped repeat scope done [2152-5-12]. clot removed clips placed epi injected. Post procedure hct remained stable. . # Mechanical Mitral Valve: Patient s/p mitral valve replacement ([Doctor Last Name 1395] [Doctor Last Name ] valve) mitral stenosis/atrial fibrillation [2104]. Patient admitted heparin bridge procedure. given SBE prophylaxis (clindamycin 600mg IV) procedures. home coumadin initially restarted [5-5], dc'd [5-7] due bloody bowel movements. bleeding episodes stated heparin stopped given intervals. coumadin restarted [2152-5-15]. increasing warfarin requirement usual dose 5.5 mg slow rise INR therapeutic plateau (2.3) reached 8 mg warfarin Q PM likely related increase PO nutrients supplemented Boost. may need less warfarin returns usual home diet. bridged heparin [2152-5-25]. . # CHF: Patient ECHO [2151-6-20] EF 50-55% moderate severe tricuspid regurgitation pulm artery htn noted. CXR [2152-4-12] performed cardiologist revealed probable small left pleural effusion, evidence CHF; BNP 218 [2152-4-12]. Patient presents volume overloaded systolic ejection murmur; repeat ECHO essentially unchanged [6-/2151], worsening pulm htn. Pro-BNP elevated 2791 [5-4]. home medications, including nebivolol, valsartan, diltiazem discontinued setting bleed symptoms blood loss would masked. Transfusions performed slowly 4 hours order fluid overload. Patient without oxygen requirement clear lungs throughout hospitalization. ICU, home diltiazem restarted tolerated well. . #Splenomegaly/pancytopenia: Patient presented thrombocytopenia admission labs (plts 79); unclear etiology (heme low suspicion HIT). Per outpt cardiology records, patient's platelets 129 [2152-4-12]. Patient's anemia [12-22] hemolysis mechanical valve (LDH elevated, low haptoglobin). Splenic ultrasound shows splenomegaly; heme likely perform outpt BM bx. Valsartan associated leukopenia; investigation revealed pt cough ace-inhibitor. ACE [Last Name (un) ] rx'd pending consultation f/u Dr. [Last Name (STitle) ]. also follow heme-onc outpatient. . #Atrial fibrillation: Patient rate controlled diltiazem, nebivolol; anticoagulated heparin (was coumadin) house. colonoscopy, pt episode AFib RVR, required dose esmolol. transferred ICU overnight monitoring. ICU, home regimen diltiazem restarted. dose Dilt ER without beta blocker ambulatory HR 120-130. Dilt ER increased 180 PO daily excellent rate control, never greater 90. febrile 99.6 day discharge peak rate 12 hrs 114. Patient successfully bridged back coumadin discharge INR 2.3. . #Fever: day prior discharge, [2152-5-24], patient low-grade temperature 100.4. felt well, without cough, diarrhea, abdominal pain dysuria. urinalysis negative. Abdomen benign exam eating drinking normally. day disharge temperature 99.6 12pm. counseled continue monitoring temperature home call primary care doctor new symptoms. antibiotics started. close follow-up Dr. [Last Name (STitle) ]. . #Difficult crossmatch blood: Patient required several transfusions difficult crossmatch. investigation blood bank revealed new clinically significant alloantibody, anti-E. patient notified new finding carry information her. card describing finding issued pathology. . # HTN: Patient stable home medications. hypertension recorded. . #Transition care: need close monitoring INR discharge follow blood loss. hematocrit checked discharge. also heart failure medications re-evaluated restarted. Unclear nebivolol rather carvedilol. concern whether Valsartan causing pancytopenia may want consider restarting ACE inhibitor instead Valsartan. hematology/oncology appointment evaluate pancytopenia. Medications Admission: Home Medications (reconciled Dr. [Last Name (STitle) ]: Valsartan 160 mg daily Diltiazem 120mg daily Furosemide 20mg daily Coumadin 5.5mg daily Nebivolol 10mg 1 tablet daily Iron 325 mg 1 tablet twice day Calcium citrate 600mg +400 iu 1 tablet twice day Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Disp:30 Capsule, Extended Release(s) Refills:2 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times day). 4. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice day. 5. warfarin 8 mg PO day: Dose adjusted per Dr. [Last Name (STitle) ]. 6. multivitamin Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Elective colonoscopy Secondary Diagnosis: s/p mitral valve replacement [Doctor Last Name 1395] [Doctor Last Name ] mechanical prosthesis diastolic CHF RV failure secondary Pulmonary Hypertension Mitral insufficiency Atrial fibrillation,chronic Transfusion reaction alloantibody Anti E. Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted planned colonoscopy follow positive Colovantage colon cancer screen. required heparin taking Coumadin mechanical mitral valve. colonoscopy [2152-5-5] polyp removed started bleed colon. required two additional colonoscopies [2152-5-9] [2152-5-12] stop bleeding. bleeding stopped, able start Coumadin [2152-5-15] get back close goal INR 2.5-3.5. patient able get close goal INR 2.3 Coumadin leaving hospital. need INR closely followed. INR checked [2152-5-26] 1pm Dr. [Last Name (STitle) ] continue follow him. temperature slightly elevated 100.4 [2152-5-25], symptoms feeling unwell. important continue check temperature. begin feel unwell please follow primary care doctor nearest emergency department. . Please go follow appointments. see evidence bleeding please contact primary care physician immediately go nearest ED. Also congestive heart failure causes hold water legs. notice increased swelling legs increase weight please contact primary care doctor cardiologist. nebivolol valsartan stopped. Please discuss cardiologist medications resume congestive heart failure. Please follow-up hematology follow-up low blood counts possible bone marrow biopsy. . Changes made medications. Please: - STOP Bystolic (nebivolol) - increase diltiazem 180mg daily - increase warfarin (Coumadin) 8mg daily (4 x 2mg tablets) - STOP valsartan now. Dr. [Last Name (STitle) ] may want restart medication future. Followup Instructions: Name: [Last Name (LF) 7726],[First Name3 (LF) 177] A. Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] Appt: [Last Name (LF) 2974], [4-26] 1pm Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2152-6-7] 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13999], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2152-5-25]	[ "V5861", "42731", "4168", "4019", "4280" ]
Admission Date: [2154-11-14] Discharge Date: [2154-11-24] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance Attending:[First Name3 (LF) 11217] Chief Complaint: fever cough Major Surgical Invasive Procedure: Left Midline placed [11-22] History Present Illness: Ms. [Known lastname 31102] [Age 90 ] yo h/o COPD aspiration pneumonia noted cough past several weeks. saw PCP started mucinex robitussin. well day admission 1 pm onset nonbloody nonbilious emesis x 3. home nurse noted fever 101.2, HR 140, patient's "lungs good" today. reason, patient brought ambulance. Here, patient found satting 97%4L low 90s 2 L. baseline 93% 2L). CXR showed RLL infiltrate. note, baseline wit activities, helping cooking even day prior admission. . ED, patient given Ipratropium Neb, Albuterol 0.083% Neb, CefTRIAXone 1g, Metronidazole 500mg, MethylPREDNISolone 125mg ? COPD. Blood urine cultures obtained. . ROS: chest pain, dysuria, frequency. + weight loss Past Medical History: 1) Diabetes mellitus (Hgb A1C 5.8% [2-8]) 2) Frequent UTI 3) Gastroesophageal reflux disease 4) S/p CVA w/residual mild R hemiparesis 5) Osteoporosis 6) Mild cognitive impairment 7) Depression/Anxiety 8) Osteoarthritis 9) Hypothyroidism (last TSH 2.8 [11-7]) 10) Chronic diarrhea 11) COPD, night O2 home (FEV1 0.88 (73% pred), FVC 1.2, elevated EV1/VC ratio [1-6]), prior intubations, placed steroid taper last admission [3-11]. Social History: Smoked 2ppd [2131]. [2-4] glass wine 3-4x/week. Worked secretary. Independent ADLs, IADL. 24 hour caretaker. [Name (NI) ] (daughter) Healthcare proxy. Pt confirmed FULL CODE. Family History: non-contributory Physical Exam: Vitals: T96 BP 150-180/62-69 P 68-73 R 20 sat 97%RA, 93%4LNC Gen: elderly cachectic female sitting bed 60 degrees, sleepy awakens difficulty, NAD HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP clear, uvula midline, dry MM Neck: JVP 8 cm, HJR, LAD, thyromegaly, carotid bruits CV: distant heart sounds, nl S1/S2, m/r/g noted Lungs: decreased breath sounds bases, otherwise CTA Ab: soft, NTND, NABS, HSM percussion, rebound guarding Extrem: wwp, c/c/e Neuro: MAFE Skin: rashes Pertinent Results: [2154-11-14] 08:25PM BLOOD WBC-24.5# RBC-3.75 Hgb-12.6 Hct-36.8 MCV-98 MCH-33.6* MCHC-34.3 RDW-14.9 Plt Ct-350 [2154-11-17] 04:11AM BLOOD WBC-10.6 RBC-3.19* Hgb-10.6* Hct-31.4* MCV-99* MCH-33.1* MCHC-33.6 RDW-15.1 Plt Ct-257 [2154-11-22] 08:45AM BLOOD WBC-13.5* RBC-3.86* Hgb-12.5 Hct-37.9 MCV-98 MCH-32.5* MCHC-33.1 RDW-15.4 Plt Ct-349 [2154-11-14] 08:25PM BLOOD Neuts-88* Bands-0 Lymphs-7* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2154-11-16] 06:25AM BLOOD Neuts-93.5* Bands-0 Lymphs-4.8* Monos-1.4* Eos-0.1 Baso-0.1 [2154-11-16] 06:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ Stipple-1+ Tear Dr[Last Name (STitle) ]1+ [2154-11-14] 09:15PM BLOOD Glucose-210* UreaN-35* Creat-1.4* Na-140 K-5.1 Cl-105 HCO3-23 AnGap-17 [2154-11-18] 03:33AM BLOOD Glucose-53* UreaN-41* Creat-0.9 Na-152* K-3.7 Cl-119* HCO3-23 AnGap-14 [2154-11-21] 05:20AM BLOOD Glucose-60* UreaN-31* Creat-0.9 Na-142 K-3.9 Cl-105 HCO3-25 AnGap-16 [2154-11-15] 11:25AM BLOOD ALT-36 AST-30 LD(LDH)-204 AlkPhos-109 Amylase-55 TotBili-0.3 [2154-11-15] 11:25AM BLOOD Lipase-12 [2154-11-18] 08:09PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2154-11-19] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.02* [2154-11-19] 02:38PM BLOOD cTropnT-<0.01 [2154-11-17] 04:11AM BLOOD Calcium-7.6* Phos-1.6* Mg-2.8* [2154-11-15] 12:11PM BLOOD Type-ART pO2-53* pCO2-28* pH-7.48* calTCO2-21 Base XS-0 Intubat-NOT INTUBA [2154-11-18] 12:13PM BLOOD freeCa-1.16 . Micro: Urine culture [11-16], [11-17] Negative Stool culture [11-17] negative Blood cultures: 10/12 [2-6] + Strep Pneumo sensitive ceftriaxone, others negative NGTD . CXR: [11-18] FINDINGS: dense consolidation right lower lobe. pleural effusions identified. pulmonary vasculature normal. heart mediastinal contours stable. Soft tissue osseous structures remarkable scoliosis. Surgical staples present right upper quadrant. IMPRESSION: Right lower lobe pneumonia. . CXR: [11-21] heart size normal. aorta unfolded. small improved right-sided layering pleural effusion. Right basilar consolidation may represent atelectasis aspiration pneumonitis. Left lung field clear. pneumothorax. IMPRESSION: Small stable right effusion right basilar consolidation may represent either atelectasis pneumonia. . CXR: [11-23] FINDINGS: small right apical pneumothorax, decreased size interval approximately 18 mm 11 mm maximal visceral parietal pleural separation. tracheal deviation findings suggestive tension physiology. interval clearing right lower lobe opacity previously described. consolidation identified. superimposed edema. mildly tortuous atherosclerotic aorta noted. cardiac silhouette within normal limits size mild left ventricular configuration. definite effusion. levoconcave curvature thoracic spine. Surgical clips identified right upper quadrant. IMPRESSION: Right apical pneumothorax decreased size. evidence underlying tension Brief Hospital Course: Patient 90-year old female MMP admitted fevers cough, initially floor, transferred unit, transferred back floor prior discharge. # Cough: patient history aspiration pneumonia also history COPD oxygen dependent. Due location infiltrate radiographs quick decompensation, clinical picture seemed fit aspiration pneumonia. Blood cultures, [2-8], returned positive strep pneumoniae sensitive ceftriaxone. begun 14-day treatmet regimen ceftriaxone, 1g IV treat pneumonia. regards COPD element clinical presention, patient continued advair, ipratropium, albuterol, PO steroids taper. steroid taper completed [11-23]. also noted patient small right apical pneumothorax CXR noted [11-22] amenable monitoring. likely secondary bleb bursting ICU stay. otherwise asymptomatic. Follow CXR showed marked improvement size [11-23]. need follow CXR [6-9] days assess resolution day prior discharge, patient's white count showed mild elevation. UA urine culture sent ensure urinary tract infection cause. Consideration given restarting additional abx, possibly flagyl, cover possible aspiration pneumonia. urine negative UTI. Blood cultures NGTD. patient's WBC stabilized 14. remained entirely asymptomatic localizing signs. However, given low threshold aspiration component, started Flagyl 500mg PO TID x 10days ([12-3]). steroids may also contributed lymphocytosis . # UTI: patient urinary complaints, UA positive UTI urine culture grew E-Coli, sensitive ceftriaxone. treated appropriately this. . # ARF: Initially, patient's renal function impaired slight elevation creatinine level, baseline. levels resolved fluid boluses remained steady throughout stay. . # Hypothyroidism: patient continued continued levothyroxine. . # Psych: per daughter, patient history depression anxiety. stay, patient showed period somnolence, including second stay floor, daughter stated somewhat normal. patient continued mirtazapine fluoxetine lorazepam PRN. . # HTN: Patient history hypertension, normal levels stay, often remaining high 80s 90s despite fluid boluses. ace inhibitor beta blockade held initially, SBPs tolerated, added regimen. . # CHF: Initially, due underlying diastolic cardiac dysfunction hypovolemic status initially, diuresis implemented. patient's vital signs stabilized clinical illness began improve, gentle diuresis attempted help respiratory status. continued diuresed gently needed rehab. . # TIA history: clinical issue stay, patient continued aspirin. . # FEN/aspiration risk: Patient placed nectar thickened liquid diet aspiration risk. Medications Admission: Ipratropium Bromide Neb 1 NEB IH Q8H Fluticasone-Salmeterol (100/50) 1 INH IH [Hospital1 ] Aspirin 81 mg PO DAILY Fluoxetine HCl 20 mg PO DAILY GlipiZIDE 2.5 mg PO DAILY Metoprolol 12.5 mg PO BID Mirtazapine 30 mg PO HS Levothyroxine Sodium 50 mcg PO DAILY Lisinopril 2.5 mg PO QD Lorazepam 0.5 mg PO QD Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation q6hrs:prn. 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation q4-6hrs:prn. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day) needed perineal redness. 14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) 3 days: [11-28] last dose. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qd:prn. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO prn needed fluid overload: need assessed daily. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) INJ Injection TID (3 times day). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 9 days: complete 10 day course (last day [12-3]) empiric coverage possible aspiration component pneumonia. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: 1. Pneumonia 2. COPD 3. Pontine stroke 4. Hypothyroidism 5. Depression anxiety requiring hospitalization 6. Hypertension 7. Diabetes mellitus II 8. CHF Discharge Condition: Patient discharged rehab facility stable condition, requiring oxygen adeqaute saturations, tolerating PO feeds, without fever. Discharge Instructions: Patient advised return emergency department acquires chest pain, shortness breath, nausea, vomiting, fevers, chills, pain ordinary her. Patient advised keep follow-up appointments assigned. Followup Instructions: 1. PCP [Name Initial (PRE) 176] 1 week. Please call appointment. 2. need Midline removed assessment physician antibiotic regimen completed. 3. need follow Chest X-Ray re-assess resolution infectious processes/pneumothorax	[ "5070", "496", "4280", "5849", "5990", "2760", "2449", "25000" ]
Admission Date: [2116-3-8] Discharge Date: [2116-3-26] Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Infected Pacemaker Major Surgical Invasive Procedure: Screw-in pacer wire placement ([2116-3-12]) PICC line placement ([2116-3-13]) TEE Removal pacemaker History Present Illness: Patient 86 year old female patient PMHx significant mechanical aortic valve, CHB s/p PM complicated large hematoma requiring evacuation presents OSH found abscess previous hematoma site. . Patient recently discharged [Hospital1 18] found complete heart block. Patient pacemaker placed however developed large chest hematoma setting anticoagulated mechanical valve. Patient required 9 units PRBC hematoma evacuated. . discharged nursing home [2-13] found infected PM abscess previous hematoma site. NH incision clavicle began open start draining temps 104. OSH, WBC [Numeric Identifier 71077] (69% PMNs, 17% Bands) pacemaker removed local surgeon patient started vanc gent (per ID consult). continues spike temperatures prelimanary wound blood cultures OSH growing gram + cocci clusters. Patient also found tachycardic HR ranging 114-140s. transferred [Hospital1 18] management. Past Medical History: CAD s/p 2-vessel CABG [2104] CHB s/p PM complicated large hematoma evacuation s/p [First Name8 (NamePattern2) ] [Initials (NamePattern4) 1525] [Last Name (NamePattern4) 1291] [2104] CHF HTN Diabetes Hypothyroidism Dementia, mild-moderate s/p appy s/p TAH Social History: Recently living nursing home previous discharge [Hospital1 18] non-smoker non-drinker Family History: unable obatin patient due dementia Physical Exam: 99.2 BP 123/55 HR 77 RR 20 Sat 95% 5L nc Gen: moaning, NAD HEENT: OP clear, scleral icterus Neck: carotid bruits, prominent a-waves , JVP 7cm Chest: 5cm x 3cm x 1.5cm incision left upper chest extending pectoral muscle tissue without frank drainage erythema; lungs bibasilar rales CV: irregular, II/VI systolic murmur across precordium mechanical S2 Abd: mildly distended, nontender, soft, normal bowel sounds, HSM Extr: 2+ DP pulses, edema, cool Neuro: alert, conversant, oriented self Pertinent Results: TTE ([2116-3-11]): mild symmetric left ventricular hypertrophy normal cavity size. Regional left ventricular wall motion normal. Left ventricular systolic function hyperdynamic (EF>75%). Right ventricular chamber size free wall motion normal. mechanical aortic valve prosthesis present. transaortic gradient higher expected type prosthesis. masses vegetations seen aortic valve cannot excluded. Significant aortic regurgitation present, cannot quantified. mitral valve leaflets moderately thickened. severe mitral annular calcification. mild mitral stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation seen. [Due acoustic shadowing, severity mitral regurgitation may significantly UNDERestimated.] tricuspid valve leaflets mildly thickened. mild pulmonary artery systolic hypertension. pericardial effusion. . Labs: [2116-3-8] 01:51AM BLOOD WBC-28.0# RBC-3.53 Hgb-10.8* Hct-31.3* MCV-89 MCH-30.6 MCHC-34.5 RDW-17.0* Plt Ct-271 [2116-3-24] 03:41AM BLOOD WBC-11.2* RBC-3.26* Hgb-10.2* Hct-29.8* MCV-92 MCH-31.2 MCHC-34.1 RDW-16.5* Plt Ct-352 [2116-3-8] 01:51AM BLOOD Neuts-75* Bands-15* Lymphs-2* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2116-3-21] 01:11PM BLOOD Neuts-92.9* Bands-0 Lymphs-4.2* Monos-2.9 Eos-0.1 Baso-0 [2116-3-24] 03:41AM BLOOD Plt Ct-352 [2116-3-24] 03:41AM BLOOD PT-80.0* PTT-52.8* INR(PT)-10.5* [2116-3-8] 01:51AM BLOOD PT-22.2* PTT-39.7* INR(PT)-2.2* [2116-3-24] 09:00AM BLOOD FDP-10-40 [2116-3-24] 09:00AM BLOOD Fibrino-410* D-Dimer-[2125]* [2116-3-21] 01:11PM BLOOD Ret Aut-4.3* [2116-3-24] 03:41AM BLOOD Glucose-165* UreaN-24* Creat-2.1* Na-133 K-3.5 Cl-104 HCO3-17* AnGap-16 [2116-3-8] 01:51AM BLOOD Glucose-190* UreaN-22* Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-23 AnGap-15 [2116-3-21] 01:11PM BLOOD LD(LDH)-336* CK(CPK)-126 [2116-3-23] 02:33AM BLOOD TSH-6.0* [2116-3-23] 02:33AM BLOOD T4-2.9* T3-53* [2116-3-23] 02:56AM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 . [3-15] CT Head FINDINGS: evidence acute intracranial hemorrhage, mass effect, hydrocephalus, shift normally midline structures. remain large areas periventricular white matter hypodensity consistent chronic small vessel infarction. right thalamic lacune seen. fluid level sphenoid sinus. soft tissues unchanged. IMPRESSION: evidence intracranial hemorrhage mass effect. . [3-20] TTE Conclusions: left atrium mildly dilated. thrombus seen left atrial appendage. left-to-right shunt across interatrial septum seen rest. small secundum atrial septal defect present. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Right ventricular chamber size free wall motion normal. complex (>4mm) atheroma descending thoracic aorta. aortic prosthesis appears well seated, normal leaflet/disc motion. masses vegetations seen aortic valve. Trace aortic regurgitation seen. mass vegetation seen mitral valve. Mild moderate ([1-21]+) mitral regurgitation seen. pericardial effusion. Compared prior study (images reviewed) [2116-3-20] significant change. . [3-23] CT Head FINDINGS: study significantly motion degraded lower mid levels. Allowing deficiency, acute intracranial hemorrhage appreciated. diffuse cerebral periventricular white matter hypodensity consistent chronic small vessel infarction. Chronic lacunar infarcts left basal ganglia right thalamus stable. evidence suggest acute major vascular territorial infarction seen. Sphenoid sinus air- fluid level noted. Carotid vascular calcification seen. IMPRESSION: Motion limited study; allowing limitation, acute intracranial hemorrhage seen. Sphenoid sinus air-fluid level (are symptoms sinusitis?). . [3-24] CT Head FINDINGS: case yesterday, number images degraded patient motion. Allowing deficiency, definite interval change identified. again, chronic lacunar infarct noted within right thalamic region, well generalized bilateral cerebral periventricular white matter hypodensity, consistent chronic small vessel infarction. sign presence intracranial hemorrhage. heavy atherosclerotic calcification distal vertebral arteries cavernous carotid arteries. surrounding osseous soft tissue structures remarkable redemonstration sphenoid sinus air-fluid level. stated yesterday, finding suggests possible acute sinusitis requires clinical correlation, sinus drainage could impeded presence nasogastric tube. CONCLUSION: intracranial hemorrhage. Brief Hospital Course: Assessment/Plan: 86 yo woman abscess surrounding pacemaker site, s/p surgical pacemaker removal NSR, 9 second period asystole, treated temporary external pacer plan permenant pacer course Abx completed. pacer infection seemed resolving [3-20] another TEE eval endocarditis. mental status never seemed improve po intake poor. [3-21], hypotensive episode required pressors intubation. appeared [Month (only) ] po inability mount tachycardic response [2-21] heart block. quickly weaned pressors vent mental status never improved. CT scans show acute intracranial event. daughter made decision make CMO, consistent patient's stated wishes. passed away two days later. . Hospital course complicated by: . ## Wound abscess/bacteremia: Wound grew VRE MRSA . ## Hematoma: recurred pacer site, s/p 1uPRBC's appropriate hct increase, bleeding. - U/S area showed small cystic structure aspirated . ## Delerium: Continues waxing [Doctor Last Name 688] mental status. Likely related infection, pacer, hematoma, hospitalization, underlying dementia. Head CT without bleed [3-15], [3-23], [3-24]. Became acutely hypotensive [3-21] requiring intubation recovered mental status that. Unclear etiology likely multifactorial episodes hypotension. . ## Valves: s/p St. [Male First Name (un) 1525] aortic valve placement [2104]; also moderate MS (valve area 1.0-1.5cm^2), [1-21]+ MR, 2+ TR recent TTE - TTE TEE negative vegetations - INR intermittently high low heparin gtt fluctuating doses coumadin . ## Rhythm: history recent CHB - due episode 9 second asystole, EP screwed pacer wires [3-12] external device. - telemetry - resumed beta blockade pacer place . ## Coronaries: s/p 2-v CABG OSH [2104] (anatomy unknown) - cont aspirin, statin; continue beta-blockade . ## Pump: diastolic CHF LVEF 70-75% [1-/2116] TTE; - cont home dose PO Lasix . ## HTN - resumed beta blockade pacer wires place - Lisinopril 80 - hydral added [3-19] . ## Hyperlipidemia - atorvastatin per outpatient dose . ## Dementia - held psychotropics given altered mental status . ## Hypothyroidism - cont thyroid replacement . ## DM2 - hold sulfonylurea; cover RISS . ## COPD - cont Spiriva; prn ipratropium nebs . ## FEN: NGT [2-21] po getting tube feeds - cardiac/purreed diet, encourage pos - trend lytes; replete prn . ## Prophylaxis - bowel regimen; heparin gtt . ## Code: DNR/DNI /CMO. - appreciate palliative care consult . ## Access: L PICC placed IR . Medications Admission: Meds transfer: Vancomycin 1gm [Hospital1 ] Gentamycin 100mg qd synthroid 0.1mg daily Protonix 40mg IV qam . Outpt meds: glyburide, metoprolol, lipitor, coumadin, lexapro, diovan, risperdal, lasix, amlodopine Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Cardiopulmary arrest 2. Sepsis 3. Infected hematoma 4. Pacemaker removal Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: None	[ "51881", "496", "99592", "5849", "V4581", "4019", "25000", "2449" ]
Admission Date: [2146-8-7] Discharge Date: [2146-8-20] Date Birth: [2066-7-17] Sex: Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2836] Chief Complaint: Respiratory distress Major Surgical Invasive Procedure: Intubation [2146-8-7] History Present Illness: Mr. [Known lastname 32913] 80-year-old male presented rehabwith respiratory distress. setting recent hospitalization ([141-12-2]) treated florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, intubation respiratory distress context LLL PNA grew E.coli. took place duodenal perforation s/p laparoscopic cholecystectomy OSH [2146-6-2], brought [Hospital1 18] repair duodenal injury, placement lateral duodenostomy tube, feeding jejunostomy tube, PTBD (6/[2146]). Past Medical History: Past Medical History: HTN, prostate CA, duodenal ulcer Past Surgical History: partial gastrectomy BII reconstruction, prostatectomy bilateral inguinal node dissection, laparoscopic cholecystectomy Social History: lives long term care facility. drink alcohol, smoked 20 years. Family History: non-contributory Physical Exam: ADMIT EXAM: Vitals: =100.4, HR = 109, RR = 20, O2Sat = 100% NRB, BP = 132/74 General: Sedated, intubated, thin ill appearing white male HEENT: Sclera anicteric,Pupils 5 minimally reactive, moving eyes around, blinking much blinks light shinning the, Neck: supple, JVP elevated recumbent 0 deg LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Coarse breathsounds left base compared right Abdomen: soft, midline scar well healed. Drains left appear intact, multiple bags full dark yellow/[Location (un) 2452] fluid. erythema skin surrounding them. Hypoactive bowel sounds normal pitch. Ext: warm, well perfused, 2+ pulses DP pulses bilaterally clubbing, cyanosis edema Neuro: Unable assess patient sedated intubated DISCHARGE EXAM: Vitals: 98.2 97.8 89 113/56 16 99%RA General: distress, thin appearing male, interactive upon stimulation HEENT: anicteric sclera, PERRLA CV: RRR, +S1/S2, m/r/g Lungs: Sparse coarse breath sounds diffusely, otherwise CTAB Abdomen: soft, well-healed incision. Drains x4 intact. +BS, NT, ND, r/r/g Ext: warm, well perfused, 2+ distal pulses Pertinent Results: IMAGING: 1) CHEST (PORTABLE AP) ([2146-8-7]): endotracheal tube positioned 4.2 cm level carina. nasoenteric catheter courses diaphragm tip stomach. left PICC unchanged position terminating mid SVC. consolidation within left lung base. appears similar prior examination likely reflects atelectasis resolving pneumonia. new confluent opacity identified. pneumothorax. Blunting bilateral costophrenic angles unchanged prior likely suggests possible small effusions. overt interstitial edema. Cardiomediastinal hilar contours within normal limits. IMPRESSION: Expected position support devices. pneumothorax. Persistent retrocardiac opacity possible atelectasis resolving pneumonia. Probable small bilateral pleural effusions. 2) BILAT LOWER EXT VEINS ([2146-8-7]): [Doctor Last Name ]-scale color Doppler images bilateral common femoral, superficial femoral, deep femoral, popliteal calf veins demonstrate normal flow, compressibility response augmentation. IMPRESSION: evidence deep venous thrombosis bilateral lower extremities. 3) CT HEAD W/O CONTRAST ([2146-8-7]): evidence hemorrhage, edema, mass effect infarction. Prominence ventricles sulci compatible age-related global atrophy, unchanged. mild left cavernous carotid artery calcification. osseous lesions seen. mucosal retention cysts mucosal thickening within maxillary sinuses. small amount aerosolized secretions seen within left sphenoid sinus. mastoid air cells grossly clear. IMPRESSION: Age appropriate volume loss mild carotid calcification. Otherwise normal study. evidence acute intracranial process. 4) CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST ([2146-8-7]): Wet read- bibasilar atelectasis, left greater right. given history, aspiration certainly possible. dense atherosclerotic calcifications. hypodense vascular space consistent anemia. unchanged right upper lobe pulmonary nodules. known multiple biliary drains stent prior procedure bile leak. scattered free fluid however focal collection evidence abscess. MICRO/PATH: GRAM STAIN (Final [2146-8-7]): >25 PMNs >10 epithelial cells/100X field. Gram stain indicates extensive contamination upper respiratory secretions. Bacterial culture results invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2146-8-7]): TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Preliminary): LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): GRAM STAIN SPECIMEN INDICATES CONTAMINATION OROPHARYNGEAL SECRETIONS INVALIDATES RESULTS. Specimen screened Cryptococcus species. New specimen recommended ADMIT LABS: [2146-8-7] 12:25PM BLOOD WBC-16.2* RBC-3.03* Hgb-9.0* Hct-29.5* MCV-97 MCH-29.8 MCHC-30.6* RDW-16.8* Plt Ct-738* [2146-8-7] 12:25PM BLOOD Neuts-66.5 Lymphs-22.6 Monos-2.4 Eos-7.8* Baso-0.7 [2146-8-7] 12:25PM BLOOD PT-11.5 PTT-30.5 INR(PT)-1.1 [2146-8-7] 12:25PM BLOOD Plt Ct-738* [2146-8-7] 12:25PM BLOOD Glucose-890* UreaN-68* Creat-2.3* Na-134 K-5.6* Cl-105 HCO3-18* AnGap-17 [2146-8-7] 12:25PM BLOOD ALT-12 AST-29 AlkPhos-196* TotBili-0.5 [2146-8-7] 12:25PM BLOOD Albumin-2.6* [2146-8-7] 03:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 [2146-8-7] 02:17PM BLOOD Type-ART Temp-38.0 Tidal V-450 FiO2-100 pO2-159* pCO2-41 pH-7.28* calTCO2-20* Base XS--6 AADO2-513 REQ O2-86 Intubat-INTUBATED [2146-8-7] 12:31PM BLOOD Lactate-1.0 DISCHARGE LABS: [2146-8-18] 05:39AM BLOOD WBC-9.4 RBC-2.63* Hgb-8.2* Hct-24.5* MCV-93 MCH-31.0 MCHC-33.2 RDW-17.1* Plt Ct-628* [2146-8-18] 05:39AM BLOOD Plt Ct-628* [2146-8-18] 05:39AM BLOOD Glucose-108* UreaN-69* Creat-1.5* Na-131* K-4.1 Cl-105 HCO3-18* AnGap-12 [2146-8-18] 05:39AM BLOOD ALT-13 AST-36 AlkPhos-313* TotBili-0.4 DirBili-0.2 IndBili-0.2 [2146-8-18] 12:50PM BLOOD Vanco-19.2 Brief Hospital Course: 80 year old male s/p CCY complicated duodenal perforation multiple drains place recently discharged prolonged hospital course treated pan sensitive Ecoli pneumonia rehab presents acute respiratory distress leukocytosis. [2146-8-7]: patient tachypnic admission hypoxemic increased oxygen requirement. intubated, CXR post-intubation revealed stable infiltrates bilaterally. admitted medical ICU. ABG revealed non-anion gap acidosis without appropriate respiratory compensation. CT Chest revealed PNA, LE ultrasound revealed DVT. continued TPN. started vancomycin, cefipime, flagyl empirically given leukocytosis without left shift obvious initial course. Blood urine cultures obtained. CT abdomen CT head obtained. [2146-8-8]: patient remained intubated sedated, CMV/Assist settings. care transferred Surgical ICU team. continued TPN, remained NPO, nothing medication J tube. Antibiotics stated above, continued. [2146-8-9]: patient's ventilator settings adjusted CPAP/PS. continued TPN, kept NPO, nothing medication J tube. Antibiotics continued, adjusted include vancomycin cefipime. [2146-8-10]: patient successfully extubated day. continued TPN, kept NPO, nothing medication J tube. day, able spend much time sitting chair, noted conversational interactive. Antibiotics continued. Planning begun transfer regular floor. [2146-8-11]: patient kept NPO, continued TPN. day, transferred back floor continued recovery. continued look well. Antibiotics continued. [2146-8-12]: patient kept NPO, TPN, foley catheter PTBD, Tube, [Doctor Last Name 406] drain place. Physical Therapy continued work patient. continued antibiotics (vancomycin cefepime). [2146-8-13]: patient kept NPO, TPN, catheters drains place, antibiotics runing. [2146-8-14]: prior drains maintained. patient remained NPO, TPN. continued work physical therapy. Dispo planing rehab initiated. [2146-8-15]: drains (PTBD, Tube, foley, [Doctor Last Name 406] drain) maintained. patient remained NPO, TPN, antibiotics. Thereafter, patient continued recover well, remarkable events. drains maintained, remained NPO, TPN, stated antibiotics. antibiotics continued [2146-8-21]. patient's blood sugar monitored throughout stay; insulin dosing adjusted accordingly. patient's complete blood count examined routinely. patient's white blood count fever curves closely watched signs infection. patient received subcutaneous heparin venodyne boots used stay; seen worked Physical Therapy. time discharge, patient well, afebrile stable vital signs. patient TPN, nothing J tube except medication. receive IV antibiotics (cefipime vancomycin) [2146-8-21]. Discharge planning extended care facility made, thorough follow-up instructions provided. Medications Admission: 1. Acetaminophen IV 1000 mg IV Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB NG TID please crush give via j-tube 60cc water avoid j-tube clogging 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 5. Heparin 5000 UNIT SC TID 6. Insulin SC Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 8. Pantoprazole 40 mg IV Q24H Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID via j-tube 3. CefePIME 2 g IV Q24H 4. Heparin 5000 UNIT SC TID 5. Insulin SC Sliding Scale Fingerstick Q4h Insulin SC Sliding Scale using REG Insulin 6. Octreotide Acetate 200 mcg SC Q8H 7. Ondansetron 4 mg IV Q8H:PRN nausea 8. Pantoprazole 40 mg IV Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Vancomycin 750 mg IV Q 24H 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 13. Heparin Flush (10 units/ml) 10 mL IV PRN PICC Flush 14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Respiratory distress, setting recent hospitalization ([2146-7-14]) treated florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, intubation respiratory distress context LLL PNA grew E.coli. took place duodenal perforation s/p laparoscopic cholecystectomy OSH [2146-6-2], brought [Hospital1 18] repair duodenal injury, placement lateral duodenostomy tube, feeding jejunostomy tube, PTBD (6/[2146]). Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Lethargic arousable. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: Mr. [Known lastname 32913] admitted surgery service [Hospital1 18] evaluation management respiratory distress. recovered well, safe return extended care facility complete recovery following instructions: Please resume regular medications, unless specifically advised take particular medication. Also, please take new medications prescribed. Please allow patient get plenty rest, continue ambulate tolerated, continue TPN. Please administer tube feesd, patient receive CRUSHED Cinemet J tube. Please follow-up surgeon Primary Care Provider (PCP) advised. Care Drains: Please look sites every day signs infection (increased redness pain, swelling, odor, yellow bloody discharge, warm touch, fever). Maintain suction bulb drains, allow bag-drains hang gravity. Note color, consistency, amount fluid drain. Call doctor nurse practitioner amount increases significantly changes character. Be sure empty drains frequently. Record output, instructed so. The patient may shower; wash area gently warm, soapy water. Keep insertion site clean dry otherwise. Avoid swimming, baths, hot tubs; submerge water. Make sure keep drain attached securely patient's body prevent pulling dislocation. Please call doctor nurse practitioner patient experiences following: New chest pain, pressure, squeezing tightness. New worsening cough, shortness breath, wheeze. Vomiting cannot keep fluids medications. Dehydration due continued vomiting, diarrhea, reasons. Signs dehydration include dry mouth, rapid heartbeat, feeling dizzy faint standing. Blood dark/black material vomit bowel movement. Burning urination, blood urine, discharge. Shaking chills, fever greater 101.5 degrees Fahrenheit 38 degrees Celsius. Any change symptoms, new symptoms concern you. Followup Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office needed [Telephone/Fax (1) 2998] needed. Appointment:- Department: SURGICAL SPECIALTIES When: FRIDAY [2146-9-9] 10:45 With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2146-8-18]	[ "0389", "51881", "486", "5849", "99592", "412", "4019" ]
Admission Date: [2150-5-1] Discharge Date: [2150-5-10] Date Birth: [2098-2-21] Sex: F Service: MICU patient admitted Medical Intensive Care Unit Service [5-1] transferred Intensive Care Unit service [Hospital1 139] Service [2150-5-6], planned discharge [2150-5-12]. CHIEF COMPLAINT: Altered mental status. HISTORY PRESENT ILLNESS: 52 year old woman history insulin dependent diabetes mellitus history self-induced hypoglycemic episodes, presented [2150-5-1], [Hospital1 69] agitation altered mental status. EMS checked fingerstick 102 time. brought [Hospital1 69] Emergency Room evaluation. Emergency Department, fingerstick 400. given Ativan, Versed Haldol, 7 mg Droperidol insulin 10 units. underwent lumbar puncture time cerebral spinal fluid showing 24 white blood cells, 350 red blood cells, 70 protein, 152 glucose 81% neutrophils, 1% band 14% lymphocytes. got dexamethasone 10 mg intravenously, Ceftriaxone 2 grams intravenously, Vancomycin 1 gram intravenously, Acyclovir 500 mg intravenously Toradol. getting medication, dropped systolic blood pressure 90s received several liters intravenous fluid thought aspirated. also got Dilantin due question seizures. transferred Medical Intensive Care Unit night [5-1] early morning [5-2]. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus 13 years multiple episodes self-induced hypoglycemia attention seeking behavior. 2. Migraine headaches relieved Fioricet. 3. Depression. 4. Dementia memory difficulties progressing recent years. primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 7516] [Hospital 8503]. ALLERGIES: known drug allergies. HOME MEDICATIONS: 1. Insulin. 2. Fioricet. SOCIAL HISTORY: divorced two children. son [Doctor First Name 1191] heroin abuse. one son involved care. lives alone. smokes one pack per day. FAMILY HISTORY: Son heroin abuse; otherwise unknown. Medical Intensive Care Unit treated presumptively Vancomycin, Ceftriaxone Acyclovir meningitis, encephalitis aspiration pneumonia. patient became hypoxic. Chest x-ray showed congestive heart failure left retrocardiac opacity. Bronchoscopy performed unrevealing. patient self-extubated bronchoscopy remained stable, however, still requiring oxygen via face mask. eventually weaned face mask onto nasal cannula. repeat lumbar puncture performed [5-5] showing one white blood cell, eight red blood cells. time, culture first lumbar puncture came back negative. Vancomycin Ceftriaxone discontinued. Levofloxacin started treatment pneumonia. Acyclovir continued herpes simplex virus encephalitis/meningitis. Herpes simplex virus PCR sent second sample cerebrospinal fluid [5-5] lumbar puncture. eventually came back negative. patient received ten day course Acyclovir discontinued due negative PCR. Medical Intensive Care Unit also given intravenous Lasix effective diuresis improvement O2 saturation. evaluated Psychiatric recommended adding multivitamins, thiamine, folate medication regimen given concern alcohol use. also recommended Haldol agitation medical work-up. also seen Neurology, whose impression encephalitis continue treating also rule metabolic etiology myocardial infarction, adrenal insufficiency, thyroid disease. agreed thiamine folate supplementation. LABORATORY: Data admission white blood cell count 20.4, hematocrit 37.6 91% neutrophils, 7% lymphocytes. Platelet count 333. INR 1.1, PTT 29.1. Urinalysis showed 250 glucose, 50 ketones. Serum sodium 143, potassium 3.8, chloride 107, bicarbonate 23, BUN 12, creatinine 0.6, glucose 122, calcium 7.8, phosphate 2.3, magnesium 1.7. ALT 40, AST 68, increased slightly. LDH 278, alkaline phosphatase 93. Total bilirubin 0.4. Due increase ALT AST, hepatitis panel done. Hepatitis C virus antibodies negative. Hepatitis B surface antigen surface antibodies negative. ANCA negative. [Doctor First Name ] positive 1:80 titer. HIV antibodies negative. Vitamin B12 came back 1071. Folate normal 10.2. Thyroid stimulating hormone 0.96. Free T4 level 1.2. Cortisol stimulation test pre-stimulation 9.0, 30 minutes 26.7; 60 minutes 36.6. Serum toxicology screen urine toxicology screen positive barbiturates due Fioricet headaches. RPR negative. CK troponin sent well patient troponin leak 8.2, subsequently decreased less 0.3. Cardiology consultation obtained. recommended transthoracic echocardiogram showed normal left ventricular wall thickness cavity sizes. Due sub-optimal technical quality, focal wall motion abnormality cannot fully excluded. Overall left ventricular systolic function normal, greater 55% ejection fraction. Right ventricular chamber size free wall motion normal. Aortic valve leaflets mildly thickened. masses vegetations seen. aortic valve stenosis regurgitation. echocardiogram essentially normal. recommended continuing aspirin continuing follow troponin. recommended outpatient follow-up cardiac issues one month. patient remained asymptomatic without chest pain hemodynamic instability. mental status improved throughout Intensive Care Unit stay. Herpes simplex virus two antibodies negative. Herpes simplex virus one IgG positive, showing previous exposures. EEG showed encephalopathy seizure activity. Influenza B negative. RSV antigen negative. BAL cultures negative. Urine cultures negative times two. Blood cultures negative. Legionella urinary antigen negative. Insulin negative. MRI head negative. CT scan head negative. Bartonella IgG IgM sent still pending time dictation. patient transferred Floor continued improve, although mental status get back baseline. patient poor insight illness. remained oriented month day demanded go home. deemed competent incapable taking care given cognitive deficits fact lives home alone. patient refused consider options. finished ten day course antibiotics including ceftriaxone, Vancomycin Levofloxacin presumed pneumonia. congestive heart failure resolved stable O2 saturation room air. evaluated Physical Therapy felt physical therapy issues. also evaluated Occupational Therapy felt cognitive deficits would prevent taking care home. [Last Name (un) ] consultation obtained gave input formulating insulin regimen patient. family meeting scheduled [2150-5-11] determine safest disposition patient. patient's discharge condition, medications, plan dictated addendum [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 805]. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Name8 (MD) 6371] MEDQUIST36 D: [2150-5-10] 20:50 T: [2150-5-10] 21:20 JOB#: [Job Number 25485]	[ "41071", "5070", "4280" ]
Admission Date: [2103-8-8] Discharge Date: [2103-8-16] Date Birth: [2034-12-3] Sex: F Service: VASCULAR CHIEF COMPLAINT: Cold foot pain progressive last three days prior admission. Information obtained patient transfer records. patient transferred [Hospital6 18346]. HISTORY PRESENT ILLNESS: patient 68 year-old black female well known service status post abdominal aortic repair aorta bifemoral status post right ABF limb removal interposition saphenous vein graft secondary infection, status post left fem [Doctor Last Name ] jump graft fem [Doctor Last Name ] tibial peroneal artery vein presents three day history left foot pain onset coldness numbness within last 24 hours. seen [Hospital3 22439] diagnosed acute ischemic foot. IV heparin 5000 unit bolus 1000 units per hour started 1600. discontinued 1820 transfer main land. REVIEW SYSTEMS: Positive numbness, coolness pain. denies interval changes since last hospitalization [Month (only) 547] year secondary left thigh abscess. denies chest pain, shortness breath. nondiabetic. ALLERGIES: known drug allergies. PAST MEDICAL HISTORY: Coronary artery disease, hypertension, hypercholesterolemia, peripheral vascular disease, history MRSA, sacroiliitis, infected right ABF limb secondary MRSA, status post removal. PAST SURGICAL HISTORY: Abdominal aortic aneurysm repair aorta bifemoral [2092], right ABF limb removal interposition graft [2102-6-8], left fem [Doctor Last Name ] [2098], left jump graft fem [Doctor Last Name ] [Doctor First Name ] peroneal artery [2102-8-8], right breast biopsy [2099], I&D left thigh abscess [2103-4-8]. MEDICATIONS TRANSFER: Lipitor 20 mg q day, Colace 100 mg b.i.d., Lopressor 25 mg b.i.d., ferrous sulfate 325 mg q day, aspirin 81 mg q.d. SOCIAL HISTORY: patient lives son. remaining review systems unremarkable. PHYSICAL EXAMINATION: patient afebrile. alert black female complaining left foot pain. HEENT examination unremarkable. Pulse examination shows intact carotid, brachial radial pulses bilaterally bilateral carotid bruits. Femoral pulses 2+ right absent left palpation doppler. bruits. Popliteal pulses absent bilaterally. right, DP dopplerable. PT absent palpation doppler. pedal pulses popliteal pulses left absent palpation doppler. Chest clear auscultation bilaterally. Heart regular rate rhythm. Normal S1 S2. murmurs, rubs gallops. Abdomen benign. bruits, masses organomegaly. Right foot toes cool. left foot cold ankle cool ankle mid calf. foot modeled. capillary refill. foot diminished dorsiflexion plantar flexion. left first toe strength [4-12] left foot strength [4-12]. left leg moderate amount weakness [4-12] elevation bed. Neurological examination except motor sensory extremities unremarkable. HOSPITAL COURSE: patient admitted Vascular Service. made NPO, IV hydration normal saline 80 cc per hour begun. Interventional Radiology requested see patient anticipated intervention. patient's admitting laboratories white count 15.8, hematocrit 33.9, platelets 456, electrolytes 137, 4.6, 103, 19, 22 0.7. PT/INR normal. PTT 26.7. patient taken angio. Initial arteriogram demonstrated hydronephrotic obstructed right kidney. Left limb graft open. stenosis aorta anastimosis. dilated 6 mm 15 mm residual gradient clot fem [Doctor Last Name ] graft. Tissue plasminogen activator continued. Follow thrombolysis arteriogram demonstrates successful recanalization left common femoral access catheter fem [Doctor Last Name ] graft injection level distal anastomosis demonstrated complete occlusion. able identify distal run off. catheter removed point. time patient became hypoxic, hypertensive tachycardic. Emergency head CT obtained rule intracranial hemorrhage, negative. patient transferred SICU continued monitoring care. patient given 1 gram vancomycin prior interventional work night admission. Infectious disease consulted regarding antibiotic coverage positive blood cultures sheath. started Ceptaz 1 gram q 8 hours Gentamycin 80 IV q 8 hours. Vancomycin 1 gram q 12 hours continued. Blood cultures obtained second 2/2 bottles grew gram negative rods, anaerobic bottle growing gram positive cocci. Identifications speciation pending. Infectious disease recommended continued antibiotics history MRSA enterococcus infection. abdominal pelvic CT reviewed felt graft could possible site infection along right hydronephrosis. point consulted. Urology felt chronic hydronephrosis changed previous abdominal CT. urine cultures pending. Urinalysis showed 0 2 white blood cells. felt point given picture hydronephrosis etiology bacteremia. Urine culture [8-10] negative urine specimen right kidney gram stain showed bacteria polys. white count peaked 25.5. patient require intubation time hypertension, tachycardia extubated SICU day three. Blood cultures poly microbial predominantly GI flora, Flagyl added antibiotic regimen [2103-8-12]. right nephrostomy tube placed [3-11]. removed urine cultures proven negative. patient returned angio retrieval foreign body time line change loss guidewire. guidewire removed inferior vena cava snare IJ triple lumen catheter placed continued show improvement diminished white count 17.0, hematocrit 23.8 transfusion given secondary patient's Jehovah's witness beliefs. transferred VICU continued monitoring care. left foot stable showed improvement diminishment pain, complete relief pain. patient beginning wiggle toes. patient continued show clinical improvement transferred regular nursing floor hospital day number seven. IV heparin coumadinization continued. Abdominal CT pelvic upper left leg obtained, showed diminished collection inguinal area. discreet collection noted. Multiple diverticuli, free fluid pelvis. White count continued defervesce. renal numbers remained stable. heparin adjusted PTT 60 80. Lopressor adjusted persistent tachycardia. Physical therapy requested see patient begin ambulation case management requested see patient regarding rehabilitation screening. Flagyl discontinued [2103-8-15]. continued Ceptaz 1 gram q 8 hours, Gentamycin 80 mg q 12 hours, Vancomycin 1 gram q 12 hours. cultures follows, 8/2 cultures blood grew enterococcus cloacae, Klebsiella, pneumonia, MRSA enterobacter buccalis. Enterobacter sensitive Ceptaz, Ceftriaxone, Gentamycin, _______, Penicillin, Tobra Bactrim. enterococcus sensitive Ampicillin, Gentamycin, Penicillin, Vanco. Resistant streptomycin Cipro. staph aureus MRSA sensitive Gent, Rifampin, Tetracycline Vanco. Klebsiella pan sensitive. Repeat cultures [8-9] grew organisms [8-12] blood cultures growth. time dictation white count 16.7 hematocrit 25.0 platelets 339. BUN 9, creatinine 0.7, K 4.0, Gentamycin levels [8-14] peak 5.9, trough 2.6. Final recommendations regarding antibiotic course therapy determined prior discharge Infectious Disease. patient's heparin drip discontinued [2103-8-16]. Coumadin 5 mg q day begun. Lopresor adjusted 50 mg t.i.d. DISCHARGE MEDICATIONS: Coumadin 5 mg q.d. goal INR 2.0 3.0, Gentamycin 100 mg IV q 12 hours, begun [2103-8-15] trough peak pending third dose. Lopressor 50 mg t.i.d., Colace 100 mg b.i.d., antibiotics Ceftazidime 1 gram q 8 hours Vancomycin 1 gram q 12 hours. Percocet tablets 5/325 one q 4 6 hours prn pain, Zantac 150 mg b.i.d., Procrit 40,000 units subQ q week. Dressings include nephrostomy dressing, changed daily basis. Ambulation tolerated, full weight bearing, essential distances healing sandal. PT/INR checked daily basis patient therapeutic INR 2.0 3.0. heparin, PTT. patient follow Dr. [Last Name (STitle) 1391] two three weeks post discharge rehab prn needed. DISCHARGE DIAGNOSES: 1. Left foot ischemia status post tissue plasminogen activator improvement. 2. Right hydronephrosis etiology unknown status post right nephrostomy tube. 3. Polymicrobial bacteremia treated. 4. Hypertension controlled. 5. Peripheral vascular disease. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2103-8-16] 09:01 T: [2103-8-16] 10:26 JOB#: [Job Number 31666]	[ "9971", "41401", "4019", "2720" ]
Admission Date: [2147-8-1] Discharge Date: [2147-8-8] Date Birth: [2107-7-7] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Chocolate Flavor Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness breath Major Surgical Invasive Procedure: [2147-8-1] - Mitral valve replacement (27mm St. [Male First Name (un) 923] Mechanical Valve)and Tricuspid Valve Repair MC3 Annuloplasty system. History Present Illness: 40 year-old woman, known service, presented [Hospital ] Hospital [Month (only) 205] waking shortness breath. reported first time episode, retrospect probably increasing dyspnea exertion. chest CT done ruled PE. echocardiogram revealed severe mitral valve regurgitation significant pulmonary hypertension. referred surgical evaluation. Past Medical History: severe mitral regurgitation hypertension pulmonary hypertension cardiomegaly anemia depression Social History: Occupation: disability Last Dental Exam >1 year Lives with: children Race: Tobacco: smoked 20 years, quit 5 years ago ETOH: rarely Family History: non-contributory Physical Exam: Pulse: 96 Resp: 16 O2 sat: 97% RA BP: 150/90 Height: 5'4" Weight: 115.1 kg General: WDWN female acute distress 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: SEM III/VI Crisp valve snap Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: - Left:- Pertinent Results: [2147-8-1] ECHO Pre-bypass: mass/thrombus seen left atrium left atrial appendage. atrial septal defect seen 2D color Doppler. moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function mildly depressed (LVEF= 40 %). right ventricular cavity mildly dilated normal free wall contractility. simple atheroma descending thoracic aorta. aortic valve leaflets (3) appear structurally normal good leaflet excursion. aortic valve stenosis. aortic regurgitation seen. mitral valve shows characteristic rheumatic deformity. moderate thickening mitral valve chordae. mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate severe (3+) mitral regurgitation seen. Moderate severe [3+] tricuspid regurgitation seen. trivial/physiologic pericardial effusion. Post-bypass: time post-bypass exam, patient receiving norepinephrine 0.08 mcg/kg/min. mitral valve mechanical prothesis well-seated without paravalvular regurgitation. mechanical leaflets opening appropriately small regurgitant "washing" jets.The mean gradient across mitral valve 7 mm hg heart rate 90. tricuspid valve minimal transvalvular gradient 4 mm Hg. tricuspid stenosis mild tricuspid regurgitation. Ventricular function similar prebypass findings. aorta intact post decannulation. findings communicated [Month/Day/Year 5059] time exam. [2147-8-4] WBC-23.2* RBC-3.70* Hgb-8.6* Hct-28.5* RDW-19.4* Plt Ct-185 [2147-8-5] WBC-21.0* RBC-3.94* Hgb-9.6* Hct-31.2* RDW-19.0* Plt Ct-227 [2147-8-6] WBC-13.5* RBC-3.70* Hgb-8.4* Hct-28.6* RDW-19.6* Plt Ct-223 [2147-8-7] WBC-10.0 RBC-3.69* Hgb-8.8* Hct-29.0* RDW-18.9* Plt Ct-297 [2147-8-8] WBC-9.2 RBC-3.78* Hgb-9.0* Hct-29.6* RDW-18.9* Plt Ct-346 Warfarin dosing: [2147-8-3]: 5mg [2147-8-4]: 4mg [2147-8-5]: 5mg [2147-8-6]: 5mg [2147-8-7]: 2mg [2147-8-8]: 4mg - discharge dose PT/INR Results: [2147-8-4] PT-20.9* INR(PT)-1.9* [2147-8-5] PT-23.4* PTT-31.4 INR(PT)-2.2* [2147-8-6] PT-29.0* PTT-48.5* INR(PT)-2.9* [2147-8-7] PT-38.3* PTT-39.3* INR(PT)-4.0* [2147-8-8] PT-38.4* INR(PT)-4.0* [2147-8-4] Glucose-97 UreaN-16 Creat-0.7 Na-135 K-3.7 Cl-102 HCO3-25 AnGap-12 [2147-8-5] Glucose-87 UreaN-20 Creat-0.7 Na-139 K-3.6 Cl-105 HCO3-25 AnGap-13 [2147-8-6] Glucose-93 UreaN-18 Creat-0.6 Na-136 K-3.5 Cl-105 HCO3-24 AnGap-11 [2147-8-7] Glucose-82 UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-105 HCO3-24 AnGap-13 [2147-8-8] UreaN-14 Creat-0.8 K-4.2 Brief Hospital Course: Ms. [Known lastname 82901] admitted [Hospital1 18] [2147-8-1] surgical management valvular heart disease. taken operating room underwent mitral valve replacement using St. [Male First Name (un) 923] mechanical valve tricuspid valve repair using MC3 annuloplasty system. Please see operative note details. Postoperatively taken intensive care unit monitoring. postoperative day one, awoke neurologically intact extubated. weaned pressors. chest tubes epicardial wires removed transferred step floor. experienced copious diarrhea found c.dif positive, oral Vancomycin begun. Coumadin heparin initiated mechanical mitral valve. Warfarin monitored daily dosed goal INR 3.0 - 3.5. Heparin eventually discontinued INR reached 2.0. remainder postoperative course uneventful. several days continued make clinical improvements diuresis medically cleared discharge home postoperative day seven. INR discharge 4.0. Prior discharge, arrangements made confirmed Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17466] management Warfarin dosing outpatient. Medications Admission: Zestril 30mg qd Nifedipine ER 60 qd Metoprolol XL 50 qd Ativan prn Tylenol Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO day: take 2 tabs(4mg) daily...daily dose may vary according INR..use directed local MD. [Last Name (Titles) ]:60 Tablet(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). [Last Name (Titles) ]:60 Tablet(s) Refills:2 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (Titles) ]:30 Tablet(s) Refills:2 4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [Last Name (Titles) ]:30 Tablet(s) Refills:2 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice day 7 days: drop 1tab(40mg) daily seven days discontinue. [Last Name (Titles) ]:21 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice day 7 days: drop 1 tab(20mEq) daily seven days discontinue. [Last Name (Titles) ]:21 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours 7 days. [Last Name (Titles) ]:28 Capsule(s) Refills:0 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours needed pain. [Last Name (Titles) ]:30 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: Care VNA Greater [Location (un) ] Discharge Diagnosis: Mitral Tricuspid Valve Regurgitation Possible Rheumatic Valvular Heart Disease Hypertension Pulmonary Hypertension Anemia C. difficile Colitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds signs infection. include redness, drainage increased pain. Please contact [Name2 (NI) 5059] ([Telephone/Fax (1) 4044] wound issues. 2) Report fever greater 100.5. 3) Report weight gain 2 pounds 24 hours 5 pounds 1 week. 4) wash incision daily soap water. lotions creams powders incision healed. bathing swimming 6 weeks. 5) lifting 10 pounds 10 weeks date surgery. 6) driving 1 month date surgery. 7) Take Warfarin directed goal INR 3.0 - 3.5. Please check PT/INR [8-10] call results Dr [Last Name (STitle) ],[First Name3 (LF) ] @ [Telephone/Fax (1) 50485]. 8) Take Lasix KCl directed two weeks stop 9) Complete one week course PO Vancomycin directed 10) Please call questions concerns Followup Instructions: [Hospital 409] clinic 2 weeks Please follow-up Dr. [Last Name (STitle) ] 1 month. ([Telephone/Fax (1) 1504] Please follow-up Dr. [Last Name (STitle) 17466] [12-27] weeks. [Telephone/Fax (1) 50485] Please follow-up Dr. [Last Name (STitle) 2603] 3 weeks. please call schedule appointments Completed by:[2147-8-8]	[ "4019", "2859", "311" ]
Admission Date: [2162-1-7] Discharge Date: [2162-1-20] Date Birth: [2107-9-8] Sex: Service: CA [Doctor First Name 147] HISTORY PRESENT ILLNESS: 54 -year-old gentleman multiple medical problems, including diabetes, hypertension, hyperlipidemia, peripheral vascular disease, status post bilateral femoral popliteal bypasses, presenting unstable angina increased shortness breath. Cardiac catheterization showed three vessel disease ejection fraction moderately depressed. patient admitted Medical service referred Cardiac Surgery surgical revascularization. PAST MEDICAL HISTORY: Coronary artery disease, status post percutaneous transluminal coronary angioplasty times one, peripheral vascular disease, status post bilateral femoral popliteal bypasses, hypertension, hyperlipidemia, peripheral neuropathy, diabetes insulin dependent. ADMITTING MEDICATIONS: Include Lipitor 20 mg q HS, Actos 45 mg day, Celebrex 200 mg day, Neurontin 300 mg day, Atenolol 25 mg day, Monopril 20 mg day, NPH 90 units subcutaneous q 60 units subcutaneous q PM. Ciprofloxacin clindamycin started medical admission. ALLERGIES: patient known drug allergies. PHYSICAL EXAMINATION: admission, alert oriented male acute distress. Head neck examination unremarkable. Cardiovascular examination: regular rate rhythm without murmurs. Lungs clear auscultation bilaterally. Extremity examination significant bilateral healed femoral popliteal incisions. left lower extremity demarcated area erythema edema / induration. palpable distal pulses patient pain left shoulder upon abduction. abdomen mildly distended, soft nontender. ADMISSION LABORATORY DATA: White count admission 7.6, hematocrit 26, platelets 288,000. HOSPITAL COURSE: Prior surgery, patient seen Dermatology left lower extremity edema erythema. Diagnosis elephantiasis nostra verrucosa. Treatment topical MetroGel affected area [Hospital1 ]. patient also area erythema right pretibial area diagnosed necrobiosis lipoidica diabeticorum. followed plan treatment outpatient basis. Infectious Disease consulted placed patient clindamycin ciprofloxacin presumed left lower extremity cellulitis. Th[Last Name (STitle) 1050] brought Operating Room [2162-1-11] coronary artery bypass graft times three Dr. [Last Name (Prefixes) ]. patient tolerated procedure well complications. patient transferred Cardiac Intensive Care Unit postoperatively hemodynamic monitoring. remained hemodynamically stable afebrile, extubated postoperative day zero. patient transferred floor postoperative day one well. Chest tube, pacing wires, central line, Foley catheter removed without problems. patient worked Physical Therapy able achieve level 5 ambulation. patient's postoperative course complicated sternal drainage developed several days surgery. patient's white count remained normal remained afebrile throughout postoperative course. Cultures sent fluid organisms gram stain culture showed sparse growth gram positive cocci, believed contaminant skin. skin remained healthy appearing sternum remained stable. patient watched several extra days hospital sternal drainage remained without sign infection. [Last Name (un) ] Diabetes service consulted manage insulin regimen. Finally, postoperative day nine, patient felt safe go home visiting nurse [First Name (Titles) ] [Last Name (Titles) 11197] wound daily basis dressing changes. DISPOSITION: patient discharged [2162-1-20]. completed course ciprofloxacin clindamycin per Infectious Disease complete two week course. DISCHARGE MEDICATIONS: Include Lopressor 100 mg po bid, NPH insulin 100 units subcutaneous q AM, 50 units subcutaneous q HS, Lasix 20 mg po q day times seven days, potassium chloride 20 mEq po q day times seven days, aspirin 81 mg po q day, Percocet one two tablets po q four six hours prn, Colace 100 mg po bid, Zantac 150 mg po bid, Actos 45 mg po q day, Lipitor 20 mg po q HS, MetroGel 1% [Hospital1 ] left lower extremity. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft times three. 2. Left lower extremity cellulitis. DISCHARGE STATUS: patient discharged home [Hospital6 407] services previously mentioned. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 33441] MEDQUIST36 D: [2162-1-20] 10:10 T: [2162-1-20] 10:21 JOB#: [Job Number 34542]	[ "41401", "4280", "4019", "2724" ]
[Numeric Identifier 38710] Admission Date: [2118-3-12] Discharge Date: [2118-3-15] Date Birth: [2118-3-12] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [Known lastname 38711] [Known lastname 38712], twin number one, delivered 34 3/7 weeks gestation, weighing 2350 grams admitted Intensive Care Nursery Labor Delivery management prematurity. Mother 33-year-old gravida III, para III woman, estimated date confinement [2118-4-20]. Prenatal screens included blood type positive, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B strep unknown. Pregnancy [Last Name (un) 5153] fertilization conception, diamniotic dichorionic twin gestation. mother admitted [Hospital1 69] 28 weeks gestation cervical shortening. received betamethasone time, discharged home bed rest. presented [2118-3-11] pre-term labor progressed vaginal delivery epidural anesthesia. Rupture membranes four half hours prior delivery. Received intrapartum antibiotics five half hours prior delivery unknown group B strep prematurity. maternal fever. twin emerged spontaneous cry. dried bulb suctioned. Apgar scores 8 9 one five minutes respectively. PHYSICAL EXAMINATION: admission, weight 2350 grams (50th percentile), length 45 cm (45th percentile), head circumference 31.5 cm (30th percentile). general, active, alert, pink premature female infant. Skin without rashes. Anterior fontanel open, flat, sutures mobile. Eyes red reflex bilaterally. Palate intact. Breath sounds bilaterally equal, clear, easy work breathing. Regular rate rhythm, without murmur. Normal pulses. Abdomen soft, without hepatosplenomegaly, masses. Genitalia normal pre-term female external genitalia, anus patent. Spine straight intact. Extremities normal, hip clicks. Normal reflexes tone gestational age. HOSPITAL COURSE SYSTEM: 1. Respiratory: respiratory distress. remained room air since admission, oxygen saturations high 90s. comfortable breathing 30 50 times per minute. apnea. 2. Cardiovascular: Soft murmur heard first 12 hours life, resolved. hemodynamically stable since admission. Recent blood pressure 65/29 mean 41. 3. Fluids, electrolytes nutrition: Started ad lib feeds formula shortly admission. Received intravenous D-10-W 12 hours maintain glucose 40. Since intravenous discontinued, maintained glucose 60s feeds. Discharge weight 2345 grams. 4. Gastrointestinal: mild jaundice time discharge. Bilirubin level [3-14] 9.8. Follow-up bilirubin level [3-15] 9.7. 5. Hematology: Hematocrit admission 43.6%. 6. Infectious Disease: Received 48 hours ampicillin gentamicin rule sepsis. 7. Neurology: Examination age appropriate. Head ultrasound indicated. 8. Sensory: Hearing screening performed automated auditory brain stem response passed ears. CONDITION DISCHARGE: Stable pre-term infant, feeding well, mild jaundice. DISCHARGE DISPOSITION: Discharged home parents. NAME PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 38713], M.D., telephone number [Telephone/Fax (1) 38714], fax number [Telephone/Fax (1) 38715]. CARE RECOMMENDATIONS: 1. Feeds: Ad lib breast bottle feeding every three four hours. Monitor weight. 2. Monitor jaundice. 3. Medications: None. 4. Car seat position screening - infant unable maintain saturations positioned car. Repeat screening done car bed. remained well saturated throughout test. Recommend travel car bed. 5. State newborn screen drawn prior discharge, pending. 6. Immunizations received: Received hepatitis B immunization Synagis [2118-3-13]. 7. Immunizations recommended: Synagis respiratory syncytial virus prophylaxis considered [Month (only) 359] [Month (only) 547] infants meet following three criteria: (1) Born less 32 weeks gestation; (2) Born 32 35 weeks, plans day care respiratory syncytial virus season, smoker household, preschool siblings; (3) chronic lung disease. 8. Follow-up appointments: a. parents make follow-up appointment pediatrician discharge. DISCHARGE DIAGNOSIS: 1. AGA pre-term female 2. Rule sepsis 3. Physiologic jaundice [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 36138] MEDQUIST36 D: [2118-3-14] 00:22 T: [2118-3-14] 01:00 JOB#: [Job Number 38716]	[ "V053" ]
Admission Date: [2192-6-17] Discharge Date: [2192-7-6] Service: NEUROLOGY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Found Major Surgical Invasive Procedure: PEG History Present Illness: Pt. 88 year old history HTN bilateral hip replacement brought EMS today found down. History per daughter per EMS report. Daughter reports pt. active baseline, lives independantly, shopping, takes care grandchild 2 days week. last seen well yesterday afternoon friend. [Name (NI) ] friend expecting church morning arrive. went house afterwards tried knock pt. answer. friend became concerned called EMS. EMS found lying floor bathroom, puddle cleaning fluid around her. describe awake oriented. unable state long floor. BP 200/110 scene. noted fib, rate 70s-80s. Pt. complaints presents, denies pain, weakness. know here. Past Medical History: Hypertension Bilateral Hip replacement Bilateral cataract repair, daughter reports anisocoria baseline history arrhythmia stroke daughter aware Social History: Lives alone [Hospital3 28354], daughter, Ob/Gyn [Hospital1 ], lives area. tobacco, occ social EtOH. active independant baseline. Daughter, [Name (NI) ] [Name (NI) ], HCP [Name (NI) ] [Hospital1 ]), H [Telephone/Fax (1) 73415], C [Telephone/Fax (1) 73416], Bp [Telephone/Fax (2) 73417] Family History: Father -> Aortic Stenosis Mother -> Alzheimer's, ? stroke Brother -> MI Physical Exam: T- 97.8 BP- 210/151 HR- 78 RR- 18 O2Sat- 96% RA Gen: Lying bed, NAD HEENT: NC/AT, moist oral mucosa, + racoon eyes bilaterally Neck: C collar CV: RRR, Nl S1 S2, murmurs/gallops/rubs Lung: Clear auscultation bilaterally aBd: +BS soft, nontender ext: edema Neurologic examination: Mental status: Awake alert. Cannot say is, month year are, says first name asked (not last name). Speech non-fluent, says words (says name, answers simple Y/N questions, asked last name says something unintelligible, paucity spontaneous speech); follows simple commands (stick tongue, wiggle toes, raise arm). dysarthria. + R sided neglect. Cranial Nerves: R pupil 6 mm, irregular, NR. L pupil 2.5 mm, minimally reactive. R NLF flattening. Tongue midline. Blinks threat L, R. Crosses midline R, bury sclera, burys sclera L gaze. L gaze preference. Motor: Decreased bulk throughout. Tone normal. observed myoclonus tremor. Holds L arm anti-gravity x 10 sec drift. Holds R arm anti-gravity x 10 sec drift motor impersistance. Holds R leg briefly anti-gravity, quickly drifts bed. Holds L leg anti-gravity x 5 sec. Sensation: Withdraws pain 4 extremities. Reflexes: +2 symmetric throughout. Toes upgoing R, L Pertinent Results: [2192-6-17] 03:19PM BLOOD ALT-41* AST-73* CK(CPK)-923* AlkPhos-141* Amylase-47 TotBili-1.4 [2192-6-18] 04:35AM BLOOD CK-MB-14* MB Indx-3.3 cTropnT-0.04* [2192-6-17] 10:30PM BLOOD CK-MB-23* MB Indx-3.7 cTropnT-0.04* [2192-6-17] 03:19PM BLOOD cTropnT-0.04* [2192-6-25] 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.4* [2192-6-24] 05:55PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.6 [2192-6-21] 07:25AM BLOOD Calcium-9.2 Phos-2.2* Mg-1.9 [2192-6-18] 08:55PM BLOOD %HbA1c-6.0* [2192-6-23] 12:35AM BLOOD Triglyc-72 HDL-52 CHOL/HD-3.1 LDLcalc-94 [2192-6-25] 12:55PM BLOOD Osmolal-257* [2192-6-19] 02:59PM BLOOD Osmolal-266* [2192-6-24] 05:55PM BLOOD TSH-7.7* [2192-6-17] 03:19PM BLOOD TSH-3.9 [2192-6-24] 05:55PM BLOOD Cortsol-23.8* [2192-6-25] 06:30AM BLOOD T3-74* Free T4-1.2 [2192-6-17] 03:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2192-6-17] 03:31PM BLOOD Lactate-4.1* Head CT: 1. Left early subacute infarct hemorrhagic transformation posterior cerebral artery territory involving left posterior corona radiata, thalamus, temporal lobe, occipital lobe. 2. Right frontal lobe late subacute infarct Echo: left atrium moderately dilated. right atrium moderately dilated. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). masses thrombi seen left ventricle. Right ventricular chamber size free wall motion normal. aortic valve leaflets severely thickened/deformed. moderate severe aortic valve stenosis (area 0.8-1.0cm2), valve area may slightly DERestimated, technically suboptimal acquisition LVOT velocities. Moderate (2+) aortic regurgitation seen. mitral valve leaflets mildly thickened. Moderate (2+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. physiologic pericardial effusion. MRA/MRI: FINDINGS: carotid vertebral arteries visualized origins intracranial courses. evidence stenosis occlusion. mild atherosclerotic changes identified. distal cervical internal carotid arteries measure 4.3 mm diameter left 4.5 mm diameter right following NASCET criteria. CONCLUSION: Mild atherosclerotic changes cervical arterial vessels. Otherwise, evidence stenosis occlusion. Brief Hospital Course: Ms. [Known lastname 39540] 89-year-old woman history hypertension presented found down. hospital course problem follows: 1. Neuro: STROKE. Ms. [Known lastname 39540] admitted stroke service evaluation. MRI brain showed left subacute infarct posterior corona radiata, thalamus, temporal lobe, occipital lobe, well right frontal lobe infarct. appeared result multiple emboli discovered atrial fibrillation (previously unknown), started Heparin drip. next morning, found excessively somnolent; stat Head CT showed hemorrhagic transformation ischemic strokes. ICH heparin discussed daughter medical decision maker. daughter decided continue heparin despite risk worsening ICH. transferred step-down closer monitoring. blood pressure controlled IV prn BB initally; ultimately controlled oral lisinopril metoprolol. maintained euglycemic normothermic. continued Heparin goal PTT 40-60 started Coumadin. several days low INRs, INR found 10.6 [7-4]; given 5 mg Vitamin K subcutaneously 5 mg orally, 2 units FFP. resumed Heparin drip INR sub-therapeutic; restarted lower dose warfarin. goal INR [1-7]. exam improved somewhat fully awake alert moving left side well; hemiparetic right movement R LE. 2. Hypercholesterolemia. LDL found 94; goal < 70, started Lipitor 10. 3. DENS fracture. found Dens fracture CT due initial fall. evaluated spine service recommended keep C-collar 3 months (through [2192-9-17]). 4. Atrial fibrillation. rate controlled metoprolol anti-coagulated above. 5. ID. mild temperature bumps pan-cultured. empirically started vanco zosyn leukocytosis improved. infectious source found, remained afebrile completion antibiotics. 6. Hyponatremia. thought due combination cerebral salt wasting SIADH. renal service consulted. fluid restriction failed improve sodium, recommended using 3% saline. improved Na, PEG place, sodium maintained salt tabs. 7. Subclinical hypothyroidism. found elevated TSH normal free T4 (1.2) low T3 (73). clinically significant point, followed outpatient future. 8. Nutrition. evaluated speech swallow several occasions failed feeding trial. PEG therefore placed feeding. 9. Airway edema. electively intubated PEG placement, found significant epiglottal edema preventing extubation. given 3 days prednisone, bronchoscopic evaluation 3 days revealed persistent edema. consultation daughter, decided receive tracheotomy. 10. CODE: DNR; intubated electively above. 11. Dispo: discharged rehab facility. Medications Admission: Lisinopril Atenolol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed pain, fever: per PEG. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Per PEG. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Per PEG. 5. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times day): Per PEG. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed): Per PEG. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed: Per PEG. 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 11. Neutra-Phos [Telephone/Fax (3) 4228] mg Packet Sig: Two (2) packets PO day 1 doses: Please give per PEG 8 pm [2192-7-6]. Discharge Disposition: Extended Care Facility: [Hospital6 459] Aged - MACU Discharge Diagnosis: 1. Stroke 2. Intracranial hemorrhage 3. Atrial fibrillation 4. Pneumonia 5. Hyponatremia Discharge Condition: Stable. neurological examination, patient awake alert, aphasic, without speech. findings consistent right homonymous hemianopsia. Right pupil surgical left reactive. left arm leg consistently anti-gravity (3+). However, right arm leg generally weaker often fluctuated hospital course, ranging 1+ 3+. day discharge right side [12-6]+. Discharge Instructions: Please take medications prescribed follow appointments scheduled. new, worsening, concerning symptoms, please call phyician return nearest emergency room. patient contune wear cervical collar 3 months follow appointment orthopedic clinic time. Please follow INR daily, paient coumadin history atrial fibrillation. goal INR [1-7]. Given history hyponatremia, please check chemistry (including soudium) CBC least weekly. Please aim systolic blood pressure 120's 130's possible. Lisinopril added prior discharge. Followup Instructions: 1. Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2192-8-21] 3:30 2. Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2192-9-27] 10:40 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 1228] Date/Time:[2192-9-27] 11:00 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2192-7-6]	[ "42731", "51881", "5990", "4019", "2720", "2449" ]
Admission Date: [2154-2-4] Discharge Date: [2154-2-20] Date Birth: [2099-5-31] Sex: Service: Cardiothoracic Surgery HISTORY PRESENT ILLNESS: patient complained chest tightness, dyspnea palpitations past month. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. L4 L5 S1 S2 herniated disks. 4. Pin implant left fifth finger. PAST SURGICAL HISTORY: Status post cholecystectomy. SOCIAL HISTORY: patient previous smoker quit 20 years ago. MEDICATIONS HOME: 1. Aspirin 325 q. day. 2. Lisinopril 10 mg q. day. ALLERGIES: patient known drug allergies. REVIEW SYSTEMS: Negative myocardial infarction, transient ischemic attack, cerebrovascular accident, claudication, orthopnea, hepatitis peptic ulcer disease. PHYSICAL EXAMINATION: Vital signs heart rate 70s sinus rhythm, blood pressure 110/70. patient alert oriented x 3. jugular venous distension, bruits. Chest clear auscultation. Cardiovascular examination regular rate rhythm, S1 S2, S3 S4 3/6 systolic ejection murmur. Abdomen positive bowel sounds, nontender, nondistended. Extremities cyanosis, clubbing edema. echocardiogram done [2153-12-15] showed ejection fraction 60%, severe atrial fibrillation, mild mitral regurgitation, mild aortic insufficiency left ventricular hypertrophy. Cardiac catheterization [2154-2-4] showed preserved left ventricular ejection fraction, left anterior descending 60% mid vessel, obtuse marginal #1 40%, mitral regurgitation, moderate aortic stenosis aortic valve area 0.7 cm. LABORATORY DATA: White blood cell count 11.6, hematocrit 44.6, platelet count 200, BUN 21, creatinine 1.0, liver function tests within normal limits negative urinalysis. HOSPITAL COURSE: patient admitted [2154-2-4] taken operating room [2154-2-5] aortic valve replacement [Street Address(2) 11688]. [Male First Name (un) 923] mechanical valve coronary artery bypass grafting x 1 left internal mammary artery left anterior descending coronary artery. Anesthesia reversed patient transferred intensive care unit successfully weaned vasopressors extubated postoperative day one. Chest tubes pacing wires discontinued postoperative day three transferred floor continued recovery rehabilitation. placed heparin Coumadin anticoagulation. postoperative day four began experiencing significant dyspnea diaphoresis decreased blood pressure well tachycardia. transferred back CSRU. Chest x-ray revealed hematoma left middle lobe. chest CT also done showed evidence PE. large pericardial effusion present well moderate-sized bilateral pleural effusions loculated effusion left. patient aggressively diuresed respiratory status improved. also transfused two units packed red blood cells 6% hematocrit drop. Coumadin heparin discontinued. Renal consulted increasing creatinine well decreased urinary output. echocardiogram done showed left ventricular ejection fraction 55% mildly dilated left atrium. patient remained intensive care unit next several days. remitting episodes shortness breath responded well diuresis. Chest x-ray remained stable. postoperative day six creatinine trending downward urine output improving. started levofloxacin positive urinalysis. Culture pending. patient began experiencing decreased appetite slight abdominal distention. Liver function tests trending upward. GI consulted. believed due low flow state. postoperative day seven hematology consulted continued decreasing hemoglobin hematocrit despite evidence real bleeding. postoperative day eight patient began improving decreased liver function tests, increased appetite, decreased creatinine. Urine output stable. Respiratory status improving hematocrit remained stable. postoperative day nine transferred back floor. Physical therapy involved rehabilitation anticoagulation resumed. postoperative day 10 patient episodes sinus tachycardia bursts wide complex tachycardia. Beta blocker increased. episodes noted. postoperative day 12 patient complained right ankle pain increased white blood cell count. Rheumatology consulted. joint aspirated fluid sent culture. results still pending. Fluid analysis consistent pseudogout. treated colchicine intra-articular steroid injection good pain relief. postoperative day 13 patient continued episodes supraventricular tachycardia without wide complex tachycardia. Cardiology consulted. Beta blocker changed Lopressor sotalol episodes supraventricular tachycardia noted. patient continued presence bilateral pleural effusions. right thoracentesis performed drained 1.5 liters bloody fluid. Culture sent still pending, left thoracentesis also performed drained one liter bloody fluid. point postoperative day 15 patient's respiratory status continues improve. ambulating independently hallways. eating well, making sufficient urine continuing recover nicely. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 17400] MEDQUIST36 D: [2154-2-20] 10:03 T: [2154-2-20] 10:17 JOB#: [Job Number 49602]	[ "4241", "5845", "5990", "41401" ]
Admission Date: [2106-10-23] Discharge Date: [2106-10-27] Date Birth: [2052-3-29] Sex: Service: MEDICINE Allergies: Tylenol-Codeine #3 Attending:[First Name3 (LF) 7651] Chief Complaint: Chest Pain Major Surgical Invasive Procedure: - Percutaneous Coronary Intervention w/ Drug-Eluting Stent Placement (x2) Right Coronary Artery. History Present Illness: 54 year old male PMH hypercholesterolemia admitted chief complaint chest pain. Pt reports afternoon substernal chest pain diaphoresis. Previously good health denies h/o angina. . ED EKG revealed STE inferior leads V5/V6. Pt loaded 600mg plavix, given 325 ASA given heparin bolus. . Cath revealed 70% mid-RCA lesion occlusion PDA. Thrombectomy RCA PCI placed RCA PDA lesions. given fentanyl CP. . transfer CCU pt sinus rhythm, SBP 160 vitals otherwise unremarkable. Venous sheath still place. Pt still complaining chest pain STE yet resolved, improved. . review systems, s/he denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. denies exertional buttock calf pain. review systems negative. . Cardiac review systems notable absence dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia. 2. CARDIAC HISTORY: Unremarkable. 3. PAST MEDICAL HISTORY: Left Inguinal Hernia. Social History: Works skilled metal worker. Lives fiance [Location (un) 6151] stays every night mother [Name (NI) 86]. Primary caretaker mother, limited support siblings. - Tobacco history: - ETOH: - Illicit drugs: Family History: Father died MI Mother s/p quadruple bypass Physical Exam: VS: T=afebrile (Tmax=99.7, Range=97-99.7 x 24 hrs) BP=91-114/59-79 HR=80-104 RR=16-20 O2-Sat= 95-97% GENERAL: NAD. Oriented x3. HEENT: Sclera anicteric, non-injected. PERRL, EOMI. NECK: Supple. lymphadenopathy asymmetry noted. CARDIAC: PMI located 5th intercostal space, midclavicular line. Regular rate rhythm. Normal S1, S2. m/r/g S3/S4 noted. thrills, lifts. LUNGS: CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: c/c/e. femoral bruits. Venous sheath place SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Exam Discharge: GENERAL:54 yo acute distress HEENT: PERRLA, pharyngeal erythemia, mucous membs moist, lymphadenopathy, JVP non elevated CHEST: CTABL wheezes, rales, rhonchi CV: S1 S2 Normal quality intensity RRR murmurs rubs gallops ABD: soft, non-tender, non-distended, BS normoactive. Pos hernia. EXT: wwp, edema. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength U/L extremities. Gait WNL. SKIN: rash PSYCH: A/O , calm, appropriate Pertinent Results: ADMISSION HOSPITAL COURSE LABS [2106-10-23] 10:22PM PLT COUNT-227 [2106-10-23] 10:22PM NEUTS-55.7 LYMPHS-37.0 MONOS-5.2 EOS-1.4 BASOS-0.7 [2106-10-23] 10:22PM WBC-8.3 RBC-5.00 HGB-15.5 HCT-42.0 MCV-84 MCH-31.0 MCHC-36.8* RDW-13.5 [2106-10-23] 10:22PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.1 [2106-10-23] 10:22PM GLUCOSE-160* UREA N-15 CREAT-0.7 SODIUM-142 POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-19* ANION GAP-17 [2106-10-23] 10:30PM PT-17.9* INR(PT)-1.6* [2106-10-23] 10:22PM BLOOD cTropnT-<0.01 [2106-10-24] 04:51AM BLOOD CK-MB-261* MB Indx-8.1* cTropnT-7.56* [2106-10-24] 01:22PM BLOOD CK-MB-209* MB Indx-7.2* [2106-10-25] 05:12AM BLOOD CK-MB-83* MB Indx-5.1 [2106-10-23] 10:22PM BLOOD CK(CPK)-106 [2106-10-24] 04:51AM BLOOD CK(CPK)-3224* [2106-10-24] 01:22PM BLOOD CK(CPK)-2917* [2106-10-25] 05:12AM BLOOD CK(CPK)-1614* [2106-10-24] 04:51AM BLOOD Triglyc-155* HDL-34 CHOL/HD-6.3 LDLcalc-150* . DISCHARGE LABS [2106-10-27] 07:15AM BLOOD WBC-8.0 RBC-4.70 Hgb-14.6 Hct-40.6 MCV-86 MCH-31.0 MCHC-35.9* RDW-13.4 Plt Ct-201 [2106-10-25] 05:12AM BLOOD PT-14.9* PTT-36.4* INR(PT)-1.3* [2106-10-27] 07:15AM BLOOD Glucose-134* UreaN-19 Creat-0.8 Na-141 K-4.1 Cl-104 HCO3-28 AnGap-13 . IMAGING [2106-10-23] Cardiac Cath: COMMENTS: 1. Selective coronary angiography right dominant system demonstrated two vessel coronary artery disease. LMCA normal. LAD patent. LCx less 50% stenosis. RCA 70% mid-vessel lesion subtotal occlusion bifurcation complete occlusion PDA. 2. Limited resting hemodynamics revealed systolic diastolic arterial hypertension. 3. Successful aspiration thrombectomy, PTCA stenting distal RCA PDA 3.0 x 18 mm Promus DES (see PTCA comments). 4. Successful direct stenting mid RCA 3.5 x 28 mm Promus DES (see PTCA comments). 5. Successful RFA AngioSeal (see PTCA comments) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal ventricular function. 3. Successful aspiration thrombectomy PCI fo distal RCA PDA 3.0 x 18 mm Promus DES. 4. Successful PCI mid RCA 3.5 x 28 mm Promus DES. [2106-10-24] TTE: left atrium right atrium normal cavity size. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses cavity size normal. mild moderate regional left ventricular systolic dysfunction severe hypokinesis basal 2/3rds inferior inferolateral walls. remaining segments contract normally (LVEF = 40-45 %). Transmitral tissue Doppler imaging suggests normal diastolic function, normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size normal focal basal free wall hypokinesis. ascending aorta mildly dilated. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. mild pulmonary artery systolic hypertension. pericardial effusion. IMPRESSION: Normal left ventricular cavity size regional biventricular systolic dysfunction c/w CAD (prox/mid RCA distribution). Mild pulmonary artery systolic hypertension. Brief Hospital Course: Mr. [Known lastname ] 54 yo male PMH hyperlipidemia presented chest pain found STEMI s/p 2 drug-eluting stent placement. . # Acute Inferior Myocardial Infarction (STEMI): Initial EKG showed ST elevation II, III, aVF, V5 V6, well ST depression I, aVL, aVR, V1 V2. Pt underwent emergent catheterization, revealed 70% stenosis RCA, 100% occlusion PDA. Aspiration thrombectomy performed, 2 Drug-Eluting Stents placed (distal-RCA PDA, mid-RCA). Post-PCI echocardiogram performed HD 2 notable mild LV dysfunction, w/ EF 40-45%, severe hypokinesis basal [3-4] inferior/inferolateral walls mild pulmonary hypertension. post-cath course complicated right groin hematoma site access HD 2, resolved without intervention. also developed low-grade temps Tmax 100.5, without concerning signs symptoms infection acute thromboembolic event. started Aspirin, Plavix, Atorvastatin, Lisinopril, Metoprolol. tolerated medications well, time discharge, pt experienced observed arrhythmias telemetry, asymptomatic, feeling well ready go home. . # Hypertension: Pt previously HCTZ/lisinopril, stopped secondary side-effects (lightheadedness). started Metropolol Lisinopril long-term improved cardiac outcome. . # Hyperlipidemia: time admission, pt lipid-lowering medications, lipid panel admission revealed LDL 150, borderline low HDL TG 155. pt status-post acute myocardial infarction, started atorvastatin, require long-term continuation. . TRANSITIONAL ISSUES: - follow-up NP [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 67876] [2106-11-4], previous outpatient Cardiology (Dr. [Last Name (STitle) ] [2106-11-23], Dr. [Last Name (STitle) ] [2106-12-21] - recommend CBC + BMP check-up first outpatient consultation. - Dry weight estimated 89kg. aim healthy weight reduction via low-salt/low-fat cardiac diet. Medications Admission: None. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 6. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual directed needed chest pain. Disp:25 tablets Refills:0 Discharge Disposition: Home Discharge Diagnosis: ST Elevation myocardial infarction Acute Systolic dysfunction Dyslipidemia Discharge Condition: Medically Stable. Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], pleasure taking care hospitalization [Hospital1 69]. admitted heart attack. Images heart (catheterization) showed critical vessels supply blood heart blocked, 2 stents (drug-eluting) placed order keep blood vessels open. Echocardiogram (which ultrasound heart) catheterization procedure showed impaired heart function. findings predispose future heart problems, including fluid backup lower extremities lungs. Please START taking following medications addition home medications: 1. Metoprolol - lower heart rate, control blood pressure help heart pump better. 2. Atorvastatin - lower cholesterol prevent future plaque build-up heart's arteries. 3. Plavix - prevent re-occlusion stented arteries blockage drug-eluting stent placed. 4. Aspirin - prevent platelet blockage drug-eluting stent placed. 5. Lisinopril - control blood pressure help heart pump better. 6. Nitroglycerin - alleviate heart-related chest pain. Please take medication chest pain home similar chest pain brought hospital. Take one tablet, wait 5 minutes, take another tablet. Please call 911 still chest pain 2 tablets, please call Dr. [Last Name (STitle) ] use nitroglyerin all. important compliant medications, especially Plavix (Clopidogrel) Aspirin. Skipping changing doses medications result life-threatening blockage arteries blocked heart attack. stop unless cardiologist, Dr. [Last Name (STitle) ], tells ok. addition, please: 1. Weigh every morning, call primary care physician weight goes 3 lbs (total). 2. Continue exercise plan physical therapist discussed admission. 3. Involve family friends lifestyle modifications (including low-salt/low-fat diet, aerobic exercise new medication regimen) order facilitate long-term maintenance care. Thank entrusting health staff. Please contact [Name (NI) 91659] ([Telephone/Fax (1) 10339]) chest pain concerning symptoms. Followup Instructions: Name: [Last Name (LF) ], [Name8 (MD) ] NP Location: [Hospital ] MEDICAL ASSOCIATES, P.C. Address: [Street Address(2) 75807], STES 3A, B, [Location (un) ],[Numeric Identifier 8538] Phone: [Telephone/Fax (1) 54268] Appointment: THURSDAY [11-4] 10:45AM Name: [Last Name (LF) ], [First Name8 (NamePattern2) 640] [Last Name (NamePattern1) ] MD Specialty: CARDIOLOGY Address: [Street Address(2) 75807],STE 2C, [Location (un) ],[Numeric Identifier 23881] Phone: [Telephone/Fax (1) 44655] Appointment: TUESDAY [11-23] 10:30AM Department: CARDIAC SERVICES When: TUESDAY [2106-12-21] 9:00 With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [Telephone/Fax (1) 127] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2106-10-27]	[ "41401", "2720", "4019" ]
Admission Date: [2124-12-20] Discharge Date: [2124-12-26] Date Birth: [2046-8-3] Sex: F Service: SURGERY Allergies: Sulfonamides / Lasix Attending:[First Name3 (LF) 17683] Chief Complaint: fever, lethargy, swelling chin, respiratory distress Major Surgical Invasive Procedure: none History Present Illness: Pt 78 yo NH resident found fever (102.3) 3 days cellulitis chin. Presented [Hospital1 18] ED [2124-12-20] complaints. Also lethargic. intubated ED stidor respiratory distress. Past Medical History: * Diabetes * Hypercholesterolemia * CHF: EF> 60% LAE, 1+ MR [First Name (Titles) ] [Last Name (Titles) ] [2-8]; prior admissions overload * hx sacral decubitus ulcer * hx gastric ulcer * osteomyelitis L4-L5 s/p laminectomy * Cryptogenic Cirrhosis * osteoarthritis * Hypertension * CAD (details unknown) * h/o spontaneous PTX (with CT placement) * nutritional deficiency * hx MRSA Social History: lives [Location ] x 3 years, daughter son visit everyday. Former 25 pack-year smoking hx. alcohol. Retired [Last Name (un) 104638] schools. Family History: Sister Daughter cryptogenic cirrhosis Physical Exam: 100.1, 97.8, 65, 91/38, 12 99% intubated Vent AC FiO2 50% PEEOP 5 CTA RRR Abd: soft, NT, ND Neck: Swollen, erythematous, crepitous HEENT: MMM, obvious abscess cellulitis Pertinent Results: [2124-12-20] 10:50AM BLOOD WBC-8.6 RBC-2.82* Hgb-9.8* Hct-27.4* MCV-97 MCH-34.9# MCHC-35.9# RDW-13.6 Plt Ct-106* [2124-12-20] 10:50AM BLOOD Neuts-80* Bands-2 Lymphs-6* Monos-11 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2124-12-20] 10:50AM BLOOD PT-14.0* PTT-24.8 INR(PT)-1.3 [2124-12-20] 10:50AM BLOOD Glucose-212* UreaN-16 Creat-0.7 Na-134 K-4.6 Cl-100 HCO3-20* AnGap-19 [2124-12-20] 10:50AM BLOOD ALT-26 AST-41* CK(CPK)-32 AlkPhos-139* Amylase-45 TotBili-2.5* [2124-12-20] 10:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 . RADIOLOGY Final Report CT NECK W/CONTRAST (EG:PAROTIDS) [2124-12-20] 1:02 PM CT NECK CONTRAST: subcutaneous soft tissues anterior neck swollen diffuse fat stranding thickening ill defined imaging fasical planes. process extends level clavicular heads angle mandible, prominent right side. Blurring fat planes anterior strap muscles increased asymmetric soft tissue infiltration anterior posterior hyoid bone noted, largely right sided suggestion small ~1 cm fluid collections posterior right submandibular gland adjacent right portion hyoid bone found. Soft tissue stranding extends right carotid sheath, blurring fat plane. However, internal jugular carotid vasculature within neck enhance normally, evidence filling defects irregularity. patient intubated, likely accounting large amount fluid secretions within nasopharynx, oropharynx, nasal cavity, right inferior maxillary sinus. base brain unremarkable. suspicious bone lesions found. Lung apices clear. IMPRESSION: Marked edema stranding soft tissues anterior neck described, prominent right side, consistent cellulitis/fasciitis light provided history infectious signs symptoms. Possible small, early fluid loculations adjacent right submandiblaur gland right portion hyoid bone. . RADIOLOGY Final Report NECK,SOFT TISSUE US PORT [2124-12-21] 12:48 PM COMPARISON: CT scan [2124-12-10]. ULTRASOUND SOFT TISSUES NECK: edema strap muscles, slightly conspicuous deep neck soft tissues hyoid, without discrete fluid collections. IMPRESSION: Edematous changes within strap muscles soft tissues right neck, without discrete fluid collections. Results discussed covering resident study performed. . Brief Hospital Course: patient admited General Surgery service Dr. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] placed SICU. IV Antibiotics started (Vanco, Zosyn, Clindamycin). ENT consulted agreed IV Abx following patient wihtout surgery unless condition worsened. HD 2 cellulitis improved vent weaning began. [12-22] decadron started help laryngeal swelling per reccommendation ENT; NG tube placement unsuccessful. continued improvement neck swelling/erythema airwayu swelling. Pt extubated [12-23] without event. [2124-12-24] patient started full liquid diet transfered floor continued improvement clinical course. antibiotics continued. PICC line placed [2124-12-24]. morning [2124-12-25] patient found rate controlled AFib. Given rate control, multiple comorbidities, return NSR, opted anticoagulate. worsening patients baseline anemia (HCT lowest 22.4). anemia acute disease observed; given signs hypovolemia, opted transfuse. [2124-12-26] patient tolerating regular diet, afebrile, signs cellulitis. discharged back Nursing Home finish 14-day course Vanco/Zosyn. Clindamycin stopped [2124-12-25] per ID recommendations. Medications Admission: Tylenol, aldactone, insulin, doxepin, benadryl, nirtofuratone, protonix, reglan, albuterol Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) 8 days. Disp:24 Recon Soln(s) Refills:0 2. Vancomycin Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) 8 days. Disp:8 1gm/200ml Refills:0 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution Sig: directed Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [Hospital1 10283] Center - [Location (un) ] Discharge Diagnosis: neck cellulitis Discharge Condition: good Discharge Instructions: Restart home medications usual. Regular diet. may resume activity tolerated. * Increasing pain * Fever (>101.5 F) Vomiting * Inability eat drink * Return erythema/swelling neck * symptoms concerning Followup Instructions: Call Dr.[Name (NI) 22019] office follow-up appointment ([Telephone/Fax (1) 25089] [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845]	[ "4280", "4240", "42731", "5990", "2875", "4019", "2720", "2859" ]
Admission Date: [2131-10-2] Discharge Date: [2131-10-12] Date Birth: [2074-8-16] Sex: Service: SURGERY Allergies: Cellcept Attending:[First Name3 (LF) 371] Chief Complaint: Trauma- MVC Major Surgical Invasive Procedure: 1. Intubation 2. Open reduction internal fixation right distal radius History Present Illness: PI: patient 57 yo male s/p renal transplant, HTN, IDDM airlifted OSH following MVA. History mainly obtained records patient intubated. Earlier tonight patient MVA car versus tree accident moderate damage. unrestrained, airbag worked. According notes, able ambulate scene clear whether patient lost consiousness. FSBS scene 52, received amp D50. brought OSH. laceraration head periorbital ecchymoses. CT head showed small SAH (R-frontal temporal) focal, punctate hemorrhage R basal ganglia well small vessel disease. transferred [Hospital1 18], intubated fiberoptics raspy voice (according daughter baseline). Injuries include L-rib fractures ([2-17]), C1 fracture (minimally displaced), widened mediastinum. head CT repeated. Past Medical History: 1. Insulin dependent diabetes mellitus 2. Cerebral vascular event 3. Hypertension 4. Laproscopic cholecystectomy 5. Renal transplant x 2 Social History: n/a Family History: n/a Physical Exam: A&Ox2 PERRLA left 2-->1mm Right periorbital hematoma multiple lacerations CTA bilaterally RRR Abd soft, ntnd, foley place Rectal nml tone, heme negative C spine ttp, step Pertinent Results: [2131-10-2] 10:47PM BLOOD WBC-16.9* RBC-4.09* Hgb-13.3* Hct-37.9* MCV-93 MCH-32.5* MCHC-35.1* RDW-14.1 Plt Ct-147* [2131-10-3] 02:50AM BLOOD WBC-11.1* RBC-3.44* Hgb-10.9* Hct-31.7* MCV-92 MCH-31.7 MCHC-34.5 RDW-14.1 Plt Ct-136* [2131-10-3] 04:13PM BLOOD WBC-14.2* RBC-3.16* Hgb-10.4* Hct-29.6* MCV-94 MCH-33.0* MCHC-35.2* RDW-14.2 Plt Ct-127* [2131-10-4] 01:53AM BLOOD WBC-13.4* RBC-3.03* Hgb-9.7* Hct-28.7* MCV-95 MCH-31.8 MCHC-33.6 RDW-14.3 Plt Ct-137* [2131-10-5] 02:09AM BLOOD WBC-10.4 RBC-2.77* Hgb-8.8* Hct-25.5* MCV-92 MCH-31.9 MCHC-34.7 RDW-14.0 Plt Ct-120* [2131-10-5] 11:10AM BLOOD WBC-11.5* RBC-2.82* Hgb-9.1* Hct-26.1* MCV-93 MCH-32.4* MCHC-34.9 RDW-14.0 Plt Ct-121* [2131-10-6] 02:46AM BLOOD WBC-11.5* RBC-2.91* Hgb-9.1* Hct-26.7* MCV-92 MCH-31.3 MCHC-34.1 RDW-13.8 Plt Ct-173 [2131-10-7] 03:09AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.6* Hct-24.2* MCV-90 MCH-32.1* MCHC-35.7* RDW-13.8 Plt Ct-170 [2131-10-11] 04:55AM BLOOD WBC-7.6 RBC-3.28* Hgb-10.2* Hct-29.9* MCV-91 MCH-31.2 MCHC-34.2 RDW-14.0 Plt Ct-530* [2131-10-2] 10:47PM BLOOD PT-13.6* PTT-20.8* INR(PT)-1.2 [2131-10-2] 10:47PM BLOOD Plt Ct-147* [2131-10-3] 02:50AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.3 [2131-10-3] 02:50AM BLOOD Plt Ct-136* [2131-10-3] 04:13PM BLOOD Plt Ct-127* [2131-10-5] 02:09AM BLOOD Plt Ct-120* [2131-10-5] 11:10AM BLOOD Plt Ct-121* [2131-10-6] 02:46AM BLOOD Plt Ct-173 [2131-10-10] 01:52AM BLOOD Plt Ct-423# [2131-10-11] 04:55AM BLOOD Plt Ct-530* [2131-10-2] 10:47PM BLOOD Fibrino-369 [2131-10-6] 10:50AM BLOOD Parst S-NEGATIVE [2131-10-3] 02:50AM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-138 K-4.4 Cl-105 HCO3-26 AnGap-11 [2131-10-3] 04:13PM BLOOD Glucose-142* UreaN-16 Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-26 AnGap-11 [2131-10-4] 01:53AM BLOOD Glucose-210* UreaN-15 Creat-0.8 Na-138 K-4.5 Cl-106 HCO3-24 AnGap-13 [2131-10-5] 02:09AM BLOOD Glucose-68* UreaN-11 Creat-0.8 Na-141 K-3.9 Cl-108 HCO3-26 AnGap-11 [2131-10-5] 11:10AM BLOOD Glucose-181* UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 [2131-10-7] 03:09AM BLOOD Glucose-141* UreaN-19 Creat-0.8 Na-136 K-4.3 Cl-103 HCO3-25 AnGap-12 [2131-10-8] 01:52AM BLOOD Glucose-229* UreaN-21* Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-25 AnGap-12 [2131-10-11] 04:55AM BLOOD Glucose-51* UreaN-16 Creat-0.9 Na-136 K-5.0 Cl-103 HCO3-21* AnGap-17 [2131-10-2] 10:47PM BLOOD Amylase-71 [2131-10-3] 02:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.5* [2131-10-11] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [2131-10-7] 08:57AM BLOOD Vanco-6.7* [2131-10-4] 01:53AM BLOOD Phenyto-9.0* [2131-10-5] 02:09AM BLOOD Phenyto-7.0* [2131-10-2] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2131-10-5] 12:14PM BLOOD FK506-LESS [2131-10-6] 02:46AM BLOOD FK506-7.8 [2131-10-11] 10:03AM BLOOD FK506-PND [2131-10-3] 12:16AM BLOOD Type-ART pO2-166* pCO2-42 pH-7.41 calHCO3-28 Base XS-2 [2131-10-7] 07:21PM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-129* pCO2-38 pH-7.46* calHCO3-28 Base XS-3 Brief Hospital Course: Admitted trauma service T-SICU. Intubated sedated. Seen orthopedics radius fracture unltimately ORIF ([10-5]) radius without complication. Evaluated Orthopedic spine service- recommended continued hard cervical collar. Transplant nephrology followed throughout hopsitalization. Patient febrile stay SICU treated Vancomycin Zosyn empirically. Video swallow study HD6 revealed mild oral mild moderate pharyngeal dysphagia [1-17] tongue weakness. resulted recommendation ground consistency diet thin liquids Patient extubated HD 4 ([10-4]) HD 11: Patient continued waxing [Doctor Last Name 688] baseline confusion (oriented person intermittently time). Repeat Head CT revealed decreased intracranial bleed. CT Sinus revealed nondisplaced posterior wall fracture maxillary sinus fluid ni left maxillary bilateral ethmoid sinuses. CT cervical spine revealed know right C1 lateral mass fracture. Continued immunosuppressive therapy transplant. Medications Admission: See admission H & P Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). Disp:180 Tablet(s) Refills:2 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed fever. Disp:30 Tablet(s) Refills:0 3. Albuterol Sulfate 0.083 % Solution Sig: [12-17] Inhalation Q6H (every 6 hours) needed. Disp:1 1 Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 5. Prednisone 5 mg Tablet Sig: 1.5 tabs Tablets PO bedtime: TOTAL DOSE 7.5 mg PO QD. Disp:60 Tablet(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times day). Disp:120 Capsule(s) Refills:2 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times day). Disp:20 Refills:2 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) needed. Disp:1 1 Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: 1. Right subarachnoid hemorrhage 2. Thalamic contusion 3. 1st cervical vertebrae lateral mass fracture 4. Right distal radius fracture 5. Left sided rib fractures (Rib 1, [2-20]) 6. Pulmonary contusion Discharge Condition: Stable Discharge Instructions: 1. Wear cervical collar TIMES 2. Physical therapy, occupational therapy, speech therapy 3. Neuro rehab per protocols accepting facility 4. Follow daily tacrolimus (FK05) levels Followup Instructions: 1. Trauma clinic 2 weeks [Telephone/Fax (1) 24689] 2. [Hospital ] clinic [Telephone/Fax (1) 9769] 3. Orthopedic spine clinic 6 weeks. Call [Telephone/Fax (1) 54028] 4. Follow transplant doctor within 1-2 weeks	[ "4019", "25000", "V5867" ]
Admission Date: [2200-11-27] Discharge Date: [2201-2-10] Date Birth: [2142-2-13] Sex: Service: MEDICINE Allergies: Dofetilide / Lipitor / Haldol / Reglan Attending:[First Name3 (LF) 759] Chief Complaint: Dyspnea Major Surgical Invasive Procedure: multiple ET intubation 3 MICU admissions (now extubated) right IJ [2200-12-10] (removed) right PICC line placement [2201-1-5] (removed) NGT placement [2201-1-7] (removed) left PICC line placement [2201-1-27] (still place) NGT placement [2201-1-30] (removed) 2 units pRBC transfusion ([2201-1-31] [2200-12-24]) 1 unit plate transfusion ([2201-1-30]) History Present Illness: patient 58 year old male severe cardiomyopathy (EF ~20%) seen ED [Month (only) ] treated pneumonia. presents progressive symptoms including sinus pain, cough, rhinorrhea, headache mild shortness breath. describes cough productive pink sputum. denies lower extremity edema. patient first presented ED [2200-11-5] evaluated emergency department found RML pneumonia. discharged Z-pack later changed levofloxacin given concern possible interaction amiodarone. completed 7 day course levofloxacin great improvement symptoms. Approximately six days prior presentation, began recurrence symptoms. took three days amoxicillin 500 mg, left previous dental procedure. made feel somewhat better. [11-24], presented PCP. [Name10 (NameIs) ] time repeat CXR showed "probable partial resolution right-sided pneumonia." symptoms continued worsen next three days PCP ultimately advised come emergency department. . ED, vital signs 100.5, HR 69, BP 98/66, RR 20, O2 sat 97%. received 500 mg levofloxacin admitted floor. Past Medical History: 1. Dilated cardiomyopathy unclear etiology (EF=20 percent) 2. 3+ MR (s/p repair [8-29] [Hospital1 112]) 3. AF (s/p maze procedure [8-29], AV paced, coumadin amiodarone) 4. COPD: PFT [5-30](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) 5. Hypercholesterolemia 6. AICD pacer placement [12-28] following episode NSVT 7. Polymorphic ventricular tachycardia [2-27] dofetilide therapy 8. CAD s/p IMI [2189] LAD stent [12-28] (patent cath [8-29]), s/p SVG OM1 9. Depression/anxiety Social History: 20pk/yr smoking history quit 10yr ago. Denies intravenous drug use alcohol use. Lives [Hospital1 392] w/ girlfriend 11yr old son live him. work used work security company catering company. Family History: Noncontributory Physical Exam: VS - 100.5, BP 106/69, HR 69, RR 20, O2 sat 93% RA GEN - well appearing male, lying bed NAD, occastionally coughing HEENT - LAD, sclera anicteric, conjunctival palor CV - rrr, III-IV/VI systolic murmur, best heard apex radiation axilla PULM - crackles left base right middle areas; good inspiratory effort ABD - soft, non-tender, non-distended EXT - warm, edema Pertinent Results: Admission Labs: [2200-11-27] 02:07PM LACTATE-2.2* [2200-11-27] 02:00PM UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 [2200-11-27] 02:00PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0 [2200-11-27] 02:00PM WBC-13.0* RBC-4.41* HGB-14.3 HCT-45.4 MCV-103* MCH-32.5* MCHC-31.6 RDW-13.7 [2200-11-27] 02:00PM NEUTS-83.1* LYMPHS-9.5* MONOS-6.3 EOS-0.4 BASOS-0.8 [2200-11-27] 02:00PM PLT COUNT-161 [2200-11-27] 02:00PM PT-21.0* PTT-29.3 INR(PT)-2.0* MICU Admission Labs: [2200-11-30] 01:59PM BLOOD WBC-23.8# RBC-4.24 Hgb-14.4 Hct-44.0 MCV-104* MCH-34.0* MCHC-32.7 RDW-14.1 Plt Ct-147* [2200-11-30] 05:30AM BLOOD Neuts-76* Bands-2 Lymphs-9* Monos-5 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 [2200-12-2] 11:50AM BLOOD PT-53.5* PTT-42.9* INR(PT)-6.4* [2200-12-2] 11:50AM BLOOD Fibrino-746* D-Dimer-3362* [2200-11-30] 01:59PM BLOOD Glucose-138* UreaN-44* Creat-2.5* Na-134 K-5.4* Cl-97 HCO3-16* AnGap-26* [2200-11-30] 01:59PM BLOOD ALT-50* AST-110* LD(LDH)-848* CK(CPK)-49 AlkPhos-74 [2200-11-30] 05:30AM BLOOD proBNP-6548* [2200-12-1] 03:17PM BLOOD Cortsol-27.0* [2200-12-1] 05:29PM BLOOD Cortsol-36.9* [2200-12-2] 11:50AM BLOOD ANCA-NEGATIVE B [2200-11-30] 02:09PM BLOOD Lactate-10.9* K-5.3 [2200-11-30] 04:00PM BLOOD O2 Sat-74 . Discharge labs: [2201-2-10] 06:04AM BLOOD WBC-10.0 RBC-2.71* Hgb-9.2* Hct-29.7* MCV-110* MCH-33.9* MCHC-30.8* RDW-21.5* Plt Ct-67* [2201-2-10] 06:04AM BLOOD PT-11.4 PTT-26.5 INR(PT)-1.0 [2201-2-10] 06:04AM BLOOD Glucose-119* UreaN-36* Creat-0.3* Na-143 K-3.8 Cl-112* HCO3-25 AnGap-10 [2201-2-10] 06:04AM BLOOD ALT-75* AST-49* LD(LDH)-546* CK(CPK)-25* AlkPhos-325* TotBili-2.3* [2201-2-10] 06:04AM BLOOD Albumin-1.9* Calcium-7.9* Phos-3.0 Mg-2.1 Labs: [2200-12-2] 11:50AM BLOOD ESR-66* [2200-12-24] 03:36AM BLOOD Parst S-NEG [2201-1-3] 04:34AM BLOOD LAP-154* [2200-11-30] 01:59PM BLOOD CK-MB-3 cTropnT-0.05* [2200-11-30] 10:49PM BLOOD CK-MB-5 cTropnT-0.08* [2200-12-1] 04:23AM BLOOD CK-MB-NotDone cTropnT-0.08* [2200-12-22] 03:28PM BLOOD CK-MB-NotDone cTropnT-0.02* [2200-12-23] 02:45AM BLOOD CK-MB-NotDone cTropnT-0.11* [2201-1-24] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.09* [2201-2-6] 02:54PM BLOOD CK-MB-NotDone cTropnT-0.18* [2201-2-7] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.13* [2201-2-7] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.12* [2201-2-9] 06:36AM BLOOD CK-MB-7 cTropnT-0.06* [2201-2-9] 12:08PM BLOOD CK-MB-NotDone cTropnT-0.07* [2201-2-10] 06:04AM BLOOD cTropnT-0.08* [2201-1-20] 03:59AM BLOOD Triglyc-539* [2201-2-8] 08:26AM BLOOD Triglyc-278* HDL-17 CHOL/HD-12.7 LDLcalc-143* [2200-12-22] 03:28PM BLOOD T3-125 Free T4-GREATER TH [2200-12-23] 02:45AM BLOOD T4-22.2* calcTBG-0.31* TUptake-3.23* T4Index-71.7* [2200-12-24] 03:36AM BLOOD T4-20.2* T3-105 Free T4-6.2* [2200-12-25] 03:50AM BLOOD T4-20.8* T3-97 Free T4-7.3* [2200-12-26] 04:20AM BLOOD T4-20.4* T3-93 Free T4-6.1* [2200-12-27] 04:56AM BLOOD T4-18.5* T3-88 [2200-12-28] 02:57AM BLOOD T4-15.7* T3-82 [2200-12-29] 03:23AM BLOOD T4-13.5* T3-74* [2200-12-29] 10:31AM BLOOD T4-16.0* calcTBG-0.53* TUptake-1.89* T4Index-30.2* [2200-12-30] 05:15AM BLOOD T4-15.2* T3-69* [2201-1-6] 05:13AM BLOOD T4-19.3* T3-99 Free T4-6.2* [2201-1-7] 04:15PM BLOOD T4-GREATER TH T3-116 calcTBG-0.31* TUptake-3.23* [2201-1-9] 05:34AM BLOOD T4-24.6* T3-115 calcTBG-0.28* TUptake-3.57* T4Index-87.8* [2201-1-11] 04:30AM BLOOD T4-24.3* T3-113 calcTBG-0.33* TUptake-3.03* T4Index-73.6* [2201-1-13] 05:41AM BLOOD T4-18.4* T3-88 calcTBG-0.48* TUptake-2.08* T4Index-38.3* [2201-1-21] 03:08AM BLOOD T4-11.4 T3-47* calcTBG-0.72* TUptake-1.39* T4Index-15.8* [2201-2-3] 03:29AM BLOOD T4-7.9 T3-45* Free T4-1.7 . Microbiology: [2200-11-28] Urine Legionella - negative [2200-11-29] Blood cultures - NGTD [2200-11-30] Viral antigen panel - negative, cultures pending [2200-11-30] Urine culture - negative [2200-11-30] BAL - 4+ polys, gram stain negative, PCP neg, AFB neg, cultures negative [2200-12-1] Blood cultures, urine cultures - negative [2200-12-3] Blood cultures, urine cultures - negative [2200-12-3] Sputum cultures - 2+ yeast [2200-12-3] Stool - C. diff negative [2200-12-5] Blood, urine cultures - NGTD [2200-12-5] Sputum cultures - yeast [2200-12-7] Blood, urine cultures - NGTD [2200-12-8] Stool - C. diff negative [2200-12-9] Blood, urine cultures - NGTD . Imaging studies: CXR ([2200-11-27]) Comparison made prior chest x-ray [11-24]. Since time, increase density right mid zone. heart remains enlarged. costophrenic angles sharp. findings suggest [Month (only) 9140] right-sided pneumonia probably lies apical segment right lower [Month (only) 3630]. . TTE [2200-12-1]: left atrium moderately dilated. definite intracardiac shunt identified. Left ventricular wall thicknesses normal. left ventricular cavity moderately dilated severe global hypokinesis septal dysynchrony. Right ventricular chamber size normal moderate global free wall hypokinesis. aortic valve leaflets mildly thickened. aortic valve stenosis. aortic regurgitation seen. mitral valve leaflets moderately thickened mildly restrained leaflets. annuloplasty ring well seated increased gradient c/w mild functional mitral stenosis. Mild (1+) mitral regurgitation seen. pulmonary artery systolic pressure could determined. anterior space likely represents fat pad. Compared prior study (images reviewed) [2200-9-11], severity mitral regurgitation lower (may related acoustic shadowing). transmitral gradient increased (previously 5mmHg mean) estimated mitral valve area smaller (prior P1/2 time 95ms). Left ventricular systolic function depressed (global) -EF 20%. CXR [1-24]: [Month/Year (2) ] air space disease bilaterally, right greater left. Complement superimposed failure may present lack distention pulmonary vessels persistent sharp features costophrenic sulci suggest otherwise. . Thyroid U/s ([2200-12-11]) IMPRESSION: normal EEG recording stage II sleep. epileptiform features focal slowing noted. However, brief period wakefulness recorded, precluding full evaluation possible encephalopathy. clinical suspicion encephalopathy remains, repeat study wakefulness could considered. . [Month/Day/Year ] ([2200-12-29]) Conclusions: left atrium mildly dilated. Left ventricular wall thicknesses normal. left ventricular cavity moderately dilated moderate regional systolic dysfunction near akinesis inferior inferolateral walls mild hypokinesis remaining segments. Right ventricular cavity size normal mild global free wall hypokinesis. abnormal septal motion/position. aortic valve leaflets appear structurally normal good leaflet excursion. aortic regurgitation seen. mitral valve leaflets structurally normal. mitral valve annuloplasty ring present. minimally increased gradient consistent trivial mitral stenosis. Trivial mitral regurgitation seen. [Due acoustic shadowing, severity mitral regurgitation may significantly UNDERestimated.] pulmonary artery systolic pressure could quanitified.There pericardial [Month/Day/Year 17838]. . EEG ([2201-1-18]) IMPRESSION: normal EEG recording stage II sleep. epileptiform features focal slowing noted. However, brief period wakefulness recorded, precluding full evaluation possible encephalopathy. clinical suspicion encephalopathy remains, repeat study wakefulness could considered. CT [1-22]: 1. Abnormal markedly distended urinary bladder mild hydroureter hydronephrosis bilaterally setting well positioned Foley catheter. likely due obstruction catheter system flushing replacement recommended. cause lower quadrant intraabdominal pain identified. 2. Nonspecific opacities within right middle [Month/Year (2) 3630] left lower [Last Name (LF) 3630], [First Name3 (LF) ] represent resolving pneumonia, however acute infectious process chronic interstitial process (especially within lower [First Name3 (LF) 3630]) cannot excluded. Moderate right-sided pleural [First Name3 (LF) 17838] compression atelectasis. 3. Cholelithiasis without evidence acute cholecystitis. 4. Simple right renal cyst. 5. Mild amount intraabdominal pelvic free fluid. . Abd U/S ([2201-1-31]): RIGHT UPPER QUADRANT ULTRASOUND: Limited evaluation liver shows evidence biliary ductal dilatation. gallstone noted fundus gallbladder. gallbladder wall normal gallbladder distention pericholecystic fluid. extrahepatic biliary ductal dilatation common duct measuring 4 mm. IMPRESSION: Cholelithiasis, without evidence biliary ductal obstruction cholecystitis. . CXR ([2201-2-1]) previously seen Dobbhoff tube right mainstem bronchus removed. feeding tube distal tip beyond pylorus. left-sided AICD, unchanged. noted diffuse airspace opacities bilaterally relative sparing left upper lung zone. may secondary underlying pulmonary edema versus multifocal pneumonia. streaky densities left base consistent subsegmental atelectasis. small right-sided pleural [Month/Day/Year 17838]. . CT abd ([2201-2-7]) IMPRESSION: 1. Persistent linear opacities left lung base. Interval change configuration opacities right middle [Month/Day/Year 3630] appearance nodular density. Decrease size right-sided pleural [Month/Day/Year 17838] persistent compression atelectasis. 2. Cholelithiasis without evidence acute cholecystitis. 3. Multiple hypoattenuating lesions kidneys, small characterize. 4. Slightly increased amount pelvic ascites. 5. Resolution abnormally distended urinary bladder hydroureter. . CXR ([2201-2-8]) interval removal feeding tube. left AICD unchanged. Sternal wires unchanged. noted diffuse interstitial infiltrates focal infiltrate left lower [Month/Day/Year 3630]. left lower [Month/Day/Year 3630] infiltrate slightly confluent film prior week. Brief Hospital Course: patient 58 year old male dilated cardiomyopathy presents cough, fevers increased shortness breath recent course antibiotics pneumonia. Breif summary: [11-27] - [11-30]: admitted medicine service pneumonia [11-30] - [1-4]: admitted MICU respiratry failure, intubated [12-31]. [1-4] - [1-13]: transferred floor, medicine [1-13] - [1-21]: readmitted MICU repeat resp distress [1-21] - [1-25]: readmitted floor [1-25] - [2-3]: readmitted MICU CHF excerbation [2-3]: transferred floor. 58 year old gentleman atrial fibrillation, iCMP (EF 20%), h/o VT amiodarone, s/p pacemaker, CAD s/p CABG, COPD, initially admitted pneumonia, complex hospital course included 3 MICU admissions, hypoxic respiratory failure secondary pneumonia/CHF exacerbation, amiodarone-related thyrotoxicosis, ARF (resolved Cr peaked 2.4, resolved 0.4 today)leukocytosis, thrombocytopenia, vocal cord paralysis. . patient originally admitted medicine [11-27] pneumonia. [11-30] patient developed hypotension hypoxic respiratory failure, intubated, placed triple pressors transferred MICU. levaquin admission, started broad spectrum antibiotic course MICU transfer included azithromycin, ceftriaxone, vancomycin. Pt also received flagyl course empirically c. diff. MICU stay prolonged difficult. Pt weaned pressors [12-8] could extubated [12-31] secondary pneumonia pulmonary edema related decompensated cardiomyopathy difficult manage setting sepsis. patient also persistently febrile [12-31]. source could definitively identified. Chest x-ray reveal bilateral air space opacities. Numerous blood, urine sputum cultures revealing source. BAL lavage also unrevealing. DFA, viral cultures legionella negative. . patients stay complicated amiodarone related thyrotoxicosis, type II. Pt started steroids reason. Tapazole briefly given discontinued secondary rise LFT's belief type II. Thyrotoxicosis resolve. addition, pt persistently elevated WBC--elevated LAP score pointed leukemoid reaction. . patient transferred general medical floor [1-4]. point fevers resolved respiratory status satisfactory. Notably mental status remained poor since extubation. floor persistently delirious. WBC remained elevated intermittently tachycardic. thyrotoxicosis resolve despite increased dosing decadron. [1-12] [1-13] pt developed diarrhea. [1-13], pt developed fever 103.9 became tachycardic 140's. Vancomycin zosyn empirically started. also believed mental status somewhat worse. Laboratories revealed WBC 24.5 21.6 lactate 2.6. Urinalysis CXR unrevealing. Pt transferred MICU given septic physiology. . MICU patient improved. NGT placed failed speech swallow. terms thyrotoxicosis patient followed endocrine, continued steroids Cholestyramine stopped [1-21]. Patient also noted thrombocytopenia HIT Ab sent negative. Antibiotics stopped [1-17]. Patient called floor [1-21]. . Patient maintained 6L shovel mask [1-25], noted hypoxic. pulled FM O2 sats 68% RA transiently. sats, mid 90s past days dropped low 90s 10L mask. Pt progressively [Month/Day (4) 9140] tachypnea increasing O2 requirement [1-25]. ABG facemask 7.55/30/49. placed 100% NRB. given 20 IV lasix 5 pm put 1 L 2 hours. CXR done morning shows [Month/Day (4) 9140] bilateral airspace disease possible component pulmonary edema. admitted MICU hypoxia pulmonary edema [1-25]. . MICU 3rd time, treated CHF exacerbation IV lasix responded pulmonary status gradually improved; noted melena [2201-1-31] drop HCT Hct nadired [2201-1-29] 23.6; GI consulted, given pt HD stable responded well transfusion (1 unit MICU admission), EGD held now, conservative management unless acute bleeding. Given complicated hospital course, family meeting held [2201-2-2] time pt made DNR/DNI, PEG placement, expressed wishs made comfortable; defibrilator turned EP per pt's request [2201-2-3], pacer left place; Given vocal cord paralysis, PEG recommended, however, pt currently refusing replacement Dobhoff feeding device, prefered eat PO understanding po puts pt high risk aspiration. called floor [2201-2-3] discussion long term goal care. floor, remained afebrile, SBP remained 80-100s, transient drop SBP 68-72s responded fluid bolus IVNS 500cc; goals care readdress patient guardian (please see goals care note Dr. [Last Name (STitle) ] Dr. [Last Name (STitle) 12879], pt expressed wishes give IV TPN, PT reahab try, goals care needs readdress siutation arises needs transferred MICU coming back hospital discharged rehab. started IV TPN [2201-2-6] PT started working patient weekend [2201-2-7] get patient ready rehab placement. issues addressed listed below: Acute Renal Failure: morning [2200-11-30] patient's creatinine noted increased 1.0 2.5 ultimately peaked 3.0 associated decreased urine output. renal failure occured setting increased NSAID use, hypotension new onset peripheral eosinophilia 8%. Urine electrolytes revealed FENA 1.2 % setting lasix use. Urinalysis showed many WBCs eosinophils. Urine contain muddy brown casts. differential diagnosis acute renal failure included prerenal azotemia, acute tubular necrosis acute interstitial nephritis. received IV fluids pressure support maintain renal perfusion. NSAIDS immediately discontinued. Ceftriaxone also discontinued given concern AIN. renal function quickly improved return baseline creatinine MICU day 8. floor, renal function remained NL, w/Cr 0.3-0.4. . Thryotoxicosis: patient found elevated T4 T3 levels undetectable TSH [11-21], three weeks hospital course. treated Methamizol Dexamethasone. Methamizole subsequently discontinued LFT elevation. Dexamethasone tapered. TFT trending down. Endocrinology following. patient dependent Amiodaron prevention VT/Vfib continued. patient recurrent problems due thyroid hyperactivity, radioablation thyroid considered. T4/T3 levels continued trend floor, point steroids could tapered. pt needs continued 2-3 months IV methylpredinosolone 40mg, continued slow taper next month. needs Thyroid function test checked weekely discharge; . Thrombocytopenia: Pt. falling platelet count starting [1-9]. Reached nadir oof 23 [2201-1-23], plateaued. Unclear etiology, possibilities include amiodarone, methamazole. HIT seems less likely given negative HIT antibody x2. plt count continued decline floor, hematology consulted; received total 1 unit platelets admission currently steroids amiodorone induced thyrotoxicosis. Plateletes remained stable 50,0000s time discharge. . Dilated cardiomyopathy: [Date Range 461] performed [2200-12-1] [12-31] revealed severe LV global hypokinesis ejection fraction 20%. Given intial hypotension outpatient cardiac regimen held. blood pressure stabilized pressors restarted outpatient eplerenone, ace-inhibitor beta blocker; found thyroid storm likely partly repsonsible worsened cardiac function. However, meds d/c'ed except metoprolol given low BP baseline prior discharge. . Mitral Regurgitation: patient known 3+ MR status post mitral valve repair [2198]. Repeat [Year (4 digits) 113] admission revealed 1+ mitral regurgitation. felt issue stable throughout admission. . Atrial Fibrillation: patient status post maze procedure [2198]. patient also status post AICD placement NSVT throughout hospitalization noted either atrial ventricularly paced rhythm. Given initial concern amiodarone might contributing [Year (4 digits) 9140] pulmonary function amiodarone held majority hospitalization, reintroduced pulmonary process became clearly pulmonary edema. went run VT/Vfib frequent shocks reloaded amiodarone drip x 1 day transitioned amiodarone 200daily. EP changed pacer settings shock VT rate>183 VF. discovered thyrotoxicosis started esmolol drip improved ectopy. transitioned back oral beta blockers. floor, pt HR 70's-90's, sinus rhythm telemetry. 3rd MICU admissions, pt decided deactivate AICD, continue hold amiodorone given pulm toxicity. . Cardiac: patient status post inferior MI [2189] stent placement [2197]. EKG unchanged admission. Cardiac enzymes unremarkable admission MICU, rechecked called floor pt multiple chest pain complaints (ECGs paced, CE unremarkable); two [Year (4 digits) 113] done admission remained poor EF 20%; However, ASA stopped due thrombocytopenia, melena Hct drop; kept beta blocker (although get much due aspiration hypotensive episodes either mouth IV), Cardiac meds d/c'ed prior discharge due low BP; follow cardiology address whether cardiac meds need restarted; Depression/anxiety: continued lexapro, stopped taking POs. Pt became depressed psych consulted. restarted lexapro [2-3] ( 5mg qday x 1 week, increase 10mg qday that); see goals care/code status below. Nutrition: patient required short course TPN MICU course otherwise received tube feeds intubated nutritional needs. floor, reevaluated speech swallow found completely unable swallow fluids without aspiration. Initially, amenable PEG tube, delayed setting thrombocytopenia. However, transfer floor [2-3], interested Dauboff PEG placed. understands may aspirated die making decision; intially floor expressed interested TPN PEG, [2201-2-6] agreed IV TPN nutritional support, made NPO, agreed give small amounts apple sauce, ice chips, small amounts water, small amounts pureed foods comfort, remained full aspiration precautions. Goals care/Code: Initially full Code. However, prolonged hospital course, voiced sentiments CMO. family meeting MICU team guardian decided goals care. paitent changed DNR/DNI meeting [2-2]. congruence decision, ICD inactivated [2-3] Dauboff removed. situation arises (any fever, chill, chest pain, SOB, concerning symptoms), please contact patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), goals care needs readdressed point. Guardianship: [Name (NI) 108850] obtained hospitalization long intubation period [Month (only) ]. patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), Medications Admission: 1. Amiodarone 200 mg daily 2. Atrovent TID 3. ASA 81 mg daily 4. Beclomethasone (NASAL) 2 puffs nostril [Hospital1 ] 5. Clonazepam 1 mg TID 6. Coumadin 3 mg--one two tablet(s) mouth directed [Company ] coumadin clinic 7. Eplerenon 25 mg daily 8. Lexapro 20 mg daily 9. Lisinoprol 5 mg daily 10. Lorazepam 1 mg daily PRN 11. Nasonex 50 mgc two sprays nostril every day 12. Protonix 40mg daily 13. Senna 14. Toprol XL 25 mg 15. Triamcinolone 0.05 %--apply 2ml [Hospital1 ] 16. Zocor 10 mg daily Discharge Medications: 1. TPN Day 3 Central standard TPN 3 1 fat based 80kg weight, total TPN Volume [2194], Amino Acid(g/d)340, Dextrose(g/d) 120, Fat(g/d) 40, Kcal/day [2194]; trace elements standard vitamin added; 50 meqNaAc; 20 meq NaPO4; 10 meq KAc; 40 meq KPO4; 10 meq MgSO4, 12 meq CaGluc, 20 units insulin added TPN 2. Artificial Tear Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times day): please swab around inside mouth solution - cannot take swish/swallow aspirates may thrush . 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times day) needed mouth hygiene: please swab around inside mouth solution - cannot take swish/swallow aspirates may thrush . 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) needed. 7. sliding scale insulin please continue sliding scale insulin check FS qid pt TPN 8. Pantoprazole 40 mg IV Q24H unable tolerate PO protonix 9. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) needed Nausea. 10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours): hold SBP<90 HR<55. 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): hold oversedation. 12. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) 2 months: 2 months, please continue slower taper next mongh, decrease dosage 10mg per week; Please also make sure check weekly thyroid function tests including (T4, free T4, T3) . 13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once day (at bedtime)) needed. 14. PICC line PICC line care per rehab protocol 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) needed: 10 ml NS followed 2 ml 100 Units/ml heparin (200 units heparin) lumen Daily PRN. Inspect site every shift. . 16. Lorazepam 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every 4 hours) needed anxiety. 17. Morphine 10 mg/mL Solution Sig: 0.5 ml Intravenous every 4-6 hours needed pain: hold oversedation RR<12. 18. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO day: full aspiration precaustions, please crush meds give apple sauce. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: Pneumonia Congestive heart failure (exacerbation) responded lasix Vocal cord dysfunction due intubation thyroid toxicosis amiodorone (improved) depression hyponatremia resolved Thrombocytopenia (platelets 50,000 stable) Melena (responded pRBC transfusion, Hct remained stable) ------- Secondary diagnosis: Dilated cardiomyopathy (EF 20%) 3+ Mitral regurgitation (s/p repair [8-29] [Hospital1 112]) Atrial fibrillation (s/p maze procedure [8-29], AV paced, coumadin amiodarone) coumadin amiodorone stopped admission AICD deactivated) COPD PFT [5-30](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) Hyperlipidemia Coronary artery disease s/p IMI [2189] LAD stent [12-28] (patent cath [8-29]), s/p SVG OM1 Discharge Condition: afebrile, VSS (SBP baseline upper 80-90s), full aspiration precautions Discharge Instructions: Full aspiration precautions: Pt remain NPO, offer PO comfort (apple sauce, ice chips, small amounts water, small amounts pureed foods); Patient aware understand risks aspiration taking POs, willing accept risks comfort. . entensive discussion prolonged hospitalization; Given multiple medical problems, see goals care discussion notes Dr. [Last Name (STitle) ] Dr. [Last Name (STitle) 12879] (attached); pt DNR/ DNI, expressing wishes comfort measure point hospitalization, now, willing accept IV TPN willing work PT; . situation arises (any fever, chill, chest pain, SOB, concerning symptoms), please contact patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), goals care needs readdressed point. . instructions: 1. Weigh every morning, [Name8 (MD) 138] MD weight > 3 lbs. 2. Adhere 2 gm sodium diet . Please take medications prescribed. . Please follow appointments Followup Instructions: Please follow PCP 1-2 weeks discharge addition following appointments: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2201-2-27] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2201-2-27] 3:40 Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 3512] Date/Time:[2201-3-24] 1:00 also need follow otolaryngology (Ear, Nose, & Throat) evaluation vocal cords throat. Call [Telephone/Fax (1) 31733] make appointment. Tell seen ENT resident hospital told schedule follow-up appointment. Completed by:[2201-2-11]	[ "486", "51881", "42731", "496", "5849", "0389", "99592", "4280", "4240", "2761", "412", "V4582", "V4581", "5070" ]
Admission Date: [2169-11-18] Discharge Date: [2169-11-29] Date Birth: [2098-11-18] Sex: F Service: MEDICINE Allergies: Celebrex / Cipro / Augmentin / Vicodin Attending:[First Name3 (LF) 9965] Chief Complaint: Dyspnea Major Surgical Invasive Procedure: None History Present Illness: 71F RA/CREST prednisone, possible COPD recent workup possible lung neoplasm presents 2 days worsening dyspnea cough productive yellow sputum. patient USOH including able walk across room without becoming SOB stopping approx. 2 days ago. reports progressive dyspnea exertion dyspnea rest last 2 days. unable walk across room without becoming SOB. also chronic cough last thirty years usually non-productive become productive thick yellow sputum last 2 days. Denies hemoptysis. Denies fevers chills home. denies CP, N/V, dysuria, urgency, frequency, HA, neck stiffness. sick contacts. received influenza vaccine year. endorses 10lb unintentional weight loss last month [1-25] poor appetite. also endorses severe back pain progressive last 3-4 weeks initially intermittent constant. pain pleuritic nature. denies h/o falls trauma back. back pain past nothing similar this. denies bony pain besides back. endorses night sweats last ten days so. also intermittent colitis flares, one recently abdominal pain [3-28] watery loose BMs/day. denies melena hematochezia. underwent colonoscopy [2169-4-23] reports polyps removed evidence cancer pathology. . Regarding patient's RLL mass, incidentally discovered CXR [2169-7-24] chronic cough 30 years intensified summer. outside pulmonologist recommended CT scan CT peripherally located, broad based RLL lesion. prescribed Augmentin able complete 3 days [1-25] GI upset. Repeat CT scan 1 month later unchanged decision made seek investigation [Hospital1 18]. [2169-10-25] underwent flexible bronchoscopy IP service normal airway surveillance. "Radial EBUS via R basilar posterior segment showed mass 4cm entrance subsegment". Brushings washings taken BAL done. reports cough worse since bronchoscopy. Initial pathology brushings/washings positive malignancy review equivocal recommended obtain tissue. seen Dr. [Last Name (STitle) ] thoracic surgery [11-7] recommended CT-guided core needly biopsy done [2169-11-20]. . OSH, initial VS 98 108 120/54 16 94% 2L NC. Labs notable WBC 25.9 30% bands, Cr 0.97.CXR showed RLL infiltrate. given Duoneb transferred [Hospital1 18] management. . [Hospital1 18] ED, initial vs were: 99.8 96 102/42 19 94% 2L NC. CXR showed RLL infiltrate consistent pnemonia. EKG showed sinus tachycardia non specific ST changes anteriorly. Labs notable WBC 22.9 88%N 7% bands, Hct 33.5 (most recent 36), BUN 32, Cr 1.3, Mg 1.3, Phos 2.4, trop neg x1. Blood cultures sputum culture drawn Foley placed. Patient given vancomycin, Zosyn. given codeine benzonatate cough, Tylenol 1 gram fever, Mag sulfate repletion, hydrocortisone 50mg given known chronic prednisone use. Initial lactate 5.5, given 5L NS, repeat lactate 2.5 subjective improvement symptoms. seen thoracic surgery recommended MICU admission follow along. VS transfer: 99.4 94 109/50 16 97% 4L NC. . Upon arrival ICU, patient reports feeling much better overall since presentation. denies SOB says codeine helped back pain cough tremendously. Past Medical History: ?COPD RLL lung mass found CXR [7-/2169] Rheumatoid arthritis CREST overlap syndrome features inflammatory polyarthritis, Raynaud's, reflux, sclerodactyly, prednisone, followed [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 3057] HTN Diverticulosis Hemorrhoids R knee surgery benign mass R ovarian surgery many years ago benign mass h/o shingles infection 4 yrs ago Chronic rhinitis Osteoarthritis s/p right hip replacement Social History: Smoked 1-2ppd x 45 years, quit <10 years ago. Denies EtOH illicits. Lives [Hospital1 1562] husband pharmacist. Worked property manager affordable housing. Daughter pulmonologist [University/College ]. recent travel. Family History: Father PGM died colon cancer late 40s/early 50s. known FH lung disease/malignancy, autoimmune disease. Physical Exam: Admission: Vitals: T: 98.7 BP: 153/55 P: 87 R: 23 O2: 92% 4L NC General: Alert, oriented, acute distress, thin HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Diminished BS right 2/3 bases inspiratory expiratory crackles, pleural friction rub egophony present, otherwise Clear without wheezes CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley pale yellow urine Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: A&Ox3, answering questions appropriately, moving extremities. . Discharge: Vitals - 98.9 (afebrile since 0735 [11-22]) 142/64 92 24 92%2L General - Lying bed NAD. NC place 2L. CV - RRR, S1 S2, m/r/g Lung - CTA left. Breath sounds remained decreased right. Abdomen - Soft, NT/ND, BSx4 Ext- PICC line place left Neuro- Awake, alert oriented. Moving extremeties. Pertinent Results: Admission labs: [2169-11-18] 02:26PM WBC-22.9# RBC-3.67 HGB-10.2* HCT-33.5* MCV-91 MCH-27.8 MCHC-30.5* RDW-17.8* [2169-11-18] 02:26PM NEUTS-88* BANDS-7* LYMPHS-0 MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2169-11-18] 02:26PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+ [2169-11-18] 02:26PM PLT SMR-NORMAL PLT COUNT-404 [2169-11-18] 02:26PM PT-14.0* PTT-26.8 INR(PT)-1.2* [2169-11-18] 02:26PM GLUCOSE-137* UREA N-32* CREAT-1.3* SODIUM-145 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-20 [2169-11-18] 02:26PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-124* TOT BILI-0.3 [2169-11-18] 02:26PM cTropnT-<0.01 AP CXR: Worsening consolidative opacification within right lung base concerning pneumonia. CTA chest: IMPRESSION: 1. Rapid interval progression consolidative process involving right lower lobe posterior aspect right upper lobe since [2169-11-13] PET-CT, obscuration previously seen mass-like lesions posterior aspect right lower lobe. Findings compatible worsening pneumonia. underlying co-existent neoplasm may also present, obscured pneumonia. Right lower lobe bronchi appear impacted. 2. New small right pleural effusion. 3. 11-mm thyroid isthmus nodule. Comparison prior ultrasound examinations non-emergent ultrasound evaluation recommended clinical stable. 4. Moderate severe emphysema. EKG: ST 105, LAD, TWF I, aVL, V5-V6, II, III, aVF, low voltage limb leads, ST depressions/elevations [11-22] ECHO: IMPRESSION: Mild mitral valve prolapse moderate mitral regurgitation. Normal global regional biventricular systolic function. Late saline contrast left heart injection agitated saline suggesting intrapulmonary shunting. [2169-11-24] CT Chest: 1. Persistent right lower lobe consolidation parapneumonic effusion new cavitary changes, concerning necrotizing pneumonia. Underlying mass cannot excluded followup CT recommended resolution pneumonia evaluation pulmonary mass. Discussed Dr. [First Name8 (NamePattern2) ] [Name (STitle) 25139] phone [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7867] 19:42 [2169-11-24]. 2. Increased trace left pleural effusion. 3. Increased right hilar subcarinal lymphadenopathy, likely reactive given time course development, metastasis cannot excluded could evaluated resolution infection. 4. 11-mm thyroid isthmus nodule ultrasound could performed evaluation done previously Brief Hospital Course: Ms. [Known lastname ] 71 y/o F RA chronic prednisone, chronic cough recent workup possible lung neoplasm presented 2 days worsening productive cough dyspnea found pneumonia. . # Pneumonia - patient presented OSH found elevated WBC left shift. CXR showed RLL PNA. Transferred [Hospital1 18] HD stable although saturating 94% 2L. Lactate noted 5.5 improved following ~5L IVF. CTA performed showed rapid interval progression consolidative process involving right lower lobe posterior aspect right upper lobe. Started vanc zosyn admitted MICU management. MICU patient remained hemodynamically stable although continued spike fevers 102.1. Transferred floor HOD #1. floor patient intermittently febrile although continued subjective improve. Continued cefepime/vancomycin/azithro. Pulmonary interventional pulmonary consulted. ultrasound lung showed fluid amenable thoracentesis. PICC line placed continued antibiotic therapy [2169-11-22] xray showed good line placement. Also revealed significant interval improvement pleural effusion. concern fevers related antibiotics antibiotics ultimately switched meropenem vancomycin/cefepime. patient continued fevers day discharge although frequency severity markedly improved. clinically appeared well, breathing comfortably room air, subjectively better lung sounds markedly improved. One urine legionella sent time discharge followed ID. last dose meropenem [2169-12-2]. . # ?Lung Malignancy: BAL brushings [10/2169] suspicious adenocarcinoma although definitive biopsy deferred patient hospitalized. patient follow-up thoracic surgery evaluation likely biopsy. . # Anemia: patient chronic anemia hematocrit baseline ~36. Iron studies admission c/w anemia chronic disease. Throughout patient's stay hct ~30. Acute chronic anemia thought combination repeated blood draws immunosupression underlying malignancy infection. Reitc count 0.4 supportive this. e/o hemolysis active bleeding. concern medication induced marrow suppression cefepime changed meropenem. change meds, anemia stabilized. require 1 unit pRBC cefepime. . # RA/CREST: Chronic, low dose prednisone. Managed Dr. [Last Name (STitle) 3057]. Prednisone initially held in-house although re-started transfer floor. Hydroxychloroquine held active infection although re-start discharge. Methotrexate Saturday per home dosing. . # HTN: Held diltiazem initially although restart discharge. . # Chronic rhinitis: Stable. Continued home fluticasone. # Incidental findings: 11-mm thyroid isthmus nodule. Comparison prior ultrasound examinations non-emergent ultrasound evaluation recommended clinical stable. # Transitional Issues: 1) Continue meropenem 8 additional days complete 10 day treatment course (last day [2169-12-7]) 2) need re-address need lung biopsy upcomming thoracic surgery visit 3) F/u thoracic nodule 4) Repeat CBC PCP appointment within 1 week discharge rehab Medications Admission: DILTIAZEM HCL - 240 mg Capsule,Ext Release Degradable - 1 Capsule(s) mouth day FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts nasal day HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) mouth twice day except one Wed. Sat. IRON POLYSACCH COMPLEX-B12-FA [NIFEREX-150 FORTE] - 150 mg-25 mcg-1 mg Capsule - 1 Capsule(s) mouth day KAPRIDEX - (Prescribed Provider; PPI) - Dosage uncertain METHOTREXATE SODIUM - 2.5 mg Tablet - 8 Tablet(s) mouth EVERY SATURDAY NABUMETONE - 500 mg Tablet - 1 Tablet(s) mouth [12-25] qd pc needed prn pain OXAZEPAM [SERAX] - 15 mg Capsule - 1 Capsule(s) mouth 1 po hour prior MRI long air flights PREDNISONE - 1-5MG PO DAILY, usually takes 2-3mg daily, 3mg recently ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet - 2 (Two) Tablet(s) mouth needed ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg Tablet - 1 (One) Tablet(s) mouth day CALCIUM CARBONATE-VIT D3-MIN - (OTC) - Dosage uncertain CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (OTC) - 100 mcg Tablet - 1 (One) Tablet(s) mouth day LORATADINE [CLARITIN] - (Prescribed Provider; OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) mouth day OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - 1,000 mg Capsule - 1 (One) Capsule(s) mouth day Discharge Medications: 1. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO day. 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. Niferex-150 Forte 150-25-1 mg-mcg-mg Capsule Sig: One (1) Capsule PO day. 4. nabumetone 500 mg Tablet Sig: 1-2 Tablets PO day needed pain. 5. prednisone 1 mg Tablet Sig: Three (3) Tablet PO day. 6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times day needed fever pain. 7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO day. 8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO day. 9. Claritin 10 mg Tablet Sig: One (1) Tablet PO day needed allergy symptoms. 10. multivitamin Tablet Sig: One (1) Tablet PO day. 11. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO day. 12. Calcium 500 + (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO day. 13. codeine sulfate 30 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) needed cough. Disp:30 Tablet(s) Refills:0 14. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [5-2] MLs PO Q6H (every 6 hours). Disp:200 ML(s) Refills:0 15. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous every six (6) hours 4 days. 16. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection every eight (8) hours. 17. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous every eight (8) hours. 18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice day. Discharge Disposition: Extended Care Facility: [Location (un) ] care rehab Discharge Diagnosis: Primary: Pneumonia, Pleural effusion Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: pleasure taking care [Hospital1 18]! admitted due shortness breath cough. hospital found pneumonia fluid surrounding lung. stay treated antibiotics condition significantly improved. ready discharged rehabilitation facility continuation care. See changes home medication regimen: 1) Please CONTINUE Meropenem 500mg IV every 6 hours additional 4 days complete 14 day course [2169-12-2] 2) Please STOP Methotrexate otherwise instructed 3) Please STOP hydroxychloroquine see Dr. [Last Name (STitle) 3057] next . See instructions regarding follow-up care: Followup Instructions: Please follow-up Primary Care Physician, [Name10 (NameIs) ],[First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 33278]), within 1 week discharge rehabilitation facility **Please call Dr. [Last Name (STitle) ] [Location (un) 830], [Hospital Ward Name 23] 9 [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 3020] Fax: [Telephone/Fax (1) 89999] schedule appt biopsy RLL lung mass . Department: RHEUMATOLOGY When: FRIDAY [2170-3-9] 1 PM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 2310], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 861] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2169-12-15] 9:30 With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 13125] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2169-11-30**]	[ "0389", "486", "5119", "2762", "2760", "41401", "4019", "496" ]
Admission Date: [2147-11-8] Discharge Date: [2147-11-26] Date Birth: [2147-11-8] Sex: Service: NBB HISTORY PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] [Known lastname 74435] former 2.345 kg product 34 [3-15] week gestation pregnancy born 34 year-old, G2, P1 2 woman. Prenatal screens: Blood type AB positive, antibody negative, Rubella immune, RPR nonreactive. Hepatitis B surface antigen negative. Group beta strep status unknown. Mother's obstetrical history notable Cesarean section 36 weeks due breech presentation. pregnancy uncomplicated. presented preterm labor taken elective repeat Cesarean section. infant emerged spontaneous respirations, required blow-by oxygen, delivery room Apgars 8 1 minute 8 5 minutes. admitted NICU treatment prematurity. intrapartum sepsis risk factors temperature 99.6 degrees Fahrenheit. Rupture membranes occurred delivery. intrapartum antibiotic treatment. infant prenatal amniocentesis performed showing chromosomes 46XY. PHYSICAL EXAMINATION: Upon admission Neonatal Intensive Care Unit, anthropometric measurements revealed weight 2.345 kg, length 44 cm, head circumference 32 cm, 50th percentile gestational age. Physical examination upon discharge: Weight 2.765 kg. Length 48 cm, head circumference 33 cm. General: Alert, active infant room air. Skin warm dry. Color pink. Diaper rash. Head, eyes, ears, nose throat: Anterior fontanel open flat. Sutures apposed. Positive red reflex bilaterally. Neck supple. Chest: Breath sounds clear equal, easy respirations. Cardiovascular: Regular rate rhythm, murmur. Normal S1 S2. Femoral pulses +2. Abdomen soft, nontender, nondistended. masses. Cord drying. Genitourinary: Normal male phallus. Testes palpable bilaterally, high canal. Patent anus. Musculoskeletal: Spine straight, normal sacrum. Hips stable. Moves extremities. Neuro: Alert, nonfocal, symmetric tone reflexes. HOSPITAL COURSE SYSTEMS INCLUDING PERTINENT LABORATORY DATA: System 1: Respiratory. infant required treatment oxygen continuous positive airway pressure. admission NICU, chest x-ray remarkable 9 rib expansion, streaking perihilar densities, consistent transient tachypnea newborn. able wean C-pap room air day life. continued room air rest Neonatal Intensive Care Unit admission. episodes spontaneous apnea bradycardia. time discharge, breathing comfortably room air respiratory rate 40 60 breaths per minute oxygen saturations greater 97%. System 2: Cardiovascular: infant maintained normal heart rates blood pressures. soft intermittent murmur noted admission audible time discharge. Baseline heart rate 140 160 beats per minute recent blood pressure 72/31 mmHg, mean arterial pressure 46 mmHg. System 3: Fluids, electrolytes nutrition. infant initially n.p.o. maintained IV fluids. Enteral feeds started day life one. day life 2, noted thick, bilious green aspirate abdominal distention abdominal x-ray showing dilated bowel loops. transferred [Hospital3 1810] underwent upper gastrointestinal enema studies. normal returned [Hospital1 ] Hospital feedings resumed. tolerated feedings well since time. time discharge, taking minimum 130 mm/kg per day Enfamil 24 calorie per ounce formula mouth. Weight day discharge 2.765 kg. Serum electrolytes sent 3 times first week life within normal limits. System 4: Infectious disease. Due unknown etiology preterm labor unknown group beta strep status mother, infant evaluated sepsis upon admission Neonatal Intensive Care Unit. white blood cell count differential within normal limits. blood culture obtained prior starting IV ampicillin gentamycin. blood culture growth 48 hours antibiotics discontinued. System 5: Hematological. Hematocrit birth 49.4%. infant receive transfusions blood products. System 6: Gastrointestinal. previously mentioned, infant upper gastrointestinal enema contrast studies done [Hospital3 1810]. studies within normal limits. infant passed stool prior enema maintained normal stooling patterns since time. Enteral feeds well tolerated. peak serum bilirubin noted day life #5, total 11.2 mg/dl. recheck level [2147-11-15] 9 mg/dl. require treatment. infant require follow-up pediatric surgery 2 3 weeks discharge. System 7: Endocrine. infant noted undescended testes bilaterally upon admission Neonatal Intensive Care Unit. evaluated urology team [Hospital3 1810]. abdominal ultrasound performed [2147-11-10] testes visualized. recommendation consult service, serum testosterone level sent 151 ng/dl well normal range. admission, testes noted high canals undescended palpable time discharge. infant follow- urology consult team attending Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 64463] 4 6 weeks discharge. System 8: Neurology. infant maintained normal neurologic examination neurologic concerns time discharge. System 10: Sensory Audiology: Hearing screening performed automated auditory brain stem responses. infant passed ears. System 11: Psychosocial. [Hospital1 188] social work involved family. contact social worker [Name (NI) 4457] [Name (NI) 36244] reached [Telephone/Fax (1) 8717]. CONDITION DISCHARGE: Good. DISCHARGE DISPOSITION: Home parents. PRIMARY CARE PHYSICIAN: [First Name8 (NamePattern2) 40133] [Last Name (NamePattern1) 311], [Apartment Address(1) 76003], [Location (un) ], [Numeric Identifier 68635], telephone number [Telephone/Fax (1) 76004]. CARE RECOMMENDATIONS: 1. Feeding ad lib: Enfamil 24 calorie per ounce formula minimum 130 ml/kg per day intake. 2. medications. 3. Iron vitamin supplementation: Iron supplementation recommended preterm low birth weight infants 12 months corrected age. infants fed predominantly breast milk receive Vitamin supplementation 200 i.u. (may provided multi-vitamin preparation) daily 12 months corrected age. 4. Car seat position screening performed. infant evaluated car seat 90 minutes without episodes desaturation bradycardia. 5. State newborn screens sent [11-11] [2147-11-26] notification abnormal results date. 6. Immunizations: Hepatitis B vaccine administered [2147-11-24]. 7. Immunizations recommended: Synagis RSV prophylaxis considered [Month (only) ] [Month (only) 958] infants meet following four criteria: (1) Born less 32 weeks; (2) Born 32 weeks 35 weeks two following: Day care RSV season, smoker household, neuromuscular disease, airway abnormalities school age siblings; (3) chronic lung disease (4) hemodynamically significant congenital heart disease. Influenza immunization recommended annually Fall infants reach 6 months age. age, first 24 months child's life, immunization influenza recommended household contacts out-of-home caregivers. infant received ROTA virus vaccine. American Academy Pediatrics recommends initial vaccination preterm infants following discharge hospital clinically stable least 6 weeks fewer 12 weeks age. FOLLOWUP: 1. Pediatric surgery Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], 2 3 weeks discharge. Phone number [Telephone/Fax (1) 76005]. 2. Pediatric urology: Attending [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 64463] 4 6 weeks discharge. Phone number [Telephone/Fax (1) 45268]. DISCHARGE DIAGNOSES: 1. Prematurity 34 3/7 weeks gestation. 2. Respiratory distress, consistent transient tachypnea newborn. 3. Suspicion sepsis ruled out. 4. Undescended testicles. 5. Suspicion bowel obstruction ruled out. [First Name8 (NamePattern2) 73452] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(2) 73453] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2147-11-26] 00:49:42 T: [2147-11-26] 15:28:59 Job#: [Job Number 76006]	[ "V053", "V290" ]
Admission Date: [2177-12-18] Discharge Date: [2177-12-23] Date Birth: [2126-9-8] Sex: Service: Trauma Surgery CHIEF COMPLAINT: Stabbing left upper quadrant. HISTORY PRESENT ILLNESS: Patient 55-year-old male, presented ED following stabbing left upper abdomen reported significant blood loss scene. Hematocrit arrival ED 12 blood alcohol 31, systolic blood pressure 110, heart rate 115. patient taken emergently operating room exploratory laparotomy. PAST MEDICAL HISTORY: Hypertension, otherwise unknown. PAST SURGICAL HISTORY: Unknown. MEDICATIONS: Aspirin, otherwise unknown. ALLERGIES: Unknown. PHYSICAL EXAMINATION: patient's first set vital signs 7:20 a.m. recorded heart rate 100, blood pressure 160/palp, respiratory rate 20, saturations 100%. patient intubated time. Patient's physical exam notable stab wound left upper quadrant costal margin anterior anterior axillary line tenderness palpation greater left right. abdomen distended guarding palpation. distended. Patient's rectal examination guaiac negative normal tone. LABORATORIES: patient's hemoglobin 4.5, hematocrit 14, platelets 203. Coags revealed INR 1.1, PT 13, PTT 21.1, lactate 2.9, fibrinogen 261. Blood gas 7.46/28/269/21/-1. Blood alcohol 31. Peripheral IV access established ED blood transfusion immediately initiated. left subclavian central line placed, patient emergently taken operating room. Intraoperatively, patient noted transverse colonic stab injury minimal soilage. injury repaired primarily. Exploration abdomen revealed injury. wound closed fascial level otherwise, skin left open. patient received 5,000 mL crystalloid, 4 units packed red blood cells intraoperatively. Estimated blood loss 150 cc, included clot. Hematocrit end case 29 following 4 units red blood cells infused total. patient left intubated transfer Intensive Care Unit. patient extubated without complication postoperative day #1. Patient epigastric tube place. patient uncomplicated ICU course transferred floor postoperative day #3. patient started triple antibiotics ampicillin, Levaquin, Flagyl. continued transfer floor. patient's hematocrit remained stable. patient alert oriented pain well controlled following extubation. Patient started clear liquids diet postoperative day #4, started medications mouth. midline incision noted slight erythema superior pole. unchanged postoperative day #5. postoperative day #5, patient ambulating comfortably bowel movement. tolerating regular diet. discharged home Levaquin Flagyl one week, instructions wound care. keep wound covered dry gauze. patient's Left upper quadrant clean, dry evidence infection covered Vaseline gauze gauze dressing. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. q.d. 3. Levaquin 500 mg p.o. q.d. x7 days. 4. Flagyl 500 mg p.o. t.i.d. x7 days. 5. Dilaudid 2-4 mg p.o. q.4h. FOLLOWUP: patient followup Trauma Clinic one week. MISCELLANEOUS: patient receive visiting nurse care dressing changes stab wound well midline incision changed day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9325], M.D. [MD Number(1) 14131] Dictated By:[Name8 (MD) 997] MEDQUIST36 D: [2177-12-24] 12:50 T: [2177-12-29] 05:19 JOB#: [Job Number 100472]	[ "4019" ]
Admission Date: [2161-3-2] Discharge Date: [2161-3-8] Date Birth: [2089-11-15] Sex: F Service: NEUROSURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: nausea, vomiting Major Surgical Invasive Procedure: s/p suboccipital craniotomy tumor resection biopsy History Present Illness: 71F NSCLC, HTN, hypercholesterolemia, admitted refractory nausea/vomitting since starting Tarceva. denies abdominal/chest pain, SOB, diarrhea/constipation problems w/bladder incontinence. unsteadiness gait well trouble using right hand. Past Medical History: 1. NSCLC: prior w/u [Hospital1 112]/[Company 2860] (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3273])- lung nodules found preop CXR [6-14], CT showed RLL nodule c/w primary lung cancer multifocal bronchoalveolar carcinoma, PET/CT showed FDG-avid R lung nodule mediastinal/pericardial LAD, s/p bronch/mediastinoscopy mediastinal LN dissection path showing NSCLC-adenoca; sought 2nd opinion [Hospital1 18] ([Doctor Last Name 3274]/[Doctor Last Name 1058]), s/p 2 cycles Taxol carboplatin [Date range (1) 3275], s/p 4 cycles Navelbine [2165-9-14], CT chest [2-16] showed interval worsening lung metastases LAD, started Tarceva ?[2-20] 2. Hypertension 3. Hypercholesterolemia 4. Degenerative joint disease Social History: former smoker half one pack day 20 30 years, quit 20 years ago. significant amount passive smoking exposure, asbestos exposure, rare social drinking. Family History: Positive cardiac vascular disease, cancer. possible history amoxicillin allergy, although clear whether poor tolerance, taken penicillin past without difficulty. daughter physician comes visit along son-in-law. worked bookkeeper electrical company past. Physical Exam: T:96.9 BP:140/78 HR:64 RR:20 O2Sats:95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm well-perfused. Neuro: Mental status: Awake alert, cooperative exam, normal affect. Orientation: Oriented person, place, date. Language: Speech fluent good comprehension repetition. Naming intact. dysarthria paraphasic errors. Cranial Nerves: I: tested II: Pupils equally round reactive light, 4 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength sensation intact symmetric. VIII: Hearing intact voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk tone bilaterally. abnormal movements, tremors. Strength full power [6-13] throughout. pronator drift. Sensation: Intact light touch bilaterally. Toes downgoing bilaterally Coordination: normal finger-nose-finger, heel shin (+) Romberg Pertinent Results: [2161-3-2] 09:10PM WBC-11.9* RBC-5.25 HGB-15.3 HCT-44.5 MCV-85 MCH-29.2 MCHC-34.4 RDW-16.7* [2161-3-2] 09:10PM NEUTS-70.0 LYMPHS-24.3 MONOS-4.0 EOS-1.3 BASOS-0.5 [2161-3-2] 09:10PM ANISOCYT-1+ MICROCYT-1+ [2161-3-2] 09:10PM PLT COUNT-406 [2161-3-2] 09:10PM GLUCOSE-97 UREA N-34* CREAT-0.8 SODIUM-133 POTASSIUM-7.7* CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 [2161-3-2] 09:10PM estGFR-Using [2161-3-2] 09:10PM ALT(SGPT)-33 AST(SGOT)-97* ALK PHOS-109 AMYLASE-111* TOT BILI-0.6 [2161-3-2] 09:10PM LIPASE-81* [2161-3-2] 09:10PM CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.4 MRI head: 1. Enhancing mass right cerebellar hemisphere, mass effect described above, consistent metastatic lesion. additional mass/abnormal enhancement. 2. Old lacune left caudate nucleus nonspecific T2 hyperintensity right frontal lobe, likely post-traumatic chronic small vessel ischemic change. 3. Mucosal changes right sphenoid sinus. CT abdomen/pelvis: 1. evidence intra-abdominal metastatic disease. 2. 9-mm hypoattenuating liver lesion likely cyst monitored closely followup exams. 3. New small bilateral pleural effusions adjacent atelectasis. 4. Large paraesophageal hernia. 5. Stable pericardial lymph node. Brief Hospital Course: # Nausea vomiting: Concerning presentation brain metastasis. Tarceva d/c'd thursday last week w/continued N/V well unsteadiness gait # NSCLC: treatment plans per Dr. [Last Name (STitle) 3274] [Doctor Last Name 1058] - hold Tarceva - CT head # Code status: DNR/DNI [3-4], patient came [Hospital Ward Name ] SICU west. underwent preop evaluation surgery scheduled [3-5] Dr. [Last Name (STitle) 548]. successful surgery reported complications. Please see operative note full details. went back ICU 24 hours came floor. Physical therapy saw major issues progression. plans say daughter several days recuperate. patient see neuro oncology Dr. [Last Name (STitle) 548] next week course steroids unforeseeable future. Medications Admission: [Doctor First Name ] 60MG [Hospital1 ] FLONASE 50 mcg 2 sprays ou qd LIPITOR 10 MG qd PRILOSEC 40 mg qd Discharge Medications: 1. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) 2 days. Disp:12 Tablet(s) Refills:0 2. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO twice day 2 days: Start dose taking 3mg TID. Disp:8 Tablet(s) Refills:0 3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice day: finished taking 3mg [Hospital1 ], take 2mg [Hospital1 ] directed MD otherwise. Disp:60 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. Disp:30 Tablet(s) Refills:0 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day needed constipation: Please take medication long taking percocet. . Disp:60 Capsule(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: cerebellar mass Discharge Condition: neurologically stable Discharge Instructions: ?????? family member check incision daily signs infection ?????? Take pain medicine prescribed ?????? Exercise limited walking; lifting, straining, excessive bending * Please continue preadmission medications coming hospital. ?????? may wash hair sutures and/or staples removed ?????? may shower time assistance use shower cap ?????? Increase intake fluids fiber pain medicine (narcotics) cause constipation ?????? Unless directed doctor, take anti-inflammatory medicines Motrin, aspirin, Advil, Ibuprofen etc. ?????? prescribed anti-seizure medicine, take prescribed follow laboratory blood drawing ordered ?????? Clearance drive return work addressed post-operative office visit CALL SURGEON IMMEDIATELY EXPERIENCE FOLLOWING: ?????? New onset tremors seizures ?????? confusion change mental status ?????? numbness, tingling, weakness extremities ?????? Pain headache continually increasing relieved pain medication ?????? signs infection wound site: redness, swelling, tenderness, drainage ?????? Fever greater equal 101?????? F Followup Instructions: Need follow-up oncologist 9-mm hypoattenuating liver lesion likely cyst needs watched. PLEASE RETURN OFFICE 7 DAYS REMOVAL STAPLES/SUTURES PLEASE CALL [Telephone/Fax (1) ] SCHEDULE APPOINTMENT DR.[Last Name (STitle) 548] SEEN 1 WEEK. NEED CAT SCAN BRAIN WITHOUT CONTRAST Completed by:[2161-3-8]	[ "4019", "2720", "V1582" ]
Admission Date: [2198-3-13] Discharge Date: [2198-3-16] Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 2234] Chief Complaint: Bloody bowel movements Major Surgical Invasive Procedure: None History Present Illness: Ms. [Known lastname ] 86 y/o F PMH diverticulosis, hepatic cyst s/p resection, HTN presents ED BRBPR X 3 home. Patient feeling well today 1430 pm large loose bowel movement bright blood. occurred X 2 patient presented ED. note, known history diverticular bleed requiring ICU admission transfusion 4 U PRBCs 9/[2196]. denies abdominal pain throughout. denies chest pain, shortness breath, dizziness/lightheadedness today. ED, patient's initial vitals HR 67, BP 127/64. BP remained 110s-130s systolic. received 2 L normal saline. hematocrit demonstrated decrease 29.7 31-32 (2 weeks ago); repeat Hct [2190] pm (four hours presentation) demonstrated drop 24.4 (no interval transfusion receive IVF). Two large-bore peripheral IVs placed, patient transfused 1 U PRBCs (still running arrived floor). remained asymptomatic throughout. GI [Year (4 digits) 653] recommended observation ICU tagged RBC scan bloody BMs continued. MICU received one unit pRBC. stabilized, hemodynamically stable. two small episoded BRBPR. GI evaluated deferred scope time likely diverticular bleed easy intervention. feels well transfer floor, without complaints pain. Past Medical History: 1. Hypothyroidism 2. H/O E. Coli Sepsis ([4-/2194]) 3. HTN 4. H/O Bronchitis 5. Hepatic Cystadenoma S/P Resection ([2184]) 6. Cholangitis S/P Stenting 7. PUD (Duodenum) 8. TAH/BSO 9. DJD 10. CAD (2VD s/p DES D1) 11. Osteoarthritis knees 12. Diverticulosis 13. Neuropathy 14. Spinal stenosis Social History: Lives [Hospital3 ] facility [Location (un) 583], moved U.S. rural [Country 651] 40 years ago. Denies smoking, alcohol, drug use. Lives alone [Hospital3 4634] family near by. Previously worked laundering/ironing. Family History: known liver, gall bladder, lung heart disease. known cancers. Physical Exam: VS: 98.6, BP 133/62, HR 81, O2Sat 98 RA, RR 20 GEN: pleasant, comfortable, elderly female NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: supraclavicular cervical lymphadenopathy, supple RESP: CTA b/l good air movement throughout CV: RR, S1 S2 wnl, m/r/g ABD: slighlty distended prior midline & right-sided scars, +b/s, soft, nontender palpation, masses hepatosplenomegaly EXT: trace anterior tibial edema, extremities warm SKIN: rashes/no jaundice NEURO: AAOx3. face symmetric & speaking clearly full sentences. moving extremities without difficulty. Pertinent Results: [2198-3-13] 04:20PM WBC-6.8 RBC-3.76* HGB-10.1* HCT-29.7* MCV-79* MCH-26.9* MCHC-34.1 RDW-14.0 PLT COUNT-344 NEUTS-78.0* LYMPHS-14.2* MONOS-5.4 EOS-2.0 BASOS-0.3 [2198-3-13] 08:09PM BLOOD Hgb-8.1* Hct-24.4* [2198-3-14] 07:51AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.6* Hct-27.8* MCV-78* MCH-26.7* MCHC-34.3 RDW-14.9 Plt Ct-284 [2198-3-15] 05:35AM BLOOD WBC-6.3 RBC-3.33* Hgb-9.0* Hct-26.7* MCV-80* MCH-26.9* MCHC-33.6 RDW-14.6 Plt Ct-245 [2198-3-16] 06:00AM BLOOD WBC-6.5 RBC-3.51* Hgb-9.5* Hct-27.7* MCV-79* MCH-27.0 MCHC-34.2 RDW-15.6* Plt Ct-257 [2198-3-13] 04:20PM GLUCOSE-115* UREA N-21* CREAT-1.3* SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14 EKG Sinus rhythm occasional atrial ectopy. Compared previous tracing [2198-2-28] atrial morphology changed rate slowed. Atrial ectopy appeared. Otherwise, diagnotic interim change. Intervals Axes Rate PR QRS QT/QTc P 68 200 88 390/404 0 Brief Hospital Course: 86 year old female known history diverticulosis presents BRBPR drop hematocrit. # GI bleeding: Likely diverticular bleed given history diverticula clinical presentation. Hemodynamically stable minimal bloody bowel movements since second day admission. Coagulation studies checked found within normal limits. admission received 1 unit PRBC HCT remained stable. GI service consulted admission thought role colonoscopy likely represented diverticular bleed. family, primary caregivers, [Name (NI) 653] discuss nature diverticular bleeding little intervention done via colonoscopy. Given HCT remained stable three days post-initial transfusion, discharged home follow-up. Specifically, HCT check VNA 3 days post-discharge seen PCP 6 days post-discharge. # Acute Renal Failure: Likely related hypovolemia diarrhea/blood loss. Resolved hydration. # Hypothyroidism: Continued Levothyroxine. # History choledocholithiasis: Continued ursodiol home dose. # Hypertension: Anti-hypertensives initially held given concern potential hemodynamic instability. ICU, restarted Amlodipine home dose. remainder inpatient stay, Metoprolol Cozaar restarted. Thus, discharged prior outpatient regimen. Medications Admission: amlodipine 5 mg daily actigall 300 mg [Hospital1 ] cozaar 25 mg daily levothyroxine 75 mcg daily meloxicam 15 mg daily - patient self-d/c metoprolol 50 mg [Hospital1 ] prilosec 20 mg daily darvocet prn calcium/vitamin Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO day. 7. Calcium 600 + 600-400 mg-unit Tablet Sig: One (1) Tablet PO day. 8. Outpatient Physical Therapy evaluate treat home needed. 9. Outpatient Lab Work VNA continue outpatient services. Additionally, CBC drawn [2198-3-19] results faxed Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 16691]. Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Gastrointestinal bleeding, likely due diverticuli Secondary: Hypertension, hypothyroidism Discharge Condition: Hemodynamically stable. Discharge Instructions: admitted blood stool black stools. found bleeding intestines, likely diverticuli past. transfused one unit blood blood levels stable since. Thus, discharged outpatient follow-up physical therapy home continued recovery. Take medications prescribed. medications changed hospital. Please keep outpatient appointments. Return hospital seek medical advice notice fever, chills, difficulty breathing, chest pain, bloody stools, black stools, bloody vomit symptom concerning you. Followup Instructions: Provider: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5004] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2198-3-22] 12:40 Provider: [Name Initial (NameIs) 11595] (RHEUM LMOB) [Doctor Last Name 11596] Phone:[Telephone/Fax (1) 2226] Date/Time:[2198-4-4] 11:30	[ "5849", "2851", "4019", "2449" ]
Admission Date: [2129-10-14] Discharge Date: [2129-10-17] Date Birth: [2070-7-27] Sex: Service: Neurosurgery HISTORY PRESENT ILLNESS: patient 59-year-old gentleman past medical history hypertension subarachnoid hemorrhage ruptured basilar tip aneurysm treated using coil embolization [2129-5-5]. returns stent placement coil embolization residual basilar tip aneurysm. HOSPITAL COURSE: patient underwent procedure [2129-10-14] placement stent coiling remainder aneurysm without intraprocedural complication. patient monitored PACU, well without complaints. pain, confusion, chest pain, shortness breath, nausea vomiting. apparent anesthesia complications. Postoperatively, awake, alert, without complications, moving everything well, lying flat, oriented times three, speech clear. pupils equal, round, reactive light. EOMs full. diplopia. nystagmus. Right groin sheath removed oozing hematoma, good pedal pulses. patient bed ambulating, tolerating regular diet, transferred regular floor. continued Plavix aspirin. discharged home postprocedure day number three stable condition, neurologically intact follow-up Dr. [Last Name (STitle) 1132] one month repeat angiogram time. Continue Plavix one week aspirin indefinitely. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q.d. 2. Percocet one two tablets p.o. q. four hours pain. CONDITION DISCHARGE: Stable. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2129-10-17] 10:53 T: [2129-10-17] 14:48 JOB#: [Job Number 47665]	[ "4019", "53081" ]
Admission Date: [2152-9-29] Discharge Date: [2152-10-4] Service: MED Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 898] Chief Complaint: CC:[CC Contact Info 41404] Major Surgical Invasive Procedure: none History Present Illness: 86 female w/ breast ca briefly tamoxifen, paroxysmal afib, presumed diastolic dysfunction, ?COPD eval resp distress. Per daughter, [Name (NI) 41405] increased sob/tachypnea x [12-31] days treated w/ levaquin ?pna diuretics volume overload. day admission, initially improved following additional lasix w/ episode shaking, diaphoresis followed reported unresponsiveness lethargy. Transferred ED afebrile, hypertensive systolic 170's 86% ra w/ abg7.35/74/59. Started bipap, diuresed w/ 60 iv lasix 1200 cc urine output. Repeat gas 100 fio2 7.25/99/257. MICU Pt placed Bipap target O2 sat 90-92%, diuresed, abx tx continued vanc + ceftaz. MICU achieved 95-97% O2 sat weaned BIPAP 3L NC. Transferred medical floor. Past Medical History: COPD (1L O2 baseline, Sat reported) Breast Ca (tamoxifen) Paroxysmal AFIB ??????no coumadin (fall risk) Diastolic Dysfunction (CHF) Hypothyroidism HTN UTI (previous proteus enterococcus, susceptible levo. Per [Hospital1 18] records). s/p R hip ORIF [2152-7-7] Social History: Resides [Location (un) 2716] Point (extend care). Per record, quit smoking 30 years ago, 3 cigs qd. Retired teacher. Family History: reported records. Son ([Telephone/Fax (1) 41406]) MD [First Name8 (NamePattern2) ] [Last Name (Titles) ] Diabetes Center. Physical Exam: T:98.1 97.9 BP: 120-130/30-40 HR 90 (70-110) RR:20 O2Sat:95(92-97) 3LNC Gen: Pt. awake, alert disoriented. According home health aide (present) pt. baseline today. Skin: Nl. Skin turgor. Small well healed surgical scar neck base. HEENT: EOMI. Sclera anicteric. Heart: Irreg. Irreg. auscultation. murmurs noted. rubs gallop. S1 S2 JVP < 10cm. Lungs: Distant breath sounds. Bibasilar rales B/L (R>L), wheezes, rhonchi. Abd: Soft, obese, nontender palpation, nondistended, [Doctor Last Name ]??????s sign. Normal bowel sounds. Extrem: Strength 4/5 flexion & extension UE b/l. Strength 4-/5 LLE raise, [4-3] LLE extension, Strength 2/5 RLE raise, [2-3] RLE extension. Plantarflexion dorsiflexion 4-/5 b/l. 1+ edema b/l. Pertinent Results: [2152-9-29] 01:25PM BLOOD WBC-7.2 RBC-3.94* Hgb-11.6* Hct-36.6 MCV-93 MCH-29.4 MCHC-31.6 RDW-13.5 Plt Ct-250 [2152-9-29] 01:25PM BLOOD PT-12.1 PTT-24.6 INR(PT)-0.9 [2152-9-29] 01:25PM BLOOD Glucose-141* UreaN-17 Creat-0.8 Na-141 K-4.4 Cl-93* HCO3-39* AnGap-13 [2152-9-29] 01:25PM BLOOD Acetone-NEG [2152-9-29] 01:25PM BLOOD TSH-3.6 [2152-9-29] 01:38PM BLOOD Type-ART pO2-59* pCO2-74* pH-7.35 calHCO3-43* Base XS-10 [2152-9-29] 04:51PM BLOOD Lactate-0.6 [2152-9-29] 04:51PM BLOOD freeCa-1.11* [2152-9-30] PORTABLE CHEST: Comparison made film one day earlier. patient made slightly improved inspiratory effort current film. cardiac mediastinal contours unchanged, prominence left hilum noted. Previously noted pulmonary edema persists without change. improved aeration left base. [2152-10-2] SWALLOWING EVAL RECOMMENDATIONS: 1.Advance regular consistency po diet. 2.Should pt develop s/s aspiration, worsening pna, difficulty upper airway secretions, please reconsult video swallow study. [2152-9-29] EKG: Sinus arrhythmia Normal ECG change previous Brief Hospital Course: 1. COPD: Patient observed Nursing Home ([Location (un) 2716] Point) increased SOB two days seen PCP [Last Name (NamePattern4) ] [2152-9-29]. noted oxygen saturation 80% RA, thought potentially secondary CHF exac vs. PNA. treated levofloxacin lasix improvement oxygen saturation 85% RA, BP incr. 160s. IV nitro started nursing home, antibiotics switched azithro + ceftaz, transferred [Hospital1 18] ED. arrival ED, diaphoretic, shaky unresponsive. temperature 99.6 pt hypertensive 160-170/60, oxygen saturation 86% RA. ABG 7.25/99/257 suggesting CO2 retention. Per MICU note, daughter reported [Name2 (NI) ], recent F/C/N/V, CP mild SOB last couple weeks, PND , orthopnea. Daughter reports increased LE edema weight gain (undocumented) [2-1] weeks, urinary Sx. MICU, pt placed BIPAP target O2 sat 90-92%, diuresed, abx tx continued vanc + ceftaz. MICU achieved 95-97% O2 sat weaned BIPAP 3L NC. Transferred medical floor continued wean O2, continued steroids (prednisone taper) continued ipratropium neb, added albuterol neb. 48 hours later, patient weaned 3L NC 02 90-95% sats RA >95% sats mild crackles base. d/ced condition. 2. CHANGE MS: Pt. found unresponsive brought ED diaphoretic, acidotic, low O2 Sat. confused disoriented, baseline per home attendant. Unit, palced BiPAP improving sats hypercarbic, retaining. Still poor mental status. BiPAP weaned day transfer floor, pt much closer baseline per home health aide. d.c medicine floor, home health aid reports patient baseline mentation. Although still oriented, thoughts organized vocal. 3. ID: Pt's COPD CXR infiltrate worrisome PNA + COPD exac. Txed inpatient Vanc+ceftaz, transferred floor continued ceftaz, converted azithro+ceftriax. d/c wbc 5.4 crit 33.1 plat 228, abx 10d cefpodoxime 200 [Hospital1 ] azithro 250 QD. 4. Atrial fibrillation: Per PCP, [Name10 (NameIs) ] patient fall risk, PCP recommend coumadin lovenox given risk. beta blocker dose titrated improved rate control. 5. Hypothyroidism: patient's TSH checked admission within normal limits. discharge midly elev 5.0. levothyroxine continued present dose. PCP consider TSH level 2wks determine current levoxyl dose adequate. 6. Documented desat sleep ? sleep apnea. Pt. observed 15 min 02 sat sleep. awake o2 sat 90-92% RA, pt desats low 80s high 70s 30 sec apneic events sleep, sats rise high 80s. d/c nocturnal 02 2L, may wish consider sleep apnea w/u o.p. 6. C/o R eyelid pain. [10-4] pt c.o mild R eye discomfort - home health aid admit chronic R eye dryness/discomfornt. exudate, scleara clear, obvious foreign body, erythema, edema. Txed artificial tears. clinical indication exam pathologic process. Medications Admission: ADMIT: zyprexa 2.5 qhs, levoxyl 125 qd, neurontin 100 tid, donezepil 10 qhs, trazodone 50 qhs, atrovent neb qid MICU: Famotidine 20 mg IV Ipratropium Bromide Neb 1 NEB Q6H Levothyroxine 125 mcg PO Aspirin 81 mg PO Heparin 5000 UNIT SC TID Ceftazidime 1 gm IV Vancomycin HCl 1000 mg IV Q24H Nitroglycerin 0.05 mcg/kg/min IV DRIP TITRATE sbp Olanzapine 2.5 mg PO Methylprednis. Succ 60 mg IV Q8Hx3d Metoprolol 25 mg PO BID hold sbp<100 hr<60 Olanzapine 2.5 mg PO TID PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation every eight (8) hours. 2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once day). 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID PRN (). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO QD (once day): Taper day 1 ([2152-10-3]):40,40,40,20,20,20,10,10,10,10. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) needed shortness breath wheezing. 8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) 10 days. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 10. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 10 days. 11. Nocturnal 02 2L nasal can. Discharge Disposition: Extended Care Facility: [Location (un) 2716] [Last Name (un) ] - [Location (un) 55] Discharge Diagnosis: COPD exacerbation + PNA 1. COPD exacerbation + PNA 2. Dementia 3. Hypothyroidism 4. Diastolic dysfunction 5. Depression Discharge Condition: fair. Discharge Instructions: Please return ED experience increasing shortness breath, increased oxygen requirement, shortness breath [Location (un) ], fever, chest pain. Followup Instructions: Please follow primary care physician within next 2 weeks.	[ "486", "51881", "4280", "2859" ]
Admission Date: [2103-9-20] Discharge Date: [2103-9-25] Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 7708] Chief Complaint: BRBPR Major Surgical Invasive Procedure: [2103-9-24] Colonoscopy History Present Illness: Ms. [Known lastname 72724] [Age 90 ] y/oF history remote colon ca s/p resection ~23 years ago, mild hypertension admitted night [2103-10-21] BRBPR. noticed change stools last days, brought daughter??????s attention last night maroon stool toilet. another episode red blood morning, moderate quantity. problem before. abdominal pain, occasional nausea vomiting. change bowel habits days earlier, ahd constipation use finger aid evacuation stool. history hemorrhoids. . DJD taking naproxen PRN, one analgesic recently, daughter thinks Tylenol. . ED: initial vitals 97.6, HR 72, BP 127/48 RR 18 Sat 98% 2L. received 2L normal saline. episode BRBPR ED 500cc. Vitals however remained stable without tachycardia hypotension. rectal exam frankly bloody, hemorrhoids appreciated. seen GI decision scope immediately see clears, back-up plan IR scan/embolism likely preceded endoscopy. . ICU: presented Hct 27.4, dropped 24.7 night. subseqently received 2 units [9-20], 1 unit PRBC [9-21]. Hct remained stable 30s since then. Past Medical History: - Colon Ca s/p resection 23 years ago [Last Name (un) 51768], FL - Hypertension - Depression - Degenerative Joint Disease Social History: lives home daughter son-in-law, denies etoh, smoking Family History: NC Physical Exam: Vitals: 96.8, 121/48, 65, 18, 98%RA HEENT: NC/AT, clear oropharynx, MMM Neck: supple, LAD CV: RRR m/g/r Chest: CTAB Abd: +BS NT/ND, soft Ext: c/c/e Skin: rashes, lesions, jaundice Neuro: A&Ox3 Pertinent Results: LABS: [2103-9-20] WBC-8.8 RBC-3.05* HGB-9.0# HCT-27.4# MCV-90 MCH-29.6 MCHC-33.0 RDW-13.4 [2103-9-20] 02:50PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.1 [2103-9-20] 02:50PM cTropnT-0.02* [2103-9-20] 02:50PM CK(CPK)-94 [2103-9-20] 02:50PM GLUCOSE-117* UREA N-47* CREAT-1.0 SODIUM-140 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [2103-9-20] 03:35PM URINE RBC-0-2 WBC-<1 BACTERIA-RARE YEAST-NONE EPI-0-2 [2103-9-20] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2103-9-20] 07:47PM WBC-7.8 RBC-2.76* HGB-8.6* HCT-24.7* MCV-89 MCH-31.1 MCHC-34.8 RDW-13.5 [9-21] 5:18pm - Hct 30.2 [9-22] 1:35pm - Hct 30.7 [2103-9-23] 03:02PM BLOOD Hct-32.1* [2103-9-24] 05:25AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.3* Hct-30.7* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.9 Plt Ct-249 [2103-9-25] 05:15AM BLOOD WBC-8.5 RBC-3.39* Hgb-10.4* Hct-30.3* MCV-90 MCH-30.7 MCHC-34.2 RDW-13.8 Plt Ct-263 [2103-9-25] 05:15AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-104 HCO3-28 AnGap-11 . Imaging: CXR: acute CP process ECG: Sinus 1:1 70 bpm, normal axis, intervals. e/o ischemia Colonoscopy: Diverticulosis sigmoid colon descending colon Two small polyps sigmoid ascending colon 1.5 cm penduculated polyp sigmoid colon. (polypectomy) Erythema petechiae several colonic folds sigmoid colon Otherwise normal colonoscopy cecum Brief Hospital Course: [Age 90 ] y/oM remote h/o semi-colectomy colon ca a/w likely lower GI bleed absence abdominal pain. # GIB: Patient reported painless hematochezia maroon stools x 2-3 days prior admmission BRBPR morning admission. Differential included diverticulosis, AVM, colon CA, colonic ischemia. Pt's Hct nadired 24.7. received 3 units PRBC ICU. remained hemodynamically stable floor hospital course. remainder hospital course require transfusions [2103-9-21]. day [Hospital ] transfer floor reported two bloody bowel movements [Hospital1 ] hematocrit checks continued HCT remained stable around 30. reported bloody maroon bowel movements. colonoscopy [2103-9-24] showed diverticulosis well polyps. polypectomy pathology pending. Although initially started empirically IV PPI [Hospital1 ], changed PO daily dosing prior discharge. # HTN- Norvasc initially held restarted prior discharge home dose 5 mg daily. # [Name (NI) 1068] Pt Remained stable zoloft. # Code: Full Medications Admission: Allergies: NKDA Home medications: Zoloft 50mg PO daily Norvasc 5mg PO daily Naproxen PRN Tylenol PRN Aspirin PRN Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis 1. Gastrointestinal Bleed 2. Diverticulosis 3. Sigmoid/Colon Polyps. Biopsy reports pending Secondary Diagnosis 1. Depression 2. Osteoarthritis 3. Hypertension Discharge Condition: Hemodynamically stable, stable hematocrit x 3 days, afebrile Discharge Instructions: admitted hospital maroon colored stools bleeding gastrointestinal tract. blood counts initially low transfused 3 units blood. this, blood counts remained stable bleeding. colonoscopy [2103-9-24] showed diverticulosis, small outpouchings colon, polyps. One polyp removed biopsy sent pathology. results biopsy pending time discharge. made following changes medications 1. added Pantoprazole 40mg mouth daily Please take medications prescribed follow primary care doctor below. Please return ED call primary care physician develop bloody, maroon dark tarry stools notice bleeding rectum. Also call develop nausea, vomiting, lightheadedness, dizziness, chest pain, shortness breath concerning symptoms. Followup Instructions: Please follow primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] Thursday [10-4] 5:15pm. Call [Telephone/Fax (1) 14825] questions regarding appointment. repeat hematocrit also checked time. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7476] MD [MD Number(1) 7715]	[ "2851", "4019", "311" ]
Admission Date: [2118-5-7] Discharge Date: [2118-5-12] Date Birth: [2070-8-1] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: Melena Major Surgical Invasive Procedure: EGD Radiofrequency ablation liver lesions History Present Illness: 47 yo man h/o etoh/HCC cirrhosis, esophageal varices melena black emesis dark tarry stools [5-6]. states melena started [5-5]. also lightheadedness. notes abdominal pain ambulance ride improved zofran. partner encouraged go [Name (NI) ]. [Doctor First Name 8125] hct 37.2. ED VS: 98.7 76 117/75 18 99% 2L NC. 2L NS. 2 Melenic, guaiac + stools. HR 80, SBP 120, hemodynamically stable. initially go floor, housestaff uncomfortable. ROS: wt change, change abdominal girth, fevers, chills, head ache, chest pain, sob, palpitations, sob, dysuria, hematuria, confusion, rash. Past Medical History: - Etoh/HCV cirrhosis varices, ascites, previous episodes encephalopathy, Last viral load 7,340 IU/mL [2117-2-26]. patient liver biopsy patient treatment date hepatitis C followed Dr. [Last Name (STitle) 497] (last seen [4-11]). EGD [2115-12-23] revealing varices lower third esophagus, two bands placed, portal gastropathy. Grade 3 esophageal varices multiple admissions GIB, banding past; last EGD [9-11] varices small band. - Ethanol abuse history DTs: + hallucinations past intubations seizures. - h/o Nephrolithiasis. - MVA [2113-5-4] two fractured lumbar vertebrae, torn rotator cuff, humeral head fracture. - h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia - foot surgery - facial reconstruction child - leg cramps - asthma - Hep B SAg/sAb negative ; Hep immune - HIV negative [2115-7-5] - AFP 1.81 [2117-2-4], U/S [2117-2-25] 1.1cm echogenic focus left lobe, f/u MRI limited Social History: long history alcohol abuse (since high school). currently drinking pint vodka per day mixed drinks, last drink [5-6] am. history DTs, seizures intubations + hallucinations. currently smokes less pack per day smoked 30+ years. unemployed used work carpenter. history IVDU (cocaine heroin) last use 15 years ago. history incarceration past. Family History: know liver disease colon cancer. Father history alcoholism Physical Exam: VS: 97.9 HR 89 BP 129/82 RR 24 Sat 93% RA GEN: NAD HEENT: AT, NC, PERRLA, EOMI, conjuctival injection, anicteric, OP clear, MMM Neck: supple, LAD, carotid bruits CV: RRR, nl s1, s2, m/r/g PULM: CTAB, w/r/r good air movement throughout ABD: protuberant, soft, NT, ND, + BS, obvious HSM percusion, ? small fluid wave, caput EXT: warm, dry, +2 distal pulses BL, femoral bruits Skin: spider angiomas chest, scattered [Last Name (LF) 94195], [First Name3 (LF) ] damage NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. sensory deficits light touch appreciated. asterixis. PSYCH: appropriate affect, anxiety, tremulousness, diaphoresis Pertinent Results: Admission labs: [Age 90 ]\|105\|10 -----------<128 3.7\|25\|0.6 Ca: 7.5 Mg: 1.3 P: 2.6 ALT: 38 AP: 124 Tbili: 4.9 Alb: 2.3 AST: 111 . 11.8 7.5>--<152 33.9 PT: 19.6 PTT: 35.6 INR: 1.8 Fibrinogen: 256 EGD: actively bleeding vessels (please see full report OMR details) Radiofrequency ablation: 1. Successful radiofrequency ablation patient's liver tumor. [2118-5-12] 05:45AM BLOOD WBC-6.0 RBC-2.72* Hgb-10.1* Hct-28.6* MCV-105* MCH-37.1* MCHC-35.2* RDW-17.0* Plt Ct-91* [2118-5-12] 05:45AM BLOOD Plt Ct-91* [2118-5-12] 05:45AM BLOOD Glucose-169* UreaN-8 Creat-0.6 Na-130* K-3.4 Cl-96 HCO3-29 AnGap-8 [2118-5-12] 05:45AM BLOOD ALT-29 AST-92* LD(LDH)-276* AlkPhos-107 TotBili-3.6* [2118-5-12] 05:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.4* Brief Hospital Course: 46 yo man alcoholic cirrhosis, known esophageal varices admitted melena emesis. patient hemodynamically stable throughout admission. episodes melena hospital course. patient initially maintained two large bore IVs plan transfuse hematocrit less 28. EGD demonstrate actively bleeding lesions. patient actively drinking prior admission. Although denied history withdrawal seizures tachycardic, hypertensive nauseated admission. maintained q2 hour CIWA scale, decreasing benzo requirements throughout admission. patient also maintained thiamine, folate multivitamin. clonidine discontinued admission restarted patient called floor. patient coagulopathy secondary chronic cirrhosis. disease secondary ETOH HCC, followed Dr. [Last Name (STitle) 497]. disease complicated portal hypertension, hypertensive gastropathy, esophageal varices s/p banding melena past, well ascites, thrombocytopenia, anemia, coagulopathy. medications initially held clear patient actively bleeding, nadolol, furosemide, spironolactone lactulose restarted. patient stable thrombocytopenia. receive FFP prior planned RFA three liver lesions. procedure went well patient discharged following day. patient continued outpatient pain regimen Neurontin lidocaine patch. also chronic stable anemia macrocytic, likely multifactorial given GIB, EtOH use liver disease. Vitamin B12 1787 [4-12], folate 11.8 [4-12]. patient full code throughout admission. Communication follow: mother [Name (NI) ] (HCP) [Telephone/Fax (1) 94196], Partner [Name (NI) ] (h) [Telephone/Fax (1) 94197], (c) [Telephone/Fax (1) 94198]. Medications Admission: Pt poor historian, unable verify meds Clonidine 0.1 mg PO TID Fluticasone 50 mcg/Actuation Nasal [Hospital1 ] Folic Acid 1 mg PO DAILY Furosemide 40 mg PO DAILY Gabapentin 300 mg PO Q8H Lactulose 10 gram/15 mL ThirtyML PO four times day - takes constipated Nadolol 40 mg PO DAILY Pantoprazole 40 mg PO Q24H - states [Hospital1 ] Ferrous Sulfate 325 mg PO DAILY Hexavitamin PO DAILY - likely taking Thiamine HCl 100 mg PO DAILY Lidocaine 5 %(700 mg/patch) Topical DAILY Spironolactone 100 mg PO DAILY Nicotine 21 mg/24 hr Transdermal DAILY Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times day). 7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12, 12 hours. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic cirrhosis GI bleed Secondary: HCV Liver lesions Asthma Discharge Condition: Stable Discharge Instructions: admitted hospital concern gastrointestinal bleeding. hospital, EGD demonstrate actively bleeding vessels. also radiofrequency ablation lesions liver. blood counts stable since admission hospital. Please take medications prescribed. Please call physician come emergency room anyfevers, vomiting, blood stool vomit, confusion symptoms find concerning. Followup Instructions: Please call [Telephone/Fax (1) 250] schedule [Telephone/Fax (1) 648] primary care doctor follow discharge. Please call Liver Center ([Telephone/Fax (1) 1582] set [Telephone/Fax (1) 648] Dr. [Last Name (STitle) 497] within several weeks discharge.	[ "2875", "3051", "49390" ]
Admission Date: [2155-8-10] Discharge Date: [2155-8-27] Service: HISTORY PRESENT ILLNESS: 80-year-old white female past medical history significant non-Q-wave MI 6/[2155]. patient transferred [Hospital1 346] [Hospital6 33] question small-bowel obstruction. patient bowel movement. Prior admission felt bloated, although nausea vomiting, stopped passing gas approximately two days prior admission. patient brought [Hospital6 33] [8-9] secondary increased abdominal pain, diffuse across lower abdomen, mostly crampy. admitted fluid resuscitated [Hospital6 33]. NG [Hospital ] Hospital showed dilated loops small bowel air-fluid level. PAST MEDICAL HISTORY: 1, patient found small-bowel obstruction transferred [Hospital1 188] exploratory laparotomy lysis adhesions. Past medical history significant non-Q-wave MI [2155-6-21], time approximately four cardiac stents placed. 2. Chronic obstructive pulmonary disease. 3. Hypertension. PAST SURGICAL HISTORY: patient colectomy approximately 30 years ago vaginal hysterectomy. ALLERGIES: patient known allergies medications. HOME MEDICATIONS: 1. Serevent two puffs q.h.s. 2. Combivent 2 puffs q.i.d.p.r.n. 3. Albuterol Atrovent 25/500 q.i.d. 4. Zantac 50. 5. Ativan 2 mg q.4h. 6h. anxiety. 6. Morphine pain. 7. Hydralazine 2 mg IV q.8h. blood pressure control. SOCIAL HISTORY: patient long-term smoker. PHYSICAL EXAMINATION: Physical examination admission revealed following: VITAL SIGNS: Temperature 97.4, blood pressure 150/20, pulse 82, respiratory rate 16, saturation 93% room air. HEAD NECK: Head neck examination: Pupils equal, round, reactive light. Extraocular muscles intact. Mucous membranes moist. RESPIRATORY: patient clear auscultation bilaterally. moving air well. CARDIAC: Examination showed regular rate rhythm, normal S1 S2 without murmurs, rubs, gallops. ABDOMEN: Abdomen noted soft, distended, mild tenderness diffusely. guarding rebound. EXTREMITIES: Without edema, stools guaiac negative time. LABORATORY DATA: Prior admission, labs drawn [Hospital6 3622] revealed white count 11.0, hematocrit 37.1, platelet count 346,000, sodium 136, potassium 3.5, BUN 25, creatinine 1.3, glucose 132, calcium 10.5, magnesium 1.9, LFTs ALT 1125, AST 21, amylase 20, lipase 22. [2155-8-11], patient received CT scan abdomen, demonstrated multiple loops small bowel region narrowing right lower quadrant iliac fossa consistent mechanical small-bowel obstruction, single low attenuation cyst liver, tiny gallstone without evidence cholecystitis, scattered sigmoid diverticula without diverticulitis, extensive vascular calcification region mesenteric artery. HOSPITAL COURSE: Given patient's CT findings, decided patient would taken operating room emergent exploratory laparotomy lysis adhesions. [2155-8-11], patient exploratory laparotomy tolerated operation well. Approximate blood loss 200 cc. transfused intraoperatively six units platelets, 800 cc crystalloid. Intraoperative central line placed, chest film obtained confirm placement patient transferred operating room Post Anesthesia Care Unit. there, transferred Surgical Intensive Care Unit observation monitoring laparotomy given history non-Q-wave MI chronic obstructive pulmonary disease. Post Anesthesia Care Unit, patient evaluated Cardiology Service, noted transient right bundle branch block Post Anesthesia Care Unit decided resume Aspirin. Overnight, postoperative day #0 postoperative day #1, patient major events. continued monitored Surgical Intensive Care Unit. Intensive Care Unit decided diurese patient. transfused one unit packed red blood cells. hematocrit noted increase 29.7. Overnight, postoperative day #1 postoperative day #2, patient noted low urine output. ICU, patient kept NPO. noted increasing hematocrit infusion one unit packed red blood cells. [2155-8-12] patient received transthoracic echocardiogram, demonstrated preserved left ventricular ejection fraction. decided start Lopressor patient rate pressure control. postoperative day #2 postoperative day #3, patient continued well without major events. NG tube noted draining 350 cc postoperative day #2 postoperative day #3. Again, patient noted low hematocrit 27.7 [2155-8-13]. patient continued well, although one episode anxiety. decided [2155-8-13] change patient pCO2, regular morphine prn. found stable Lopressor IV Vasotec. transfused one unit packed red blood cells. evening [2155-8-13], patient transferred Intensive Care Unit floor, noted well overnight events [8-13] [8-14]. Overnight, [8-13] [8-14], patient's NG tube put approximately 150 cc. still passing flatus. postoperative day #4 postoperative day #5, [2155-8-14] [2155-8-5] patient continued well. decreased abdominal pain, able ambulate. patient remained without flatus. patient diuresed 3.5, repleted. point, total parenteral nutrition started patient. patient tolerated TPN well advanced goal total parenteral nutrition [2155-8-15]. [2155-8-16], patient evaluated rehabilitation services physical therapy. patient noted making progress ambulatory ability. Overnight, [2155-8-16] [2155-8-17] patient noticed increased amounts flatus. able pass flatus point. remained TPN [2155-8-17]. NG tube noted put approximately 250 cc [2155-8-16]. [2155-8-17] [2155-8-18] patient continued well. [2155-8-17], patient NG tube pulled. taking small sips. TPN continued, IV fluids not. [2155-8-18], Dermatology Service consulted facial rash. impression 80-year-old female onset malar rash treatment small-bowel obstruction. prescribed hydrocortisone 1% cream patient, seemed help contact dermatitis. Overnight, [2155-8-18] [2155-8-19], patient complained shortness breath approximately 4 morning, relieved nebulizers. LABORATORY DATA: patient found hematocrit 26. TPN continued [2155-8-19]. [2155-8-19], Pulmonary Service consulted patient's complaint dyspnea. impression 80-year-old female known chronic obstructive pulmonary disease status post myocardial infarction recent abdominal surgery differential diagnosis episodes dyspnea mostly multifactorial chronic obstructive pulmonary disease exacerbation. recommended increasing Atrovent four puffs b.i.d.; restarting Flovent checking PFTs. Also, differential diagnosis bronchitis increased amounts sputum increased shortness breath. However, patient without clear chest x-ray infiltrate. patient treated Azithromycin possible tracheobronchitis total course five days. differential diagnosis pulmonary edema deconditioning given prolonged hospital course. decided treat patient approximately five days Azithromycin adjust MDIs nebulizers according recommendations. [2155-8-20], patient transfused one unit packed red blood cells. hematocrit improved 26 33. patient continued well. ambulating. However, overnight [2155-8-19] [2155-8-20], patient started vomit twice. nasogastric tube replaced, drained approximately 100 cc stomach. Dermatology Department followed patient. patient given increase Hydrocortisone ointment 1% 2.5% b.i.d. worsening facial rash. Overnight, [2155-8-20] [2155-8-21], patient complaints. felt respiratory status better morning. without nausea vomiting NG tube replaced. Overnight, NG noted put approximately 350 cc. hematocrit stable 33.8 33.9 day before. Overnight, [2155-8-21] [2155-8-22], patient well. nasogastric tube noted put 650 cc fluid previous day. hematocrit stable 33.2. blood pressure medications time IV Lopressor Enalapril, Hydralazine. patient tolerated well good pressures rate. maintained telemetry. patient diuresed 2 mg Lasix [2155-8-21]. [2155-8-22], decided patient passing flatus able bowel movement. point, nasogastric tube taken out. patient noted tolerate 630 PO ice chips [2155-8-22]. Overnight, [2155-8-22] [2155-8-23], patient continued well nasogastric tube discontinued complaints nausea, vomiting, abdominal pain. TPN continued. point, patient decided best course action would go acute rehabilitation prior leaving home [State 760]. Overnight, [2155-8-23] [2155-8-24], patient continued well. began tolerating clear liquid diet. continued pass flatus. labs noted stable. diuresed 10 mg Lasix [2155-8-24]. Overnight, [2155-8-24] [2155-8-25], patient continued well. able tolerated clear liquid diet throughout day without nausea vomiting. hematocrit noted stable 32.8. Overnight, [2155-8-25] [2155-8-26] patient continued well. felt slight amount nausea soft diet. diuresed approximately 20 mg Lasix [2155-8-25] [2155-8-26] given positive fluid balance course past two days, weight noted 75.8, fairly close known dry weight. patient, however, emesis soft diet. decided continue soft diet. point, decided stop patient's TPN; discontinued central line; switch IV cardiac medications PO cardiac medications; take telemetry. Overnight, [2155-8-26] [2155-8-27], patient continued well. decided point transferred acute rehabilitation facility [State 350], prior going [State 760]. CONDITION DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Small-bowel obstruction, status post exploratory laparotomy. 2. Non-Q-wave myocardial infarction. 3. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Protonix 40 mg PO q.d. 2. Enalapril 5 mg PO b.i.d. 3. Metoprolol 12.5 mg PO b.i.d. 4. Enteric aspirin 325 mg PO q.d. 5. Ativan 0.5 mg 6. Colace 10 mg PO b.i.d. 7. Ipratropium bromide 4 puffs q.i.d. 8. Flovent 110 mcg two puffs b.i.d. 9. Albuterol nebulizers one nebulizer q.6h.p.r.n. bronchospasm. 10. Albuterol one two puffs q.4h. 6h.p.r.n. bronchospasm. 11. Salmeterol two puffs b.i.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Name8 (MD) 16207] MEDQUIST36 D: [2155-8-27] 04:56 T: [2155-8-27] 10:02 JOB#: [Job Number 43770]	[ "4280", "53081", "4019", "V4582" ]
Admission Date: [2161-8-27] Discharge Date: [2161-9-3] Date Birth: [2121-2-5] Sex: Service: MED Allergies: Bactrim Attending:[First Name3 (LF) 15241] Chief Complaint: sob Major Surgical Invasive Procedure: none History Present Illness: Mr. [Known lastname 15225] 40 year old man AIDS (criteria CD-4 counts opportunistic infections) admitted dyspnea, fevers, hypoxia. Mr. [Known lastname 15225] says usual state (chronically poor) health 3 days ago began fatigue usual. began fevers 99.0-100.0 yesterday started develop left sided chest pain came deep breaths coughing, fevers 103 degrees chills rigors. coughing scant, thick yellow sputum, without blood sputum. came Infectious Disease Outpatient Clinic morning found temp 102 degrees, oxygen saturation walking hallway 71.%. brought Emergency Room admitted there. last hospitalized [6-29] -> [2161-7-6] persistent pain right-sided kidney stone. hospital- ization, stent placed right kidney help remove stone. stent removed prior discharge. chest X ray admission revealed faint opacity left lower lobe obscured left hemidiaphragm lateral view. was, therefore, put cefpodixime 7 days." ER VSS temp 101.7 HR 99 BP 112/72 R24, 74% RA, 99% 2L. Cxray notable LLL infiltrate. EKG notable sinus tach 92, negative axis, R wave transition v3, flat waves V5-V6, q3T3, q [12-30]/avf (no change baseline). INR 0.9. Cr 1.6. Blood cultures sent. ed received tylenol, ceftriaxone 2mg iv, MS contin heparin IV. 40 w/AIDS (CD4 count 9 [2161-4-23]) admitted [8-27] dyspnea, fevers 103, hypoxia. (In [Hospital ] clinic temperature 102 degrees ambulatory o2 sat 71%. Please see ID admit note OMR complete HPI/history.) short, patient usual state health three days prior admission experienced fatigue, fevers 99.0-100.0, pleuritic chest pain cough. (Patient last hospitalized [Hospital1 18] [6-29] [2161-7-6] persistent pain right-sided kidney stone, stent placed removed.) ER admission: VSS temp 101.7 HR 99 BP 112/72 R24, 74% RA, 99% 2L. Chest xray notable LLL infiltrate. EKG notable sinus tach 92, negative axis, R wave transition v3, flat waves V5-V6, q3T3, q [12-30]/avf (no change baseline). INR 0.9. Cr 1.6. ed patient received tylenol, ceftriaxone 2mg IV, MS contin heparin IV. ROS: Man HIV/AIDS last CD4 count 9. transfer [Hospital Ward Name ] patient continues express sharp chest pain left sternal area radiating left shoulder [5-7] intensity worse inspiration, patient also reports SOB. Patient reports intermittent hematuria. denies abdominal pain, diarrhea, melena, headache, sore throat, dysuria, lower extremity swelling pain, orthopnea. Past Medical History: 1. AIDS dx [2142]: [5-1] VL 23K; [3-31] CD4 1 VL 47K- initially monotherapy starting [2144], variable degrees resistance HAART. 2. PCP x5: [2146](intubated) c/b perirectal HSV pancreatitis pentamidine and/or steroids, [1-/2155] c/b LUE axillary vein thrombosis, [5-/2155], [7-/2155], [3-/2157] 3. Disseminated MAC bacteremia [2148] 4. Didanosine associated pancreatitis [6-/2150] 5. Aseptic meningitis [1-/2154] secondary TMP/SMX 6. Cerebral MAC (diff [2148] organism) c/b seizures [3-/2157] 7. Necrotic HSV L chest wall lesion resistant acyclovir ganciclovir treated Foscarnet [3-30] 8. Acyclovir resitant HSV R chest wall lesion [5-1] treated Foscarnet (to stop [2161-7-2]) 9. Neurosurgical drainage R sided subdural fluid collection [11-27] c/b post-op seizure intubation airway protection 10. HTN 11. Chronic peripheral neuropathy (legs>arms) 12. Systolic CHF (Echo [9-30] EF 50% w/ 1+AR, [11-28]+MR, 1+ TR) 13. Coagulopathy [12-29] lupus anticoagulant c/b DVT/PE [4-28] [9-30], anticoagulation IVC filter place 14. IMI [4-28] (presumed [12-29] hypercoagulable state) s/p RCA stenting 15. Aflutter s/p ablation [12-31] 16. Thrush-resistant fluconazole (now tx w/ voriconazole) 17. Asthma 18. Chronic renal failure 19. Hyperkalemia Social History: -Divorced; contracted HIV ex-wife child died AIDS. subsequently tested found HIV+ wife admitted IVDU. since died.-Lives alone dog, [Month/Year (2) 15233]. Lives studio apt rented mother.-Smoked 1 ppd x 2 years (on job). Quit 5 mths ago stopped working operations manager scrap metal. -EtOH- occas wine; Marijuana occas nausea; Exercises 5x/wk-H/o asbestos exposure Family History: Mom-mild HTN hypercholesterolemia; brother- asthma, HTN. 3 sisters-alive healthy Physical Exam: OBJ: 99.9 BP 142/104 HR 97 R 20 98% 1.5 L GEN: emaciated gentleman, mild respiratory distress HEENT: OP clear, evidence thrush, cervical lymphadenopathy CV: RRR systolic murmur LUNG: crackles auscultated Left base ABD: +BS/NT/ND, organomegally, rebound, guard EXT: edema/cyanosis/pulses intact, skin dorsum hands red-purple color right greater left NEURO:[1-8] intact, upper extremity, lower extremity strength symmetric intact Skin: normal skin tone, erythema/rashes Pertinent Results: [2161-8-27] 01:15PM POTASSIUM-4.4 [2161-8-27] 12:55PM PT-12.0 PTT-18.2* INR(PT)-0.9 [2161-8-27] 11:56AM LACTATE-1.9 [2161-8-27] 11:54AM GLUCOSE-92 UREA N-23* CREAT-1.6* SODIUM-135 POTASSIUM-6.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [2161-8-27] 11:54AM ALT(SGPT)-15 AST(SGOT)-43* ALK PHOS-73 AMYLASE-31 TOT BILI-1.3 [2161-8-27] 11:54AM ALBUMIN-3.8 [2161-8-27] 11:54AM WBC-3.1* RBC-3.36* HGB-11.3* HCT-35.6* MCV-106* MCH-33.7* MCHC-31.8 RDW-16.2* [2161-8-27] 11:54AM NEUTS-71.6* LYMPHS-11.6* MONOS-12.3* EOS-3.6 BASOS-0.7 [2161-8-27] 11:54AM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+ [2161-8-27] 11:54AM PLT COUNT-223 renal u/s ([2161-8-5]): IPRESSION: 1. Diffuse echogenicity bilateral kidneys consistent patient's history HIV. 2. Simple cyst upper pole right kidney slightly smaller prior examination. 3. evidence hydronephrosis, stones masses bilaterally. Ct abdomen: [2161-6-17] IMPRESSION: 6-mm partially obstructing calculus within proximal right ureter, acute forniceal rupture. EKG: EKG notable sinus tach 92, negative axis, R wave transition v3, flat waves V5-V6, q3T3, q [12-30]/avf (no change baseline). cath [5-28]: FINAL DIAGNOSIS: 1. Patent RCA stents. 2. Normal biventricular filling pressures. 3. Mild LV systolic dysfunction dopamine infusion. CXRAY ([2161-8-27]): IMPRESSION: Patchy bibasilar opacities consistent pneumonia. Lower extremity u/s:IMPRESSION: Chronic deep venous thrombosis extending proximal left superficial femoral vein left popliteal vein, multiple collaterals. Brief Hospital Course: 40 w/ AIDS (CD4 9), multiple medical problems presents dypnea fever. SOB - floor antibiotic changed cefipime. One day following admission, patient developed additional chest pain hypoxia initially read o2 sat 70s requiring 10L O2 patient 93% (abg 7.35/34/90 10L face-mask), patient's systolic blood pressure also 100s compared baseline 130s. Unclear relative hypotension secondary pain medications, dehydration, developing heart failure possible PE, verus worsening PNA, therefore patient transferred unit. [Hospital Unit Name 153] supportive measures continued. patient provided IV fluid. Empiric treatment PCP [Name Initial (PRE) ] (primaquine) discontinued. CT [8-29] showed: LLL PNA, effusion, enlargement nodule left lung apex new nodule medial LUL nodule, possibly representing differences slice selection compared [9-30]. Patient need follow Dr. [Last Name (STitle) 2148] regarding work-up findings. (A contrast CT performed secondary patient's CRI.) Labs [8-31] notable HCT 25.5, Retic 0.7, LDH normal, INR 1.6, Cr 1.6 (down elevated 1.9 admission), note Trop maximum 0.83 echo performed [8-29] demonstrated normal systolic function, therefore felt represent possible RV strain. Patient's respiratory status improved antibiotics patients transferred unit. note cryptococcal antigen negative. Nasopharyngeal culture ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B RSV negative. CMV DNA negative. Patient o2 sat 94% ambulating discharged subjective feeling intermittent dyspnea discharge oxygen. Patient also discharged Lovenox SC, INR therapeutic. picc line placed discharge outpatient cefipime. 2. Fever - Patient AIDS, history fever chest xray/chest CT notable PNA. Blood cultures / urine cultures in-house negative. Patient without diarrhea. Reticulocyte low, LDH normal, bili slightly elevated. 3. CRI/Hematuria - Patient history renal stones, recent admission kidney stone urthethral stent presents elevated CR compared baseline. etiology likely prerenal patient responded fluids. discharge CR 1.3 (baseline 1.3-1.8). 4. Cardiac/CAD - note patient history RCA stent, IMI past, q waves inferior leads EKG. Patient maintained cardiac medications secondary concerns regarding drug interactions (discussed attending). Patient experienced elevated troponins episodes chest pain. echo demonstrated intact systolic function. Patient discharged aspirin. 5. HIV - Patient antiretroviral medications tonofovir, stavudine, ritonavir, Fuzeon, Emtricitabine, Atazanavir. Patient empiric AIDS coverage cipro, azithro, acyclovir. 6. Neurology/History seizure - Maintain kepra. Seizure thought due focus scar prior brain abscess. Patient reports using gabapentin neuropathic pain. 7. Anemia - Patient presented hematocrit 34, wide variation baseline (34-44). Throughout hospitalization hematocrit went 25 stabilized. decrease likely reprented fluid shifts hydration. differential anemia includes low production given anemia chronic disease, low reticulocyte count. Iron studies demonstrated low iron, low b12. Therefore b12 provided. Patient history procrit use resumed discharge. 10. Code - DNR/DNI. Medications Admission: (per OMR [2161-8-4]) ACYCLOVIR 400MG--One capsule mouth twice day ALBUTEROL 90MCG--2 puffs every 4 hours needed coughing relieved serevent. ATAZANAVIR 150 MG--Two capsules (300 mg) mouth (one time) daily. AZITHROMYCIN 250MG--One capsule mouth twice day CIPROFLOXACIN HCL ORAL 500 MG TABLET 500MG--One tablet mouth twice day COUMADIN 5MG--Take 7.5 mg/day notice. DILAUDID 2MG--One tablet every 3 hours needed pain controlled morphine contin. EFFEXOR XR 75MG--One capsule daily. EMTRICITABINE 200 MG--One capsule mouth daily. ETHAMBUTOL HCL 400MG--One tablet mouth three times day FLONASE 50MCG--Two sprays nostril twice day FUSEON 90 MG--Inject one vial (90 mg) sq [Hospital1 ]. ITRACONAZOLE 10MG/ML--20 cc (200 mg) swish swallow daily. KEPPRA 500MG--One tablet mouth twice day suppression seizures LOVENOX 120MG/.8ML--One injection sq daily. NEUPOGEN 300MCG/0.5--Inject one cc every week (every 2 weeks). NEURONTIN 100MG--Two capsules three times day two 400 mg capsules 1000 mg mouth three times day control discomfort peripheral neuropathy. OPIUM 10%--One cc mouth four times day needed diarrhea OXANDROLONE 10MG--One tablet (10 mg) mouth twice day weight loss. PENTAMIDINE ISETHIONATE 300MG--Given aerosol monthly PERCOCET 5-325MG--One two tablets every 4 hours needed pain controlled morphine contin. PROCRIT [Numeric Identifier ] U/ML--One cc every week (every 2 weeks). RITONAVIR 100MG--One capsule daily, two capsules atazanavir (reyetaz). SEREVENT DISKUS 50MCG--Two puffs [Hospital1 ]. STAVUDINE 15MG--One capsule mouth twice day SYRINGE/SAFETY GLIDE 25GX0.625"--Use one cc 25 g x 0.625" syringes procrit g-csf injections. TENOVOFIR 300 MG--One tablet daily ULTRASE MT 18 59-18-59--Two capsules mouth meal ZOFRAN 4MG--One tablet mouth q 6 hours needed nausea / vomiting MEGACE 40MG--One tablet daily, enhancement appetite. -per patient take albuterol/dilaudid/itraconazole -he take gabapentin amphotericin Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) needed. Disp:1 30 Refills:0 2. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO QD (once day). Disp:90 Capsule(s) Refills:2 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QAM (once day (in morning)). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 6. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qd (). Disp:30 Capsule(s) Refills:2 7. Ethambutol HCl 400 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 8. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [Hospital1 ] (2 times day): 90 mg SC injection. Disp:60 Kit(s) Refills:2 9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 10. Morphine Sulfate 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q8H (every 8 hours). Disp:4 Tablet Sustained Release(s) Refills:2 11. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 12. Oxandrolone 2.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times day). Disp:240 Tablet(s) Refills:2 13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QD (once day). Disp:30 Capsule(s) Refills:2 14. Salmeterol Xinafoate 50 mcg/Dose Disk Device Sig: One (1) Disk Device Inhalation Q12H (every 12 hours): (50 mcg) 2 INH IH Q12H . Disp:60 Disk Device(s) Refills:2 15. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QD (once day). Disp:30 Tablet(s) Refills:2 16. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 17. Amphotericin B 50 mg Recon Soln Sig: One (1) Recon Soln Injection QID (4 times day): DOSE: 20 mg. Disp:120 Recon Soln(s) Refills:2 18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. Disp:30 Tablet(s) Refills:0 20. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:1 30 Refills:2 21. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO QD (once day). Disp:30 Tablet(s) Refills:2 22. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once day). Disp:60 Tablet(s) Refills:2 23. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times day) needed. Disp:15 ML(s) Refills:0 24. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO bedtime. Disp:45 Tablet(s) Refills:2 25. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) injection 0.8 ML Subcutaneous Q12H (every 12 hours) 4 days. Disp:8 injection 0.8 ML Refills:0 26. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO four times day needed pain 7 days. Disp:20 Tablet(s) Refills:0 27. Outpatient Lab Work Please obtain INR value [2161-9-6] 28. Cefepime HCl 2 g Piggyback Sig: One (1) Piggyback Intravenous Q12H (every 12 hours) 10 days. Disp:20 Piggyback(s) Refills:0 29. Please continue procrit administration prior hospitalization. Normally given every Tuesday. 30. instruction Please take pentamadine prior hospitalization. (dose provided hospital [8-28]) 31. Outpatient Lab Work Please obtain INR outpatient. Please send results Dr. [Last Name (STitle) 2148] 32. Oxygen Oxygen 2L via nasal cannual PRN dyspnea 33. oxygen 2 liters continuous Discharge Disposition: Home Service Facility: Staff Builders-TLC-[Location (un) 1456] Discharge Diagnosis: PNA Discharge Condition: stable Discharge Instructions: Please return experience increasing shortness breath, chest pain pressure Please continue procrit pentamadine prior hospitalization. Followup Instructions: Follow Dr. [Last Name (STitle) 2148] within 2 weeks. ([Telephone/Fax (1) 457]) Appointment made Tuesday 3:00 pm. Provider UROLOGY UNIT Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 164] Date/Time:[2161-9-23] 9:00 Provider [First Name11 (Name Pattern1) 610] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2161-9-28] 1:15 [Name6 (MD) ] [Last Name (NamePattern4) 15242] MD, [MD Number(3) 15243]	[ "486", "40391", "4280", "5849" ]
Admission Date: [2108-3-8] Discharge Date: [2108-3-16] Date Birth: [2047-10-22] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: CP fatigue Major Surgical Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->OM, PDA) [2108-3-12] History Present Illness: 60 y/o WF exertional angina increased rest. underwent cardiac cath [Hospital3 6101] [2108-3-8] revealed 50-60% LM stenosis, 100% RCA transferred [3-8] cardiac surgery. Past Medical History: CAD s/p MI PVD OA s/p cardiac thrombus obesity s/p carotid->carotid bypass s/p TAH ^chol. Social History: Lives husband. [Name (NI) 1403] computer operator. Cigs: 20-30 pk. yr., quit [2094] ETOH: denies Family History: F died MI age 53, brother +CAD Physical Exam: WDWNWF NAD AVSS HEENT: NC/AT, PERLA, oropharynx benign Neck: FROM, supple, carotids without bruit Lungs: Clear A+P CV: RRR without R/G/M Abd: +BS, soft, nontender, without masses hepatosplenomegaly, obese Ext: without C/C/E, pulses Fem: 2+ bil., DP: 1+ bil., PT: 1+ bil., Rad: 2+ bil. Neuro: nonfocal Pertinent Results: [2108-3-16] 03:27AM BLOOD WBC-8.3 RBC-3.38* Hgb-10.3* Hct-30.4* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.7 Plt Ct-144* [2108-3-15] 08:44PM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1 [2108-3-16] 03:27AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-138 K-4.3 Cl-101 HCO3-29 AnGap-12 RADIOLOGY Final Report CHEST (PORTABLE AP) [2108-3-13] 4:17 PM CHEST (PORTABLE AP) Reason: eval ptx s/p ct d/c [Hospital 93] MEDICAL CONDITION: 60 year old woman s/p CABG REASON EXAMINATION: eval ptx s/p ct d/c CHEST, AP PORTABLE SINGLE VIEW INDICATION: Status post bypass surgery. Discontinued lines extubated. Evaluate pneumothorax. FINDINGS: AP single view chest obtained patient sitting semi-upright position analyzed direct comparison next preceding chest examination [2108-3-12]. interval, patient extubated, NG tube removed. holds Swan-Ganz catheter sheath replaced central venous line seen terminate overlying SVC level 2 cm carina. pneumothorax developed, new infiltrates seen. _____ previous examinations, noted parenchymal densities upper lobe areas resolved. interpreted representing edema. IMPRESSION: Satisfactory chest findings instrument removal, evidence pneumothorax. DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 6102], [Known firstname ] [Hospital1 18] [Numeric Identifier 6103] (Complete) Done [2108-3-12] 1:31:43 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2047-10-22] Age (years): 60 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Shortness breath. ICD-9 Codes: 786.05, 786.51, 440.0 Test Information Date/Time: [2108-3-12] 13:31 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler color Doppler Test Location: Anesthesia West cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% 55% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Findings LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. catheter pacing wire seen RA extending RV. ASD 2D color Doppler. LEFT VENTRICLE: Wall thickness cavity dimensions obtained 2D images. Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size free wall motion. AORTA: Simple atheroma ascending aorta. Simple atheroma aortic arch. Complex (>4mm) atheroma descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. patient received antibiotic prophylaxis. TEE probe passed assistance anesthesioology staff using laryngoscope. TEE related complications. patient. Conclusions PRE-CPB:1. left atrium mildly dilated. left atrial appendage thrombus cannot excluded. atrial septal defect seen 2D color Doppler. 2. Left ventricular wall thicknesses normal. left ventricular cavity size normal. mild regional left ventricular systolic dysfunction anterior mid apical hypokinesis. 3. . Right ventricular chamber size free wall motion normal. 4. simple atheroma ascending aorta. simple atheroma aortic arch. complex (>4mm) atheroma descending thoracic aorta. 5. three aortic valve leaflets. aortic valve leaflets mildly thickened. aortic valve stenosis. Trace aortic regurgitation seen. 6. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. 7. trivial/physiologic pericardial effusion. POST-CPB: infusion phenylephrine. Episode transient RV dysfunction secondary air visible RCA. Epi 8-10 mcg given prompt resolution. Preserved biventricular systolic function. Trace MR. Aortic contour normal post decannulation. certify present procedure compliance HCFA regulations. Electronically signed [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2108-3-12] 16:17 Brief Hospital Course: patient transferred [Hospital6 5016] [3-8]. preop vascular evaluation regarding previous carotid surgery cleared. Carotid doppler showed patent graft. [2108-3-12] underwent CABGx3(LIMA->LAD, SVG->OM, PDA). cross-clamp time 50 mins., total bypas time 66 mins. tolerated procedure well transferred CVICU stable condition Neo Propofol. extubated post op night continued progress. neo eventually weaned off. chest tubes d/c'd POD#1 wires d/c'd POD#3. continued progress discharged home stable condition POD#4. Medications Admission: Metformin 1000 mg PO BID Avandia 4 mg PO daily Fosamax 70 mg PO q week Verapamil SR 240 mg PO BID Lipitor 80 mg PO daily Isordil 140 mg PO TID Toprol XL 25 mg PO daily Lisinopril 10 mg PO daily Folic acid 1 mg PO daily ASA 81 ng PO daily Nitro spray PRN Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours needed pain. Disp:50 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 7 days. Disp:14 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times day) 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 9. Rosiglitazone 8 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO week. Disp:4 Tablet(s) Refills:2 Discharge Disposition: Home Service Facility: [Company 1519] Discharge Diagnosis: CAD PVD OA s/p MI s/p cardiac thrombus obesity ^chol. Discharge Condition: Good Discharge Instructions: Follow medications discharge instructions. drive 4 weeks. lift 10 lbs. 2 months. Shower daily, let water flow wounds, pat dry towel. use creams, lotions, powders wounds. Call office sternal drainage, temp>101.5 Followup Instructions: Make appointment Dr. [Last Name (STitle) 6104] 1-2 weeks. Make appointment Dr. [Last Name (STitle) 4783] 2-3 weeks. Make appointment Dr. [Last Name (STitle) ] 4 weeks. Wound check [Hospital Ward Name 121] 6 [3-26] 11AM. Call [Telephone/Fax (1) ] changes. Completed by:[2108-3-16]	[ "41401", "412", "2720", "25000", "4019", "2859", "V1582" ]
Admission Date: [2143-7-6] Discharge Date: [2143-7-20] Date Birth: [2073-7-21] Sex: F Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 2736] Chief Complaint: Shortness breath, nausea Major Surgical Invasive Procedure: cardiac cath [2143-7-15] cardiac cath [2143-7-18] cardiac biopsy [2143-7-18] History Present Illness: 69 y/o w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF EF 30-35% w/ significant LVH, recent NSTEMI, presented generalized weakness, mild confusion, nausea vomitting. discharged [Hospital 26580] hospital admitted [Date range (3) 54882]. Per obtained discharge summary, presented progressive SOB LE edema ruled NSTEMI trop 0.38, 0.48, 0.98. subsequently cardiac cath completed [2143-7-1] showed mid LAD 40% stenosis, mid Lcx 99% unfavorable total occlusion, rPDA 40% stenosis, pulmonary hypertension, mod-severe MR, depressed LVEF ~45% LVH. TEE better evaluate MR [2143-7-2] showed 3+ MR [First Name (Titles) 15015] [Last Name (Titles) ] hitting back wall probably mild mitral stenosis LVEF 30-35% dilated atria b/l, elevated wedge pressure significant LVH. diuresed lasix (-10L per patient), started metoprolol losartan. discharged lasix 100mg [Hospital1 ] reports improvement SOB edema diuresis throughout hospital stay. . Upon discharge home, initially feeling well, became weak, SOB LE persisted may slightly worsened. reported weight gain. PND, +orthopnea (sleeps w/ 2 pillows nightly). morning admission became nauseous vomitted ~5 times (bilious w/ food non-bloody), unable take POs thus re-presented [Hospital1 46]. Per cardiologist Dr. [Last Name (STitle) 3321], transferred [Hospital1 18] cardiac MRI evaluation MV repair/replacement. . OSH, A&O x3, vitals prior transfer afebrile, HR 74 BP 86/61, 20 99% 4L. Upon arrival floor mild SOB c/o LE edema. Nausea/vomitting much improved. feeling "spacy" earlier, feels lucid. Feels generalized weakness. Denies F/C, HA, vision changes, cough, CP, palpitations, abd pain, diarrhea, constipation, melena, hematochezia, dysuria hematuria. Past Medical History: Recent NSTEMI admitted [Hospital 26580] hosp [Date range (1) 54883] CATH: [2143-7-1]: LMCA normal, mid LAD 40% stenosis, mid Lcx 99% unfavorable total occlusion, rPDA 40% stenosis, pulmonary hypertension, mod-severe MR, depressed EF ~45% CABG: none HTN DM2 systolic diastolic CHF Peripheral vascular disease COPD - home O2 B12 deficiency Hypothyroidism H/o DVT [2142-10-8] - coumadin Insominia Osteoporosis cholecystectomy hysterectomy appendectomy h/o thyroidectomy parathyroidectomy exploratory laporotomy [2142-10-8] (for possible gut ischemia none seen) h/o diverticulitis s/p partial colectomy w/ temp colostomy reanastamosis Social History: lives w/ husband, independent ADL iADLs, recently walking treadmill cardiac rehab, h/o 45 pack years quit tob 10 years ago, ETOH IVDA. Family History: mother w/ CVA, known MI, HTN, malignancy DM. Physical Exam: PHYSICAL EXAM ADMISSION: VS: 98.4 100/66 85 16 98% RA 55.3kg GENERAL: NAD, A&Ox3 HEENT: PERRLA, EOMI, sclerae anicteric, oral MM dry, OP lesions. NECK: Supple, thyroid gland, JVP 13cm HEART: RRR, nl S1, nl S2, cannot appreciate murmurs LUNGS: mild crackles bilateral bases R>L, rh/wh, resp unlabored. ABDOMEN: Soft/NT/ND, rebound/guarding, +BS. EXTREMITIES: 2+ pitting edema knee b/l w/ venous stasis skin changes, decreased sensation feet b/l, callus (? non-healing ulcer) left foot plantar surface, pulses diminished DP/PT b/l, 2+ peripheral pulses UE b/l Pertinent Results: ADMISSION LABS: [2143-7-7] 06:24AM BLOOD WBC-7.2 RBC-5.83# Hgb-15.8# Hct-50.0# MCV-86# MCH-27.1# MCHC-31.6# RDW-19.1* Plt Ct-231 [2143-7-7] 06:24AM BLOOD Neuts-70.2* Lymphs-19.8 Monos-7.4 Eos-1.8 Baso-0.8 [2143-7-7] 08:40AM BLOOD PT-14.4* PTT-31.0 INR(PT)-1.2* [2143-7-7] 06:24AM BLOOD Glucose-98 UreaN-43* Creat-1.6* Na-137 K-4.0 Cl-97 HCO3-23 AnGap-21* [2143-7-7] 06:24AM BLOOD ALT-39 AST-50* LD(LDH)-364* CK(CPK)-41 AlkPhos-108* TotBili-1.1 [2143-7-7] 06:24AM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7 Calcium-9.2 Phos-5.3# Mg-2.4 Iron-PND [2143-7-7] 06:24AM BLOOD CK-MB-4 cTropnT-0.30 [2143-7-19] 01:55AM BLOOD WBC-12.1# RBC-5.63 Hgb-15.3 Hct-47.1 MCV-84 MCH-27.1 MCHC-32.4 RDW-19.4* Plt Ct-190 [2143-7-19] 10:45AM BLOOD PT-16.8* PTT-115.7* INR(PT)-1.5* [2143-7-19] 01:55AM BLOOD Glucose-119* UreaN-51* Creat-1.8* Na-130* K-4.1 Cl-91* HCO3-23 AnGap-20 [2143-7-19] 01:55AM BLOOD Calcium-9.2 Phos-5.8# Mg-2.3 [2143-7-20] 03:15AM BLOOD WBC-22.5# RBC-5.99* Hgb-16.2* Hct-51.5* MCV-86 MCH-27.0 MCHC-31.4 RDW-19.7* Plt Ct-292# [2143-7-20] 03:15AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2143-7-20] 03:15AM BLOOD PT-19.3* PTT-90.8* INR(PT)-1.7* [2143-7-20] 03:15AM BLOOD Glucose-77 UreaN-66* Creat-3.0# Na-131 K-4.8 Cl-87* HCO3-21* AnGap-28* [2143-7-20] 03:15AM BLOOD Calcium-9.5 Phos-7.0* Mg-2.3 Pertinent studies: Cardiac MRI ([2143-7-8])- 1. Normal left ventricular cavity size segmental wall motion abnormalities (see above) mildly reduced systolic function LVEF 41%. effective forward LVEF severely depressed 19%. multiple areas hyperenhancement described consistent myocardial infarction/scar. 2. Moderately severely increased LV wall thickness. 3. Severely increased LV mass index. 4. Normal right ventricular cavity size abnormal global systolic function. RVEF moderately depressed 23%. 5. Severe mitral regurgitation. leaflet tethering consistent "ischemic" (post-infarction) mitral regurgitation. 6. indexed diameters ascending descending thoracic aorta normal. indexed diameter main pulmonary artery mildly enlarged. 7. Mild right left atrial enlargement. 8. Normal coronary artery origins evidence anomalous coronary arteries. 9. note made moderate severe right pleural effusion small left pleural effusion. CXR ([2143-7-10])- Interval increase moderate right effusion associated atelectasis. New small left effusion. Spirometry ([2143-7-11])- Mild restrictive ventilatory defect severe gas exchange defect. DLCO reduced proportion reduction TLC consistent interstitial pulmonary vascular process. reduced FEV1/SVC ratio (62.4, 87% predicted) indicates coexisting obstructive ventilatory defect. prior studies available comparison. TEE ([2143-7-11])- atrial septal defect seen 2D color Doppler. mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function low normal (LVEF 50-55%). borderline normal free wall function right ventricle. complex (>4mm) atheroma descending thoracic aorta. aortic valve leaflets (3) mildly thickened aortic valve stenosis regurgitation. mitral valve leaflets structurally normal mild (1+) mitral regurgitation. tricuspid valve leaflets mildly thickened. small pericardial effusion echocardiographic signs tamponade. Dobutamine stress echo ([2143-7-12])- Resting images acquired heart rate 85 bpm blood pressure 84/60 mmHg. demonstrated near-akinesis inferior wall mild hypokinesis elsewhere (EF 35%). small pericardial effusion. Doppler demonstrated mild mitral regurgitation aortic stenosis, aortic regurgitation significant resting LVOT gradient. low dose dobutamine [5mcg/kg/min; heart rate 84 bpm, blood pressure 84/58 mmHg), failure augment systolic function inferior wall, mild augmentation segments. mid-dose dobutamine [10 mcg/kg/min; heart rate 88 bpm, blood pressure 76/50 mmHg), failure augment systolic function inferior wall, mild augmentation segments. . Cardiac cath ([2143-7-15])- 1. Two vessel coronary artery disease. 2. Moderate diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. 4. Successful PTCA stenting distal Cx BMS. . Right Heart cardiac cath ([2143-7-18]) 1. Moderately elevated biventricular pressures. 2. Severe pulmonary hypertension. 3. Depressed cardiac index. 4. Successful RV biopsy. . Cardiac biopsy [2143-7-18]: Myocardial tissue extensive amyloid deposition (confirmed [Country ] red stains) primarily subendocardial associated blood vessels. Urine culture [2143-7-20]: KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS Blood culture [2143-7-20]: Blood Culture, Routine (Final [2143-7-26]): GROWTH. Brief Hospital Course: [Known firstname ] [Known lastname ] 69 yo w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF EF 30-35% w/ significant LVH, ruled NSTEMI, 3+ MR, LVEF 30-35% dilated atria b/l, elevated wedge pressure significant [Hospital 54884] transferred [Hospital1 18] cardiac MRI evaluation MV repair/replacement, mild MR repeat TEE, s/p BMS LCx, cardiac biopsy positive cardiac amyloidosis. --For summary hospital course, please refer accept note dated [2143-7-19]. Pt transferred [Hospital1 1516], SBP 80s/50s, remained asymptomatic, ~9pm, one measurement 60s/40s, although remeasurement high 70s/50s. Pt completely asymptomatic, even sitting up, remained talkative joking MDs. 60s/40s felt due measurement error due Pt's thin body habitus, even using small adult cuff. Cardiology fellow resident consulted, felt Pt stable. Pt remained afebrile HR 70s-80s throughout. Pt discomfort pain dyspnic. O2 sat ~97% 2L nc. following morning ([7-20]) 0700, Pt found tachypnic 25 still sat 95% 2L nc. working harder breathe stated feel short breath questioned. morning lab results returned ~0830, Pt noted leukocytosis ~22k Cr jumped 3.0 1.8 day prior. Stat blood cultures, urine analysis, urine cultures, chest XR send. foley cath discontinued. started IV vancomycin cefepime. Pt never febrile, though one oral temp 35.5C ~ midnight ~36.1C four hours later. Pt never tachycardic BP remained 80s/50s, consistent prior BPs floor. Pt began feel short breath time (0830), tachypnic 30s-40s, put non-rebreather mask. looked family notified come hospital given rapidly deteriorating state. arrival family discussion Pt, still lucid, Pt decided made comfort measures exception antibiotics, declined intubation declined transfer CCU. Pt given lorazepam morphine help dyspnea, initially difficult control. Palliative care consulted recommended IV morphine, provided, Pt appeared respond. Pt became less less responsive 1300, received Eucharist 1400 expired 1440. Pt's family consented autopsy. ------------ #Acute chronic congestive heart failure: Mrs. [Known lastname ] admitted CHF likley due MR possibly secondary ischemic cardiomyopathy versus infiltrative cardiomyopathy. evidence diffuse coronary disease, significant single vessel disease (Lcx 99% stenosed) likely explain global hypokinesis. Additional contributing factors include MR (see below) diastolic dysfunction (significant LVH seen) raising suspicion potential infiltrative cardiomyopathy well. Infiltrative etiologies consider include amyloid, multiple myeloma, sarcoid, hemachromotosis, HIV myocarditis, far negative. workup far, serum protein electrophoresis, ACE, TSH, iron levels, normal. Infiltrative disease supported echo findings cardiac MRI. Given negative work-up thus far highly concerning specific cardiac amyloid without systemic involvement. Therefore patient underwent endocardial biopsy [2143-7-18]. Results biopsy consistent cardiac amyloidosis ([Country ] red stainin positive). Final stains studies still pending. Symptomatically, initially lower extremity edema, stable right lower lobe pleural effusion, inspiratory crackles exam dyspnea. initially responded well diuresis furosemide 80mg IV BID decreased 80 daily. However continued dyspnea chest xray findings consistent volume overload setting low blood pressure made diuresis difficult. HD8, patient right sided catheterization showed elevated PA PCWP pressures consistent class II pulmonary artery hypertension resulting form left ventricular overload. Following cardiac catheterization placement BMS LCx, patient transferred CCU diuresis lasix gtt pressure support initially dopamine gtt. good response diuresis changed dopamine milrinone improvement urine output. Additionally, metolazone added augment diuresis. CCU diuresed 3 L 4 days improvement respiratory status. Milrinone stopped inital maintenance blood pressure. Repeat right heart catherization [2143-7-18], done endocardial biopsy, showed continued elevation right heart pressures well persistent low cardiac index 1.28. Though still volume overloaded lasix gtt stopped due hypotension rising creatinine improvement blood pressure. plan establish home oral regimen congestive heart failure end stage patient expressed desire go home. transferred [Hospital1 1516]. . review EKG echocardiogram, noted patient left bundle branch block causing dyssynchronous rhythm. felt cardiac output may improve BiV pacing. However evaluation echocardiogram felt BiV pacing would likely helpful patients right heart dysfunction significant left heart dysfunction. #Acute Respiratory Distress: see . #Mitral regurgitation: outside hospital TEE, Pt thought moderate severe mitral regurgitation. Pt transferred cardiac MRI, showed normal left ventricular cavity size segmental wall motion abnormalities mildly reduced systolic function LVEF 41% severely depressed calculated effective forward LVEF 19%. Multiple areas hyperenhancement observed interpreted consistent myocardial infarction/scar. also moderately severely increased LV wall thickness, severely increased LV mass index, normal right ventricular cavity size abnormal global systolic function moderately depressed RVEF 23%. Also observed cardiac MRI severe mitral regurgitation leaflet tethering consistent "ischemic" (post-infarction) mitral regurgitation. Given findings, cardiac surgery consulted regarding possiblility mitral repair versus replacement suggested repeat TEE [Hospital1 18], surprisingly showed mild symmetric left ventricular hypertrophy, overall low normal left ventricular systolic function (LVEF 50-55%) structurally normal mitral valve leaflets mild (1+) mitral regurgitation. Complex (>4mm) atheroma descending thoracic aorta also observed. Pt therefore require surgery, attention re-centered known left circumflex stenosis (see below). . #Coronary artery disease: Pt diagnostic cardiac cath performed Dr. [Last Name (STitle) 3321] prior admission showing stenosis Lcx 99%, 40% mLAD, 40% r PDA unknown age, intervention time. determine whether affected areas salvagable, patient dobutamine viability echo, showed minimal viability inferior wall apparently-viable myocardium elsewhere. taken cardiac cath [2143-7-15] bare metal stent placed left circumflex artery. Catherization also showed elevated filling pressures, pulmonary HTN cardiac index 1.23. Following procedure, patient started aspirin, plavix heparin. catheterization site c/d/i bruits hematomas appreciated. Right heart catherization [7-18] demonstrated continued poor cardiac index. . #Acute kidney injury: admission creatinine noted 1.6 (1.0 discharge two days before). thought pre-renal poor kidney persusion CHF, poor PO intake nausea, recently started losartan prior admission. Losartan held admission. still volume overloaded gently diuresed. patient require additional diuresis inotropic support. started lasix gtt resultant increase creatinine. Furosemide held due decreased kidney function. . # Atrial Fibrillation: HD # 8 patient noted atrial fibrillation RVR associated nausea vomiting. initally rate controlled metoprolol. However, endocardial biopsy noted HR 130s drop systolic blood pressure 70s. given IV metoprolol fluids spontaneous conversion sinus rhythm. given PO amiodarone load started heparin drip. Given CHADS2 score 3 started warfarin. discontinued [Hospital1 1516]. . # RLL infiltrate: Patient noted possible RLL infiltrate vs atelectasis chest xray white count 12. remained afebrile noted scant sputum. X ray also showed R sided pleural effusion. Therefore felt changes likely represented atelectasis antibiotics started. . #Nausea: Pt reported significant nausea vomiting admission, given PO zofran PRN effectively controlled nausea one episode vomiting throughout remainder hospital course. Nausea always associated volume overload atrial fibrillation. . # Code Status: poor prognosis poor cardiac function cardiac amyloid discussed depth patient family. expressed understanding congestive heart disease likely end stage. additionally decided would want intubation CPR made DNR/DNI. Pt made comfort measures [7-20] expired 1440 (see above). # COPD: evidence acute exacerbation. Pt continued home albuterol tiotropium. . # Diabetes: well controlled, sliding scale # Hypothyroidism: stable home levothyroxine, TSH normal # peripheral neuropathy: stable, vicodin PRN pain Medications Admission: albuterol 1puff q4H PRN aspirin 81mg daily conjugated estrogens 1 vag application PRN furosemide 100mg [Hospital1 ] hydrocodone/acetaminophen 5/500 1-2 tabs q4H PRN levothyroxine 75mcg daily oxazepam 15-30mg qHS PRN tiotropium 18mcg daily vitamin B12 IM coumadin 1mg daily zoledronic acid administered clinic zolpidem 10mg qHS losartan 25mg daily metoprolol succinate 25mg daily KCL 20meQ daily Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Cardiac amyloidosis Congestive heart failure Coronary artery disease Secondary Diagnoses: Mild mitral regurgitation Hypothyroidism Diabetes mellitus, type 2 Chronic obstructive pulmonary disease (COPD) Discharge Condition: Pt expired [2143-7-20]. Completed by:[2143-7-28]	[ "5849", "496", "9971", "5180", "4168", "42731", "41401", "4280", "4240", "25000", "4019", "V5861" ]
Admission Date: [2172-12-5] Discharge Date: [2172-12-18] Date Birth: [2090-8-9] Sex: F Service: SURGERY Allergies: Cephalexin Hcl Attending:[First Name3 (LF) 3200] Chief Complaint: abdominal pain, SBO Major Surgical Invasive Procedure: [2172-12-6] 1. Exploratory laparotomy. 2. Small-bowel resection. 3. Ileocolic anastomosis. 4. Abdominal washout. 5. Closure abdominal wall defect. 6. post op ileus History Present Illness: 82-year-old female underwent laparoscopic robot assisted TAHBSO, LOA endometrial cancer reduction hernia [2172-11-17]. seen Acute Care service afterwards small bowel obstruction resolved conservative management. RLQ ventral hernia past nine years since right hip replacement. reduced surgery became reincarcerated post-operatively thought likely source obstruction. ultimately discharged home [2172-11-27]. returned [Hospital1 18] ED presenting OSH acute abdomen. Past Medical History: Past Medical History: asthma, HTN, chronic sinusitis, LE edema/cellulitis, laparoscopic robot assisted TAHBSO, LOA endometrial cancer ([2172-11-17]) Past Surgical History: right hip replacement ([2163]), bladder neck suspension, open appy, ovarian cystectomy, cytoscele/rectocele repair, thyroid surgery Social History: Denies smoking, alcohol, drug abuse. 20-pack-year smoker quit 20 years ago. Family History: Two sisters breast cancer. Uterine cancer youngest daughter. [Name (NI) ] history ovarian colon cancer. Physical Exam: ED: 98.7 99 122/50 18 97RA GEN: A&O, NAD, NGT place HEENT: scleral icterus, mucus membranes moist CV: RRR, M/G/R PULM: Clear auscultation b/l, W/R/R ABD: large R sided ventral hernia, minimally tender palpation, feels firm indurated, rest abdomen soft, minimally distended, rebound guarding Ext: LE edema, LE warm well perfused Pertinent Results: CT Abd/Pelvis [2172-12-5] : 1. New/increased fluid right lower quadrant hernia sac ill-defined small bowel loops mesenteric edema within sac, well increased intermesenteric fluid peritoneal cavity, raises concern bowel ischemia. Extraluminal gas hernia sac, seen previously, remote patient's surgery, perforation excluded. 2. Relative caliber change small bowel hernia neck, mildy dilated proximal bowel loops, may due early/partial obstruction. 3. Increased/new pelvic fluid appears organizing peritoneal enhancement; findings may reactive peritonitis, underlying infection excluded. 4. Unchanged postsurgical soft tissue densities urethra rectum right ischial tuberosity anus. 5. Small right renal hypodensity, small characterize study, could evaluated non-urgent ultrasound. [2172-12-5] 07:40PM WBC-20.6# RBC-3.79 HGB-11.5* HCT-34.5* MCV-91 MCH-30.4 MCHC-33.3 RDW-12.9 [2172-12-5] 07:40PM NEUTS-56 BANDS-38* LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2172-12-5] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ [2172-12-5] 07:40PM PLT SMR-NORMAL PLT COUNT-290 [2172-12-5] 07:40PM PT-15.7* PTT-25.9 INR(PT)-1.4* [2172-12-5] 07:40PM GLUCOSE-129* UREA N-30* CREAT-2.2# SODIUM-140 POTASSIUM-5.5 CHLORIDE-108 TOTAL CO2-20* ANION GAP-18 [2172-12-5] 07:45PM LACTATE-2.1* [2172-12-6] 12:28 PERITONEAL FLUID GRAM STAIN (Final [2172-12-6]): REPORTED PHONE [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 83986] @ 5:41A [2172-12-6]. 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [2172-12-10]): Due mixed bacterial types (>=3) abbreviated workup performed; P.aeruginosa, S.aureus beta strep. reported present. Susceptibility performed P.aeruginosa S.aureus sparse growth greater.. ANAEROBIC CULTURE (Final [2172-12-10]): BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2172-12-7]): Test cancelled laboratory. PATIENT CREDITED. pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis Mucormycosis strongly suspected, contact Microbiology Laboratory (7-2306). Brief Hospital Course: Mrs. [Known lastname 101374] evaluated Acute Care service Emergency Room well GYN service given recent surgery. WBC 20K CT scan demonstrated incarcerated hernia evidence ischemia exam. admitted ICU vigorous fluid resuscitation broad spectrum antibiotics. [2172-12-6] taken Operating Room underwent exploratory laparotomy repair strangulated, perforated ventral hernia. tolerated procedure well returned ICU stable condition. maintained stable hemodynamics pain well controlled IV Dilaudid. remained intubated overnight successfully weaned extubated post op day #1. Due extensive surgery nasogastric tube remained decompression bowel function returned. Following transfer Surgical floor [2172-12-9] remained stable nasogastric tube removed. taking small amount liquids next days became distended tympanic exam. stopped passing flatus KUB showed dilated large bowel. treated Methylnaltrexone immediately effective. passing flatus normal bowel movement. narcotics discontinued pain effectively managed Tylenol. diet advanced regular appetite fair. Eventually improved Carnation Instant Breakfast supplements along addition Megace. Physical Therapy service evaluated numerous occasions due prolonged hospitalization decreased mobility short term rehab recommended prior return home. dischargaed [2172-12-18]. Medications Admission: diovan 160', prevacid 30', lasix 20', ibuprofen, percocet Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO day. 7. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times day). 8. fluticasone-salmeterol 100-50 mcg/dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 9. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO Q6H (every 6 hours) needed pain. Discharge Disposition: Extended Care Facility: [Hospital3 ] home Discharge Diagnosis: Strangulated, perforated ventral hernia. . Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: Please call doctor nurse practitioner return Emergency Department following: You experience new chest pain, pressure, squeezing tightness. New worsening cough, shortness breath, wheeze. If vomiting cannot keep fluids medications. You getting dehydrated due continued vomiting, diarrhea, reasons. Signs dehydration include dry mouth, rapid heartbeat, feeling dizzy faint standing. You see blood dark/black material vomit bowel movement. You experience burning urinate, blood urine, experience discharge. Your pain improving within 8-12 hours gone within 24 hours. Call return immediately pain getting worse changes location moving chest back. You shaking chills, fever greater 101.5 degrees Fahrenheit 38 degrees Celsius. Any change symptoms, new symptoms concern you. Please resume regular home medications , unless specifically advised take particular medication. Also, please take new medications prescribed. Please get plenty rest, continue ambulate several times per day, drink adequate amounts fluids. Avoid lifting weights greater [5-18] lbs follow-up surgeon. Avoid driving operating heavy machinery taking pain medications. Incision Care: Please call doctor nurse practitioner increased pain, swelling, redness, drainage incision site. Avoid swimming baths follow-up appointment. You may shower, wash surgical incisions mild soap warm water. Gently pat area dry. * staples removed rehab. Followup Instructions: Call Acute Care Clinic [Telephone/Fax (1) 600] follow appointment [2-12] weeks. Completed by:[2172-12-18]	[ "0389", "51881", "99592", "49390", "4019", "53081", "2724", "V1582" ]
Admission Date: [2126-9-15] Discharge Date: [2126-9-17] Date Birth: [2094-11-20] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Headache Major Surgical Invasive Procedure: Conventional Cerebral Angiogram History Present Illness: pt 31 year-old right-handed woman G3P3 post-partum day 7, presents sudden onset severe headache starting 3am. reports recent pregnancy complicated GBS positive, developing temperature 100.8. According husband, concern baby's HR, induced time. excessive bleeding, otherwise uncomplicated delivery [9-6]. [9-10] reports developing sore throat mild exudate tonsils. saw PCP [Last Name (NamePattern4) ] [9-11], reportedly tested negative strep. symptoms sore throat improved, feeling better 3am [9-14]. reports awoke headache, initially [6-23], escalated [11-23] within 30 minutes. accompanied photo phonophobia, well nausea vomiting. notes movement tended make symptoms worse. took Motrin 2 Excedrin relief, around 9:30am called PCP. [Name10 (NameIs) ] told try caffeine, see improved symptoms, not, come ED evaluation. ED given Dilaudid Compazine, improved symptoms, hydralazine elevated blood pressure. adult, headaches every months described throbbing. Usually headaches behind left eye. nausea, vomiting, photophobia, phonophobia, autonomic symptoms headaches. HA start gradually. respond well Motrin Excedrin. first cousin migraines family member migraines. [Known firstname 26317] one headache second trimester throbbing associated photophobia. notes increased frequency headaches pregnancies severe one described second trimester. denies neck stiffness, rash, confusion. diplopia blurred vision. reports able produce small amount milk, primarily giving child formula. similar things prior pregnancies. general review systems, pt denies recent fever chills. night sweats recent weight loss gain. Denies cough, shortness breath. Denies chest pain tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation abdominal pain. recent change bowel bladder habits. dysuria. Denies arthralgias myalgias. Denies rash. Past Medical History: - Hypothyroidism - Anemia Social History: patient lives [Location 2251] husband children. currently stay-at-home Mom, used work director Multicultural affairs local [Location (un) ]. EtOH, smoking illicits. Family History: Heart disease maternal side, DM paternal side. Physical Exam: Vitals: P:52 R: 16 BP:164/62 SaO2: 95% RA General: Awake, cooperative, NAD. HEENT: NC/AT, scleral icterus noted, MMM, lesions noted oropharynx Neck: Supple, carotid bruits appreciated. nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, masses organomegaly noted. Extremities: C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: rashes lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able relate history without difficulty. Attentive, able name [Doctor Last Name 1841] backward without difficulty. Language fluent intact repetition comprehension. Normal prosody. paraphasic errors. Pt. able name high low frequency objects. Able read without difficulty. Speech dysarthric. Able follow midline appendicular commands. Pt. able register 3 objects recall [4-16] 5 minutes. pt. good knowledge current events. evidence apraxia neglect. -Cranial Nerves: I: Olfaction tested. II: PERRL 3 2mm brisk. VFF confrontation. Funduscopic exam revealed papilledema, exudates, hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact light touch. VII: facial droop, facial musculature symmetric. VIII: Hearing intact finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength trapezii SCM bilaterally. XII: Tongue protrudes midline. -Motor: Normal bulk, tone throughout. pronator drift bilaterally. adventitious movements, tremor, noted. asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: deficits light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. extinction DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor bilaterally. -Coordination: intention tremor, dysdiadochokinesia noted. dysmetria FNF HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride arm swing. Able walk tandem without difficulty. Romberg absent. Pertinent Results: Admission Labs: PT-11.8 PTT-29.9 INR(PT)-1.0 PLT COUNT-354 NEUTS-56.8 LYMPHS-38.5 MONOS-3.3 EOS-0.6 BASOS-0.7 WBC-5.9 RBC-4.88 HGB-12.2 HCT-39.4 MCV-81* MCH-25.0* MCHC-31.0 RDW-14.4 URIC ACID-6.3* ALT(SGPT)-167* AST(SGOT)-89* ALK PHOS-102 TOT BILI-0.3 GLUCOSE-83 UREA N-10 CREAT-1.0 SODIUM-144 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-17 ALT(SGPT)-128* AST(SGOT)-49* ALK PHOS-92 [2126-9-14] 03:00PM URINE RBC-[4-18]* WBC-[4-18] BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2126-9-15] 12:57AM CEREBROSPINAL FLUID (CSF) WBC-17 RBC-[Numeric Identifier 47655]* POLYS-83 LYMPHS-14 MONOS-3 CEREBROSPINAL FLUID (CSF) WBC-4 RBC-[Numeric Identifier ]* POLYS-60 LYMPHS-34 MONOS-4 ATYPS-2 CEREBROSPINAL FLUID (CSF) PROTEIN-253* GLUCOSE-74 ALBUMIN-3.9 LIPASE-76* CT HEAD W/O CONTRAST Study Date [2126-9-14] 2:52 PM Diffuse sulcal effacement involving right posterior frontal parietal regions. Differential considerations include subacute subarachnoid hemorrhage focal meningitis. MRI recommended assessment. MR HEAD W & W/O CONTRAST Study Date [2126-9-14] 8:46 PM 1. Areas negative susceptibility enhancement cerebral sulci right frontal parietal lobes, raises possibility hemorrhage, without superimposed inflammation/infection related cerebritis meningitis. acute infarction. 2. Associated cerebral edema involving right cerebral hemisphere described above. 3. mass effect. 4. Patent major intracranial arteries without obvious evidence aneurysm. 5. Consultation interventional neuroradiology/neurosurgery, evaluation necessary, conventional angiogram considered, performing non-contrast CT head study, document presence hemorrhage. 6. Patent major dural venous sinuses. Evaluation cortical veins limited present study. Correlation clinical neurological examination LP also considered given imaging findings above. CTA HEAD W&W/O C & RECONS Study Date [2126-9-15] 2:50 1. Evidence high attenuation right-sided cerebral sulci, relate hemorrhage enhancement prior gadolinium administration, may relate leptomeningeal enhancement related cerebritis meningitis. Effacement cerebral sulci associated edema right side, seen prior study. 2. Patent major intra- extra-cranial arteries without focal flow-limiting stenosis, occlusion, aneurysm. 3 Prominent nasopharyngeal soft tissues, tonsils, correlated direct visualization, narrowing oropharynx. Mild right maxillary sinus disease. 4. Heterogeneous thyroid- non-emergent ultraosund considered. Conventional Angiogram [9-16]: (prelim impression Dr. [Last Name (STitle) ] Mild beading multiple distal vessels right MCA territory. aneurysm dissection vascular malformation seen. Brief Hospital Course: Ms. [Known lastname ] 31 year-old G3P3 woman history hypothyroidism delievered baby [9-6] [9-14] onset severe bifrontal headache, associated photo- phonophobia, nausea vomiting, period 30 minutes. arrival, patient's exam notable hypertension. felt normal cognition, mild photophobia, meningismus. Laboratory results remarkable elevated LFTs (normal [9-3]), normal platelets. CT brain suggestive small right frontal, parietal, temporal subarachnoid hemorrhage. LP consistent subarachnoid hemorrhage ([Numeric Identifier ] RBCs Tube 4). initially admitted ICU/Neurosurgery service monitoring. underwent conventional angiogram show aneurysm AVM. hemodynamically neurologically stable therefore transferred neurology floor. Given improvement symptoms lack findings neurologic exam, discharged plans follow-up stroke clinic. felt patient's presentation consistent post partum cerebral angiopathy (otherwise known Call [Doctor Last Name 8271] syndrome). Much less likely would thrombosis small cortical vein leading right-sided subarachnoid hemorrhage. started verapamil SR 180mg daily prevent vasospasm SAH. given Keppra 500mg [Hospital1 ] seven days, Keppra 500mg daily three days, instructed stop [Doctor Last Name (ambig) 13401]. [Known firstname 26317] told drive, bath tub herself, bath children tub herself, climb next month. instructed refrain strenuous physical activity three months (should lift objects 20lbs.) time discharge, RF, CRP, ESR well ANCA, [Doctor First Name ], Homocystine, Protein C, ACA pending. Medications Admission: - Levothyroxine - Iron Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:30 Capsule(s) Refills:2 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. Disp:5 Tablet(s) Refills:0 3. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:3 4. counter fiber supplement constipation. Use directed. 5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice day 7 days: take two tablets day seven days, take one tablet daily three days, off. Disp:17 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Post-partum cerebral angiopathy (Call-[Doctor Last Name 8271] Syndrome) Subarachnoid hemorrhage Migraine headaches. Discharge Condition: Normal neurological examination Discharge Instructions: admitted severe headache found small amount bleeding top brain subarachnoid space. likely due abnormal narrowing blood vessels related pregnancy history migraines. normal neurological examination. condition expected improve taking verapamil indicated. refrain strenuous physical activity three months. Please avoid driving, tub bathing, swimming alone activity may injure others suddenly lose consciousness two weeks. Please return emergency room experience new different nature headaches. Difficulty speaking, visual loss, numbness, tingling weakness concerning symptoms. Followup Instructions: Please see Dr. [Last Name (STitle) ] Wednesday, [2126-10-2] 4pm stroke neurology division [Hospital1 ]. Office located [Hospital Ward Name 516] [Hospital Ward Name 23] Building, [Location (un) 858]. Completed by:[2126-9-17]	[ "2449", "2859" ]
Admission Date: [2130-3-26] Discharge Date: [2130-4-4] Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: chest pain Major Surgical Invasive Procedure: [2130-3-29] 1. Coronary artery bypass grafting x5 left internal mammary artery left anterior descending artery reverse saphenous vein graft posterior descending artery sequential reverse saphenous vein graft first second obtuse marginal artery reverse saphenous vein graft diagonal artery Y-grafted sequential vein graft. 2. Aortic valve replacement 23-mm St. [Male First Name (un) 923] Epic tissue valve. 3. Left atrial appendage resection. [2130-3-30] re-exploration mediastinum History Present Illness: 88 year old male admitted [Hospital 5279] Hospital ACS [Date range (1) 85977]. Cardiac catheterization time revealed coronary artery mitral regurgitation. transferred [Hospital1 69] surgical evaluation. Past Medical History: Atrial fibrillation NSTEMI [2-15] Vertebral fx([2063]) Macular degeneration/legally blind [Doctor Last Name 9376] syndrome Benign Prostatic Hypertrophy Hypertension Bilateral knee arthritis Social History: Lives alone Occupation: retired dairy farmer historic house restorer Tobacco: remote-quit many years ago, previously smoked 1ppd ETOH:[1-11] glasses wine/week Family History: Brother-afib heart failure; father sister CVA Physical Exam: Pulse: 65 Resp: 14 O2 sat: B/P Right: 130/60 Height: 5'6" Weight:163lbs. General: Skin: Dry [x] intact [x] Old well-healed incision across left abdomen HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur II/VI SEM across pre-cordium Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities:[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 Right:- Left:- Pertinent Results: [2130-4-4] 05:50AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.4* Hct-30.6* MCV-89 MCH-30.3 MCHC-34.0 RDW-15.4 Plt Ct-162 [2130-3-26] 02:43PM BLOOD WBC-6.6 RBC-3.78* Hgb-11.7* Hct-33.9* MCV-90 MCH-30.8 MCHC-34.4 RDW-13.9 Plt Ct-218 [2130-4-4] 05:50AM BLOOD Plt Ct-162 [2130-4-4] 05:50AM BLOOD PT-17.8* INR(PT)-1.6* [2130-3-26] 02:43PM BLOOD Plt Ct-218 [2130-3-26] 02:43PM BLOOD PT-18.3* PTT-40.7* INR(PT)-1.7* [2130-4-4] 05:50AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-13 [2130-3-26] 02:43PM BLOOD Glucose-91 UreaN-25* Creat-1.2 Na-136 K-4.3 Cl-96 HCO3-29 AnGap-15 [2130-3-26] 02:43PM BLOOD ALT-21 AST-20 LD(LDH)-225 CK(CPK)-189 AlkPhos-101 Amylase-62 TotBili-1.3 [2130-3-26] 02:43PM BLOOD Lipase-29 [2130-3-26] 02:43PM BLOOD cTropnT-0.04* [2130-4-4] 05:50AM BLOOD Mg-2.1 [2130-4-1] 02:52AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1 [2130-3-27] 02:52AM BLOOD %HbA1c-5.9 eAG-123 Final Report CHEST RADIOGRAPH INDICATION: Status post CABG, evaluation interval change. COMPARISON: [2130-4-1]. FINDINGS: compared previous radiograph, lung volumes increased. Small bilateral pleural effusions. Moderate cardiomegaly. pulmonary edema. right venous introduction sheath removed. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: SUN [2130-4-2] 4:40 PM Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 6.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 7.5 cm <= 5.2 cm Right Atrium - Four Chamber Length: 8.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.1 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 60% 65% >= 55% Left Ventricle - Stroke Volume: 72 ml/beat Left Ventricle - Cardiac Output: 4.99 L/min Left Ventricle - Cardiac Index: 2.72 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 10 < 15 Aorta - Sinus Level: 2.5 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: 3.1 cm <= 3.0 cm Aortic Valve - Peak Velocity: 3.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 30 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 21 mm Hg Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 1.0 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - E Wave deceleration time: 170 ms 140-250 ms TR Gradient (+ RA = PASP): 39 41 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Marked LA enlargement. LEFT VENTRICLE: Normal LV wall thickness, cavity size regional/global systolic function (LVEF >55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter sinus level. Normal ascending aorta diameter. Mildly dilated aortic arch. AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve leaflets. Moderate (area 1.0-1.2cm2) MITRAL VALVE: Mildly thickened mitral valve leaflets. MVP. Mild mitral annular calcification. Mild thickening mitral valve chordae. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PS. Physiologic PR. PERICARDIUM: pericardial effusion. GENERAL COMMENTS: rhythm appears atrial fibrillation. Conclusions left atrium markedly dilated. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). right ventricular cavity mildly dilated normal free wall contractility. aortic arch mildly dilated. number aortic valve leaflets cannot determined. aortic valve leaflets moderately thickened. moderate aortic valve stenosis (valve area 1.0-1.2cm2). mitral valve leaflets mildly thickened. mitral valve prolapse. Trivial mitral regurgitation seen. Moderate severe [3+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. pericardial effusion. IMPRESSION: Moderate aortic stenosis. Preserved regional global biventricular systolic function. Moderate severe tricuspid regurgitation. Moderate pulmonary hypertension. Electronically signed [First Name8 (NamePattern2) ] [Name8 (MD) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2130-3-28] 16:54 Brief Hospital Course: Transferred [Doctor First Name 5279] NH [3-26] surgery. required IV heparin NTG pre-operatively. Pre-operative workup completed underwent surgery [3-29] Dr. [Last Name (STitle) ]. Transferred CVICU stable condition titrated epinephrine, phenylephrine, propofol drips. developed tamponade returned re-exploration following morning [3-30]. Extubated later afternoon without complications. Coumadin restarted Atrial fibrillation. Transferred floor POD #3 begin increasing activity level. Chest tubes pacing wires removed per protocol. Gently diuresed toward preop weight. urinary retention required foley reinsertion discharged foley rehab ampicillin foley removed. ready discharge rehab [4-4]. discharged rehab Pleasantview [Location (un) ] [Location (un) 3844]. Medications Admission: Aspirin 81 daily Lasix 40 daily Lisinopril 10 daily Metoprolol XL 50 daily Ocuvite Macrobid 100 daily Simvastatin 20 daily Flomax 0.4 QHS Nitroglycerin-prn Coumadin Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice day. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed pain. Disp:50 Tablet(s) Refills:0 7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO day: due INR check [4-6] - goal INR 2.0-2.5 dose adjusted based lab results . 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 9. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) 5 days: foley removed . 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times day): continue twice day 10 days decrease day . 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): twice day lasix 10 days decrease day . 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Outpatient Lab Work please check cr/bun, potassium, magnesium twice week twice day lasix Discharge Disposition: Extended Care Facility: Pleasant View Discharge Diagnosis: aortic stenosis coronary artery disease PMH: Afib(coumadin), Vertebral fx([2063]), Macular degeneration/legally blind, [Doctor Last Name 9376] syndrome, Benign Prostatic Hypertrophy, Coronary Artery Disease, Hypertension, Bilat knee arthritis Discharge Condition: Alert oriented x3 nonfocal gait * Sternal pain managed oral analgesics Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming, look incisions Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month follow surgeon lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] * Target INR 2.0-2.5 Fib; first blood draw rehab transfer please. Followup Instructions: Please call schedule appointments Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] Wed [4-19] @ 1:15 PM- please reschedule rehab still receiving high-level care Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] F. [Telephone/Fax (1) 85978] 6 weeks Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 55499] 4 weeks Please call cardiac surgery need arises evaluation readmission hospital [Telephone/Fax (1) 170] Completed by:[2130-4-4]	[ "41401", "5990", "4241", "42731", "4019", "4168", "V5861" ]
Admission Date: [2126-5-31] Discharge Date: [2126-6-7] Date Birth: [2046-7-15] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: right pelvic/femur fracture Major Surgical Invasive Procedure: [2126-5-31] ORIF right subtrochanteric hip fracture intramedullary nail History Present Illness: Ms. [Known lastname 48639] 79 year-old lady developmental delay transferred group home attending day care (lives primarily brother, [Doctor First Name ] due hip pain found right pelvic/femur fracture. Initially reported "found down" history gathered seems found seated table, poorly interactive, screaming/crying, tremulous (versus shaking). patient's brother corroborates saying told may seizure - unaware fall report. brought outside hospital first CT head negative pelvic x-ray showed pubic ramus fracture. unable give good history. denied pain. point, OSH transferred [Hospital1 18] orthopedic evaluation. ED, initial vs 5 98.1 80 98/52 18 98% 2L Nasal Cannula. Trauma exam included rectal exam without blood. CT torso showed signs trauma "evidence aspiration" given Levofloxacin/Metronidazole. admitted Medicine management. transfer floor, VS 99.1, 97, 24, 121/62, 100%. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. 10-system review negative detail. Past Medical History: developmental delay HTN arthritis Social History: Lives brother [Name (NI) ] [Location (un) 5503], Attends day care group home smoking, alcohol illicits Family History: non-contributory Physical Exam: ADMISSION EXAM VS: 98.5, 114/62, 99, 20, 99% 2L NC GEN: Alert, oriented, acute distress HEENT: NCAT MMM EOMI sclera anicteric, OP clear NECK: supple, JVD, LAD PULM: Good aeration, CTAB wheezes, rales, ronchi CV: RRR normal S1/S2, mrg ABD: soft NT ND normoactive bowel sounds, r/g EXT: WWP 2+ pulses palpable bilaterally, c/c/e NEURO: CNs2-12 intact, motor function grossly normal SKIN: ulcers lesions . DISCHARGE EXAM VS: 98.9-99.4, 118-123/63-66, 65-71, 18, 98-99%RA BM: none I/Os: poor PO intake, UOP recorded incontinent GEN: Alert, oriented, acute distress HEENT: NCAT MMM EOMI sclera anicteric, OP clear NECK: supple, JVD, LAD PULM: Good aeration, CTAB wheezes, rales, ronchi CV: RRR normal S1/S2, mrg ABD: soft NT ND normoactive bowel sounds, r/g EXT: WWP 2+ pulses palpable b/l, dressing right lateral thigh/pelvis - c/d/i, non-tender palpation, patient left hip legs slightly bent, asking legs straightened. Pertinent Results: ADMISSION LABS: [2126-5-31] 02:50AM BLOOD WBC-12.9* RBC-4.34 Hgb-12.5 Hct-37.1 MCV-86 MCH-28.8 MCHC-33.7 RDW-14.0 Plt Ct-125* [2126-5-31] 02:50AM BLOOD Neuts-91.5* Lymphs-6.0* Monos-1.9* Eos-0.3 Baso-0.2 [2126-5-31] 02:50AM BLOOD PT-13.7* PTT-26.7 INR(PT)-1.3* [2126-5-31] 02:50AM BLOOD Glucose-215* UreaN-19 Creat-0.8 Na-142 K-4.1 Cl-104 HCO3-20* AnGap-22* [2126-5-31] 02:50AM BLOOD ALT-26 AST-42* AlkPhos-110* TotBili-0.5 [2126-5-31] 02:50AM BLOOD Albumin-3.8 [2126-6-1] 05:01AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.7 DISCHARGE LABS: [2126-6-5] 06:22AM BLOOD WBC-6.8 RBC-3.68* Hgb-11.0* Hct-32.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-160# [2126-6-4] 07:30AM BLOOD Glucose-88 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-107 HCO3-27 AnGap-9 PERTINENT LABS: [2126-5-31] 06:24AM BLOOD Lactate-6.2* [2126-5-31] 06:47AM BLOOD Lactate-7.7* [2126-5-31] 07:18AM BLOOD Lactate-4.8* [2126-5-31] 11:57PM BLOOD Lactate-3.6* [2126-5-31] 02:50AM BLOOD cTropnT-<0.01 [2126-5-31] 11:35PM BLOOD cTropnT-<0.01 [2126-6-1] 05:01AM BLOOD cTropnT-<0.01 MICRO DATA: [2126-5-31] 05:55AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]->1.050* [2126-5-31] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2126-5-31] 05:55AM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [2126-6-2] BLOOD CULTURE x2 NEGATIVE [2126-6-2] URINE CULTURE - NEGATIVE [2126-5-31] BLOOD CULTURE x2 [FINAL RESULT PENDING] [2126-5-31] URINE CULTURE - NEGATIVE EKG [2126-5-31]: Sinus rhythm. Possible right ventricular hypertrophy. Modest ST-T wave changes non-specific. previous tracing available comparison. CT C-SPINE W/O CONTRAST [2126-5-31]: fractures. Multilevel degenerative changes. CT ABD/PELVIS W/CONTRAST [2126-5-31]: 1. Comminuted right intertrochanteric, left acetabular, left ischial, left sacral fractures. 2. Mixed density right upper lobe nodule. Recommend 6-month followup chest CT. 3. Probable pulmonary hypertension. 4. Probable cystitis, correlate urinalysis. 5. 2.6-cm right adnexal cyst. Recommend non-emergent pelvic ultrasound evaluation. 6. Nonspecific liver renal hypodensities. Recommend non-emergent abdominal ultrasound. CXR [2126-5-31]: acute intrathoracic process radiographic evidence injury. Please refer subsequent CT torso details, including small right apical lung nodules. BILATERAL HIP X-RAYS [2126-5-31]: 1. Comminuted right intertrochanteric fracture. 2. Fractures left acetabulum ischium. 3. Severe bilateral hip right knee osteoarthritis. LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT O.R. [2126-5-31]: Images show placement metallic fixation device fracture proximal femur. information gathered operative report. HIP UNILAT MIN 2 VIEWS RIGHT O.R. [2126-5-31]: Images show placement metallic fixation device fracture proximal femur. information gathered operative report. EKG [2126-6-1]: Sinus rhythm. Short P-R interval. Left axis deviation, consider left anterior fascicular block. Intraventricular conduction delay right bundle-branch block type. Since previous tracing [2126-5-31], rate faster, ST-T wave abnormalities prominent. RUQ ULTRASOUND [2126-6-4]: Focal liver lesions seen recent CT correspond simple hepatic cysts. liver otherwise normal appearance showing signs cirrhosis splenomegaly. extrahepatic common bile duct dilatation also noted, could age-related ectasia, clinical correlation recommended. CT HEAD W/O CONTRAST [2126-6-4]: 1. acute intracranial process. 2. Ventriculomegaly dilation occipital horns likely due atrophy. 3. Chronic small vessel ischemic disease. MR HEAD [2126-6-5]: acute infarct seen. Ventriculomegaly proportion sulci could due normal pressure hydrocephalus proper clinical setting. Small vessel disease. Limited study due motion. MR [Name13 (STitle) ] [2126-6-5]: 1. Somewhat motion limited axial images. 2. evidence ligamentous disruption marrow edema within vertebral bodies suggest acute trauma. 3. Multilevel degenerative changes disc bulging multiple levels minimal extrinsic indentation spinal cord disc bulging C3-4 level. 4. evidence intrinsic spinal cord signal abnormalities. EEG [2126-6-4]: abnormal awake sleep EEG intermittent generalized frontally dominant bursts slowing admixed sharp features. findings indicative mild moderate diffuse encephalopathy likely related patient's history static encephalopathy. electrographic seizures present. clinical concern seizures high, 24 hour bedside EEG telemetry study recommended. Brief Hospital Course: Ms. [Known lastname 48639] 79 y/o lady w/ developmental delay presented group home right pelvic femur fracture. stay complicated brief MICU stay post-operative tachycardia hypotension (possibly due blood loss) resolved. also underwent workup possibe seizure given history obtained providers group home. discharged rehab. # Right pelvic femur fracture: s/p surgery [2126-5-31]. comminuted right intertrochanteric fracture, fracture left acetabulum ischium. s/p ORIF right subtrochanteric hip fracture intramedullary nail [5-31]. Pain well controlled Tylenol low-dose narcotics (which needed time discharge). started enoxaparin prophylaxis [5-31] continue 4 weeks (end day [6-28]). touch-down weight-bearing right leg. f/u Ortho clinic [2126-6-18]. # Mechanism fracture: unclear, possibly seizure. Though first believed fall, later clarified group home staff actually found seated table shaking (still unclear tremulous/crying shaking/seizing). Patient unable describe event. Since fall, fracture initially suspicious severe osteoporosis setting seizure versus possible elder abuse. Social Work ongoing investigations regarding elder abuse group home though felt unlikely. regards cause, seizure investigated due presentation. EEG MR imaging head performed suggestive seizure, Neurology consult felt seizure highly likely probable given history obtained. Seizure could explain high lactate presentation (~7). fellt risks antiepileptics outweighed benefits started one admission. Tramadol stopped due risk decreasing seizure threshold. follow Neurology [2126-7-15]. # Osteoporosis: clinically diagnosed. BMD scan (she clinical diagnosis osteoporosis given fracture). started calcium vitamin D; might benefit bisphosphonate therapy outpatient. inpatient imaging indicated. # Post-operative tachycardia/hypotension: requiring MICU stay, resolved. operation [5-31] noted go fast heart rhythm (HR 140's); EKG done. Labs revealed Hct drop 37.1 26.4. given Metoprolol 5mg IV. Also next hours, received liters IV fluids 2 units blood. tachycardia persisted evening developed hypotension 80's observed MICU overnight. time tachycardia hypotension resolved able return medical floor next day. Estimated blood loss 200cc possible underestimated hypovolemia. Alternately, could related fact receive home Metoprolol prior procedure causing tachycardia. Finally, etiologies considered peri-operative MI ruled EKG serial troponins. normotensive (on antihypertensive meds) tachycardia duration stay. able continued antihypertensive medication (Lisinopril) also Metoprolol. # Acute anemia: likely blood loss, Hct stable. s/p surgery 200cc blood loss, however pelvic/femur fractures bleed extensively. [5-31], Hct fell 37.1 26.4, received 2u pRBC repeat Hct 31.8. next day ([6-1]) noted Hct 25 received 2u pRBC Hct increasing 33.9. Hct stable time discharge, require transfusions. Hct 32.8 [6-5]. need Hct checks unless clinical concern bleeding. # Thrombocytopenia: unclear etiology. Four score 2 makes HIT unlikely. obvious signs cirrhosis hypersplenism. h/o ITP. signs symptoms suggest TTP. Though plt dropped 125 75, platelet level stabilized plt 160 time discharge. # Leukocytosis: resolved, low suspicion infection. WBC 12.9 presentation (neutrophil predominance, bands) signs symptoms infection (negative urinalysis urine cultures, blood cultures growth date, clear CXR). antibiotics continued admitted, leukocytosis resolved (WBC 6.8 discharge). Initial leukocytosis might represented stress response fracture. # Hypertension: controlled. Besides episode hypotension (see above) require antihypertensive medications blood pressure reasonably controlled. continued Lisinopril Metoprolol. # Developmental delay: stable, guardianship extension progress. Mental status baseline alert interactive, answering questions. family felt derived great benefit adult day program. good family support (especially brother [Doctor First Name ]. continues Donepezil. Guardianship required extension courts admission [Doctor First Name ] legal guardianship [Name (NI) ] include [Name (NI) 1501] admission clause due date originally attained on. Legal paperwork processed information shared rehab hospital. # Mixed density right upper lobe nodule: incidental finding CT. 6-month followup chest CT recommended. outpatient. # 2.6cm right adnexal cyst: incidental finding CT. Non-emergent pelvic ultrasound recommended evaluation. done outpatient. # Nonspecific liver renal hypodensities: incidental finding CT. Non-emergent abdominal ultrasound recommended, done inpatient. revealed several simple hepatic cysts mild dilation extrahepatic bile duct. # Transitional issues -Code status: Full Code -Emergency Contact: [Name (NI) ] [Name (NI) 48639] (brother): [Telephone/Fax (1) 112245] -Guardianship extension: paperwork submitted, awaiting court date currently -Dispo: rehab hospital per PT evaluation -Ongoing investigation question elder abuse group home -Pending time discharge: final result blood cultures [6-2] -Incidental findings requiring follow-up (see above): RUL lung nodule, right adnexal cyst -Lovenox duration: [Date range (1) 94218] -Patient might benefit bisphosphonate therapy -Follow-up: Ortho [2126-6-18] Neurology [2126-7-15] Medications Admission: (confirmed [Doctor First Name ], patient's brother) Donepezil 10mg daily Lisinopril 40mg daily Tramadol 50mg daily Metoprolol tartrate 100mg twice day Colace [Hospital1 ] Miralax 3350 1 packet PRN Discharge Medications: 1. Donepezil 10 mg PO HS 2. Lisinopril 40 mg PO DAILY hold sbp < 100 map < 60 3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain hod sedation rr < 10. 4. Metoprolol Tartrate 100 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Senna 2 TAB PO DAILY:PRN constipation 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Acetaminophen 650 mg PO Q6H:PRN pain/fever 9. Calcium 500 + NF (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral twice day 10. Morphine Sulfate IR 5-10 mg PO Q8H:PRN pain Hold sedation RR < 12. 11. Enoxaparin Sodium 30 mg SC Q12H planned duration: weeks post-op ([Date range (3) 112246]) 12. Miconazole Powder 2% 1 Appl TP TID:PRN rash apply affected area Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: PRIMARY: comminuted right intertrochanteric fracture fracture left acetabulum ischium thrombocytopenia anemia SECONDARY: developmental delay osteoporosis Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: admitted due right pelvis femur fracture. underwent surgery discharged rehab plans follow-up Orthopedic Surgery (appointment listed below). Note stay, worked possible seizure follow Neurology (appointment listed below). made following changes medications: -START Lovenox (Enoxaparin) injections prevent blood clots (from [Date range (1) 94218]) -START Tylenol needed pain -START Morphine needed pain -START Calcium/Vitamin osteoporosis -STOP Tramadol (this could predispose seizures) Followup Instructions: ORTHOPEDICS When: TUESDAY [2126-6-18] 10:20 With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ORTHOPEDICS When: TUESDAY [2126-6-18] 10:40 With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage NEUROLOGY When: MONDAY [2126-7-15] 4:00 PM With: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 540] MD [Telephone/Fax (1) 541] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "2851", "2875", "42731" ]
Admission Date: [2175-11-6] Discharge Date: [2175-11-13] Service: . HISTORY PRESENT ILLNESS: patient [Age 90 ] year old man history coronary artery disease status post coronary artery bypass graft surgery, severe aortic stenosis recent non-ST elevation myocardial infarction week prior admission, complicated congestive heart failure ejection fraction 30s. time, aortic valve area noted 0.5 cm squared. patient initially refused cardiac catheterization, pacemaker anti-coagulation outside hospital discharged home return next day shortness breath rest. noted systolic blood pressure 80s; temperature 100.6 F., right lower lobe infiltrate found chest x-ray. ruled myocardial infarction started treatment antibiotics, heparin drip Natrecor. transferred [Hospital1 69], initially admitted [Hospital Unit Name 196] Service taken cardiac catheterization. Catheterization revealed severe three vessel disease severe biventricular diastolic dysfunction patent graft. patient also critical aortic stenosis, severe pulmonary hypertension successful balloon valvuloplasty bringing aortic valve area 0.5 cm squared 0.7 cm squared. patient started Dobutamine catheterization laboratory transferred Cardiac Care Unit. Cardiac output dobutamine 2.88 significantly change dobutamine stopped. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft [2167] left internal mammary artery left anterior descending, saphenous vein graft left circumflex obtuse marginal ramus, saphenous vein graft right coronary artery. 2. Severe aortic stenosis valve area 0.5 cm squared. 3. Tachycardia / Bradycardia syndrome. 4. Atrial fibrillation. 5. Recent non-ST elevation myocardial infarction. 6. Asthma. 7. Congestive heart failure ejection fraction 30%. 8. Hypertension. 9. Chronic renal insufficiency. 10. Hyperlipidemia. 11. Diabetes mellitus type 2. 12. History urinary tract infection. 13. Status post transurethral resection prostate. 14. Benign prostatic hypertrophy. MEDICATIONS HOME: 1. Captopril 6.25 mg twice day. 2. Augmentin twice day. 3. Lasix 60 mg p.o. twice day. 4. Digoxin 0.125 mg p.o. q. day. 5. Coreg 3.125 mg p.o. twice day. 6. Aspirin 325 mg p.o. q. day. 7. Pravachol 60 mg p.o. q. day. 8. Atrovent Albuterol inhalers. 9. Flovent inhaler. ALLERGIES: patient known drug allergies. SOCIAL HISTORY: patient lives home; denies alcohol tobacco use. PHYSICAL EXAMINATION: admission, temperature 100.4 F.; pulse 69; blood pressure 105/38; respiratory rate 22; saturation 99% non-rebreather. Generally, patient confused, moving around bed. jugular venous pressure 7 cm II/VI systolic ejection murmur heard right upper sternal border. lung examination diffuse wheezes crackles bases. rest examination unremarkable. LABORATORY: admission showed BUN creatinine 48 1.9. Troponin 2.38 CK 40. EKG pre-cath showed atrial fibrillation rate 60 beats per minute, left axis deviation, right bundle branch block ST depressions V1 V6. SUMMARY HOSPITAL COURSE: patient transferred post catheterization Cardiac Intensive Care Unit. [Unit Number ]. CORONARY ARTERY DISEASE: Catheterization revealed severe three vessel disease patent graft. patient status post two recent non-ST elevation myocardial infarctions. continue aspirin Pravachol. Initially, beta blocker held secondary hypotension presumed cardiogenic shock, however, beta blocker, ACE inhibitor digoxin started prior discharge without complications. 2. CONGESTIVE HEART FAILURE: patient shown ejection fraction 30% severe biventricular diastolic dysfunction low cardiac output. resumed home Lasix dose well home ACE inhibitor beta blocker felt euvolemic time discharge. 3. SICK SINUS SYNDROME: patient continues refuse pacemaker in-house became bradycardic times, otherwise regular rate atrial fibrillation. 4. ATRIAL FIBRILLATION: patient continues refuse anti-coagulation remained atrial fibrillation. continued Carvedilol multiple indications, one rate control. 5. ASTHMA / QUESTION CHRONIC OBSTRUCTIVE PULMONARY DISEASE: patient continued oxygen via nasal cannula. continued saturate well throughout admission long two three liters states home dose oxygen. also continued Atrovent Albuterol nebulizers transitioned inhalers end hospital stay well Flovent inhaler. 6. PNEUMONIA: patient treated Levaquin two days followed Caveats Clindamycin two days outside hospital. continued Ceftriaxone total ten day course. appeared improve oxygen saturation sputum production decreased time discharge complications. 7. DIABETES MELLITUS: patient initially started Regular insulin sliding scale, however, blood sugar remained less 150 times, Regular insulin sliding scale stopped prior discharge. 8. CODE STATUS: patient remained "DO RESUSCITATE" "DO INTUBATE" throughout hospital stay. 9. MENTAL STATUS: admission, patient appeared confused continued throughout hospital stay. Likely patient baseline dementia, however, due this, difficulty swallowing. evaluated Speech Swallow Team day discharge recommended patient take anything mouth mental status clears. happen, started tube feeds PEG tube considered high aspiration risk. DISCHARGE MEDICATIONS: 1. Digoxin 0.125 mg p.o. q. day. 2. Carbuterol 3.125 mg p.o. twice day. 3. Lasix 60 mg p.o. twice day. 4. Captopril 6.25 mg p.o. three times day. 5. Lipitor 10 mg p.o. q. h.s. 6. Aspirin 325 mg p.o. q. day. 7. Flovent two puffs twice day. 8. Risperidone 0.5 mg p.o. twice day p.r.n. 9. Atrovent nebulizers q. six hours. 10. Albuterol nebulizers q. six hours. 11. Colace 100 mg p.o. twice day. 12. Senokot one two tablets p.o. q. day p.r.n. 13. Heparin subcutaneously 5000 units q. eight hours ambulating. 14. Protonix 40 mg p.o. q. day. 15. Guaifenesin p.r.n. DISPOSITION: patient discharged rehabilitation facility. DISCHARGE STATUS: Stable; patient denied chest pain throughout entire admission. DISCHARGE INSTRUCTIONS: Follow-up appointments determined. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 2543] MEDQUIST36 D: [2175-11-13] 13:46 T: [2175-11-13] 14:33 JOB#: [Job Number 53887]	[ "4241", "4280", "42731", "4168", "25000", "4019", "2720", "41401" ]
Admission Date: [2149-7-29] Discharge Date: [2149-8-4] Date Birth: [2117-7-23] Sex: Service: CARDIAC SURGERY HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: 31 year-old gentleman known history bicuspid aortic valve severe aortic regurgitation experiencing increasing dyspnea exertion last three months. patient seen Dr. [Last Name (Prefixes) ] admitted [7-29] elective aortic valve replacement. Cardiac catheterization [2149-10-6] showed left ventricular ejection fraction 52%, severe aortic regurgitation mild aortic stenosis, mild left ventricular diastolic dysfunction, normal coronary arteries. Echocardiogram [2149-1-5] showed moderate severe aortic regurgitation, left ventricular ejection fraction 55%, normal left ventricular function, dilated aortic root bicuspid aortic valve. PAST MEDICAL HISTORY: Bicuspid aortic valve. MEDICATIONS: Zestril 10 mg po q.d. ALLERGIES: Fava beans. SOCIAL HISTORY: patient lives parents. denies tobacco use. Occasional ETOH use. HO[Last Name (STitle) ] COURSE: patient admitted [2149-7-29] taken Operating Room Dr. [Last Name (Prefixes) ] underwent aortic valve replacement 25 mm Carbomedic valve. patient originally scheduled Bentall procedure, upon examination transesophageal echocardiogram Operating Room found dilation proximal ascending aorta sinotubular junction, elected proceed aortic valve replacement. Ejection fraction Operating Room 50%. Please see operative note details. patient transferred Intensive Care Unit stable condition. patient weaned extubated mechanical ventilation first postoperative night. patient consistently tachycardic heart rates 1 teens 120s sinus tachycardia, responded intravenous Lopressor. patient remained hemodynamically stable minimal chest tube drainage. postoperative day number one patient began ambulating hallway. patient remained Intensive Care Unit due lack bed availability floor. postoperative day number two patient transferred Intensive Care Unit regular floor stable condition. patient continued sinus tachycardia rates 1 teens increasing doses Lopressor. question whether tachycardia due poor pain control. patient's pain medications switched Dilaudid patient started around clock Motrin, seemed improve patient's pain control, change sinus tachycardia. Labetalol added patient's regimen Lopressor, improve tachycardia heart rate decreased 90s low 100s. postoperative day number two patient started Coumadin patient's mechanical aortic valve. patient began working physical therapy patient's pacing wires removed postoperative day number three. Labetalol increased postoperative day number three continued tachycardia. postoperative day number four patient completed level five physical therapy walking 500 feet climbing one flight stairs. patient remained hospital continued titration Coumadin therapy. postoperative day number five patient's INR rose 2.0 postoperative day number six patient cleared discharge home. CONDITION DISCHARGE: Temperature max 99.1, pulse 99 sinus rhythm, blood pressure 118/70, respiratory rate 16, room air oxygen saturation 95%. patient's weight [8-4] 104 kilograms. patient weighed 109 kilograms preoperatively. Neurologically patient awake, alert oriented times three, nonfocal. Cardiovascular regular rate rhythm. murmur rub, sharp valve click. Lungs breath sounds clear bilaterally. rales, wheezes rhonchi. Gastrointestinal positive bowel wounds, obese, nontender, nondistended. Extremities 2+ pitting edema. Sternal incision clean dry. Sternum intact. erythema drainage. LABORATORY DATA: White blood cell count 11.3, hematocrit 34.1, platelets count 342, sodium 138, potassium 4.5, chloride 101, bicarb 24, BUN 21, creatinine 0.9 glucose 145. PT 20.8, INR 2.9. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg po b.i.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. K-Ciel 20 milliequivalents po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Zantac 150 mg po b.i.d. 6. Labetalol 40 mg po b.i.d. 7. Percocet 5/325 one two tablets po q 4 hours prn. 8. Ibuprofen 600 mg po q 6 hours prn. 9. Coumadin 3 mg po [8-4]. Blood drawn [8-5] results faxed primary care physician [Last Name (NamePattern4) ].[Name (NI) 14088] office determine Coumadin dosing. DISCHARGE DIAGNOSES: 1. Aortic regurgitation. 2. Status post aortic valve replacement. Th[Last Name (STitle) 1050] follow primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] one two weeks phone [8-5] Coumadin dose. patient follow Dr. [Last Name (STitle) 120] cardiologist one two weeks. patient follow Dr. [Last Name (Prefixes) ] four weeks. patient discharged home stable condition. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2149-8-4] 11:23 T: [2149-8-4] 11:36 JOB#: [Job Number 14089]	[ "9971", "42789", "V5861" ]
Admission Date: [2185-5-15] Discharge Date: [2185-5-23] Date Birth: [2129-2-10] Sex: Service: MEDICINE Allergies: Aspirin / Prednisone Attending:[First Name3 (LF) 898] Chief Complaint: shortness breath Major Surgical Invasive Procedure: -Right internal jugular central access line placed [5-15] removed [5-19] -Peripheral arterial line placement History Present Illness: Mr. [Known lastname 24078] 56-year old male history pulmonary sarcoidosis, obstructive sleep apnea asthma presents home one day chills, myalgias, cough productive yellow sputum tinged blood right sided chest pain. note previously diagnosed community acquired pneumonia [Month (only) 956] treated azithromycin complete resolution symptoms. feeling well one day prior presentation symptoms developed suddenly. pain primarily right side chest worsens deep inspiration. unable take deep breath secondary pain. breathing worse lying flat left side. myalgias chills taken temperature home. mild nausea vomiting, abdominal pain, diarrhea constipation. blood tinged sputum one day. taking normal PO intake normal urine output without dysuria. denies lower extremity edema. denies recent travel sick contacts. [Name (NI) ] recent steroids immunosuppresants. smoker. review systems negative. . ED, initial vs were: T: 98.7 P: 116 BP: 73/45 R: 16 O2 sat: 88% RA. chest CT contrast showed pulmonary embolism showed severe right middle right lower lobe pneumonia. received 5 liters normal saline. blood pressure ranged 70s 90s systolic subsequently right sided sepsis catheter placed started levophed soon stopped. received levofloxacin, vancomycin, aspirin 325 mg morphine 4 mg IV x 1, tylenol 1000 mg PO x 1. EKG showed sinus tachycardia, normal axis, normal intervals, isolated 1 mm STE lead III resolved subsequent EKGs. admitted MICU management. . Past Medical History: Sarcoidosis complicated uveitis Hyperglycemia Hypercholesterolemia Obstructive Sleep Apnea Anxiety Depression Benign Prostatic Hypertrophy Exercise Induced Asthma Social History: denies history smoking, alcohol illicit drug use. lives wife dog. recent travel sick contacts. . Family History: family history sarcoidosis lung disorders. Physical Exam: INITIAL ADMISSION PHYSICAL EXAM [2185-5-15]: Vitals: T: 97.4 BP: 95/56 P: 96 R: 27 O2: 93% 100% NRB General: Alert, oriented, tachypneic, using accessory muscles HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Left side coarse breath sounds, right inspiratory expiratory ronchi, dullness percussion right, egophony right CV: Tachycardic, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neurologic: Alert oriented x 3, strength 5/5 throughout, sensation intact light touch across dermatomes . . PHYSICAL EXAM TRANSFER MEDICAL FLOOR ICU [2185-5-19]: Vital Signs: Tmax [Age 90 ]F, BP 142/81, HR 77, RR 18, Oxygen Sat 97% room air General: Alert & oriented x3, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Right sided basilat decreased breath sounds rhonchi expiration/inspiration, left side decreased aeroation bases. CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis. Trace edema bilaterally noted (R=L) Neuro: CNs [3-10] grossly tact, PERRLA, EOMI, focal deficits. Gait assessment deferred. Pertinent Results: ADMISSION LABS: [2185-5-15] 11:00AM GLUCOSE-158* UREA N-25* CREAT-1.6* SODIUM-139 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16 [2185-5-15] 11:00AM ALT(SGPT)-31 AST(SGOT)-21 CK(CPK)-46 ALK PHOS-64 TOT BILI-1.5, LIPASE-17 [2185-5-15] 11:01AM LACTATE-2.4* [2185-5-15] 11:00AM TOT PROT-6.4 ALBUMIN-4.0 GLOBULIN-2.4 CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-1.5* [2185-5-15] 11:00AM CORTISOL-45.6* [2185-5-15] 11:00AM CRP-89.2* [2185-5-15] 11:00AM WBC-10.6# RBC-5.22 HGB-14.1 HCT-41.1 MCV-79* MCH-27.0 MCHC-34.4 RDW-13.9 [2185-5-15] 11:00AM NEUTS-71* BANDS-18* LYMPHS-6* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2185-5-15] 11:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2185-5-15] 11:00AM PLT SMR-NORMAL PLT COUNT-183 [2185-5-15] 11:00AM PT-14.1* PTT-25.0 INR(PT)-1.2* . . CARDIAC ENZYMES: [2185-5-15] 06:16PM CK(CPK)-72 [2185-5-15] 06:16PM CK-MB-NotDone cTropnT-<0.01 [2185-5-15] 11:00AM cTropnT-<0.01 [2185-5-15] 11:00AM CK-MB-NotDone . ABGs: [2185-5-15] 06:28PM TYPE-ART TEMP-36.3 PO2-88 PCO2-28* PH-7.42 TOTAL CO2-19* BASE XS--4, LACTATE-1.4 . URINE STUDIES: [2185-5-15] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.024 [2185-5-15] 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG . IMAGING STUDIES: [2185-5-15] PORTABLE CXR -Findings consistent right lower lobe atelectasis.Superimposed infection cannot excluded. Document resolution upon treatment exclude underlying obstructive process. . [2185-5-15] CTA: 1. Severe right middle lobe pneumonia involvement portions right lower lobe, right upper lobe lingula. evidence aortic dissection pulmonary embolism. 2. Unchanged sequelae known underlying sarcoidosis. 3. Unchanged non-obstructive left renal calculi. . [2185-5-19] CHEST XRAY, PA LATERAL: Since [5-18], consolidation right middle lower lobes improved. Moderate-to-severe left mid upper pulmonary edema unchanged. Left-sided pleural effusion slightly increased [2185-5-17]. Atelectatsis right lower lobe stable. right central line removed. remainder exam unchanged. IMPRESSION: 1. Improving pneumonia right middle lower lobes. 2. Persistent moderate edema, despite decreased central venous pressure. 3. Slight increase left side pleural effusion. . MICROBIOLOGY: [2185-5-15] Blood Culture, Routine (Final [2185-5-21]): GROWTH. [2185-5-16] Sputum Culture results--> FINAL REPORT [2185-5-18] GRAM STAIN (Final [2185-5-16]): >25 PMNs <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2185-5-18]): SPARSE GROWTH OROPHARYNGEAL FLORA. . [2185-5-15] 5:35 pm URINE Source: CVS. FINAL REPORT [2185-5-16] Legionella Urinary Antigen (Final [2185-5-16]): NEGATIVE LEGIONELLA SEROGROUP 1 ANTIGEN. . EKGs [2185-5-15] -[2185-5-16]: Sinus tachycardia, normal axis, normal intervals, isolated 1 mm STE lead III resolved subsequent EKGs . DISCHARGE LABS: Brief Hospital Course: summary, 56-year-old male sarcoidosis, OSA, anxiety/depression, hyperlipidemia presented shortness breath, right sided chest pain fevers found multifocal right sided PNA per chest CT imaging. Admitted ICU sepsis concerns setting hypotension systolic range 70s mild tachycardia. Resuscitated generous IVFs given IV antibiotics, supportive oxygen briefly Levophed blood pressure stabilization. Patient hemodynamically stabilized well [1-28] days ICU never required intubation. transferred general medical floor [2185-5-19]. detailed hospital course please see below: . #Multifocal PNA: Patient's initial presentation concerning septic shock became tachycardic 120s range hypotensive systolic 70s emergency room [2185-5-15]. Blood pressures improved generous IVFs required brief pressor support Levophed. CTA chest done admission [2185-5-15] showed right sided multi-focal PNA. note, Mr. [Known lastname 24078] pre-existing poor pulmonary reserve baseline sarcoidosis asthma. also endured 2 previous bouts pneumonia past year. initially started triple coverage ED Levaquin, IV Vancomycin & Zosyn. continued ICU [5-18] switched IV Ceftriaxone continuance Levaquin. arrived general medical floor [5-19] appeared labored breathing later afternoon repeat CXR done team decided place back prior Vancomycin Zosyn regimen CTX Levaquin discontinued. CXR done [2185-5-19] showed mild effusions overall improving pneumonia right middle lower lobes. continued improved shortness breath decreasing oxygen requirements cough persistent phlegm production lessened. Fevers gradually defervesced. Initial blood cultures negative. Sputum gram stain showed >25 PMNs 3+ gram positive cocci pairs chains 2+ gram negative rods also identified. Sputum culture showed sparse growth oropharyngeal flora. Patient developed drug rash, leukocytosis eosinophilia, Zosyn discontined. Placed PO levoquin high-dose. complete total 14 day course. asked follow-up outpatient pulmonologist, Dr. [Last Name (STitle) ], next weeks. . #Sarcoidosis: Mr. [Known lastname 24078] pulmonary sarcoidosis extrapulmonary manifestations sarcoid form prior uveitis flare-ups. typically take home oral steroids ongoing basis sarcoid chest CT admission sarcoid disease appeared stable compared prior films. Given acute infection role additional steroids admission. Moreover, dyspnea respiratory congestion seemed gradually improve antibiotics supportive oxygen alone. was, however, continued usual inhaled steroids ongoing Advair Albuterol nebulizers. . #Obstructive Sleep Apnea: continued usual home nightly CPAP regimen inpatient. . #Hypercholesterolemia: Daily cholestyramine continued. Mr. [Known lastname 24078] also enrolled participate research study included daily administration possible statin (vs. placebo) protocol completed [5-21]. . #Depression: hospital course occasional apparent depressed moods times denied suicidal ideation maintained appropriate affect transferred general medical floor. continued usual Effexor daily clonazepam continued concomitant anxiety. . #Benign Prostatic Hypertrophy: given usual home finasteride therapy time discharge return usual Flomax well. reported difficulty urination hospital course. . #Exercise Induced Asthma: continued usual daily Advair monteleukast. place PRN albuterol inhaler given nebulizer treatments as-need basis q4-6 hours. . #GERD: continued PPI regimen severe GERD history. . #Hyperglycemia / Pre-diabetes: home standing medications mild moderate hyperglycemic tendency. QID fingersticks sliding scale insulin regimen meals QHS. Fasting post-prandial glucose levels predominantly normal borderline normal hospital course. additional standing insulin oral medications added medications. . # Fluids, Electrolytes Nutrition: several liters IVFs initial 48 hours hospital stay good PO intake IVFs tapered. Electrolytes monitored repleted needed continued regular diet. . # Prophylaxis: Subcutaneous heparin given TID DVT prevention, PPI GERD above, bowel regimen Colace Senna continued. . # Code Status: Patient maintained full code status entire hospital course ; confirmed directly patient. Medications Admission: Albuterol 90 mcg 1-2 puffs q4-6H:PRN Cholestyramine-Aspartame 2 grams daily Clonazepam 0.5 mg PO daily:PRN Fexofenadine 60 mg Tablet [Hospital1 ] Finasteride 5 mg PO daily [Proscar] Flomax 0.4 mg daily Fluticasone nasal 50 mcg 2 sprays daily Fluticasone-Salmeterol 500 mcg-50 mcg 1 puff [Hospital1 ] Montelukast 10 mg PO QHS Omeprazole 40 mg [Hospital1 ] Ranitidine HCl 300 mg daily Venlafaxine 100 mg TID Aspirin 81 mg q 3 days Bismuth Subsalicylate [Pepto-Bismol] 1 tablet QID:PRN Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: [1-28] Inhalation every 4-6 hours needed shortness breath wheezing. 2. Cholestyramine-Sucrose 4 gram Packet Sig: 0.5 Packet PO DAILY (Daily). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once day (at bedtime)) needed. 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO day. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk Device Sig: One (1) Inhalation twice day. 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times day). 11. Ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO day. 12. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QMOWEFR (Monday -Wednesday-Friday). 14. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO QID (4 times day) needed. 15. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) 6 days. Disp:18 Tablet(s) Refills:0 16. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) needed Itch 7 days: drive sedating medication. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: -Pneumonia -Respiratory distress . Secondary: -Sarcoidosis -Hyperglycemia -Hypercholesterolemia -Obstructive Sleep Apnea -Anxiety -Depression -Benign Prostatic Hypertrophy -Exercise Induced Asthma Discharge Condition: Clinically stable. apparent distress normal vital signs time discharge. Discharge Instructions: pleasure taking care [Hospital1 771]. admitted fevers, cough shortness breath. Additional imaging studies revealed right sided pneumonia. initially taken care intensive care unit given IV antibiotics, IV fluids supportive oxygen therapy help breathing. . clinically stabilized symptoms improved transferred general medical wards. continued supportive oxygen slowly weaned antibiotics continued. Chest physical therapy also provided help recuperate faster. . important follow-up appointments listed below. Also, please continue take listed medications prescribed outlined below. . experience new fevers, chills, bloody sputum, worse cough, worse shortness breath, dizziness, lightheadedness, chest pains, heart palpitations concerning symptoms please return emergency room call primary care physician. Followup Instructions: 1) Please follow-up primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ] [6-8] 8:45am. Phone:[Telephone/Fax (1) 9347] . 2) Please call #[Telephone/Fax (1) 612] set follow-up appointment pulmonologist, Dr. [Last Name (STitle) ] next 1-2 weeks time. . Completed by:[2185-5-23]	[ "0389", "5849", "486", "99592", "32723", "49390", "2720", "53081" ]
Admission Date: [2111-7-1] Discharge Date: [2111-7-2] Service: MED Allergies: Macrobid Attending:[First Name3 (LF) 99] Chief Complaint: bradycardia, hypotension Major Surgical Invasive Procedure: none History Present Illness: 82F w/ PMH sig HTN, Fe deficiency anemia, cardiomegaly p/w [12-26] mth h/o increasing gait unsteadiness, falls, dysphagia, nonproductive cough, DOE, bilat ankle edema, generalized weakness. Around 9:30pm 1 day PTA, pt's daughter noted pale, cool touch, slurred speech increased gait unsteadiness. time, PO temp noted 94 degrees w/ SBP 90s (baseline 130s), patient's daughter seek medical attention. course day today, pt noted become progressively lethargic, 'slumping multiple times' thus brought ED daughter eval. ROS also notable 2 days subjective chills, constipation, abdominal pain en route ED. Past Medical History: HTN CVA '[81] "large heart" hx MI AI osteoporosis hyperchol L hip pinning TAH/BSO Fe def anemia Social History: lives w/ dtr home tob, EtOH, OTC/illicit drug use uses wheelchair independent ADLS Family History: noncontributory Physical Exam: T92.8 BP92/60 P66 RR20 100% sat AC 550 x 20, peep 5, 100% FiO2 Gen - pale, intubated & sedated [Year (2 digits) ] - PERRL, OP clear, MM dry Neck - RIJ site ok, JVP/LAD Lungs - [Month (only) ] L base o/w clear CV - RRR, R/M/G Abd - soft, NT/ND, NABS, masses, rebound/guarding Ext - 1+ LE edema bilat, warm, rashes, 1+ pedal pulses Neuro - moves 4 ext spont, symmetric DTRs, normal muscle tone Pertinent Results: [2111-7-1] 08:15PM WBC-25.5# RBC-3.02 HGB-8.5* HCT-26.9* MCV-89 MCH-28.0 MCHC-31.4 RDW-14.0 PLT COUNT-135* [2111-7-1] 08:23PM GLUCOSE-125* LACTATE-10.1* NA+-135 K+-6.2* CL--101 TCO2-15* UREA N-44* CREAT-3.4# CALCIUM-8.4 PHOSPHATE-5.6# MAGNESIUM-1.7 [2111-7-1] 08:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-MOD [2111-7-1] 08:26PM PO2-274* PCO2-14* PH-7.46* TOTAL CO2-10* BASE XS--9 INTUBATED-INTUBATED O2 SAT-90 [2111-7-1] [Month/Day/Year ]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: Upon arrival ED, patient noted triage nurses unresponsive, 'cold & clammy,' heart rate 30s, palpable pulse, breathing agonally. improvement 1 mg atropine, epinephrine, glucagon, externally paced, intubated, started levophed. given broad spectrum antibiotic coverage presumed sepsis (levo/flagyl/vanc), along w/ agressive fluid recussitation subsequently transferred MICU management. Unfortunately, despite agressive pressor fluid therapy, patient's clinical condition continued rapidly deteriorate next 12 hours. continued display signs symptoms vasodilatory shock, including hypothermia, rising lactate, leukocytosis, hypotension refractory fluid maximum dosages 3 simultaneous pressors. decided based grave clinical condition poor prognosis CPR would medically indicated, patient passed away 7am [2111-7-2]. family notified, autopsy granted. Medications Admission: vitamin d3 400 daily calcium carbonate 500 q6hrs lipitor 10 daily lisinopril 40 daily hctz 25 daily procardia XL 90 daily atenolol 100 daily [Month/Day/Year ] 325 daily actonel 30 week iron 325 twice day percocent/ambien/[Last Name (un) ] #3/ativan/trazadone PRN Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Likely Septic/Vasodilatory Shock Discharge Condition: expired Completed by:[0-0-0]	[ "0389", "5849", "51881", "2875", "99592" ]
Admission Date: [2198-5-27] Discharge Date: [2198-6-5] Date Birth: [2144-10-19] Sex: Service: NEUROLOGY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 11344] Chief Complaint: AMS, hypothermia Major Surgical Invasive Procedure: none History Present Illness: Patient 53yo male PMH Cerebral palsy, mental retardation, seizures presents via EMS hypothermia altered mental status. AM, caretaker noticed responding like normally gurgling. found hypothermic 32C. Last night normal self cough, [First Name3 (LF) ], abd pain. caretaker states presents way infections. recently uti 3 weeks ago, completed abx course. also went [Hospital1 ] 3 days ago seizure. keppra, dilantin, lamictal. ED, initial VS were: BP80/55 HR52 RR13 O2sat:100% RA Temp31.5. received 2LNS improvment SBP 100, dropped 80's systolic point started norepinephrine gtt. CVL placed received another 500cc. EKG showed sinus brady 43 qtc 505. Head CT showed acute process CXR showed bowel liver pneumonia. Labs showed WBC count 2.8 clean UA. FS 78, started D5 IVF levophen gtt. dilantin level 18.2. given hydrocortisone 100iv vancomycin 1gm zosyn 4.5g question sepsis. Vital signs prior transfer Current VS 64 98% RA 33.7F 109/61 levophed. access 18 20g IV. . arrival MICU, vital signs T34.6C, HR77, BP136/101, RR18, O2sat:98%. noted right sided fat deposit right neck near central line noted ED. ecchymosis associated stridor appreciated. calm obeys commands intermittantly. . Review systems: Unable obtain secondary altered mental status Past Medical History: Cerebral palsy mental retardation seizures lower extremity edema thought secondary venous insufficiency seasonal allergies contact dermatitis status-post treatment bowel bladder incontinence, aspiration pneumonia [2196] UTI aspiration pneumonia [2197] Social History: lives caretaker [Name (NI) 123], phone number [Telephone/Fax (1) 93387]. immediate family still alive. goes daily daycare. current guardian [Name (NI) ] [Name (NI) 93392] phone number [Telephone/Fax (1) 93393]. baseline, pt appears quite interactive, able respond meaningfully. Family History: aunt passed away 3 years ago lung cancer. parents passed away. mother died heart condition. unclear father passed away of. Physical Exam: Physical Exam Admission: Vitals: T34.6C, HR77, BP136/101, RR18, O2sat:98%General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: full ROM, right IJ place CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: wheezes rales, positive upper airway rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: moves 4 limbs command, unable otherwise participate neuro exam **************** discharge: Neuro: awake, alert. Mumbles, typically able understood anyone know well. follow commands. Looks around room. Moves RUE > others spontaneously, moves extremities least antigravity response light touch. Pertinent Results: Lab Results Admission: [2198-5-27*] 10:45AM BLOOD WBC-2.3 RBC-4.72 Hgb-14.9 Hct-46.6 MCV-99* MCH-31.7 MCHC-32.1 RDW-14.4 Plt Ct-167 [2198-5-27] 10:45AM BLOOD Neuts-56.7 Lymphs-31.3 Monos-4.7 Eos-3.8 Baso-3.6* [2198-5-27] 10:45AM BLOOD Glucose-190* UreaN-12 Creat-0.6 Na-145 K-4.7 Cl-110* HCO3-29 AnGap-11 [2198-5-27] 10:45AM BLOOD ALT-25 AST-36 AlkPhos-128 TotBili-0.2 [2198-5-27] 10:45AM BLOOD cTropnT-<0.01 [2198-5-27] 10:45AM BLOOD Albumin-4.0 [2198-5-28] 03:52AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6 [2198-5-30] 06:10AM BLOOD Cortsol-8.6 [2198-5-29] 03:10AM BLOOD TSH-2.0 [2198-5-27] 10:45AM BLOOD Phenyto-18.2 [2198-5-28] 03:52AM BLOOD Phenyto-20.2* [2198-5-27] 10:53AM BLOOD Lactate-1.4 [2198-5-27] 10:53AM BLOOD Type-[Last Name (un) ] Comment-GREEN TOP [2198-5-27] 11:14AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2198-5-27] 11:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Discharge labs: [2198-6-5] 04:30AM BLOOD WBC-10.8 RBC-4.42* Hgb-14.8 Hct-42.6 MCV-96 MCH-33.4* MCHC-34.7 RDW-13.8 Plt Ct-227 [2198-6-5] 04:30AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-139 K-4.4 Cl-100 HCO3-28 AnGap-15 [2198-6-5] 04:30AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1 [2198-6-4] 05:25AM BLOOD Phenyto-20.0 [2198-5-30] 12:29 pm STOOL CONSISTENCY: APPLICABLE Source: Stool. FINAL REPORT [2198-5-31] C. difficile DNA amplification assay (Final [2198-5-31]): test cancelled FORMED stool specimen received, acceptable C. difficle DNA amplification testing.. PATIENT CREDITED. Studies: Cardiovascular Report ECG Study Date [2198-5-27] 10:46:20 Marked sinus bradycardia 43 beats per minute. Q-T interval prolonged. Cannot rule inferoposterior myocardial infarction indeterminate age. Compared previous tracing [2198-4-30] significant change Radiology Report CT HEAD W/O CONTRAST Study Date [2198-5-27] 10:41 IMPRESSION: 1. acute hemorrhage intracranial process. 2. Chronic developmental abnormalities . Radiology Report CHEST (PORTABLE AP) Study Date [2198-5-27] 10:51 IMPRESSION: acute intrathoracic process within limitations study. Radiology Report -77 DIFFERENT PHYSICIAN [Name9 (PRE) 2221] Date [2198-5-27] 1:33 PM FINDINGS: Tip right internal jugular central venous catheter terminates expected location body right atrium could withdrawn several centimeters standard positioning. visible pneumothorax. Lung volumes remain low, accentuating cardiac silhouette bronchovascular structures. Even allowing factor, likely mild pulmonary vascular congestion present. Patchy areas atelectasis developed bases. Questionable small left pleural effusion. Radiology Report -76 PHYSICIAN [Name9 (PRE) 2221] Date [2198-5-27] 2:34 PM FINDINGS: Tip right internal jugular central venous catheter may withdrawn slightly, continues terminate expected location body right atrium cavoatrial junction. Otherwise, significant change appearance chest since recent radiograph performed one hour earlier. Neurophysiology Report EEG Study Date [2198-5-28] IMPRESSION: abnormal continuous ICU monitoring study presence moderately diffuse encephalopathy extremely active epileptiform features multifocal generalized appearance. Additionally, two sustained electrographic seizures recorded reported above. Radiology Report CHEST (PORTABLE AP) Study Date [2198-5-28] 11:35 IMPRESSION: Nasogastric tube stomach preliminary impression tube could folded back gastro-esophageal junction communicated Dr. [Last Name (STitle) ] 2 p.m phone [2198-5-28]. subsequent confirmatory radiograph, final positioning communicated via page 3 pm. Radiology Report PORTABLE ABDOMEN Study Date [2198-5-28] 11:35 IMPRESSION: radiographic evidence obstruction. Radiology Report CHEST (PORTABLE AP) Study Date [2198-5-28] 2:21 PM IMPRESSION: Nasoenteric tube projects expected position stomach. Neurophysiology Report EEG: [2198-5-29] IMPRESSION: abnormal continuous ICU monitoring study presence mild moderate diffuse encephalopathy extremely active paroxysmal multifocal independent interictal discharges frequent runs generalized rhythmic epileptiform activity. bursts discharges appear obvious clinical accompaniment. comparison previous day's tracing, symptomatic electrographic/clinical seizures. [5-30]: IMPRESSION: abnormal continuous ICU monitoring study mild diffuse encephalopathy perhaps subtle left hemisphere predominance. extremely active multifocal generalized epileptiform activity. latter activity appeared sustained associated clear clinical accompaniment. [5-31]: IMPRESSION: abnormal video EEG monitoring session prolonged electrographic seizure accompanied clinical features described pushbutton activations. Also, second half recording, 10-15 seconds runs epileptic discharges one lasted 20 seconds minor left arm tonic extension likely represented brief seizure. addition, frequent generalized polyspikes abundant multifocal epileptic discharges. findings indicative diffuse cortical irritability epileptogenicity. addition, background activity diffusely slow disorganized intermittent runs slowing indicative moderate diffuse encephalopathy consistent patient's history static encephalopathy. Compared prior day's recording, study worse due significant increased epileptiform activity two electrographic seizures. [6-1]: IMPRESSION: abnormal video-EEG monitoring session due frequent generalized polyspikes abundant multifocal epileptic discharges. findings indicative diffuse cortical irritability potential epileptogenicity. Additionally, background activity disorganized diffusely slow indicative moderate diffuse encephalopathy consistent patients history static encephalopathy. Compared prior day's recording, study significantly improved due absence electrographic seizures. [6-2]: IMPRESSION: abnormal video-EEG monitoring session frequent generalized polyspikes abundant multifocal epileptic discharges. findings suggestive wide spread cortical irritability potential epileptogenicity. addtion, background activity diffusely slow disorganized signifying moderate diffuse encephalopathy consistent patients history static encephalopathy. Compared prior day's recording, study unchanged. [6-3]: IMPRESSION: abnormal video-EEG monitoring session two electrographic clinical seizures lasting less one minute. seizures described earlier pushbutton activations seizure detection programs. addition abundant multifocal epileptic discharges frequent generalized polyspike discharges. findings indicative wide spread cortical irritability potential epileptogenicity. Furthermore, background activity disorganized diffusely slow indicative moderate diffuse encephalopathy consistent patients history static encephalopathy. Compared prior day's recording, study worse due two brief electrographic seizures. [6-4]: [6-5]: pending Brief Hospital Course: PRIMARY REASON HOSPITALIZATION: Patient 53yo male PMH Cerebral palsy, mental retardation, seizures presented via EMS hypothermia altered mental status. treated recently UTI 3 weeks prior admission completed course antibiotics. presentation ED became hypotensive, recovered blood pressure IVF hydrocortisone. admitted ICU rewarmed bair hugger maintained blood pressure without aggressive fluid resuscitationa pressors initial resuscitation. experienced several short-lasting seizures unit transferred floor hypothermia shock picture resolved infectious source indentified. transferred neurology epilepsy monitoring unit. . # Hypothermia: Patient temperature reportedly 32C home recorded 31.5C ED. recovered bair hiffer dropped 34C [5-29] recovery bair hugger again. hypotensive following initial resuscitation. Potential etiologies hypothermia include hypothalamic dysfunction vs. hypopituitarism vs. medications, infection, post-ictal state. TSH found normal along cortisol. cultures, exam, monitoring, infectious source identified. Vancomycin Zosyn started admission discontinued [Month/Year (2) ] curve WBC returned [Location 213] source culture data. . 2. Seizure Disorder: Patient baseline seizure disorder 3 different anti-epileptics. recent dose adjustments home presentation seizure 3 days PTA OSH. Overnight [4-11], patient another cluster 3 brief tonic-clonic seizures given 1mg lorazepam. EEG [5-28] showed epileptiform discharges brief organized seizures. EEG [5-29] showed organized seizure activity. continued levetiracetam, phenytoin, lamotrigine via NGT. Antibiotics discontinued infectious source identified felt antibiotics lowering seizure threshold. monitoring, several seizure including 1 prolonged (45min) clonic seizure involved 1-2 min right arm extention followed agitated behavior. antiepileptics increased follows: MEDICATION INCREASES: Lamictal 300mg mouth twice daily Levetiracetam (Keppra) 2000mg mouth twice daily CONTINUED: phenytoin (Dilantin) 100mg mouth twice daily typically seizure baseline prior discharge. . 3. Shock: Patient hypotension, hypothermia, WBC count <4000 admission, meeting criteria shock. Underlying infection suspected infectious source identified. rceived Fluid resuscitation pressors resolved patient's hypotension first night required resuscitation following. . # Altered mental status: Patient remained somnolent baseline admission. presented acute change behavior baseline interactiveness minimal responsiveness. reportedly presented like infections past. Differential includes infection, seizure, toxic/metabolic encephalopathy. TSH checked normal, cortisol. seen organized seizure activity EEG monitoring AEDs adjusted mentioned above. returned normal mental baseline (per caregiver) prior discharge. . # Gurgling throat: Patient's caregiver reports new gurgling sound throat. likely secretions URI may represtent aspiration, especially considering treated potential infection. Speech swallow saw patient found safe swallow aspiration. . #Hct drop: Patient??????s Hct dropped 46.6 37.2 overnight [5-27], slowly downtrending 36.9. Possibly fluid boluses hospitalization. Patient hemodynamically stable obvious sign bleed, Hct stabilized returned baseline without intervention. Medications Admission: hydrocortisone 2.5% cream apply areas redness twice daily needed lamotrigine 250mg PO BID levetiracetam 500mg tabs. Take 3 tabs mouth 6am 4 tabs mouth 9pm dilantin 200mg PO daily???? timolol maleate 0.5% solution. 1 gtt right eye QAM MVI one capsule daily loratadine 10mg PO daily senna 8.6 mg PO BID prn constipation potassium chloride 10meq PO daily bisacodyl 10mg PR daily prn constipation thiamine 100mg PO daily carbamide peroxide 6.5%drops, one dropper full day needed ear wax Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO twice day. Disp:180 Tablet(s) Refills:2 3. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times day): hold loose stool. 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times day) needed constipation. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] (2 times day). 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO twice day. 10. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO twice day. Discharge Disposition: Home Discharge Diagnosis: viral infection epilepsy generalized clonic seizures Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Neuro: awake, alert. Mumbles, typically able understood anyone know well. follow commands. Looks around room. Moves RUE > others spontaneously, moves extremities least antigravity response light touch. Discharge Instructions: Dear Mr. [Known lastname 26010] caregiver, [Name (NI) ] admitted hospital evaluation seizures hypothermia. infection evaluation show specific source infection, likely indicating viral illness cause temperature changes seizure frequency. saw long seizure started right arm going straight, followed agitated behavior. increased two seizure medications, Lamictal levetiracetam (Keppra). increased medications listed below, caregiver felt baseline prior discharge. Please continue phenytoin (Dilantin) dose previously taking. MEDICATION INCREASES: Lamictal 300mg mouth twice daily Levetiracetam (Keppra) 2000mg mouth twice daily CONTINUE: phenytoin (Dilantin) 100mg mouth twice daily Followup Instructions: Please follow Dr. [Last Name (STitle) 2442] [Hospital 875] clinic follows: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 3506] Date/Time:[2198-8-21] 9:00 Please follow previously scheduled appointments: Provider: [First Name4 (NamePattern1) 488] [Last Name (NamePattern1) 1112], MD Phone:[Telephone/Fax (1) 2010] Date/Time:[2198-6-6] 1:45 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2199-5-7] 9:45	[ "0389", "78552", "2760", "99592", "42789" ]
Admission Date: [2146-9-19] Discharge Date: [2146-9-27] Date Birth: [2074-12-2] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Aortic stenosis Major Surgical Invasive Procedure: [2146-9-22]: Aortic valve replacement size 21-mm [Doctor Last Name ] Magna tissue valve. History Present Illness: 71 year old male experiencing mild chest pressure dizziness, fatigue SOB past several months. presented [Hospital 11560] [Hospital3 ] [9-15] worsenig SOB chest pain extended left hand. also notes dyspnea exertion climbing stairs. admitted ruled myocardial infarction. echocardiogram revealed significant aortic stenosis. Cardiac cath revealed sigificant CAD carotids clear. note admission noted thrombocytopenia platelet counts around 70,000 seen Hematology felt idiopathic thrombocytopenic purpura. ok's receive ASA proceed cath. transferred [Hospital1 18] surgical evaluation aortic valve replacement. Past Medical History: Aortic Stenosis Benign Prostatic Hyperplasia Thrombocytopneia ITP Past Surgical History: Tonsillectomy herniorrhaphy Social History: Race:Caucasian Last Dental Exam: Lives with: wife, 3 daughters Contact: [Name (NI) ] (wife) Phone #[Telephone/Fax (1) 112498] Occupation: Cigarettes: Smoked [x] yes [] Tobacco use:denies ETOH: < 1 drink/week [x] [2-8] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Father died 65 sleep Mother died 90 Diabetes Sister breast cancer Brother stomach cancer 62 Physical Exam: Physical Exam Pulse:63 Resp:18 O2 sat:97/RA B/P Right:134/81 Left:128/84 Height: 5'8" Weight:205 lbs General: Skin: Warm [x] Dry [x] intact [xX] HEENT: NCAT [X] PERRLA [X] EOMI [x] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [4-8] HSM______ Abdomen: Round Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [] _____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [Name (NI) 167]:+2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit: Right: referred Left:Referred Pertinent Results: Echocardgiogram [2146-9-22] PREBYPASS: Normal LV wall motion systolic function LVEF > 55%. Mild moderated LVH. Right ventricular chamber size free wall motion normal. number aortic valve leaflets cannot determined level calcification, functionally bicuspid.. aortic valve leaflets severely thickened/deformed. critical aortic valve stenosis (valve area <0.8cm2). mitral valve appears structurally normal trivial mitral regurgitation. Normal TV PV. clot LAA. Intact interatrial septum PFO seen. descending thoracic aorta mild diffuse atherosclerotic plaque. coronary sinus appears normal. Normal transmitral diastolic inflow velocity spectral profile (E > A)and pulmonary venous spectral Doppler profile (S >D) e' = 6-8 cm/sec indicating perhaps either normal diastolic function mild decrease active relaxation. pericardial effusion. POSTBYPASS: Normallly functioning bioprosthetic AV significant AI. LVEF > 60%, Otherwise unchanged Spleen Ultrasound [2146-9-21]: Transverse sagittal images obtained spleen. borderline splenomegaly spleen measures 13.3 cm length. IMPRESSION: Borderline splenomegaly. Chest CT [2146-9-20]: FINDINGS: Cardiac size normal. aorta normal caliber. ascending aorta measures 3.4 cm. tiny area calcification proximal medial ascending aorta. also two small calcifications arch. descending aorta normal caliber. Mediastinal lymph nodes meet CT criteria pathologic enlargement. calcification aortic valve. pleural pericardial effusion Peripheral Blood Smear: Normal RBC WBC morphology, big platelets rare megakaryocyte fragments. . [2146-9-27] 06:10AM BLOOD WBC-6.5 RBC-3.37* Hgb-10.4* Hct-30.4* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.3 Plt Ct-132* [2146-9-26] 05:22AM BLOOD WBC-5.4 RBC-3.30* Hgb-10.3* Hct-29.2* MCV-89 MCH-31.2 MCHC-35.2* RDW-14.2 Plt Ct-113* [2146-9-25] 04:54AM BLOOD WBC-6.4 RBC-3.19* Hgb-9.8* Hct-28.2* MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 Plt Ct-85* [2146-9-24] 01:31AM BLOOD WBC-7.9 RBC-3.54* Hgb-10.9* Hct-30.9* MCV-87 MCH-30.8 MCHC-35.3* RDW-14.5 Plt Ct-120* [2146-9-27] 06:10AM BLOOD PT-13.0* PTT-25.3 INR(PT)-1.2* [2146-9-24] 01:31AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.3* [2146-9-27] 06:10AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-137 K-4.4 Cl-102 HCO3-30 AnGap-9 [2146-9-26] 05:22AM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-136 K-3.8 Cl-99 HCO3-32 AnGap-9 [2146-9-25] 04:54AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-138 K-3.9 Cl-101 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [Known lastname ] transfer [Hospital6 3105] surgical evaluation aortic valve replacement. Hematology consulted underlying cause thrombocytopenia, unclear. Splenic Ultrasound showed Borderline splenomegaly. Given range current platelet count would safe undergo heart surgery appropriate anticoagulation. patient brought Operating Room [2146-9-22] patient underwent Aortic valve replacement size 21-mm [Doctor Last Name ] Magna tissue valve. Overall patient tolerated procedure well post-operatively transferred CVICU stable condition recovery invasive monitoring. POD 1 found patient extubated, alert oriented breathing comfortably. patient neurologically intact hemodynamically stable, weaned inotropic vasopressor support. Beta blocker initiated patient gently diuresed toward preoperative weight. patient transferred telemetry floor recovery. Chest tubes pacing wires discontinued without complication. patient evaluated physical therapy service assistance strength mobility. time discharge POD 5 patient ambulating freely, wound healing pain controlled oral analgesics. patient discharged home services good condition appropriate follow instructions. Medications Admission: None Discharge Medications: 1. Aspirin EC 81 mg PO DAILY extubated RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) mouth daily Disp #30 Tablet Refills:0 2. Atorvastatin 10 mg PO DAILY RX atorvastatin 10 mg 1 tablet(s) mouth daily Disp #30 Tablet Refills:0 3. Furosemide 40 mg PO DAILY Duration: 7 Days RX furosemide 40 mg 1 tablet(s) mouth daily Disp #7 Tablet Refills:0 4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX potassium chloride [Klor-Con] 20 mEq 1 packet mouth daily Disp #7 Packet Refills:0 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 2 mg [1-3] tablet(s) mouth every four (4) hours Disp #40 Tablet Refills:0 6. Metoprolol Tartrate 25 mg PO TID hold hr less 60 sbp less 100 RX metoprolol tartrate 25 mg 1 tablet(s) mouth three times day Disp #90 Tablet Refills:0 Discharge Disposition: Home Service Facility: Care Tenders Discharge Diagnosis: Aortic Stenosis Benign Prostatic Hyperplasia Thrombocytopneia ITP ? MRSA UTI, Tonsillectomy herniorrhaphy Discharge Condition: Alert oriented x3 nonfocal Ambulating, gait steady Sternal pain managed oral analgesics Sternal Incision - healing well, erythema drainage Edema: 1+ Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming, look incisions Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments: Wound Check Cardiac Surgery Office [Telephone/Fax (1) 170], [2146-10-4] 10:45 Surgeon Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2146-10-25] 1:30 Cardiologist Dr. [First Name8 (NamePattern2) 29069] [Name (STitle) 29070] [2146-10-20] 1:00pm ( Address: [Doctor Last Name ] [Hospital1 3597], NH Phone: [Telephone/Fax (1) 37284]) Please call schedule following: Primary Care Dr. [Last Name (STitle) ],RAOUF [Telephone/Fax (1) 112499] [4-7] weeks Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2146-9-27]	[ "4241" ]
Admission Date: [2169-6-9] Discharge Date: [2169-6-13] Date Birth: [2103-1-1] Sex: Service: MEDICINE Allergies: Penicillins Attending:[Doctor First Name 1402] Chief Complaint: Shortness Breath Major Surgical Invasive Procedure: none History Present Illness: 66M known PMH, suspected HTN DM, presents shortness breath increased LE edema. patient followed doctors, somewhat difficult historian, essentially reports 2-3 weeks increased difficulty breathing, LE edema difficulty ambulating home fall AM. reports sleep sitting chair past year half. Denies chest pain rest exertion; LH, palpitations, URI sx, F/C. Reports occasional cough, non-productive. seen ED year ago fall job, noted elevated sugars hypertension, seen follow [Hospital1 18] (uncertain where), told start metformin although take it. Reports today woke sleep "couldn't get deep breath." Tried walk around, felt unsteady apparently fell, although hit head. LOC presyncope Past Medical History: ?Hyperglycemia, HTN. s/p injury fall 1 year ago--seen [Hospital1 18] ED. Social History: Retired appliance technician mechanic, retired since injury last year. Lives [Location 86] wife, son well. Smoked 1-2ppd 30+ years, quit 20 years ago. ETOH: 3 pints whisky week, heavier use younger years (about 1.5 gallons week). Denies cocaine IVDU. Family History: significant CAD, HTN, DM Physical Exam: per Dr. [Last Name (STitle) ]: VS: 97.5 BP 146/88 HR 107 RR 28 O2 95% 2LNC Gen: Obese male, NAD. Slightly dyspneic. HEENT: NCAT. Sclera anicteric. Dry MM. Neck: Supple JVD ear. Thick neck. CV: Irregularly irregular, normal S1, S2. P2 tap palpation. m/r/g appreciated. S3 S4. Chest: BS BL, diminished bases. appreciable crackles, wheezes. Abd: Distended. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. Ext: Skin changes c/w venous stasis. 3+ pitting edema. Skin: Acanthosis nigricans neck. Venous stasis changes above. Pertinent Results: Admit EKG: Atypical flutter vs Afib 122. Low voltage. NL axis/intervals. QS V1V2 concerning prior anterior MI. Nonspecific TW flattening inferior-lateral leads. prior available comparison. . Admit CXR: Cardiac size cannot evaluated. Large bilateral pleural effusions present. upper zone redistribution seen. Appearances suggestive cardiac failure. Infiltrates lower lobes cannot excluded. IMPRESSION: Evidence failure bilateral effusions. . Admit labs: Trop-T: 0.01 0.02 CK: 214 146 MB: 5 4 136 97 8 --------------< 331 4.2 34 1.0 ALT: 38 AP: 79 Tbili: 0.4 Alb: 3.6 AST: 29 LDH: Dbili: TProt: TSH:2.8 Cholesterol:149 Triglyc: 79 HDL: 65 LDLcalc: 68 proBNP: 1730 . 14.2 6.5 >----< 230 43.6 N:63.7 L:26.7 M:7.8 E:1.7 Bas:0.1 . Discharge labs: WBC-5.1 RBC-4.78 Hgb-13.3* Hct-41.4 Plt Ct-222 PT-13.8* PTT-53.1* INR(PT)-1.2* Glucose-150* UreaN-11 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-36* AnGap-9 . Radiology [6-11]: Echo: left atrium mildly dilated. right atrium moderately dilated. estimated right atrial pressure 16-20 mmHg. moderate symmetric left ventricular hypertrophy normal cavity size. Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. Overall left ventricular systolic function low normal (LVEF 50%). right ventricular cavity moderately dilated free wall hypokinesis. ascending aorta mildly dilated. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. main pulmonary artery dilated. pericardial effusion. IMPRESSION: Right ventricular cavity enlargement free wall hypokinesis, pulmonary artery dilation moderate pulmonary artery systolic hypertension. constellation findings suggestive primary pulmonary process. Prominent left ventricular hypertrophy low normal systolic function. absence history systemic hypertension, infiltrative process (e.g., amyloid) considered. . [6-12]: DVT scan: negative Brief Hospital Course: 66M likely PMH DM, HTN, COPD, p/w progressive LE edema shortness breath setting taking medications. also found atrial fibrillation. Hospital course problem: . #) CHF: diastolic dysfunction predominantly right sided heart failure. patient likely untreated CHF progressive decline. etiology likely [2-10] 1) untreated HTN leading diastolic dysfunction, 2) OSA leading right heart failure, 3) atrial fib leading mild systolic dysfunction. aggressively diuresed initially IV lasix (pt responds 40 IV) goal 2-3 L negative per day. diuresed 11L improvement O2 requirement RA improvement leg edema. also initially treated nitro gtt weaned setting starting ACEi, aldactone, lasix PO, BB. patient echo supported conclusions. Upon discharge, RA ambulating. also counseled importance low Na diet monitoring weight closely. discharge weight 136 kilograms . # Cards Ischemic: evidence ischemia prompted exacerbation. EKG echo above. started ASA, checked lipids, treated BB. need close followup PCP NP outpt management. . # Cards Rhythm: patient presented AFib unknown chronicity. treated increasing doses metoprolol rate control. also treated heparin gtt bridged coumadin three days. INR remained subtherapeutic d/c. received coumadin 5mg qhs x3 doses. Per [Company 191] anticoag nurses, discharged 7.5mg qhs x1 back 5mg qhs thereafter. INR check scheduled [6-15] [Company 191]. -We recommend followup Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] echo potential DCCV [1-10] months documented properly anticoagulated >1 month time. concerned good candidate longterm anticoagulation given poor med compliance past. TSH normal. . # DM: A1c checked pending. treated ISS temporarily glargine. held metformin dispo given heart failure. started glyburide 5 daily followup [Last Name (un) ]. becomes hypoglycemic, please d/c glyburide. . # OSA: patient witnessed desats apneic episodes night. thick neck. unable get BiPap trial house [2-10] patient refusal. benefit outpt sleep study. strongly conveyed patient wife. . # HTN: ACEI, aldactone, BB above, titrated current doses . # Dysuria: U/A neg, resolved. received one dose cipro stopped. . # FEN: DM/Low Na/Cardiac diet. Lytes need checked later week several weeks later ensure K Creatinine stable. . # Code: Full . # Contact/social: family involved. patient received medical care past. need frequent followup encouragement. Without wife present, get somewhat agitated redirected easily. . # Dispo: strongly recommended rehab patient refused. Medications Admission: none Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Succinate 100 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 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Outpatient Lab Work please INR electrolytes checked [6-15]. goal INR [2-11] coumadin may need adjusted. potassium needs monitored cardiac meds adjusted needed. 8. Warfarin 2.5 mg Tablet Sig: variable Tablet PO bedtime: take 3 tabs (7.5mg) night [6-13], 2 tabs (5mg) following night. INR checked [6-15] [Company 191*] nurses make adjustments. Disp:100 Tablet(s)* Refills:2 Discharge Disposition: Home Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: - CHF exacerbation: right sided failure, mild systolic dysfunction, diastolic dysfunction. - DMII - HTN - Atrial fibrillation (unknown duration) - likely obstructive sleep apnea Secondary: - hyperlipidemia Discharge Condition: fair Discharge Instructions: admitted shortness breath. atrial fibrillation congestive heart failure. also diabetes, high blood pressure, high cholesterol, obstructive sleep apnea. treated conditions. . came medications. started multiple medications important take instructed. . need keep followup appointments scheduled. important coumadin level checked regularly. also electrolytes INR checked within three days . Please weigh daily. Please adhere low sodium diet. weight discharge 136 kilograms. gain 2 pounds day, please contact PCP. . Please contact PCP return emergency department experience shortness breath, chest pain, worsening leg swelling, abdominal pain, dizziness, severe headache. . recommended go rehab short stay improve physical medical health. refused despite request. Followup Instructions: * Please contact [Name (NI) 191] [Telephone/Fax (1) ] TONIGHT TOMORROW confirm registration info. * Please followup Dr. [Last Name (STitle) ] [Company 191] [6-15] 4:10 pm. number [Telephone/Fax (1) ]. office located [Hospital Ward Name 23] [Location (un) ] central suite. Please lab work performed time. . Please followup Dr. [First Name8 (NamePattern2) 48991] [Name (STitle) 19868] [7-19] 2pm. office located [Hospital 191] clinic [Hospital Ward Name 23] 6, [Hospital1 18] [Hospital Ward Name ]. Phone number [Telephone/Fax (1) ]. . Please followup [Hospital ] Clinic. located 1 [Last Name (un) ] Way. Phone number: ([Telephone/Fax (1) 4847]. Thursday [6-22] 2pm. . Please followup Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] one month. number ([Telephone/Fax (1) 1987]. Please contact office appointment. . Please sleep study performed. phone number ([Telephone/Fax (1) 48992]. Please contact appointment . coumadin clinic [Company 191**] center monitor coumadin level you.	[ "42731", "25000", "4280", "32723", "2720" ]
Admission Date: [2104-9-14] Discharge Date: [2104-9-28] Service: MED Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 21990] Chief Complaint: Shortness Breath Major Surgical Invasive Procedure: Intubation History Present Illness: [Age 90 ]M h/o CAD/CABG, Dementia, presented [Hospital1 18] ED fever (101.5) mild decr OS (93%) CXR demonstrating LLL infiltrate. also RLE erythema consistent cellulitis. Pt given IV levaquin, flagyl, ancef DCed back NH PO levaquin/flagyl/keflex. NH, rigors/shaking, hypoxia (OS74%) promptly returned ED. received Benzos en transit ED empiric seizure Rx. ED, lethargic, T104.6, HR110, BP160/100, RR14 OS100%. intubated emergently airway protection placed sepsis protocol. received ceftriaxone 1 gm IV , vancomycin 1 gm IV, IVF (total 5L NS). CK 1012, MB 72 (MBI 7.1) troponin 1.31. EKG showed old RBBB. Health care proxy met cardiologist, decided pt DNR cath candidate, decided keep pt intubated. Later ED, recurrence possible seizure activity. seen Neuro: head CT negative, LP thousands RBCs (but reported traumatic tap). Pt started empiric acyclovir possible HSV Meningitis. Pt sent [Hospital Unit Name 153]. Past Medical History: Dementia, CAD S/P CABG ([2086]) S/P NSTEMI ([9-13]), CHF (EF43% - '[02]), 2+ MR, Chronic Venous Stasis, HTN, Glaucoma Social History: Pt demented, reportedly functional baseline nursing home. converses residents, quite social, feed himself. continent stool urine. tobacco/EtOH. Family History: Unknown. Physical Exam: T99.7 BP120/57 HR84 RR28 OS97%RA GEN: Awake Alert. Conversing (wants go home). SKIN: Warm dry. RLE erythema absent. CV: RRR. II/VI SEM LSB/Apex Rad Axilla. Lungs: Mild end-expiratory wheezes R base. Dim BS L base. ABD: Mildly distended. S/NT. Pos BS. Ext: C/C/E. 1+ DPs. Pertinent Results: [2104-9-25] 03:30AM BLOOD WBC-16.1* RBC-3.50* Hgb-10.3* Hct-32.0* MCV-91 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-322 [2104-9-24] 04:18AM BLOOD WBC-14.7* RBC-3.25* Hgb-9.8* Hct-29.3* MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 Plt Ct-293 [2104-9-23] 04:15AM BLOOD WBC-18.0* RBC-3.29* Hgb-9.6* Hct-29.8* MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-260 [2104-9-22] 05:36PM BLOOD WBC-21.2# RBC-3.52 Hgb-10.6* Hct-32.1* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.4 Plt Ct-306 [2104-9-22] 06:34AM BLOOD WBC-13.9* RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.3 RDW-14.4 Plt Ct-305 [2104-9-21] 05:00AM BLOOD WBC-12.4* RBC-3.92* Hgb-11.6* Hct-34.6* MCV-88 MCH-29.7 MCHC-33.7 RDW-13.8 Plt Ct-322 [2104-9-20] 05:49AM BLOOD WBC-9.7 RBC-3.62* Hgb-10.8* Hct-32.2* MCV-89 MCH-29.7 MCHC-33.4 RDW-13.9 Plt Ct-256 [2104-9-19] 04:28AM BLOOD WBC-7.6 RBC-3.45* Hgb-10.5* Hct-30.0* MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-227 [2104-9-18] 03:57AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.2* Hct-29.7* MCV-87 MCH-30.0 MCHC-34.3 RDW-14.0 Plt Ct-183 [2104-9-17] 05:00AM BLOOD WBC-8.1 RBC-3.48* Hgb-10.6* Hct-30.7* MCV-88 MCH-30.4 MCHC-34.4 RDW-14.7 Plt Ct-171 [2104-9-16] 05:15AM BLOOD WBC-7.5 RBC-3.36* Hgb-10.1* Hct-29.5* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.0 Plt Ct-159 [2104-9-15] 11:56AM BLOOD WBC-7.3 RBC-3.76* Hgb-11.2* Hct-33.0* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.5 Plt Ct-160 [2104-9-15] 05:12AM BLOOD WBC-7.1 RBC-3.54* Hgb-10.8* Hct-30.9* MCV-88 MCH-30.4 MCHC-34.7 RDW-14.3 Plt Ct-147* [2104-9-14] 05:00PM BLOOD WBC-9.9 RBC-4.04* Hgb-12.2* Hct-36.8* MCV-91 MCH-30.1 MCHC-33.0 RDW-13.7 Plt Ct-186 [2104-9-14] 04:30AM BLOOD WBC-6.8 RBC-4.22* Hgb-12.5* Hct-36.5* MCV-86 MCH-29.5 MCHC-34.2 RDW-13.6 Plt Ct-191 [2104-9-25] 03:30AM BLOOD Plt Ct-322 [2104-9-24] 04:18AM BLOOD Plt Ct-293 [2104-9-24] 04:18AM BLOOD PT-13.0 PTT-41.4* INR(PT)-1.1 [2104-9-23] 04:15AM BLOOD PT-13.2 PTT-56.8* INR(PT)-1.1 [2104-9-22] 06:34AM BLOOD PT-13.0 PTT-41.0* INR(PT)-1.1 [2104-9-18] 03:57AM BLOOD PT-13.5 PTT-53.1* INR(PT)-1.2 [2104-9-15] 06:54AM BLOOD PT-13.7* PTT-65.2* INR(PT)-1.2 [2104-9-14] 05:00PM BLOOD PT-13.7* PTT-42.2* INR(PT)-1.2 [2104-9-14] 04:30AM BLOOD PT-13.3 PTT-43.3* INR(PT)-1.1 [2104-9-25] 03:30AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-141 K-4.1 Cl-104 HCO3-24 AnGap-17 [2104-9-24] 04:18AM BLOOD Glucose-95 UreaN-36* Creat-0.9 Na-139 K-4.3 Cl-104 HCO3-27 AnGap-12 [2104-9-22] 05:36PM BLOOD Glucose-159* UreaN-44* Creat-1.2 Na-139 K-3.7 Cl-101 HCO3-25 AnGap-17 [2104-9-21] 05:00AM BLOOD Glucose-118* UreaN-31* Creat-0.9 Na-143 K-4.1 Cl-102 HCO3-31* AnGap-14 [2104-9-20] 08:25PM BLOOD K-4.1 [2104-9-20] 05:49AM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-142 K-4.2 Cl-107 HCO3-30* AnGap-9 [2104-9-19] 04:28AM BLOOD Glucose-116* UreaN-26* Creat-0.9 Na-144 K-4.3 Cl-112* HCO3-25 AnGap-11 [2104-9-18] 03:57AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-141 K-3.3 Cl-110* HCO3-24 AnGap-10 [2104-9-17] 05:00AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-140 K-3.8 Cl-111* HCO3-20* AnGap-13 [2104-9-16] 05:15AM BLOOD Glucose-93 UreaN-28* Creat-1.2 Na-139 K-4.2 Cl-113* HCO3-20* AnGap-10 [2104-9-15] 05:16PM BLOOD Glucose-92 UreaN-29* Creat-1.1 Na-141 K-3.8 Cl-112* HCO3-20* AnGap-13 [2104-9-15] 11:56AM BLOOD Glucose-85 UreaN-29* Creat-1.1 Na-140 K-4.5 Cl-110* HCO3-20* AnGap-15 [2104-9-15] 05:12AM BLOOD Glucose-94 UreaN-29* Creat-1.1 Na-141 K-3.3 Cl-111* HCO3-21* AnGap-12 [2104-9-14] 11:37PM BLOOD Glucose-116* UreaN-30* Creat-1.1 Na-141 K-3.6 Cl-111* HCO3-21* AnGap-13 [2104-9-14] 05:00PM BLOOD Glucose-184* UreaN-37* Creat-1.6* Na-139 K-4.6 Cl-101 HCO3-15* AnGap-28* [2104-9-14] 04:30AM BLOOD Glucose-120* UreaN-37* Creat-1.3* Na-139 K-4.2 Cl-103 HCO3-25 AnGap-15 [2104-9-21] 05:00AM BLOOD CK(CPK)-127 [2104-9-20] 05:49AM BLOOD CK(CPK)-140 [2104-9-19] 04:28AM BLOOD CK(CPK)-104 [2104-9-18] 03:57AM BLOOD CK(CPK)-194* [2104-9-17] 12:35PM BLOOD CK(CPK)-249* [2104-9-17] 05:00AM BLOOD CK(CPK)-308* [2104-9-15] 11:56AM BLOOD CK(CPK)-794* [2104-9-15] 05:12AM BLOOD CK(CPK)-858* [2104-9-14] 05:00PM BLOOD ALT-28 AST-116* LD(LDH)-426* CK(CPK)-1012* AlkPhos-104 TotBili-0.6 [2104-9-21] 05:00AM BLOOD CK-MB-3 cTropnT-2.01* [2104-9-20] 05:49AM BLOOD CK-MB-4 cTropnT-2.75* [2104-9-19] 04:28AM BLOOD CK-MB-5 cTropnT-3.33* [2104-9-18] 03:57AM BLOOD CK-MB-8 cTropnT-3.64* [2104-9-17] 12:35PM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-2.54* [2104-9-17] 05:00AM BLOOD cTropnT-2.60* [2104-9-15] 11:56AM BLOOD CK-MB-50* MB Indx-6.3* cTropnT-1.73* [2104-9-15] 05:12AM BLOOD CK-MB-56* MB Indx-6.5* cTropnT-1.60* [2104-9-14] 05:00PM BLOOD CK-MB-72* MB Indx-7.1* [2104-9-14] 05:00PM BLOOD cTropnT-1.31* [2104-9-25] 03:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2 [2104-9-17] 12:35PM BLOOD Triglyc-145 HDL-31 CHOL/HD-4.5 LDLcalc-81 [2104-9-14] 05:00PM BLOOD Cortsol-54.2* [2104-9-22] 10:55PM BLOOD Type-ART pO2-105 pCO2-35 pH-7.49* calHCO3-27 Base XS-3 Intubat-INTUBATED [2104-9-21] 05:42PM BLOOD Type-ART pO2-413* pCO2-43 pH-7.43 calHCO3-29 Base XS-4 [2104-9-21] 06:33AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.46* calHCO3-32* Base XS-6 [2104-9-20] 02:42PM BLOOD Type-ART Temp-36.6 pO2-120* pCO2-28* pH-7.48* calHCO3-21 Base XS-0 [2104-9-18] 11:13AM BLOOD Type-ART pO2-144* pCO2-38 pH-7.39 calHCO3-24 Base XS--1 Intubat-INTUBATED [2104-9-16] 05:25PM BLOOD Type-ART pO2-167* pCO2-30* pH-7.37 calHCO3-18* Base XS--6 [2104-9-15] 10:56AM BLOOD Type-ART PEEP-5 O2-50 pO2-125* pCO2-30* pH-7.40 calHCO3-19* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [2104-9-15] 12:05AM BLOOD Type-ART pO2-380* pCO2-30* pH-7.41 calHCO3-20* Base XS--3 [2104-9-21] 05:42PM BLOOD Lactate-2.1* [2104-9-14] 06:46PM BLOOD Lactate-3.0* [2104-9-14] 05:26PM BLOOD Lactate-15.2* [2104-9-14] 04:35AM BLOOD Lactate-1.7 Brief Hospital Course: 1. Pulmonary: pt intubated ED airway protection. LLL infiltrate CXR overwhelmingly impressive. ICU, well vent pressure support minimal settings time. RSBIs often elevated >100 [2-11] agitation, spontaneous breathing trial [9-22], became tachypneic, tachycardic, pulling tube (he time manage pull OGT.) also began secretions suctioned tube around time. Later day, turned, turned [Doctor Last Name 352] became hypoxic 80s, generalized tonic-clonic activity. large mucous plug suctioned tube sats began rise. [9-24], decided extubate him, appeared mental status going tolerate vent without sedation, meaning would never great RSBI spontaneous breathing trial. long discussion health care proxy, [Name (NI) ] [Name (NI) ], decided would extubate Mr. [Known lastname 6930] would reintubate failed extubation. tolerated extubation well remainder stay ICU O2 sats greater 96% RA. infiltrates slowly improved CXR. 2. Cardiovascular: admission, Mr. [Known lastname 6930] elevated troponin CKs. decided cardiologist/PCP candidate cath would managed medically. first days hospitalization, CK MB declined expected, troponins continued rise, peaking 3.64 HD#5. Cardiology consulted, EKG changes suggest ongoing ischemia CKs time flat. explanation rising troponins, eventually trended downward. rhythm, atrial fibrillation also wandering atrial pacemaker time. blood pressure labile here, times systolics 90s. Eventually, pressure came back normal range started beta-blocker ACE, well continued ASA. also lipid panel checked normal. statin started [2-11] elevated ALT baseline. 3. GI: developed diarrhea admission, C diff toxin positive. begun Flagyl 500 mg po tid total 14 day course. 4. Infectious Disease: never grew bacteria sputum, blood, urine cx. treated ceftaz total 14 days. initially treated vancomycin given appeared septic cellulitis. d/c'ed approximately 5 days cellulitis appear impressive, began spiking fevers 102 stopped restarted. discontinued CDiff returned positive, felt caused fevers. However, spiked another fever leukocytosis vanc stopped, finally restarted would total 14 days vancomycin. 5. Neuro: presentation concern seizure, although temp 104 seemed much c/w rigors. evaluated Neuro ED normal head CT. LP done well, reveal leukocytosis quite red cells, HSV PCR sent begun acyclovir. later felt tap bloody (the ED resident said hit artery) acyclovir discontinued. Later admission, aforementioned episode hypoxia mucous plug, felt seizure activity tonic clonic jerking. evaluated Neuro, felt likely due hypoxia actual seizure disorder. EEG revealed generalized mild encephalopathy frank epileptiform discharges. extubated, mental status quickly returned baseline (per PCP), mild dementia. 6. Heme: [9-26], pt hematocrit drop 32 27. stabilized Hct 29 day discharge without intervention. Iron studies consistent anemia chronic disease. 7. Code Status: DNR/DNI Medications Admission: ASA 81 mg po qd Metoprolol 25 mg po bid Risperdal 0.25 mg po bid MVT Brimonidine eye drops NTG sl prn Discharge Medications: 1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Disp:1 bottle Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once day). Disp:30 Tablet(s) Refills:2 3. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:1 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 11 days. Disp:33 Tablet(s) Refills:0 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours needed shortness breath wheezing. Disp:1 inh Refills:5 8. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours 5 days. Disp:10 grams Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary Dx: Pneumonia Secondary Dx: Clostridium Dificile Colitis, Hypoxia-Induced Seizures, Non ST-Elevation Myocardial Infarction, Anemia Chronic Disease. Discharge Condition: Fair. Discharge Instructions: 1) fevers, chills, pain, shortness breath, diarrhea, concerning symptoms, please contact doctor return ER. 2) Take medications instructed. 3) Please doctor evaulate liver enzymes. become normal, may benefit statin therapy decrease LDL raise HDL cholesterol levels. Followup Instructions: 1) Please see primary doctor next 1-2 weeks ([Last Name (LF) ],[First Name3 (LF) ] N. [Telephone/Fax (1) 719]).	[ "0389", "78552", "51881", "486", "4280" ]
Admission Date: [2178-11-3] Discharge Date: [2178-11-4] Service: Cardiothoracic Surgery HISTORY PRESENT ILLNESS: 82-year-old female past medical history significant non-insulin-dependent diabetes mellitus, gastric cancer, status post upper gastrointestinal bleed treated radiation therapy, hypertension. 82-year-old female status post inferior wall myocardial infarction post infarction ventricular septal defect changes transferred intra-aortic balloon pump place Neo-Synephrine dopamine systolic blood pressure around 80. large ST elevations inferior leads. anuric lactic acid 8.5. Cardiac catheterization revealed ventricular septal defect changes. arrived gravely ill condition. ALLERGIES: known drug allergies. PHYSICAL EXAMINATION PRESENTATION: vital signs admission temperature 95.2, heart rate 183, atrial fibrillation, blood pressure 123/81, respirations 14, satting 97%; arterial blood gas 7.28/23/180/111. physical examination deferred family. LABORATORY DATA PRESENTATION: laboratories white blood cell count 18.1, hematocrit 37.9, platelets 240. Magnesium 2.5. ALT 33, AST 53, alkaline phosphatase 145. Creatine kinase 216. Troponin 37.7. Total bilirubin 0.6. HOSPITAL COURSE: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] discussed possibility surgery patient's family, given low (if zero) chance survival family whished proceed surgery stop support. [2178-11-4], hospital day two, drips discontinued earlier day. Systolic blood pressure dropped 50s 40s. patient maintained morphine drip 10 mg per hour. became asystolic without vital signs 1:35 a.m., pronounced dead time. Dr. [Last Name (STitle) 70] notified. medical examiner's office notified declined autopsy. patient wished proceed autopsy. DIAGNOSIS TIME DEATH: Post infarction ventricular septal defect. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 15735] MEDQUIST36 D: [2178-11-13] 13:22 T: [2178-11-17] 08:37 JOB#: [Job Number 29579]	[ "41401", "25000", "4019" ]
Admission Date: [2125-8-9] Discharge Date: [2125-8-19] Date Birth: [2069-9-23] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2485] Chief Complaint: Back pain, RUQ pain, dyspnea Major Surgical Invasive Procedure: Right arterial line History Present Illness: 55 yo F w/history metastatic renal cell carcinoma setting [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 21344] Lindau syndrome presented clinic [8-8] appeared ill complained three weeks worsening right lower quadrant back pain, nausea/vomiting, weakness, fatigue, inability rise chair. reported subjective 20lb weight loss. also two episodes bladder incontinence past two days. ED COURSE: Initial vitals 89/62, HR 60 SR 97% RA. BP inc 110/72 1 liter NS bolus. found K 6.2 Ca 13.3. hyperkalemia given 10 units insulin 1 amp D50, 1 amp calcium gluconate, 30mg kayecelate. neurological symptoms, given 10 mg decadron head CT, thoracolumbar MRI performed rule CNS involvement cord compression respectively. UA also sent. Ms. [Known lastname ] trasferred OMED service care. FLOOR COURSE: Ms. [Known lastname ] arrived floor K 6.2 Ca 11.5. patient difficulty word finding sleepy receiving narcotics. History therefore obtained chart. Per reports, noted shortness breath, dyspnea exertion preventing carrying activities daily living, diffuse body aches, diarrhea fecal incontinence. . Given incontinence thoracic pain, neurologic work ?cord compression, subsequently c, t, l spine MRI notable metastatic disease diffusely evidence epidural disease L5 vertebral body level, compression. patient received lasix, insulin, glucose bicarb well kayexalate electrolyte management, also received total 3L NS acute pancreatitis. total uop floor response lasix 720cc. progressive O2 requirement tachypnea morning transfer [Hospital Unit Name 153] satting 93% 5L nasal cannula. admit increased shortness breath overnight notes general, dyspnea worsening last days. complains severe abdominal pain, admits LH. denies chest pain, headache, weakness, notes severe chronic pain related spinal metastasis. transferred [Hospital Unit Name 153] hypoxia volume management. Past Medical History: Past Oncological History: Initially presented age 9 vision changes secondary hypertensive emergency. diagnosed pheochromocytoma underwent left adrenalectomy. underwent right adrenalectomy [2088] diagnosed second pheochromocytoma. [2111], underwent hysterectomy complicated postoperative bleeding. ultrasound noted renal cysts leading biopsy right kidney, reported normal. well [2120] diagnosed L2 vertebral hemangioma presenting back pain radicular symptoms. One year prior, daughter diagnosed brain tumor, likely hemangioma, testing found [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 21344]-Lindau disease. -Nexivar discontinued [2125-5-29] following progression disease liver. seen [Hospital1 18] [2125-6-27], time options treatment Sutent vs enrollment trial perifosine discussed. remained therapy returned [Hospital1 18] anticipation enrollment perifosine. -In [2121-5-29], Ms. [Known lastname ] developed left flank pain hematuria. Left radical nephrectomy [2121-6-2] revealed polycystic kidney five clear cell type renal cell carcinomas ranging size 0.6 cm 9 cm. tumor invasion renal capsule, perinephritic adipose tissue, large renal veins, margins negative. lymph nodes recovered specimen. TNM stage T2 Nx Mx. -Ms. [Known lastname ] subsequently followed MRIs every six months. MRI [3-/2124] notable polycystic kidney disease right kidney gradually increasing size lesion caudate lobe liver. Biopsy liver lesion [2124-6-29] revealed metastatic clear cell renal cell carcinoma. [2124-7-29], started sorafenib (Nexavar). confusion, taking 200 mg p.o. b.i.d. MRI [2125-4-11] showed growth liver lesion 6 cm. addition, polycystic right kidney, 5 cm mass enhancement peripheral margins septations, raising concern slowly growing cystic neoplasm. patient went Nexavar progression liver development probable new tumor remaining right kidney. . PRIOR TREATMENT: 1. Left adrenalectomy age 9 right adrenalectomy age 18 pheochromocytomas. 2. Left nephrectomy renal cell carcinoma (5 independent tumors noted) [2121-5-29]. 3. Biopsy-documented metastatic disease caudate lobe liver [2124-3-29], patient started sorafenib. 4. Development progressive disease liver probable new renal primary (or metastases) right kidney setting polycystic disease. . Past Medical History: Ms. [Known lastname ] never officially diagnosed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 21344]-Lindau disease, daughter diagnosed personal family history makes us fairly certain it. also hypertension. . Past Surgical History: - L nephrectomy [5-31] - Bilat adrenalectomy [3-2] pheochromocytoma - TAH/BSO benign ovarian abnormalities, - appendectomy [2088] - right knee surgery ligament tear - resection hemangioma [2121]. Social History: -Lives husband [State 2748] - Remote tobacco use - EtoH drug use Family History: - Pt's daughter diagnosed [Name (NI) ] [Last Name (NamePattern1) 21354], hx benign brain tumors, pheochromocytomas, & bilateral renal cell carcinoma - brother died brain tumor [2103] - mother died renal failure age 47 - sister diagnosed late 40s breast CA - Another sister diabetes mellitus, diabetic nephropathy & s/p renal transplant - brother died myocardial infarction age 58 - Maternal grandmother hx kidney problems Physical Exam: Vitals: 97 HR 84 BP 98/60 R 22 Sat 93% 5L nasal cannula Gen: 55 yo F, pale, ill-appearing, round face, obvious respiratory distress, accessory muscle use. HEENT: conjunctival pallor, anicteric, PERRL/EOMI, MM dry, op clear. Neck: JVD flat, supple CV - RRR, MRG Resp: CTAB faint bibasilar rales ABD - hypoactive BS, mild distention marked tenderness palpation diffusely, especially epigastrium, rebound/guarding. Skin - pale, dry warm well perfused. EXT - c/c/e, tender touch Neuro - sleepy arousable voice. oriented x 3. Nonfocal exam, limited secondary pain. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2125-8-17] 04:05AM 37.3* 3.71* 8.9* 29.0* 78* 23.9* 30.5* 22.0* 178 [2125-8-16] 04:38AM 27.1* 3.54* 8.7* 27.3* 77* 24.7* 32.0 21.8* 211 [2125-8-15] 04:38AM 20.21 3.99 9.5* 30.7* 77* 23.8* 30.9* 21.5* 270 . [2125-8-11] 05:00AM 15.1* 3.00* 6.4* 22.6* 75* 21.3* 28.3* 21.8* 363 [2125-8-9] 01:00PM 12.7* 3.14* 6.8* 24.2* 77* 21.6* 28.1* 21.5* 484* [2125-8-8] 01:35PM 9.1 3.27* 6.9* 24.5* 75* 21.0* 28.0* 21.7* 596* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2125-8-17] 04:05AM 121* 79* 2.1* 143 3.3 105 17* 24* [2125-8-16] 04:01PM 124* 72* 2.1* 138 3.1* 103 16* 22* [2125-8-15] 02:52PM 119* 73* 2.3* 139 3.2* 100 19* 23* [2125-8-13] 08:28PM 80 79* 3.0* 136 4.6 101 12* 28* . [2125-8-10] 05:15AM 119* 49* 2.1* 140 5.0 108 19* 18 [2125-8-9] 01:00PM 107* 48* 2.1* 135 6.7 107 17* 18 . Alb Calcium Phos Mg [2125-8-17] 04:05AM 1.9* 8.8 4.4 2.2 [2125-8-14] 07:58PM 10.0 6.2* 2.5 [2125-8-11] 05:00AM 2.3* 4.0* 3.5 1.6 [2125-8-8] 01:35PM 3.3* 13.3* 3.8 2.5 . ENZYMES & BILIRUBIN - ALT & AST remained WNL admission - LDH increased 120's peak 870, trending prior death - Alk Phos 601 & Amylase 1789 admission & continued trend admission 169 & 78 respectively. . Lactate [2125-8-17] 09:05AM 1.6 . MICRO: URINE CULTURE (Final [2125-8-13]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. VANCOMYCIN SENSITIVITY CONFIRMED ETEST. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 NITROFURANTOIN-------- <=16 TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 . BLOOD CULTURES X8-NGTD STOOL: C-DIFF X2-Negative VRE-Swab: negative . IMAGING: . Chest xray: - [2125-8-16]: Essentially unchanged chest radiograph left atelectasis pleural effusion. . - [2125-8-15]: AP chest compared [8-13] 17: Mild pulmonary edema new. Left lower lobe atelectasis worsened, right infrahilar atelectasis new. Moderate cardiac enlargement persists. Small left pleural effusion may present, changed appreciably. pneumothorax. Nasogastric tube ends distal stomach. pneumothorax. . - [2125-8-8]: 1. Enlarged cardiac silhouette. 2. evidence acute congestive heart failure consolidation . CT HEAD: - [2125-8-16]: significant interval change compared prior examination [2125-8-8]. However, due motion artifact, study limited subtle lesion cannot entirely excluded. . [2125-8-8]: 1. acute abnormality including intracranial hemorrhage detected. 2. Although obvious intracranial metastasis identified, small isodense metastasis cannot excluded non contrast study. MRI brain recommended characterization. Small hypodense area right frontal [Doctor Last Name 534] might represent metastasis although proper location brain metastasis. . CT ABDOMEN & PELVIS: - [2125-8-16]: 1. Somewhat limited examination due lack IV contrast however evidence abscess. Extensive phlegmon involving peripancreatic soft tissues mesentery. 2. Liver metastases bone metastases unchanged, pericardial effusion, left pleural effusion stable.3. Multiple cysts right kidney complex lesion right lower pole unchanged. . - [2125-8-9]: 1. Compared prior study, increased stranding surrounding pancreas, tracking left paracolic space, mild wall thickening seen descending colon. Findings concerning acute pancreatitis. . [2125-8-13] ECHOCARDIOGRAM: PERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood, inflammation cellular elements. RV diastolic collapse. Echocardiographic signs tamponade may absent presence elevated right sided pressures. Significant, accentuated respiratory variation mitral/tricuspid valve inflows, c/w impaired ventricular filling. Left ventricular systolic function hyperdynamic (EF>75%). ventricular septal defect. Right ventricular chamber size free wall motion normal. Small pericardial effusion without overt tamponade. . [2125-8-13] RUQ Ultrasound: 1. evidence cholelithiasis. mildly distended gallbladder lumen moderate amount sludge uncommon ICU patient. high clinical suspicion acute cholecystitis, consider correlation HIDA scan. 2. Reidentification known hepatic metastatic lesions complex right renal cysts. Brief Hospital Course: A/P: 55 yo F metastatic RCC setting VHL presented acute pancreatitis hypercalcemia, ARF, mental status changes, respiratory distress significant back pain. . #. Respiratory Distress: Mild hypoxemia 3L NC initially placed NRB O2 sats improved. setting severe pancreatitis concerned ARDS, however, never required intubation airway protection. CXRs multiple occassions clear without evidence consolidation. However, remained hypoxic likely caused continued severe LLL atelectasis + small pleural/pericardial effusions, well depressed mental status. diuresed due pancreatitis, narcotic regimen initially held help improve mental status, clear. remained supplemental O2 throughout hospital course intubated. . #. Acute Renal Failure: Baseline creatinine unknown admitted Cr 2.1, likely compromised L nephrectomy thus single kidney polycystic kidney disease setting VHL, >5cm RCC mass R kidney. Also setting poor PO intake possibly pre-renal. - Continued anion gap metabolic acidosis likely due chronic renal failure pt low lactate levels. - Multiple electrolyte abnormalities admission including hyperphosphatemia & hypocalcemia requiring therapy; Initially admitted hyperkalemia & hypercalcemia resolved. initially received one dose Calcitonin floor possible cause hypocalcemia. Another possibility severe hypocalcemia pancreatitis. Repleted calcium IV calcium drip. - required bicarbonate repletion, however discontinued pt's bicarb levels improved. - renal service consulted, provided recommendations therapy admission. . #. Infection/inflammation w/increasing WBC left shift - low grade fevers, however steroids, first stress dose slowly titrated down, however due elevated WBC remained stress dose levels. pt made CMO steroids d/c'd alltogether. - Known enterococcus UTI, VRE colonized; unlikely source infection. sources infection included pancreatitis phlegmon & pneumonia/atelectasis. Abd CT showed large peripancreatic phelgmon increased fat stranding likely resulting considerable intra-abdominal inflammation. started broad spectrum abx vanco zosyn, switched ampicillin entoroccus UTI. Vanco switched Meropenem abdominal source noted below. abx d/c'd pt made CMO noted below. . #. Coagulopathy. likely decreased nutritional status antibiotics - INR improved max 2.9 ->to 1.5 [8-16] vitamin K x1. - actively bleeding admission, concern especially given known hemangiomas. . #. Acute Pancreatitis: Potentially [3-2] cyst VHL complex metastasis. - Although admitted elevated amylase, lipase, LDH & alk phos,ALT & AST remained nml. Initially pt given aggressive IVF due tenous respiratory status. bili trended 4.4 [8-17]. Increased fat stranding phlegmon suggests inflammation likely infection. pancreatitis resolving persistent abdominal pain large 10cm liver mass. U/S done c/w biliary sludge, however cholelithiasis. started Meropenem intra-abdominal source infection [8-17]. pain managed dilaudid prn renal failure prevented use morphine. However, Morphine drip started pt. made CMO. . #. Cardiovascular dysfunction: -->Pump: Non-contributory pericardial effusion, appears bloody/cellular/inflammatory ECHO. EF >75%, mild diastolic dysfunction. -->Rhythm: Continued sinus tach (100-120) frequent APBs, likely due pain infection. Also h/o pheochromocytoma norvasc, labetolol valsartan, initially held due hypotension. course became tachycardic HR 150s likely MAT. started lopressor 5mg TID titrated control HR. HR also controlled pain control. -->Ischemia: wall motion abnormalities signs ischemic dysfunction . #. Adrenal insufficiency setting bilateral adrenalectomy, home steroid dependence, prednisone 5mg daily. Pt. placed stress dose steriods due hypotension infection. steroids d/c'ed pt made CMO. . #. Metastatic RCC: CT scans negative cord compression, however, 10cm liver metastasis, abundant evidence probable VHL hemangiomas cervical, lumbar thoracic spine. Heme Onc followed pt. & discussed possibility treatment Sutent pt stable d/c medicine floor. tenuous throughout [Hospital Unit Name 153] course receive sutent. Pt's pain controlled aggressive pain medication. Palliative care consulted pain control help goals care clinical status deteriorated. managed morphine drip made CMO. . #. MS changes: Pt drowsy sedated, appeared pain movement. MS changes likely combination pain, uremia, ICU delerium, inflammation/ infection. underwent 2 head CTs show acute process, however due movement, limited study, subtle lesion could entirely excluded. Despite narcotics several days interactive responsive. . #. Code status: Initially full code made DNR/DNI, CMO prior death help Palliative care [Hospital Unit Name 153] team clinical status persistently deteriorated. . #. Goals care. Ms. [Known lastname ] known advanced metastatic RCC diffuse liver metastases setting severe acute pancreatitis rising white count continued MS changes despite electrolyte normalization sedation. - family meeting spouse addressing concerns worsening status including resp distress, elevated WBC despite abx, & metastatic RCC, resulted change code status DNR/DNI shifting care comfort only. - morphine drip initiated ease pain & make comfortable; prior CMO adequate pain control via standing pain medications. - Palliative care following pt since [8-10]. . Pt expired morning [8-19] 11am. Per pt's request organs donated NDRI coordination pathology department. husband agreed autopsy. Medications Admission: Prednisone 5 mg p.o.daily Norvasc 10 mg p.o. b.i.d. Trandate 200 mg p.o. b.i.d., Diovan 160 mg p.o. daily. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a	[ "5849", "2767", "2761", "5990", "2762", "4019" ]